International Dentistry Australasian Edition - Vol.12 No.3

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Daniel Bäumer, Otto Zuhr, Markus Hürzeler Surgical soft tissue improvement in the course of implant therapy Andreas Kurbad VITA IMPLANT SOLUTIONS: the implant prosthetic restoration concept Peter Raftery Indispensable articaine Aneta Grzesinska A conservative restorative smile makeover Angelo Itri Dentinal bridge formation: clinical results after Biodentine™ removal Rory McEnhill Single upper arch restoration using digital smile design Avish J. Jagathpal, Ashana Harryparsad, Rajesh Doolabh and Benjamin F. Calitz Mechanically-retained facial prosthesis for a large defect following Cancrum Oris: a clinical report

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Contents Volume 12 No. 3

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Clinical Surgical soft tissue improvement in the course of implant therapy

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Daniel Bäumer, Otto Zuhr, Markus Hürzeler

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Case Report VITA IMPLANT SOLUTIONS: the implant prosthetic restoration concept Andreas Kurbad

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Clinical Indispensable articaine Peter Raftery

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Clinical A conservative restorative smile makeover Aneta Grzesinska

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Clinical Dentinal bridge formation: clinical results after Biodentine™ removal Angelo Itri

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Clinical Single upper arch restoration using digital smile design Rory McEnhill

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Case Report Mechanically-retained facial prosthesis for a large defect following Cancrum Oris: a clinical report Avish J. Jagathpal, Ashana Harryparsad, Rajesh Doolabh and Benjamin F. Calitz

60 Products

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Bridge2Aid Australia In May 2017, Bridge2Aid Australia completed a very successful training programme thanks to the support from Henry Schein Halas and The Henry Schein Cares Foundation.

Bridge2Aid is a charity organisation that has been working in Tanzania for the last 14 years. In 2016 they set up an Australian local branch. The aim in doing so was further their work in some of the poorest communities on the planet by including volunteers from the Australian dental community.

They send volunteer teams of 7 dentists and 4 nurses to train rural health workers in Emergency Dental Care and oral health education. To date they have trained 521 health workers and given access to emergency dental treatment to nearly 5 million people. During training they have also been able to give 46,117 people free dental treatment.

Their May programme included Australia’s first volunteer Paul Duke, who is an Oral & Maxillofacial Surgeon and the past President of the South Australian Dental Association.

During each programme, Bridge2Aid train 6 rural health workers in emergency dental skills, primarily for extractions. This means that when they leave they do so leaving a legacy where the community can continue to support itself for emergency cases. During this visit they were able to train 18 rural health workers and treat 2,713 people. Often locations have no running water or electricity so simple hand instruments are the only option.

The team consisted of 7 volunteer dentists and 4 volunteer nurses.

One of those 2,713 people was Rachel who for 13 years had been suffering. As a child she caught polio and has never been able to walk upright since. A single mother of 2 sons and 4 daughters, she earns money by selling groundnuts. Her lack of sufficient income has meant she simply couldn’t travel to find help for her dental pain, as it increased she has needed to rely more and more on her children. The team from Bridge 2 Aid were able to quickly resolve her pain issue and treat the infection. They also took the opportunity to educate her about oral health which she will be able to pass on to her children.

Subira is a young rural health worker who has been at her post for just over 2 years. If you are one of the 50,000 people in her area then she is your only option for emergency dental treatment. She was one of 6 clinical officers who were trained in Morogoro, Tanzania in July 2016. The health centre where she works cover a huge area but there are no staff with dental training. Prior to Subira’s training, all patients with oral and dental problems were referred to the District Hospital which is more than 6 hours away by car. With transport in short supply and money scarce , this simply is not an option for most people. Word of Subira’s new skills has spread fast, in the last 3 months she has been able to treat 115 patients who all presented with sever oral pain.

Henry Schein Halas through the Henry Schein Cares Foundation believe that all people regardless of race, gender or social stance should have access to health care. We are therefore so happy to be supporting Bridge 2 Aid as they expand to include Australia. The good work they are doing makes a real difference to people’s lives. If you would like to volunteer or find out more about Bridge 2 Aid please visit their website www.bridge2aid.com.au or email volunteering@bridge2aid.com.au

Vol. 12 No. 3 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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Surgical soft tissue improvement in the course of implant therapy Daniel Bäumer1, Otto Zuhr2, Markus Hürzeler3 Abstract Soft tissue management has become a crucial part of implant therapy in the esthetic zone, as implant placement nowadays requires not only functional success, but also pleasing esthetic outcomes. New surgical techniques and materials provide clinicians with helpful tools that contribute to functional and esthetic success. More importantly, sophisticated clinical concepts are required to achieve the best possible result despite initially differing circumstances.

During therapy, there are different points in time when it is possible to improve soft tissue conditions: at tooth extraction, together with implant placement or at uncovering. In the case of tissue deficits, augmentations using autologous soft tissue can be performed in different ways, such as socket seal surgery, the modified roll flap procedure or incisionfree tunneling techniques. Often not just one of them, but also a combination also have to be used subsequently at the different treatment steps. Once the desired soft tissue shape is created, it needs to be transferred from the provisional to the final restoration in the prosthetic part of the treatment. This article gives an overview of a strategic approach from tooth extraction to implant impression.

Keywords: Soft tissue, esthetic zone, implant placement, implant uncoverage

Introduction

1

Dr. med. dent. Daniel Bäumer ITI Scholar at the University of Florida (William Martin).

2

Dr. med. dent. Otto Zuhr is in professional partnership with Markus Hürzeler. He is currently an Assistant Professor in the department of periodontology at the University of Frankfurt, Germany.

3

Prof. Dr. med. dent. Markus Hürzeler maintains a private practice specializing in periodontics and implant dentistry in Munich, Germany. He is a Clinical Associate Professor at the University of Freiburg, Germany and the University of Texas in Houston, USA.

When it comes to implant placement in the esthetic zone, clinicians are nowadays required to implement a lot of innovative aspects in their treatment concept and meet the standard of knowledge from tooth extraction to insertion of the final prosthetic solution. Thanks to new surgical techniques and improved materials much better results can be achieved nowadays to the benefit of the patient. This includes tissue-conserving extraction methods, scientifically documented methods for the preservation and augmentation of hard and soft tissues, the application of modern incision and suturing techniques as well as careful pre-implantation diagnostics (Bäumer et al. 2013).

In contrast to earlier times when a high survival rate was the focus, special attention is now paid to the esthetic outcome. This relates not only to the appearance of the prosthetic solution, but also to that of the peri-implant tissues. Because “red-and-white esthetics” strongly influence the way in which people perceive themselves and are perceived by others, the appearance of the teeth and peri-implant tissues must be equally weighted during treatment planning to successfully restore balanced dentofacial harmony (Chiche et al. 1994, Kokich et al. 1984, Magne & Belser 2002). One important part of the treatment, therefore, consists of addressing the soft tissues adequately: taking the parameters of the pink esthetic score (Furhauser et al. 2005) into account, the aim is to (1) achieve sufficient soft tissue volume, (2) an adequate vertical gingival level around the implant with complete interdental papillae and (3) a natural surface texture without scarring from surgical interventions. The peri-implant tissues are restored not only for esthetic reasons, but also to achieve the right functional properties: sufficient tissue is needed for long-term stability (Zuhr et al. 2014) and to improve peri-implant hygiene conditions.

The surgical techniques that are applied in order to achieve these goals should be as atraumatic as possible and avoid the creation of scars, which has led to the development of minimally invasive techniques. During the course of implant therapy,

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there are three different points in time when it is possible to improve the peri-implant soft tissue: at the time of tooth extraction, at implant placement or afterwards at implant uncoverage. The point chosen for soft tissue improvement depends on the extent of the soft tissue defect at the implant site, which should be evaluated at each treatment step.

Before implant placement Alveolar ridge preservation procedures can be very beneficial if, at the time of extraction, it is already certain that delayed implant placement will be performed at a later date. Many studies have confirmed the positive effect of socket preservation techniques on the preservation of the alveolar bone (Carmagnola et al. 2003, Fickl et al. 2008a, Fickl et al. 2008b). Besides augmentation in the socket with demineralized bovine bone material, suturing free epithelialized grafts into the socket in the manner of “socket seal surgery” can counteract later volume loss to a relevant extent and offers improved conditions at the subsequent surgical step. In this context, Jung et al. (Jung et al. 2004) described the “socket seal surgery” according to the method initally reported by Landsberg and Bichacho (Landsberg & Bichacho 1994), where the bone subsitute material was covered with a thick free mucosal graft harvested from the palate to prevent ridge resorption and to enhance bone regeneration. They reported that 6 to 8 weeks after surgery soft tissue healing was complete and a closed soft tissue cover with a thick and mature mucosa had formed over the former extraction socket. Although this method cannot completely compensate for the tissue shrinkage that occurs following tooth extraction, it optimally enhances the starting conditions for implantation by improving the ability to achieve primary wound closure and closed healing of the implant and possibly another graft. From a clinical perspective, supplementary filling of the extraction socket with bone subsitutute material does not appear to be necessary if it is known at the time of extraction that implantation will be delayed (6 to 8 weeks later).

Although it is easier to obtain a thick free mucosal graft, such as those used for socket seal surgery, than it is to harvest a subepithelial connective tissue graft, the conditions for survival of the free mucosal graft in the recipient bed are disproportionately less favorable. The parts of the graft with

epithelium in socket seal procedures are not covered by a flap with a blood supply but remain exposed to the oral cavity. Hence, the clinician must consider the factors important for graft survival when the graft is harvested as well as the factors relating to recipient site preparation. First, it is important to ensure that the “punch” is thick enough. The thicker the graft, the larger the wound surface areas accessible to diffusion and revascularization in the recipient bed following surgery. Because the palatal mucosa is thickest in the premolar region, it is advisable to harvest thick free mucosal grafts from this part of the palate. However, to avoid wound healing problems, it is crucial to ensure that periosteum is left on the bone. It is also important to harvest the graft congruent to the soft tissue opening of the extraction socket in order to minimize the distances to be covered by diffusion and revascularization. In this respect, the harvesting of slightly overextended grafts appears to have additional advantages in terms of optimal shape adaptation.

Standardized punches are not suitable for harvesting overextended grafts. Instead, the tissue should be harvested with a scalpel after the extraction socket has been precisely measured (Figs 1 - 5).

To avoid the need to harvest autologous tissue, xenogenous replacement materials were introduced to the market. These seem to enhance the wound healing process during the initial healing phase (Jung et al. 2013, Thoma et al. 2012), but their quality regarding the increase of tissue volume and their esthetic effect remain questionable.

The socket seal surgery is characterized by simple technical execution and relatively low surgical effort. Still, it

Figure 1: The socket is measured using a periodontal probe.

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Figure 2: An individualized punch is harvested from the anterior palate.

Figure 3: An overextended and rather thick graft is preferable to improve healing in the socket.

Figure 4: The graft contains epithelium and connective tissue.

Figure 5: It should fit with slight pressure in the recipient site.

comes with two relevant disadvantages: the use of thick connective tissue grafts from the palate to cover extraction sockets cannot completely compensate for the tissue defects that occur following tooth extraction (Fickl et al. 2008a, Fickl et al. 2008b). Besides this, although color blending of the grafts into natural surroundings appears to be acceptable from an esthetic point of view, the formation of scars (Fig. 6), which are almost impossible to be removed during the following treatment steps, is often observed.

with a tunneling technique (Figs 7 - 10).

If the buccal bone appears to be thinner than 1 mm or if fenestrations result on the buccal side of the implant at the time of implant placement (Fig. 11), more extensive surgery with combined hard and soft tissue augmentation is needed. Former methods were affected with high biologic and technical

During placement If soft tissue augmentation needs to be performed in the course of implant therapy, this is often done in the same surgical intervention when the implant itself is placed.

If the buccal lamella is intact and appears to have a thickness of at least 1 mm, soft tissue augmentation can be done in terms of ridge preservation in conjunction with immediate implants (Lang et al. 2012, Esposito et al. 2012).

In order to do so, a subepithelial connective tissue graft is sutured into a pouch on the buccal side, which is created

Figure 6: Unfortunately formation of scars is often observed.

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Figure 7: A pouch is created using a tunneling technique.

Figure 8: A subepithelial connective tissue graft is harvested from the palate using the single-incision technique.

Figure 9: The graft is placed into the pouch with the help of sutures.

Figure 10: The buccal contour is improved to counteract resorption.

complication rates: for horizontal and vertical augmentations using an ePTFE membrane (e.g. Gore-Tex®), failure rates of 25 to 40% had to be expected (Donos et al. 2008, Rocchietta et al. 2008).

This uncertainty about the treatment outcome was too high for daily practice, which led to the development of more reliable procedures (Hürzeler et al. 2009). An excellent method for performing horizontal hard tissue augmentation with simultaneous

implant insertion is the “modified double-layer technique”, especially at sites with comparatively small defects. It allows predictable horizontal alveolar ridge augmentation to be achieved using particulate autogenous bone grafts or xenogeneic bone substitutes with bioabsorbable barrier membranes (Fig. 12), provided that the body of the membrane is adequately supported and stabilized by a bone graft (von Arx & Buser 2006).

Figure 11: The implant is not covered by bone on the buccal side.

Figure 12: Bovine bone is covered by two collagen membranes (cross-linked & non-cross-linked).

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Figure 13: A soft tissue graft is used to increase tissue volume.

Figure 14: Even in the case of wound dehiscence, the soft tissue graft protects the underlying membranes.

This clinical concept includes many innovative elements: to provide the best-possible blood supply, a modified flap design is used. Instead of incisions close to the defect, a cshaped incision distal to the second premolar is made. A slightly palatal incision on the crest is performed at the implant site and intrasulcular incisions along the neighboring teeth. This avoids scar formation in the esthetically relevant area and postoperative pain is reduced by avoiding vertical incisions in the densely innervated frontal area. To gain access and mobility in the surgical area, a mucoperiostal/mucosal flap is prepared along the two teeth distal to the implant. If needed, a coronal sliding flap can be prepared from the palatal side, too, in order to cover the graft at the time of suturing (Tinti & Parma-Benfenati 1995).

The core idea of the technique is the combination of two different types of collagen membranes, which could have a synergistic effect: the defect and bone substitute material are covered with a slowly resorbing, cross-linked collagen barrier membrane, which is in turn covered with a second conventional, non-cross-linked collagen membrane. The objective of this approach is to compensate for the lack of dimensional stability and rapid resorption of the non-crosslinked collagen barrier membrane by combining it with a dimensionally stable and slowly resorbing collagen membrane. As non-crosslinked membranes allow very good integration into the tissue through their rough surface and show a low complication rate of only 10% (Blanco et al.

2005), this still takes advantage of the high biocompatibility, good tissue integration and excellent clinical handling of noncross-linked collagen membranes.

Simultaneous augmentation of peri-implant hard and soft tissues is performed to optimize the volume of both the hard and soft tissues. After placing the membranes over the implant and bone substitute, a free subepithelial soft tissue

graft from the anterior palate is added above them and sutured without tension on the inner surface of the buccal flap. The connective tissue graft is positioned so that it covers the alveolar ridge both buccally and below the incision line (Fig. 13). This ensures closed healing of the implant and augmentation site, even in cases of mild wound dehiscence (Fig. 14). Besides this protective effect it also creates additional soft tissue volume which is valuable at the time of implant uncoverage.

At uncoverage At second-stage implant uncovering surgery, 5 months after implant placement, the defect situation in the edentulous area is reassessed. Depending on the extent of the tissue present, three surgical procedures are possible.

If a buccal tissue deficit is no longer present, a minimally invasive individualized mucosal punch procedure can be used to uncover the implant. Standardized punches are again not the method of choice, and the tissue is removed manually with a scalpel so as to outline the emerging shape of the future crown (Fig. 15).

In the case of moderate tissue deficits at second-stage implant uncovering surgery, a modified roll flap technique without cutting the papillae can be used to compensate (Fig. 16) (Hurzeler et al. 2010). First, the soft tissue in the area above the implant is de-epithelialized. The tissue around the implant shoulder in the palatal and interproximal areas is then dissected via a horizontal incision extending to the bone. A buccal pedicle flap is elevated, exposing the implant. Next, microblades and tunneling knives are used to elevate and undermine a buccal partial-thickness flap. The incision must be extended laterally to the adjacent teeth to ensure sufficient flap mobility. The non-de-epithelialized interproximal soft tissues in the edentulous area are also

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Figure 15: If sufficient tissue is present, a simple individualized mucosal punch can be performed for uncoverage.

Figure 16: A roll flap is used to compensate moderate defects .

included in the incision until a soft tissue collar around the uncovered implant has been fully mobilized. The pedicle flap can now be rolled into the buccal pouch to compensate for the tissue deficit.

The presence of extensive tissue deficits when the implant

is uncovered makes it necessary to perform further soft tissue augmentation with a free subepithelial connective tissue graft obtained from the palate or tuberosity region. A conventional mucosal punch is placed, and a connective tissue graft is inserted into a buccal pouch created using a tunneling technique (Fig. 17). In many cases, a palatal island flap may also be needed to release tension on the interproximal soft tissue and to cover exposed bone palatal to the implant shoulder (Tinti & Parma-Benfenati 1995).

Regardless of the technique used to uncover the implant, an important step is to convert the extisting provisional restoration into an implant-supported provisional. Thus, an ideally contoured laboratory-fabricated provisional restoration can be placed immediately after implant uncovering. It is important to consider that any subsequent alterations to the contours of the provisional after soft tissue healing always results in a change in the peri-implant soft tissue contours. The emergence profile should therefore correspond largely to that of the definitive restoration. Ideally, the implant position should be transferred to a diagnostic cast

Figure 18: An intraoperative index shows the technician the position of the implant for fabrication of a provisional.

Figure 19: An individualized impression post can be used to copy the emergence profile created by the provisional.

Figure 17: When higher amounts of tissue are needed, a connective tissue graft can be placed using a tunneling technique and a palatal island flap.

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Figure 20: Schematic illustration of the possible grafting procedures at the different points in time.

at the time of implant placement using an intraoperative index (Fig. 18) (i.e., an impression post attached to the implant and splinted to the adjacent teeth using flowable composite).

If the implant is uncovered by simple tissue punch, fabrication of the final restoration can begin 3 months later. However, if implant exposure was achieved with the modfiied roll flap technique or an additional connective tissue graft, fabrication of the final restoration should be postponed for 5 months. In order to copy the shape of the provisional, it is helpful to use an individualized impression post (Fig. 19) (Rieder 1996).

Conclusion Effective surgical techniques for soft tissue management around implants in the esthetic zone have been developed and should be implemented in every clinician’s treatment spectrum. Depending on the extent of the soft tissue defect, peri-implant soft tissue can be improved at the different surgical steps. The need for augmentation should be analyzed before every intervention and it may also be necessary to augment soft tissue at multiple steps during the course of implant therapy so that the procedures are subsequently combined (Fig. 20).

References Bäumer, D., Zuhr, O., Hansen, K. & Hürzeler, M. (2013) Das Einzelzahnimplantat in der ästhetischen Zone Entwicklungen nach 20 Jahren. Implantologie 21, 7-16.

Blanco, J., Alonso, A. & Sanz, M. (2005) Long-term results and survival rate of implants treated with guided bone regeneration: a 5-year case series prospective study. Clinical Oral Implants Research 16, 294-301.

Carmagnola, D., Adriaens, P. & Berglundh, T. (2003)

Healing of human extraction sockets filled with Bio-Oss. Clinical Oral Implants Research 14, 137-143.

Chiche, G., Kokich, V. & Caudill, R. (1994) Diagnosis and treatment planning of esthetic problems. In: Chiche G. & Pinault A. (eds.) Esthetics in Fixed Prosthodontics, 33-52, Chicago IL: Quintessence Publishing Inc. Donos, N., Mardas, N. & Chadha, V. (2008) Clinical outcomes of implants following lateral bone augmentation: systematic assessment of available options (barrier membranes, bone grafts, split osteotomy). Journal of Clinical Periodontology 35, 173-202.

Esposito, M., Maghaireh, H., Grusovin, M. G., Ziounas, I. & Worthington, H. V. (2012) Soft tissue management for dental implants: what are the most effective techniques? A Cochrane systematic review. European Journal of Oral Implantology 5, 221-238.

Fickl, S., Zuhr, O., Wachtel, H., Bolz, W. & Huerzeler, M. B. (2008a) Hard tissue alterations after socket preservation: an experimental study in the beagle dog.

Clinical Oral Implants Research 19, 1111-1118.

Fickl, S., Zuhr, O., Wachtel, H., Stappert, C. F., Stein, J. M. & Hurzeler, M. B. (2008b) Dimensional changes of the alveolar ridge contour after different socket preservation techniques. Journal of Clinical Periodontology 35, 906-913.

Furhauser, R., Florescu, D., Benesch, T., Haas, R., Mailath, G. & Watzek, G. (2005) Evaluation of soft tissue around single-tooth implant crowns: the pink esthetic score. Clinical Oral Implants Research 16, 639-644. doi:10.1111/j.1600-0501.2005.01193.x.

Hürzeler, M., Thalmair, T., von Mohrenschildt, S. & Fickl, S. (2009) Double-layer technique for alveolar ridge augmentation: A case report. Practical Periodontics & Aesthetic Dentistry 21, 185-191.

Hurzeler, M. B., von Mohrenschildt, S. & Zuhr, O. (2010)

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Stage-two implant surgery in the esthetic zone: a new technique. International Journal of Periodontics and Restorative Dentistry 30, 187-193.

Jung, R. E., Philipp, A., Annen, B. M., Signorelli, L., Thoma, D. S., Hammerle, C. H., Attin, T. & Schmidlin, P. (2013) Radiographic evaluation of different techniques for ridge preservation after tooth extraction: a randomized controlled clinical trial. Journal of Clinical Periodontology 40, 90-98. doi:10.1111/jcpe.12027.

Jung, R. E., Siegenthaler, D. W. & Hammerle, C. H. (2004) Postextraction tissue management: a soft tissue punch technique. International Journal of Periodontics and Restorative Dentistry 24, 545-553.

Kokich, V. G., Nappen, D. L. & Shapiro, P. A. (1984) Gingival contour and clinical crown length: their effect on the esthetic appearance of maxillary anterior teeth. American Journal of Orthodontics 86, 89-94.

Landsberg, C. J. & Bichacho, N. (1994) A modified surgical/prosthetic approach for optimal single implant supported crown. Part I--The socket seal surgery. Practical Periodontics & Aesthetic Dentist 6, 11-17; quiz 19.

Lang, N. P., Pun, L., Lau, K. Y., Li, K. Y. & Wong, M. C. (2012) A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Clinical Oral Implants Research 23 Suppl 5, 39-66. doi:10.1111/j.1600-0501.2011.02372.x.

Magne, P. & Belser, U. (2002) Natural Esthetics. In: Magne, P. & Belser (eds.). Bonded Porcelain Restoration in the Anterior Dentition, Chicago IL. Quintessence Publishing Inc..

Rieder, C. E. (1996) Customized implant abutment

copings to achieve biologic, mechanical, and esthetic objectives. International Journal of Periodontics and Restorative Dentistry 16, 20-29.

Rocchietta, I., Fontana, F. & Simion, M. (2008) Clinical outcomes of vertical bone augmentation to enable dental implant placement: a systematic review. Journal of Clinical Periodontology 35, 203-215.

Thoma, D. S., Sancho-Puchades, M., Ettlin, D. A., Hammerle, C. H. & Jung, R. E. (2012) Impact of a collagen matrix on early healing, aesthetics and patient morbidity in oral mucosal wounds - a randomized study in humans.

Journal of Clinical Periodontology 39, 157-165. doi:10.1111/j.1600-051X.2011.01823.x.

Tinti, C. & Parma-Benfenati, S. (1995) Coronally positioned palatal sliding flap. International Journal of Periodontics and Restorative Dentistry 15, 298-310. von Arx, T. & Buser, D. (2006) Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: a clinical study with 42 patients. Clinical Oral Implants Research 17, 359-366.

Zuhr, O., Baumer, D. & Hurzeler, M. (2014) The addition of soft tissue replacement grafts in plastic periodontal and implant surgery: critical elements in design and execution.

Journal of Clinical Periodontology 41 Suppl 15, S123-142. doi:10.1111/jcpe.12185.

Reprinted with permission of the authors and the ITI International Team for Implantology from Forum Implantologicum, Volume 12/Issue 2/2016.

About the ITI The International Team for Implantology (ITI) is an academic association that unites professionals around the world from every field of implant dentistry and related disciplines. It actively promotes networking and exchange among its membership of currently more than 15,000.

In 37 years, the ITI has built a reputation for scientific rigor combined with concern for the welfare of patients. The organization focuses on the development of well-documented treatment guidelines backed by extensive clinical testing and the compilation of long-term results with the objective of continuously improving treatment methods and outcomes. The ITI funds research as well as Scholarships for young clinicians, organizes congresses and continuing education events, and runs more than 630 Study Clubs around the globe. The organization also publishes reference books such as the ITI Treatment Guide series and operates the ITI Online Academy, a peer-reviewed, evidence-based e-learning platform with a unique user-centric approach. www.iti.org

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CASE REPORT

VITA IMPLANT SOLUTIONS: the implant prosthetic restoration concept Andreas Kurbad1

For implant prosthetic crown reconstructions with VITA IMPLANT SOLUTIONS (IS) blanks (VITA Zahnfabrik, Bad Säckingen, Germany), there is a 3-step restoration concept. It begins with the implantation and leads to the final ceramic reconstruction via the temporary restoration for the optimization of the emergence profile. All blanks have an integrated interface to a titanium/adhesive base (e.g., Sirona TiBase, Bensheim, Germany) and enable an efficient restoration. Dr. Andreas Kurbad (Viersen-Dülken, Germany) explains the individual steps in a case report.

1. The patient case 20 years after the endodontic treatment of tooth 46, a 39-year-old patient had recurrent acute complaints. Mesial and distal periapical brightening in the X-ray showed evidence of bone resorption. After a root tip resection did not result in the desired therapeutic success, the tooth should be extracted in a manner that protects the bone. Because of the intact bone below the resection area, the gap was to be provided with an immediate guided implantation.

2. Prosthetic planning 1

Dr. Andreas Kurbad, Dentist, Viersen-Dülken, Germany.

VITA® and other VITA products mentioned are registered trademarks of VITA Zahnfabrik H. Rauter GmbH & Co. KG, Bad Säckingen, Germany.

The entire dentition was initially scanned with the CEREC Omnicam, and the crown was then designed and functionally optimized with the CEREC software V 4.4 (Sirona Dental, Bensheim, Germany). A plaster model etched for 46 was used to create an X-ray template. After a bone-protecting extraction, a DVT was created with the X-ray template used. The intraoral scan with crown planning was imported into the image data and virtually implanted with the Galaxis software (Sirona Dental, Bensheim, Germany). The data was used to grind an insert that converted the X-ray template into a drill template through perfect fitting.

Figure 1: Finding: Status after root tip resection 46.

Figure 2: Virtual implantation enables a guided drilling protocol.

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CASE REPORT

Figure 3: Status post implantation region 46.

Figure 4: Post-operative screwed-on scan body for the digital determination of the implant position.

Figure 5: The virtual design of the emergence profile stabilizes and shapes the gingival structures.

Figure 6: Virtual position of the abutment crown in the VITA CADTemp IS blank.

3. Gingival shaping

here for the sake of undisturbed healing. The blank was ground while keeping the interface in mind. After completion, the completed crown was adhesively fixed and VITA CADTemp IS blank integrated on the titanium base.

The drilling template made possible a positionally stable implantation with optimal use of the bone. Digital forming was performed with a scan post screwed on. A temporary abutment crown made of VITA CAD-Temp IS could be virtually designed to the exact implant position. The focus was on the formation and maintenance of the gingival structures. Occlusal and approximal interferences were still consistently avoided

Figure 7: The temporary abutment crown stabilizes and shapes the emergence profile.

4. Final restoration An ideal gingival emergence profile appeared after four months of the healing phase. The missing cement joint of the

Figure 8: Optimally shaped and inflammation-free soft tissue.

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KURBAD

Figure 9: Final abutment crown with occlusal and approximal contacts.

Figure 11: Closure of the screw channel of abutment crown 46 with composite.

Figure 10: Characterization of the ground restoration with VITA ENAMIC STAINS.

Figure 12: Red and white harmony following the integration of 46.

abutment crown contributed to the absence of inflammation.

After a new scan, the final abutment crown could be fabricated from "VITA ENAMIC IS". The dentine-like modulus of elasticity of the hybrid ceramic allows for the absorption of the chewing force, providing long-term relief of the bony

VITA CAD-Temp IS blank for the gingival shaping.

structures around the implant. After elaboration and individualization, the restoration is harmoniously integrated into the gingival structures and residual dentition. Immediate implantation and VITA IMPLANT SOLUTIONS (IS) have enabled an efficient treatment protocol.

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Remembering Armin Roth

Armin Roth, a much loved member of the dental community,

passed away on the 13th July 2017, just a day shy of his 81st

birthday. Armin’s 40 years of service in the industry laid the foundation that many of us enjoy today. Always proving to be a

true gentleman, Armin was well known and respected in the

industry. After his retirement from Henry Schein Halas, he went on to be awarded an Honorary Life Membership Award from The

Australian Dental Industry Association and continued to be a

much needed resource for the industry. People often referred to him as the ‘Godfather’ of

the dental industry with a memory like an elephant who rarely forgot a detail and could provide background on multiple subjects.

During Armin’s career with Halas Dental, which began in 1965, he has always been at the

forefront of change in assisting the Australian Dental Industry.

Armin represented the

industry on the ADA DIME committee for over 30 years which earned him an Award of Merit from the Federal ADA.

He was honoured as an Honorary Associate of the Faculty of

Dentistry of the University of Sydney and was later awarded an Honorary Fellowship of the Academy of Dentistry International.

On 20th July 2017, a memorial service for family and friends was held at the Concordia Club

in Sydney. If it wasn’t such a sad occasion it would have been fantastic reunion for all the faces of the dental industry. People not seen by the industry in years arrived to pay their

respects. Armin’s wife Elisabeth took the time to greet each person on arrival. The large

crowd also included many people from different organisations and clubs he had been

involved in over the years. Members of the Swiss Community shared many similar stories about Armin, proving that he touched people wherever he went.

Armin leaves behind, his loving wife Elisabeth, his children Dominik, Karolina, Caecilia and

Veronika, their partners Michelle, Hanspeter, Maclean and Dominic and 5 grandchildren Lucy, Zora, Anna, Arielle and Aurora

In the words of the late Martin Halas, “We take pride in offering better products for better dentistry”. We can only do this with people who make a difference.

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CLINICAL

Indispensable articaine Peter Raftery1

Introduction Dentistry is given a wide berth by Hollywood, and when it does feature it is generally related to ineffective local anaesthesia (LA). Painful dental treatment is so universally dreaded that the ability to deliver predictably successful dental LA can be the ultimate ‘practice builder’. The benefits of being effective with a syringe do not end there; failing to achieve sufficiently profound LA can be dispiriting (for operator as well as patient) and expensive. It is therefore of the utmost importance to be technically sound and wellinformed about LA. A busy GDP auditing his strike-rate reported that LA failures resulted in 10% of treatments being abandoned over a five day period.1 An informal assessment of my own LA performance confirmed to me that my struggles and prilocaine were related. “It works well in my hands” is a phrase I have often heard from colleagues when discussing prilocaine - just not in my hands then. Conversely, I very rarely miss with articaine and here at least I am in good company. Dentists looking for an evidence based product select articaine, shown to be a superior agent to lidocaine – itself previously labelled the ‘gold-standard’ agent.2,3 The selection of prilocaine is generally associated with those (dreaded) “allergic to adrenaline” patients.

Rather than true allergy, these patients will have had an unpleasant ‘pounding heart’ episode in the past that they do not wish to repeat. In all likelihood this would have been following a rare intravascular injection and probably involved a ‘market-leading ‘ lidocaine 2% preparation containing as it does a generous 1:80,000 dose of adrenaline. For this reason I have found such patients are generally amenable to trying the reduced-concentration adrenaline preparations of articaine (1:200 000) which are available and so far all of these have gone off without incident. For anyone unwilling to try this strategy there is always plain mepivacaine (a 3% preparation that is adrenaline free) which I have had acceptable outcomes with.

Market share and evidence

1

Peter Raftery, BDentSc, MSc, MFDS, MClinDent, MRD, MEndo Specialist Endodontist, Hampshhire, UK

Recent figures from Strategic Data Marketing show that lidocaine accounted for 57% of UK sales with articaine at 31% and mepivacaine and priolocaine accounting for much smaller shares (7% and 5% respectively).28 Articaine also occupies second position in dental LA sales in the USA with 40% of the market share. In Canada and Denmark articaine is the clear number one, 4,5 whilst in Germany, the dominance is overwhelming with 4% articaine preparations accounting for 96.7% of the market.6 The striking sales figures are supported by an evidence base. Randomised controlled trials (RCTs) - accepted as being among the best forms of evidence - have shown that 4% articaine preparations perform every bit as well as 2% lidocaine preparations for the traditionally taught injections (maxillary infiltrations and mandibular blocks - whether the pulps are healthy or inflamed).7-10 However, articaine is able to do what lidocaine cannot do in anesthetising mandibular teeth (incisors and molars)12 via a simple buccal infiltration. Buccal articaine is as effective as the traditional lidocaine block at anesthetising mandibuilar teeth with healthy13 and inflamed14 pulps and - most

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interestingly - it is the single best method for rescuing anaesthesia in cases of lower molars with ‘hot pulps’ where the lidocaine block has failed.15

Safety aspects All amide dental local anaesthetics (lidocaine, articaine, mepivacaine and prilocaine) are very safe but like all drugs; harm is possible from overdose. Attaining toxic drug blood levels relates to interplay between the dose administered and the rate of clearance from the body. Toxic effects, which are difficult to achieve over the course of a normal dental treatment appointment, manifest mainly in the cardiovascular and central nervous systems.

Dose administered The maximum recommended doses for lidocaine, articaine and prilocaine are similar, expressed here as maximum number of 2.2ml cartridges by bodyweight. The UK’s preeminent local anaesthetic expert - John Meechan - advises the following; • Lidocaine 2% preparations – the maximum dose is one cartridge per 7 kg bodyweight up to a maximum of 10 cartridges.

• Prilocaine 3% preparations – the maximum dose is 0.9 cartridges per 7 kg bodyweight up to a maximum of nine cartridges.

• Articaine 4% preparations – the maximum dose is 0.8 cartridges per 7kg bodyweight up to a maximum of eight cartridges.

A slow submucosal deposition makes for gradual drug release into the bloodstream whereas accidental IV administration rapidly elevates blood drug levels and so aspiration ought to be routine. Aspiration is easily done with Septodont’s UltraSafety Plus system. If using an alternative armamentarium it is imperative to check for ‘self-aspiration’ capability.

It is worth remembering that amides readily cross the blood-brain barrier and are able to reach the foetal circulation in pregnant women (no adverse effects reported in dental literature). It is unclear whether LA is excreted in breast milk and so it may be prudent for nursing mothers to avoid breastfeeding in the hours after LA use.

Rate of clearance Amide local anaesthetics are primarily metabolised (detoxified) in the liver and excreted via the kidneys in urine although articaine undergoes some additional early metabolism in the bloodstream because of some molecular

characteristics unique to it. This is a factor in making articaine’s half-life (measure of time for 50% reduction in blood level of the drug) the shortest by far. Liver and kidney function therefore play a significant role in drug elimination.

Patients with hypotension, or cirrhosis may struggle to metabolise amides giving rise to higher blood levels of drug and increased risks of toxicity. Likewise patients with renal impairment may risk toxicity through an inability to eliminate metabolites - some of them active - from the bloodstream.

Cardiovascular system Excessive blood concentration of LA depresses normal electrical excitability of the myocardium. The resultant decrease in myocardial contractility and decreased cardiac output both contribute to circulatory collapse.

Methemglobinaemia is a condition of respiratory depression in which circulating red blood cells no longer give up their oxygen to the tissues. Administration of excessive amounts of prilocaine can - in theory - predispose red blood cells to this non-functional state. Patients reaching such a state of respiratory distress, which do not respond to 100% oxygen therapy, are thought to have methemglobinaemia and require urgent hospital admission.

Central nervous system As blood concentrations of LA rise beyond the therapeutic range the effect on the CNS manifests as an initial drowsiness giving way to seizures. Circumoral tingling is said to be a precursor symptom.

Controversies Every dentist performing the traditional (Halstead) block technique will, irrespective of LA agent selected, unavoidably be risking a paraesthesia.16 Paraesthesia is altered sensation, often tingling, sometimes temporary but sometimes permanent, in an area supplied by the nerves16 (inferior alveolar or lingual) which run close to the target area for the needle tip required by the Halstead technique. Lingual nerve paraesthesias tends to be permanent and so seems to be the type reported more frequently.17 Paraesthesia is thankfully rare (estimated at one such incident per career of a full-time dentist16 or described elsewhere as one in every 785,000 blocks)18 so that at present (in the UK) these iatrogenic injuries are not considered to be negligent and warning of patients is not considered necessary.

Suspicion regarding paraesthesia and articaine were raised not long after its introduction to USA following early usage reports from Canada18 and later Denmark.18 It is

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interesting however to note that no solution is implicated more frequently in studies on paraesthesia than 2% lidocaine preparations.19-23 Failure to specifically implicate articaine with paraesthesia extends to the UK literature – most of which comes from the well-respected King’s College London professor Tara Renton.

Her studies19, 23-24 as well as others with UK involvement21 did not show any increased association for articaine.

Professor Brian Millar (also from King’s College London) coauthored a recent review paper on articaine which concluded that: “Articaine-induced paraesthesia after inferior alveolar nerve block is no longer a controversial issue and is no greater than for other local anaesthetics in use in the dental clinic.”25 This view was shared by the Pharmacovigilance Working Party of the European Union when in 2006 they reviewed the safety of articaine following publication of the concerning Denmark reports on paraesthesia. This review, described as the “most careful scientific analysis of the perceived ‘problem’ of articainerelated paraesthesia to date”, determined that no medical evidence exists to prohibit the use of articaine according to the current guidelines.26 For final clarity on this subject it is worth mentioning explicitly that ever since articaine’s introduction to the UK market 1999 the MRHA has licensed it for ‘any and all’ dental injections including inferior dental nerve blocks. UK dental indemnity firms ‘do not advise against’ articaine’s use for IDN blocks.27 If an association of paraesthesia with any one specific agent does not seem to hold then what is becoming apparent is that instances of permanent lingual nerve paraesthesia are associated with repeat IDN injections.23 An explanation for this may be deformation of the thin, bevelled leading edge of the LA needle point once it has struck the bony landmarks during the first IDN block. It is thought that reinsertion of this, now deformed, needle can predispose to tearing of the lingual nerve during the second injection. In any event, in light of the excellent results from buccal articaine13,15 it would seem that repeat IDN block injections ought to be strictly avoided.

Conclusion Because of its incredible clinical performance and safety profile I predict that the popularity of articaine 4% preparations in the UK is soon to soar to a Teutonic state of near complete market dominance. I have noted in recent times that the literature and mood from the profession is becoming less frantic about the issue of articaine and paraesthesia.

References 1 . Kaufman E, Weinstein P, Milgrom P. Difficulties in achieving local anaesthesia. J Am Dent Assoc. 1984 Feb;108(2):205-8.

2 . Katyal V. The efficacy and safety of articaine versus lignocaine in dental treatments: a meta-analysis. J Dent.

2010 Apr;38(4):307-17 3. Brandt RG, Anderson PF, McDonald NJ, Sohn W, Peters MC. The pulpal anesthetic efficacy of articaine versus lidocaine in dentistry: a meta-analysis. J Am Dent Assoc.

2011 May;142(5):493-504.

4. Malamed SF. Handbook of Local Anaesthesia 6th Edition. Elsevier 2014 .Chapter 4, p66 5. Hillerup S1, Jensen RH, Ersbøll BK. Trigeminal nerve injury associated with injection of local anesthetics: needle lesion or neurotoxicity? J Am Dent Assoc. 2011 May;142(5):531-9.

6 . Market data, GlaxoSmithKline, Germany.

7 Evans G, Nusstein J, Drum M, Reader A, Beck M. A prospective, randomized, double-blind comparison of articaine and lidocaine for maxillary infiltrations. J Endod.

2008 Apr;34(4):389-93.

8. Kanaa MD, Whitworth JM, Meechan JG. A comparison of the efficacy of 4% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:80,000 epinephrine in achieving pulpal anesthesia in maxillary teeth with irreversible pulpitis. J Endod. 2012 Mar;38(3):279-82.

9. Mikesell P, Nusstein J, Reader A, Beck M, Weaver J. A comparison of articaine and lidocaine for inferior alveolar nerve blocks. J Endod. 2005 Apr;31(4):265-70 10. Claffey E1, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of articaine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod. 2004 Aug;30(8):568-71.

11. Jaber A, Whitworth JM, Corbett IP, Al-Baqshi B, Kanaa MD, Meechan JG. The efficacy of infiltration anaesthesia for adult mandibular incisors: a randomised double-blind cross-over trial comparing articaine and lidocaine buccal and buccal plus lingual infiltrations. Br Dent J. 2010 Nov;209(9):E16.

12. Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomized double-blind crossover study. J Endod. 2006 Apr;32(4):296-8 13. Corbett I P, Kanaa MD, Whitworth JM, Meechan JG. Articaine infiltration for anesthesia of mandibular first molars.

J Endod. 2008 May;34(5):514-8 14. Poorni S, Veniashok B, Senthilkumar AD, Indira R,

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Ramachandran S. Anesthetic Efficacy of Four Percent Articaine for pulpal anesthesia by using inferior alveolar nerve block and buccal infiltration techniques in patients with irreversible pulpitis: A prospective randomized double-blind clinical trial.

J Endod.

2011 Dec;37(12):1603-7 15. Kanaa MD, Whitworth JM, Meechan JG. A prospective randomized trial of different supplementary local anesthetic techniques after failure of inferior alveolar nerve block in patients with irreversible pulpitis in mandibular teeth.

J Endod. 2012 Apr;38(4):421-5 16. Pogrel MA, Thamby S. Permanent nerve involvement resulting from inferior alveolar nerve blocks. J Am Dent Assoc.

2000 Jul;131(7):901-7.

17. Hillerup S, Jensen R. Nerve injury caused by mandibular block analgesia. Int J Oral Maxillofac Surg.

2006 May;35(5):437-43.

18. Haas DA, Lennon D. A 21 year retrospective study of reports of paresthesia following local anesthetic administration. J Can Dent Assoc. 1995 Apr;61(4):319-20, 323-6, 329-30.

19. Renton T, Janjua H, Gallagher JE, Dalgleish M, Yilmaz Z. UK dentists’ experience of iatrogenic trigeminal nerve injuries in relation to routine dental procedures: why, when

and how often? Br Dent J. 2013 Jun;214(12):633-42.

20. Pogrel MA, Bryan J, Regezi J. Nerve damage associated with inferior alveolar nerve blocks. J Am Dent Assoc. 1995 Aug;126(8):1150-5.

21. Malamed SF, Gagnon S, Leblanc D. Articaine hydrochloride: a study of the safety of a new amide local anaesthetic. J Am Dent Assoc. 2001 Feb;132(2):177-85.

22. Pogrel MA. Permanent nerve damage from inferior alveolar nerve blocks--an update to include articaine. J Calif Dent Assoc. 2007 Apr;35(4):271-3.

23. Renton T, Adey-Viscuso D, Meechan JG, Yilmaz Z. Trigeminal nerve injuries in relation to the local anaesthesia in mandibular injections. Br Dent J. 2010 Nov;209(9):E15.

24. Renton T. Prevention of iatrogenic inferior alveolar nerve Injuries in relation to dental procedures. Dent Update.

2010 Jul-Aug;37(6):350-2, 354-6, 358-60 25. Kakroudi SH, Mehta S, Millar BJ. Articaine Hydrochloride: is it the Solution? Dent Update. 2015 JanFeb;42(1):88-90, 92-3.

26. Malamed SF. Articaine versus lidocaine: the author responds. J Calif Dent Assoc. 2007 Jun;35(6):383-5.

27. Personal communication, (N Torlot), Dental Defence Union, 2015 28. SDM Data: UK Anaesthetics Market Q4 2014

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A conservative restorative smile makeover Aneta Grzesinska1

Introduction The patient was a 37-year-old female who presented to the practice requesting six porcelain veneers for her upper front teeth. Her chief complaint was loss of tooth tissue; she felt her teeth had become thin and brittle. Additionally, fillings on incisal margins of teeth UR1 and UL1 had chipped (Figures 1-4b).

The patient reported being examined and diagnosed in few other dental clinics and restoration of the upper incisors and canines was planned by her previous dentist. The dentist provided her with whitening trays and 10% carbamide peroxide gel (Pola Office), which she has been using for three weeks. She did not complain about any pain or sensitivity.

Histories and clinical findings

Dr Aneta Grzesinska PGCert Advanced Aesthetic Dentistry UCL Private practice, London, UK

1

The patient was in good general health, with no known allergies and taking no medication. She had, however, reported heavy vomiting during her three pregnancies.

Her dental history included regular attendance to the dental clinic, a recent course of home whitening with a 10% carbamide peroxide, multiple crown restorations in the past, and no pain or sensitivity in the past few years. The patient reported using a manual toothbrush, and occasionally using whitening toothpaste. She reported flossing one to two times per week, but no interdental brush use, and occasional mouthwash use.

On examination, it was noted that the patient had soft gingival tissues in a good condition. She had a high smile line/gummy smile but had a well-developed habit of hiding it. A diastema and chipped irregular incisal margins of the upper and lower front teeth were noted.

Enamel erosion on the palatal and interproximal surfaces of upper front teeth with dentine exposure (anterior clinical erosion [ACE] class III) was reported, as well as palatal and lingual surfaces of the upper and lower premolars (ACE class I) and lingual surfaces of the lower incisors were observed (ACE class III).

All molars except the lower wisdoms were restored with PBC crowns over 10 years previously, according to the patient, but which were not fitted properly, as metal margins were visible. The aesthetic look was altered by high opacity of the crown restorations.

Active carious lesions were diagnosed on the UL5, LL8 and LR8. The patient did not report any pain or sensitivity of these areas. The front upper incisors had chipped incisal margins and small discoloured fillings on interproximal areas. Her oral hygiene was fair – BPE 011/111, occlusion class I. No occlusal or functional issues appeared to be associated with either the anterior teeth or the occlusion as a whole.

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Figure 1: The patient complained that her teeth had lost thickness and shape

Figure 2: Maximum intercuspation

Figure 3a: Right smile

Figure 3b: Left smile

Figure 4a: Right view in maximum intercuspation

Figure 4b: Left intercuspation

A radiographic examination and vitality testing of the treatment-involved teeth indicated absence of pathology, recording the normal responses of healthy vital teeth. Tooth

Figure 3c: Front smile

view

in

maximum

Figure 5: Facebow record

UL6 and UL7 were suggested for root canal re-treatment and crown replacement. Alginate impressions were taken and face bow record for study models (Figure 5).

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6a

6b

6c

6d

6e

Diagnosis and treatment aims Diagnosis: ACE class III; enamel erosion as a main cause of thinning and chipping of the incisal margins of the front teeth together with loss of volume.

Treatment aims: treatment of carious lesions; improve appearance of upper teeth; diastema closure; protect exposed dentine; improve smile aesthetic.

A recommended treatment for patients with ACE class II is providing palatal composite restorations to preserve the tissue

Figures 6a-6e: Preparations. Showing the retracted gingival margin

(Vailati and Belser, 2010). The ideal treatment plan proposed consisted of: • Treatment of carious lesions • Crown lengthening in upper front teeth area to reduce gummy smile • Upper and lower old crowns replacement improving fit and aesthetic of restorations (after UL7 root canal retreatment) • Restoration of upper incisor, canines and UR4, UL4 and UL5 premolars, with porcelain veneers after restoration of palatal eroded surfaces of incisors and canines with composite.

The patient did not agree to any surgical procedures on her gingiva – she said that she can hide her gummy smile and it is not bothering her. She was also aware that her old crowns needed to be replaced in the near future, but for now she wanted only upper front teeth to be restored due to financial limitations.

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7a

7b

7c

Figures 7a-7c: Impressions

A compromised treatment plan was made, consisting of: • Treatment of carious lesions • Composite direct platforms on upper incisors and canines on palatal and incisal surfaces as a test drive for future restorations and protection of exposed dentine tested for at least four weeks • Porcelain veneers for teeth UR4-UR1 and UL1-UL4 and composite restoration with reshaping of buccal surface of UL5. To achieve desirable volume, eight veneers were planned instead of six, which was advised previously by the other dentist to avoid a hollow look of the smile.

Treatment Once treatment was fully consented, alginate impressions were taken to produce a wax-up for palatal veneers. Palatal veneers were placed directly during a two-hour appointment using a clear matrix (Elite Transparent, Zhermack) based on the wax-up.

No anaesthesia was provided during the appointment and

the patient felt very comfortable with the new restorations. A control appointment was scheduled for seven days’ time and occlusal contacts were evaluated. No chipping of the material was observed, and the patient did not have any discomfort.

The patient was going on holiday for three weeks, so another appointment was scheduled in three weeks’ time.

After three weeks, evaluation of the restorations was performed – no chipping was observed, and the patient was without any pain or sensitivity.

On the next appointment, carious lesions on the mesial surfaces of UL5, LL8, and LR8 were treated. Alginate impressions and face bow registration record using BluMousse was taken to produce a wax-up for the final restorations on the buccal area.

Based on the wax-up, a mock-up was tested. The patient was fairly satisfied with the design, although she requested more volume and length on the incisors. The incisors were re-shaped and minimal preparation was performed through

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Figure 8: The provisional restorations in situ

Figure 9: Retracted view of provisional restorations in situ

Figure 10: Provisional restorations right view

Figure 11: Provisional restorations left view

a mock-up, with almost no preparation on the buccal surface to preserve most of the enamel (Figures 6a-6e).

After immediate dentine sealing, an impression was taken with the single cord technique using 3M Espe Express heavy and light body. Two impressions were taken due to insufficient capturing of details (Figures 7a-7c). Provisionals were placed using a matrix based on the wax-up and crown and bridge acrylic temporary material shade A1, and then customised with Filtek A1B after silane and bond application (Figures 8-11).

A shade matching appointment was scheduled in the lab with an initial prescription. More volume was added according to patient request, and corrections of the incisal embrasures were completed.

Two days later, the patient returned for shape reassessment. Embrasures were corrected again and the volume was reassessed. The patient was very detailorientated and indecisive. After achieving a final satisfying

result, alginate impressions of the temporaries and photographs were taken to help the technician transfer the desirable shape to the final restorations (Figure 12).

In two weeks, an appointment for trying in final restorations and cementation was scheduled. Temporary veneers were removed with local anaesthesia – no chipping occurred during the two weeks. The gingival tissue was in very good condition, since the patient was advised to use Corsodyl mouthwash daily.

Veneers were tried in using Relyx try-in paste (translucent shade); a reassessment of dark triangles between teeth UR2, UR3, and UR1 was necessary. The patient also requested more translucency on the incisal margins, even though she did not want any translucency before when advised. The patient was provided temporary veneers and the restorations were sent back to the lab, together with the new instructions.

The final restorations were tried in after two days. The patient was very happy with the final result; she appreciated

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Figure 12: The restorations

Figure 14: The final restorations in situ

Figure 13: The final result

that the translucency advised before looked very natural (Figures 13 and 14). The veneers were freshly etched by the lab, so after cleaning off the try-in paste and decontamination with acetone, silane was applied.

Cementation was performed under local anaesthesia using Optragate, and bite block isolation, retracting cord (sutures) Teflon tape, silane, bond and Relyx veneer cement (translucent shade). The excess cement was cleaned initially using microbrushes and then with a surgical blade after polymerisation. Glycerine was applied and then the restorations were cured again for 10 seconds on the proximal areas, and gingival and palatal margins. Finally, the restorations were polished with porcelain polishers.

Postoperative RVG X-rays were taken to check for the cement residues, which were found on interproximals on teeth UR3 and UR2, and removed. The patient was scheduled for a control appointment in two days’ time. Alginate impressions for a Michigan splint and face bow record was taken. The

post-treatment instructions were as follows: • After fitting the splint, the patient was recalled every seven days for one month, and then after three weeks, six week, three months and six months • The patient was advised on daily oral hygiene maintenance (brushing, flossing daily, Tepe pink in the molar areas, Oral-B Enamel Erosion Shield toothpaste and regular visits to the hygienist, ideally every six months).

Tooth Mousse (GC) was advised once a week.

References Vailati F, Belser UC (2010) Classification and treatment of the anterior maxillary dentition affected by dental erosion: the ACE classification. Int J Periodontics Restorative Dent 30(6): 559-571 Reprinted with permission by Aesthetic Dentistry Today June 2017

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Dentinal bridge formation: clinical results after Biodentine™ removal Angelo Itri1 Introduction Vital Pulp Therapy (VPT) is a biologic and conservative treatment modality to preserve the vitality and function of the coronal or remaining radicular pulp tissue in vital permanent teeth (Akhlaghi et al. 2015). In this conservative therapy group there are: indirect pulp capping, direct pulp capping, miniature pulpotomy and full pulpotomy (Ghoddusi et al.

2014). When one of these therapy modalities are performed, the most important biological target is dentinal bridge formation. Dentinal Bridge is a new reaction tissue that preserves pulp vitality and protects it from abnormal and continuous physical stimuli (cold, hot, percussion); it is due to a series of inflammatory responses leading to the formation of a hard-calcified dentin. This tissue was observed for the first time after calcium hydroxide application on a pulp exposure; owing to a high pH (12,5) calcium hydroxide causes liquefaction necrosis of the superficial pulp, removing up to 1,5 mm of the inflamed tissue. This is followed by neutralization of toxicity in the deep layers with coagulative necrosis. Clinically, dentinal bridge formation is valued by Rx analysis where the pulp chamber is reduced after 3-6 months from VPT therapy.

The aim of this article is to demonstrate a real dentinal bridge formation after complete Biodentine™ removal.

Clinical Case

1

Angelo Itri, D.D.S. Private Practice, Genoa, Italy

A 29 year-old female patient with no systemic disease came to my office to restore 2.1 element where was a carious process on the mesial side (Fig. 1).

No spontaneous pain. Her dentist had made a conservative therapy two times in 4 months where the direct restoration had an incorrect adhesion. After a clinical analysis of Rx, cold, electric and percussion tests, a carious process close to the pulpal horn was detected (Fig.2 - 3).

After obtaining the patient’s consent, local anaesthesiawas performed (Articaine HCL 4% and 1:200000 adrenaline, Septanest, Septodont), the carious dentine was completely excavated and the pulp was exposed (fig 4-5-6-7).

A miniature pulpotomy by low speed handpiece was performed and Biodentine™ (Septodont) (Fig.8) was placed.

To improve hardness resistance a thin Equia Coat (GC) layer was applied on Biodentine™ restoration (Fig.9). Cold, Electric and Percussion Analysis were performed at 7,14,30,60,90, 180 and 360 days (table 1). After 360 days second restaurative step was performed (fig.10).

After obtaining the patient’s consent, local anaesthesia was performed (Articaine HCL 4% and 1:200000 adrenaline, Septanest, Septodont), and the Biodentine™ restoration was completely removed to observe dentinal bridge type formation (Fig.11). In this case a complete Biodentine™ removal was performed only to value real dentinal bridge formation; clinically this procedure is absolutely unnecessary to achieve clinical success.

A composite direct restoration (ASTERIA) was performed on 2.1 and 1.1 elements (fig.12a, 12b, 12c).

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Figure 1: Preoperative clinical photograph of carious process on 2.1 and 1.1.

Figure 3: Magnification: yellow line is the pulp chamber contour; red line is the cavity contour. It shows that the carious process is 1mm close to the pulpal horn.

Figure 2: Preoperative Rx of carious process on 2.1 and 1.1; the pulpal horn was very close to the carious process.

Figure 4: Preoperative clinical photograph.

The carious process looks very small and simple to achieve restorative success.

Figure 6: Pulpal exposure (palatal view).

Figure 5: A steel matrix protect element 1.1 during carious excavation. Presence of deep carious process under the initial cavity.

Figure 7: Pulpal exposure (occlusal view).

No apical suffering signs were detected (Fig.13) and clinical tests were normal (Table 1).

Discussion Clinical practice success on VPT procedure is made when no spontaneous pain is present. Dausch et al. (1952)

Figure 8: Biodentine™ in situ during VPT procedure.

demonstrated that, after a pulp amputation and calxyl application, clinical success was 98% while histologically only 76%. Dentinal bridge formation is an important Rx success parameter. In recent articles, dentine bridge formation was evaluated. Nowicka et al. (2015) performed on 44 third molars without carious process a voluntary pulp

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Table 1: Clinical tests Tooth 21

Electric

Cold

Persussion

pre op

17

+

-

7 days

17

++

-

14 days

11

++

-

30 days

18

++

-

60 days

10

++

-

90 days

10

+

-

180 days

15

+

-

360 days

15

+

-

Figure 9: Biodentine™ after equia coat layer application.

exposure and analysed dentinal bridge thickness and density after application of four types of materials. The results show that Biodentine™ and MTA resulted in the formation of bridges with a significantly higher average volume compared with Single Bond Universal.

Only The CBcT offers a correct volumetric Rx analysis of dentinal bridges, but in common practice a 2D evaluation had never been made. Dentinal Bridge is made of colliquative and/or liquefaction necrosis processes. This events create a hard tissue layer that protect the residual pulp tissue by chemical-physical stimulus. When a VPT is performed and a restoration is made, an empty space is present between a pulp capping material and a dentinal bridge caused by superficial pulp destruction (Franz et al.

1984). Dentine fragments, which are displaced into the pulp during cavity preparation, are acting as initial loci for mineralization or pulp stone formation (Mjor et al. 1991).

Angiogenesis is essential for pulp wound-healing process because blood vessels play an important role in nutrition and oxygen supply, as a conduct for transport of metabolic

waste, pulp homoeostasis and metabolism, and stem/progenitor cell migration (Nakashima et al. 2005). A correct material choice in VPT is very important to improve cells vitality. In recent research has been demonstrated that Biodentine™ caused a cytotoxic effect similar to MTA, suggesting that it may be considered an alternative in pulpcapping treatment (Poggio et al. 2015).

Dentinal Bridge formation time is 90 days (Hᴓrsted et al.

1981). In my clinical practice, in Rx analysis the dentinal bridge presence is clear after 180-360 days. This observation highlights that a dentinal bridge is one of the parameters of a VPT follow up, but the clinical waiting period observation is about 1 year.

Matsuo et al. (1996) demonstrated that dentinal bridge formation was not clearly detected in Rx analysis and in his study, he did not include reparative dentine formation as a criterion for success and observational period was more variable (3 to 24 months).

Hyper-sensitivity after VPT procedure has neverbeen present in a period of about 30-40 days.This characteristic

Figure 10: Biodentine™ after 13 months (palatal view).

Figure 11: Dentinal Bridge Formation after Biodentine™ removal.

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Figure 12: Dentinal Bridge Formation after Biodentine™ removal (Fig. 11 magnification).

Figure 12a, 12 b: Direct composite restoration of 2.1 and 1.1.

Figure 13: rx analysis post op.

is due to presence of theinflammation that is a prerequisite for tissuehealing and pulp regeneration (Goldberg et al.2015).

Conclusion VPT success in clinical practice depends onmany factors.

A correct material choice is helpfulto achieve pulp vitality and dentinal bridge formation after a pulp capping procedure.

References Hᴓrsted P, El Attar K, Langeland K. Capping of monkey pulps with Dycal and a Ca-eugenol cement. Oral Surg Oral Med Oral Pathol. 1981 Nov;52(5):531-53.

Figure 12c: Direct composite restoration of 2.1 and 1.1.).

Daush H, Sauerwein E. The effect of calxyl on the pulp tissue. Deutshe Zahnarztliche zeitschrift. 1952 Dec. Nowicka A, Wilk G, Lipski M, Kołecki J, BuczkowskaRadlińska J. Tomographic Evaluation of Reparative Dentin Formation after Direct Pulp Capping with Ca(OH)2, MTA, Biodentine™, and Dentin Bonding System in Human Teeth. J Endod. 2015 Aug;41(8):1234-40. doi: 10.1016/j.joen.2015.03.017. Epub 2015 May 29.

Franz FE, Holz J, Baume LJ. Ultrastructure (SEM) of dentine bridging in the human dental pulp. J Biol Buccale. 1984 Sep;12(3):239-46.

Akhlaghi N, Khademi A. Outcomes of vital pulp therapy in permanent teeth with different medicaments based on review of the literature. Dent Res J (Isfahan). 2015 SepOct;12(5):406-17.

Ghoddusi J, Forghani M, Parisay I. New approaches in vital pulp therapy in permanent teeth. Iran Endod J. 2014 Winter;9(1):15-22. Epub 2013 Dec 24.

Goldberg M, Njeh A, Uzunoglu E. Is Pulp Inflammation a Prerequisite for Pulp Healing and Regeneration? Mediators Inflamm. 2015;2015:347649. doi: 10.1155/2015/ 347649. Epub 2015 Oct 11.

Mjör IA, Dahl E, Cox CF. Healing of pulp exposures: an ultrastructural study. J Oral Pathol Med. 1991 Nov; 20(10):496-501.

Nakashima M, Akamine A. The application of tissue engineering to regeneration of pulp and dentin in endodontics. J Endod. 2005 Oct;31(10):711-8.

Poggio C, Ceci M, Dagna A, Beltrami R, Colombo M, Chiesa M. In vitro cytotoxicity evaluation of different pulp capping materials: a comparative study. Arh Hig Rada Toksikol. 2015 Sep 1;66(3):181-8. doi: 10.1515/aiht2015-66-2589.

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Single upper arch restoration using digital smile design Rory McEnhill1

The patient presented with a chipped UL6 that he wanted repaired. He was a very anxious patient who attended the dentist on a ‘needs must’ basis. Key clinical features included: • Decoronated LL6, retained root • Gingival recession upper posterior quadrants • Thick gingival biotype despite some volume loss • Generalised tooth wear and associated parafunction • Heavily restored dentition.

Care provided

1

Private Practice, Belfast, N. Ireland

This was a walk-in patient. He was a phobic patient who attended the dentist only when a problem needed a solution. He had fractured the LL6, most likely as a nonworking side interference. The tooth had been sensitive prior to the fracture, but now was less so that the tooth had broken. He was concerned that there would be issues relating to tooth decay if he didn’t get it fixed. In addition, he was complaining about the rough edge left on the tooth and this was irritating his tongue.

The tooth was quickly repaired with some composite, despite the fact that he needed a more definitive restoration such as a crown. During the course of this appointment, discussion centred on the tooth wear and the aetiology of the tooth wear was explained to the patient.

The patient was a school principal under a lot of pressure and he noticed that his problems were more common towards examination times. The patient was advised about what was required to prevent further unpredictability, ie, stabilisation splint, and this led to him wanting to know what could be done for his teeth.

The utility of digital smile design was discussed to assess what a patient’s potential ideal smile could look like. The patient was interested in this as he had been getting ever more disillusioned about his teeth in recent times, and decried them as ‘old man’s teeth’.

The digital smile templates came back and a trial mock-up was carried out. Photos were taken to compare to the before and the after. The results were remarkable and immediately the patient emotionally connected with what was possible. Happily, this case would be an additive case, meaning that very little preparation of his teeth would be required to achieve an aesthetic result.

A Dahl appliance was used to increase the occlusal vertical dimension. To supplement the upper porcelain veneers and crowns that were required, further bite stabilisation was required by the provision of implants in the lower left first molar positions. Further full coverage crowns were placed on the LL6, LR6 and LL5.

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Figure 1: Right lateral smile

Figure 2: Central smile

Figure 3: Left lateral smile

Figure 4: Right retracted view

Figure 5: Central retracted view

Figure 6: Left retracted view

Figure 7: Right close-up view

Figure 8: Central close-up view

Figure 9: Left close-up view

Pre-treatment radiography, diagnosis and treatment discussion Radiographs highlighted excellent bone health generally.

None of the upper or lower teeth had any periodontal or apical issues. A CT scan highlighted the bone quality at the implant sites. Diagnosis was as follows: 1. General tooth wear 2. Soft tissue recession 3. Missing LL6 and LR5 4. Loss of aesthetics.

The patient had very low expectations and was just happy that he could be seen compassionately and if his function and aesthetics could be improved then he

would be very happy. The treatment objectives were as follows: • Digital smile design • Porcelain veneers/crowns/bridge for UL6-UR6, LL5-LL7, and LR5-LR6 • Implant for LL6.

This patient was initially a difficult patient to treat due to his phobia and would require IV sedation to do anything dentally. Once he had seen his digital smile design mockup, he was able to visualise the final result and he became emotionally connected to the treatment.

The following aspects were considered and the following options for treatment were outlined to the patient:

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Figure 10: Full face view – initial presentation

Figure 11: Digital smile design planning

Figure 12: Digital smile design mock-up

1. Place fill/crown UL6 and provide a stabilisation splint full time, or 2. Porcelain veneers/crowns UL6-UR6, lower crowns LL5, LL7 and LR6, porcelain bridge LR5 and LR6 3. Implant placements on LL6 4. Maxillary soft tissue grafting to reposition the soft tissue.

The patient confirmed his desire to go for options one, two and three. The patient appreciated that the soft tissue grafting is an important part of the treatment plan, but now was not the correct time for him to do this. He was content that the margins of the posterior restorations would be left at the cemento-enamel junction. As his smile line was favourable, this was not a problem aesthetically either.

Treatment progression At the first surgical stage, the UL6 was repaired with composite, and an informal consultation and discussion regarding the patient’s hopes and expectations took place.

A discussion about the use of digital smile design to digitally plan the ideal smile for the patient took place.

The patient returned and had digital design smile photos taken, as well as digital scans of the occlusal surfaces. Using these, milled models were created and restorative templates were made for the mouth. The patient returned and the templates were filled with Protemp acrylic and placed over the patient’s teeth. Photos were taken of the temporary result and then a slide show of the before and after photographs

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Figure 13: Digital smile design mock-up

were shown to the patient. This provided a very tangible idea of what the final result could look like.

From this mock-up, the patient made an emotional connection and committed to getting the upper 12 teeth restored, whilst also restoring his missing and poorly restored lower posterior teeth. Further impressions were taken, and in addition, a face bow registration was sent to the lab to fabricate a definitive wax-up, and as before a restorative template was made.

The LL6 was removed and the inflammatory tissue curetted and the site left to heal and mature for three months.

Figure 14: Digital smile design mock-up

This case was to be carried out in a re-organised fashion. A

composite Dahl appliance was placed on the upper left to upper right canine using the wax-up and a palatal step to allow axial loading on each tooth.

This allowed posterior disclusion, while also giving the patient a trial run with the aesthetics that we could potentially have from the final restorations.

After two months, the posterior overeruption and anterior intrusion was sufficient to commence the porcelain work.

The posterior amalgams were removed and new composite restorations placed. The UL5 porcelain crown was replaced with an acrylic crown. Following the new composite restoration placements, an equilibration was carried out to ensure coincidence of centric relation and centric occlusion.

Figure 15: Right lateral smile

Figure 16: Left lateral smile

Composite restorations

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Figure 17: Right retracted view

Figure 18: Central retracted view

Figure 19: Left retracted view

Figure 20: Rght retracted close-up

Implant placement

with the smile line. This was confirmed as the patient did not need anaesthetic due to the minimal preparation of the veneers. Rubber dam was applied and floss ligatures were used to keep the dam in position. The veneers were cemented with Nexus light cure clear cement, the excess removed and polished.

At the same appointment, the UL5, UL6, LL5, LL7 E.max porcelain crowns, the UL4 E.max veneer and the LL6 screwretained Anyridge implant restorations were prepared and impressions taken. These were returned from the lab, tried in and the occlusion confirmed and finally bonded with Nexus dual cure clear for the crowns, and Nexus light cure for the UL4 veneer. The LL6 implant crown was torqued into position and the access cavity filled with Teflon tape and composite.

The remaining upper and lower right quadrants were prepared for a mixture of E.max crowns on the UR6 and LR7, and a cantilevered bridge on the LR5 and LR6. This site was originally earmarked for bone grafting and implantation, of which the patient had second thoughts and decided that for financial, surgical and emotional reasons that he would

An implant was placed in the LL6 position – a 4x11.5mm Megagen Anyridge implant. A sulcus former was placed at the time of placement. An ISQ reading was taken and this was over 70, suggesting that a rapid restoration of this site would be possible.

Restoration provisions The digital smile design highlighted that all the restorations would be mostly additive and consequently the veneer preparations would be very conservative. The wax-up template was then filled with acrylic and the veneers were prepared using the Galip Gürel veneer technique.

The upper canine to canine were prepared for porcelain veneers. The temporary anterior restorations with the introduced canine guidance were photographed in a full-face photo and a rubber impression taken to allow the lab to fabricate an incisal guidance table. A1 was chosen for this case.

The E.max veneers were returned and tried in with try-in paste and the photo confirmed that they were in harmony

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Figure 21: Central retracted close-up

Figure 22: Left retracted close-up

prefer to go with the cantilevered bridge.

Due to the fact that the LR6 needed to be crowned and also due to the balanced, managed occlusion, a cantilevered bridge was deemed to be an effective implant alternative in the circumstances. The UL4 and UL5 were prepared for E.max veneers. Upon receipt of the final restorations, these were tried in and the aesthetics and occlusion confirmed and the veneers bonded with Nexus light cure clear, whilst the crowns and bridge were bonded with Nexus dual cure clear.

result at the finish is very rewarding. This case was possible principally due to the power of digital smile design. The patient was a very anxious and phobic patient and he only attended the dentist when in pain or discomfort. For him to consider undergoing all the demanding treatments that were required, shows how much of an emotional connection he was able to make with the proposed treatment.

To be able to directly visualise an ideal smile in your mouth, in real time, provides a wonderfully emotive treatment planning tool for the dentist. It allows the clinician to change the patient’s point of value and be able to assess why it is worth spending the money required to create a beautiful smile. In addition, it allows the patient to feel in control of the situation, as ultimately it is they who are making the final call on the aesthetics before any operative treatment begins.

The Galip Gürel veneer preparation technique allows us to be as conservative as possible when providing porcelain veneers. The requisite amount of tooth substance is removed to facilitate the veneer provision. In this case, due to the additive nature of the treatment, the whole process was a very conservative one and at no point did the patient have any sensitivity.

The Dahl appliance used in this case is a very useful tool in allowing us to provide reorganised dentistry without having to crown every tooth in a patient’s mouth. There is always a concern when using the Dahl technique that the posterior teeth do not re-establish occlusal contact.

However, a study by Gough and Setchell (1999) highlighted that 96% of posterior teeth re-establish occlusal contact. In addition, the fact that we were replacing the posterior restorations prior to crown provision afforded us extra security.

With regard to the final aesthetics, the author feels that the

Review and ongoing maintenance The patient returned two weeks later and the hygiene, the occlusion and the aesthetics were critically assessed. The patient was very happy with the final result. Impressions were taken to fabricate a Tanner splint that was fitted subsequently.

This was adjusted over the course of a number of review appointments. The patient uses this every night as an insurance policy. He was informed of the importance of maintaining gingival health and was advised to attend with his hygienist bi-annually.

The treatment was very successful on a number of fronts.

The patient’s phobia disappeared as he became a very positive patient. His confidence levels improved immeasurably as he was extremely happy with the appearance of his teeth, as well as the security of his more solid bite. The case was very successful in aesthetic considerations, as his smile has broadened considerably, the smile line is more ideal and the final result highly attractive.

Reflection This case was very enjoyable. To be able to deal with the functional issues definitively and provide a beautiful aesthetic

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References

Figure 23: Full face view

final result is a very natural one. The incisal edges of the teeth mimic the lower labial curve for nicely.

The subtle graduation in colours in the restorations with incisal edge translucency accentuates the result. Most importantly, a nervous patient regained his confidence and has become a model patient who attends regularly for preventive reasons, rather than interventions.

As a number of the upper restorations have supragingival margins, this provides a better bond to the veneer as the vast majority of the bonding is to enamel. The patient is aware that to achieve better health and aesthetics that connective tissue grafting would be ideal to bulk up and reposition the soft tissue in these deficient areas.

The patient is aware that the bulk of the problems related to his grinding and the subsequent abfraction cavities that developed as a result, leading to the soft tissue recession.

This problem has been managed by developing canine guidance and also the provision of a tanner splint at night time. The patient has a favourable smile line and does not show the supragingival margins.

Atash, R, Van Den Abbeele, A (2005) Strengths of eight contemporary adhesives to enamel and to dentine: an in vitro study on bovine primary teeth. Int J Paediat Denti 15(4): 264273 Coachman C, Van Dooren E, Gürel G, Landsberg CJ, Calamita MA, Bichacho N (2012) Smile design: From digital treatment planning to clinical reality. In: Cohen M (ed) Interdisciplinary Treatment Planning. Vol 2: Comprehensive Case Studies. Chicago: Quintessence: 119-1174 Dahl BL, Krogstad, O (1975) An alternative treatment in cases with advance localised attrition. J Oral Rehabil 2(3): 209-214 Dawson PE (2007) Functional Occlusion: From TMJ to Smile Design. St Louis: Mosby Dube, C (2004) Quantitative polygraphic controlled study on efficacy and safety of oral splint devices in tooth-grinding subjects. J Dent Res 83(5): 398-403 Gough MB, Setchell, DJ (1999) A retrospective study of 50 treatments using an appliance to produce localised occlusal space by relative axial tooth movement. Br Dent J 187(3): 134139 Gürel G (2011) The Science and Art of Porcelain Laminate Veneers. Chicago: Quintessence Kern M, Wolfart S (2011) Ten year results of 3- unit bridges made of monolithic lithium disilicate. University Clinic Schleswig-Holstein, Kiel, Germany Magne P, Belser U (2002) Bonded porcelain restorations in the anterior dentition: a biomimetic approach. Chicago: Quintessence Paradella TC, Fava M (2007) Bond strengths of adhesive systems to human tooth enamel. Braz Oral Res 21(1): 4-9 Ritter AV (2005) Direct resin-based composites: current recommendations for optimal clinical results. Compend Contin Educ Dent 26(7): 481 Ritter RG (2010) Multifunctional uses of a novel ceramiclithium disilicate. J Esthet Restor Dent 22(5): 332-341 Rufenacht CR (1990) Fundamentals of Esthetics. Chicago: Quintessence Steiner M, Sasse M, Kern M (2011) Fracture resistance of all-ceramic crown systems. Christian Albrechts University, Kiel, Germany Van der Zaag J (2005) Controlled assessment of the efficacy of occlusal stabilisation splints on sleep bruxism. J Orofac Pain 19 (2): 151-158

Reprinted with permission by Aesthetic Dentistry Today June 2017

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CASE REPORT

Mechanically-retained facial prosthesis for a large defect following Cancrum Oris: a clinical report Avish J. Jagathpal,1 Ashana Harryparsad,2 Rajesh Doolabh3 and Benjamin F. Calitz4 Abstract Retention is of critical importance in the satisfactory performance of a large maxillofacial prosthesis. Large defects often lack sufficient undercut to allow prostheses to be self-retentive. External modifications of the prosthesis are often required to provide an acceptable result. Clinical history: A 10-year-old male presented with a large facial defect and gross scarring following radical ablative surgery in treatment of cancrum oris. The intention of treatment was to restore esthetics to the patient using a removable facial prosthesis until the patient is old enough to receive an implant retained prosthesis. Methods: Due to the patient's age and nature of the defect, the prospective size and weight of the prosthesis required the use of mechanical retention that could not be achieved with conventional retentive methodology. An acrylic framework was manufactured as a substructure for the silicon prosthesis. Elastic-retained spectacles were luted via a custom screw-retained chrome-cobalt nose pad. To stabilize the inferior border of the prosthesis, a clear soft thermoplastic polyurethane brassiere strap was threaded through the chin cup and connected to the spectacle strap. This provided the prosthesis with adequate resistance to vertical displacement. Conclusion: The patient’s appearance was enhanced, enabling early rehabilitation and psychosocial reintegration until a more rigid, implant based prosthesis becomes a viable treatment option. Rapid facial growth is expected over the years to follow and regular maintenance visits will be required.

Introduction

1

BDS, PDD, Graduate student, Department of Prosthodontics, School of Dentistry, University of Pretoria, Pretoria, South Africa

2

Consultant, Department of Prosthodontics, School of Dentistry, University of Pretoria, Pretoria, South Africa

3

Graduate student, Department of Prosthodontics, School of Dentistry, University of Pretoria, Pretoria, South Africa

4

BTech, Dental technician, DuraArt Dental Laboratory, Pretoria, South Africa

Trauma, congenital malformation, and ablative surgery may result in large facial defects that cannot be surgically restored. Such defects lead to aesthetic, functional, and phonetic insufficiencies.1 These are associated with severe psychological strain, often giving rise to alteration in a patient’s self-esteem, emotional stability, personality, and social interaction.2 A facial prosthesis, whether provisional or definitive, therefore enables an environment that is conducive to better function, aesthetics and social reintegration.3 Rehabilitation of such defects however, presents a unique challenge for the restoring maxillofacial prosthodontist. The typical result is that the inferior base of a prospective prosthesis typically rests on movable tissue.4 When coupled with the lack of sufficient undercut, the inevitable consequence is the inability of the prosthesis to be self-retentive.5 Retention is of critical importance in the satisfactory performance of a maxillofacial prosthesis. It aids to enhance aesthetics, comfort, function, adaptation, and the concealing of the prosthesis. Extrinsic retention is typically attained via secondary mechanical factors, skin adhesives and implants (magnets, ball or bar attachments).6 The use of adhesives in large facial defects is limited as it may irritate the supporting tissues, may not withstand the prosthesis weight, and causes deliquescence of the adhesive material when exposed to moisture.

Modifications to overcome difficulties are often required to provide an acceptable result. This requires certain innovative methodology as outlined in this article and techniques that can be extrapolated to treatment of patients with similar defects.

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CASE REPORT

Fig. 1: Frontal profile photo of the patient 2 years following treatment of cancrum oris. Note severe facial scarring and the union of external and internal facial structures.

Fig. 2: Left profile photo depicting severe loss of facial prominence due to loss of the nasal cartilage, premaxilla, anterior mandible and associated labial tissue.

Clinical report A 10-year-old male was referred to the post-graduate prosthodontic clinic of the University of Pretoria Oral and Dental Hospital, South Africa, for prosthetic assessment and management. The patient presented with a large facial defect and gross scarring following radical ablative surgery 2 years prior, for the treatment of Cancrum Oris (Noma) (Fig. 1, 2 and 3). Clinical and radiographic evaluations were carried out. Clinical examination revealed that extensive fibrosis was present as a consequence of the resection, resulting in a maximum mouth opening of 1mm. The exposed oral and nasal mucosa were dry and tender to palpation.

Despite the gross extent of scarring, the patient was phonetically functional, and was able to compress most foods against his palate using the tongue, as a form of mastication.

A three-dimensional cone beam computerized tomographic evaluation (Planmeca, ProMax3D Max) of the patient revealed a resection of the pre-maxilla, ranging from tooth 13 to 24, and alveolectomy of the left anterior mandible. Developing tooth buds were present in the distal segments of both the maxilla and mandible. Limited retained secondary dentition was evident in the anterior segments.

The treatment aim was to achieve closure of the defect, and attain concurrent re-establishment of an aesthetic profile.

Attempts at retention of the prosthesis were expected to be challenging; due to the age of the patient, implant retained prostheses were contra-indicated. Furthermore, financial constraints and the expected weight of the prosthesis as a consequence of size precluded the use of dermal adhesives

Fig. 3: Right profile of the patient.

in aiding retention. As an alternative, eyeglass frames have historically proven helpful in providing mechanical retention and concealing prostheses. To improve mechanical stability of a large prosthesis, elastic strips are often placed around the back of the head to join both ends of the eyeglass frames.3 It was therefore decided to utilize a spectacle-aided retention method with reinforcing elastics to stabilize the superior and inferior aspects of the prosthesis onto the patient’s face.

Treatment sequence The initial phases of the construction followed conventional maxillofacial impression protocols. The nasal cavity was packed with cotton wool and lined with petroleum jelly (Vaseline Jelly, Original) to prevent nasal aspiration of the primary impression material. The patient was taught to breathe through a high-volume evacuator tip (Dochem, Evacuator tips, 1A5151 vented “S” white) placed between his palate and tongue, and was further instructed to close his eyes and not make any facial movements during the impression taking procedure. A dam-technique was used to acquire a full facial impression; bands of periphery wax (Kemdent, white periphery wax) were linked together and adapted to the border of the intended impression. Pink modelling wax (Zeta, Tenawax) was moulded and attached to this periphery to form the dam walls. Bite registration material (Heraeus, Flexitime) was injected onto the periphery wax to create a seal against the patient’s skin and prevent the impression material from leaking beyond the dam as seen in figure 4.

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AV I S H E T A L

Figure 4: Fabrication of an impression-dam to retain the flowable alginate impression material. Note the high-volume evacuator tip retained between the patient’s tongue and residual hard palate to act as a breathing apparatus during the impression taking procedure.

The nasal aperture has been blocked out with cotton wool.

Figure 5: Wax try-in of the sculpted prosthesis

Regular set alginate (Dentsply, Blueprint 20+) was mixed to a high-flow consistency and poured into the dam, and reinforced with pieces of wooden tongue blades (Astra Med, tongue depressor) incorporated into the impression material.

The primary cast was poured in hard dental stone (Wiegelmann Dental, Bondur M yellow), and a light-cured acrylic (Willman and Pein, GmbH Plaque photo) special tray was fabricated based on this impression.

At the secondary impression stage, the patient was again instructed on the procedure and breathing exercises were practiced using the high-volume evacuator tip. Cotton wool was again packed into the nasal cavity to prevent material aspiration and petroleum jelly was used as a separator over structures that could be incorporated into the impression, such as eyebrows and eyelashes. Impressions were taken using a polyether impression material (3M ESPE Impregum Penta) in the custom tray, and a master cast was poured in die stone (Velmix, Whip Mix - Resin rock). The advantage of this technique is that all facial landmarks are present on the casts, which enable the ideal sculpting of prosthetic structures in anatomically correct positions without the need for the patient being present for repeated trials.

A wax try-in was sculpted in pink modelling wax on the master cast in co-ordination with respective facial landmarks.

The initial try-in of the wax-up (Fig. 5) was performed where rapid alterations of the facial contours were made using modelling clay (Staedtler, Noris Club Modelling Clay), which

provided good stability while adhering to the wax pattern.

The wax try-in was adjusted and a second try in was performed. A satisfactory marginal fit and suitable aesthetic profile were acquired. The skin shade and tone were determined using a colour chart. As the position of the spectacle frame could only be verified at chair-side, a template of the nasal bridge was created using silicone putty (Zhermack, Zetalabor 85 Shore A). With the template, the correct position of the exposed acrylic spots for luting could be determined, by transferring it to the plaster cast.

A polymethyl methacrylate (PMMA) substructure was constructed in high-impact acrylic (Vertex, Castavaria) to reinforce the silicone and prevent excessive flexure of the prosthesis. As PMMA has limited adherence chemically and mechanically with platinum cured silicones, the substructure was exposed along the prosthetic nasal bridge to allow for the luting process of the spectacles. Acrylic denture teeth (Ivoclar, Ivostar, shade A2, mould 01) were further luted to the substructure to provide a more aesthetic appearance of the facial prosthesis. Once the substructure was complete, processing of the silicone was initiated.

Special care had to be taken not to include any residues of latex (gloves), sulphur (silicone based impression materials), tin (Impression paste catalyst) or acetate (Cyanoacrylate glue) during the multiple treatment stages.

This was done to ensure that no contamination of the silicone had occurred during the curing process.

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AV I S H E T A L

Figure 6: Eyeglass frames (Tomato Glasses, TKAC3) with custom chrome-cobalt nose pad designed to be luted to the acrylic substructure of the prosthesis

Figure 7: Completed facial prosthesis. Note the patent nasal and oral orifices to allow breathing through the prosthesis.

Figure 8: Frontal profile of the patient with the facial prosthesis in place.

Figure 9: Left lateral profile of the completed prosthesis in situ.

The eyeglass frames and brassiere strap link together posterior to the auricle via a discrete hook to provide resistance of the prosthesis to vertical displacement.

The size of the prosthesis prevented conventional flasking processes, and custom plaster split-moulds were created. The silicone (Technovent, M511 Platinum cured silicone) of the prosthesis was coloured intrinsically, using polychromatic pigments (Technovent, intrinsic silicone pigment). Following final fabrication of the prosthesis, the spectacle framework (Tomato Glasses, TKAC3) attached to a custom chromecobalt nose pad (Fig. 6) was luted to the exposed sub-structure via using cold cure PMMA. Final extrinsic staining (Technovent, extrinsic pigment) was performed and treated with a sealant. The nasal apertures and mouth were perforated in accordance with the acrylic substructure to allow the patient to breathe through the prosthesis.

To prevent movement of the inferior border of the prosthesis, a transparent soft thermoplastic polyurethane

brassiere strap (MRP, SKU1702710001001) was threaded through the chin cup anteriorly and connected to the spectacle strap posteriorly, as seen in figures 7 and 8.

Adequate retention was achieved and a satisfactory seal was established on the prosthesis boundary (Fig. 8 and 9).

Rapid facial growth is expected over the years to follow and regular maintenance visits will be required. The brassiere straps and spectacle elastics were selected for their adjustable nature and can allow interim alterations between replacements. This is expected to be done at 2-year intervals until the patient is old enough to receive an implant retained prosthesis. Regular follow up will entail exploring improvement of the patient’s mouth opening and the further possibility of restoring his dentition and masticatory function.

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AV I S H E T A L

Discussion Due to the gross amount of extraoral scarring, the patient’s mouth opening was limited to 1mm and masticatory efforts were accomplished using pressure of the patient’s tongue against his palate. It was deduced that minimal mobility of the extraoral tissue would be present and that a full-facial prosthesis may be constructed to restore aesthetics to the patient. The primary concern during the process of treatment planning however, was retention. Typically, eyeglass frames used in maxillofacial prosthetics rely on the presence of ears and a nose-bridge for support. However, this effect is compromised, and in some cases, negated in patients having undergone surgical removal of either of these anatomical structures.5 Furthermore, this form of support suspends the prosthesis from the supero-lateral aspects, providing resistance in the vertical plane from these two points only.4 In these instances, clinicians consequently make use of adhesives to retain parts of the prosthesis albeit to a less effective result. The weight and span of the prosthesis in this specific patient rendered the use of adhesives inadequate.

Alternative methods or retention were therefore approached until the child is of the age to receive an implant retained prosthesis, as skeletal growth is a less-understood variable when implants are used in children.7 The procedure described exhibits an effective alternative means of retaining a large facial prosthesis where retention would otherwise be severely compromised.

The incorporation of the brassiere straps effectively reduced movement of the inferior aspect and provided even load distribution along the support structures incorporated into the prosthesis. The tension on the prosthesis can also be attuned via the adjustable straps to maintain close approximation to the tissues as the child grows. In the South African context, a holistic view needs to be taken and factors such as finance, distance to reach treatment centres, and maintenance of prostheses need to be factored into a treatment plan. It is for

this reason that a multidisciplinary team approach is needed to ensure appropriate care is given.

Conclusion The crucial role of facial features in daily interpersonal relationships is easily appreciated. In most societies, personal attractiveness plays an integral role in a patient’s self-esteem.2 With a rudimentary extra-oral prosthesis retained by glasses and a facial strap, the patient’s appearance was enhanced, enabling early rehabilitation and allowing psychosocial reintegration until a more rigid, implant based prosthesis becomes a viable treatment option.

References 1. Goiato MC. Patient satisfaction with maxillofacial prosthesis. Literature review. J Plast Reconstr Aesthet Surg.

2009;62:175-80 2. Hatamleh MM, Watson J, Srinivasan D. Closed-eye orbital prosthesis: A clinical report. J Prosthet Dent.

2015;113:246 - 9.

3. Fonseca EPF. The Importance of form, characterization and retention in facial prosthesis. J Prosthet Dent.

1966;16:338 - 43.

4. Tautin FS, Schoemann D. Retaining a large facial prosthesis. J Prosthet Dent. 1975;34:342 - 5.

5. Parr RP. Accessory retention for a facial prosthesis. J Prosthet Dent. 1979;41:546 - 7 6. Ajay O, Gilsa KV, Nidhin R. Nasal Prosthesis - A case report. J Med Dent Sci. 2014;13:113 - 6.

7. Percinoto C, de Mello Vieira AE, Barbieri CM, Melhado FL, Moreira KS. Use of dental implants in children: A literature review. Quintessence Int. 2001;32:381 – 3

Acknowledgements The authors thank Henk du Plessis (Dura Art Dental Laboratory) for their materials and Mrs Celisha Singh (Vision Hub Optometry) for sponsorship of spectacles.

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