Dental News December 2012

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3

CONGRESSES

ARTICLES 12.

Minimal Invasive Dentistry: Mock-Up and Tooth Tissue Preservation Techniques

By Dr. Olivier Etienne

24.

54.

56.

The EMA First Step Appliance

74.

Hidrotic Ectodermal Dysplasia A Case Study

By Dr. Adel Jragh & Dr. Hassan Mousawi & Dr. Manar Al-Nouri

40.

Dental facial Cosmetic International Conference Jumeira beach Hotel, Dubai

By Dr. Derek Mahony & Dr. Terry Whitty

64.

30.

23rd Jordanian International Dental Conference Amman, Jordan, The Land Mark Hotel

The Effect of Curing Light Type and Intensity on the Depth of Cure of Dental Resin Composites

By Dr. Hashem M. Ridha & Dr. Hadi A. AlBahrani & Dr. Abdulaziz H. Aljazzaf

Dental News, Volume XIX, Number IV, 2012

3rd ScientiďŹ c Day of the Lebanese Society of Prosthodontics Monroe Hotel, Beirut, Lebanon

ITI Congress Middle East Beach Rotana Hotel, Abu Dhabi, UAE

ADVERTISING INDEX ACE Surgical 58 ACTEON 27 A-DEC 49 AL TURKI 71 BA Intl 19 BIEN AIR 21 BISCO 63 CARESTREAM 15, 53 Carl MARTIN 59 CAVEX 35 COLTENE 7 D4D 17 DENTSPLY 23 DISCUS PHILIPS 9 DMG 71 DURR 67 EMOFORM 4 GC 37 GEISTLICH 39 GSK C3, 31, 51, 61 HENRY SCHEIN 69 HU FRIEDY 10 INIBSA 41 IVOCLAR 1, C4

JDENTALCARE 65 KAVO C2 KERR 33 MEDESY 22 METASYS 72 MICRO MEGA 25 MORITA 13 NSK C1 ORTHO ORGANIZERS 80 PLANMECA 45 RITTER 43 SCI CAN 75 SDI 70 SIRONA 8 SULTAN 52 THOMMEN 29 TEBODONT 5 ULTRADENT 79 VITA 77 VOCO 47 W&H 6 ZHERMACK 2 ZIMMER 73

International Calendar w w w.dent alnews .com Volume XIX, Number IX, 2012 EDITORIAL TEAM Alfred Naaman, Nada Naaman, Jihad Fakhoury, Dona Raad, Antoine Saadé, Lina Chamseddine, Tarek Kotob, Mohammed Rifai, Bilal Koleilat, Mohammad H. Al-Jammaz COORDINATOR Suha Nader ART DEPARTMENT Ibrahim Mantoufeh SUBSCRIPTION Micheline Assaf, Nariman Nehmeh ADVERTISING Josiane Younes PHOTOGRAPHY Albert Saykali TRANSLATION Gisèle Wakim, Marielle Khoury DIRECTOR Tony Dib ISSN 1026-261X

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The 24th Saudi Dental Society International Dental Conference

11 January 28 - 30, 2013 at the Riyadh International Exhibition Center.

Email: sds_riyadh@hotmail.com Website: www.sds.org.sa

AEEDC 2013

February 5 - 7, 2013 at the state-of-the-art Dubai International Convention & Exhibition Centre (DICEC) Website: www.aeedc.com

7th Annual Meeting of the Saudi Orthodontic Society

February 19 - 20, 2013 at The Ritz-Carlton Hotel Riyadh, Saudi Arabia Email: saudi_o_s@hotmail.com

The Oman International Dental Conference

February 27 - 28, 2013 At the Bustan Palace, Muscat, Oman Email: : info@omanidc.com Website: www.omanidc.com

IDS 2013

March 12-16, 2013 at the Koelnmesse, Cologne, Germany.

Website: www.ids-cologne.de

The Biennial Orthodontic Congress - Singapore

March 22 - 24, 2013 at the prestigious Marina Bay Sands, Singapore.

Email: oceinfo@iirx.com.sg Website: www.oce-aos.com

Dubai Implantarium

April 4 - 6, 2013 at the Armani Hotel, Burj Khalifa Dubai Email: denthany@aoiaegypt.com

The 17th Kuwait Dental Association Conference

April 13-15, 2013 at the Radisson Blu Hotel, Kuwait.

Email: info@kda.org.kw Website: www.kda.org.kw

13th International Convention (LUSD) Lebanese University

May 1 - 4, 2013 at President Rafic Hariri Campus, Beirut, Lebanon Email: congresul@ul.edu.lb

8th CAD/CAM & Digital Dentistry International Conference

May 2 - 3, 2013 at The Address Hotel Dubai Marina, Dubai, UAE Email: info@cappmea.com Website: www.cappmea.com

The 2nd Arabian Academy of Esthetic Dentistry meeting (ARAED)

May 3 - 4, 2013 at the Kempinski Hotel, Dead Sea, Kingdom of Jordan.

Website: www.araed-org.com

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12 Minimal Invasive Dentistry Mock-up and Tooth Tissue Preservation Techniques

Minimal Invasive Dentistry: Mock-up and Tooth Tissue Preservation Techniques Dr. Olivier Etienne drolivieretienne@gmail.com

Introduction During the past 20 years, bonding has no doubt represented a major revolution in dentistry.

Constant improvements in terms of bonding to dental tissue, together with technical improvements in ceramic materials, have made it possible to develop aesthetic dentistry with less risk of fracture.

This adhesive revolution has quickly become part of the concept of tissue conservation by providing new types of preparations, mixtures of traditional techniques and new ideas related to bonding.

Especially, one crucial clinical factor has become apparent: the difference in bonding quality between dentine and enamel. In fact, due to the nature of these two substrates, enamel bonding is always superior to dentine bonding1. The practitioner must always systematically find the best compromise between sufficient thickness, to ensure strength and aesthetics (table 1), and maximum conservation of the enamel on the prepared surface. However, when taking into consideration the variations in ceramic translucency and the original shade of the substructure, a more “aggressive� approach may be necessary in order to better conceal a discolouration2. Similarly,

All-ceramic Restorations

Minimum Thickness (in mm) Labial

Lingual

Occlusal

All ceramic crowns

1,2

1,2

1,5

Pressed Veneers (leucite, lithium disilicate)

0,8

Not applicable

1,5

Feldspathic Veneers

0,6

Not applicable

1,5

Table 1: Minimum thickness recommended for different ceramic types on a non-discoloured substructure Dental News, Volume XIX, Number IV, 2012

pressed-ceramic veneers require more overall thickness than feldspathic ones.

Whenever clinically possible, it is recommended to favour a minimally-invasive enamel preparation that will enhance the longevity of the restoration3,4 and prevent post-operative sensitivity. When preparing for this, the varying degree of enamel thickness must be taken into account first (fig. 1).

Fig. 1: Labial view and medium sagittal cut of four central maxillary incisors of different ages (from left to right: patients of 19, 32, 42 and 68 years respectively).

Enamel thickness is variable between teeth and also in each tooth depending on the height.

This thickness depends on the patient’s age, dental history and, most of all, on possible wear of the enamel. This loss of thickness can be aggravated, either by abrasive compounds (toothpaste with high concentrations of bicarbonate) or acids (acidic drinks, citrus fruits, etc.). In order to optimise the aesthetic result and to get a better preview via the wax-up, detailed clinical observations of the initial wear should be undertaken right from the start.

Normally the natural thickness of the labial enamel of anterior teeth will measure on average between:

14 Esthetic Dentistry Mock-up and Tooth Tissue Preservation Techniques

Thickness of the labial enamel of anterior teeth

Thickness (in mm) Mininmal

Maximal

Gingival area

0.3

0.5

Middle part

0.6

1.0

Incisal area

1.0

2.1

Table 2: Natural thickness of the labial enamel of anterior teeth.

These average values represent a wide range of variations for each patient and for each individual tooth (table 2).

Evolution of preparation concepts Taking these basic requirements into account, several clinical propositions have been suggested to minimise the preparation of dental tissue.

Mainly, these propositions are based on the idea of progressive reduction or the idea of controlled penetration5.

Fig. 2: It is possible to achieve a uniform preparation by using vertical grooves with a thickness that is visually controlled and does not exceed the diameter of the bur. Monitoring with a pre-operative silicone index makes it possible to conďŹ rm this uniform reduction.

The Index Technique Development of this approach involves using the final morphology of the reconstruction as a reference. This is performed before preparation with an aesthetic wax-up built on the initial plaster cast. Using this model as a guide, it is possible to prepare either a thermoformed transparent matrix (ensuring both control of the preparation and, later, fabrication of the temporary veneers by using it as a mould) or to make one or more silicone indexes to check the preparation (fig. 3) 8.

I. Progressive Reduction Methods In progressive reduction methods, a reference point such as an adjacent tooth, the dimension of the cutting tool or a pre-op silicone index are used in order to visually enhance and mechanically control the amount of tooth structure that is to be removed.

The Depth Cut Technique During preparation of the teeth, the simplest method is to estimate the volume removed by comparison with neighbouring teeth. This threedimensional visualisation has great operator variability and makes the results not very efficient in terms of tissue conservation.

In order to improve this procedure, vertical grooves can be cut in the tooth at the beginning of the preparation while visually making sure not to penetrate more than the diameter of the bur.6,7 As in the previous method, it relies on the contour of the tooth to be restored and therefore has the great advantage of controlling the preparation.

If the shape of the tooth can be reproduced in the same proportions then this is the method of choice (fig. 2).

Dental News, Volume XIX, Number IV, 2012

Fig. 3: When using the technique with silicone indexes it is necessary to work out an aesthetic plan beforehand. This is fabricated on a situation model, a duplicate of the study model with the help of a wax-up.

Several indexes can be prepared from this model and will be sectioned in their horizontal or vertical axes. To make it easy to reposition these indexes they should cover the gingiva and the surrounding teeth.

As P. Magne demonstrated, this option9,10,11 consists of preparing two silicone indexes cut into strips (one for the vertical and one for the horizontal axis); making it possible to assess the reduction of tissue during preparation. This method completely supports the principle of maximum tissue conservation and ensures a predictably consistent outcome. However, this is a complex and time-consuming procedure because

16 Esthetic Dentistry Mock-up and Tooth Tissue Preservation Techniques

Table 3: ISO references, diameters and cutting depth of selected burs for veneers preparation

Reference (ISO)

Diameter of chuck

Diameter of bur (ISO)

Cutting Depth

868 B

1,6 mm

2,0 mm (020)

0,4 mm

834

1,6 mm

2,1 mm (021)

0,5 mm

801 L

1,0 mm (oberer Teil)

2,3 mm (023)

0,65 mm

801 L

1,0 mm (oberer Teil)

2,9 mm (029)

0,95 mm

Average enamel thickness according to the dental surface concerned Teeth

buccal/labial max.

Table 4 Average thickness at the centre of each dental surface according to Naveau et al.15 (max: maxilla ; mdb: mandible)

mdb

palatal/lingual max.

mdb

Proximal

occlusal

max.

mdb

max.

mdb

Incisor

1,0

0,9

0,7

0,6

0,7

0,65

0,9

0,9

Canine

0,8

0,8

0,7

0,6

0,75

0,6

1,1

1,0

Premolar

1,3

1,25

1,4

1,1

1,15

1,05

1,3

1,25

Molar

1,45

1,55

1,6

1,4

1,3

1,35

0,55

0,5

frequent use of the control indexes is necessary.

II. Controlled Penetration Methods Contrary to the methods described above, the idea of controlled penetration makes it possible to perform a predictable reduction of dental tissue (table 3) thanks to the use of specially designed burs. Using their shape will physically limit the potential for possible errors.

The Direct Technique The first clinical suggestions for this technique recommend the use of specific burs that limit the depth of penetration due to their shape (fig. 4).

Consequently there is no guarantee with respect to enamel preparation.

The Indirect Technique The logical evolution of all these concepts was put forward by G. Gürel in 200316 : it combines the idea of minimum reduction while considering the volume of the final restorative shape, and also the use of specific burs that make a controlled penetration possible. This technique is based on a simple, but rigorous procedure ensuring a high level of reproducibility irrespective of the clinician.17,18

Clinical Procedure Phase I: Aesthetic analysis and wax-up Smile analysis is an indispensable prerequisite for any planned aesthetic restoration. It is based on several well defined criteria19/20. The changes envisaged are illustrated by modelling with composite resin, applying it directly to the dry tooth without the use of an adhesive (fig. 5).

Fig. 4: The diamond burs used for a controlled penetration should be used parallel to the surface. In other words, once there is contact with the shank further penetration cannot be made. This technique suffices when the final shape of the reconstruction is identical to the initial shape.

While with this technique the depth of penetration is controlled and known, the initial thickness of the enamel cannot be assessed. Also, with time and through varying aetiological wear and tear there is a natural variation (table 4) between teeth.12,13,14 Dental News, Volume XIX, Number IV, 2012

Fig. 5: The aesthetic analysis and the patient’s wishes indicate the need for bonded ceramic veneers. With the help of composite resin placed freehand on the labial surfaces an initial chairside impression can be taken. To simulate the shortening of the canines the teeth that are too long are marked with a black felt-tip pen (arrows). The superimposition of the images illustrates the aesthetic advantages of the elimination of the diastema and the realignment of the incisors.

18 Esthetic Dentistry Mock-up and Tooth Tissue Preservation Techniques

Once the desired modifications have been agreed upon (form of teeth, diastema closure, etc.) an impression will enable the dental technician to make a more detailed wax-up (fig. 6).

To avoid clogging up the instruments, it is recommended to use a bis-acryl resin for this mock-up and not a conventional powder/liquid system.

Once in place the matrix will indicate the final restoration and should be left on the teeth as a guide during preparation.

Phase III : A minimally invasive preparation through the mock-up

Fig. 6: The diagnostic model is modiďŹ ed according to the instructions given by the practitioner (impressions, photos etc). The wax-up makes it possible to lengthen and re-size the teeth. At this point, it becomes evident that the tissue reduction will not be uniform: the white zones (wax) will be spared more than the zones in ochre (plaster). The new appearance is recorded using a double mix silicone impression made in order to optimise precision. This impression will serve as a mould when making the intraoral mock-up.

Depending on the material chosen, the thickness of the restorative material should determine the diameter of the bur and thus the depth of penetration (table 3). Once determined, the horizontal grooves are cut into the labial surface ensuring a penetration parallel to the surface, until there is contact with the smooth part of the chuck on the resin of the mock-up (fig. 11).

Based on this model, a rigid matrix can now be made either by using thermoforming or with a silicone impression.

Phase II : Making the mock-up The mould is filled with a composite resin and inserted over the patient’s teeth until polymerization is completed (fig. 7).

Fig. 7: Details of the wax-up are reproduced by the double mix impression. The resin (Luxatemp Star, DMG) is dispensed into it before repositioning it in the mouth. After polymerization, the aesthetic appearance can be immediately assessed. Because of its variable thickness, the resin layer should not be removed at this point.

Dental News, Volume XIX, Number IV, 2012

Fig. 11: The resin mock-up in place over the prepared teeth. The depth of the grooves do not depend only on the diameter of the bur, but also on the aesthetic template (mock-up) used. Once the mock-up is removed the depth of the guide grooves varies. It is now possible to ďŹ nalise the preparation by joining the bottom of the grooves. The enamel layer is preserved better and the thickness of the ceramic veneer is standardised.

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20 Esthetic Dentistry Mock-up and Tooth Tissue Preservation Techniques

Once these labial grooves have been made, the occlusal reduction should be undertaken before removing the mock-up. To visualise the depth limit for the preparation better, the bottom of each groove can be highlighted with a pencil or felt tip marker (fig. 8).

Fig. 8: With the mock-up in place, the bur is moved over the labial surface, in parallel lines, until contact with the shank is achieved. Three to four grooves are sufficient to mark the final depth of the preparation.

After establishing the occlusal reference points, the grooves are accentuated with a pencil.

The mock-up is removed leaving only the coloured grooves (fig. 9).

provisional restoration.

A preparation based on this principle of tissue conservation ensures that only necessary enamel surfaces need to be adjusted for aesthetic and functional results (fig. 10).

Fig. 10: Clinical case after one week. The final aesthetic appearance is determined by the volume of the relevant anterior teeth. Preparation through the mock-up has made it possible to create the desired final result.

Limitations of the technique In certain specific cases, when one or more teeth are malaligned from the desired archform, it will be necessary to prepare and reduce these teeth first.

This prevents any risk of incorrect positioning of the thermoformed index or the impression when doing the mock-up. To ensure a perfect placement of the mock-up impression over the teeth, one should check first that the initial reduction is enough with the help of a silicone index.

The labial surfaces are fully involved in this technique. However, when it comes to the palatal area, it is difficult to extend this technique for partial crowns. With the help of the silicone indexes, it is possible to visually control the situation in static and dynamic occlusion and to ensure a proper thickness of material.

Conclusion Fig. 9: The remaining parts of the mock-up are removed and allow the practitioner to get a clear view of the guiding grooves. Preparation will continue until the coloured grooves are completely removed, and completed within the proximal zones in accordance with the aesthetic needs. The impression can be used again, when filled with bis-acrylic resin (Luxatemp Star, DMG), in order to make the provisional restorations.

These are then joined together and the final preparation design is completed. At the end of the appointment, an impression is taken. Then the mock-up impression can be used to make the Dental News, Volume XIX, Number IV, 2012

Saving tooth structure should be the foremost concern because it ensures both a better longevity and, more importantly, makes future interventions more feasible. Each decision and clinical intervention should be made taking a therapeutic gradient into consideration. When it comes to tissue conservation it is fundamental to recognise that bonding to enamel is far superior to that to dentine when indications call for adhesive bonding. In other words, all techniques that make it possible to preserve enamel should be favoured when the thickness of the restoration allows this.

22 Esthetic Dentistry Mock-up and Tooth Tissue Preservation Techniques

The most successful development in this respect is based on the management of the final mock-ups, used as a template for the preparation, associated with drills of optimal shape for a controlled penetration.

REFERENCES

1 STANGEL I, ELLIS TH, SACHER E. ADHESION TO TOOTH STRUCTURE MEDIATED BY CONTEMPORARY BONDING SYSTEMS. DENT CLIN NORTH AM. 2007 JUL;51(3):677-94.

2 SPEAR F, HOLLOWAY J. WHICH ALL-CERAMIC SYSTEM IS OPTIMAL FOR ANTERIOR ESTHETICS ? J AM DENT ASSOC. 2008 SEP;139 SUPPL:19S-24S. 3 CHRISTENSEN GJ. WHAT IS A VENEER? RESOLVING THE CONFUSION. J AM DENT ASSOC. 2004 NOV;135(11):1574-6.

4 PEUMANS M, VAN MEERBEEK B, LAMBRECHTS P, VANHERLE G. PORCELAIN VENEERS: A REVIEW OF THE LITERATURE. J DENT. 2000 MAR;28(3):163-77.

5 KOIS JC. NEW PARADIGMS FOR ANTERIOR TOOTH PREPARATION: RATIONAL AND TECHNIQUE. CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE. 1996;2(1)1-8.

6 SEYMOUR KG, SAMARAWICKRAMA DY, LYNCH EJ. METAL CERAMIC CROWNS--A REVIEW OF TOOTH PREPARATION. EUR J PROSTHODONT RESTOR DENT. 1999 JUN-SEP;7(2):79-84.

7 AHMAD I. PROTOCOLS FOR PREDICTABLE AESTHETIC DENTAL RESTORATIONS. BLACKWELL SCIENCE. 1ST EDITION. 2006.

8 PARIS JC., ORTET S. ET AL. SMILE ESTHETICS: A METHODOLOGY FOR SUCCESS IN A COMPLEX CASE. EUR J ESTHETIC DENTISTRY. 2011 ;6(1) :50-74 9 MAGNE P, MAGNE M. USE OF ADDITIVE WAX-UP AND DIRECT INTRAORAL MOCK-UP FOR ENAMEL CONSERVATION WITH PORCELAIN LAMINATE VENEERS. EUR J ESTHET DENT. 2006 APR;1(1):10-9.

10 MAGNE P, BELSER UC. NOVEL PORCELAIN LAMINATE PREPARATION APPROACH DRIVEN BY A DIAGNOSTIC MOCKUP. J ESTHET RESTOR DENT. 2004;16(1):7-16; DISCUSSION 7-8.

11 MAGNE P, BELSER U. BONDED PORCELAIN RESTORATIONS IN THE ANTERIOR DENTITION: A BIOMIMETIC APPROACH. QUINTESSENCE PUBLISHING; 2002.

12 ATSU SS, AKA PS, KUCUKESMEN HC, KILICARSLAN MA, ATAKAN C. AGE-RELATED CHANGES IN TOOTH ENAMEL AS MEASURED BY ELECTRON MICROSCOPY: IMPLICATIONS FOR PORCELAIN LAMINATE VENEERS. J PROSTHET DENT. 2005 OCT;94(4):336-41.

13 LAMBRECHTS P, BRAEM M, VUYLSTEKE-WAUTERS M, VANHERLE G. QUANTITATIVE IN VIVO WEAR OF HUMAN ENAMEL. J DENT RES. 1989 DEC;68(12):1752-4.

14 GRINE FE. ENAMEL THICKNESS OF DECIDUOUS AND PERMANENT MOLARS IN MODERN HOMO SAPIENS. AM J PHYS ANTHROPOL. 2005 JAN;126(1):14-31.

15 NAVEAU A, RENAULT P, PIERRISNARD L. PULPE ET PROTHÈSE FIXÉE À ANCRAGE PÉRIPHÉRIQUE. CAH PROTH. 2007;138:55-64.

16 GUREL G. PREDICTABLE, PRECISE, AND REPEATABLE TOOTH PREPARATION FOR PORCELAIN LAMINATE VENEERS. PRACT PROCED AESTHET DENT. 2003 JAN-FEB;15(1):17-24.

17 GÜREL G. THE SCIENCE AND ART OF PORCELAIN LAMINATE VENEERS. QUINTESSENCE PUBLISHING, CAROL STREAM, IL: 2003 18 GUREL G. PORCELAIN LAMINATE VENEERS: MINIMAL TOOTH PREPARATION BY DESIGN. DENT CLIN NORTH AM. 2007 APR;51(2):419-31.

19 ROMANO R, BICHACHO N, TOUATI B, EDS. THE ART OF THE SMILE. CAROL STREAM, IL: QUINTESSENCE PUBLISHING; 2005.

20 FRADEANI M. ESTHETIC REHABILITATION IN FIXED PROSTHODONTICS: ESTHETIC ANALYSIS. QUINTESSENCE PUBLISHING. 2005.

Dental News, Volume XIX, Number IV, 2012

24 Prosthetic Dentistry

The EMA First Step appliance Dr. Derek Mahony info@derekmahony.com Dr. Terry Whitty

Figure1 The EMA First Step appliance.

Figure 1

Sleep apnea, in its simplest definition, occurs when a patient stops breathing during sleep. This can be as a result of Central Sleep Aponea (CSA) i.e. a neurological condition, in which the brain temporarily stops sending signals to the muscles that control breathing. More commonly, the sleep Aponea occurs from Obstructive Sleep Aponea (OSA).

OSA is caused by a narrowing, or complete closure, of the upper Airway, while we sleep. This obstruction to our breathing rapidly depletes the supply of oxygen to our body. This, in turn, forces our body to “wake up” - termed an arousal in order to recommence breathing.

Figure 2 The EMA First Step kit includes all materials and parts to construct the appliance including complete instructions.

Figure 3 Position the upper lugs between the canine and first bicuspid. Use the blue sticky wax included.

Figure 4 Using the included jig mark the position for the lower lugs.

Dental News, Volume XIX, Number IV, 2012

Figure 2

Figure 3

Figure 4

The number of times, per hour, that our breathing ceases (aponeas) or becomes diminished (hyponeas), is used to categorise the level of OSA as either mild, moderate or high. This is based on what we term the apnea-hypopnea index (AHI).

The higher the score, the greater the number of times, per hour, that sleep has been interrupted, and the greater the risk of compromising our overall systemic health.

The symptoms of OSA can include daytime sleepiness, fatigue, frequent napping, headaches, poor memory, inattention, irritability, and insomnia.

The long term effects can be very serious.

Snoring is also often a symptom of OSA, but it is also possible to have OSA and not snore; and vice versa.

Obstructive Sleep Aponea may be a risk factor for the development of other medical conditions, including high blood pressure (hypertension), heart failure, heart rhythm disturbances, athero

26 Prosthetic Dentistry The EMA First Step appliance

Figure 5 Position the lower lugs using the blue sticky wax included.

Figure 6 Upper and lower models with lugs in place.

sclerotic heart disease, pulmonary hypertension and insulin resistance. In other words, sleep apnoea is a serious medical condition that requires proper diagnosis by a medical practitioner, typically through a sleep study (using a polysomnogram). This PSG is used to determine the type, and severity, of the problem, before a treatment strategy is developed.

Figure 5

Figure 6

Treatments for OSA include weight loss, surgery, mechanical maintenance of the airway, using continuous positive airway pressure (CPAP), or the use of oral appliances. Acceptance of the efficacy of oral appliances, in the treatment of OSA, has increased significantly, in the last 5 years. This has been as a result of research conducted by the sleep medicine community, showing that whilst an oral appliance may not be as effective as CPAP, (considered to be the gold standard of treatment), patient compliance is significantly higher. This means that patients are more likely to wear an oral appliance, during sleep, than a CPAP mask, connected to a mechanical pumping device.

The number, and variety, of oral appliances, to treat snoring and sleep aponea, has seemingly exploded in the past few years. A type termed mandibular advancement splints (MAS) or mandibular repositioning appliances (MRA), are the most common oral appliances, prescribed for OSA.

Figure 7 Use a vacuum- or pressureforming machine to form the material over the model and lugs. The material will form well over the lugs due to the nature of the proprietary thermoforming plastic.

This type of appliance moves the lower jaw forward, which tightens the soft tissue, and muscles, of the upper airway to prevent obstruction of the airway during sleep. The tightening created, by the device, also prevents the tissues of the upper airway from vibrating as air passes over them - the most common cause of snoring.

Figure 7

The price for an MAS/MRA varies from $25 to $2500. You can imagine that they also vary in quality and effectiveness. All oral appliances have their advantages, and disadvantages, and it seems every other week someone is patenting something new.

EMA First Step appliance Figure 8 Trim with scissors.

Dental News, Volume XIX, Number IV, 2012

Figure 8

The EMA First Step appliance is a new and unique appliance that is not only a mandibular advancement splint, but also acts as a clinical diagnostic

28 Prosthetic Dentistry The EMA First Step appliance

aid. It’s a simple device, incorporating two flexible splints, connected by flexible straps, that hold the mandible forward, in the desired position.

Figure 9 Attach elastic strap, right side.

Figure 10 Attach elastic strap, left side.

Figure 11 Changing the length of the elastic strap changes the amount of titration. A shorter strap increases advancement.

The advantages of the EMA first Step appliance include: Figure 9

Figure 10

Figure 11

1. A low profile which is comfortable to wear; 2. Fits the upper and lower jaw snugly; 3. Easily able to be adjusted, in 1mm increments by the patient 4. Vertical and lateral excursions are possible; and 5. It is inexpensive and easy to construct.

The EMA First Step appliance has some unique clinical and diagnostic advantages, including the ability to: 1. Test a patient’s tolerance to an MAS; 2. To measure the correct mandible repositioning (This is very useful especially if another MAS is to be subsequently constructed); 3. Easily test if an MAS is suitable for the patient in treating their OSA; and 4. Test for Bruxing or other undesirable nocturnal habits that may contraindicate use of an MAS. The EMA First Step appliance is easy to fabricate.

It comes in kit form, with all parts needed for construction. Construction time is approximately 15 minutes and can easily be completed in the dental laboratory, or in a dental chair.

A vacuum - or pressure - forming machine is all that is required to assist in the EMA construction.

Figures 1-13 are a step-by-step guide to the construction of the EMA First Step appliance.

Figure 12 Airway obstructed.

Figure 13 Airway maintained with the EMA appliance.

Dental News, Volume XIX, Number IV, 2012

Figure 12

Figure 13

30

HIDROTIC ECTODERMAL DYSPLASIA - A CASE STUDY Abstract Dr. Adel Jragh ajragh@hotmail.com Dr. Hassan Mousawi bu_zahed@hotmail.com

Dr. Manar Al-Nouri manardr@live.com

Ectodermal dysplasia is a multiple disorder disease, which affect two or more ectodermal structures such as the development or function of teeth, hair, nails and sweat glands. It occurs in two forms: Hypohidrotic form, or Hidrotic form. A case ectodermal dysplasia in hidrotic form was reported. Early dental treatment with implants supported prosthesis improve patient’s, both functionally and esthetically.

Introduction Ectodermal Dysplasia is not a single disorder, but a group of closely related disorders known as the Ectodermal Dysplasias. The condition was first described by Thurnman in 1848 1 and was coined

by Weech in 1929 2. Ectodermal dysplasias are heritable conditions in which there are abnormalities of two or more ectodermal structures such as the development or function of teeth, hair, nails and sweat glands 3. Freire-Maia and Pinheiro described numerous varieties of ectodermal dysplasia involving all possible Mendalian modes of inheritance 4. More than 192 different syndromes have been identified till date 5; depending on the particular syndrome, ectodermal dysplasia can affect the skin, eye lens or retina, parts of the inner ear, development of fingers and toes, nerves and other parts of the body 6. Despite some of the syndromes having different genetic causes, the symptoms are sometimes very similar. Ectodermal dysplasia can be classified by its mode of inheritance or by which structures are involved.

Diagnosis is usually conducted by clinical observation often accompanied by family medical histories so that it can be determined whether transmission is autosomal, dominant or recessive. Ectodermal dysplasia can occur in any race but is much more prevalent in caucasians than any other group.

From the clinical point of view, two main forms have been distinguished 7: Dental News, Volume XIX, Number IV, 2012

1. Hypohidrotic form/ Christ-SeimensTourian Syndrome 2. Hidrotic form/ Clouston syndrome The hypohidrotic ectodermal dysplasia is found to be the most common form among this large group of hereditary disorders, and is estimated to affect at least one in 17,000 people worldwide [8].

It exhibits the classic triad-hypohirdosis, hypotrichosis, and hypodontia. Usually X-linked recessive inheritance is seen with this syndrome. Males are affected severely while females show only minor defects 9,10,11. In the hidrotic form of ectodermal dysplasia teeth, hair, and nails are affected, while the sweat glands are usually spared 12. It is commonly inherited as an autosomal dominant trait. GJB6, encoding gap junction protein 6 (connexin-30), is the only gene currently known to be associated with hidrotic ectodermal dysplasia 13,14.

Most individuals with hidrotic ectodermal dysplasia syndrome have an affected parent. Offspring of affected individuals have a 50% chance of inheriting the mutation and being affected. Other inheritance modalities like autosomal recessive have also been reported 15. Table 1 The characteristic facial features associated with ectodermal dysplasias are: frontal bossing, depressed nasal bridge, prominent supra orbital ridges and obliquely set ears, midface is depressed, the lower third of the face appears small due to lack of alveolar bone development, lips are protruberant 16. A cephalometric study by Vierucci and collegues has shown significant differences in the craniofacial features of unaffected and affected children 17. In the oral cavity the most striking feature is oligodontia; the condition of missing over 6 teeth or more, excluding 3rd molar. Teeth in the anterior region of the maxilla and the mandible are conical or pointed in shape 18. The enamel may also be defective. There is a wide midline diastema and hypoplastic labial frenum.

32 Oral Pathology HIDROTIC ECTODERMAL DYSPLASIA - A CASE STUDY

HYPOHYDROTIC

HYDROTIC Mode Of Inheritance

Most Often Autosomal Dominant

Most Often X-Link Recessive

Scalp Hair

Soft, Dawny, Color Is Darker

Fine In Texture, Fair And Short

Teeth

Anodontia To Hypodontia

Anodontia To Hypodontia

Lips

No Abnormality

Protruding

Sweat Glands

Active

Reduced To Absent

Nasal Bridge

No Flattening

Underdeveloped

Nails

Dystrophic Nails

No Abnormality

eyebrows

frequently absent

absent

eyelashes/ pubic/axillary hairs

scanty/absent

variably affected

Table. 1: differences between the hidrotic and the hypohidrotic forms of ectodermal dysplasia

Figure 1 Pedigree of the patient family

Fig 1

Figure 2 Frontal view picture

Fig 2

Commonly, there is only one molar tooth in the second molar region, which usually exhibits a bud crown form. Cosmetic dental treatment is almost always necessary and children may need dentures as early as two years of age 19. Multiple denture replacements are often needed as the child grows, and dental implants may be an option in adolescence, once the jaw is fully grown. Nowadays this option of extracting the teeth and substituting them with dental implants is quite common. In other instances, teeth can be crowned in conjunction with orthodontic treatment. Due to the complexity of the dental treatment, a multidisciplinary approach is best. This case report describes the implant oral rehabilitation of a patient with ectodermal dysplasia with severe atrophy of the residual alveolar crest, and maxillary sinus pneumatization.

Case presentation:

Figure 3 Intra oral picture frontal view

Figure 4 Preoperative panoramic radiographs view Dental News, Volume XIX, Number IV, 2012

Fig 4

A 21-year-old female diagnosed with genetic ectodermal dysplasia present to Amiri Dental Center Dep. of Prosthodontics for implant rehabilitation of her partially edentulous maxilla and mandible.

Her family history revealed that her grandmother, father, uncle, and her brother had the same condition (Figure 1). Her chief complaints were unaesthetic appearance and difficulty in chewing food.

Her medical history revealed anemia, with no other current pathologic conditions or allergies to any medications. She did report taking folic acid under the supervision of her physician. She assured a clinical history of normal sweating from birth with normal tolerance to heat (Figure 2).

The clinical examination revealed very fine and soft hair on the scalp, slow growing nails, multiple

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34 Oral Pathology HIDROTIC ECTODERMAL DYSPLASIA - A CASE STUDY

Figure 5 preoperative CT scan ďŹ nding of the maxillary arch

Figure 6 preoperative CT scan ďŹ nding of the mandibular arch

missing teeth (excluding third molars): #2, 3, 4, 5, 12, 13, 14, 15, 18, 23, 24, 25, 26, 28, 29 and 31. Enamel Hypoplasia was found on teeth #13, and 23. The panoramic radiograph assessment showed abnormal morphology of teeth: #7, 8, 9, 10, and 21. Also, horizontal bone loss in posterior mandibular area, super eruption of teeth #19, and 30, loss of occlusal vertical dimension, underdeveloped alveolar ridges, and bilateral inferior expansion of the maxillary sinus were noticed (Figure 3, and 4).

occlusal record, and a face bow transfer. Study models were mounted, and a diagnostic wax-up with the new vertical dimension of occlusion was fabricated. A CT scan was ordered to evaluate the presence of sufficient cancellous and cortical bone volume at each potential implant position site, and for site-specific selection of the implants according to the surgical and prosthetic treatment plan (Figure 5, and 6). Finally, the case and the treatment plan were presented to the patient. Following patient consent, all the mandibular teeth were prepared and provisional restorations were placed

Diagnosis: s %CTODERMAL DYSPLASIA (Hidrotic form/Clouston syndrome). s 0ARTIALLY MAXILLARY AND MANDIBULAR OLIGODONTIA s #OLLAPSED VERTICAL DIMENSION s -ASTICATORY AESTHETICS

and verbal dysfunctions. s "ILATERAL MAXILLARY SINUS PNEUMATIZATION The treatment plan of the maxillary arch involved extraction of all teeth. A bilateral sinus lifting procedure, and alveolar ridge augmentation.

Followed by immediate complete denture, implant placement, and maxillary cemented fixed partial dental prosthesis on dental implant. In the mandibular arch, crowns retained by natural teeth and cemented fixed partials dental prosthesis, along with cemented dental crowns retained by dental implants # 28, and 29. Initially, preliminary impressions were made, along with a centric relation Dental News, Volume XIX, Number IV, 2012

Figure 7 Provisionals with maxillary wax rims

based on the wax-up. A new bite registration with the maxillary wax rim was made to fabricate the maxillary immediate denture (Figure 7).

The second visit involved, extraction of all maxillary teeth and alveoloplasty procedure were performed under local anaesthesia. A bilateral sinus lifting procedure and a simultaneous alveolar ridge augmentation of the maxilla using autogenous corticocancellous particulate bone grafts from the maxillary crest were performed to reconstitute the lacking bone. This was followed by delivering of immediate maxillary complete denture. After 4 months of socket healing implant surgery was

24 36 Oral Pathology HIDROTIC ECTODERMAL DYSPLASIA - A CASE STUDY

Figure 8 Post-implant

Figure 9 A) metal frame work on the articulator.

B and C) cemented maxillary and mandibular final restorations.

D) crowns in centric relation.

Figure 10 Postoperative panoramic view

performed under local anesthesia. The reopening of the mucoperiostal flaps revealed that the augmented bone had been resorbed to a significant extends within four months. Using the prefabricated templates from the maxillary denture, 8 standard self-tapping implants (Dentium, IMPLANTIUM® Implant, Korea) were inserted in the maxilla, and 2 implants in the mandible in site of teeth # 28, and 29 (figure 8). Bone augmentation around the dental implants was performed using a mixture (ratio 1:0.5) of Cadaver Freezed Dried Bone and Demineralized Freezed Dried Bone (Grafton® DBM Putty in a Jar and MinerOss® mixture of allograft mineralized cortical and cancellous chips, BioHorizons IPH, USA). Postoperative healing was uneventful. Following 4 months of healing, the implants were uncovered and healing abutment surgery was performed. All implants were completely osseointegrated in the new bone. Two weeks after replacing the healing abutments, final impressions for both arches were made with a light body-vinyl polysiloxane and heavy putty impression material in a custom impression trays. The working casts were then mounted on a semi-adjustable, non-arcon type articulator using facebow records (Hanau 95H2, WhipMix, USA). Maxillary and mandibular metal frameworks were fabricated and returned from the laboratory for a try in. The frameworks were verified and new centric relation records were obtained. The new vertical dimension of occlusion was evaluated and verified. The final prostheses were cemented with glass ionomer luting cement (GC Fuji I® - GC America, Inc., USA). Oral hygiene instructions were given and reinforced to the patient (figure 9, 10, and 11).

Discussion

Figure 11 Preoperative and postoperative clinical pictures.

Dental News, Volume XIX, Number IV, 2012

It has been suggested that for a disorder to be classified as ectodermal dysplasia, abnormalities of at least two of the following structures must be present: hair, teeth, nails or sweat glands. There is, however, no universal agreement on the precise number of abnormal features which should be present. In the case reported above, defective hair, slow growing nails, and Oligodontia were seen and a diagnosis of ectodermal dysplasia was made. However, no defective sweat glands were observed; the presence of a positive family history of this condition suggested an autosomal domi

38 Oral Pathology HIDROTIC ECTODERMAL DYSPLASIA - A CASE STUDY

nant mode of inheritance, thus excluding the hypohidrotic type. Historically, prosthetic treatment for ectodermal dysplasia patients involved removable partial dentures, complete dentures and fixed partial dentures. The advent of dental implants has provided an additional treatment modality for restoration of the dentition in this group of patients 2. The oral rehabilitation of patients presenting with congenitally missing dentition is challenging because of the need for a multidisciplinary approach. Additional considerations, such as the patient’s age, stage of growth, inherent anatomic deficiencies present in conjunction with the missing teeth, soft tissue defects, existence of malformed dentition, severe diastemas and psychological status, must be considered 20. Since absence of teeth induces alveolar bone loss, patients with ED are usually present with a “knife edge crest” morphology making implant reconstruction challenging. Therefore, patients frequently require bone grafting and sinus-lifting procedures 21, 22, 23.

There are aesthetic, functional and psychological reasons that make it important to start oral rehabilitation early in life. However, this is usually a difficult condition to manage prosthodontically because of the typical oral deficiencies and patient’s age. Numerous clinical reports have demonstrated the importance of prosthetic dental treatment in ectodermal dysplasia patients for physiologic and psychosocial reasons.

Conclusion The treatment of patients with severe oligodontia due to ectodermal dysplasia will differ according to the unique anatomic limitations, dental status, and age of patients. The clinical report we have presented is a typical example of the required multidisciplinary treatment planning concepts necessary for successful rehabilitation of these patients.

Furthermore, three years follow up data on this patient has shown that dental implants are the most dramatic and effective treatment modality for patients with ectodermal dysplasia if carefully planned. Importantly, aesthetic dental interventions in patients with ectodermal dysplasia and malformed teeth and malocclusion help with the development of a positive self-image and overall oral health.

Dental News, Volume XIX, Number IV, 2012

Reference 1.RAJENDRAN R., SIVAPATHASUNDARAM B. SHAFER’S TEXTBOOK OF ORAL PATHOLOGY. 5TH ED. PHILADELPHIA: SAUNDERS;1983.

2.WEECH A. HEREDITARY ECTODERMAL DYSPLASIA. AMER J DIS CHILD. 1929; 37 (6):766.

3.HICKEY A, VERGO T, PROSTHETIC TREATMENTS FOR PATIENTS WITH ECTODERMAL DYSPLASIA, J PROSTHET DENT 2001;86:364-368.

4.HALL K.R. PEDIATRIC OROFACIAL MEDICINE AND PATHOLOGY: 4TH ED; LONDON; CHAPMAN AND HALL;1994:163.

5.ROCKMAN R, HALL K, FIEBIGER M, MAGNETIC RETENTION OF DENTAL PROSTHESES IN A CHILD WITH ECTODERMAL DYSPLASIA, JADA 2007;VOL 138(5):610-615.

6.ITTHAGARUN A, KING M. ECTODERMAL DYSPLASIA: A REVIEW AND CASE REPORT. QUINTESSENCEINT. 1997 SEP;28(9):595-602.

7.PASCHOS E, HUTH C, HICKEL R, CLINICAL MANAGEMENT OF HYPOHIDROTIC ECTODERMAL DYSPLASIA WITH ANODONTIA: CASE REPORT, J CLIN PEDIATR DENT 2002;27(1):5-8.

8.GEETHA V, PRADEESH S. HYPOHIDROTIC ECTODERMAL DYSPLASIA: CASE REPORT, OMP 2011; VOL 2(1):123-126 9.ELDER D, ELENITSAS R, JAWORSKY C AND JOHNSEN B . LEVER’S HISTOPATHOLOGY OF THE SKIN. USA. LIPPINCOTT WILLIAMS & WILKINS, 1997, 8TH ED. ; P- 125 10.NEVILLE W., DAMM D., ALLEN M. AND BOUQUOT E. ORAL AND MAXILLOFACIAL PATHOLOGY. USA. W.B.SUNDERS COMPANY, 2002, 2ND E.D.; P-541 11.SHAFER, HINE AND LEWY SHAFER’S TEXTBOOK OF ORAL PATHOLOGY. NEW DELHI. ELSEVIER; 2006, 5TH E.D., P 808 12.LOWRY B., ROBINSON C., MILLER R. HEREDITARY ECTODERMAL DYSPLASIA: SYMPTOMS, INHERITANCE PATTERNS, DIFFERENTIAL DIAGNOSIS, MANAGEMENT CLIN.PEDIATR 1966;5:395-402.

13.ATAR G, UZAMIS M., OLMEZ S. ECTODERMAL DYSPLASIA WITH ASSOCIATED DOUBLE TOOTH, J DENT FOR CHILDREN 1997; SEP- OCT: P- 362- 364 14.PIGNO A, BLACKMAN B, CRONIN J., CAVAZOS E. PROSTHODONTIC MANAGEMENT OF ECTODERMAL DYSPLASIA: A REVIEW OF THE LITERATURE, J PROSTHET DENT 1996;76:541545 15.JYOTHI S, MAMATHA G. HEREDITARY ECTODERMAL DYSPLASIA:DIAGNOSTIC DILEMMASREV CLÍN PESQ ODONTOL. 2008 JAN/ABR;4(1):35-40.

16.SHAW M. PROSTHETIC MANAGEMENT OF HYPOHIDROTIC ECTODERMAL DYSPLASIA WITH ANODONTIA: CASE REPORT AUST.DENT J 1990; 35: 113-116.

17.VIERUCCI S., BACCETTI T., TOLLAW I. DENTAL AND CRANIOFACIAL FINDINGS IN HYPOHIDROTIC ECTODERMAL DYSPLASIA DURING PRIMARY DENTITION PHASE J. CLINICAL PED DENT 1994; 18: 291-297.

18.SUSHMA R, MINAL W, YASMIN M. ANHIDROTIC ECTODERMAL DYSPLASIA- A REPORT OF TWO CASES BOMBAY HOSPITAL JOURNAL, VOL. 51, NO. 2, 2009 19.YENISEY M, GULER A, UNAL U. ORTHODONTIC AND PROSTHODONTIC TREATMENT OF ECTODERMAL DYSPLASIAEA CASEREPORT. BR DENT J 2004;196:677-679.

20.CHEN T, DARBY B, ADAMS G, REYNOLDS C. A PROSPECTIVE CLINICAL STUDY OF BONE AUGMENTATION TECHNIQUES AT IMMEDIATE IMPLANTS. CLIN ORAL IMPLANTS RES. 2005;16:176–184.

21.PENARROCHA M., GOMEZ D., GARCIA B., IVORRA M. BONE GRAFTING SIMULTANEOUS TO IMPLANT PLACEMENT. PRESENTATION OF A CASE. MED ORAL PATOL ORAL CIR BUCAL. 2005;10:444–447.

22.TRIPLETT G., SCHOW R. AUTOLOGOUS BONE GRAFTS AND ENDOSSEOUS IMPLANTS: COMPLEMENTARY TECHNIQUES. J ORAL MAXILLOFAC SURG. 1996;54:486–494.

23.WIDMARK G., ANDERSSON B., CARLSSON G., LINDVALL M., IVANOFF J. REHABILITATION OF PATIENTS WITH SEVERELY RESORBED MAXILLAE BY MEANS OF IMPLANTS WITH OR WITHOUT BONE GRAFTS: A 3- TO 5-YEAR FOLLOW-UP CLINICAL REPORT. INT J ORAL MAXILLOFAC IMPLANTS. 2001;16:73–79.

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40

The effect of curing light type and intensity on the depth of cure of dental resin composites.

Dr. Hashem M. Ridha dds_2003@hotmail.com

Dr. Hadi A. Al-Bahrani

Dr. Abdulaziz H. Aljazzaf

Dental News, Volume XIX, Number IV, 2012

INTRODUCTION Many factors affect the degree of polymerization in light activated resin composites, such as the source light intensity, duration of exposure, material composition, shade, and translucency.

Researchers have been studying the relative effect of these factors on the kinetics of polymerization and a number of studies provided mathematical models to predict the degree of polymerization and depth of cure in light activated resin composites.

The mathematical model which is the scope of this study was first proposed by Jacobs 1 as Cd= Dp * In(E0/Ec) where Cd is the depth of cure of the polymer millimeters, E0 is the input energy at the surface of the resin J/cm 2, Ec is the minimum exposure required to allow the polymer to reach its gel point, and Dp is a material dependent and wavelength dependent characteristic length and is defined as the resin penetration depth at a particular wavelength. It is a characteristic coefficient with a unit of millimeter that accounts for the solid volume ratio, the particle size, the scattering effect, and the absorption coefficient of the composite. This model shows a linear relationship between the depth of cure (Cd) of a polymer and the natural logarithm of input energy (E0) at the surface of the resin.

In a previous study, Katsilieri 2 has demonstrated that this mathematical model can fully describe this logarithmic relation between the output energy of

a halogen dental curing unit and the DOC of three different VLDC’s with three different shades. The two parameters needed to describe the relation between DOC and input energy was identified for each composite. A statistical protocol was further developed to statistically analyze the differences in these two curing parameters between different composites. However, whether this equation will apply to the DOC obtained from other light sources is still unknown.

The purpose of this study was to further investigate the effect of using different light source types with different light output intensities on the parameters of this mathematical model D= Dp In(E0/Ec) which predicts the depth of cure in visible light dental composites ( VLDC’s).

The null hypothesis of this study is that using different light source types with different light output intensities will not significantly affect the parameters of the proposed mathematical model D= Dp In(E0/Ec) calculated from the experimental data.

MATERIALS AND METHODS Sample preparation: Three shades (A3, B1, D3) of a hybrid resin (AELITE ALL PURPOSE BODY, BISCO INC.) composite were used to prepare the specimens for this study.

A Teflon mold with 4 X 6 mm holes was used to

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42 Operative Dentistry The effect of curing light type

Table I Dental curing units

Unit Name

Light Type Manufacturer/ Vendor

Measured Output intensity- mW/cm2

Optilux VCL 401

Halogen

Kerr Dental

430

Elipar High light

Halogen

3M/ESPE

430

Astralis 5

Halogen

Ivoclar Vivadent

255

Visilux 2

Visilux 2

3M/ESPE

350

Demi

Visilux 2

Kerr Dental

540

Allegro

Visilux 2

Den-Mat

350

Figure 1 Sample preparation assembly Figure 1

Figure 2 Experiment design

prepare the composite specimens (figure 1). Three LED and three halogen dental curing units with different light output intensities (Table I) were used to cure the three shades (B1, A3, D3) of the composite specimens. Each curing unit-shade combination was cured for 10, 20, 30, and 40 seconds. Also, three samples were obtained for each shade-irradiation time combination (figure 2). During the fabrication of the resin samples, the output intensity of each curing light was measured in mW/cm 2 using the Demetron radiometer (Demetron Radiometer, model 100, P/N 10503 by Kerr Dental) before and after making each shade-light combination group of samples. Then the before and after readings were averaged for each sample group and that output intensity average was used to calculate the output energy in each shade-light combination group.

When the B1 shade samples were prepared, the majority of the samples cured to the full depth of the Teflon mold. To avoid any false results, it was decided to remake all the B1 shade samples and a deeper Teflon mold (4 X 12) was used for that purpose. The halogen lights and their corresponding measured output intensities are: Optilux VCL 401 Curing-Light by Kerr Dental with 270 mW/cm 2, Elipar High light by 3M/ESPE with 430 mW/cm 2, Astralis 5 by Ivoclar Vivadent with 255 mW/cm². The LED units are: Visilux 2 by 3M/ ESPE with 350 mW/cm², Demi from Kerr Dental with 540 mW/cm², and Allegro from Den-Mat with 350 mW/cm². These are the initial testings (Table I) performed for each of the curing lights using the Demetron radiometer with the metal sheet in the middle as described previously.

ISO scraping test: Figure 2 Dental News, Volume XIX, Number IV, 2012

A plastic spatula was used to remove any soft composite from the end of the specimens. The

44 Operative Dentistry The effect of curing light type

Table II The a and b values for the different light-shade combination regression lines represented by the mathematical model: Y=a * ln(x)-b

B1

A3

D3

a

b

a

b

a

b

1.1382

6.6845

0.5361

2.4491

0.4891

2.0704

Elipar

1.0223

5.7548

0.4473

1.7667

0.4844

2.1516

Astralis5

0.9082

4.3664

0.4532

1.7796

0.4737

2.0228

Visilux2

1.0512

5.9991

0.5421

2.8352

0.5473

2.9449

Demi

1.0512

5.8305

0.5297

2.6062

0.4572

2.0213

Allegro

0.9261

4.4845

0.4761

2.0888

0.4663

2.092

Optilux

Dp Comparison

Ec

Difference

SE

p-value

Difference

SE

p-value

Overall p-value

A3

Allegro

vs

B1

Allegro

-0.44

0.05

<0.0001

-41.4

31.5

0.1888

<0.0001

A3

Allegro

vs

B1

Allegro

0.01

0.03

0.758

-8.7

36

0.8098

0.0002

B1

Allegro

vs

D3

Allegro

0.45

0.05

<0.0001

32.7

37.6

0.8852

<0.0001

A3

Astralis 5

vs

B1

Astralis 5

-0.46

0.07

<0.0001

-75.5

33.8

0.0254

<0.0001

A3

Astralis 5

vs

D3

Astralis 5

0.03

0.04

0.5064

25.4

26.1

0.3314

0.0222

B1

Astralis 5

vs

D3

Astralis 5

0.13

0.07

<0.0001

50.2

38.8

0.1962

<0.0001

A3

Demi

vs

B1

Demi

-0.52

0.04

<0.0001

-115.9

45.8

0.0114

<0.0001

A3

Demi

vs

D3

Demi

0.08

0.05

0.1374

59.4

50.2

0.2365

0.0021

B1

Demi

vs

D3

Demi

0.60

0.06

<0.0001

175.3

43

<0.0001

<0.0001

A3

Elipar High Light

vs

B1

Elipar High Light

-0.57

0.07

<0.0001

-220.5

53.1

<0.0001

<0.0001

A3

Elipar High Light

vs

D3

Elipar High Light

-0.04

0.05

0.4529

-36.1

35.9

0.3155

0.2956

B1

Elipar High Light

vs

D3

Elipar High Light

0.53

0.07

<0.0001

184.5

59.7

0.002

<0.0001

A3

Optilux

vs

B1

Optilux

0.60

0.06

<0.0001

250.5

55.2

<0.0001

<0.0001

A3

Optilux

vs

D3

Optilux

0.05

0.05

0.3192

35.1

40.9

0.3916

0.3154

B1

Optilux

vs

D3

Optilux

0.65

0.06

<0.0001

285.5

44.8

<0.0001

<0.0001

A3

Visilux 2

vs

B1

Visilux 2

-0.51

0.04

<0.0001

-112.7

46.1

0.0144

<0.0001

A3

Visilux 2

vs

D3

Visilux 2

0.00

0.04

0.9192

-81.8

64.5

0.6272

0.0213

B1

Visilux 2

vs

D3

Visilux 2

0.50

0.05

<0.0001

81.3

63.1

0.1971

<0.0001

Table III Comparisons between shade-light combinations

remaining length of the specimen was measured by a micrometer of 0.01 mm accuracy, and 3 measurements were obtained for each specimen.

The mean average of each specimen was divided by two to calculate the depth of cure (DOC)1.

RESULTS The results of the ISO scarping technique: depth of cure (DOC) vs. the curing energy (in a logarithmic scale) were plotted for all the light source-shade combinations. The non-linear equation DOC = Dp ln(E0/Ec) was used to define the relationship Dental News, Volume XIX, Number IV, 2012

between exposure and DOC. The values for Dp and Ec were estimated for each of the eighteen shadelight combinations using non-linear regression models (Table II). Comparisons between regression lines were performed using F-tests to determine if the (Dp, Ec) pairs were significantly different for each pair of shade-light combinations. Additional tests were performed to compare the individual Dp and Ec estimates using bootstrap sampling.

Bootstrap sampling can be used to estimate parameters and their standard errors when direct estimates are not easily computed3 . Sampling

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46 Operative Dentistry The effect of curing light type

Figure 3 Regression lines of the different resin shades cured under Optilux light: Output energy in logarithmic scale vs. depth of cure in mm’s

Figure 4 Regression lines of the different resin shades cured under Elipar High Light: Output energy in logarithmic scale vs. depth of cure in mm’s

Figure 5 Regression lines of the different resin shades cured under Astralis 5 light: Output energy in logarithmic scale vs. depth of cure in mm’s

Figure 6 Regression lines of the different resin shades cured under Visilux 2 light: Output energy in logarithmic scale vs. depth of cure in mm’s

Figure 7 Regression lines of the different resin shades cured under Demi light: Output energy in logarithmic scale vs. depth of cure in mm’s

Figure 8 Regression lines of the different resin shades cured under Allegro light: Output energy in logarithmic scale vs. depth of cure in mm’s

Dental News, Volume XIX, Number IV, 2012

was performed 1000 times with replacement from the original data, the non-linear regression analyses were performed within each sample, and the results from the 1000 samples were combined to obtain empirical distributions of the differences in Dp and Ec between each pair of shade-light combinations. The means, standard errors, and p-values were estimated to compare the shadelight combinations. Under the different curing lights, the Dp values ranged 0.45-0.54 for A3, 0.91-1.05 for B1, and 0.47- 0.55 for D3. The Ec values ranged 50.8-186.7 for A3, 122.4-355.2 for B1, and 68.9-217.3 for D3. A3, B1, and D3 had significantly different regression lines for Allegro, with significantly higher Dp for B1 than A3 and D3. A3, B1, and D3 had significantly different regression lines for Astralis 5 and Visilux 2 with significantly higher Dp for B1 than A3 and D3 and significantly higher Ec for B1 than A3. A3, B1, and D3 had significantly different regression lines for Demi, with significantly higher Dp and Ec for B1 than A3 and D3. B1 had significantly different regression lines than A3 and D3 for Elipar High Light and Optilux, with higher Dp and Ec for B1 than A3 and D3. For shade A3, Allegro and Demi did not have different regression lines, and Astralis 5 and Elipar High Light did not have significantly different regression lines. The detailed comparisons indicated significantly higher Dp for Demi and Visilux 2 than for Astralis 5 and Elipar High Light; significantly lower Ec for Elipar High Light and Astralis 5 than Demi and Visilux 2; and significantly lower Allegro than Visilux 2.

For shade B1, Allegro and Astralis 5 did not have different regression lines, and Elipar High Light and Visilux 2 did not have significantly different regression lines. The detailed comparisons indicated significantly lower Dp for Allegro and Astralis 5 than for Demi, Optilux, and Visilux 2; significantly lower Ec for Allegro and Astralis 5 than for Demi, Elipar High Light, Optilux, and Visilux 2; and lower Ec for Demi than for Optilux. For shade D3, Allegro and Demi did not have significantly different regression lines, and Astralis 5 and Elipar High Light did not have significantly different regression lines. The detailed comparisons indicated higher Ec for Visilux 2 than for Allegro, Astralis 5, Demi, Elipar High Light, and Optilux; but no significant differences for Dp. Overall, the results of this study confirm that the shade factor

48 Operative Dentistry The effect of curing light type

has a more dominant effect on the depth of cure in VLDC’s. Although, most of the significant effects on the Dp and Ec parameters occurred in the B1 shade-light combination, both parameters didn’t show significant differences between A3 and D3 shades in all the groups (Table III). Also, most of the differences for Dp values occurred in the B shade-light combinations. However, none of the D3 shade-light combinations showed significant differences for Dp.

DISCUSSION Several Mathematical models were mentioned in the literature to predict the depth of cure in VLDC’s.

The advantage of the model used in this study is that both parameters Dp and Ec can be explained in terms of energy which provides a physical meaning that helps to understand this particular model. For example, a high Dp value refers to a greater penetration of the photons through the material bulk and a deeper depth of cure, while a high Ec value means that the critical amount of energy needed to form the gel layer within the resin composite is high 2. The ISO scraping technique is chosen in this study to measure the depth of cure of the resin specimens because it requires minimum instrumentation and provides similar or more conservative values than those determined by other methods like IR spectroscopy or hardness tests 4. The ISO defines depth of cure as 50 percent of the length of the composite specimen after the uncured material is removed with a plastic spatula 5. Although a number of researchers attempted to use the total remaining length after scarping away the uncured material, many studies confirmed a significant reduction in the hardness of the composite specimen from the top surface to the bottom 6,8. If the total length is used, under-polymerization would be the result and the clinical performance would be compromised4. The use of curing energy instead of curing time, in the x-axis of the chart (Figures 3 - 8), provides a standardized basis for comparison since it is the light total energy that determines the curing depth. This type of standardized comparison should be used when comparing the effect of curing light on depth of cure in VLDC’s.

The results of this study indicate that the shade factor has a more dominant effect on the depth of cure than curing light type or light output Dental News, Volume XIX, Number IV, 2012

intensity. The Dp and Ec values were significant between some of LED and halogen lights, but that significance was not consistent enough between all the groups to confirm that LED or halogen lights are significantly different from each other regarding their effects on the parameters of the mathematical model in this study. For example, when comparing between the halogen and LED curing lights, it was found that the Dp value was significant (P<0.05) between Allegro vs. Optilux for only B1 shade, Astralis 5 vs. Demi, Astralis 5 vs. Visilux 2 for shade A3 and B1, Demi vs. Elipar High light, and Elipar High Light vs. Visilux 2 only for A3 shade. Several studies have concluded that the effect of light type by itself, whether LED or halogen, is not significant on the depth of cure of VLDC’s 9,11. However, In these studies, the interaction of light type with other factors like exposure duration or shade presented significant effects on the depth of cure of VLDC’s. For the effect of the light output intensity, the results of the study indicate that all the curing lights used, meet the ISO minimum requirement (1.5mm) for the depth of cure in resin composites. Although the effect on Dp and Ec values was significant between a number of the curing lights, the results were not consistent enough to conclude that the source output intensity by itself can significantly affect the parameters of the mathematical model used in this study. For example, in the A3 shadelight combination group, Demi and Elipar High Light were significantly different in both Dp and Ec, while none of the parameters were relevantly different between Demi and Optilux; even though the output intensity difference between Optilux and Demi is much more than between Elipar High Light and Demi. Other similar situations occurred within the same and other shade-light combination groups. A possible explanation might be the wavelength differences between the curing lights. In a study by Nomoto 12, it was confirmed that in the 450-490 nm wavelength range, the polymerization and depth of cure of VLDC’s would primarily be affected by the exposure energy rather than the light wavelength; however, in other ranges, the wavelength might have a more dominant effect over the exposure energy regarding the polymerization and depth of cure of VLDC’s. In our study, it is not possible to make any conclusions regarding the effect of

50 Operative Dentistry The effect of curing light type

wavelength since this factor was not measured through the experiment. For the shade effect, the results of this study confirm that the shade has a more dominant effect on the parameters Dp and Ec compared to light type or light output intensity.

Overall, most of B1 shade-light combinations had significantly (P<0.05) higher Dp and Ec values than the A3 and D3 shade-light combination and no significant differences were found between the A3 and D3 groups (Table III). According to Katsileri 2, the concentration of the photoinitiator Camphorquinone in B1 shade resins is usually the least to achieve the lighter and whiter shade compared to A3 and D3 shades. Because of that, in the lighter shades, light penetrates deeper through the material bulk and that gives a higher Dp value. Also, due to the less photoinitiator concentration in the lighter shade, light absorption would be less. This means that the amount of energy necessary to form the gel layer within the resin is higher, which leads to higher Ec values. This comes in agreement with a number of studies which confirmed greater depth of cure for the lighter shades of VLDC’s 4,13,15.

SUMMARY AND CONCLUSIONS Depth of cure is an important parameter in evaluating the clinical usefulness of visible light dental composites VLDC’s. Several factors affect the depth of cure in VLDC’s such as material composition, shade, exposure duration, light type, light output intensity, and peak wavelength. The purpose of this study was to further investigate the effect of using six different light source types with different light output intensities on the parameters of a mathematical model that predicts the DOC in VLDC’s. In this equation: D= Dp In(E0/ Ec), D is the depth of cure in millimeters, E is the curing energy in J/cm 2, Ec is the critical curing energy for the composite to reach a gel layer, and Dp is a characteristic coefficient. Within the limited scope of this experimental study, the following conclusions were drawn: 1) Several factors play combined influential effects on the kinetics of polymerization and depth of cure in VLDC’s.

2) As we cure lighter shades “B1”, the effect of

Dental News, Volume XIX, Number IV, 2012

using different lights w/ different output intensities on the two parameters Dp and Ec will be greater and more significant than for darker shades “A3 or D3”.

CLINICAL IMPLICATIONS Several factors affect the depth of cure in VLDC’s and clinicians should recognize that using curing lights with increased output intensities doesn’t absolutely increase the DOC of VLDC’s especially with the darker shades.

REFERENCES 1. JACOBS PF, REID DT. RAPID PROTOTYPING & MANUFACTURING : FUNDAMENTALS OF STEREOLITHOGRAPHY. DEARBORN, MI: SOCIETY OF MANUFACTURING ENGINEERS IN COOPERATION WITH THE COMPUTER AND AUTOMATED SYSTEMS ASSOCIATION OSME;1992.

2. KATSILIERI I. A SIMPLE MATHEMATICAL MODEL PREDICTING DEPTH OF CURE OF LIGHT ACTIVATED DENTAL COMPOSITES [THESIS]. INDIANAPOLIS: INDIANA UNIVERSITY SCHOOL OF DENTISTRY; 2006.

3. EFRON B, TIBSHIRANI R. AN INTRODUCTION TO THE BOOTSTRAP. NEW YORK: CHAPMAN & HALL; 1993.

4. FAN PL, SCHUMACHER RM, AZZOLIN K, GEARY R, EICHMILLER FC. CURING-LIGHT INTENSITY AND DEPTH OF CURE OF RESIN-BASED COMPOSITES TESTED ACCORDING TO INTERNATIONAL STANDARDS. J AM DENT ASSOC 2002;133(4):429-34; QUIZ 91-3.

5. ISO. 4049:2000 DENTISTRY: POLYMER-BASED FILLING, RESTORATIVE AND LUTING MATERIALS. GENEVA, SWITZERLAND: INTERNATIONAL ORGANIZATION FOR STANDARDIZATION;2000:14-5.

6. DEWALD JP, FERRACANE JL. A COMPARISON OF FOUR MODES OF EVALUATING DEPTH OF CURE OF LIGHT-ACTIVATED COMPOSITES. J DENT RES 1987;66(3):727-30.

7. HANSEN EK, ASMUSSEN E. CORRELATION BETWEEN DEPTH OF CURE AND SURFACE HARDNESS OF A LIGHT-ACTIVATED RESIN. SCAND J DENT RES 1993;101(1):62-4.

8. HANSEN EK, ASMUSSEN E. VISIBLE-LIGHT CURING UNITS: CORRELATION BETWEEN DEPTH OF CURE AND DISTANCE BETWEEN EXIT WINDOW AND RESIN SURFACE. ACTA ODONTOL SCAND 1997;55(3):162-6.

9. CUNHA LG, SINHORETI MA, CONSANI S, SOBRINHO LC. EFFECT OF DIFFERENT PHOTOACTIVATION METHODS ON THE POLYMERIZATION DEPTH OF A LIGHT-ACTIVATED COMPOSITE. OPER DENT 2003;28(2):155-9.

10. LEONARD DL, CHARLTON DG, ROBERTS HW, COHEN ME. POLYMERIZATION EFFICIENCY OF LED CURING LIGHTS. J ESTHET RESTOR DENT 2002;14(5):286-95.

11. RAMP LC, BROOME JC, RAMP MH. HARDNESS AND WEAR RESISTANCE OF TWO RESIN COMPOSITES CURED WITH EQUIVALENT RADIANT EXPOSURE FROM A LOW IRRADIANCE LED AND QTH LIGHT-CURING UNITS. AM J DENT 2006;19(1):31-6.

12. NOMOTO R. EFFECT OF LIGHT WAVELENGTH ON POLYMERIZATION OF LIGHT-CURED RESINS. DENT MATER J 1997;16(1):60-73.

13. KAWAGUCHI M, FUKUSHIMA T, MIYAZAKI K. THE RELATIONSHIP BETWEEN CURE DEPTH AND TRANSMISSION COEFFICIENT OF VISIBLE-LIGHT-ACTIVATED RESIN COMPOSITES. J DENT RES 1994;73(2):516-21.

14. SHORTALL AC, WILSON HJ, HARRINGTON E. DEPTH OF CURE OF RADIATIONACTIVATED COMPOSITE RESTORATIVES--INFLUENCE OF SHADE AND OPACITY. J ORAL REHABIL 1995;22(5):337-42.

15. COOK WD, STANDISH PM. CURE OF RESIN BASED RESTORATIVE MATERIALS. II. WHITE LIGHT PHOTOPOLYMERIZED RESINS. AUST DENT J 1983;28(5):307-11.

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PICTURES FROM THE EXHIBITION FLOOR

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Dubai gathered for the fourth time the world experts of Dental Facial Cosmetic on 09th - 10th November 2012, an international conference, open to all aspects and specialists working in the field of aesthetic dentistry and implantology.

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Dental News, Volume XIX, Number IV, 2012

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References: 1. Burwell A et al. J Clin Dent 2010; 21(Spec Iss): 66–71. 2. LaTorre G, Greenspan DC. J Clin Dent 2010; 21(3): 72-76. 3. West NX et al. J Clin Dent 2011; 22(Spec Iss): 82-89. 4. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 62-67. 5. Efflandt SE et al. J Mater Sci Mater Med 2002; 26(6): 557-565. Prepared December 2011, Z-11-516.

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3rd Scientific Day of the Lebanese Society of Prosthodontics

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November 17, 2012 Al Bustan Hotel, Lebanon

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Dear colleagues, The pleasure is ours to meet you today on this sunny morning of the fall at this renamed resort, AlBustan Hotel, in the heart of Mount-Lebanon. The choice of this site at this period of the year was sort of a challenge, due to the weather uncertainties. On the other side, I’m pretty sure that this day will be a nice experience and a chance to discovering the beauty of an area bathed in the pure nature. This gathering falls within the scope of the activities of the Lebanese Society of Prosthodontics which is always devoted to bring the best for you.

What could be more than having Steve Morgano among us presenting the latest and more importantly the safest procedures, according to the concept of Evidence-based Dentistry? We are all amazed by revolutionary theories, new techniques and appliances, advocated for their simplicity and speed. However, the key of success on the long term comes with techniques that are evidence-proved and that survive the test of time.

As dentists, we are pushed by the industry or driven by the trend. Steve Morgano is definitely the man who could help to buffer and moderate the too excessive enthusiasm and the commercial drift in our practice.

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Turn Complex Class II into Simple Class I Cases With its non-invasive design, the Carriere Distalizer Appliance corrects Class II malocclusion at the beginning of treatment, prior to bracket placement when patient motivation is highest.

Call us today at 888.851.0533 or visit us online at OrthoOrganizers.com.

Carriere Ortho 3D A FREE App. for iPads, iPhones, and Android tablets and phones

* Images courtesy of Dr. Clark Colville. © 2012 Ortho Organizers, Inc. All rights reserved.

Programat

速

A STORY OF SUCCESS

Putting people at the centre The new Programat ceramic furnaces are focussed on you, the user.

The combination of timetested technology and innovation allows you to achieve the best possible firing results.

P300

P500

Color

P700

Multimedia

The range of second-generation furnaces is now complete. All G2 furnaces are equipped with power saving technology and numerous technological innovations.

www.ivoclarvivadent.com Ivoclar Vivadent AG Bendererstr. 2 | 9494 Schaan | Principality of Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60