Class IV restoration with direct composite resin: A case study utilising the layering-stratification technique with a novel composite system
Maurizio Bossù
Pulpotomy procedures using Biodentine™ in an immature permanent tooth and in a deciduous tooth
Wynand P. Dreyer and Andre W van Zyl Burning Mouth Syndrome
Corneliu Gherasim
Intentional replantation
Alan Yap
Performance and practicality with a lightcure, resin cement
Louis Mackenzie
Silver diamine fluoride: a practical guide
Edward Li
Restorative: ceramic smile makeover
Falk Schwendicke
Root caries: challenges and recommendations
Jasmina Bijelic-Donova, Clara Anton Y Otero, Pekka K. Vallittu, and Ivo Krejci
A surface-retained glass fiber-reinforced bridge with a CAD/CAM-fabricated pontic
Arti Hindocha
Using mandibular advancement devices for OSA
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Class IV restoration with direct composite resin: A case study utilising the layering-stratification technique with a novel composite system
Anthony Mak and Andrew Chio
Pulpotomy procedures using Biodentine™ in an immature permanent tooth and in a deciduous tooth
Maurizio Bossù
Burning Mouth Syndrome
Wynand P. Dreyer and Andre W van Zyl
Intentional replantation
Corneliu Gherasim
Performance and practicality with a light-cure, resin cement
Alan Yap
Silver diamine fluoride: a practical guide
Louis Mackenzie
Restorative: ceramic smile makeover
Edward Li
Root caries: challenges and recommendations
Falk Schwendicke
A surface-retained glass fiber-reinforced bridge with a CAD/CAM-fabricated pontic
Jasmina Bijelic-Donova, Clara Anton Y Otero, Pekka K. Vallittu, and Ivo Krejci
Using
Arti Hindocha
Henry Schein Australia supports YWAM Medical Ship Dental Outreach
Vol. 19 No. 2 ISSN 2071-7962
Henry Schein Australia announced its continued support for the YWAM MS School Dental Programme, to provide dental services, training opportunities, and health education to primary and secondary schools in the National Capital District in Papua New Guinea. Henry Schein donated consumable products to support the mission that took place from 19 May to 1 June 2024 at Sevese Morea Elementary/Primary School, Kila Kila Secondary School, and Carr Memorial Adventist School. Two more outreaches are scheduled in the third and fourth quarters of 2024.
“For more than 12 years, Henry Schein Australia has been supporting the YWAM Medical Ship in its efforts to help improve the oral health and wellbeing of young children through dental wellness,” said Mike Covey, Henry Schein Vice President – APAC Region and Managing Director, Australia. “We are committed to helping close the gap of health care inequities by working with organisations that support communities in need, and our mission of ‘helping health happen’ is exemplified through our continued partnership with YWAM.”
During the most recent outreach, more than 640 students received oral health assessments out of which more than 500 students received dental treatment. More than 270 teeth needed to be extracted, more than 560 to be restored.
In addition, oral health and nutrition education was held for more than 3,200 attendees, with oral health kits containing toothbrushes and toothpaste distributed to the children. These education sessions are an integral part of the outreach and aim to empower the students to care for the own oral and overall health.
Another important goal is to build capacity in the dental professionals of Papua New Guinea and to provide collegial support between the international and the local dentist. Over the course of this school dental programme outreach period, four dental residents, four oral health therapy residents, and three dental assistants from NCD PHA Dental Services, Port Moresby, participated in the programme for one week each.
This initiative is just one example of the work of Henry Schein Cares, the company’s global corporate citizenship programme, which aims to drive change through five pillars: catalysing health care access; advancing policies, solutions, and innovation; relationship building for change; empowering Team Schein; and sustaining the planet. The purpose is to drive this positive change through the engagement of the company’s constituencies to help make the world healthier. By adhering to these pillars, Henry Schein is committed to “doing well, by doing good” and recognises the importance of being accountable to the five constituencies that make up the company’s Mosaic of Success — customers, suppliers, Team Schein Members, shareholders, and society at large.
If you have any questions about Henry Schein Cares and other projects we are involved in, please email scheincares@henryschein.com.au
PUBLISHING EDITOR
Ursula Jenkins
EDITOR
Dr Andre W van Zyl
ASSOCIATE EDITORS
Prof Cecilia Goracci
Prof Simone Grandini
EDITOR-IN-CHIEF EMERITUS
Prof Dr Marco Ferrari
EDITORIAL REVIEW BOARD
Prof Paul V Abbott
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 Roberto Giorgetti
Dr Johan Hartshorne
Dr Patrick J Henry
Prof Dr Reinhard Hickel
Dr Sascha A Jovanovic
Dr Gerard Kugel
Prof Ian Meyers
Prof Maria Fidela de Lima Navarro
Prof Hien Ngo
Dr Hani Ounsi
Prof Antonella Polimeni
Prof Eric Reynolds
Prof Andre P Saadoun
Prof Errol Stein
Prof Lawrence Stephen
Prof Zrinka Tarle
Prof Franklin R Tay
Prof Manuel Toledano
Dr Bernard Touati
Prof Martin Vorster
Prof Peet van der Vyver
Dr Martin Vorster
Prof Laurence Walsh
Prof Fernando Zarone
International Dentistry - Australasian Edition is published by Modern Dentistry Media CC, 50 Pineslope Gardens, The Straight, Pineslopes 2194, South Africa
No editorial matter published in International Dentistry - Australasian Edition may be reproduced in any form or language without the written permission of the publishers. While every effort is made to ensure accurate reproduction, the authors, publishers and their employees or agents shall not be held responsible or in any way liable for errors, omissions or inaccuracies in the publication whether arising from negligence or otherwise or for any consequence arising therefrom.
Class IV restoration with direct composite resin: A case study utilising the layering-stratification technique with a novel composite system
Anthony Mak1 and Andrew Chio2
1 Dr Anthony Mak, BDS (USyd), Grad Dip Clin Dent (Oral Implants) (USyd), Private Practice, Sydney, Australia, focusing on comprehensive and implant dentistry.
2 Dr. Andrew Chio, BDSc. (Melb.) Private Practice, Melbourne, Australia
The concept of layering or stratification of direct composite restorations utilises the combination of optical properties from the different resin layers with the aim of emulating the natural colour, characteristics and translucency of the natural dentition. Progressive improvements in composite resin technologies have led to the simplification of this treatment procedure that is commonly perceived as complex. However, difficulties exist in mimicking the remaining tooth structure when restoring teeth in the anterior segment of the dentition because of the variety of shades, chroma, and translucency levels of many current composite resin systems.
The G-ænial A’CHORD represents the evolution of the highly successful G-ænial system that has been utilised in dental practices throughout the world for the past 10 years. Compared to its predecessor, the G-ænial A’CHORD system provides an upgrade from the original G-ænial system in the following aspects:
• Beautiful and harmonious under any light with a natural fluorescence.
• Optimal handling properties allowing for the material to be easily sculpted with conventional composite manipulation instruments or brushed with restorative brushes.
• The Full-Coverage Silane Coating (FSC) technology that covers the nano-fillers with silane coupling agent leads to high polish and gloss with only a few steps.
• The incorporation of additional opaque and enamel shades allows an infinite range of opacity and value possibilities.
• Simplification with 5 CORE shades which covers all 16 Vita shades.
CLINICAL
Case Report
The following case study demonstrates the use of the G-ænial A’CHORD (GC Europe) direct composite system in the restoration of a complex class IV in a 22-year old female patient. The patient presented to the practice relaying her dissatisfaction of an existing restoration on her upper left central incisor (FDI tooth 21). She requested its replacement with a new restoration that was conservative and “invisible” when she smiled or engaged in normal conversation. She also relayed that the existing class IV restoration had been done 4 times by her previous dentist without an outcome or result that was satisfactory to her.
Clinical examination revealed a high smile-line with a symmetrical and aesthetic gingival architecture. The existing composite restoration on the tooth 21, while clinically acceptable, did not integrate with the shade of the tooth and to the other teeth in her dentition. The discolouration and minor ledging on the disto-labial aspect of the existing restoration also indicated the likelihood of marginal leakage in the region.
The pre-operative colour assessment showed that the upper left central incisor (21) was slightly more chromatic than the adjacent upper right central incisor (11). The upper left central incisor (21) also exhibited a very slight labial displacement in its alignment compared to the adjacent right central incisor (11).
The patient’s health history was unremarkable.
Radiographic and periodontal examination showed that the tooth 21 demonstrated no pathology or issues requiring intervention prior to the commencement of the restoration. The 21 exhibited a normal response when the vitality was thermally tested.
The treatment options were discussed with the patient and the advantages and disadvantages of each of the options were carefully identified. The options presented were:
1) A single reductive ceramic veneer on tooth 21.
2) A full surface composite veneer on tooth 21. The patient was advised that due to the slight labial displacement of tooth 21, a very small labial reduction would be required to allow the space to mask the chromatic dentine.
3) A conservative complex class IV on the tooth 21 to be completed additively to minimise any preparation and reduction of the natural tooth structure.
She preferred the conservative approach to her treatment involving an additive protocol (option 3). She relayed that she would be happy with a harmonious composite restoration on tooth 21 and did not feel that the slightly chromatic upper left central (21) would be an aesthetic concern for her.
From the clinician’s perspective, final plan and goal of the treatment was to restore the tooth 21 with a durable and long-lasting conservative direct composite restoration with a final result that is biomimetic with optimal aesthetic and morphological integration with her existing natural dentition.
Step by step
Prior to the commencement of the restorative process, diagnostic images and the selection of the estimated shade was completed. Diagnostic impressions were also taken to allow the fabrication of silicone palatal stent or matrix that would facilitate the three-dimensional blueprint for the layering of the composite increments.
Figure 1: Pre-Operative unretracted view illustrating the unaesthetic and failing direct composite restoration on the upper left central incisor (tooth 21).
Figure 2: Pre-Operative Retracted a) with regular flash b) with Polarized filter.
Figure 3 : The working field was isolated with the use of the rubber dam. The existing restoration and caries was removed and a 2 mm bevel prepared on the labial margin of the preparation to facilitate the aesthetic and functional integration of the restoration to the remaining natural tooth structure.
Figure 5: The palatal stent was trimmed and tried-in to verify the fit of the silicone matrix and to ensure the absence of any interferences to its seating from the rubber dam and clamps.
Figure 7: The adhesive procedure commenced with the with the cavity selectively etched with 37% phosphoric acid gel Ultra-Etch (Ultradent). The etching gel was rinsed away and the adhesive protocol was completed by the application of a universal bonding agent, G-Premio BOND (GC Europe). The universal bonding agent was then air dried for 5 seconds with maximum air pressure and light-cured for 10 seconds according to the manufacturer’s instructions.
Figure 9: The interproximal wall was then completed utilising the same semi-translucent enamel shade, G-ænial A’CHORD shade JE (GC Europe). The interproximal wall was formed with the use of a plastic myeloid strip and pull through technique to help developing an anatomical contour.
Figure 4: The bevel was prepared and finished with a tapered diamond bur (Komet 6862.314.012 and 8862.314.012). All the transition angles of the cavity were rounded with an oval or eggshaped polishing diamond bur (Komet 8379.314.023). The burs form part of the “Dr Anthony Mak Custom C&B Selection” Kit from Komet Dental.
Figure 6: The cavity was lightly air abraded with a 29-micron aluminium oxide powder AquaCare (Velopex) prior to the adhesive procedure and Teflon (PTFE) tape was utilised to prevent the inadvertent bonding to the adjacent teeth.
Figure 8: Following the adhesive protocol, a thin layer of semitranslucent enamel, G-ænial A’CHORD shade JE (GC Europe), was used to create the palatal shell.
Figure 10: The dentine layer was then completed by the application of an opaque shade, G-ænial A’CHORD shade AO2 (GC Europe). This increment was shaped to emulate the extensions of natural dentine core morphology and was extended just slightly short the prepared bevel. The dentine or opaque shade provides the correct opacity to the final restoration.
Figure 11: A chromatic body shade, G-ænial A’CHORD shade A2 (GC Europe) was then applied and extended beyond the bevel to mask the transition line. Internal anatomy (i.e. mamelons) in the incisal third was also sculped and formed in this increment of composite resin.
Figure 13: A final translucent shade of G-ænial A’CHORD shade JE (GC Europe) was then layered to bring the anatomy to full contour and to achieve a natural optical blending effect.
Figure 14 a, b: Glycerine gel was then applied over the buccal surface of the restoration and light-cured to maximise the polymerisation of the layered direct composite restoration due to the absence of the oxygen-inhibition layer.
Figure 15: The restoration was then polished and finished to incorporate the primary, secondary and tertiary anatomy with the aim to produce a life-like restoration that mirrored the adjacent right central incisor (tooth 11).
Figure 12: White tints, Essentia White Modifier (WM) (GC Europe) was utilised to accentuate the mamelons and to replicate the similar characteristics and features present in the adjacent right central incisor (tooth 11). Comparisons to the polarised diagnostic images taken prior to commencement of the restoration provided a reference for the incorporation of these internal features.
Figure 16: The polishing and finishing protocol employed the use of abrasive discs (Soflex; 3M-ESPE), polishing diamond burs (Komet), followed a graded sequence of silicone polishers and finishers (Astropol; Ivoclar-Vivadent). The restoration was then completed using a Diapolisher paste (GC Europe) on a felt-buff (Flexi-Buff; Cosmedent Inc) to recreate the gloss of natural enamel.
Conclusion
While developments in single shaded universal composite systems for the anterior dentition continue to improve and advance layering techniques for the placement of a truly
aesthetic anterior direct composite restoration will always be necessary in the contemporary aesthetic dental practice. This is due to the intrinsic anatomy of the natural tooth where the emulation of the optical and morphological properties cannot
14a)
14b)
Figure 17: Immediate post-operative (Unretracted). The finished and polished G-ænial A’CHORD (GC Europe) restoration demonstrates the morphological and optical aesthetic integration of the completed restoration to the existing natural dentition.
Figure 18: Immediate post-operative (Retracted) a) regular flash b) polarised filter
Figure 19: 2-week review demonstrating the complete optical and functional G-ænial A’CHORD restoration on the tooth 21.
Figure 20: 2-week review demonstrating the complete optical and functional G-ænial A’CHORD on the tooth 21.
be achieved by a single mass of restorative material. The G-ænial A’CHORD (GC Europe) composite system has a simplified approach to the shading/layering process while providing a final
result that is truly biomimetic, aesthetic and long-lasting.
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Pulpotomy procedures using Biodentine™ in an immature permanent tooth and in a deciduous tooth
Maurizio Bossù1
1 Maurizio Bossù,
DDS, PhD, Associate Professor, Department of Oral and Maxillofacial Science, “Sapienza” University of Rome, Rome,
Italy
Introduction: Calcium silicate-based cements have demonstrated remarkable clinical outcomes, and, among others, Biodentine™ may be considered a valid option in the treatment of primary and permanent teeth and a promising material to be applied in different area of endodontics.
Methods: Two cases of vital pulp therapy in a deciduous and an immature permanent tooth have been reported. Pulpotomy procedures were performed using Biodentine™ as pulp dressing material in both cases. Clinical and radiographical follow-up were performed until 1-year post-treatment.
Discussion: Biodentine™ demonstrated a 100% success rate in both reported cases showing to be more than suitable as pulpotomy material. Specifically, in case of immature permanent tooth, apexogenesis was appreciated.
Conclusion: Biodentine™ demonstrated a great induction of new hard tissue formation and may be considered a valid choice in vital pulp therapy.
Introduction
Calcium silicate-based cements have demonstrated remarkable outcomes mainly in endodontics and have resulted in predictable, safe, and successful therapies.1-3 These cements are considered as unique ceramic compounds capable to react with water forming a solid mass. 4 Among others, Biodentine™ demonstrates a greater resistance to compression and flexion than other tricalcium silicate-based cements, as well as sealing properties, bonding strength, and a great release of calcium ions. 5-7 In addition, Biodentine™ shows better results when compared to MTA in terms of handling, reduced setting time, and color stability, caused by the absence of bismuth oxide.8
Due to these reasons, Biodentine™ can be considered a valid option in the treatment of primary and permanent teeth and a promising material that can be applied in different area of endodontics. 9 Among others, vital pulp therapy provides favorable clinical survival results over time, allowing maintenance of vitality of primary teeth until their natural exfoliation as well as apexogenesis in immature permanent ones10
Case report
Case 1: cariously exposed immature permanent tooth
A deep carious lesions involving the mandibular first molar (3.6) was observed in a female patient aged 6 years, as previously reported by Bossù et al.1 The dental element presented immature root formation and reversible pulpitis. Vital pulp therapy was carried out to allow apexogenesis. Briefly, after local anesthesia and rubber dam isolation, the caries was removed and the pulp tissue was exposed. Coronal
involving the mandibular observed in a female patient previously reported by Bossù element presented immature reversible pulpitis. Vital pulp to allow apexogenesis. anesthesia and rubber dam was removed and the exposed. Coronal pulp was high-speed diamond bur under Hemostasis was achieved pellets moisturized within 5 minutes. Then, prepared according to instructions and placed stumps with a thickness restoration with resin performed after 3 days, once was clinically appreciated Periapical radiographs immediately after pulpotomy (Figure 1a), then the and radiographically 1b), 3 (Figure 1c), and
involving the mandibular observed in a female patient previously reported by Bossù element presented immature reversible pulpitis. Vital pulp to allow apexogenesis. anesthesia and rubber dam was removed and the exposed. Coronal pulp was high-speed diamond bur under Hemostasis was achieved pellets moisturized within 5 minutes. Then, prepared according to instructions and placed stumps with a thickness restoration with resin performed after 3 days, once was clinically appreciated Periapical radiographs immediately after pulpotomy (Figure 1a), then the and radiographically 1b), 3 (Figure 1c), and
Clinical evaluation revealed an absence of pain, discomfort, swelling or in ammation at every time point, reporting a success rate of 100%.
The absence of pulp reaction was further con rmed by the radiographic assessment, as demonstrated by the progressive formation of the dental roots, closure of the apical foramina as well as the increase of root walls thickness.
Clinical evaluation revealed an absence of pain, discomfort, swelling or in ammation at every time point, reporting a success rate of 100%. The absence of pulp reaction was further con rmed by the radiographic assessment, as demonstrated by the progressive formation of the dental roots, closure of the apical foramina as well as the increase of root walls thickness.
immediately after vital pulp
formation of the dental roots could be observed over time with an absence of periapical reaction.
Progressive formation of the dental roots could be observed over time with an absence of periapical reaction.
b. at 1 month; c. at 3 months; d. at 1 year of follow-up. Progressive formation of the dental roots could be observed over time with an absence of periapical reaction. 29
pulp was amputated by high-speed diamond bur under abundant irrigation. Hemostasis was achieved using sterile cotton pellets moisturized with saline solution within 5 minutes. Then, Biodentine™ was prepared according to the manufacturer’s instructions and placed on radicular pulp stumps with a thickness of 2-4 mm. Definitive restoration with resin composite was performed after 3 days, once the cement hardening was clinically appreciated by a dental probe. Periapical radiographs were obtained immediately after pulpotomy procedures (baseline) (Figure 1a), then the element was clinically and radiographically evaluated after 1 (Figure 1b), 3 (Figure 1c), and 12 months (Figure 1d).
Clinical evaluation revealed an absence of pain, discomfort, swelling or inflammation at every time point, reporting a success rate of 100%. The absence of pulp reaction was further confirmed by the radiographic assessment, as demonstrated by the progressive formation of the dental roots, closure of the apical foramina as well as the increase of root walls thickness.
Case 2: cariously exposed deciduous tooth
A deep carious lesions involving the mandibular second deciduous molar (8.5) was observed in a male patient aged 5 years. The dental element presented reversible pulpitis, therefore vital pulp therapy was carried out. Briefly, after local anesthesia and rubber dam isolation, the caries
was removed and the pulp tissue was exposed. Coronal pulp was amputated by high-speed diamond bur under abundant irrigation. Hemostasis was achieved using sterile cotton pellets moisturized with saline solution within 5 minutes. Then, Biodentine™ was prepared according to the manufacturer’s instructions and placed on radicular pulp stumps with a thickness of 2-4 mm. Definitive restoration with resin composite was performed after 3 days, once the cement hardening was clinically appreciated by a dental probe. Periapical radiographs were obtained immediately after pulpotomy procedures (baseline) (Figure 2a), then the element was clinically and radiographically evaluated after 1- (Figure 2b), 6- (Figure 2c), and 12-months (Figure 2d).
Clinical evaluation revealed absence of pain, discomfort, swelling or in ammation at every time points. Radiographically, absence of periapical reactions was appreciated. The overall success rate at 12-month follow-up was 100%.
Discussion
The reported clinical cases showed that Biodentine™ yielded successful clinical and radiographical outcomes when applied in vital pulp therapy of immature permanent tooth and primary tooth, respectively. After 1 year of followup, it might be speculated that apexogenesis, as the
Fig. 1: Periapical radiographs of the dental element (3.6) treated with Biodentine™. a.
therapy (Baseline);
Fig. 1: Periapical radiographs of the dental element (3.6) treated with Biodentine™. a. immediately after vital pulp therapy (Baseline); b. at 1 month; c. at 3 months; d. at 1 year of follow-up.
Fig. 1: Periapical radiographs of the dental element (3.6) treated with Biodentine™. a. immediately after vital pulp therapy (Baseline); b. at 1 month; c. at 3 months; d. at 1 year of follow-up. Progressive
local anesthesia and rubber dam isolation, the caries was removed and the pulp tissue was exposed. Coronal pulp was amputated by highspeed diamond bur under abundant irrigation. Hemostasis was achieved using sterile cotton pellets moisturized with saline solution within 5 minutes. Then, Biodentine™ was prepared according to the manufacturer’s instructions and placed on radicular pulp stumps with a thickness of 2-4 mm. De nitive restoration with resin composite was performed after 3 days,
radiographically evaluated after 1 (Figure 2b), 6 (Figure 2c), and 12 months (Figure 2d)
Clinical evaluation revealed absence of pain, discomfort, swelling or in ammation at every time points. Radiographically, absence of periapical reactions was appreciated.
The overall success rate at 12-month follow-up was 100%.
Fig. 2: Periapical radiographs of the dental element (8.5) treated with Biodentine™. a. immediately after vital pulp therapy (Baseline); b. at 1 month; c. at 6 months; d. at 1 year of follow-up. Absence of periapical reactions can be observed at all evaluated time points.
Discussion
continued physiologic development and formation of the root’s apex,11 was obtained.
The present report clinically confirmed the excellent features of Biodentine™ as good biocompatibility and promotion of mineralized dentinal tissue deposition1
Conclusion
4. Primus CM, Tay FR, Niu LN. Bioactive tri/dicalcium silicate cements for treatment of pulpal and periapical tissues. Acta Biomater. 2019 Sep 15;96:35-54.
The reported clinical cases showed that Biodentine™ yielded successful clinical and radiographical outcomes when applied in vital pulp therapy of immature permanent tooth and primary tooth, respectively. After 1 year of follow-up, it might be speculated that apexogenesis, as the continued physiologic
Biodentine™ demonstrated a great induction of new hard tissue formation and may be considered a valid choice in vital pulp therapy of primary as well as immature permanent teeth.
References
Conclusion
1. Bossù M, Mancini P, Bruni E, Uccelletti D, Preziosi A, Rulli M, Relucenti M, Donfrancesco O, Iaculli F, Di Giorgio G, Matassa R, Salucci A, Polimeni A. Biocompatibility and antibiofilm properties of calcium silicate-based cements: an in vitro evaluation and report of two clinical cases. Biology (Basel) 2021;10:470.
Biodentine™ demonstrated a great induction of new hard tissue formation and may be
3. Bossù M, Iaculli F, di Giorgio G, Salucci A, Polimeni A, di Carlo S. Different pulp dressing materials for the pulpotomy of primary teeth: A systematic review of the literature. J Clin Med 2020;9, 838.
development and formation of the root’s apex [11], was obtained.
5. Rajasekharan S, Martens LC, Cauwels RGEC, Anthonappa RP, Verbeeck RMH. Biodentine™ material characteristics and clinical applications: A 3 year literature review and update. Eur Arch Paediatr Dent 2018;19:1–22.
6. Malkondu Ö, Kazandag MK, Kazazoglu, E. A review on Biodentine™, a contemporary dentine replacement and repair material. Biomed Res Int 2014;2014:160951.
The present report clinically con rmed the excellent features of Biodentine™ as good biocompatibility and promotion of mineralized dentinal tissue deposition [1].
7. Camilleri J. Investigation of Biodentine™ as dentine replacement material. J Dent 2013;41:600–610.
8. Çelik BN, Mutluay MS, Arıkan V, Sarı Ş. The evaluation of MTA and Biodentine™ as a pulpotomy materials for carious exposures in primary teeth. Clin Oral Investig 2019;23:661-666.
9. Rajasekharan S, Martens LC, Cauwels RGEC, Anthonappa RP. Biodentine™ material characteristics and clinical applications: a 3 year literature review and update. Eur Arch Paediatr Dent 2018;19:1-22.
considered a valid choice in vital pulp therapy of primary as well as immature permanent teeth.
10. Bossù M, Iaculli F, Di Giorgio G, Salucci A, Polimeni A, Di Carlo S. Different Pulp Dressing Materials for the Pulpotomy of Primary Teeth: A Systematic Review of the Literature. J Clin Med 2020;9:838.
11. American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. Pediatr Dent 2017;39:325–333.
Fig. 2: Periapical radiographs of the dental element (8.5) treated with Biodentine. a. immediately after vital pulp therapy (Baseline); b. at 1 month; c. at 6 months; d. at 1 year of follow-up. Absence of periapical reactions can be observed at all evaluated time points.
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Oral Lesions with Prof Wynand P. Dreyer1
Dr Andre W van Zyl2
Masterclass in Oral Diseases Burning Mouth Syndrome
Introduction
Burning Mouth Syndrome (BMS) is the condition where a burning sensation is experienced of the oral mucosal surfaces without any identifiable clinical symptoms or lesions.1 This is a taxing burden on both patient and the attending dental practitioner. This is due to the pain and discomfort associated with this symptom complex and its possible persistence over an extended period. The symptoms entail a burning and/or painful sensation of the mouth and may be associated with a dry mouth and, at times, an altered taste perception. The pain is most often felt on the tongue, but other oral structures may also be involved. It is difficult to diagnose BMS and it can only be confirmed once all possible local and/or underlying systemic conditions have been ruled out. Systemic conditions include iron deficiency anaemia and other nutritional deficiencies, hormonal changes, use of certain chronic medications, acid reflux, local traumatic insults to the oral tissues (with or without the presence of xerostomia) and other, less common, conditions such as Sjögren’s syndrome. This may need to be done in conjunction with the patient’s general practitioner/physician and where available, an oral medicine specialist.
References
1. Ślebioda Z, Lukaszewska-Kuska M, Dorocka-Bobkowska B. Evaluation of the efficacy of treatment modalities in burning mouth syndrome—A systematic review. Journal of Oral Rehabilitation. 2020;47(11):1435-47.
2. Scala A, Checchi L, Montevecchi M, Marini I, Giamberardino MA. Update on Burning Mouth Syndrome: Overview and Patient Management. Critical Reviews in Oral Biology & Medicine. 2003;14(4):275-91.
3. Ritchie A, Kramer JM. Recent Advances in the Etiology and Treatment of Burning Mouth Syndrome. J Dent Res. 2018;97(11):1193-9.
4. Bookout GP LM, Short RE. 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519529/. Burning Mouth Syndrome.
1 Wynand P. Dreyer
Professor emeritus, Oral Medicine and Periodontics, Stellenbosch University. BDS (Wits), HDD (Wits), PhD (Stellenbosch), FCD(SA)OMP
2 Andre W. van Zyl
MChD (Oral Medicine & Periodontics)
Private Practice, Hermanus, South Africa
The attending dental practitioner must ensure that the patient is carefully screened and examined for any oral lesions or conditions. This requires a comprehensive examination of all oral mucosal and dental tissues to identify the presence of any abnormality that may be associated with the patient’s symptoms, such as soft tissue trauma or habitual bruxing/clenching. Most patients with BMS will suffer from an unexpressed cancerphobia and a detailed screening of the oral soft tissues is essential to eliminate the presence of oral cancer. This should include a visual inspection of all oral mucosal soft tissues using good illumination and appropriate retraction of the tongue to examine the underside of the tongue and floor of the mouth. This must be followed by a thorough palpation of the lymph nodes draining the oral tissues. The patient should also be referred for a full blood screening and other appropriate tests to rule out other nutritional deficiencies and allergic conditions (see below). If an underlying local or systemic condition is involved, it is referred to as secondary BMS and should improve once the patient receives appropriate treatment.
Clinical presentation
BMS is classified as primary if no underlying causes can be found or secondary if systemic or local underlying causes are found.2 BMS onset may be sudden or gradual and although it cannot be tied to any specific cause, it is quite common to find patients blaming the onset after routine dental therapy- often a simple scaling of the teeth. Burning is the most common complaint and tends to be more frequent on the tip, anterior dorsum and lateral sides of tongue and the inside mucosal surfaces of the lips.3 The
Figure 1: Geographic tongue (also known as Eythema Migrans or Benign migratory glossitis/ stomatitis). The atrophic areas or red areas (black arrows) are surrounded by white borders (yellow arrows). The borders are however often difficult to identify. Patients with these lesions may complain of a burning sensation and sensitivity to spicy foods. This is not to be confused with BMS.
burning may however affect any oral surface and often patients will complain not just of burning but tingling, taste alteration and even numbness.
Post-menopausal women are affected more than premenopausal women or men. Decades ago BMS was thought to be caused almost exclusively by hormonal changes in post-menopausal women. This is however not accepted anymore. Another school of thought that was prevalent decades ago and which is now not accepted is that BMS was purely psycho-somatic. Clinicians should always explain to the patient that the burning sensation is real, but without any real mucosal abnormalities.
Three clinical variants are well described and accepted, namely1, 4:
• No burning present upon waking, with burning sensation starting through morning hours and getting progressively worse through the day and worst at bedtime. Approximately one third will present with this variant.
•In the 2nd type, there is a non-stop burning sensation,
Figure 2: Erosive oral lichen planus with clear ulceration. Any lesion or condition which can be identified clinically, is not BMS and needs to be further identified with histology.
every hour of every day. These patients usually are the most difficult to treat and may find it difficult to sleep. Close to 60% will present with this variant.
• The 3rd type is uncommon where burning does not occur every day and the burning sensation is intermittent throughout day.
Systemic assessment/Blood tests:
It may be in your interest to refer the patient to her medical GP for the blood tests as it will ensure a team approach to solve this complex clinical condition.
It is recommended to request the following tests2:
•Vitamin B 12
•Iron profile
•Thyroid hormone
•Folate (serum/plasma)
•Vitamin D
•Parathyroid hormone
Common clinical conditions that may present with a burning sensation and need to be eliminated before a diagnosis of BMS can be made:
•Geographic tongue (Fig. 1).
or
5: Atrophic tongue changes due to iron deficiency anaemia. This may cause a burning sensation and is known as secondary BMS. One should always assess the salivary flow for xerostomia with atrophic tongue changes such as this as it may further aggravate the burning sensation.
Figure 3: Non-erosive (red lesions) oral lichen planus of gingiva and white-red lesions lateral of tongue. This may also present with burning sensation or be sensitive to spicy foods.
Figure 4: Red and white lesions on the lateral border of tongue presenting with a burning sensation, identified as lichenoid stomatitis on histology. Such changes may be subtle
missed by the inexperienced clinician.
Figure
This is a very common condition, may present with a burning sensation and may show subtle changes that can easily be missed
•Oral lichen planus (Fig. 2 & 3).
This may present with minor erosions that can present with burning and be difficult to distinguish from normal alveolar mucosa
•Lichenoid stomatitis (Fig. 4).
This may be varied in presentation and symptoms and may also present with burning sensation on almost all oral mucosal surfaces
•Anaemia with atrophic tongue lesions (Figure 5).
This may be due to iron deficiency anaemia or Vit B12/Folic acid deficiency.
Discussion/conclusion
It should be clear that to diagnose BMS one has to be very sure that no oral mucosal abnormalities are present, that the salivary flow is not suppressed by taking medicine with anti-cholinergic properties (mostly anti-depressants, sedatives and sleeping medication) and that no hormonal abnormalities or vitamin and iron deficiency is present.
All mucosal surfaces have to be examined in great detail and the patient should be assured that there really is no oral cancer present anywhere. This cannot be stressed enough.
To modify any medication prescribed by medical specialists or general practitioners, one should gain the trust
of these colleagues and be able to explain the situation and the role of the anti-cholinergic effects of such medications with clarity and in detail. In our experience medical colleagues are always willing to help once they understand the distress BMS may cause and the role of salivary flow in preventing, alleviating or aggravating the situation.
BMS patients are usually highly stressed and should be treated with patience, empathy and compassion and a sincere effort must be made to explain to the patient the nature and prognosis of his/her condition. It is also important to allow the patient time to ask questions and raise concerns and a sympathetic sincere approach may help the patient to better understand and accept the diagnosis.
Cognitive behavioural therapy may be of value.3
Clinical Tip:
Patients do not understand or easily accept the explanation of pain with no identifiable cause for the pain. A good analogy to use when explaining this concept is that of Phantom Limb pain, which is the perception of pain from a limb that is not there anymore. It does not make the pain any less real for those patients. BMS patients will understand this explanation and will better accept their burning pain if explained in this manner.
BMS patients need our support and should never be seen as an irritation in an otherwise busy clinical practice.
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Intentional replantation
Corneliu Gherasim1
1 Corneliu Gherasim
Specialist Endodontist, Private Practice, London, UK
Lecturer, International University of Catalonia, Spain
In 1982, Grossman defined intentional replantation as being ‘a purposeful removal of a tooth and its reinsertion into the socket almost immediately after sealing the apical foramina’.
In addition, Grossman (1982) stated that it is: ‘The act of deliberately removing a tooth and, following examination, diagnosis, endodontic manipulation and repair –returning the tooth to its original socket to correct an apparent clinical or radiographic endodontic failure’.
Intentional replantation should only be used as a last resort therapy after all other endodontic procedures (primary and secondary root canal treatment) have failed and where apical surgery is not feasible due to poor access, or the proximity of the apical area to nerves or other anatomical structures.
Contraindications of this treatment include cases where extraction could result in fracturing the roots or the coronal part of the tooth.
Research has reported a success rate for the procedure of 83% in cases where no orthodontic extrusion was performed prior to intentional replantation.
This figure jumps up to 94% in cases where both procedures were performed (Choi et al, 2014).
Benefits of intentional replantation
• Less invasive than apical surgery
• Procedure of relatively low difficulty with a high success rate
• Inexpensive, quick procedure in comparison with apical surgery.
Case study
Intentional replantation of a lower left second molar associated with a large periapical cyst-like lesion
A 44-year-old male with no contributing medical history was referred for an endodontic evaluation of the teeth from the mandibular left quadrant.
The patient’s chief complaint was a throbbing discomfort located in the lower left molars.
Upon examination, both first and second lower left molars appeared to be tender to percussion. No sinus tracts or pockets were noted at this stage.
A preoperatory radiograph was taken (Figure 1). This revealed that the LL6 presented with what appeared to be a well-adapted full coverage crown, substandard root canal fillings, apical resorption of the distal root and associated periapical radiolucencies.
In the case of the LL7, a complex configuration of the root canal system – c-shaped anatomy – was noted, as well as a large associated periapical radiolucency.
Coronally, LL7 presented with a large coronal restoration with radiographic signs of secondary decay.
The pulpal diagnosis was that of a previously root treated tooth for LL6 and of pulp necrosis for LL7, while both teeth shared the same periapical diagnosis: symptomatic apical periodontitis.
Treatment plan
A discussion of treatment going forward was initiated with the patient. All options, with advantages and disadvantages, were discussed.
The agreed treatment plan included the restorability assessment of LL7 and, if restorable, root canal therapy for both LL6 and LL7.
In the eventuality that one or both treatments would fail, apical surgery (LL6) or intentional replantation (LL7) were suggested.
All procedures – endodontic, restorative and surgical – were performed exclusively with the aid of a dental operating microscope.
The root canal treatments and the immediate adhesive coronal restorations were performed in two separate sessions, which were uneventful. Arrangements to review the case after one year were made (Figure 2).
Figure 1: Preoperative radiograph
Figure 2: One-year review radiograph
Figures 3A and 3B: Buccal sinus tract and a pocket of 10mm associated with LL7 were noted
Eight months after the completion of root canal therapy, the patient returned to the practice due to a recent episode of flare-up associated with the lower left molars.
Upon clinical inspection, a buccal sinus tract and a pocket of 10mm associated with LL7 were noted (Figures 3a and 3b).
CBCT scan analysis showed a previously root treated LL6 and LL7 with root fillings within standards. Also, a large periapical cyst-like lesion, situated in close proximity to the mandibular canal, associated with LL7 and encompassing the distal root of LL6 was noted (Figure 4).
Treatment options included:
• Apicoectomy (very difficult, poor prognosis on account of a very challenging access and extent of the bone defect)
• Intentional replantation of LL7
• Extraction and replacement with a single implant supported crown.
The risks and benefits were explained to the patient. In the end, the patient opted for intentional replantation of LL7.
Treatment procedure
Antisepsis was carried out using 0.2% chlorhexidine gluconate; then, the inferior alveolar nerve block was performed using a cartridge of lidocaine (2% lidocaine with 1/80000) as well as buccal and lingual infiltration anaesthesia.
The LL7 was extracted as atraumatically as possible. During the extraoral period, the periodontal tissue was kept hydrated with the help of a moist gauze (Figures 5a to 5c). Subsequently, 3mm of the root apex were resected, and the root end cavity was prepared and filled with mineral trioxide aggregate (MTA) (Figures 5d to 5f).
Due to the patient having a limited mouth opening, and also the size of the bone defect, complete removal of the granulation tissue was not possible. Blood clots were removed by normal saline rinsing. Immediately after, the tooth was repositioned into its bone socket and a flexible buccal splint was placed (Figures 5g to 5j). The postoperative radiograph showed a correct repositioning of LL7 and a retrofilling within radiographic standards (Figure 5k).
Figure 4: A large periapical cyst-like lesion, situated in close proximity to the mandibular canal, associated with LL7 and encompassing the distal root of LL6 was noted
The splint was removed one week later. Three months after, the buccal sinus tract appeared to be healed and the periodontal probing was within normal limits (Figures 6a and 6b).
One-year review
The tooth was asymptomatic to all clinical tests, with
periodontal probing and mobility within the normal limits. Radiographic examination showed signs of bone regeneration in the periapical area associated with LL6 and LL7. This was further confirmed by means of CBCT scan analysis. At this point, the outcome of the procedure was deemed as favourable and a full coverage crown on the LL7 was advised (Figures 7a to 7d).
Figures 5A, 5B and 5C: During the extraoral period, the periodontal tissue was kept hydrated with the help of a moist gauze
Figures 5D, 5E and 5F: 3mm of the root apex were resected, and the root end cavity was prepared and filled with MTA
Figures 5G, 5H, 5I and 5J: The tooth was repositioned into its bone socket and a flexible buccal splint was placed
Conclusion
As an endodontic procedure for teeth with persistent endodontic disease where periradicular surgery is not feasible, intentional replantation is a reliable, low complexity manoeuvre that is usually associated with a predictable outcome, given good case selection.
References Choi YH, Bae JH, Kim YK, Kim HY, Kim SK, Cho BH
(2014) Clinical outcome of intentional replantation with preoperative orthodontic extrusion: a retrospective study. Int Endod J 47(12): 1168-76
Grossman LI (1982) Intentional replantation of teeth: a clinical evaluation. J Am Dent Assoc 104: 633-39
This article first appeared in Clinical Dentistry and has been reprinted with permission. Gherasim C (2023) Intentional replantation. Clinical Dentistry 3(2): 44-47
Figure 5K: Postoperative radiograph
Figures 6A and 6B: Three months later. Buccal sinus tract was healed and periodontal probing within normal limits
Figures 7A, 7B, 7C and 7D: The outcome of the procedure was favourable and a full coverage crown on the LL7 was advised
1
Performance and practicality with a light-cure, resin cement
Alan Yap1
Since 1983 PANAVIA™ by Kuraray Noritake Dental Inc. has been the gold standard for dental cements throughout the world. Their latest cement, PANAVIA™ Veneer LC, sets a new standard for porcelain veneer cements through incredible performance and ease of use. The following clinical case demonstrates the use of PANAVIA™ Veneer LC.
Case report
A 31-year-old female (Fig 1) was referred for porcelain veneers to replace lost tooth structure and to improve aesthetics. The patient exhibited moderate attrition of her anterior and bicuspid teeth (Fig 2), the result of nocturnal bruxism and a tendency to an edge-to-edge occlusion. She had a Class I malocclusion on a Skeletal Class I tending III base with the right maxillary canine in cross-bite. The treatment plan included orthodontic treatment, porcelain veneers, and an occlusal splint.
Orthodontic treatment (by Dr Nour Tarraf) included full-fixed appliances with TADs and IPR of mandibular anteriors, and arch retractions to reduce protrusion (Fig 3, postorthodontic treatment). A preliminary digital design (Fig 4) was performed to guide the diagnostic wax-up and a digital mock-up (Fig 5) was utilised to verify the diagnostic wax-up prior to carrying out the intra-oral mock-up. The patient was unable to afford the restoration of the maxillary bicuspids until a later stage so the restoration was limited to the maxillary anterior teeth.
Using the diagnostic wax-up, silicone keys were fabricated to guide tooth preparations. Orthodontic treatment allowed prosthetic treatment to be additive in design which meant that tooth preparations could be conservative.
Labial reductions were limited to 0.3mm and incisal reductions were performed only where needed to create an incisal butt joint for the veneer (Fig 6). Minimal preparations allowed the veneers to be bonded almost entirely to enamel, which is important for the long-term survival of porcelain veneers.1 There was no need to significantly mask the
colour of the cervical region of the tooth and non-carious cervical lesions were absent, so fine chamfer margins were prepared at equi-gingival level.
Splinted provisional veneers (Fig 7) were fabricated using bisacryl ensuring sufficient interdental space to allow hygiene access for small interdental brushes. The labial surface of the provisional veneers were glazed with a unfilled resin and cemented using the spot-etch technique, ensuring all excess flowable composite was removed prior to curing (Fig 8). Twice daily interdental cleaning of the provisional veneers and thorough brushing of labial margins during the provisional phase maintained soft tissue health, important for the try-in and cementation of the definitive veneers.
A dry try-in of the definitive veneers was performed to check the fit of the veneers and a wet try-in was performed using try-in paste to assess aesthetics. The PANAVIA™ Try-in pastes accurately mimic the cement shades. Four useful shades are available (Fig 9). The White and Brown shades are useful to correct small discrepancies in shade requiring subtle increases or decreases in shade value respectively. Conveniently the try-in pastes are the same as the PANAVIA™ V5 range of try-in pastes (excluding opaque). Following the try-in procedure the teeth were isolated using rubber dam and the floss ligature technique.
KATANA™ Cleaner (Fig 10) was used to clean the veneers prior to silanating with CLEARFIL™ CERAMIC PRIMER PLUS (Fig 11). Veneers that have not been pre-etched should be etched with hydrofluoric acid prior to silanization. The use
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7 Fig. 8
of the ProsMate™ Baton allows the cleaning, etching and silanization of all veneers simultaneously (Fig 12). The veneers are arranged systematically on the ProsMate™ Tray ready for the cementation procedure (Fig 13). Tooth surfaces were pre-treated with phosphoric acid (K-ETCHANT Syringe and PANAVIA™V5 Tooth Primer (Fig 14).
The newly designed cement applicator tip reduces air bubbles and the wide 16-gauge tip (Fig 15) allows light and easy control of cement extrusion while also providing efficient wide coverage during application. PANAVIA™
Veneer LC has excellent handling because of its ideal paste consistency. It is non-sticky and its viscosity prevents the cement from flowing beyond the veneer margins until the veneer is seated. It is not runny or stringy. Furthermore its thixotropic properties results in lower film thickness during seating of the veneer. These excellent handling properties are due to the development of new filler technology which consists of spherical silica and nano cluster fillers (Fig 16). The “touch-cure” mechanism of PANAVIA™ V5 Tooth Primer importantly seals the bonding interface while the extended
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 9
Fig. 10
working time and stability of the cement under ambient light allows the simultaneous cementation of multiple veneers. In this case all six lithium disilicate veneers (technical work by Yugo Hatai) were cemented simultaneously with PANAVIA™ Veneer LC Paste (Clear).
Tack-curing each veneer for one second allowed smooth and easy bulk removal of excess cement with an explorer (Fig 17). Remaining excess uncured paste was removed with brushes. Final curing was performed by light curing lingual and labial surfaces.
Following removal of the rubber dam residual cured cement was removed with a sickle scaler, number 12 scalpel blade, serrated ribbon, interproximal polishing strip, floss, interdental brush and a rotary brush.
The optical characteristics of PANAVIA™ Veneer LC, use of fine chamfer margins, and well-fitting translucent restorations produces a gradual and smooth transition of colour from tooth to veneer where margins disappear and soft tissues respond in a healthy way (Fig 18). The color stability, excellent abrasion resistance and high gloss durability of PANAVIA™ Veneer LC preserves integrity and aesthetics at the margins over the long term. The extraordinary bond strength of PANAVIA™ products, so familiar to our profession over the last 20 years, is still second to none (Fig 19).
References
1. Layton DM, Walton TR. The up to 21-year clinical outcome and survival of feldspathic porcelain veneers: accounting for clustering. Int J Prosthodont. 2012 NovDec;25(6):604-12. PMID: 23101040.
Fig. 18
Fig. 19
Fig. 15
Fig. 16
Fig. 17
Silver diamine fluoride: a practical guide
Louis Mackenzie1
1
Louis Mackenzie, BDS Clinical Lecturer, School of Dentistry, University of Birmingham, UK Private Practice, Birmingham UK Head Dental Officer, Denplan
The COVID-19 pandemic and subsequent limitations on the use of aerosol generating procedures has renewed interest in the use of silver diamine fluoride (SDF) as a simple, minimally invasive method for stabilising and arresting carious lesions.1,2,3
Silver diamine fluoride (SDF)
SDF is a colourless alkaline (pH 9-10) solution containing silver (~25%) and fluoride (~5%) stabilised in ammonia. It has been used internationally for caries management for decades but is currently only licenced as a desensitising agent in the UK, with one CE marked product: RIVA STAR (SDI. Australia) – Figure 1.
Silver has been used as an antimicrobial agent worldwide for over a century, as it has been demonstrated to be capable of destroying bacterial cell walls, inhibiting bacterial metabolism and enzyme activity and reducing biofilm formation. In SDF, this combines with the remineralising properties of fluoride to offer a range of clinical indications and reported advantages, listed in Table 1.1,2,3
The principal disadvantage of SDF is a potential for black/brown discolouration of carious dentine, caused by precipitation of metallic silver and silver oxide, which limits its acceptance aesthetically. Staining may be reduced with the use of potassium iodide solution.
Contraindications for SDF are listed in Table 2 and other cautions include the following:
• Unaesthetic staining of restorative margins
• Staining, irritation or burns of mucosa and skin
• Damage to worktops and clothing
• Slight metallic taste/ammonia odour (but generally well tolerated)
• May reduce bond strengths of glass ionomer and resin composite materials (but may stabilise hybrid layers)
Clinical procedure for SDF caries treatment
Silver diamine fluoride is available in a range of concentrations eg 12-40%, with 38% considered to be the most effective.
The following step-by-step stages have been recommended for treatment of carious lesions1,2,3 and key clinical stages are simulated on an extracted tooth (Figure 2A)
•Cover worktops and protect the patient’s clothing with a plastic bib
•Apply a suitable barrier material (eg petroleum jelly) to protect the patient’s lips
• Remove visible plaque
• Excavate soft, necrotic, infected dentine eg using a hand instrument (Figures 2B,C)
•Isolate the treatment area eg rubber dam, liquid dam
Table 1: Clinical indications and advantages of SDF
Immediate relief of dentine hypersensitivity (Silver iodide blocks dentine tubules and has low solubility) eg cervical abrasion cavities
Relief of symptoms from carious cavities (especially occlusal lesions)
Promotes minimally invasive cavity preparation (eliminating the need for extensive caries excavation)
Minimises the need for aerosol generating procedures
Inexpensive and obviates the need for local anaesthesia
Quick and easy application makes it useful for patients who are: vulnerable, uncooperative, have behavioural problems and those with limited access to conventional dental treatment
Stabilisation/arrest of caries into dentine in deciduous teeth eg may avoid the need for hospital admission (GA/Sedation)
Stabilisation of deciduous teeth soon to be exfoliated
Stabilisation/arrest of caries in elderly patients eg root caries
Acclimatisation to dental treatment and stabilisation of multiple lesions
Remineralisation of incipient carious lesions (2-3 times more fluoride concentration than sodium fluoride varnish)
Endodontic irrigation and inter-appointment medicament
Figure 1. RIVA STAR (SDF) delivery systems.
(provided in kit) or cotton wool rolls
•Pierce the SDF capsule (silver) with a microbrush and thoroughly wet the tip (no mixing is required) – Figure 2D
•A glass Dappens dish may also be used as a dispenser (the SDF capsule contains sufficient material to treat approximately five carious lesions)
• Apply to SDF to dentine caries (with care to avoid soft tissue contact) as in Figure 2E
• Blot excess with cotton wool or gauze
• Working time is approximately five minutes and once placed leave for 1-3 minutes
• Pierce the Potassium Iodide (KI) capsule (green) with a
new (colour coded) microbrush (Figure 2F)
• Continuously apply KI to the SDF until the creamy white precipitate (Figure 2G) turns clear (Figure 2H)
• Repeat blotting of excess material
• Leave to dry completely
• Restore tooth as required eg resin composite or glass ionomer. It is recommended to rinse enamel with water first (Figure 2I)
• Remove isolating materials
• Safely dispose of single-use capsules and used microbrushes
• Review patient for signs of arrest in around 2-4 weeks
Figure 2. Practising the use of silver diamine fluoride (RIVA STAR, SDI) for caries management on an extracted natural mandibular molar.
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Table 2: Contraindications for SDF.1
Silver/heavy metal allergy
Pregnancy and breastfeeding (risk of overloading developing thyroid with iodide)
Lesions close to the pulp/possible pulpal involvement (avoids silver ions in pulp chamber)
Signs and symptoms of periapical pathology (clinical and/or radiographic)
Ulceration, mucositis or stomatitis
Restoration of permanent anterior teeth
(large cavities may need a second SDF application)
• Six monthly re-application is recommended for SDF treated lesions that are not definitively restored
• Successful use of SDF will be significantly enhanced as part of a comprehensive prevention/caries management programme
Prescribing SDF
SDF is licenced for use in the UK as a desensitising agent (and cavity cleanser). Its use beyond the approved indications is considered to be off-licence prescribing. If used for caries management, the Medicines and Healthcare Regulatory Agency (MHRA) guidelines must be followed regarding prescribing in the patient’s best interest, based on
the best available evidence and when there is no suitable alternative treatment.3
References
1. Greenwall-Cohen J, Greenwall L, Barry S. Silver diamine fluoride – an overview of the literature and current clinical techniques. BDJ. June 2020; Vol 228, No11: 831838.
2. Crystal YO. Silver diamine fluoride (SDF): its role in caries management. Dental Update. Dec 2019; 46: 10161022.
3. Timms L, Deery C, Stevens S, Rodd H. COVID-19. Time to use silver diamine fluoride for caries arrest in general dental practice. Dental Update. Sept 2020; 47: 548-558.
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Winner of the Restorative: Ceramic Smile Makeover category at the Dentistry Clinical Case Awards 2023.
A patient in their early 30s came across my clinic through a distant friend a few years ago where she began to follow my work on social media. Originally based abroad, the patient made plans to see me while she relocated to the UK for postgraduate studies. The headlining observation from the patient was that the teeth appeared very small and ‘child-like’ (Figure 1).
The patient was now seeking a solution with minimal maintenance, longevity and superior aesthetics, akin to what she often encounters on social media.
Initial presentation
The patient presented with a mostly unrestored healthy adult dentition. Her oral hygiene was slightly sub-optimal, which was associated with an overdue appointment since she relocated and smoking five to seven cigarettes per day.
Her dental history revealed she’d undergone fixed appliance orthodontics more than 15 years previous, and currently had no fixed or removable retainers.
The teeth present with mild lower labial crowding and a midline discrepancy of 1.5mm with class I classifications for incisal/canine/molar (Figure 2).
Assessing the patient’s smile and dental anatomy, it is observed that at full smile, the lip line is moderate, with the lips showing around 2mm of gingivae beyond the zeniths of the upper incisors. However, it was also noted at this stage that the clinical crown heights appeared blunted by excessive free gingivae cervically without any papillae hypertrophy, suggesting altered passive eruption (APE).
The upper maxillary plane showed a slight cant, with the left lifting higher than the right and exacerbated by the gingival margins of the four incisors. The shade of the teeth had the base colour of Vita A2.
Treatment options
The following treatment options were considered and discussed with the patient:
• Stabilisation
• Hygiene scale and polish and thorough oral hygiene instruction
• Smoking cessation
• Pre-restorative orthodontics
• Removable or fixed appliances
• Single arch (lower) or both arches
• Crown lengthening
• Gingivectomy
• Surgical
• Non-surgical
• Prescription tooth whitening
• Restorative
• Composite veneers – six to 10 teeth upper arch
• Direct – freehand or transferred via clear silicon stent off a wax-up
• Semi-indirect – milled buccal surfaces to be bonded with heated or injectable composite
• Porcelain veneers – six to 10 teeth upper arch
• Lithium disilicate
• Composite contouring – for worn lower incisors due to anterior guidance with mild-crowding.
Orthodontics
The mild rotations presented on the upper teeth were mild enough to allow a fully restorative journey and achieve welldesigned anterior/lateral excursive movements should the patient not have the will or time to undergo the movements of teeth.
For the lower teeth, the patient agreed that orthodontics would be beneficial, however limited by the time she planned to be in the UK. This ultimately led to the compromise to focus on the upper teeth with the potential to align the lower teeth thereafter, which the patient understood as the opposite sequence to my clinical recommendation. The clinical impact of this is manageable with the mild crowding and a realistic compromise to accept for both the patient and myself.
Crown lengthening
Determining the type of APE is crucial for deciding which type of crown lengthening is suitable. With a periodontal probe and no LA at the consultation, I could determine that at the base of the sulcus, the CEJ could not be felt and more enamel was beyond that point on the upper incisors.
Preliminarily, a non-surgical approach using a laser diode to provide the gingivectomy was recommended with the understanding that once the patient was fully numb, an accurate measure of where the crestal bone/buccal plate began relative to the CEJ would be the final check ahead of any laser gingivectomy
Veneers
The patient had understood previous to our consultation that a direction involving porcelain would provide her the most long-term result with the least amount of maintenance, which suited her international lifestyle.
With the view to create larger teeth to fill her smile with fairly small natural teeth as the base, it was communicated to the patient that very little enamel removal would be required and more likely than not, I would be able to bond to greaterthan 90% enamel surfaces by preparing through a trial smile in temporary composite.
Treatment plan
Following a thorough discussion, we decided on the following treatment plan:
• Stabilisation
• Hygiene scale and polish and thorough OHI
• Smoking cessation
• Crown lengthening
• Gingivectomy – non-surgical with laser diode
• Prescription tooth whitening
• Restorative
• Porcelain veneers – upper 10 teeth with lithium disilicate. The case presented several clinical challenges, including:
• Masking maxillary cant combined with good anterior/ lateral guidance
• Improving midline discrepancy
• Designing anatomy of teeth that reflect the aesthetics and genetics of the patient.
Clinical overview
After the initial stabilisation for gingival health and lifestyle recommendations with smoking cessation, which the patient took well, the first clinical step was crown lengthening. With the use of photos at full smile stacked with intraoral contrastor photos, I could visualise the ideal lengths to allow
Fig. 2: Preoperative retracted
Fig. 1: Preoperative smile
her upper lip to gently cover the zeniths of the gingival margin. The aim would also be to reduce the suggestion of the maxillary cant.
With the anaesthetic working, a diagnosis was made to determine a type 1A APE, which was very ideal for nonsurgical crown lengthening.
The gingivectomy ranged between 0.5mm-2.5mm on the upper 3-3, performed freehand and guided healing with the use of a high-filler flowable composite applied in a crescent on each newly defined margin, held by lightly etched enamel collar (Figure 3).
Two-stage PVS impressions were taken prior the guided healing supports to allow me to hand-design the smile in wax (Figure 4). Combined with a digital workflow, an intraoral scan is also taken for my orthodontic technician to fabricate the whitening trays that will now extend onto the newly exposed enamel surfaces.
Two weeks later, I reviewed the gums, removed the composites and fitted the whitening trays.
An analogue wax-up was chosen and created by myself as I wanted more creative input in this smile, expressing what I felt suited the patient’s smile and genetics outside of the digital libraries.
This is a slow but rewarding process that lends me to listen to albums in full through a select choice of in-ear monitors, but that’s a story for another day (Figure 5).
The trial smile helped us identify a few shortcomings to my design (Figure 6) and also helped us learn that the patient preferred tighter embrasures when transitioning from the lateral incisors to canines.
It successfully showed the restorative ability to camouflage the maxillary cant (Figure 7) and allowed the patient to have more time to take-in the significant changes around the corner. Many photos and videos were taken for myself and
Fig. 3a: Laser gingivectomy
Fig. 3b: Guided healing of gingivae –two-week review
Fig. 3c: Healed appearance of gingivae – four-week review
Fig. 4a: Visualising maxillary cant with grid lines
Fig. 4b: Initial plaster model from immediate post-laser impression
Fig. 4c: Aesthetic wax-up
Figs. 5a-c: Wax-up process
Figs. 6a-c: Comparing preoperative with the wax-up and with the intraoral trial smile
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on the patient’s phone for reference.
My artful ceramist technician Lukas Kebrle met the patient at our ‘prep’ appointment and brought to the table some thoughts on narrowing mesial/distal cervical surfaces, which gave these new larger teeth a bit more tightness and dimension.
As a collective, we decided to use a medium translucency BL3 disilicate base with subtle use of aesthetic porcelain and translucent incisal enamel without introducing optically blue/grey regions (Figures 8 and 9).
The ethos in the enamel preparation is simply to create ‘just enough’ space for the porcelain to deliver the desired
Figs. 7a-c: Comparing preoperative with the crown lengthening and with the intraoral trial smile
Fig. 8: Diagram by Lukas of the proposed lithium disilicate composition
Fig. 9: Viewing secondary and tertiary anatomy of the veneers
Figs. 10a-c: Overview of the prep stages through the trial smile
Fig. 11a: 00 retraction cord in-situ ahead of the two-stage PVS
Fig. 11b: Previewing the veneers on their separate die
optical and physical properties, while also being mindful of the challenges in crafting the veneers that I have learnt over the years with my relationship with Lukas (Figure 10).
A two-stage PVS with 00 cord along all the veneers margins is my preferred approach where Lukas and I feel 3D printed models still lack in tactile feel and precision compared to plaster/metal pins (Figure 11).
The IPS e.max (Ivoclar) veneers are bonded with heated paste composite in a medium translucency BW shade and the immediate postoperative photos highlight the absent of soft-tissue trauma and initial integration of the restorative work (Figure 13).
Lukas’s initiative is also observable, which looks to improve the midline of the patient smile by leaning the mesial lobe of the UR1 towards to left, a little further than my wax-up first designed for (Figure 12).
Reflection
In hindsight, the UL2 needed more cervical preparation, as Lukas could not obtain a suitable mesio-cervical embrasure while allowing a viable path of insertion, so the final result suggests a mesial tip to the root.
If the patient permanently relocates to the UK or extends her time here, I will shift my focus onto the lower arch to provide some orthodontic treatment.
I don’t anticipate the need for porcelain veneers, and I will use composite to rebuild the worn incisal edges of the incisors and perhaps on the canines should I need to for occlusion.
This article first appeared in Clinical Dentistry and has been reprinted with permission. Li E (2024) Restorative: ceramic smile makeover. Clinical Dentistry 4(5): 24-27
Figs. 13a-c: Comparison with the wax-up versus the porcelain veneers and their internal textures crafted
Fig. 15: Before and after smile
Fig. 14: Before and after retracted
Root caries: challenges and recommendations
Falk Schwendicke1
1
Prof. Dr Falk Schwendicke, Head of the Department of Oral Diagnostics, Digital Health and Health Services Research Charité in Berlin (Germany).
Caries is the most common disease in humans; almost everyone experiences caries at some point in their life. It is now postulated that it is not the mere presence or quantity of the biofilm that is crucial, but rather environmental conditions.
The dental biofilm is normally non-cariogenic, as it is colonised by only a small number of acid-producing and acid-tolerant bacteria. It is only through carbohydrate intake that these bacteria can lower the surrounding pH by producing acid, thereby displacing other physiological bacteria, creating an ecological niche.
Repeated carbohydrate intake ultimately permanently alters the biofilm; only such a biofilm is capable of producing sufficient amounts of acid to cause a net demineralisation of the dental hard tissue (Takahashi and Nyvad, 2011). This demineralisation is not the goal of the bacteria but rather an incidental side effect.
Based on this understanding, the pathogenicity of the biofilm as well as the balance between demineralisation and remineralisation can be modified.
Instead of primarily focusing on restorative therapy, the emphasis today is on preventing caries or arresting existing lesions, through mechanical or chemical biofilm control, dietary control, or control of demineralisation and remineralisation. Notably, restorative therapy remains needed in a number of cases, with different approaches being available (Schwendicke et al, 2019).
Challenges of root caries
The implementation of preventive measures has contributed to the apparent decline of caries in children and adolescents (Jordan et al, 2019). In Germany, the average 12-year-old child now has only 0.5 decayed or filled teeth, a decrease of almost 90% since the 1970s.
This success is overshadowed by a number of observations. Firstly, a small group still has a high caries experience despite these measures. Secondly, and the focus of this article, in the older population, other forms of caries, such as secondary and/or root caries are more significant. The latter occurs on exposed root surfaces where biofilm removal is limited, either due to difficult access or due to overall poor oral hygiene.
Other relevant risk factors were the number of exposed root surfaces, inadequate oral hygiene, or existing periodontitis. The number of exposed root surfaces and periodontitis are often related, as discussed in detail below. However, the evidence on risk factors for root caries is limited and based on only a few reliable studies.
From the evidence, it can be inferred that patients who already have one or more root caries lesions are at an increased risk of developing new root caries.
For these patients, in addition to routine measures, prevention strategies, close monitoring, and early intervention for new root caries lesions are recommended.
How to manage root caries
A range of preventive and treatment measures for caries are available, with good evidence of effectiveness in children and adults. However, there are limited meaningful studies on treatment approaches for root caries in the older patient population.
A published systematic review summarised the evidence on various strategies for the prevention and treatment of root caries (Meyer-Lueckel, Machiulskiene and Giacaman, 2019). This formed the basis for a consensus paper by delegates from various professional societies (European Organisation for Caries Research, European Federation of Conservative Dentistry, and German Society for Conservative Dentistry), which aimed to provide evidence-based recommendations for prevention and therapy to dentists (Paris et al, 2020).
The following recommendations were made:
• Since the group of older adults is heterogeneous in terms of various aspects (eg, oral hygiene, general health), individual needs of these patients should be considered in the planning process
• Dental care for these patients often follows pragmatic approaches aimed at prolonging tooth survival rather than more complex procedures
• Given that the health condition of older patients can change rapidly, frequent examination intervals are recommended
• In cases of severe dependency, considerations should be made for tooth extractions
• While achieving satisfactory results may not always be possible in practice, it is important to maintain good oral hygiene in older patients. Healthy oral conditions are particularly crucial for these patients, as it is known that oral and systemic health are interconnected. For example, poor oral hygiene can cause pneumonia in dependent patients
• Like for younger patients, the goal of caries prevention for older patients is to influence the aetiological factors involved in caries development. Therefore, older patients at increased caries risk are advised to reduce their sugar intake, and basic fluoride application should be performed through brushing with fluoride toothpaste twice a day
• Due to periodontal bone loss, older patients often have open interdental spaces, which are predisposed to root caries lesions (Figure 1). These patients should practise interdental hygiene using interdental brushes and fluoride toothpaste
• Age-related impairments lead to a decrease in the
1: Exposed roots are at risk for caries; they demineralise earlier and faster because the dentine or cementum is not protected by enamel or the alveole
effectiveness of self-performed oral hygiene measures for many older patients. Especially for dependent patients, they may no longer be able to perform oral hygiene measures themselves. Therefore, caregivers, including family members, should be encouraged to support or take over oral hygiene measures.
For existing root caries lesions, non-invasive treatments are available. Their goal is to transform active lesions (soft, covered by plaque) into an inactive state (hard, free from plaque). Such inactive lesions should be considered as ‘scars’ and do not require further treatment.
For readily accessible lesions, an effective and simple measure is to consciously brush them during daily oral hygiene. Regular removal of the cariogenic biofilm leads to the lesion transitioning to an inactive state.
High-risk patients should brush their teeth with a highfluoride toothpaste (5000ppm fluoride). The application of fluoride varnish or silver diamine fluoride in the dental practice is also recommended for the treatment of root caries. However, it should be noted that silver diamine fluoride can cause irreversible black staining of the treated surfaces.
Notably, for certain lesions, restorative care will be required. The following section deals with strategies to restore such lesions and discusses different material options for this indication.
Challenges during restorative care
Root caries lesions not only differ pathogenetically but also morphologically from coronal caries, as discussed. Hence, traditional restorative treatment concepts for the management of coronal caries are less effective or sometimes not feasible at all for root caries.
Fig.
Root caries lesions can be located in hard-to-reach areas, such as interproximal spaces, which may require sacrificing a significant amount of healthy tooth structure during restoration.
Restorations of root caries lesions often have poorer durability compared to coronal restorations due to the discussed challenges.
Moreover, treating older patients, who are the main risk group, often presents challenges, too. Many patients in this group are not fully capable of receiving treatment. Mobility limitations, especially in dependent patients, may require them to be cared for outside the dental practice.
The use of devices and materials available in the dental practice is therefore greatly restricted when treating these patients. .
Materials to restore root caries lesions
For restoring root lesions, various material categories are available:
• Resin-based composite materials
• Conventional glass ionomers and their latest generation, the glass hybrids
• Materials combining the properties of both material
classes, like resin-modified glass ionomers.
Micro- and nano-hybrid resin composites have excellent physical properties, such as high stability against abrasion and erosion, a high flexural strength, polishability and aesthetics. Moreover, these materials can be placed adhesively, allowing for minimal invasive dentistry.
Notably, the placement of resin composites requires strict moisture control – which is usually hard to achieve for root
Fig. 2: Despite their excellent properties, placement of resin-based composites is technically more demanding (image courtesy Professor B Van Meerbeek)
Fig. 3a: A cervical lesion is restored with a glass hybrid. Placement of Equia Forte HT
Fig. 3b: Equia Forte Coat creates a smooth surface
Fig. 3c: The finished restoration (image courtesy J Tapia Guadix)
caries lesions – and involves various steps like acid etching and adhesive placement.
In recent years, simplification of these application steps has been one focus of manufacturers, for example by combining the etching and the adhesive steps, but nevertheless, their placement – especially in equigingival or subgingival situations – remains technically demanding (Figure 2).
While only recent generations of glass ionomers (GI) are increasingly applied to restore load-bearing cavities, this material class has always been a valid alternative for cervical lesions (as abrasion and loading challenges are more limited here than occlusal-proximally).
Particularly resin-modified glass ionomers have shown high survival in cervical lesions (it should be noted that in many studies these were non-carious lesions).
The latest generation, the so-called glass hybrids (Figure 3), claim to come with high abrasion and erosion stability and improved flexural strength. This has been achieved by alterations in the chemical composition of the material, mainly the introduction of an additional, smaller glass phase and longer acrylic acid chains. Due to an additional coating step with a nano-resin, the glass surface is transformed into a smoother and aesthetically pleasing surface.
In a range of laboratory studies, it has been confirmed that glass hybrids do come with significantly superior properties compared with their predecessors, while retaining the advantages, namely the ease of placement and their bioactivity, particularly the release of fluoride – which is relevant for root caries lesions to protect against secondary caries.
A range of studies have demonstrated that GI reduce caries risk on the restoration margins with a distance up to 300µm. Moreover, an acid-resistant intermediate zone, consisting of dissolved calcium from tooth tissue and fluoride from the material, is likely to increase the resistance against secondary lesions (Tonprasong et al, 2022).
Clinical Evidence
There is limited evidence on root lesion restorations – with comparative data especially scarce. Most studies indicate that, except for anatomical form and colour match – where glass ionomers may show higher rate of complications – and for secondary lesions – where composites may show higher risk, the risk of failure is similar between glass ionomers and composites. Generally, the risk of restoration failure is relatively high for this indication. Moreover, caries risk has been found as a modifier of failure likelihood, with composites showing more frequent failures, mainly secondary caries, in high-risk
In randomised controlled clinical trials, glass hybrids show promising outcomes for the restoration of cervical lesions. Cervical lesion prior to treatment
individuals (Meyer-Lueckel, Machiulskiene and Giacaman, 2019; Tonprasong et al, 2022; Pilcher et al, 2023).
For glass hybrids, the only data available are randomised trials comparing this material against resin composites in non-carious lesions (Figure 4).
The most interesting study for root caries is one comparing a glass hybrid (Equia Forte, GC) and resin composite restorations (Filtek Supreme XTE, 3M) for managing sclerotic non-carious cervical lesions in 88 patients middle-aged and older patients aged 50 to 70 years (Schwendicke et al,
Fig. 4a:
Fig. 4b: Glass hybrid restoration at baseline
Fig. 4c: Same restoration after six and a half years (image courtesy Professor M Basso)
2021). Over 36 months, the survival, quality and costs of 92 restorations, placed without any mechanical preparation (which eventually resulted in high annual failure rates for both groups), were evaluated. Restoration quality was assessed after one, 18 and 36 months using FDI-criteria. Costs were evaluated using a so-called micro-costing approach (accounting for the time used for placing the material) and, during follow-up, fee items of the statutory insurance in Germany. After 36 months, 17 glass hybrids and 19 resin composites showed total retention loss, five glass hybrids were partially lost. Costs were lower for glass hybrids, both initially and over follow-up.
Conclusion
Considering their improved biomechanical properties, cost-effectiveness and more forgiving nature given the
complications that root lesions typically bring about, glass hybrids may be an excellent alternative for their restoration. Nevertheless, more clinical evidence is necessary on the treatment of root caries lesions.
For the future, more focus is expected on prevention, non-invasive treatments, and bioactive materials such as silver dotation and modification with silver diamine fluoride. However, for the latter, clinical data is largely absent thus far.
References
A list of References is available on request: ursula@moderndentistrymedia.com
This article appeared in Clinical Dentistry and has been reprinted with permission. Schwendicke F. (2024) Root caries : challenges and recommendations. Clinical Dentistry 4(3): 74-77
A surface-retained glass fiber-reinforced bridge with a CAD/CAM-fabricated pontic
Jasmina Bijelic-Donova,1 Clara Anton Y Otero,2 Pekka K. Vallittu,3 and Ivo Krejci4
1 Dr. Jasmina Bijelic-Donova Resident in Prosthodontics and University Lecturer, University of Turku (Finland), Department of Prosthetic Dentistry. Correspondence: jabije@utu.fi
2 Dr. Clara Anton Y Otero, Dentist and research collaborator, Department of Cariology and Endodontics , University Hospital in Geneva (Switzerland)
3 Prof. Dr. Pekka Vallittu Dean of the Institute of Dentistry and holds the Chair of Biomaterials Science at the Faculty of Medicine, University of Turku (Finland). Director of Turku Clinical Biomaterials Centre.
4 Prof. Dr. Ivo Krejci Past President of the University Dental Clinics of the University of Geneva Currently Director of the Department of Preventive Dentistry and Primary Dental Care at the same university.
Fixed partial dentures (FPD) fabricated from FRC (hereafter abbreviated as FRC FPDs) are nowadays considered a minimally invasive and cost-effective treatment1,2. They gained popularity in the early 1990’s and since then have been commonly used in teeth with poor prognosis, as a substitute for removable partial dentures that replace a few missing teeth and in situations where costs are an issue3. Clinical experience has shown that most clinical failures are due to three main reasons: incorrect fiber orientation4, incorrectly designed fiber framework5,6 or inaccurate occlusal adjustment3. The most commonly reported reasons for FRC FPD failures are delamination and chipping of the veneering composite2,5,7–10, dislodgement4,8,9, and partial6 or complete debonding. Traditionally FRC FPDs have been fabricated directly (intraorally), semi-directly (chairside i.e. pre-making the fiber framework and the pontic partially extraorally)2,5,7 or indirectly (in a dental laboratory)3,4,6,8,9,11. Until today, CAD/CAM technology has been used only in vitro for fabricating the pontic of a simple FRC FPD12,13. To the authors’ knowledge, this technique, has not been yet implemented clinically.
This clinical report describes the treatment of a missing maxillary left first molar with FRC FPD utilizing CAD/CAM (computer-aided design and computer-aided manufacturing) technology for designing and fabricating the pontic.
A 72-year-old female patient was referred to replace a missing maxillary left first molar, which had been extracted more than 12 years earlier due to secondary caries on the crown margins and a periodontal lesion. The maxillary left wisdom tooth had to be extracted one year prior to referral because of a periodontal-endodontic lesion. Since then, the patient started to experience decreased functional stability in the second
Fig. 1: Intraoral photographs; a) maxillary arch; b) mandibular arch and c) lateral view.
quadrant, and wanted to close the gap and to regain masticatory function.
The mesiodistal width of the edentulous space was 7.5 mm (Figs. 1a, b) and the occlusal plane was not disturbed (Fig. 1c). The adjacent second molar had migrated in mesial direction and the interproximal space available for the pontic approximated a premolar size. There was no increase in mobility detected in the abutment teeth.
The patient desired a fixed, non-invasive treatment solution and particularly required to completely avoid tooth preparation or surgery. Therefore, treatment solutions such as implants or metal and/or ceramic bridge constructions were not considered. Alternatively, a surface-retained FRC FPD was proposed, emphasizing that the solution was considered semi-permanent and experimental.
Laboratory procedure
The glass fiber framework was fabricated on an isolated
plaster model utilizing various kinds of resin impregnated E-glass FRCs. The main FRC framework was made with unidirectional E-glass fiber bundles (everStick C&B, with ø 1.5 mm and 4000 glass fibers per bundle) and bidirectional E-glass fiber net (everStick Net, thickness 0.06 mm).
The pontic area was reinforced with two short pieces of unidirectional FRC (everStick C&B) placed in inciso-gingival (axial) direction to the main fiber framework, and covered with short-fiber-reinforced composite resin (everX Posterior and everX Flow, Dentin shade) (Figs. 2a-f).
Once the framework was smoothly ground to final shape (with a handpiece micromotor and fine diamond burs of 40 grit) and cleaned with air spray, an optical impression of the fiber framework was taken. A fully anatomic pontic was virtually designed (CEREC 4.6.1 Software) (Figs. 3a-e). In order to obtain a proper design and shape of the pontic, the fabricated fiber framework was placed on the model during scanning. When the virtual model was generated, the
Fig 2: Fiber framework on the plaster model. Main fiber framework from different views: a) buccal and b) palatal view. Pontic additions from different views: c) buccal (perpendicularly placed everStick C&B unidirectional fiber); d) occlusal (unidirectional fiber); after e) buccal (covered with everX composite and f) occlusal (with everX).
margins of the framework and the soft tissue of the missing tooth were marked. The automatically generated pontic was then modified (in shape, size, and position) and adjusted to fit the desired material thickness (approximately 2.5 mm of overlaying material above and below the fibers). Next, it was milled from a hybrid CAD/CAM block (CERASMART 270, HT, shade A2).
Prior to bonding of the pontic to the fiber framework, both bonding surfaces were treated. The bottom surface of the CAD/CAM pontic was sandblasted with 27 µm Al2O3, cleaned in an ultrasonic bath with distilled water for 2 min and silanated for 60 s. A bonding agent was applied to the surface, allowed to dry and light-polymerized for 20 s. The inner surface of the smoothly ground and steam-cleaned fiber framework was also treated with the same adhesive, which was left unpolymerized (protected in a light protecting box) for a minimum of 5 min and light cured for 40 s. An
Fig 3: Representation of the digital process. Virtual model with the fiber framework in situ. a) soft tissue marking of the missing tooth; different views of the designed pontic: b) buccal, c) occlusal and d) palatal view; e) virtual material thickness evaluation.
injectable resin composite (G-ænial Universal Injectable, shade A2 and G-ænial Posterior, shade A2) was then used to bond the pontic to the fiber framework and light-cured for 40 s (Figs. 4a and b).
Clinical procedure
Preceding cementation, abutments were cleaned with pumice and then isolated using rubber dam. All surfaces were cleaned by sandblasting with 27 µm Al2O3, etched with 35% phosphoric acid, rinsed and air-dried. A metal primer and a one-component universal adhesive (G-Premio BOND) were applied to the sandblasted gold inlay surfaces and all bonding teeth surfaces, respectively, following the manufacturer’s instructions and left unpolymerized. The FRC FPD cementation surfaces were also treated with an adhesive for 5 minutes (shielded from light) and light cured for 40 s from each side. A preheated resin composite
Fig 4: Creation of the FRC FPD. The milled pontic was a) fitted and b) bonded to the fiber framework.
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Fig. 5: Clinical cementation steps. a) sandblasting; b) etching with phosphoric acid; c) application of metal primer to gold restorations; d) application of primer to the tooth; e) application of resin adhesive to all surfaces and f) the adhesively treated fiber framework.
(G-ænial Posterior, shade A2) was used for luting the FRC FPD. After excess removal, all surfaces were light-cured for 40 s each, followed by occlusion adjustment and polishing (Figs. 5a-f).
The patient was examined at baseline (Figs. 6a-c), after 3 months (Figs. 7a and b) and 12 months (Figs. 8a and b). No signs of debonding, surface staining of the bridge or wear were observed. However, marginal discoloration was observed at the 3 and 12 month controls, and surface lustre was slightly lost after 12 months of service.
Subjectively, the patient expressed satisfaction with the FCR FPD and adaptation to the additional volume of material (loop and wings) was not difficult. At the one-year recall, the construction was still well accepted and not perceived as a foreign object. The patient was instructed and motivated to maintain oral hygiene. In addition, it was planned to include her into a six to nine months re-call program. This way, failures could be detected and repaired in an early stage. Due to COVID-19 related restrictions, the last follow-
up appointments could not take place in the hospital; hence, the patient was interviewed by phone. The patient reported that the FRC FPD was still in place and without subjective problems. The device had been in function for 28 months at the time of the latest follow-up interview. The FRC FPD design in the present patient case did not involve preparation of any cavities or undercuts. The retention was mainly achieved utilizing natural retentive features (tooth undercuts and pits) and by the fiber framework design (wings, loop). Because the construction is mainly surface-retained, debonding is likely to occur at some point3,8–10
However, the main advantages of the presented solution are:
1. its complete reversibility, offering the opportunity for diverse treatment options in the future;
2. tooth substance preservation, which makes the biological cost very low and 3. the possibility for an easy intraoral repair or re-bonding due to the semi-IPN network, which supports the functional survival.
The uniqueness of FRC FPDs lies in the individual (custom) fabrication of the fiber
framework. The main fiber framework construction was made of fully impregnated uni- and bidirectional E-glass FRCs, whereas short fibers were used to give an anatomical shape of the fiber framework in the pontic zone. It has to be emphasized that all fibers used (everStick, everStick Net, everX Posterior and everX Flow) have the same matrix composition. This is the multiphase polymer matrix, known as semi-interpenetrating polymer network (semi-IPN), due to which reliable bond to the veneering composite and to the luting cement could be developed 3,14,15
The pontic in this clinical case was virtually designed using digital technology. The use of a digital technique was found to be beneficial for evaluating the material thickness, and optimizing the anatomy and shape of the overlaying structure around the fibers. Compared to direct composites, hybrid ceramic CAD/ CAM block have better mechanical properties16, which might also decrease the incidence of chipping and delamination within the veneering material. Furthermore, standardizing the fabrication quality will
5a
5b
5c
5d
5e
5f
6: Clinical images at baseline. a) freshly cemented FRC FPD; b) buccal and c) palatal view.
7: Clinical images at follow-up after 3-months. a) occlusal and b) buccal view.
minimize operator-related flaws, such as air entrapment.
References
1. Ahmed KE, Li KY, Murray CA. Longevity of fiber-reinforced composite fixed partial dentures (FRC FPD)—Systematic review. Journal of Dentistry. 2017 Jun;61:1–11.
2. Wolff D, Wohlrab T, Saure D, Krisam J, Frese C. Fiber-reinforced composite fixed dental prostheses: A 4-year prospective clinical trial evaluating survival, quality, and effects on surrounding periodontal tissues. The Journal of Prosthetic Dentistry. 2018 Jan;119(1):47–52.
3. Vallittu PK, Sevelius C. Resin-bonded, glass fiber-reinforced composite fixed partial dentures: A clinical study. The Journal of Prosthetic Dentistry. 2000 Oct;84(4):413–8.
4. Vallittu PK. Survival rates of resin-bonded, glass fiber–reinforced composite fixed partial dentures with a mean follow-up of 42 months: A pilot study. The Journal of Prosthetic Dentistry. 2004 Mar;91(3):241–
6.
5. Wolff D. Fiber-reinforced Composite Fixed Dental Prostheses: A Retrospective Clinical Examination. The Journal of Adhesive Dentistry. 2010 Feb 12;13(2):187–94.
6. Kumbuloglu O, Özcan M. Clinical survival of indirect, anterior 3-unit surface-retained fibre-reinforced composite fixed dental prosthesis: Up to 7.5-years follow-up. Journal of Dentistry. 2015 Jun;43(6):656–63.
7. Frese C, Schiller P, Staehle HJ, Wolff D. Fiber-reinforced composite fixed dental prostheses in the anterior area: A 4.5-year follow-up. The Journal of Prosthetic Dentistry. 2014 Aug;112(2):143–9.
8. van Heumen CCM, Tanner J, van Dijken JWV, Pikaar R, Lassila LVJ, Creugers NHJ, et al. Five-year survival of 3-unit fiber-reinforced composite fixed partial dentures in the posterior area. Dental Materials. 2010 Oct;26(10):954–60.
8: Clinical images at follow-up after 12-months. a) occlusal and b) buccal view.
9. van Heumen CCM, van Dijken JWV, Tanner J, Pikaar R, Lassila LVJ, Creugers NHJ, et al. Five-year survival of 3-unit fiber-reinforced composite fixed partial dentures in the anterior area. Dental Materials. 2009 Jun;25(6):820–7.
10. van Heumen CCM, Kreulen CM, Creugers NHJ. Clinical studies of fiber-reinforced resin-bonded fixed partial dentures: a systematic review. European Journal of Oral Sciences. 2009;117(1):1–6.
11. Vallittu PK. Prosthodontic treatment with a glass fiber-reinforced resin-bonded fixed partial denture: A clinical report. The Journal of Prosthetic Dentistry. 1999 Aug;82(2):132–5.
12. Perea L. Fiber-reinforced Composite Fixed Dental Prostheses with Various Pontics. The Journal of Adhesive Dentistry. 2013 Oct 30;16(2):161–8.
13. Vallittu P, Özcan M. Clinical Guide to Principles of Fiber-Reinforced Composites in Dentistry - 1st Edition [Internet]. 2017 [cited 2020 Jun 30]. Available from: https://www.elsevier.com/ books/clinical-guide-to-principles-of-fiber-reinforced-composites-indentistry/vallittu/978-0-08-100607-8
14. Lastumäki TM, Lassila LVJ, Vallittu PK. The semiinterpenetrating polymer network matrix of fiber-reinforced composite and its effect on the surface adhesive properties. J Mater Sci Mater Med. 2003 Sep;14(9):803–9.
15. Vallittu PK. Interpenetrating Polymer Networks (IPNs) in Dental Polymers and Composites. Journal of Adhesion Science and Technology. 2009 Jan 1;23(7–8):961–72.
16. Ruse ND, Sadoun MJ. Resin-composite Blocks for Dental CAD/CAM Applications. J Dent Res. 2014 Dec 1;93(12):1232–4.
Reprinted with permission from GC get connected
Fig.
Fig.
Fig.
DECADES OF PROVEN PREDICTABLE PERFORMANCE
DECADES OF PROVEN PREDICTABLE PERFORMANCE
Over 1 million patients and growing
20 years of peer-reviewed published studies
Over 1 million patients and growing
Time-tested, reliable construction
20 years of peer-reviewed published studies
DECADES OF PROVEN PREDICTABLE PERFORMANCE
Time-tested, reliable construction
Over 1 million patients and growing
20 years of peer-reviewed published studies
Time-tested, reliable construction
Before treatment - November 22 *
Before treatment - November 22 *
Initial patient assessment case photo
Initial patient assessment case photo
Before treatment - November 22 *
Initial patient assessment case photo
Treatment Progress - February 26 *
Treatment Progress - February 26 * Class I platform accomplished in 3 months
Class I platform accomplished in 3 months
Treatment Progress - February 26 *
Class I platform accomplished in 3 months
Motion 3D
Motion 3D
Sagittal First employs the Carriere® Motion 3D™ Appliance to treat the AP dimension at the beginning of treatment before placing brackets or aligners.
By resolving the most difficult part of treatment first, you can achieve a Class I platform in an average of 3 to 7 months1. You know how excited patients and parents become when you mention shorter treatment times!
1 Data on File
* Case provided by Dr. Luis Carrière Carriere Motion 3D
Consultant orthodontist, Kettering General Hospital, UK Private practice, London and Northampton, UK.
According to the UK National Institute for Health and Care Excellence (NICE), obstructive sleep apnoea (OSA) is defined by repeated episodes of apnoea (temporary cessation of breathing) and hypopnoea (slow or shallow breathing), loud snoring, and excessive daytime sleepiness.
OSA is the most common form of sleep-related breathing disorder (SRBD) (Terzano et al, 2001). Chronically poor sleep disrupts hormones, leading to inflammation, weight gain, and cardiovascular issues, impairing blood sugar regulation, cognition, and memory.
Further, sleep disorders significantly increase the risk of road traffic accidents. In 2017, drowsy driving alone caused an estimated 91,000 crashes, 50,000 injuries, and nearly 800 deaths in the US (National Highway Traffic Safety Administration).
Prevalence of OSA
OSA affects an estimated 1.5 million adults in the UK, yet 85% of these are undiagnosed, and untreated (British Lung Foundation, 2015). It is thought that around eight million people aged 30 to 69 years may be affected by OSA in the UK alone.
Ling (2023) stated an estimated 39 million adults in the US are suffering, and globally, the figures are staggeringly high. Based on American Academy of Sleep Medicine (AASM) 2012 diagnostic criteria, Benjafield et al (2019) estimated that 936 million adults aged 30 to 69 years (men and women) have mild to severe obstructive sleep apnoea and 425 million adults aged 30 to 69 years have moderate to severe obstructive sleep apnoea globally. The number of affected individuals was highest in China, followed by the USA, Brazil, and India.
The role of the dental profession in the treatment of OSA
An article by Dr Aoife Brid Stack (2022) highlights the profound impact dentists can have on patients’ lives. Beyond pain relief, creating beautiful smiles, and detecting oral cancer, Dr Stack proposes that dental sleep medicine offers another opportunity to significantly improve patients’ wellbeing.
I echo her sentiments and believe dentists and orthodontists are ideally positioned to screen patients and direct them to appropriate care, often providing treatment themselves that can improve patients’ overall health and lifespan.
In 2021, NICE guidelines included mandibular advancement devices (MADs) as a treatment option for mild, moderate and severe OSA. This addition to the guidelines highlights an opportunity for dentists and orthodontists to diagnose and treat patients who are suffering from snoring or sleep apnoea in their clinics.
This minimally invasive, portable and cost-effective device has the potential to significantly improve patients’ quality of life.
Core symptoms
OSA symptoms include excessive daytime sleepiness and apnoeas or hypopnoeas (blockages or partial blockages of the airway leading to breathing cessations), leading to dysfunction as a result of non-refreshing fragmented sleep, which has an overall reduction in quality of life (Stoohs et al, 2008). Other associated symptoms are:
• Loud snoring
• Observed episodes of stopped breathing during sleep
• Waking during the night and gasping or choking
• Awakening in the morning with a dry mouth or sore throat
• Morning headaches
• Trouble focusing during the day
• Depression
• High blood pressure
• A decreased interest in sex (Mayo Clinic, 2023).
Untreated OSA has been linked with heart disease, stroke, type two diabetes, risk of motor vehicle accidents and impaired quality of life (Ahrens et al, 2011; British Lung Foundation, 2015).
OSA can shorten life expectancy and sufferers are also at a higher risk of hypertension (British Lung Foundation, 2015).
Risk factors
The most significant risk factors for OSA are age and obesity. Being over 65 years of age and a body mass index (BMI) of over 25kg/m2 has a 93% sensitivity for OSA and increased risk of developing the condition (Eckert and Younes, 2014).
Weight loss has been suggested as an alternative treatment option, as high BMI is a major risk factor for OSA. Other modifiable risk factors include alcohol consumption. With the increasing obesity crisis and increased life expectancy in many populations across the globe, the number of OSA cases looks set to rise further. Interestingly, a recent position statement from the American Academy of Sleep Medicine highlights that chronic opioid use could be another contributing factor, which is especially worrying given the need for such medication in many chronic and end-stage respiratory conditions (Lancet Respiratory Medicine, 2020).
Sleeping in a supine position encourages the tongue and soft palate to fall backwards onto the back of the throat, causing an obstruction of the upper airway (Greenstone and Hack, 2014).
Other predisposing factors for young, healthy individuals are macroglossia, excess fat in the palate, and adenoidal tonsillar hypertrophy (Douglas and Polo, 1994)
Aetiology
Sleep apnoea occurs when the upper airway becomes blocked or narrowed during sleep. This blockage disrupts
breathing patterns, causing the partial or complete cessation of breathing for brief periods. There are two main reasons why this blockage might happen.
In obstructive sleep apnoea, the most common type, relaxed throat muscles and soft tissues collapse during sleep, blocking the airway. During sleep when the upper airway relaxes, the pharyngeal dilator tone is lost and the base of the tongue and soft palate relax and rest on to the pharyngeal wall, resulting in a partial or complete airway obstruction. This is often linked to factors like excess weight and a large neck circumference.
Hypoventilation means a drop in blood oxygen levels and stimulates an enhanced respiratory effort. This is often observed as a gasp for air and restlessness. This cycle repeats throughout the night, and the more severe, the more it occurs (Parmenter and Millar, 2023; Epstein et al, 2009; Zwillich, 1998). Less commonly, central sleep apnoea happens when the brain fails to send proper signals to the muscles controlling breathing. This can be caused by underlying medical conditions or heart problems.
Diagnosis
Diagnosis often begins with a two-pronged approach: gathering evidence through patient history and questionnaires, and conducting specialised sleep studies.
During an initial consultation, medical history forms can be a valuable tool for uncovering potential sleep-disordered breathing (SDB).
Research suggests that screening for SDB is crucial during hypertension treatment, as the two conditions are often linked. SDB is prevalent in diabetics due to its impact on glucose metabolism. In children, SDB is frequently associated with ADHD (Urbano et al, 2021).
Secondly, clinicians can utilise questionnaires like the Epworth Sleepiness Scale (ESS) and STOP-BANG to assess potential risk factors based on symptoms like daytime sleepiness, loud snoring, and witnessed breathing pauses during sleep.
The ESS is subjective, scoring the patient out of 24 for varying daytime sleepiness symptoms. The higher the scores, the more severe the symptoms of daytime sleepiness.
STOP-BANG is an acronym for the first letter of each symptom or physical attribute often associated with OSA:
•Snoring: this question assesses whether or not you snore loudly enough to bother a bed partner
•Tiredness: this symptom involves feeling daytime tiredness, which may include falling asleep during daily tasks
•Observed apnoea: if a sleep partner has noticed that you stop breathing or gasp for air as you sleep, this can be a sign of OSA
•Pressure: high blood pressure is also a symptom
•BMI: physicians look for a body mass index that is higher than 35
•Age: those who are older than 50 are at higher risk for OSA
•Neck circumference: physicians measure your neck circumference. A measurement greater than 16 inches is considered a risk factor
•Gender: males are considered to be more likely to have OSA.
However, these questionnaires provide a preliminary picture. Definitive diagnosis often relies on sleep studies like polysomnography, which monitors factors like brainwaves, breathing patterns, and blood oxygen levels during sleep. This detailed data allows healthcare professionals to pinpoint the severity of sleep apnoea and determine the most appropriate treatment course. Working in unity with medical professionals is the correct and holistic approach for a proper diagnosis.
The degree of OSA is classified by the number of apnoea and hypopnoea events, recorded by polysomnography, in an apnoea-hypopnoea index (AHI). Most classifications denote mild cases as five to 15 events per hour, moderate as 15 to 30 per hour, and severe as more than 30 events per hour.
MAD versus CPAP
Traditionally, CPAP has been considered the most effective treatment for sleep apnoea across mild, moderate, and severe cases (Spicuzza et al, 2015).
A CPAP machine delivers constant and steady air pressure through a hose connected to a mask or nosepiece worn during sleep. This pressurised air helps keep the airway open, preventing apnoea episodes.
However, CPAP can be difficult to tolerate for some patients, which can result in poor compliance rates. Lack of compliance is often due to intolerance of the mask, feeling claustrophobic, and feeling a lack of benefit (Ojuawo et al, 2023), escaping air, difficulty sleeping, nasal congestion and xerostomia (Mayo Clinic, 2023).
A study that analysed factors affecting long-term compliance of 400 patients referred for CPAP treatment between 2012 and 2015 found that after a mean time of three and a half years of follow-up, only around 50% of OSA patients were still using CPAP (Gabryelska et al, 2021).
Low compliance rates for CPAP range between 30% and 60%, suggesting the need for alternative treatment methods (Rotenberg et al, 2016).
A randomised controlled crossover trial by Barnes and colleagues (2004) investigated the effectiveness of
continuous positive airway pressure (CPAP) and mandibular advancement splints (MASs) in treating mild-to-moderate obstructive sleep apnoea (OSA) in 80 sleep clinic patients.
The participants underwent three-month treatment periods with each of CPAP, MAS, and an oral placebo tablet. The study found that both CPAP and MAS significantly reduced sleep apnoea severity compared to the placebo. However, CPAP was more effective than MAS in improving overall sleep apnoea. Interestingly, the study also revealed that MAS treatment improved night-time blood pressure dips, while CPAP did not show this specific benefit. Overall, the findings suggest that both CPAP and MAS are effective treatment options for mild-to-moderate OSA, but CPAP may provide a more comprehensive therapeutic effect.
A Cochrane review by Lim and colleagues (2009) evaluated the effectiveness of oral appliances (OA) compared to an inactive control in treating sleep-disordered breathing. The review found that OA improved subjective sleepiness and SDB indices compared to the control. However, CPAP remained more effective in significantly reducing the AHI.
Notably, the review also highlighted a patient preference for oral appliances over CPAP. This suggests OA may be a suitable alternative for individuals with mild sleep apneoa or those who struggle to tolerate CPAP therapy.
Mechanism of Action: MADs
Mandibular advancement devices (MADs) work by physically advancing the mandible forward relative to the maxilla, as described by Jayesh and Bhat (2015), This widens the airway and helps prevent its collapse during sleep, reducing sleep apnoea episodes. There are two different types of MADs:
1. Custom-fitted MADs, which are fabricated by a dentist/ orthodontist from a patient’s impression, offering the best comfort and compliance
2. Boil-and-bite MADs, which are the most readily available online, but these often lack proper fit and effectiveness, leading to compliance issues (Corliss, 2021).
A randomised controlled crossover trial by Vanderveken and colleagues (2007) published in the American Journal of Respiratory and Critical Care Medicine investigated the effectiveness of custom-made mandibular advancement splints (MAS) compared to off-the-shelf devices in treating sleep apnoea.
The study found that custom-made MAS significantly improved the apnoea-hypopnea index (AHI), with a success rate of 60% compared to only 31% for off-the-shelf devices. Additionally, custom-made MAS led to a greater reduction in snoring. However, compliance (measured by device
Steps for treating obstructive sleep apnoea and snoring
1. Initial consultation with patient
Screening for sleep apnoea risk. Conduct a pre-screening questionnaire to assess potential risk of OSA. Utilise validated tools, such as the Epworth Sleepiness Scale, and the STOP-BANG questionnaire (NICE, 2021). Other options include the Berlin Questionnaire and Flemons SACS Questionnaire (Xiong et al, 2019).
Depending on the score, a referral to a medical doctor for further evaluation of OSA may be recommended. For safe and effective use, mandibular advancement devices require careful patient selection and informed consent. Communication with patient’s medical practitioner. As a best practice, send a letter to the patient’s general medical practitioner informing them about the consultation, even if snoring is the primary concern. This is because snoring can be a risk factor for OSA, and early detection is crucial.
2. Impressions/intraoral scan (if available)
Take impressions or an intraoral scan (if your practice offers it) to create a precise model of the patient’s teeth and jaw. Send the impressions/scan along with a bite registration to a reputable dental laboratory accredited for manufacturing mandibular advancement devices (MADs).
3. Fit appliance for patient
Once the MAD is fabricated, the patient returns for a fitting. Depending on the severity of sleep apnoea (determined by the initial consultation or referral) and the patient’s comfort level, an adjustment period (‘titration’) is recommended. During titration, the protrusion level of the MAD is gradually increased to find the most effective and comfortable position for preventing airway closure during sleep.
4. Follow-up appointment
Schedule a follow-up appointment to assess the effectiveness of the MAD. Discuss the patient’s experience with the device, including comfort, sleep quality, and any reduction in snoring (reported by the patient or their sleep partner). Based on the findings, adjustments to the MAD or treatment plan might be necessary.
Regular follow-up appointments are crucial to monitor treatment progress and ensure the MAD continues to be effective and comfortable and to monitor any side effects.
Additional considerations
It is important to inform patients that MADs are typically most effective for mild to moderate OSA. In severe cases, a continuous positive airway pressure (CPAP) machine might be a more suitable treatment option and is still the gold standard treatment modality for severe OSA.
retention) was a challenge, with one-third of patients failing to consistently use the off-the-shelf MAS.
MADs have long been considered to be an effective way to eliminate the symptoms of snoring and, more recently, as a treatment for mild, moderate and severe sleep apnoea (Jayesh and Bhat, 2015; NICE, 2021). Yet, MADs are not without their side effects, and may cause short-term issues such as muscle discomfort, drooling or dry mouth, and temporary jaw misalignment upon waking. Potential long-term complications include changes in bite and temporomandibular joint (TMJ) discomfort.
Despite their side effects, a key reason for considering a MAD instead of CPAP are the factors that cause non-
compliance of CPAP. MADs may absolutely be considered for patients who cannot tolerate CPAP, aren’t willing to try CPAP, or for those who are awaiting referral to a sleep clinic for CPAP treatment (Fleury, Lowe and Oral Appliance Network for Global Effectiveness Group, 2014; NICE, 2021).
References available on request from ursula@moderndentistrymedia.com
This article first appeared in Clinical Dentistry and has been reprinted with permission. Hindocha A. Using mandibular advancement devices for OSA Clinical Dentistry 4 (5): 82-84
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