BALKAN JOURNAL OF STOMATOLOGY

BALKAN JOURNAL OF STOMATOLOGYOfficial publication of the BALKAN STOMATOLOGICAL SOCIETY

ISSN 1107 - 1141

Volume 12 No 3 November 2008

BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141 STOMATOLOGIC

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ALBANIARuzhdie QAFMOLLA - Editor Address:Emil KUVARATI Dental University Clinic Besnik GAVAZI Tirana, Albania BOSNIA AND HERZEGOVINA Address:Maida GANIBEGOVIĆ Faculty of DentistryNaida HADŽIABDIĆ Bolnička 4aMihael STANOJEVIĆ 71000 Sarajevo BIHBULGARIANikolai POPOV - Editor Address:Nikola ATANASSOV Faculty of StomatologyNikolai SHARKOV G. Sofiiski str. 1 1431 Sofia, BulgariaFYROMJulijana GJORGOVA - Editor Address:Ana STAVREVSKA Faculty of StomatologyLjuben GUGUČEVSKI Vodnjanska 17, Skopje Republika MakedonijaGREECEAnastasios MARKOPOULOS - Editor Address:Haralambos PETRIDIS Aristotle University Grigoris VENETIS Dental School Thessaloniki, Greece

ROMANIAAndrei ILIESCU - Editor Address:Victor NAMIGEAN Faculty of StomatologyCinel MALITA Calea Plevnei 19, sect. 1 70754 Bucuresti RomaniaSERBIADragan STAMENKOVIĆ - Editor Address:Zoran STAJČIĆ Faculty of Stomatology Miloš TEODOSIJEVIĆ Dr Subotića 8 11000 Beograd SerbiaTURKEYEnder KAZAZOGLU - Editor Address:Pinar KURSOGLU Yeditepe University Arzu CIVELEK Faculty of Dentistry Bagdat Cad. No 238 Göztepe 81006, Istanbul TurkeyCYPRUSGeorge PANTELAS - Editor Address:Huseyn BIÇAK Gen. Hospital NicosiaAikaterine KOSTEA No 10 Pallados St. Nicosia, Cyprus

Editorial board

Editor-in-Chief Ljubomir TODOROVIĆ, DDS, MSc, PhD Faculty of Stomatology, University of Belgrade Clinic of Oral Surgery PO Box 506 Dr Subotića 4, 11000 Belgrade Serbia

CouncilPresident: Prof. A. IliescuPast President: Prof. N. AtanassovPresident Elect: Prof. M. VulovićVice President: Prof. P. KoidisSecretary General: Prof. L. ZouloumisTreasurer: Dr. G. TsiogasEditor-in-Chief: Prof. Lj.Todorović

Members: R. Qafmolla P. Kongo H. Sulejmanagić S. Kostadinović N. Sharkov J. Mihailov M. Carčev J. Gjorgova T. Lambrianidis

E. Hasapis D. Bratu A. Creanga D. Stamenković M. Barjaktarević E. Kazazoglu H. Bostançi G. Pantelas F. Kuntay

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The whole issue is available on-line at he web address of the BaSS (www.e-bass.org)

BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141 TUPNBUPMPHJD

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OP E. Zabokova-Bilbilova Prevention of Enamel Demineralization During 133 T. Stafilov Orthodontic Treatment: An In Vitro Study Using GC Tooth Mousse A. Sotirovska-Ivkovska F. Sokolovska 133

OP N.K. Ersin Infraocclusion of Primary Molars: A Review and Report of Cases 138 U. Candan A.R. Alpoz 138

OP B. Obradovic Assessment of the Quality of Newly-Formed Bone for 143 Z. Stajcic Implant Insertion after Augmentation of the Maxillary Sinus Floor Lj. Stojcev Stajcic

OP S.D. Poštić Medication and Positive Remodelling of Osteoporotic Jaws 147

OP A.D. Kaya Surface Roughness of Posterior Condensable Composites 153 F. Ozata 153

OP D. Mingomataj Clinical and Radiological Evaluation of 158 D. Mingomataj Chronic Periodontitis Treated by “Beyond Apex” Fillings

OP E. Xhemo Dental Erosion: One of the Main Diagnostic 163 D. Brovina Symptoms of Gastric Oesophageal Reflux Disease E. Hoxha V. Demiraj A. Bylo

CR H. Develioglu Histo-Pathological Evaluation of Drug Allergy Observed With 166 Ö. Özgören Gingival Overgrowth Induced by Phenytoin: A Case Report M. Nalbantoglu K. Eren F. Göze

CR A. Delantoni Postextraction Inferior Alveolar Nerve Injuries - 170 P. Papademitriou-Delantoni Prevention and Treatment K. Antoniades

Contents

VOLUME 12 NUMBER 3 November 2008 PAGES 129-180

132 Balk J Stom, V ol 12, 2008

TR H.N. Alkumru Use of Polyethylene Fibre Ribbon Reinforced Composite Resin as 174 S.B. Turker Post-Core Build-Up: A Technical Report B. Evre

Book Review John W. Werning M. Gavrić Oral Cancer: Diagnosis, Management, and Rehabilitation 178

SUMMARYOne of the most difficult problems in orthodontic treatment with fixed

appliances is the control of enamel demineralization around the brackets. The bands/brackets and the different orthodontic elements that are used (elastics, plastic, sleeves, springs) make the patient’s dental hygiene more difficult and the accumulation of plaque easier. The purpose of this study was to measure the percentage of Ca, Na, K and Mg in the enamel before and after application of the topical gel - GC Tooth Mousse.

In this study, 40 healthy extracted premolars without any clinical sign of decalcification were selected. All teeth were cleaned and cut in half in the bucco-lingual direction with a diamond disc. Thus, the control and test speci-mens were obtained from the same teeth. Orthodontic brackets were bonded with Fuji Ortho LC. They were divided in 2 groups according to the period of monitoring (14 days and 1 month). Then, they were coated with a topical gel - Tooth Mousse (GC Corp, Japan), for 5 minutes each day, and stored in artificial saliva until analyzing. We have measured the percentage of Ca, Na, K and Mg in the enamel by using the method of flame atomic absorption spectrometry, with a Varian Spectra AA 55 B atomic absorption spectrometer.

The results obtained in this study refer to high percentage of Ca in enamel in the study group for the first examined period. The percentages of Ca in enamel were remarkably higher after 1 month from application of den-tal mousse. This indicates that, with an in vitro tooth-brackets model, inhibi-tion of creating white spot could be achieved with the use of resin modified glass ionomer cement, supplemented with topical gel exposure. The mineral balance in the oral environment is accomplished by application of the Recal-dentTM CPP-ACP in the form of GC Tooth Mousse.Keywords: Dental Caries; Enamel; Demineralization; Remineralization

E. Zabokova-Bilbilova 1, T. Stafilov 2, A. Sotirovska-Ivkovska 1, F. Sokolovska 2

St. Cyril and Methodius UniversitySkopje, FYROM1Department of Pedodontic DentistrySchool of Dentistry2Institute of Chemistry, Faculty of Natural Sciences and Mathematics

ORIGINAL PAPER (OP)Balk J Stom, 2008; 12:133-137

BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141

Prevention of Enamel DemineralizationDuring Orthodontic Treatment: An In Vitro Study Using GC Tooth Mousse

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Introduction

One of the most difficult problems in orthodontic treatment with fixed appliances is the control of enamel demineralization around the brackets. The bands/brackets and the different orthodontic elements that are used (elastics, plastic, sleeves, springs) make the patient’s dental hygiene more difficult and the accumulation of plaque easier2,15. After the use of fixed appliances, decalcification marks are more pronounced at the gingival part of the teeth, were higher plaque accumulation usually occurs.

These decalcification marks are seen as early as 4 weeks after band/bracket placement.

Several studies report different finding concerning possible decalcification of teeth. Mizrahi found that the maxillary incisors and mandibular first molars are most likely to exhibit signs of decalcification13. Trimpeneers found the maxillary central incisors to be most susceptible and Gorelick’s study reported the maxillary laterals11,24. One study measured the frequency of white spot formation on the teeth and ranked them from most common to least common. The ranking is: maxillary lateral, mandibular second premolar, maxillary canine and maxillary first

134 E. Zabokova-Bilbilova et al. Balk J Stom, Vol 12, 2008

premolar26. The resistance of the mandibular segments has been linked to the buffering capacity of saliva9.

Much research has been focused on reducing the occurrence of decalcification during orthodontic treatment. Researchers have turned their attention toward appliance design, bonding materials, use of fluorides, sealants and improving oral hygiene7. Many products have been developed to prevent demineralization of enamel surface, like casein phosphopeptide-amorphous calcium phosphate (CPP-ACP).

CPP-ACP can be found in multiple products. Recaldent™ is a unique complex containing amorphous calcium phosphate (ACP) and casein phosphopeptide (CPP), obtained from milk casein. The preparation is recommended in need for hard tissue remineralization. The manufacturer compares the material to “liquid enamel”. CPP-ACP complex make a strong binding with a bio-film on teeth and form calcium and phosphate reservoir. They are then incorporated into the surface of enamel and dentine21. The effect of GC Tooth Mousse, with CPP-ACP complex is part of the new and modern approach to caries prevention. The CPP-ACP complex contained in Recaldent™ is hence an ideal system for transporting free calcium and phosphate ions, and GC Tooth Mousse, containing this novel active ingredient, is the world’s first product for professional use in the dental practice12.

The proposed anticariogenic mechanism of CPP- ACP involves the incorporation of the nanocomolexes into dental plaque and onto the tooth surface, thereby acting as a calcium and phosphate reservoir. Studies have shows that CPP-ACP incorporated into dental plaque can significantly increase the levels of plaque calcium and phosphate ions. This mechanism is ideal for the prevention of enamel demineralization as there appears to be an inverse association between plaque calcium and phosphate levels and measured caries experience19.

Several in vitro and in vivo studies have shown that treatment with CPP-ACP corresponds with a reduction in demineralization and increases in remineralization5,14,22. A clinical study by Iijima et al6, who used sugar free chewing gum containing 18.8 mg CPP-ACP, showed that CPP-ACP increased resistance to demineralization, increased remineralization and created remineralized enamel that was more resistant to subsequent demineralization. Cai et al3 found that the used of sugar-free lozenges containing CPP-ACP significantly increased remineralization of enamel subsurface lesions in situ, with 18.8 and 56.4 mg of CPP-ACP increasing remineralization by 78 and 176% respectively. One study found that the treatment with 0.1% CPP-ACP, applied twice daily, resulted in a 14% decrease in smooth surface caries, and with 1.0% CPP-ACP resulted in a 55% decrease18.

The purpose of this study was to measure the percentage of Ca, Na, K and Mg in the enamel before and after application of the topical gel - GC Tooth Mousse.

Material and Method

In this study, 40 healthy extracted premolars without any clinical sign of decalcification were selected. All teeth were cleaned and cut in half in the bucco-lingual direction with a diamond disc. Thus, the control and test specimens were obtained from the same teeth. Orthodontic brackets were bonded with Fuji Ortho LC (GC America Chicago, III), a resin-modified glass ionomer cement. The teeth were divided in 2 groups according to the period of monitoring (14 days and 1 month). Then, they were coated with a topical gel - GC Tooth Mousse for 5 minutes each day, and stored in artificial saliva until analyzing.

We have measured the percentage of Ca, Na, K and Mg in the enamel by using the method of flame atomic absorption spectrometry (FAAS), with a Varian Spectra AA 55 B atomic absorption spectrometer.

Determination of the Content of Calcium, Magnesium,Potassium and Sodium in Human Tooth Enamel

Determination of Ca, Mg, K and Na by FAAS with Varian Spectra AA 55 B atomic absorption spectrometer is already described10,25. Hollow cathode lamps were used as a source of electromagnetic radiation for each element. Lamps are optimized for 15 min before analysis. A mixture of acetylene and air was used for flame. Before the analysis, instrumental parameters for better precision and sensibility on analysis were optimized (Tab. 1).

Table 1. Optimal instrumental parameters for Ca, Na, K and Mg determination by FAAS

Parameters Ca Na K Mg

Wavelength/nm 422.7 589.0 766.5 285.2

Slit/nm 0,5 0,5 1,0 0,2

Lamp current/mA 10 5 5 4

The content of the investigated elements in the tooth enamel was determined by FAAS after mineralization in a microwave digestion system from Milestone, model Ethos Touch Control. The mineralization program is presented in table 2.

Table 2. Teeth sample mineralization programme

Step Temperature/°C Time/min Power/W Pressure/bar

1 160 10 300 15

2 210 10 450 15

Preparation of Teeth for AnalysisTeeth samples are stored in artificial saliva, then

washed in de-ionized water and dried on room temperature for 2-3 hours. After crushing, powdered tooth (0.1 g) were placed in Teflon vessel and subjected to a wet mineralization in a closed system with 2 ml nitric acid.

Balk J Stom, Vol 12, 2008 Prevention of Enamel Demineralization During Orthodontic Treatment 135

Teflon vessels were placed in microwave oven and were mineralized by programme given in table 2 after the second step system ventilations (20 min). The mineralization product was transferred quantitatively into 25 ml and de-ionized water was added. The samples could by subjected to FAAS after this treatment.

Construction of Calibration DagramCalibration diagram is constructed by using a method

of standard solutions using regression analysis, where functional relationships between mass concentration and absorbance of Ca, Na, K and Mg were obtained. For the construction of calibration diagram standard solutions of Ca, Na, K and Mg, with concentration of 1 mg/L, were used. Means of absorbance for each calcium standard solution are given in table 3.

Table 3. Absorbance for appropriate mass concentrations of calcium in tooth enamel

γ(Ca)/μg/ml A

0 0

10 0,086

20 0,165

30 0,224

Analytical dependence on absorbance of concentration of Ca is given by equation: A = 0,0078· γ(Ca)/μg/mlCorrelation coefficient is 0,992.

For statistical evaluation, a one-way analysis of variance (ANOVA) was initially used to see if there was a significant difference between groups.

Results

Table 4 shows the percentage of Ca in enamel in the experimental group of teeth 14 days after application of the topical gel - GC Tooth Mousse. Average value of Ca in the examined group of teeth was 22.38%, and 20.06% in the control group. For this time period, statistically significant difference was found between mass fractions of Ca in the tooth enamel between groups.

Table 4. Values on the mass fraction of Ca in enamel 14 days after application of the topical gel

group n x SD t p

test 30 22.38 4.58

-2.23 0.033*

control 30 20.06 3.78

Table 5 shows mass fraction of Na, K and Mg in enamel in the group of examined teeth compared with the control group 14 days after application of the topical gel. For this time period, no statistically significant difference was found between mass fractions of K, Mg in the enamel between both groups. Mass fractions of Na in the enamel displayed increased value, with 0.89% in the examined group and 0.60% in the control group, the difference being statistically significant.

Table 5. Values on the mass fraction of Na, K and Mg in enamel 14 days after application of the topical gel

group parameters n x SD t p

test Na 30 0.89 0.05

2.37 0.02*

control Na 30 0.60 0.06

test K 30 0.042 0.018

1.88 0.06

control K 30 0.04 0.009

test Mg 30 0.27 0.08

-0.33 0.74

control Mg 30 0.23 0.07

Table 6. Values on the mass fraction of Ca in enamel 1 month after application of the topical gel

group n x SD t p

test 30 23.04 4.51

3.21 0.003**

control 30 21.02 3.84

Table 6 shows the mass fraction of Ca in enamel in the group of examined teeth compared to the control group of teeth 1 month after application of the topical gel. It shows highly significant statistical difference of the values (23.04% in the examined group, compared to 21.02% in the control group). Values of the mass fraction of Na, K and Mg in enamel of both groups of teeth, 1 month after application of the topical gel, is shown in table 7. These values were higher in the examined group compared to the control group of teeth.

136 E. Zabokova-Bilbilova et al. Balk J Stom, Vol 12, 2008

Table 7. Values on the mass fraction of Na, K and Mg in enamel 1 month after application of the topical gel

group parameters n x SD t p

test Na 30 0.91 0.14

-8.96 0.000000**

control Na 30 0.67 0.05

test K 30 0.042 0.017

19.09 0.000000**

control K 30 0.017 0.007

test Mg 30 0.29 0.09

-2.3 0.02*

control Mg 30 0.25 0.04

Discussion

Enamel decalcification around orthodontic bands and brackets has long been a concern. Studies show that orthodontic appliances increase the accumulation and adherence of plaque in mouth. Streptococcus mutans and Lactobacillus concentrations in the oral cavity increase in conjunction with orthodontic treatment and fixed appliances. These and other bacteria ferment carbohydrates to produce organic acids. These acids can, over time, lead to the dissolution of calcium and phosphate ions from the enamel surfaces. This process of decalcification may lead to white spot lesions and even capitation in as little as 4 weeks16,20,23.

Clinical experience shows that the use of fixed appliances in orthodontic treatment increases the risk of enamel demineralization, especially in conjunction with compromised oral hygiene. Together with topical gel GC Tooth Mousse applications, the development and use of fluoride-releasing orthodontic materials may reduce the risk of enamel demineralization during orthodontic treatment.

In this in vitro study we examined the percentage of calcium, its effect on enamel demineralization, and the alterations that are observed on the enamel surface after the use of fluoride-releasing orthodontic bonding system (Fuji Ortho LC).

Enamel lesion which have been remineralized with topical exposure to CPP-ACP have been shown to be more resistant to subsequent acid challenge, and capable to promote remineralization of enamel subsurface lesions with hydroxyapatite. In addition, the relatively low carbonate environment of the CPP-ACP treated crystalline

and lower micro strain than might be found in normal tooth enamel17.

Enamel demineralization in vitro was inhibited to a certain degree in our study. Similar decalcification prevention has been reported by many authors for other fluoride-releasing materials1,4,8. However, significant difference in demineralization inhibition was observed between 2 periods of monitoring.

The results obtained in this study refer to high percentage of Ca in enamel in the study group for the first examined periods. The percentages of Ca in enamel were remarkably higher after 1 month from application of dental mousse. The finding from this in vitro study indicate that fluoride-releasing adhesives may inhibit enamel decalcification adjacent to orthodontic brackets during the examined period by forming a protective deposit of calcium fluoride-like particles on the enamel surface.

Conclusions

Demineralization during orthodontic treatment is a significant clinical problem.

The results of this study indicate that with an in vitro tooth-brackets model, the creation of white spot inhibition could be achieved with the use of resin modified glass ionomer cement, supplemented with topical gel exposure. The effects of CPP-ACP have so far shown promising dose-related increases in enamel remineralization within already demineralized enamel lesion. The mineral balance in the oral environment is accomplished by application of the RecaldentTM CPP-ACP in the form of GC Tooth Mousse.

References

Artun J, Brobakken BO1. . Prevalence of caries white spots after orthodontic treatment with multibonded appliances. Eur J Orthod, 1986; 8:229-234. Basdra EK, Huber H, Komposch2. . Fluoride released from orthodontic bonding agents alters the enamel surface and inhibits enamel demineralization in vitro. Am J Orthod Dentofac Orthop, 1996; 109:466-472. Cai F, Shen P, Morgan MV, Reynolds EC3. . Remineralization of enamel subsurface lesions in situ by sugar-free lozenges containing casein phosphopeptide-amorphous calcium phosphate. Aus Dent J, 2003; 48(4):240-243. Corry A, Millett DT, Creanor SL, Foye RH, Gilmour WH4. . Effect of fluoride exposure on cariostatic potential of orthodontic bonding agents: an in vitro evaluation. J Orthod, 2003; 30(4):323-329.Chang HS, Walsh LJ, Freer TJ5. . Enamel demineralization during orthodontic treatment. Aetiology and prevention. Aus Dent J, 1997; 42(5):322-327.

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Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds EC6. . Acid resistance of enamel subsurface lesions remineralized by a sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. Caries Res, 2004; 38(6):551-556.Featherstone JD7. . The science and practice of caries prevention. J Am Dent Assoc, 2000; 131:887-899.Featherstone JD, Glena R, Sharaiti M, Shields CP8. . Dependence of in vitro demineralization of apatite and remineralization of dental enamel on fluoride concentration. J Dent Res, 1990; 69:620-625.Ferguson DB9. . Salivary electrolytes. In: Tenovuo J, ed. Human Saliva: clinical chemistry and microbiology. Vol. 1. Boca Raton, FL: CRC Press, 1989; pp 75-99.Flame Atomic Absortion Spectrometry, Analitical Methods, 10. Varian, Australia Pty Ltd, Publication No 85-100009-00 Revised March 1989.Gorelick L, Geiger AM, Gwinnett AJ11. . Incidence of white spot formation after bonding and banding. Am J Orthod, 1982; 81(2):93-98.Manton D, Shen P, Cai F, Cocharne NJ, Reynolds C, Messer 12. LB, Reynolds EC. Remineralization of White Spot Lesions in situ by Tooth Mousse. Abstract 185-84th General Session of the IADR, 28 June - 1 July, 2006, Brisbane, Australia.Mizrahi E13. . Enamel demineralization following orthodontic treatment. Am J Ortod, 1982; 82(1):62-67.Mellberg JR14. . Remineralization A status report. Part III. Am J Dent, 1:85-89.Ögaard B, Rolla G, Arends J, ten Cate JM15. . Orthodontic appliances and enamel demineralization. Part 2: prevention and treatment of lesions. Am J Orthod Dentofac Orthoped, 1988; 94:123-128.Reich E, Lussi A, Newbrun E16. . Caries-risk assessment. Int Dent J, 1999; 49:15-26.Reynolds EC17. . Remineralization of enamel subsurface lesions by casein phosphopeptide-stabilized calcium phosphate solutions. J Dent Res, 1996; 76(9):1587-1595.

Reynolds EC18. . Anticariogenic complexes of amorphous calcium phosphate stabilized by casein phosphopeptides: a review. Spec Care Dentist, 1998; 18(1):8-16. 19. Reynolds EC, Cai F, Shen P, Walker GD. Retention in plaque and remineralization of enamel lesion by various forms of calcium in a mouthrinse or sugar-free chewing gum. J Dent Res, 2003; 82:206-211.Robinson C, Shore RC, Brookes SJ, Strafford S, Wood SR, 20. Kirkham J. The Chemistry of Enamel Caries. Crit Rev Oral Biol Med, 2000; 11(4):481-495.Rose RK21. . Effects of an anticariogenic casein phosphatide on calcium diffusion in streptococcal model dental plaques. Arch Oral Biol, 2000; 45(7):569-575.Schupbach P, Neeser JR, Golliard M, Rouvet M, 22. Guggenheim B. Incorporation of caseinoglycomacropeptide and caseinophosphopeptide into the salivary pellicle inhibits adherence of mutans streptococci. J Dent Res, 1996; 75(10):1779-1788.Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC23. . Remineralization of enamel subsurface lesions by sugar-free chewing gum containing casein phospopeptide - amorphous calcium phosphate. J Dent Res, 2001; 80(12):2066-2070.Trimpeneers LM, Dermault LR24. . A clinical evaluation of the effectiveness of a fluoride-releasing visible light-activated bonding system to reduce demineralization around orthodontic brackets. Am J Orthod Dentofacial Orthop, 1996; 110(2):218-222.Tsalev DL, Zaprinov ZK25. . Atomic Absorption Spectrometry in Occupational and Environmental Health Practice. Volume I. Analytical Aspects and Health Significance,. Boca Raton, Florida: CRC Press, 1983. Vorhies AB, Donly KJ, Staley RN, Wefel JS26. . Enamel demineralization adjacent to orthodontic brackets bonded with hybrid glass ionomer cements: an in vitro study. Am J Ortod Dentofacial Orthop, 1998; 114(6):668-674.

Dr. Efka Zabokova-BilbilovaDepartment of Pedodontic School of Dentistry Vodnjanska 17 1000 Skopje E-mail: [email protected]

Dr. Trajce StafilovDentistry Institute of Chemistry Faculty of Natural Sciences and MathematicsSt. Cyril and Methodius University1000 SkopjeE-mail: [email protected]

Correspondence and requests for offprints to:

SUMMARYThe aim of this study was to describe the distribution and degree

of infraocclusion and to evaluate the influence of the age of diagnosis and treatment outcomes of primary molars during a period of 2 years. 21 patients, aged between 6 to 11 years, participated in the study. The children were subjected to clinical and radiographic examinations every 6 months during 2 years. Parameters assessed were age, gender, distribution and degree of infraocclusion based on radiographs, ankylosis, altered position of adjacent and successor teeth and treatment outcome.

It has been found that the most frequently affected teeth were primary second molars located in the lower arch as bilateral occurrence. The degree of infraocclusion was considered as mild in 35, moderate in 15 and severe in 6 teeth. The successors were congenitally absent in 10 infra-occluded teeth. Tipping of neighbouring teeth and the delayed eruption of the permanent successors were found to be the most frequent complications. The treatment outcome was favourable in 78% of the cases. It could be concluded that early diagnosis, correct treatment approach and follow-ups were the main factors of a successful treatment of infra-occluded primary molars. Keywords: Infraocclusion; Primary Molars; Children; Ankylosis

Nazan Kocatas Ersin, Umit Candan, Ali Riza Alpoz

Ege University, Faculty of DentistryDept. of Paediatric DentistryBornova, IzmirTurkey



Infraocclusion of Primary Molars:A Review and Report of Cases

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Introduction

The term “infraocclusion” describes a tooth which lies below the occlusal plane. Other terms used in the literature are submerged, impaction, reimpaction, re-inclusion and secondary retention. However, it is suggested that the term “infraocclusion” gives a good description of the clinical appearance and has gained increasing use during recent years1. The term “ankylosis” has been also most widely used because of the clinical, radiographic and histological evidence, which suggested that the majority of infra-occluded teeth were ankylosed. This term refers to one possible cause or frequent association with infraocclusion. It is assumed that because of tooth ankylosis, the infra-occluded tooth remains in a fixed position while eruption of adjacent teeth appear2.

The other factors involved in infraocclusion of primary teeth are congenitally missing permanent teeth, defects in the periodontal membrane, local mechanical trauma, a disturbed local metabolism, injury to the periodontal ligament, precocious eruption of the permanent first molar or a combination of the mentioned factors3-7. A

familial tendency was also indicated as the aetiology of infraocclusion8.

Infra-occluded teeth are more common with the primary teeth than the permanent teeth, and mandibular primary molars tend to be infra-occluded more frequently than maxillary primary molars2,8,9.

The aim of the study was to describe the distribution and degree of infraocclusion in a group of children aged between 6 to 11 years, and to evaluate the influence of the age of diagnosis and treatment outcomes during a period of 2 years.

Material and Methods

21 patients aged between 6 to 11 years, who were referred to the Department of Paediatric Dentistry, Ege University, due to their dental problems, enrolled in the study. The infra-occluded teeth were observed after clinical and radiographic examinations including orthopantomograph and periapical radiographs. The follow-

up examinations also comprised clinical and radiographic examinations every 6 months during 2 years. The radio-graphs were evaluated for resorption and ankylosis of the infra-occluded teeth and comparisons were made with radiographs taken before.

Parameters assessed were age, gender, distribution and degree of infraocclusion based on radiographs, ankylosis, altered position of adjacent and successor teeth, and treatment outcome. The degree of infraocclusion was considered as mild, moderate or severe, as described by Brearly and Mc Kibben10. Mild was described as occlusal surface located approximately 1 mm below the expected occlusal plane for the tooth. Moderate was described as occlusal surface approximately level with the contact point of one or both adjacent tooth surfaces. Severe was described as occlusal surfaces level with or below the interproximal gingival tissue of one or both adjacent tooth surfaces.

Mobility test was performed by direct finger pressure and percussion sound was recorded after tapping the crown of the tooth vertically as well as horizontally with the handle of a probe by the first examiner to determine ankylosis.

A therapeutic approach was chosen according to the patient’s age, occlusal status, development and condition

of the infra-occluded teeth, lack of a permanent successor and extent of root resorption.

Results

56 infra-occluded teeth were detected in 21 patients (11 boys and 10 girls) whose mean age was 9.4± 0.8 years (Tab. 1). At the time of first examination, all the patients were in the mixed dentition stage. 18 patients had more than 1 infra-occluded tooth while 3 patients had 1 tooth in infraocclusion. 11 (19.7%) infra-occluded teeth were located in the upper jaw while 45 (80.3%) teeth were found in the lower jaw. 24 (42.9%) of the infra-occluded teeth were primary first molars and 32 (57.1%) of them were second molars. The degree of infraocclusion was considered as mild in 35 (62.5%), moderate in 15 (26.8%) and severe in the remaining 6 (10.8%) teeth. Agenesis of premolars was diagnosed in 10 (17.9%) infra-occluded teeth. Ankylosis was detected in 29 lower infra-occluded molars after mobility and percussion tests, and radiographic examination.

Table 1. Distribution of 56 infra-occluded primary molars by gender, degree of infraocclusion and location in 21 patients

Gender Number of teeth

Location Degree of infraocclusion Lack of permanent

Girls Boys Maxilla Mandible Mild Moderate Severe successorPrimary first

molar 3 5 24 2 22 16 7 1 -

Primary secondmolar 7 6 32 9 23 19 8 5 10

Total 10 11 56 11 45 35 15 6 10

Out of 46 infra-occluded teeth which had permanent successors, 19 ankylosed teeth were extracted and 5 space maintainers were fitted and remained in place until the eruption of the successors. 27 infra-occluded teeth were left undisturbed waiting for the normal exfoliation, but monitored every 6 months fulfilling their function as space maintainers. At the end of 2 years, 6 teeth were exfoliated and the permanent successors erupted with a mean period of 9 months later than on the normal, contra-lateral side, and 10 teeth were extracted because of the root development of the successors. The remaining 11 teeth were still being monitored every 6 months. After orthodontic evaluation of the occlusion, it was decided to allow the 10 infra-occluded ankylosed molars with agenesis to persist. Composite build-ups were placed to 6 infra-occluded teeth with agenesis in order to restore the occlusion and interproximal contacts and waited for resorption. The degree of root resorption was unchanged or minimal in the infra-occluded teeth with agenesis at the end of 2 years. Migration of the neighbouring tooth was

present in 62.5% of the cases, and the treatment outcome was favourable in 78% of the cases.

For 2 patients who had severely infra-occluded teeth, extraction followed by orthodontic treatment was planned, but the patients refused the treatment and showed poor compliance to the follow-up examinations. After 2 years, they were recalled and their orthopantomographs were taken. In figure 1a, the patient was 9-year-old boy and his medical history was unremarkable. The patient had 2 infra-occluded teeth, upper right primary first molar and lower left primary second molar with caries. It was decided to extract the infra-occluded teeth and an orthodontic treatment was planned, but he refused the extraction and failed to come to the follow-up examinations. After 2 years, he was recalled and an orthopantomogram was taken, shown in figure 1b. The degree of root resorption was unaltered in both of the infra-occluded primary molars. The carious teeth had been restored in a private dental clinic. The infraocclusion had worsened in both the upper and lower regions and tipping of the neighbouring

Balk J Stom, Vol 12, 2008 Infraocclusion of Primary Molars 139

140 N.K. Ersin et al. Balk J Stom, Vol 12, 2008

teeth was diagnosed. The upper and lower primary incisors had exfoliated and the permanent incisors had erupted as well as the permanent first molars.

In figure 2, the patient was an 8-year-old girl and her medical history was unremarkable. The patient had referred to our clinic for her non-erupted permanent first central incisor. Her orthopantomogram and intraoral clinical examination showed a lower left second primary infra-occluded molar with the tipping of the permanent first molar and a malocclusion in the upper left region (Fig. 2a and b). In view of the severity of the infraocclusion and the malocclusions, an orthodontic

treatment was considered with fixed appliance therapy. The patient refused the orthodontic treatment because of financial circumstances. After 2 years, orthopantomogram and clinical examination revealed that the degree of root resorption of the infra-occluded tooth was unchanged although the root of the permanent successor has developed, but a resorption was observed at the distal root of the symmetrical primary second molar (Fig. 3a and b). The positions of the non-erupted upper permanent first central incisor, second premolar and first molar was unaltered and the remaining teeth in her mouth had a normal resorption and eruption.

Figure 1a: Orthopantomograph of a patient at the initial examination, showing severely infra-occluded molars

Figure 2a: Orthopantomograph of a patient at the initial examination, showing a severe infra-occluded primary molar. The left lower

permanent first molar shows a severe mesial tipping

Figure 1b: Orthopantomograph of the same patient after 2 years, showing worsened infraocclusion. The infra-occluded teeth are

more impacted with the tipping of the adjacent teeth, leading to a malocclusion in the permanent dentition

Figure 2b: The intraoral view of a patient showing the infra-occluded lower left second primary molar

Balk J Stom, Vol 12, 2008 Infraocclusion of Primary Molars 141

Discussion

The infraocclusion is a common eruption disturbance, which constitutes a major clinical problem1. It is reported that the prevalence of children with infra-occluded primary molars in the various population ranges from 1.3% to 38.5%8,11. The prevalence could be changed due to the age of the children, ethnic differences, differences in number of remaining primary molars, and differences in the criteria used12.

Infraocclusion is found from 3 years of age and prevalence of infraocclusion has been reported to reach a peak at ages from 6 to 11 years of age1. It is also mentioned that the variations in the age could possibly be related not only to genetic predisposition to infraocclusion but also to the inception of this condition and the exfoliation time the infra-occluded tooth3. The age range from 6 to 11 years is in the present study, too.

Infraocclusion of primary molars is usually found not to be sex linked. However, a more frequent occurrence in girls than in boys has been reported in some studies1,2. No gender predominance was observed in our study. Most investigations have reported that the primary second molars were most commonly found in infraocclusion. However, it has recently been reported that the primary first molars were more often found in infraocclusion1,9,13. This difference is most probably due to the fact that mandibular primary first molars ankylose earlier, produce less infraocclusion and usually exfoliate on time, which means that they may go undetected. In contrast, mandibular primary second molars produce more severe infraocclusion and a slight delay in the eruption of their successors13. In children with more than 1 tooth affected, bilateral occurrence was reported to be more common1,5,12,14. The most frequently affected teeth were

primary second lower molars (57.1%), as in a bilateral occurrence in our study.

The degree of infraocclusion can be from mild to severe. Depending on the degree of infraocclusion, the occlusion and the position of the tooth germ could be affected. Infra-occluded teeth could have a high potential to malocclusion. In the literature, complications of infra-occluded primary molars were stated as tipping of the neighbouring teeth, loss of space, extreme eruption of the antagonist, posterior open bite and rotations in the successor teeth12,15. In the present study, tipping of neighbouring tooth was found to be the most frequent complication.

Infraocclusion in children seemed to be associated with agenesis; the prevalence of missing successors underneath primary molars with infraocclusion varied from 5 to 67%1. In the present study, the prevalence of missing successors was found as 17.9% of the total cases.

When considering treatment options for the infra-occluded primary molars, there is no general agreement16-18. It was reported that the most important influencing factor was the presence or absence of the permanent successor and when successor is absent, root resorption was slow and spontaneous exfoliation less likely16. In this study, the degree of root resorption was unchanged or minimal in the infra-occluded teeth with agenesis after 2 years.

Teague et al19 reported that treatment depends upon the patient’s age, the condition of the primary molar, the patient’s preference, jaw relationship and occlusion. When the successor was present, the infra-occluded tooth could exfoliate normally. However, exfoliation was usually delayed by only 6 to 12 months compared with contra-lateral unaffected tooth and infra-occluded tooth should not be extracted solely to prevent an increase in infraocclusion1. Kurol and Koch20 compared extraction and non-extraction management of contra-lateral teeth in patient’s with bilateral infra-occluded primary molars and

Figure 3a: Orthopantomograph of the same patient after 2 years, showing no resorption of the infra-occluded primary second molar roots,

and no alterations at the left upper region with a severe malocclusion

Figure 3b: The intraoral view of the patient showing eruption of the lower left permanent canine and the first premolar

142 N.K. Ersin et al. Balk J Stom, Vol 12, 2008

found that there was no significant delay in exfoliation of non-extracted infra-occluded teeth. Mc Donald et al21 suggested that if cooperation of patients was obtained, observation was the best approach. On the other hand, some authors recommended early tooth extraction for the treatment of infra-occluded teeth and treatment regimens could remain contraversial5.

In the present study, therapeutic extraction was chosen in patients with several occlusal disturbances, risk of impaction of a permanent tooth or ankylosed teeth with significant delay in root resorption. We suggest that infra-occluded primary molar should not be extracted before the time it should exfoliate if the successor is present, unless ankylosis was detected. Only when the resorption did not proceed normally and ankylosis was observed, then extraction should be considered. In case of agenesis, it was suggested that persistence of infra-occluded primary molars could serve as a semi-permanent solution for the patients.

Conclusion

It was revealed that, in the management of the infraocclusion, early diagnosis and correct treatment approach play significant roles in eliminating the dental problems, particularly malocclusion. Multidisciplinary treatment and periodic follow-ups could be suggested in order to prevent the complications of infra-occluded primary molars.

References

Kurol J1. . Infraocclusion of primary molars: an epidemiological, familial, longitudinal clinical and histological study. Swedish Dent J, 1984; Supplement 21, pp 5-7. Douglas J, Tinanoff N2. . The etiology, prevalence, and sequelae of infraocclusion of primary molars. J Dent Child, 1991; 58:481-483.Biederman W3. . Etiology and treatment of tooth ankylosis. Am J Orthod, 1962; 48:670-684.Pilo R, Littner MM, Marshak B4. . Severe infraocclusion ankylosis: report of three cases. J Dent Child, 1989; 56:144-146.Atrizadeh F, Kennedy J, Zonder H5. . Ankylosis of teeth following thermal injury. J Periodont Res, 1971; 6:159-167.

Kurol J, Magnusson BC6. . Infraoclusion of primary molars: a histologic study. Scand J Dent Res, 1984; 2:564-576.Rogers JV7. . Amalgam restoration in a submerged tooth. Oral Surg Oral Med Oral Pathol, 1984; 57:233-234.Koyoumdjisky-Kaye E, Steigman S8. . Ethnic variability in the prevalence of submerged primary molars. J Dent Res, 1982; 61:1401-1404.Via WF9. . Submerged deciduous molars: familial tendencies. J Am Dent Assoc, 1964; 69:127-129.Brearley LJ, McKibben DH10. . Ankylosis of primary molars (I) Prevalence and characteristics (II) Longitudinal study. J Dent Child, 1973; 40:54-63.Steigman S, Koyoumdjisky-Kaye E, Matrai Y11. . Submerged deciduous molars and congenital absence of premolars. J Dent Res, 1973; 52:322-326.Teague MA, Philip B, Parry JW12. . Management of the submerged deciduous tooth: 1. aetiology, diagnosis and potential consequences. Dent Update, 1999; 26:292-296.Kula K, Tatum BM,13. Owen D, Smith RJ, Rule J. An occlusal and cephalometric study of children with ankylosis of primary molars. J Pedod, 1984; 8:146-159.Antoniades K, Kavadia S, Al Milioti K14. . Submerged teeth. J Clin Pediatr Dent, 2002; 26:239-242.Ertuğrul F, Tuncer AV, Sezer B15. . Infraocclusion of primary molars. A review and report of a case. J Dent Child, 2002; 69:166-171.Gulati AK, Welbury RR16. . The use of resin-bonded porcelain crowns for primary molars in infra-occlusion. Br Dent J, 1998; 184:588-591.Evans RD, Briggs PFA17. . Restoration of an infra-occluded primary molar with an indirect composite onlay: a case report and literature review. Dent Update, 1996; 23:52-54.Altay N, Cengiz B18. . Space-regaining treatment for a submerged primary molar: a case report. Int J Paed Dent, 2002; 12:286–289.Teague MA, Philip B, Parry JW19. . Management of the submerged deciduous tooth: 2. treatment. Dent Update, 1999; 26:350-352.Kurol J, Koch G20. . The effect of extraction of infraocluded deciduous molars: a longitudinal study. Am J Orthod, 1985; 87: 46-55.McDonald RE21. . Dentistry for the child and adolescent. 2nd ed. St Louis: CV Mosby Co, 1974; pp 79-84.

Correspondence and request for offprints to:

Dr. Nazan Kocatas ErsinEge University, Dental FacultyDept of Paediatric Dentistry35100 Bornova, IzmirTurkeyE-mail: [email protected]

SUMMARYBackground: Presence of the maxillary sinus and low bone density in

this area often could create a problem for prosthetic rehabilitation with den-tal implants. Sinus floor augmentation technique can successfully increase dimensions of the posterior maxilla for implant placement.

Objective: To assess quality of newly formed bone for implant insertion after augmentation of the floor of the maxillary sinus using Digora for Win-dows computer programme.

Materials and Methods: 30 patients with indications for sinus lift pro-cedure were involved in this clinical study. Bone density was analysed by Digora for Windows computer programme.

Results: 16 patients completed this clinical study with preoperative and postoperative orthopantomographs.

Conclusion: Cases with sufficient density and bone volume in the poste-rior maxilla require sinus lift technique with adequate bone graft for implant insertion. This is confirmed by pre- and post-operative analysis of radio-graphic images in Digora for Windows programme.Key words: Posterior Maxilla; Sinus Lift; Computer Analysis

B. Obradovic1, Z. Stajcic2, Lj. Stojcev Stajcic3

1University of Banja Luka, Medical School, Banja Luka, Bosnia and Herzegovina2Dental/Medical Centre for Maxillofacial Surgery “Beograd-centar”, Belgrade, Serbia 3 Clinic of Oral Surgery, Faculty of Stomatology, University of Beograd, Serbia

ORIGINAL PAPERBalk J Stom, 2008; 12:143-146


Assessment of the Quality of Newly-Formed Bone for Implant Insertion after Augmentation of theMaxillary Sinus Floor

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Introduction

Contemporary prosthetic rehabilitation of the posterior maxilla, instead classic dental prostheses, comprises implant insertion and subsequent rehabilitation. However, implant placement in the posterior maxilla usually presents a challenging clinical situation. When planning implant restoration in this region, several parameters need to be considered: height and width of the alveolar ridge in the posterior maxilla, and bone density. Due to the presence of maxillary sinus and low bone density in this area, it is usually required to use shorter implants, which can result in the increased risk of failure5. Sufficient density and appropriate volume of bone are therefore crucial factors for successful implant treatment7,8.

The maxillary sinus floor augmentation technique has been extensively used in the last 20 years to successfully increase the dimensions of the posterior maxilla for implant placement3. This technique is based on elevation of the Schneiderian membrane from the floor of maxillary sinus and introduction of a bone graft or a bone substitute. In these cases, the residual height of the alveolar ridge was less than 8 mm14 . Sinus lift was introduced by Boyne in the 1960s and it was soon more popularized9. This procedure is technically demanding and involves many factors that might affect implant survival, such as the type of graft used for augmentation, surgical technique and the type of implants4.

Since survival rates in the posterior maxilla are different from other sites/locations in the mouth, it would be interesting to analyse implant survival after sinus augmentation. The aim of this clinical study was to

144 B. Obradovic et al. Balk J Stom, Vol 12, 2008

assess quality of newly-formed bone for implant insertion after augmentation of the floor of maxilla sinus by using modern computer analysis programme.


The study was carried out on a group of 30 patients, of different age and gender, who required bone augmentation of the posterior maxilla and subsequent implant restoration. All surgical procedures were carried out in Dental/Medical Centre for Maxillofacial Surgery “Beograd-centar” in Belgrade, Serbia, under local anaesthesia. All patients had residual sinus floor of less than 8 mm high and low bone density. They had good oral hygiene, did not suffer from diabetes mellitus or other serious general diseases.

In the period from 2006 to 2007, 30 sinus grafting operations were performed. The sinus lift was carried out using 1 of the familiar techniques depending on clinical condition. Duration of rehabilitation between the sinus lift procedure and implant placement was 6 months. The particulate bovine bone Bio-Oss® was used for the sinus floor augmentation in majority of cases, as well as an autogenous bone graft from the mandible (symphysis, retromolar region) in cases of severe pneumatization. The type of implants used in the second stage procedure were Branemark, Straumann, and Replace Select Tappered according to the thickness of the bone and patient preferences.

Quality of newly formed bone (bone density) and implant stability was evaluated on the basis of computer programme Digora for Windows (Soredex Finland). Preoperative and postoperative analysis of height of the sinus floor was also performed in Digora for Windows programme. Figure 1 shows ortthopantomography (OPG) in Digora, started for analysis. To perform more precise computer interpretation of height of maxillary sinus line, a calibrate method was used. Figures 2 and 3 show analysis of height of the posterior maxilla in Digora, pre- and postoperatively. In Digora for Windows programme, the height of the posterior maxilla can be obtained automatically choosing the part of the posterior maxilla for height analysis (vertical line) with cursor (principle is the same on pre- and postoperative X-rays).

Figures 4 and 5 show analysis of bone density pre- and postoperatively in Digora. Principle of bone density assessing in Digora for Windows programme can be obtained automatically as well by using cursor. Length for assessing bone density preoperatively was preformed in side of rectangle in bone zone planned for augmentation and subsequent implant insertion. The same principle was used on postoperative X-rays in the zone where bone augmentation was performed.

Figure 1. OPG X ray in Digora started for analysis

Figure 2. Analysis in Digora preoperatively postoperatively

Figure 3. Analysis in Digora after augmentation

Figure 4. Analysis in Digora of bone density bone preoperatively

Balk J Stom, Vol 12, 2008 Implant Insertion into Augmented Maxillary Bone 145

Results

16 patients completed the study with preoperative and postoperative OPGs, what was the requirement for analysis of bone height (the distance between the sinus floor and the top of the alveolar ridge) and bone density. Preoperative mean-value of bone height was 7.03 mm and 15.82 mm after augmentation. Preoperative and postoperative values of the bone density in the posterior maxilla in the region of the maxillary sinus floor were of 50.80 and 114 respectively. These findings significantly improved bone conditions for implant placement.

According to the highest level of bone density in peri-implant region of 177.50 and clinical observation, all implants were stable in the second-stage surgery. Figure 5. Analysis in Digora of density postoperatively

Figure 6. Posterior maxilla before and after augmentation

Figure 6. Posterior maxilla before and after augmentation

Analysis in Digora showed no differences between bone density of xenotransplants and autotransplants. Figures 6 and 7 show OPGs before and after augmentation of the posterior maxilla, with obvious effect.

Discussion

Dental implants have reached a high level of reliability and a considerable rate of success1. Best results

are found in voluminous and highly mineralized bone. In the region of the posterior maxilla, bone is largely cancellous with low level of mineralization11. Its height is usually limited by the extended maxillary sinus. But, the amount of residual alveolar bone height is often cited as an important prognostic factor for the success of sinus augmentation procedure9.

During the study, main parameters for analysis of the posterior maxilla were the height of the residual alveolar bone and bone density. Preoperative results during Digora analysis of height (mean-value 7.03 mm) and bone density

146 B. Obradovic et al. Balk J Stom, Vol 12, 2008

(50.80) have revealed poor bone quality, and doubtful osseointegration of the placed implant in the future. This anatomical handicap could be resolved with a sinus floor augmentation procedure9.

Postoperative results of the bone height after bone graft procedure (mean-value of 15.82 mm) and bone density after 6 months (middle value 114) were confirmed by successful implant survival. Implant failure is more common with implants placed in bones of low density than in bones of high density7,8. Analysis of implant stability in Digora programme after few months showed satisfactory bone density (of mean-value 177.50), which is an important factor for implant osseointegration in the newly formed bone, which means close apposition of bone to the implant surface, “contact osseogenesis”2.

In this study, a xenograft Bio-Oss® was applied for augmentation. In cases with defect of the buccal cortex of the maxilla, autogenous bone grafts from the mandible (symphysis, retromolar region) were applied to achieve highly predictable bone augmentation6,12. It would be interesting to predict what will happen with these implants in the future. However, that would imply a long-term follow-up findings of another clinical study.

References

Adell R, ErikssonB, Lekholm U, Branemark PI, Jemt T1. . A long term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants, 1990, 5:347-359.Albrektsson T, Branemark PI, Hansson HA, Lindstrom 2. J. Osseointegrated titanium implants. Requirements for ensuring a long-lasting, direct bone-to-implant anchorage in man. Acta Orthopaed Scand, 1981; 52:155-170.Boyne PJ, James RA. 3. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg, 1980; 38:613-616.Buser D, Mericske-Stern R, Bernard JP, Behneke A, Behneke 4. N, Hirt HP, Belser UC, Lang NP. Long term evaluation of nonsubmerged ITI implants. Part I. 8-year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Impl Res, 1997; 8:161-172.

Chuang SK, Tian L, Wei LJ, Dodson TB.5. Predicting dental implant survival by use of the marginal approach of the semi-parametric survival methods for clustered observations. J Dent Res, 2002; 81:851-855.Cordaro L. 6. Bilateral simultaneous augmentation of the maxillary sinus floor with particulated mandible. Report of a technique and preliminary results. Clin Oral Impl Res, 2003; 14:201-206.Friberg B, Jemt T, Lekholm U.7. Early failures in 4641 consecutively placed Branemark dental implants, a study from stage I surgery to the connection of completed prostheses. Int J Oral Maxillofac Impl, 1991; 6:142-146.Jaffin RA, Berman CL.8. The excessive loss of Branemark fixture in type IV bone: A 5-year analysis. J Peridontol, 1991; 62:2-4.Jensen OT, Shulman LB, Block MS, Iacono VJ. 9. Report of the Sinus Consensus Conference of 1996. Int J Oral Maxillofac Impl, 1998; 13(Suppl 1):1-45.Jensen OT.10. The Sinus Bone Graft. Chicago: Quintessence, 1999.McCarthy C, Patel RR, Wragg PF, Brook IM. 11. Sinus augmentation bone grafts for the provision of dental implants: Report of clinical outcome. Int J Oral Maxillofac Impl, 2003; 18:377-382.Merkx MA, Maltha JC, Stoelinga PJ.12. Assessment of the value of inorganic bone additives in sinus floor augmentation: A review of clinical reports. Int J Oral Maxillofac Surg, 2003; 32:1-6.Pinholt EM13. . Branemark and ITI dental implants in the human bone-grafted maxilla: A comparative evaluation. Clin Oral Impl Res, 2003; 14:584-592.Stajcic Z., Stojcev Lj. 14. Atlas of Oral Implantology. Belgrade: Grafolik, 2001, p 102. (in Serb)

Correspondence and request of offprints to:

B. ObradovicUniversity of Banja Luka, Medical SchoolBanja LukaBosnia and HerzegovinaE-mail: [email protected]

SUMMARYOsteoporosis causes micro-degradations and jaw-bone reduction. Initial

positive turnover and bone recover should make hasten by local medication of osteoporotic jaws. The aim of this study was to present improvement of jaw pattern by local application of calcitonin and calcium throughout prosthetic treatment of selected osteoporotic patients. Patients undergoing study were osteoporotic and toothless (9 males and 27 females), with no malignancy. Non-osteoporotic complete denture wearers, 7 men and 7 women were con-trols. DPX-L (Lunar) was used in detection of skeletal degradations. Pano-ramic radiographs (Orthopantomograph 10, Siemens) and digital densito-meter DT II 05 (England) were used in the analysis of bone density. T-results indicated systemic osteoporosis.

After application of calcium and calcitonin in solutions, moderate increase of density (p<0.05) was verified, compensating up to 3% of total mandibular loss. The second section of results was restorative effect of pros-thetic treatment of osteoporotic patients. In this study, osteoporosis affected women patients earlier than men.

Regardless the necessity of careful selecting of patients for this kind of treatment, calcitonin and calcium in solutions should be considered as the priority of local therapy in osteoporotic toothless patients, providing positive bone remodelling, as well as success at the second level of therapy - posi-tioning of dentures. Keywords: Jaw; Osteoporosis; Calcitonin; Bone Remodelling

Srdjan D. Poštić

University of Belgrade, Faculty of Stomatology, Clinic of Prosthetic DentistryBelgrade, Serbia



Medication and Positive Remodelling of Osteoporotic Jaws

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Introduction

Osteoporosis is the most common type of bone disease over the lifetime, affecting human bones indiscriminately and haphazardly. A variety of micro-structural osteoporotic degradations and macroscopic resorption of oral bones was very well evidenced3,4,6,7,10-12,14,17. Moreover, it was reported that osteoporosis of human oral bones damaged not only bone support of remaining teeth, but induced reductions of denture retention and stability, too17. Analysis of bone layer’s appearance on panoramic radiographs is the valuable method of assessing bone changes in any of bone turnovers1,3,7,14,20.

Diet and nutritional factors are of extreme significance for prevention of osteoporosis, but minor results should be expected regarding initiation of positive remodelling of fragile osteoporotic bone8,10. Considering assorted literature data on multiple drug therapy and possibilities of

systemic medication, it could be of particular importance to focus dependable medical oral treatment approaches in osteoporotic affections4,16,17,19. Calcitonin accelerates influx of calcium, improving bone density and mineral content of bone, either in local, or systemic level7-9,10,14. This positive remodelling of osteoporotic bones could be finally reached in mandibular bone, as well as in other human bones2,5,7-9,15-19. The aim of this study is to present improvement of mandibular-bone pattern by local application of calcitonin and calcium throughout prosthetic treatment of selected osteoporotic patients.

Material and Method

The experimental group comprised 9 men (aged 64-90; mean age 87 years), and 29 women (aged 56-81;

148 S.D. Poštić Balk J Stom, Vol 12, 2008

mean age 58 years), edentulous and osteoporotic, with no malignant diseases (Fig. 1). 7 toothless men and 7 toothless women patients were controls (Fig. 2). Patients were selected concerning dental-oral history, questionnaire (age, probable treatments of osteoporosis in the past, history of fractures, menopausal periods, calcium and microelements of plasma-blood, additional Pyrilinx-D and Prolagen-C tests), oral examination (bone consistency and resorptions) and skeletal density. 3 women from the experimental group (on estrogens) and 3 osteoporotic men patients were on systemic therapy of osteoporosis after hospitalization. DPX-L analysis (Lunar, U.S.A.) and T-results of patients were provided.

Figure 1. Oral status of osteoporotic patient of the experimental group before treatment

Figure 3. Panoramic radiograph of osteoporotic jaws of the patient of the experimental group

Figure 4. Grid positioned onto regions of particular interest of the osteoporotic mandible of the patient of the experimental group, prior to

densitometric assessment

Figure 5. Determined regions of interest - Pr, M1r, M2r, Pl, M1l,M2l

Figure 6. Local application of anaesthetic on mucosal surface before injecting medicament – solution of calcitonin with calcium

Figure 2. Non-resorbed jaw of the patient of the control group

Panoramic radiographs of each patient (Orthopantomo-graph 10; serial no. 01492; Siemens, Germany), focused osteoporotic remodelling of jaws (Figs. 3-5).

Calcitonin (Miacalcic, Novartis, Switzerland; Calcitonin Huber, Galenika AD, Serbia), and calcium gluconate (Sterop, Brussles, Belgium), or calcium glubionat (Calcium-Sandoz amp., Switzerland) were used

Balk J Stom, Vol 12, 2008 Remodelling of Osteoporotic Jaws 149

The results of medication of supporting bone tissues primarily affected by osteoporosis were favourable in this study. Increase of density of mandibular segments after the therapy was significant, particularly for Pr and Pl segments (p < 0.01). Following application of calcium and calcitonin in solutions, moderate increase of jaw-bone density was observed (p < 0.05), compensating up to 3% of total mandibular-bone loss (Tabs. 1 – 3).

The second section of results were restorative effects of oral-prosthodontic treatment of the selected osteoporotic patients. Edentulous osteoporotic patients were rehabilitated in the observation period (Fig. 9).

locally to improve bone pattern in osteoporotic patients. Up to 1.5 ml of calcitonin and calcium solution (1:2) was injected submucously onto mandibular bone surfaces (Figs. 6-8). Complete dentures were fabricated for each of the patient of the experimental group (Fig. 9).

Digital densitometer DT II 05 (England, UK) was used in the analysis of mandibular segments’ bone density at panoramic radiographs after the therapy (Fig. 10)10,15.

Results

T results indicated systemic osteoporosis. The numerical values of T result ranged from -2.4 to -2.6 for male patients, and -2.5 to -2.6 for female patients.

Figure 7. Submucous injection of therapeutic solution of calcitonin and ion calcium onto buccal bone surface of osteoporotic mandible of the

patient of the experimental group

Figure 10. Panoramic radiograph of the patient after local increase of density of the edentulous mandible

Figure 8. Injection of therapeutic solution of calcitonin and calcium to the right side of the buccal mandibular osteoporotic surface

Figure 9. Complete dentures restored all of the supporting tissues and occlusion - dentures in the mouth , after necessary increments of bone

density of the lower jaw


Table 1. Increase of mandibular density of the experimental group and bone pattern improve

Table 3. Percentage of increase of density within mandibular segments uring 7 week interval of application of solution of calitonin and calcium

Mandibular segmentsconsidered

Percentage ofincrease of density

Pr 0.8% ± 0.8

Pl 0.85% ± 0.6

M1r 0.84% ± 0.1

M1l 0.83% ± 0.2

M2r 0.84% ± 0.4

M2l 0.84% ± 0.3 Pr+Pl+M1r+M1l +M2r+M2l ≅ 3%

Table 2. Statistical significance and differences of numerical values of mandibular density between the control and the

experimental group

Differences of numerical values of optical densitySegment regarding the baseline of the control group and the baseline of experimental group

Pr P < 0.01

Pl P < 0.01

M1r P < 0.05

M1l P < 0.05

M2r P < 0.05

M2l P < 0.05

-2.6

-2.4

-2.2

-2.0

-1.8

-1.6

baseline 9th months later

PrsPlsM1rsM1lsM2rsM2ls

Discussion

In dental literature there were few reports on the treatment and local medication of jaw-bones. Based on certain medical studies and monographs, there were 2 major approaches to the treatment. The first treatment approach has been related to application of bisfosfonates4,7,10,17-19. The second approach considered calcitonin as the primary accelerator of calcium’s influx to the bone4,10,17-19. Additionally, there were considerations of application of calcitonin, as well as bisfosfonates, locally to jaw-bones and denture-supporting areas2,5,7,9,10,15,16. Considering various facts on bisfosfonates - studies were mainly conducted on patients undergoing systemic therapy with bisfosfonates, and there is only a few of studies on application of bisfosfonates on the local (oral) level,

as well as the fact that certain interruptions of immune response were described as possible complication of the extended bisfosfonate usage - it seemed reasonable to apply calcitonin and calcium in solutions locally, in vivo, to osteoporotic jaws2,4,5,18,19. The effects of treatment is difficult to compare to different calcitonin effects as they were acquired in experimental animals, but not in humans9,10,15,16.

Calcitonin was described as the substance strongly regulating influx of calcium4. Calcium influx should have been provided by mobilization of “free” calcium ion from blood plasma, as well as by exchanging calcium ion of the medicament (calcium gluconate or calcium glubionas)4,10. Respecting specificity of blood flow to the human mandible, and the fact that mandible usually is not supplied by plenty of blood, it seemed reasonable

Balk J Stom, Vol 12, 2008 Remodelling of Osteoporotic Jaws 151

to assume that calcium ions from blood vessels do not provide a needed intensity of calcium influx towards osteoporotic degradations7,11. Furthermore, additional sources of calcium ion, directed towards credible local storage near enough to the mandible bone, should have beneficial effect.

There is no enough evidence in dental literature on local application of calcitonin and calcium into hard oral tissues. Because of that, it should be not possible to compare the results of the present study with results of credible studies regarding the percentage of calcium and calcitonin in train solution7,9,10,15. Moreover, in this point of view, it should not be possible to adjoin if the increment of concentration of calcium has to be applied to the surface of edentulous ridge, or the concentration of calcium in solution has to be ultimately changed (or decreased) in cases of persistence of roots of the remaining teeth.

Certainly, on the basis of the results of this study, it may be stated that calcitonin in calcium solution should have been applied to edentulous ridge prior to positioning of the denture onto supporting tissues, that is delivery of prosthesis. More precisely, it should be injected towards bone support in the initial steps of denture fabrication, i.e. taking preliminary impression, and previous to functional impression, or even in the procedure of determining jaw relations with occlusal rims.

Calcitonin and calcium liquid is not a „supernatural drop“ for instant recover of osteoporotic bone layers. However, careful selection of patients, as well as repeated application of calcitonin and calcium in solutions to bone layers, may significantly improve oral bone condition and ability to accept prosthetic restoration on denture-supporting areas.

The local application of calcitonin with calcium could be repeated, if necessary. However, there must be the necessity of careful selecting the patients, because of the fact that application of calcium should not be indicated for patients with heart disease, kidney disease or serious blood problems. Also, patients with malignant diseases must not be included in the local therapy of osteoporotic oral bones. In spite of the limitations, local application of calcitonin and calcium should be the absolute prerequisite of organizing positive bone remodelling and turnover of segments of jaws. Thus, these segments should be prepared for better acceptance of denture surface.

Edentulous osteoporotic mandibular bone should ultimately be the first of oral bones for application of calcitonin-ion calcium solution. Additionally, respecting levels of the concentration of the applied calcium ion, the osteoporotic maxillary bone could be treated with the solution of the same kind, in the prolonged period of time.

It seems that osteoporosis of the mandible affects women earlier than men. Also, osteoporosis was more frequent in women. Usage of calcitonin and calcium in solutions for osteoporotic toothless patients should be

considered as the priority of local oral treatment. In spite of the limited value of local application, calcitonin and calcium should be the absolute prerequisite for organizing positive bone remodelling and turnover of segments of jaws which should be, this way, prepared for better acceptance of denture surface. Regardless the absence of macroscopic evidence of bone tissue regeneration, local application of calcitonin with calcium could be crucial for the success at the first level of the treatment (turnover and positive bone remodelling), as well as for the second level of treatment (fabrication and positioning of dentures).

References

1. Ardakani FE, Niafar N. Evaluation of Changes in the Mandibular Angular Cortex Using Panoramic Images. J Contemp Dent Pract, 2004; 5:1-15.

2. Cheng A, Mavrokokki A, Carter G, Stein B, Fazzalari NL, Wilson DF, Goss AN. The dental implications of bisphosphonates and bone disease. Australian Dent J, 2006; 50(Suppl 2):S4-S4.

3. Drozdzowska B, Pluskiewicz W. Longitudinal changes in mandibular bone mineral density compared with hip bone mineral density and quantitative ultrasound at calcaneus and hand phalanges. Br J Radiol, 2002; 75:743-747.

4. Kanis AJ. Osteoporosis. 2nd edn. Oxford: Blackwell Science, 1996; pp 22-147.

5. Mendes Duarte P, César-Neto JB, Wilson Sallum A, Antonio Sallum E, Nociti FHJr. Alendronate Therapy May Be Effective in the Prevention of Bone Loss Around Titanium Implants Inserted in Estrogen-Deficient Rats. J Periodontol, 2005, 76:107-114.

6. Poštić SD, Rakočević Z, Krstić M, Pilipović N. A densitometric appraisal of mandibular segments in osteoporotic subjects. Progress in Osteoarthrology, 1997; 2:81.

7. Poštić SD. The analysis of osteoporotic changes of mandible and their clinical significance. PhD Thesis, University of Belgrade, 1998. (in Serb)

8. Poštić SD, Vujasinović-Stupar N, Rakočević Z, Palić-Obradović D. Prevention and reduction of osteoporotic rarefaction in mandibular segments. Acta Orthop Scand, 1999; 70(Suppl 287):42-43.

9. Poštić SD. Local hormone therapy increased density in mandibular segments-a case report. Acta Orthop Scand, 1999, (Suppl 287)70: 43.

10. Poštić SD. Osteopenic and osteoporotic changes in mandible. Belgrade: Zadužbina Andrejević, 2000, pp. 5-79. (in Serb)

11. Poštić SD. Changes in mandible due to osteoporosis. Serbian Dent J, 2007; 54:16-27.

12. Poštić SD. Quantitative study on changes in osteoporotic edentulous mandibular ridges and metacarpal bones. Revue de la Societe Anthropologique de Yugoslavie-Glasnik ADJ, 2007; 42:249-261. (in Serb)

13. Poštić SD. Assured mandibular density increase in women wearing complete dentures. Proceedings of 31st Annual Conference of European Prosthodontic Association, 2007; O60-page 91.


14. Poštić SD. Comparison of differences and methods in measurement of edentulous ridges on panoramic radiographs. Revue de la Societe Anthropologique de Yugoslavie-Glasnik ADJ, 2008 ; 43:153-161. (in Serb)

15. Poštić SD. Bone positive remodelling - clinical aspects and medications of osteoporotic jaw-bone. 13th Congress of BaSS, 2008; O88- page 117.

16. Ramirez-Yanez GO, Seymour GJ, Symons AL. Local application of prostaglandin E2 reduces trap, calcitonin receptor and metalloproteinase-2 immunoreactivity in the rat periodontium. Arch Oral Biol, 2005; 50:1014-1022.

17. Torrens JI, Duncan WE. Osteoporosis: an update for the dental professional. J Practical Hyg, 1997; 1:45-48.

18. Wechter WJ, Horton JE. Methods of treating bone resorption http://www.freepatentsonline.com/4501754.html

19. w w w. F D A . G O V / O H R M S / D O C K E T S / A C / 9 8 /TRANSPT/3463t 2.rtf.

20. Yasar F, Akgunlu F. The differences in panoramic mandibular indices and fractal dimension between patients with and without spinal osteoporosis. Dentomaxillofac Radiol, 2006; 35:1-9.


Srdjan D. PoštićFaculty of Stomatology, Clinic of Prosthetic DentistryRankeova 4, 11000 BelgradeSerbiaE-mail: [email protected]

SUMMARYObjective: The purpose of this study was to evaluate the surface rough-

ness of posterior condensable composites.Methods: Posterior condensable composites, Alert (Jeneric/Pentron)

and Surefil (Dentsply), and hybrid composite Z100 (3M), were used in this study. The study material was placed into, and hardened in cavities. After the finishing and polishing procedures were completed, specimens were ran-domly separated into 3 groups. While the surface roughness values of the first group of specimens were determined with a profilometer, the surfaces of the second group were evaluated using SEM; Vickers micro-hardness mea sures were applied to the third group of specimens. Data were analyzed using Kruskal-Wallis and Mann-Whitney U tests.

Results: All 3 groups were found to be different mutually (p<0.05). The surface roughness of condensable posterior composites was greater than that of hybrid composite resins (p<0.05). A direct correlation was found between the micro-hardness value and the surface roughness value, indicating that a composite with higher hardness value yielded a higher roughness value (r=0.738). SEM images support the statistical evaluation.Keywords: Posterior Condensable Composites; Surface Roughness; Micro-hardness

Aysegiil Demirbas Kaya, Ferit Ozata

Ege University, School of DentistryDepartment of Restorative DentistryBornova - Izmir, Turkey



Surface Roughness of Posterior Condensable Composites

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Introduction

Resin based composite restorations are being used as aesthetic material in restorative dental medicine for the past 30 years. Since they were first manufactured in 1960 by Rafael Bowen, until today they have been constantly improved. The usage of resin based composite materials in posterior teeth as an alternative to amalgam, over the past few years, has presented a number of problems when used in class II and III cavities, such as placement in the cavity1-3. These problems have made the development of composites that are more suitable for the posterior teeth necessary2,4. Due to their physical and chemical properties, posterior condensable composites have been developed for various cavities in the posterior region. The matrices and organic and inorganic structures composing these composite materials have been changed5-8. Another concern in the clinical use of resin-based composite restorative materials is their ability to withstand occlusive forces and stresses of the oral environment, particularly in posterior situations1,3.

The surface smoothness of restoration material used orally, is important in providing a plaque-free environment and insuring wear resistance9,10. Many composites form a rough and dull surface because finishing and polishing procedures are not well done11-16. This problem arises from the difference between the micro-hardness of the polymeric matrix and the inorganic components that make up the composite material12,14,15,17. Size of the fillers which compose the inorganic component and their dispersion within the matrix are different. Therefore their abilities for polishing are also different18. In this study, the surface roughness of posterior condensable composites, which have been produced over the last few years, was evaluated using a profilometer and scanning electron microscope (SEM) and compared with surface roughness of a hybrid composite. In addition to this, in order to understand the relationship between the micro-hardness and surface roughness of posterior condensable composites and hybrid composites, their micro-hardness values were also determined and compared.

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A total of 3 resin-based composites, 2 posterior condensable and 1 hybrid composite, were used in the study. The names, batch numbers and manufacturers of these products are shown in table 1.

Table 1. Composites used in the study

Product Batch number Manufacturer

Alert N15CB Jeneric Pentron, Wallingford, CT, USA

Surefill 9812000106 Dentsply, Weybridge,Surrey

Z 100 3 M. St. Paul, MN, USA

Acryl blocks with 6 mm wide and 2 mm deep cavities were prepared. The composites were placed into these cavities following the manufacturer’s recommendations, a transparent strip band (Du Pont Co, Wilmington, Del) was placed on top and they were pressed down with glass. After the glass plate was removed, they were irradiated for 40 seconds under visible light (Cavex clearlicht HL 500, Cavex Holland BL). The specimens were then immersed in distilled water for 1 week and incubated at 37°C. At the end of this period, finishing and polishing procedures were completed for all of the specimens. As surfaces of all the specimens would be appropriate for clinical settings, they were processed under water with a flame-shaped diamond mill without applying pressure. This procedure took 15 seconds.

One type of polishing system was used in this study. (Hawe Neos Dental, Dr. HV Weisserfluh Ltd, Switzerland)19. In this system, coarse (white), medium (blue), fine (yellow), and X-fine (pink) polishing disks were applied under water (according to the manufacturer’s recommendation), starting from course to fine, for 15 seconds each, with a 30000 rpm rotating tool. After each successive change in abrasive, the specimens were rinsed thoroughly to remove all debris from the previous abrasive. Then white rubber was applied for 15 seconds, and the last step of the polishing procedure was completed using a rubber cup (Crescent Dental Mfg Co, Lyons III) and luster paste (Sybron/Kerr, Romulus, Mic.).

During the polishing of each specimen, care was taken to apply the same amount of pressure in the same direction. All finishing and polishing procedures were done by the same investigator on the same day to reduce variability.

From each group of study material for which the finishing and polishing procedures were completed, 15 specimens were randomly picked for the surface roughness measurements and SEM analysis, and 10 specimens were randomly picked for micro-hardness measurements.

Surface Roughness MeasurementSurface roughness (Ra-value or arithmetic average

roughness) was determined using a Mahr Concept perthometer tool (Perthen Mahri Germany) with a 0.2μm tip radius and wave length ± 250 that can take measurements within a 3.00 mm2 area. The average was taken of 5 Ra-values taken from each specimen.

SEM AnalysisSpecimens with the finishing and polishing

procedures completed were prepared to be examined under SEM (Joel JSM 5200, Tokyo, Japan). Specimens were plated with 200 Ao gold. Scanning Electron Micrographs made at original magnifications of x100 and x500 were evaluated and compared for surface texture and roughness. The samples were tilted and examined at a 10° angle.

Surface Micro-hardness Measurement10 samples randomly selected from each study

material with the finishing and polishing procedures completed were used to perform micro-hardness measurements. The vickers M41 Photoplan Microscope with micro-hardness attachment (Vickers Instruments, York, UK), which is a pneumatically loaded micro-hardness tester, was used to measure the surface hardness. This test involves applying a 136° diamond pyramid shaped indenter into the surface of the material being tested, and measuring the diagonals of the indentation produced. 10 readings were taken at different locations on the surface of the specimen. The lengths of the diagonals of the indentation were measured and then averaged. Using this value, VHN was obtained from 100 g Vickers Hardness Scale. This procedure was repeated for all specimens.

The results obtained by using the above tests for the ability of polishing of the 3 types of resin based composite restorations used were statistically evaluated by Kruskal-Wallis and Mann-Whitney tests. The presence of a correlation between the surface roughness and micro-hardness values was also evaluated.

Results

The surface roughness values (Ra-values), arithmetic means, standard deviation and median values of the resin based composite materials used in this study are as shown in table 2. According to the Kruskal-Wallis test, the difference between all the study groups in respect to surface roughness values was found to be significant (p< 0.05).

When the surface roughness values were analyzed according to the Mann-Whitney test, 3 different resin-based composite resins were found to be different from each other. The obtained results are as summarized in table 3.

Balk J Stom, Vol 12, 2008 Surface Roughness of Condensable Composites 155

Table 2. Surface roughness (Ra-value) in μm of composites used in this study

Product Mean SD Median

Alert 0.3150 5.720E-02 0.2950

Surefill 0.2010 2.283E-02 0.1950

Z 100 0.1720 1.229E-02 0.1700

Table 3. Composites compared in respect to their surface roughness (Mann-Whitney test)

Alert Surefill Z 100

Alert - 0.000* 0.000*

Surefill - - 0.000*

Z 100 - - -

* - significant (p<0.05)

The surface profile tracings obtained from resin based composites are as shown in figure 1. The SEM analysis was generally coherent with the profilometric data. Particles broke off from the surface of the first group of posterior condensable composites had the highest surface roughness values. The surface compactness of this group could be observed under x500 magnification. Stick and spherical particles were observed to be exposed from the surface (Fig. 2). In the second group of posterior condensable composites parallel to the surface roughness data, a more homogeneous surface can be observed with rarely a few particles sticking out of place. There are scratches and striations on the surface (Fig. 3). The smoothest surface among all study groups was observed in the hybrid composites, which make up the third group. Composite filler structure was observed. In addition to this, the surface was well polishable (Fig. 4).

Figure 1. Surface profile tracing of composites finished and polished(A - Alert; B - Surefill; C - Z 100)

Figure 2. Scanning electron micrographs depicting surface profiles of Alert (magnification: A - x100; B - x500)

Figure 3. Scanning electron micrographs depicting surface profiles of Surefill (magnification: A – x100; B - x500)

A

A

B

B

C

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B

156 A.D. Kaya, F. Ozata Balk J Stom, Vol 12, 2008

Discussion

Among the 3 different resin-based composite materials, finished and polished in the same manner and conditions, the condensable posterior composites in which the filler structure and proportions were changed for usage in posterior situations were found to have, unlike hybrid composites, a rougher surface. The SEM images of the specimens are supported by profilometric measurements. The roughness values were in this order: Alert; Surefil; Z 100. In fact, the particles of Alert and Surefil condensable posterior composites have broken off from the surface during the finishing and polishing procedures structure (Figs. 2 and 3). The scratches formed during the finishing procedure have not been eliminated by the polishing procedure. On the other hand, with the hybrid composite, to which the same finishing and polishing procedures were applied, a reasonably smooth surface was obtained during the polishing procedure (Fig. 4). Although the condensable posterior composites were found to have

Micro-hardness values are as shown in table 4. The difference between all 3 groups in respect to micro-hardness was significant according to the Kruskal Wallis test (p<0.05). The results obtained when study materials were compared according to the Mann-Whitney test in respect to their micro-hardness values are shown in table 5.

Table 4. Micro-hardness (VHN) of composites used in this study

Product Mean SD Median

Alert 127.24 37.62 114.42

Surefill 87.34 17.47 82.70

Z 100 68.16 10.74 65.35

Table 5. Composites compared in respect to their micro-hardness (Mann-Whitney test)

Alert Surefill Z 100

Alert - 0.004* 0.000*

Surefill - - 0.005*

Z 100 - - -

* - significant (p<0.05)

When the presence of a correlation between micro-hardness and surface roughness of resin based composites used in the study was evaluated, roughness was observed to increase as micro-hardness increases in all of the groups; correlation coefficient was found to be r=0.73 with p=0.000 (Fig. 5).

Figure 5. Correlation graph depicts hardness value and surface roughness value

Figure 4. Scanning electron micrograph depicting surface profiles of Z 100 (magnification x100)

a different surface roughness than the hybrid composite, the two condensable posterior composites used in the study were also different from each other. Alert, which has sticks, 60-80 μm long and 6 μm in diameter and particles of various cross sections in its structure, had a rougher surface than Surefil that has particles of various cross sections and sizes in its structure. The Vickers micro-hardness measurements, profilometric measurements and SEM images of the specimens, were on the same line. The composite material with the highest surface roughness value, that does not have a homogenous surface observed in the SEM images, also had the highest VFN values.

Studies have been conducted on physical properties of condensable posterior composites developed over the past few years for use in class II and III cavities, as a form of composite material used as an alternative to amalgam in posterior teeth. In these studies physical properties in question are reported to be no better than those of hybrid composites. In addition to this, it is reported that filler proportion has been increased to increase viscosity in

Balk J Stom, Vol 12, 2008 Surface Roughness of Condensable Composites 157

these composites, and this is reported to cause an increase in porosity5-7. In condensable posterior composites the particle surfaces are made rough to make placement in cavity easier. This causes an increase in surface roughness4-7,20. As the 2 types of condensable posterior composites used in this study have higher micro-harness values than the conventional hybrid composite, their surface roughness values are also greater. The American Dental Association (ADA) Council Dental Materials considered composites containing filler particles size up to 5 μm as “polishable” composites10,21. Sizes of the condensable composites used in this study were much bigger and this clearly exposes the problem in their ability for polishing.

Conclusions

Posterior condensable composites with large filler particles produce a significantly higher surface roughness values than those with small filler particles. Statistical correlation was observed between the micro-hardness value (VHN) and surface roughness value. Composites with a higher micro-hardness value produce a correspondingly higher roughness value (r).

SEM study indicated that there are scratches and exposed filler particles on the surface of posterior condensable composites, whereas the surface of the hybrid composite is fairly smooth and homogeneous. In order to benefit from the obtained properties of condensable posterior composites and to correct their surface roughness, a layer which has better polishable properties should be formed on the surfaces of these restorations.

References

Denehy GE, Vargas M, Cobb DS1. . Achieving long-term success with class II composite resins . Calif Dent Inst Contin Educ, 1996; 59:27-36.Bayne S, Heymann H, Swift E2. . Update on dental composite restorations. J Am Dent Assoc, 1994; 125:687-701.Christensen GJ3. . Conservative posterior tooth restorations. J Esthet Dent, 1993; 5:154-160.Cobb DS, Macgregor KM, Vargas MA4. . The physical properties of packable and conventional posterior resin-based composites: A comparison. J Am Dent Assoc, 2000; 131:1610-1615.Leinfelder K, Prasad A5. . A new condensable composite for the restoration of posterior teeth. Dent Today, 1998; 17(2):112-116.

Ross W6. . A report on a new condensable composite resin. Compendium, 1998; 19:230-237.Combe EC, Burke FJT7. . Contemporary resin-based composite materials for direct placement restorations: Packables, flowables and others. Dent Update, 2000; 27:326-336.Miller MB8. . Packable composites. In: Reality 2000. Houston: Reality Publishing; 2000; pp 1444-1450.Kaplan AB, Goldstein GR, VijayaraghavanTV, Nelson IK9. . The effect of three polishing systems on the surface roughness of four hybrid composites: A profilometric and scanningelectron microscopy study. J Prosthet Dent, 1996; pp 34-38.Tjan AHL, Chan CA10. . The polishability of posterior composites. J Prosthet Dent, 1989; 61:138-146.Lee HL, Swartz ML11. . Scanning electron microscope study of composite restorative materials. J Dent Res, 1970; 49:149-158.Johnson LN, Jordan RE, Lynn JA12. . Effects of various finishing devices of resin surfaces. J Am Dent Assoc, 1971; 83:321-331.Dennison JB, Craig RG13. . Physical properties and finished surface texture of composite restorative resins. J Am Dent Assoc, 1972; 85:101-108.Chandler HH, Bowen RL, Paffenbarger GC14. . Method for finishing composite restorative materials. J Am Dent Assoc, 1971; 83:344-348.Weitman RT, Eames WB15. . Plaque accumulation on composite surfaces after various finishing procedures. J Am Dent Assoc, 1975; 91:101-106.Savoca DE, Felkner LL16. . The effect of finishing composite resin surfaces at different. J Prosthet Dent, 1980 ; 44:167-170.Christensen RP, Christensen GJ17. . Comparison of instruments and commercial pastes used for finishing and polishing composite resin. Gen Dent, 1981; 21:40-45.Jordan RE18. . Esthetic composite bonding -techniques and materials. 1st ed. Phiadelphia: BC Decker Inc, 1986; p 8.Kaya AD, Piskin B19. . An evaluation of two, finishing and polishing systems for composite resins. Ege Dişhek Fak Derg, 1996; 17:45-48.Dennison JB, Fan PL, Powers JM20. . Surface roughness of microfilled composites. J Am Dent Assoc, 1981; 102:859-862.American Dental Association Council of Dental Materials, 21. Instruments and Equipment. ANSI/ADA SPESiFiCATION NO.27 (revised): Resin-based filling materials. Chicago: American Dental Association, 1993.

Correspondence and request of offprints to:

Dr. Aysegul Demirbas KayaEge Universitesi DisHekimligi FakultesiDis Hastalıkları ve Tedavisi AD.35100 Bornova - IzmirTurkeyE-mail: [email protected]

SUMMARYBackground: The treatment of complications of the tooth pulp

inflamma tion, such as periapical lesions, has been very important for denti-stry, especially endodontics. Healing of periapical lesion can allow continua-tion of mastication and aesthetic functions of the tooth, depending from the quality of treatment and the level of fillings of pulp canals.

Material and Method: 80 cases in 70 subjects (33 males and 47 females), aged 20-55, which has been treated for periapical complications and the fillings „beyond apex“ were evaluated. The situation of teeth with this diagnosis was evaluated clinically and radiographically during 1997-2003, being controlled directly after filling until 6 years after treatment.

Results: The treated patients with this diagnosis (most of them in 1 sin-gle visit), with additional antibiotic treatment, showed a long term success, clinically and radiographically, in case of “beyond apex” fillings (in 86% of the cases).

Conclusion: A manifold control indicated that teeth filled “beyond apex” keep their aesthetic and functional value, and are valid as posts for prosthetic restorations.Keywords: Chronic Periodontitis

Doris Mingomataj1, Dhurata Mingomataj2 1 UFO University, Dept. of StomatologyTirana, Albania2 MINGOMATAJ Stomatology ClinicTirana, Albania



Clinical and Radiological Evaluation of Chronic Periodontitis Treated by “Beyond Apex” Fillings

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Introduction

The treatment of complications of the tooth pulp inflammation, such as periapical lesions, has been very important for dentistry, especially endodontics2,3. In our opinion, this matter will persist as long as caries and its consequences exist.

In respect of complications of the tooth pulp inflammation, it should be remembered that periapical infections are considered risk factors for health3,4. On the other hand, if these infections could heal, it could allow that particular teeth retain their mastication and aesthetic functions, and included into prosthetic planning. This will depend on the quality of treatment and the level of filling of pulp canals3,4,18.

The aim of this study was to evaluate, clinically and radiographically, the local periapical area of cases in which the used medication, even involuntarily, went “beyond apex”. The questions were: is there, clinically and radiographically, any problem in the successive years,

and could this tooth be functional and serve as post for prosthetic needs?

Material and Method

In this trial, 80 cases (70 subjects) among 100 of cases with pulpits (period of time 1997-2005), were analyzed. Including criteria were the presence of periodontitis and filling “beyond apex”; excluding criterion was the presence of periodontal abscess. 33 subjects were male (aged 22-55), and 47 were female (aged 20-45). Among the treated teeth, there were more multi-radicular teeth (50 cases) than mono-radicular (30 cases). Diagnostically, chronic periodontitis (associated with non-vital tooth) was revealed in 80 cases (34 multi-radicular, 30 mono-radicular), and in 16 cases a diffuse granulomatous periodontitis was found.

After preceded clinical and radiographic evaluation, the root was treated according to principles of step back/

step down technique until its apex under a radiographic control. The next step was an abundant but careful rinsing with solutions of H2O2 (3%) or sodium hypochlorite (5%), sterile drying, followed by a ZnO-Thymol-Eugenol or Endomethason, Eugenol-Thymol mummy filling; gutta-percha points were then added until lateral condensation (under instrument-guided radiographic monitoring). Finally, the treatment of the tooth coronal part followed.

Antibiotics were prescribed to all patients, comprising administration of 3 g. of amoxicillin or 2 g. of tetracycline in the single dose at the precedent day. When a periodontal reaction, as a consequence of treatment, occurred (pain or moderate oedema), the administration of antibiotics followed for 3 consecutive days (2 g. per day). Particular attention was paid to the occlusion. In cases with pulp secretion during treatment, the visit took additional

time. However, in more than 85% of cases the treatment required only one visit.

The successive clinical and radiographic controls followed in a week (if periodontal reaction occurred), a month, 3-12 months, and later (3-8 years).

Results

Long term positive effects (in our case appreciatively in 86% of cases), or low rate of complications, indicated correct treatment of root canals, because in their mechanical treatment consists the basis for the success of one-visit treatment. In figures 1-7, several examples of successful periapical treatment are shown.

Figure 1. Patient IL, male, aged 44 a) Chronic periodontitis of the tooth 46, exacerbation immediately after treatment;b) The same tooth, 16 months later; c) The same tooth after 8 years - recovered, unabsorbed filling

Figure 2. Patient OD, female, aged 24 a) Pain and oedema immediately after treatment of the tooth 36 with perforation of the mesial root; b) The same tooth after 1 year - without clinical symptoms, obturated perforation, absorbed filling;

c) The same tooth after 3 years - recovered, absorption of overfilled material

Figure 3. Patient EL, female, aged 29 a) Chronic periodontitis, exacerbated of the teeth 46 and 47;b) Immediately after treatment (46), during the treatment (47);

c) The same teeth 4 years later - recovered

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b

b

c

c

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Figure 4. Patient HR, male, aged 47 a) Abscess immediately after treatment of the tooth 21;b) The same tooth 1 year later; c) The same tooth after 8 years - no complains, partially unabsorbed mum, new bone trabeculae

Figure 5. Patient LZ, male, aged 28 a) Pain and oedema during treatment of the tooth 45; b) Filling of the tooth;c) The same tooth 6 months later - reduced periapical radiolucency, new bone trabeculae

Figure 6. Patient PM, male, aged 18 a) Teeth 11 and 21 prior to the treatment; b) The same teeth immediately after treatment;c) The same teeth 14 years later, reconstructed with pins and resin-crowns, recovered. Total absorption of the extruding material

Figure 7. Patient DZ, female, aged 37 a) Chronic periodontitis of the tooth 36, tender to percussion, with spontaneous pain, immediately after treatment; b) The same tooth 3 years later; c) The same tooth 4 years after treatment - recovered

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Discussion In this trial we aimed to evaluate the long term

success in cases of filling “beyond apex”, with respect to function, clinical symptoms, radiographic finding and possible use as posts for prosthetic appliances. It is usually accepted that the success of root canal filling depends on many factors, such as the cleaning and the treatment of root canal, its sterilization, hermetical filling that isolate foci from the canal, as well as immunological reactivity of the subject (age, general health situation, etc)1,4,8,10,12,21. In this respect, the rate of clinical-radiographic, as well as histological success, depend on the level of root canal filling18, which is in accordance with the Ketterl diagram (Fig. 8). However, with respect to histological aspects, the treatment of inflamed pulp can not assure a total periapical recovery and a required periodontal obturation2,3,18,20. Our findings confirm the opinion shared by many worldwide prominent authors.

Meanwhile, the filling “beyond apex” is used recently4,20. In the 30s of previous century, soft mums consisting of iodoform were used, later on mums consisting mild phenols, and hard cement mums during 50s-60s years20. Independently to the success, for a period of time they were abandoned because of focal infection theory, but in the next time endodontic inflammation was therapeutically treated based on the new knowledge regarding root canals, and new techniques of root canal treatment (step back or step down technique), and root canal filling (lateral or apical condensation)2,3,5,7,10-

12,18,20,21.In cases presented here, significant differences

between ZnO-Eugenol-Thymol and Endomethason-Eugenol mums were not established4,6,9,11-13,15-17,19,20,22. The recovery of periapical defect began on the first month and finished in the interval between 8th and 12th month after the treatment. In this respect, all medicaments could induce the bone reparation due to alkaline phosphatase activation5,11. Bone regeneration begins from the peripheral area towards central region, firstly dissolving the “linear” focal border, whereas subsequently bone trabeculae can be find, refilling the previous defect2,5,10,12,18,20,21. The needed recovery time depends on the dimension of the focus.

After a successful treatment, the treated teeth recover clinically and radiographically (negative axial and vertical percussion, disappeared focus, normal bone trabeculae, detectable periodontal line radiographically), and they can support prosthetic appliances independently to the amount of the resorbed medicament1,8,13,15. In any case, endodontics will evolve like all components of the life, but their problems will persist as long as caries and its consequences do exist!

References

Asllani Xh1. . Terapia stomatologjike. Tirana, 1974; pp 406-419. (in Albanian)Buchanan S2. . The art of endodontics. Fact and fiction. Dentistry Today, 1993; 12(8):32-35.Cohen S, Burns RC3. . Pathways of the pulp. 4th ed. St. Louis: The CV Mosby Co, 1987; pp 183-246.Hofer O, Reichenbach E4. . Lehrbuch der klinischen Zahnheilkunde. Band I, 2nd Aufl. Leipzig: JA Barth Verlag, 1960; pp 100-106.Ingle I, Taintor J.5. Endodontics. 3rd ed. Philadelphia: Lea Febiger, 1985; pp 226-290.Koja L, Biturku V, Qerimi D, Beligradi I, Berberi N6. . Mjekimi endodontik i lezioneve periapikale. Rev Mjekesore, 1988; 1:112-116. (in Albanian)Kongo P, Brovina D, Rusi L, Mingomataj Ç, Kuvarati E7. . Terapia Stomatologjike. Universiteti i Tiranes, 1994. (in Albanian)Kongo P8. . Rezultatet e mjekimit te peridontiteve kronike me nje seance. Bul Stomatologjik, 1979; 1:36-42. (in Albanian)

Figure 8. Diagram of Ketterl: histologically the most successful treatments are those with fillings up to 0.9 mm short from the apex

162 D. Mingomataj, D. Mingomataj Balk J Stom, Vol 12, 2008

Kuvarati M9. . Long term results after endodontic treatment of necrotic teeth with periapical lesions in one single visit by gutta-percha lateral condensation method is Albania. Balk J Stom, 1998; 2(1):37-41.Laurichesse IM, Mastreoni F, Breillat I10. . Endodontie clinique. Paris: Editions CDP, 1986 ; pp 421-428.Linn WE, Eijkman AM11. . Misserfolge bei Zahnersatzlichen Behandlung. Köln: Deutsche Arztl Verlag, 1998; pp 247-257.Mitschell DA, Mitschel L, Burton P. 12. Oxford Handbook of Clinical Dentistry. 4th ed. 2005; pp 433-439, 607-619.Mingomataj Ç, Mingomataj D.13. Ndikimi i jonoforezes medikamentoze me eugenol 5% ne mjekimin e gangrenave. Rezultate kliniko-radiologjike. Rev Mjekesore, 1987; 2:87-93. (in Albanian)Mingomataj Ç, Mingomataj D.14. Mundesia e mjekimit te dhembeve ballore te absceduar ne nje seance. Rev Mjekesore, 1988; 1:106-112. (in Albanian)Mingomataj D. 15. Studim kliniko-radiologjik mbi rezultatet e arritura ne trajtimin e pulpiteve dhe faktoret qe ndikojne ne suksesin e tyre. Bul Stomatol, 1981; 2:15-23. (in Albanian)Neziri 16. P. Pervoja jone ne trajtimin e nekrozes pulpare dhe te gangrenes se thjeshte e te komplikuar. Bul Stomatol, 1979; 2:27-32. (in Albanian)

Nura Q. 17. Rezultatet tona ne mjekimin me krezofen dhe endomethason te pulpiteve gangrenoze. Bul Stomatol, 1978; 2: 3-5. (in Albanian)Pilz W, Wannenmacher J, Taatz H.18. Grundlagen der Kariologie und Endodontie. 3. Aufl. Leipzig: JA Barth Verlag, 1980; pp 559-573.Prifti K. 19. Rezultatet e mjekimit te periodontiteve kronike ne nje seance. Bul Stomatol, (in Albanian) Walkhoff A, Hess H.20. Lehrbuch der Konservierenden Zahnheilkunde. 6. Aufl. Leipzig: JA Barth Verlag, 1960; pp 285-300.Weine FS.21. Endodontic Therapy. 5th ed. Philadelphia, New York, London: Mosby 1996; pp 314-351. Zoto F.22. Rezultatet tona paraprake ne mjekimin e periodontiteve kronike me pasten Ca(OH)2 – CHI3 me seanca te shkurtuara. Rev Mjekesore, 1984; (4-5):125-128. (in Albanian)


Dr. Doris Mingomataj UFO University, Dept. of Stomatology, Tirana, AlbaniaRruga Myslym Shyri, Pall. 47, Sh. 1, Apt. 15Tirana, AlbaniaE-mail: [email protected]

SUMMARYPassage of the gastric contents into the oesophagus (gastric oesopha-

geal reflux - GER) can be manifested by changes of tooth hard tissues. Tooth erosions that are consequence of GER are known as gastric oesophageal reflux disease (GERD). GERD is the complication of GER status. Further-more, tooth erosion is one of the main symptoms that gives evidence of the digestive disorders, being present in early stages of the disorder.

Every acid content that is found in the mouth area, with a pH<5.5, may cause melting of the enamel hydroxyapatite crystals. Gastric juice in GERD has a pH value under 2.0. So it is very important to make the right differen-tial diagnosis promptly, as well as the decision.Keywords: GERD; Gastric Juice

Edlira Xhemo, Diana Brovina, Ergysejda Hoxha, Vigjilenca Demiraj, Anyla Bylo

Faculty of Medicine, Department of Dentistry Tirana, Albania



Dental Erosion: One of the Main DiagnosticSymptoms of Gastric Oesophageal Reflux Disease

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Introduction

Many systemic diseases and pathologic conditions are manifested with oral changes too, which makes dentists to be the first health care professional to find out these diseases due to their primary manifestations. Tooth erosion is defined as a loss of the tooth hard tissues as the result of interaction of several chemical, non-bacterial, factors in the mouth region. Dental erosion is one of the intra-oral symptoms that defines disorders of gastric-oesophageal origin. gastro-oesophageal reflux (GER) is the passage of the gastric contents into the oesophagus and gastro-oesophageal reflux disease (GERD) is the complication status of GER, being manifested with changes of tooth hard tissues.

Erosion begins as demineralization of the enamel surface that causes melting of the surface stratums and loss of the tooth structure. Tooth erosion risk factors could be: intrinsic and extrinsic causes1,2.

Clinically, the tooth erosion in patients with GERD is characterized with:

Wide concavities on the enamel smooth surface;1. Cupping of the occlusal surfaces (incisal whooling) 2. with dentine exposure;Increasing of the transparency in the incisal margin; 3. Wearing of the non-occluding surfaces;4. Amalgam fillings on the enamel smooth surface;5. Wearing of the enamel surface in the gingival/cervical 6. area of teeth;

Hypersensitivity to hot and cold agents. 7. Symptoms or history of GERD;8. Excessive attrition;9. Vomiting (weekly or more often), chronic and 10. excessive vomits; Sports drinks intake (weekly or more often);11. Citrus fruits intake (more than twice daily) and soft 12. acidic and alcoholic drinks consumed (4-6 or more per week);Bruxism habit and salivary changes;13. Gastric acids regurgitation into mouth or oesophagus; 14. Eating disorders, like anorexia nervosa or bulimia;15. Hiatus hernia;16. Gastrointestinal disorders, such as peptic ulcers or 17. gastritis, pregnancy, side effects of some medicaments, diabetes or nervous system disorders.It is generally accepted that there are 3 erosion grades:

0 - no detectable erosion;1 - small pots and lightly rounded cuspids, flat fissures,

alterations in the occlusal surface (moderated grooving);

2 - ruining of cuspids with heavy grooving, fillings margins are erased over the tooth level, flattening of the occlusal surface morphology.

It is very important to make the right differential diagnosis and to decide about the relation of the dental erosion process and other possible pathology of tooth structure loss, such as attrition or abrasion.

164 E. Xhemo et al. Balk J Stom, Vol 12, 2008


We examined 60 out-patients, aged 25-38 years, at the gastroenterology ward of the University Hospital Centre in Tirana. 13 of them had evident dental erosions. Medical and dental control performed in these patients followed special protocols, such as: taking medical, dental and dietary history, and performed oral hygiene methods, as to define the disease etiological factors.

The procedure comprised:Making diagnosis based on the GERD symptoms,

signs and fibroscopic tests;Measuring pH of the gastric juice based on a 24

hours monitoring. The pH was monitored before breakfast and lunch;

Defining grades of dental erosions.Diagnostic protocol for dental erosion comprised:1. Medical History (excessive vomiting, rumination,

eating disorder, GERD, symptoms of reflux, frequent use of antacids, alcoholism, auto-immune disease such as Sjogren Syndrome, oral and/or eye dryness, medication that causes salivary hypo-function, acidic medication);

2. Dental History (history of bruxism, grinding or clenching, grinding sounds during sleep noted by bed

partner, morning masticatory muscle fatigue or pain, the use of occlusal guard);

3. Dietary History (acidic food and beverage frequency, the way of ingestion - swish or swallow, oral hygiene methods, tooth-brushing method and frequency).

The data were analyzed statistically using Kendal’s correlation coefficient in determining the relationship between the change in pH and the change in the oral status (r = 0.685; p = 0.013). SPSS 10.0 programme was used in data analysis.

Results

Results are presented in table 1. From the results it can be seen that the difference is significant enough (data were considered to be significant enough if difference was p ≤ 0.05).

A t-test was performed on the data received from the 2 sample groups (t = 0.45, p = 0.63). These results were not considered to be significant.

Table 1. Evaluation of the gastric juice pH, localization of the dental erosion and the disease time

5-6 monthsErosion Grade 1 Mandibular molars5.78.013

4 monthsErosion Grade1 Maxilar centrals6.427.5212

6 monthsErosion Grade2 of mandibular premolars3.173.5811

1.7 months+ Erosion of 6 teeth, Grade 2; especially the M sides, tubercules and lower teeth

2.752.8710

7 months+ Erosion still in its 1 Grade6.627.129

4 months+ Erosion still in its 1 Grade4.424.528

6 years+ Erosion of all teeth, teeth extracted3.473.647

4-5 years+ Erosion of all teeth, teeth extracted2.272.496

5 years+ Erosion of all teeth, teeth extracted3.343.405

5-6 months+Erosion still in its 0 Grade3.384.24

4 years+ Erosion of all teeth, fillings raised up to the eroded occlusal surface, the majority of teeth extracted

3.173.583

2.5 years+ Erosion of 6 teeth, especially the M sides, tubercules and lower teeth

2.372.872

2 years+ Erosion of 6 teeth, especially the M sides and lower 3.693.741

GERD PeriodOral StatuspH 2pH 1Case

Balk J Stom, Vol 12, 2008 Dental Erosion in Gastric Oesophageal Reflux Disease 165

Discussion

When dentists diagnose tooth erosive lesions, they have to consider the possibility of theirs systematic origin. Especially patients that suffer from GERD have to be examined continually to prevent erosive lesions. They should keep a good hygiene of their oral cavity and they should also use local fluoride paste.

In the short term the goal in the treatment of dental erosion resulting from GERD is making differential diagnosis between GERD, other mechanical forces effects (attrition, abrasion) and etiopathogenetic factors. However, it is always advisable to decrease abrasive forces (the use of soft toothbrushes and dentifrices low in abrasiveness in a gentle manner, not to brush teeth immediately after an acidic challenge to the mouth, as the teeth will abrade easily, and rinse with water immediately after an acidic challenge), provide mechanical protection (application of composites and direct bonding where appropriate to protect exposed dentin, construction of an occlusal guard is recommended if a bruxism habit is present), and monitor stability (regular recall examinations should be done to review diet, oral hygiene methods, compliance with medications, topical fluoride and splint usage).

GERD is an important etiologic factor in the erosive lesion of teeth hard tissue. Our studies are consistent with other studies carried in other countries1-10. Mandibular molars had the highest wear out and damage in our cases. The part of the teeth that had been affected the most was the mesio-lingual surface.

Exposure of the dentinal tubules results in hypersensitivity to hot, cold, sweet and tactile stimuli. We have to emphasize that the demineralization occurs faster in dentin than it does in enamel

In diagnosing and curing erosion cases caused by GERD, a tight collaboration between several specialists, especially dentists and gastroenterologists, is required.

Further examination and studies would help to get better understanding of GERD and its relation to teeth erosive lesion.

References

1. Barron RP. Dental Erosion in Gastroesophageal Reflux Disease. J Can Dent Assoc, 2003; 69(2):84-89.

2. Gandara BK, Truelove EL. Diagnosis and Management of Dental Erosion. J Contemp Dent Pract, 1999; 1(1):016-023.

3. Cameron A, Widmer R. Handbook of Pediatric Dentistry. 1998; pp 66-72.

4. Eccles JD. Dental Erosion and Diet. J Dent, 1974; 2:153-159.

5. Shaw L, Smith A. Erosion in Children: An increasing clinical problem? Dental Update, 1994; 21:103-106.

6. Jarvinen V, Meurman JH, Hyvarinen H, et al. Dental erosion and upper gastrointestinal disorders. Oral Surg Oral Med Oral Pathol, 1988; 65:298-303.

7. Nunn JH. Prevalence of dental erosion and the implications for oral health. J Oral Sci, 1996; 104:156-161.

8. Xhonga FA, Valdmanis S. Geographical comparisons of the incidence of dental erosions: A two centre study. J Oral Rehab, 1983; 10(3):269-277.

9. Khan F, Young WG, Daley TJ. Dental erosion and bruxism. A tooth wear analysis from southeast Queensland. Aust Dent J, 1998; 43:117-127.

10. Clark DC, Woo G, Silver JG, et al. The influence of frequent ingestion of acids in the diet on treatment for dentin sensitivity. J Can Dent Assoc, 1990; 56:1101-1103.


Prof. Diana BrovinaKlinika Stomatologjike UniversitareFakulteti i Mjekesise-Departamenti i StomatologjiseTirana, Albania

SUMMARYGingival overgrowths are lesions which can be seen due to diffe rent

reasons. Phenytoin (PHT), the drug used in the treatment of epilepsy, is probably one of the commonest causes of gingival overgrowth. In the pre-sented case, a male patient aged 23, who has been taking PHT for the treat-ment of epilepsy, subsequently manifested by the enlarged gingival tissue, which was cut out using gingivectomy procedure. The biopsy samples, which were taken during surgery, were assessed histo-pathologically. Histo-patho-logical evaluation showed that there were deepened rete-peg structures, and a connective tissue rich in collagen substance. Moreover, a dense plasmocyte cell infiltration was observed. This fact was interpreted as an allergic effect in gingival tissue caused by PHT.Keywords: Overgrowth, gingival; Phenytoin; Drug Allergy

Hakan Develioglu1, Özgür Özgören1, Mert Nalbantoglu1, Kaya Eren1, Fahrettin Göze2

1Cumhuriyet University, Faculty of Dentistry Department of Periodontology2Cumhuriyet University, Faculty of Medicine Department of PathologySivas, Turkey

CASE REPORT (CR)Balk J Stom, 2008; 12:166-169


Histo-Pathological Evaluation of Drug Allergy Observed With Gingival Overgrowth Induced by Phenytoin: A Case Report*

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Gingival enlargement or overgrowth has been associated with multiple factors including inflammation, side effects of drugs, and neoplastic conditions. Chronic inflammation due to accumulation of dental plaque frequently causes gingival overgrowth1. Drugs associated with gingival enlargement include anti-epileptics, like phenytoin2-5, cyclosporin6,7, and calcium antagonists, such as dihydropyridines8,9, verapamil10,11, and diltiazem.

The clinical and pathologic features in drug-induced gingival overgrowth are independent of the drug administered, which suggests a common pathway of induction12. The pathogenic mechanisms of gingival enlargement involve different factors, such as dental plaque, presence of genetically predetermined gingival fibroblasts (named responders), and effect of the drug itself, with all compounds affecting the trans-membrane flow of calcium13,14. This in turn changes the metabolism of connective tissue fibroblasts, causing an increase in the components of the extra-cellular matrix, i.e. collagen fibres and/or ground substance15,16.

Epilepsy is a condition in which a person has recurrent seizures due to a chronic underlying process. A seizure is a paroxysmal event, due to abnormal central nervous system activity, that can have various manifestations ranging from dramatic convulsive activity, with or without loss of consciousness, to phenomena not discernible by an observer17. Currently available anti-epileptic drugs act by depressing the neuronal activity in the focus of origin or by blocking the spreading mechanisms.

Phenytoin (PHT, 5,5-diphenylhydantoin) was first introduced as an anti-epileptic drug, in 193818. It is slowly absorbed from the gastrointestinal trackt, and shows marked inter individual variation19. PHT is known to concentrate in the brain, at levels 5 to 10 times that found in the serum20. The drug is extensively metabolized in the liver by microsomal enzymes, with the major metabolite (50-5% of the PHT dose) being 5-(p-hydroxypenyl)-5-phenylhydantoin (p-HPPH)21. The drug has been proposed to act via stabilization of the neuronal cell membranes and through suppression of synaptic transmissions. Depending on the membrane conditions, drug concentration and timing, it appears that PHT acts by affecting the (Na+ K) pump, Ca++ transport, or the sodium influx at a cellular level22.

* Presented at the 37th National Periodontology Congress, May 2007, Antalya, Turkey

Gingival overgrowth is one of the most common side effects associated with the administration of PHT, the most frequently used anti-epileptic drug. Gingival overgrowth, in relation to PHT, was first described in 1939, with several other subsequent authors reporting the overgrowth associated with phenobarbital, valproic acid and vigabatrin. Gingival overgrowth has not been associated with carbamazepine, a useful alternative medication in the treatment of patients with seizures that have, or are at risk of, gingival enlargement23,24.

Case Report

A male patient aged 23 with gingival enlargements was referred to the Department of Periodontology, Faculty of Dentistry at the University of Cumhuriyet. In the first step, his dental and medical history was taken and he was clinically examined. The patient had not received any prior dental therapy. In his medical history, it was determined that he has been taking medicaments (Phenytoin sodium 100mg; 2x2, and Barbexaclone 100 mg; 2x1) for the treatment of epilepsy for 3 years, which was diagnosed in the department of neurology. There were severe gingival overgrowths in all quadrants and in both buccal and oral sides of the mouth (Fig. 1). A mild inflammation and bleeding on probing were also recorded. It was thought the gingival overgrowth was due to PHT usage. However, it was not possible to stop or decrease the drug dosage for our patient.

treatment of other teeth is continuing. After medical history and clinical examination, a treatment phase I (periodontal treatment) was performed. 3 weeks after the treatment phase I, periodontal tissues were evaluated again and it was decided to perform a gingivectomy operation and remove gingival enlargements. The biopsy samples were taken during the operation and were subsequently assessed histo-pathologically. Histo-pathological evaluation showed that there were deepened rete-peg structures, thickened epithelial zone and a connective tissue rich in collagen substance. Moreover, a striking plasmocyte cell infiltration was observed (Fig. 3).

Oral hygiene applications were instituted at each appointment due to achieve an adequate plaque control; and it was achieved. The patient is still being followed-up, and is under control (Fig. 4).

Figure 1. Clinical view of the patient before the treatment

Figure 2. Radiographic view at the initial visit

Figure 3. A dense plasmocyte infiltration in connective tissue (H&E, x20)

A radiographic examination revealed no supporting bone loss except the area of the tooth 46; however, teeth 11, 17, 21, 26, 27, 35, 36 ,37, 46, and 47 were carious (Fig. 2). First molar on the right lower jaw (46) was extracted due to a serious caries, and teeth 11,12,13,21,22,23 were treated aesthetically; the conservative and endodontic

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168 H. Develioglu et al. Balk J Stom, Vol 12, 2008

Discussion

A gingival overgrowth is a common feature of gingival disease. There are many types of gingival overgrowth, varying in accordance to etiological factors and pathological processes producing them. Gingival overgrowth caused by PHT, usually begins as a painless, bead-like, and diffuse swelling of the interdental papillae, which enlarge and coalesce, leaving a nodular appearance. As the condition progresses, the marginal and papillary overgrowths unite; they may develop into a massive tissue fold covering a considerable portion of the crowns. The overgrowth is chronic, and slowly increases in size, recurs when surgically removed, and has been reported to disappear spontaneously soon after the discontinuation of the drug25. A PHT-induced gingival overgrowth begins as hyperplasia of the connective tissue core of the marginal gingiva, followed by proliferation of the epithelium. The overgrowth increases by proliferation and expansion of the central core beyond the crest of the gingival margin.

There are various risk factors that have been elucidated for a drug-induced gingival overgrowth. The identifiable factors can be considered under the following headings: age, oral hygiene, daily dose and duration of drug therapy26. The role of oral hygiene in the pathogenesis of gingival overgrowth is also complex. The presence of the overgrowth makes plaque control difficult by helping the plaque retention, resulting in a secondary inflammatory process, complicating the gingival hyperplasia caused by the drug. Effective plaque control may reduce and prevent gingival enlargement. In addition to plaque control and medical management, periodontal surgical treatment and multidisciplinary dental care are a key strategy in managing gingival enlargement.

Mild gingival enlargement may only require local management, as improvement in oral hygiene together with professional cleaning of the teeth, which can lead

to resolution of inflammation and reduction in gingival enlargement. But, if there is a serious gingival overgrowth like in our case, a periodontal surgical management is required to remove the excess tissue. In our case, gingiva had almost covered the full portion of the crowns in all quadrants. It was very difficult to achieve an adequate oral hygiene for the patient. And there was a serious aesthetical problem which affected psychological condition of the patient. In cases that have gingival enlargement covering more than about a third of the tooth surface, a consideration should be given to altering the medication. When possible, reducing the dose or changing to another drug may bring about partial or complete regression of the lesion. But this was not possible for our patient, so we warned our patient about the possibility of gingival enlargement recurring despite periodontal treatment27.

The relationship between anticonvulsant drugs and hypersensitivity has been shown in the literature28. In our case; the histo-pathological evaluation of the specimens has revealed deepened rete-peg structures and a connective tissue rich in collagen substance. These findings are classical for some gingival overgrowths, but a dense plasmocyte cell infiltration was also observed. We are of the opinion that this finding could be a result of an allergic background caused by PHT.

As a conclusion, in gingival enlargement cases, plaque control is very important. Treatment required in accordance to the degree of gingival enlargement must be performed and the importance of maintaining good oral hygiene, as a preventive measure, should be emphasized. In addition, the possible allergic drug effects should be known and if possible, the alternative medications may be considered. If there is not a chance of changing the medication, the possibility of recurrence should be told to the patient.

References

1. Carranza FA. Gingival Enlargement. In: Carranza FA (ed). Glickman’s Clinical Periodontology. Philadelphia: WB Saunders; 1990; pp 125-128.

2. Angelopoulos AP, Goaz PW. Incidence of diphenylhydantoin hyperplasia. Oral Surg Oral Med Oral Pathol, 1972; 34:898-906.

3. Brunet LI, Miranda J, Farre M, Berini L, Mendieta C. Gingival enlargement induced by drugs. Drug Safety, 1996; 15:219-231.

4. Hassell TM, Hefti AF. Drug-induced gingival overgrowth: Old problem, new problem. Crit Rev Oral Biol Med, 1991; 2:103-237.

5. Perlik F, Kolinova M, Zvarova J, Patzelova V. Phenytoin as a risk factor in gingival hyperplasia. Ther Drug Monit, 1995; 17:445-448.

Figure 4. Clinical view after treatment of the patient

Balk J Stom, Vol 12, 2008 Gingival Overgrowth Induced by Phenytoin 169

6. Adams D, Davies G. Gingival hyperplasia induced by cyclosporin A. A report of two cases. Br Dent J, 1984; 157:89-90.

7. Bennett JA, Christian JM. Cyclosporine-induced gingival hyperplasia. Case report and literature review. J Am Dent Assoc, 1985; 111:272-273.

8. Bullon P, Machuca G, Martinez-Sahuquillo A, Rios JV, Rojas J, Lacalle JR. Clinical assessment of gingival hyperplasia in patients treated with nifedipine. J Clin Periodontol, 1994; 21:256-259.

9. Lederman D, Lummermann M, Reuben S, Freedman PD. Gingival hyperplasia associated with nifedipine therapy. Oral Surg, 1984; 57:620-622.

10. Miller CS, Damm DD. Incidence of verapamil-induced gingival hyperplasia in a dental population. J Periodontol, 1992; 63:453-456.

11. Pernu HE, Oikarinen K, Hietanen J, Knuuttila M. Verapamil induced gingival overgrowth. A clinical, histologic and biochemic approach. J Oral Pathol Med, 1989; 18:422-455.

12. Akimoto Y, Tanaka S, Omata H, Shibutani J, Nakano Y, Kaneko K, et al. Gingival hyperplasia induced by nifedipine. J Nihon University Sch Dent, 1991; 33:174-181.

13. Sooriyamoorthy M, Gower DB. Drug induced gingival overgrowth. Clinical features and possible mechanisms. Med Sci Res, 1989; 17:881-884.

14. Atilla G, Kutukculer N. Crevicular fluid interleukin-1β, tumor necrosis factor-α, and interleukin-6 levels in renal transplant patients receiving ciclosporine A. J Periodontol, 1998; 69:784-790.

15. Newell J, Irwin CR. Comparative effects of cyclosporin on glycosaminoglycan synthesis by gingival fibroblasts. J Periodontol, 1997; 68:443-447.

16. Hassell T. Evidence that cyclosporine, phenytoin and dihydropiridines elicit overgrowth by different mechanisms. J Dent Res, 1990; 69:164. (Abstract 447)

17. Lowenstein DH. Seizures and epilepsy. In: Fanci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, et al (eds). Harrison’s Principles of Internal Medicine. New York: McGraw-Hill, 1998; pp 2311-2325.

18. Merrit H, Putman T. Sodium diphenyl hydantoinate in the treatment of convulsive disorders. JAMA, 1938; 111:1068-1103

19. Gugler R, Manion C, Azarnoff D. Phenytoin: Pharmaco-cinetics and bioavailability. Clin Pharmacol Ther, 1976; 19:135-142.

20. Houghton G, Richens A, Toseland P, Davidson S, Falconer MA. Brain concentrations of phenytoin, phenobarbital and primidone in epileptic patients. Eur J Clin Pharmacol, 1975; 9:773-781.

21. Dudley K. Phenytoin metabolism. In: Hassell T, Johnston M (eds). Phenytoin-induced Teratology and Gingival Pathology. New York: Raven Pres; 1980; pp 13-21.

22. Maclean M, McDonald R. Multiple actions of phenytoin on mouse spinal cord neurons in cell culture. J Pharmacol Exp Ther, 1983; 227:779-789.

23. Kimball OP. Treatment of epilepsy with sodium diphenylhydantoinate. JAMA, 1939; 31:336-344.

24. Panuska HJ, Gorlin RJ, Bearman JE, Mitchell DF. The Effect of anticonvulsant drugs upon gingiva: a series of analysis of 1048 patients. J Periodontol, 1960; 31:336-344.

25. Carranza FA. Gingival enlargement. In: Carranza FA, Newman MG (eds). Clinical Periodontology. 8th ed. Philedelphia: WB Saunders Company, 1996; pp 233-249.

26. Seymour RA, Ellis JS, Thomason JM. Risk factors for drug-induced gingival overgrowth. J Clin Periodontol, 2000; 27:217-223.

27. Hallmon WW, Rossmann JA. The role of drugs in the pathogenesis of gingival overgrowth. A collective review of current concepts. Periodontol 2000, 1999; 21:176-196.

28. Baba M, Karakaş M, Aksungur VL, Homan S, Yücel A, Acar MA, Memışoglu HR. The anticonvulsant hypersensitivity syndrome. Journal of the European Academy of Dermatology and Venereology, 2003; 17(4):399-401.


Dr. Hakan DeveliogluUniversity of CumhuriyetFaculty of Dentistry, Department of PeriodontologySivas, 58140TurkeyE-mail: [email protected]

SUMMARYSeveral sensory disturbances may occur to the inferior alveolar nerve

postoperatively. They are usually associated with lower third molar sur-gery, and even then they are rare. The aim of this study was to evaluate and describe the radiological aspects of sensory disturbances after an attempted tooth extraction, and present their preoperative and postoperative treatment. The cases demonstrated are presented with symptoms of facial pain; radiolo-gical and clinical situation are given preoperatively and postoperatively. A small comparison is also made to a case without symptoms, although the inferior alveolar nerve was in close relation to the tooth, and to which a proper operative approach was taken.Keywords:Inferor alveolar nerve, injury; Impacted lower third molars.

A. Delantoni, P. Papademitriou-Delantoni, K. Antoniades

Aristotle University of Thessaloniki, Thessaloniki, Greece

CASE REPORT (CR)Balk J Stom, 2008; 12:170-173


Postextraction Inferior Alveolar Nerve Injuries - Prevention and Treatment

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Introduction

There are several sensory disturbances that may occur to the inferior alveolar nerve during an extraction attempt. They most often occur when the tooth involved is an impacted lower third molar1-7 and include complete anaesthesia, hypoesthesia, hyperaesthesia and the most common one, paresthesia.

Paresthesia is attributed to nerve injury being of either odontogenic or iatrogenic origin8,9. It is expressed as numbness, burning sensation and/or electric type stimuli. The cause of paresthesia is often odontogenic, though it can be of systemic origin, such as viral or bacterial infections, or local neoplasms. Of the mentioned causes, those of odontogenic origin are of special concern to general dentists, which can be an attempt to extract molars and, most often, wisdom teeth, cysts, odontomas and periapical inflammations8,9.

The aim of this paper is to present 4 patients who were referred to our clinic with symptoms of sensory disturbances of the trigeminal nerve.

Report of 4 Cases

Case 1A 57-year-old patient was referred to our clinic with

intense symptoms of pain and numbness at the area of

lower right second molar, though clinically no tooth was present. The panoramic radiograph, which patient had with him, showed a residual root (Fig. 1) indicated for extraction. The position of the root was confirmed with an intraoral radiograph. The residual root was removed. During the postoperative follow-up, 3 and 8 months after the initial surgery, the paresthesia was limited to the area of 41 and 42 at the time of the first follow-up, and ceased completely at the time of the second follow-up.

Figure 1: panoramic radiograph of the patient revealing the root remnant that caused the patient’s paresthesia

Case 2A 52 years old patient was referred to our clinic

after a long history of pain and misdiagnosed trigeminal neuralgia. According to the patient’s history, he initially showed symptoms of pain about 2 years ago, when he visited a hospital with acute pain at the lower mandibular area that reflected to the ear and eye. Since then he had

Case 3A 67-year-old patient was referred to our clinic after

an unsuccessful attempt to remove the wisdom tooth. She came to us with the radiographs her dentist had taken before the attempt (Fig. 3). An intraoral and a panoramic radiograph were taken to gain a better understanding of the tooth’s position (Fig. 4, a and b). After viewing the radiographs, we ordered a computerized tomography (CT) scan to know with absolute certainty the position of the inferior alveolar nerve (Fig. 5, a and b). In the CT scans we observed the close approximation of the tooth’s residual roots to the inferior alveolar nerve. The correct localization of the inferior alveolar nerve was done, and a more careful approach to the extraction of the roots was taken. The lack of inflammation allowed us to conclude that the atypical paresthesia the patient had upon arrival, was of iatrogenic origin. When the patient came for a recall, 3 months after surgery, paresthesia was restricted in extent, but the symptoms of numbness and pain were more intense. A second recall, 6 months after surgery, was scheduled, when patient showed an improvement. The area of paresthesia was limited in extent, there was sensation at the lip and cheek area and only the anterior lower teeth area was still numb with very short paroxysmal pain involvement. Currently, 10 months after surgery, there are no symptoms of paresthesia.

visited numerous clinics from E.N.T. to Neurological and had been given medication (carbamazepine) for treatment of trigeminal neuralgia. The symptoms persisted, and about a year ago, he was referred to our clinic from a neurologist. After making an OPG (Fig. 2), we noticed a strongly inflamed wisdom tooth that was removed. The patient was re-examined 6 and 12 months after surgery and paresthesia he initially had was at the first follow-up restricted to the area between 31 and 34, and gone at the second follow-up.

Figure 2: Panoramic radiograph of the patient showing the impacted wisdom tooth with the inflammation of the surrounding tissues.

Figure 3: The intraoral radiograph prior to the extraction attempt that does not provide with the necessary information to avoid complications

Figure 4a: An intraoral radiograph of the same case as in figure 3 the way the patient presented to the clinic. We can clearly see the needed

information to proceed to further surgery

Figure 4b: Panoramic radiograph of the same case to give us all the information we need for the surgical removal of the root residues

Figure 5a: A C.T. section of the patient giving us the exact position of the inferior alveolar nerve in relation to the root residues

Balk J Stom, Vol 12, 2008 Postextraction Inferior Alveolar Nerve Injuries 171

172 A. Delantoni et al. Balk J Stom, Vol 12, 2008

Case 4In this case, the patient arrived with no symptoms

or clinical findings of paresthesia, after referral of an orthodontist for a wisdom tooth removal. The case is discussed in contrast to the previous cases to demonstrate the significance of proper preoperative control and the importance of proper surgical moves to avoid any complications. The orthopantomogram showed a close connection of the inferior alveolar nerve to the wisdom tooth’s roots (Fig. 6). We ordered a CT scan prior to the surgery. At the CT we observed the exact position of the tooth and its roots, as well as the course of the nerve (Fig. 7, a and b). The surgery was scheduled and the tooth was extracted causing minimal damage to the surrounding tissues and, therefore, after the extraction, there was limited paresthesia that lasted only a couple of weeks.

Discussion

Trigeminal paresthesia is not a commonly occurring sensory disorder. In many of the cases it is of odontogenic or iatrogenic origin. In cases of difficult tooth extraction, particularly of lower wisdom teeth, it is one of the most frequently occurring extraction complications. The most common cause of its appearance is the improper surgical procedure performed by the dentist, and underestimation of the difficulty of the operation.

When there is a need to extract a tooth that is in close approximation to the inferior alveolar nerve, one must always be aware of the tooth’s position radiologically. Initially, an intraoral radiograph and a panoramic radio-graph should be taken to provide information regarding the tooth’s exact position. If a close proximity of the tooth’s roots to the inferior alveolar nerve is observed, it should be decided whether additional radiographs, such as a CT scan, are needed to best assess the exact anatomical relationships between the tooth’s roots and the inferior alveolar nerve. Patient must be informed of the possibility of a complication during surgery, and must be aware of the fact that there is no current treatment if paresthesia is the complication. He must also be informed that paresthesia is a temporary complication in most of the cases, but seldom it is a permanent one.

The possibility of this complication during an extraction cannot always be avoided. One should try to limit it, though, by taking every possible measure available prior to surgery. Reference of the patient to an oral surgeon should be made when the dentist is not certain of his limitations. The proper radiographic control and the correct clinical movements (e.g. avoiding lingual moves or instrument placement for lower wisdom teeth) during a tooth extraction, when the tooth is in approximation to the inferior alveolar nerve, should be considered in order to avoid complications, such as paresthesia of the nerve.

References

Malden NJ,1. Maidment YG. Lingual nerve injury subsequent to wisdom teeth removal - a 5-year retrospective audit from a high street dental practice. Br Dent J, 2002; 193(4):203-205.

Figure 5b: Cross sections of the area of interest for locating the inferior alveolar nerve and obtaining all required information regarding the

position of the root residues

Figure 7b: Panoramic radiograph of the same tooth showing the close relation of the tooth’s roots to the inferior alveolar nerve

Figure 6: Panoramic radiograph of the patient prior to removal of the impacted third molar demonstrating the close relation of the nerve to the

tooth’s roots.

Figure 7a: Cross section of the impacted third molar demonstrating the exact position of all anatomical structures

Balk J Stom, Vol 12, 2008 Postextraction Inferior Alveolar Nerve Injuries 173

Song F, O’Meara S, Wilson P, Golder S, Kleijnen J2. . The effectiveness and cost-effectiveness of prophylactic removal of wisdom teeth. Health Technol Assess, 2000; 4(15):1-55.Gulicher D, Gerlach KL3. . Incidence, risk factors and follow-up of sensation disorders after surgical wisdom tooth removal. Study of 1,106 cases. Mund Kiefer Gesichtschir, 2000; 4(2):99-104.Pogrel MA, Thamby S4. . The etiology of altered sensation in the inferior alveolar, lingual, and mental nerves as a result of dental treatment. J Calif Dent Assoc, 1999; 27(7):531, 534-538.Commissionat Y, Roisin-Chausson MH5. . Lesions of the inferior alveolar nerve during extraction of the wisdom teeth. Consequences - prevention. Rev Stomatol Chir Maxillofac, 1995; 96(6):385-391.Blondeau F. Paresthesia: incidence following the extraction 6. of 455 mandibular impacted third molars. J Can Dent Assoc, 1994; 60(11):991-994.

Gregg JM7. . Studies of traumatic neuralgias in the maxillofacial region: surgical pathology and neural mechanisms. J Oral Maxillofac Surg, 1990; 48(3):228-237; discussion 238-239.Yana Y, Boukobza F, Mardam-Bey W, Derycke R8. . Paresthesia of the inferior dental nerve: clinical signs, etiological diagnosis and prognosis. Rev Odontostomatol (Paris), 1990; 19(4):307-315.Lambrianidis T, Molyvdas J9. . Paresthesia of the inferior alveolar nerve caused by periodontal-endodontic pathosis. Oral Surg Oral Med Oral Pathol, 1987; 63(1):90-92.


Dr. Antigone Delantoni94 Mitropoleos street54622, ThessalonikiGreeceE-mail: [email protected]

SUMMARY Restoration of an endodontically treated tooth is a subject that has been

evaluated and discussed widely in the dental literature. Use of polyethylene fibre ribbon reinforced composite resin as post in restoring extensively damaged teeth is something new. This article describes the use of polyethylene fibre ribbon reinforced composite resin as post-core build-up.

Keywords: Polyethylene Fibre Ribbon; Reinforced Composite Resin; Post-Core Build-Up

Hasan N. Alkumru, Sebnem Begum Turker, Buket Evren

Marmara University, Dept. of Prosthodontics Faculty of Dentistry, Istanbul, Turkey

TECHNICAL REPORT (TR)Balk J Stom, 2008; 12:174-177


Use of Polyethylene Fibre Ribbon Reinforced Composite Resin as Post-Core Build-Up:A Technical Report

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Introduction

Teeth that have been endodontically treated often have little coronal tooth tissue remaining and, as such, require a post to retain the core and restoration, and need to be restored by crowns1,5,9. Metal posts are most commonly used due to their favourable physical properties and excellent biocompatibility4,8. With recent advances in ceramic technology, the all-ceramic crown has become more popular. However, restoring a pulpless tooth with a metal post and core in combination with an all-ceramic is a challenge. The underlying metal from the post and core can alter the optical effects of a translucent all-ceramic crown and compromise the aesthetics7. There has been a significant amount of interest in the development of non-metallic post systems in recent years. Several tooth-coloured posts have been developed, such as zirconia coated CFP, all-zirconium posts and fibre-reinforced posts2,10,12.

A leno-woven polyethylene ribbon (Ribbond Bondable Reinforcement Ribbon) has been used successfully for a variety of clinical techniques, including tooth splinting, replacement of missing teeth, treatment of dental emergencies and reinforcement of resin provisional fixed prosthodontic restorations, orthodontic retention and other clinical applications11. In recent year, there has been a great deal of interest in the use of resin cement to bond a post into a prepared canal2,10. Some laboratory studies have shown a significant increase in post retention with resin cement3,6,13.

This paper describes a treatment alternative for extensively damaged tooth using polyethylene fibre ribbon reinforced composite resin as post-core build-up.

Technical Report

Clinical and radiographic examinations of a 21-year-old male patient revealed a root canal treatment due to the fracture of the maxillary right central incisor, which was restored with composite resin filling materials 4 years ago. The discolouration and secondary caries of the related tooth was not satisfactory for the patient (Fig. 1). Polyethylene fibre ribbon reinforced composite resin as post-core build-up and Empress II crown were planned as treatment options to the patient for replacement of the extensively damaged tooth. The construction of polyethylene fibre ribbon reinforced post-core restoration is not time consuming and provides tooth coloured aesthetic substructure for a complete porcelain crown, which will satisfy aesthetic requirements of the patient.

Figure 1. Initial view of teeth

Polyethylene Fibre Ribbon as Post MaterialThe root canal filling was removed to the apical

third by using gates glidden and washed with 5% sodium hypochlorite (Fig. 2A and B). After drying procedure with paper points, 37% phosphoric acid was used to etch the root canal wall and remaining tooth surface for 15 seconds, and washed thoroughly for 30 seconds (Fig. 3). Retraction cord (Stay-put; Roeko, Germany) was used to isolate sub-gingival finish line after anaesthesia. Resin cement (Variolink;

Figure 4. Polyethylene fibre ribbon embedded in resin cement (Variolink II)

Figure 5A. Insertion of polyethylene fibre ribbon into the resin cement filled tooth canal

Figure 2A. Remaining tooth structure, after removal of composite resin restoration and caries

Figure 3. Total etch of the root canal

Figure 2 B. Root canal ready for polyethylene fibre ribbon reinforced composite resin post-core restoration

Ivoclar Vivadent, Liechtenstein) was used for luting polyethylene fibre ribbon. Syntac primer (Ivoclar Vivadent), Syntac Adhesive (Ivoclar Vivadent) and Heliobond (Ivoclar Vivadent) were applied to dentine separately in accordance with the manufacturer’s directions. A piece of fibre ribbon (Kerr Connect Reinforcement Ribbon; Kerr Corp, Orange, CA), 3 mm width and 5-6 mm longer than the prepared root canal length (Fig.4), was cut off and embedded in mixed Variolink resin cement (Variolink; Ivoclar Vivadent).

Figure 5B. Forming loop by insertion of free end of fibre ribbon into root canal

Balk J Stom, Vol 12, 2008 The Use of Reinforced Composite Resin 175

176 H.N. Alkumru et al. Balk J Stom, Vol 12, 2008

After cementation of Empress II crown, routine recall visits were performed 4 times over a 1-year period. The evaluation of the polyethylene fibre ribbon reinforced composite resin as post-core build-up at these visits was made with radiographic examination. In each recall, radiograph was taken from the restored tooth with the standardized long-cone technique. No differences were observed between the initial and recall radiographs. The

The root canal was filled with resin cement. Fibre-resin combination was carefully placed into the canal by use of titanium nitride coated instruments (Brilliant Esthetic Line Composite Instrument, Coltène AG, Switzerland), leaving a loop formed 2-3 mm ribbon above the occlusal surface of the root (Fig. 5A and B). The combined fibre ribbon and luting resin was light cured for 40 sec (Optilux; Demetron Inc, Danbury, Conn). Exposed ribbon loop was then filled and covered with composite resin (Tetric Ceram, Ivoclar Vivadent) incrementally for fabricating core, and light cured for 40 sec from one surface, total of 160 seconds (Fig. 6) .

Core PreparationThe core preparation was completed with

circumferential deep chamfer finish line (Fig. 7). Medium and coarse diamond burs (Accurata, G+K Mahnhardt Dental, Germany) were used for tooth preparations. The width of the shoulder was kept 1 ~ 1.2 mm. Cervical

margin was placed 0.5 mm sub-gingivally to increase the length of preparation as well as aesthetic improvement of the final restoration. Sharp edges or irregularities were corrected to minimize stress concentration. Complete arch impression was made with a silicon impression material (Speedex; Coltene AG, Switzerland) and chair side provisional crown (Dentalon Plus; Heraeus Kulzer, Germany) was constructed. Empress II full ceramic crown (Empress II; Ivoclar, Vivadent) was fabricated. The complete seating, marginal adaptation, aesthetic appearance of crown and occlusion was checked at the first try-in. Any premature contacts of centric occlusion position and /or the lateral and anterior movements were eliminated.

Empress II Crown Cementation ProcedureThe internal surface of the crown was etched with

5% hydrofluoric acid gel (IPS ceramic etching gel; Ivoclar, Vivadent) for 20 sec. A silane coupling agent (Monobond-S; Ivoclar, Vivadent) was applied for 60 sec. The preparation was cleaned with pumice slurry and retraction cord was applied. The core surfaces and remaining tooth surfaces were etched with 37% phosphoric acid (Total Etch; Ivoclar, Vivadent) for 60 seconds. Tooth was rinsed with water and dried. Following the manufacturer’s guidelines, Syntac Primer and Syntac Adhesive were applied. The bonding agent was brushed on both preparation surfaces and internal surface of the restoration, thinned with air, and cementation was performed immediately by using Variolink II high viscosity resin cement. Excess cement was removed with brush and dental floss. The restoration was photo-polymerized for 40 sec. from all surfaces, total of 200 seconds. The occlusion was controlled to preclude premature contacts (Fig. 8).

Figure 6. Construction of composite resin (Tetric-Ceram) core

Figure 7. Final preparation for full ceramic restoration Figure 8. Full porcelain in-situ

outcome was successful. Additionally, no functional or aesthetic problems were reported by the patient.

Discussion

The purpose of a post and core is to reinforce the remaining coronal tooth structure and to replace missing

Balk J Stom, Vol 12, 2008 The Use of Reinforced Composite Resin 177

coronal tooth structure9. Due to the shearing forces that act on anterior tooth, anterior endodontically treated teeth are restored with posts more often than posterior teeth8. The metallic colour of metal posts leads to a greyish discoloration of the root and consequently of the gingiva. This may be an enormous aesthetic disadvantage in the anterior teeth5 and cosmetic concern has led to development of aesthetic posts7. The use of polyethylene fibre ribbon reinforced composite resin as a post-core restoration material satisfied the aesthetic demands beneath all ceramic restorations and also provided a level of strength to composite core material replacing the lost tooth structure.

Dental cement lute the post to radicular dentin and some properties of cements, such as compressive strength, tensile strength and adhesion, are commonly described as predictors for success of a cemented post.8. Cement provides important retention to the post and core; however, no cement can compensate for a poorly designed post7. Mendoza et al6 showed that resin cements give additional resistance to fracture compared to brittle, nonbonding zinc phosphate cement, and reported that resin luting agents are technique-sensitive and difficult to manipulate. In the presented study, before the cementation procedure, the canal was washed off and dried after the etching procedure, ensuring that the post space was free of any residue4. The root canal was filled with resin cement by using lentulospiral10 and polyethylene fibre ribbon embedded to the resin cement was placed to the prepared root canal.

Silver amalgam, composite and glass-ionomer are 3 basic direct core materials8. Kovarik5 evaluated different core materials under simulated chewing conditions and concluded that amalgam core build-ups with metal posts had a significantly higher resistance to chewing forces when compared to metal post-composite resin build-ups. In the present study, since exposed ribbon loop was filled and covered with composite resin incrementally, fibre-resin combination with 2-3 mm loop provided adequate retention and resistance for the core material clinically.

The technique presented in this paper is a chair-side procedure, and allows direct core build-up. Therein with one visit for the patient, the dentist can fabricate post-core, complete the crown preparation and make a final impression for the restoration. Since the endodontic enlargement is enough and since there is no need for extra preparation in the canal for the polyethylene ribbon, the preservation of residual dentin is possible with this technique. Therefore, the risk of root perforation can be eliminated and the remaining root dentin to resist fracture is optimized. However, a significant challenge with this technique is the handling of the polyethylene fibre ribbon during embedment of the resin cement. Titanium nitride coated instruments can be used for better handling of ribbon and resin cement combination.

Sirimai et al12 reported that the polyethylene fibre ribbon was effective in reducing the incidence of vertical root fractures and the failure thresholds were significantly lower than that of conventional cast posts. In this clinical

application, the aesthetic goal was achieved and there was functional success over 1 year period. Long-term clinical performance of polyethylene fibre ribbon reinforced composite resin as post-core build-up needs to be evaluated.

In summary, the polyethylene fibre ribbon can be used safely with composite resin for post-core build-up restorations for endodontically treated teeth. The translucent quality of fibre ribbon and composite resin enables complete porcelain crowns to be fabricated without compromising aesthetics.

References

Bateman G, Ricketts DNJ, Saunders WP1. . Fiber-based post systems: a review. Br Dent J, 2003; 195:43-48.Fernandes AS, Dessai GS2. . Factors affecting the fracture resistance of post-core reconstructed teeth: a review. Int J Prosthodont, 2001; 14:355-363.Goldman M, De Vitre R, White R, Nathanson D3. . A SEM study of posts cemented with an unfilled resin. J Dent Res, 1984; 63:1003-1005.Kakehashi Y, Lüthy H, Naef R, Wohlwend A, Schärer P4. . An all-ceramic post and core system: clinical, technical and in vitro results. Int J Periodont Rest Dent, 1998; 18:587-593.Kovarik RE, Breeding LC, Caughman WF5. . Fatigue life of three core materials under simulated chewing conditions. J Prosthet Dent, 1992; 68:584-590.Mendoza DB, Eakle WS, Kahl EA, Ho R6. . Root reinforcement with a resin-bonded preformed post. J Prosthet Dent, 1997; 78:10-15.Morgano SM, Brackett SE7. . Foundation restorations in fixed prosthodontics: current knowledge and future needs. J Prosthet Dent, 1999; 82:643-657.Morgano SM, Milot P8. . Clinical success of cast metal posts and cores. J Prosthet Dent, 1993; 69:11-16.Robbins JW9. . Guidelines for the restoration of endodontically treated teeth. J Am Dent Assoc, 1990; 120:558-566.Robbins JW10. . Restoration of the endodontically treated tooth. Dent Clin North Am, 2002; 46:367-384.Rudo DN, Karbhari VM11. . Physical behaviors of fiber reinforcement as applied to tooth stabilization. Dent Clin North Am, 1999 43:7-35.Sirimai S, Douglas NR, Morgano SM12. . An in vitro study of the fracture resistance and the incidence of vertical root fracture of pulpless teeth restored with six post-and-core systems. J Prosthet Dent, 1999; 81:262-269.Wong B, Utter JD, Miller BH, Ford JP, Guo IY13. . Retention of prefabricated posts using three different cementing procedures. J Dent Res, 1995; 74:181.


Dr. Hasan N. AlkumruMarmara UniversityFaculty of DenistryBuyukcftlik Sok. No:634365 Nisantasi, IstanbulTurkeyE-mail: [email protected]


Although there are many reference textbooks that cover oral cancer comprehensively, “Oral Cancer” by JW Werning is a practical, easy-to-read guide to the management of oral cancer. It provides readers with a systematic review of the diagnostic and treatment principles that maximize the outcomes of patients who have been diagnosed with oral cancer.

Editor JW Werning, M.D., D.M.D., has brought together contributions from authorities in the fields of head and neck surgical oncology, radiation oncology, reconstructive surgery, dentistry, and oral and maxillofacial surgery. This book provides clinicians with the unified management philosophy firmly based upon the available evidence in the peer-reviewed literature.

Unlike more comprehensive texts on head and neck cancer, this text does not address the basic science foundation of cancer biology or medical therapy. Because of its concise format and coverage of key clinical principles, it makes for a good addition to the library of residents or surgeons who manage head and neck cancer.

This book is divided onto 31 chapters in a following order: Epidemiology of Oral Cancer - Oral Precancer - Malignant Lesions of the Oral

Book Review

BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141 TUPNBUPMPHJD

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ORAL CANCER: DIAGNOSIS, MANAGEMENT, AND REHABILITATION1st Edition

Editor: John W. WerningPublisher: Thieme Medical Publishers, New York - Stuttgart, 2007

Hard cover, 368 pages with 350 illustrations and 46 tablesPrice: $ 129.95

Balk J Stom, V ol 12, 2008 179

reconstructive options that are time tested and effective for restoring form and function.

Chapter on reconstruction of the lips exhaustively covers a technique published in 1974 by Prof. M. Karapandžić from the University of Belgrade, Clinic of Maxillofacial Surgery. The description of that method is concluded with the following statement: „Based on the superior functional and cosmetic results that can be achieved, the Karapandzic flap is arguably the flap of choice for most defects“.

Exhaustive coverage was given to the topics that have until now received limited attention in other textbooks devoted to oral cancer, including the evaluation and management of oral premalignant lesions, osseointegrated implantation and dental implant imaging, and orofacial pain.

“Oral Cancer” is long on management and short on pathophysiology. This makes it concise and attractive for clinicians or residents accumulating information specifically about patient management. Its lack of pathophysiology and basic science limits its utility to residents preparing for the in-service examination. However, it will certainly help students or residents prepare for the next days operation or case presentation. For more senior clinicians, it serves as a well-referenced, up-to-date review on management techniques.

As a clinical text, it directs the reader through difficult subjects; it clearly states which topics are controversial, outlines the relevant studies, and then leads the reader to a fair conclusion of acceptable management practices. In areas in which there is consensus, management options are stated clearly and concisely. Furthermore, it informs the reader when introducing a non-standard treatment (such as radiation therapy for lesions traditionally managed by surgery). For a text addressing oral cavity cancer, it contains significant detail on radiotherapy treatment. Overall, this is a valuable addition to the book, as it is not always as well covered in traditional textbooks. Although the radiation oncology sections are well written with excellent figures, they seem in places excessive for the target audience.

The textbook appropriately concludes with a discussion of future directions in cancer therapy, novel therapeutics that are on the horizon, and options for managing treatment sequelae that can significantly affect a patient’s quality of life.

Cavity - Evaluation of Oral Premalignant Lesions - Anatomic Consideration - Imaging of Patients with Oral Cancer - Staging of Oral Cancer - Pretreatment Dental Evaluation and Management of the Oral Cancer Patient - Cancer of the Lip - Cancer of the Buccal Mucosa - Cancer of the Oral Tongue and Floor of Mouth - Cancer of the Lower Alveolar Ridge and Retromolar Trigone - Cancer of the Hard Palate and Upper Alveolar Ridge - Management of the Neck - Reconstruction of the Lips - Reconstruction of the Cheek - Reconstruction of the Tongue - Reconstruction of the Mandible - Reconstruction of the Maxilla - Radiation Therapy – Chemotherapy - Oral Rehabilitation with Osseointegrated Implants - Dental Implant Imaging - Oral Prosthetic Rehabilitation - Xerostomia and Mucositis – Osteoradionecrosis - Speech and Swallowing Following Treatment for Oral Cancer - Temporomandibular Disorder and Orofacial Pain – Chemoprevention - Novel Therapeutics for Head and Neck Cancer - Medical/Legal Issues.

Those chapters contain in-depth clinical reviews of preferred treatment approaches and reconstructive techniques for each oral cavity site facilitate the development of effective treatment strategies that are tailored to the location and extent of the lesion. They also give insightful reviews of controversial clinical issues, such as the management of early mandibular invasion and the clinically negative neck.

In addition to covering management of oral cavity cancer, the book has well-written and concise chapters on related topics such as osteoradionecrosis, prosthetic implantation techniques, chemoprevention, new therapeutic agents (including monoclonal antibodies, tyrosin kinase inhibitors, gene replacement therapy, farnesyl transferase inhibitors, etc), legal issues (malpractice litigation, cancer litigation and risk management). For the most part, the book is well referenced internally, referring the reader to places within the book that are not covered in the current chapter. Unfortunately, this is not always the case, and some topics are divided into separate chapters that might be better grouped together. For example, the chemotherapy section does not include targeted therapies, which are appropriately covered within the book, but in a separate chapter.

A key element in the surgical treatment of patients with oral cancer is state-of-the-art reconstruction, and leaders in the field have contributed site-specific chapters covering the


an essential educational tool for residents and other members of the multidisciplinary oral cancer team. Its comprehensive coverage of oral cancer prevention, diagnosis, therapy, reconstruction, and rehabilitation is intended to become an invaluable tool for all who provide a service aimed to improve both therapeutic outcome and quality of life for all patients treated for oral cancer.

Prof. Miodrag Gavrić

In what is notably missing for a clinically oriented text, it does not contain an adequate discussion of complications related to surgery or radiotherapy within each chapter, nor does it contain a separate chapter that addresses long-term post-treatment complications.

“Oral Cancer” is an up-to-date and comprehen-sive guide to the clinical management of oral cancer and its rehabilitation. This book is both an indispensable reference for experienced clinicians and

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