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www.dentalnews.com Volume XVI, Number III, 2009
CLEFT LIPS
AND PALATES
25
th
Anniversary
School of Dentistry
Lebanese University
Endodont i c
surgery versus
retreatment
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Adopting minimum intervention
in dentistry
Dr. Steffen Mickenautsch
Cleft lips and palates
Dr. Abu-Hussein Muhamad
Lumineers
Dr. David Silber
Endodontic surgery versus retreatment
Dr. Richard Mounce
25
th
Anniversary - School of Dentistry
Lebanese University
Product Review
EDITORIAL TEAM
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ART DEPARTMENT
SUBSCRIPTION
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INTERNATIONAL REVIEW BOARD
Pr. M.A. Bassiouny BDS, DMD, MSc, Ph.D. Director International Program, Temple University, Philadelphia, USA.
Pr. N.F. Bissada D.D.S., M.S.D Professor and Chairman, Department of Periodontics, Case Western Reserve
University, USA.
Pr. Jean-Louis Brouillet D.C.D, D.S.O. Chairman, Department of Restorative Dentistry, Aix-Marseille II, France.
Pierre Colon D.C.D., D.S.O. Matre de confrence des universits, Paris, France.
Dr. Jean-Claude Franquin, Directeur de lUnit de Recherche ER116, Marseille, France.
Pr. Gilles Koubi D.C.D., D.S.O. Department of Restorative Dentistry, Aix-Marseille II, France.
Pr. Guido Goracci. University LA SAPIENZA, School of Medicine & Dentistry, Roma, Italia.
Dr. Olivier Hue, Facult de chirurgie dentaire de Paris VII, rue Garancire, Paris, France.
Brian J. Millar BDS, FDSRCS, Ph.D. Guys, Kings, and St. Thomas College School of Medecine & Dentistry,
London, UK.
Pr. Dr. Klaus Ott, Director of the Clinics of Westflischen Wilhelms-University, Mnster, Germany.
Wilhelm-Joseph Pertot DEA, Matre de confrence, Aix-Marseille II, France.
Pr. James L. Gutmann, Professor and Director, Graduate Endodontics, Baylor College of Dentistry, Dallas, Texas,
USA.
Pr. Dr. Alfred Renk, Bayerische Julius-Maximilians-University, Wrzburg, Germany.
Dr. Philippe Roche-Poggi DEA. Matre de confrence des universits, Aix-Marseille II, France.
Michel Sixou D.C.D., D.E.A. Department of Priodontology, Toulouse, France.
Pr. M. Sharawy B.D.S., Ph.D. Professor and Director, Department of Oral biology, Medical College of Georgia,
Augusta, Georgia, USA.
Alfred Naaman, Nada Naaman, Jihad Fakhoury,
Dona Raad, Antoine Saad, Lina Chamseddine,
Tarek Kotob, Mohammed Rifai, Bilal Koleilat,
Mohammad H. Al-Jammaz
Lina Jadaa
Krystel Kouyoumdjis
Micheline Assaf, Nariman Nehmeh
Josiane Younes
Albert Saykali
Gisle Wakim, Marielle Khoury
Tony Dib
1026-261X
Vo l u me XVI , Nu mb e r I I I , 2009
C
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INTERNATIONAL CALENDAR
DENTAL NEWS, VOLUME XVI, NUMBER III, 2009
1
1
ADVERTISING INDEX
September 2326, 2009
The Beirut International Dental Meeting 2009
Congress Palace Dbayeh
Contact: Dr. Antoine Karam, President of the Lebanese Dental Association
Email: lda@lda.org.lb
Website: www.LDA.org.lb
October 1416, 2009
The 17
th
Scientific International Conference of Syrian Dental Association,
Damascus Ommayad Palace for conferences, Damascus Ebla Hotel
Contact: Syrian Dental Association, Damascus, Syria, POB: 11104
Tel: 963 11 222 1446 Fax: 963 11 222 48 45
Email: syrdent@scs-net.org
Website: http://www.syr-sda.com
October 15 - 17, 2009
37
th
International Expodental Rome
Pavilions 7-8-9 of the new Fiera Roma Exhibition Center
Email: pressoffice@expodental.it
Website: http:// www.expodental.it
October 21 - 23, 2009
The 4
th
Riyadh International Pharmacy Meeting - 4
th
RIDPM
Riyadh, Saudi Arabia from October 21st to 23rd, 2009 [02-04/10/1430].
Email: meeting@riyadh.edu.sa
Website: http://riyadh.edu.sa/meeting
October 27 - 29, 2009
The 5
th
Bahrain Dental Society Conference 2009
27- 29 October 2009
Email: bahds@batelco.com.bh
Website: http://www.bahrain-dental.com
November 3 - 6, 2009
1
st
Pan Arab Endodontic conference
LandMark Hotel (RadissonSAS) Amman, Jordan
Dr. Ibrahim Abu Tahun
Email: ihtahun@yahoo.com
Website: http://www.jda.org.jo/endo
November 6 - 7, 2009
1
st
Dental Facial Cosmetic International Conference
Where Science Meets Art of Beauty
Jumeirah Beach Hotel UAE
Email: info@cappmea.com
Website: http://www.cappmea.com
November 10 - 12, 2009
1
st
Dubai International Implant Summit
Crowne Plaza Dubai - UAE
Email: matios.tcholakian@index.ae
Website: http://www.diis.ae
November 10 - 12, 2009
DENTISTRY 2009
ADNEC, Abu Dhabi UAE
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November 11 - 13, 2009
Egyptian Dental Association 14
th
International Dental Congress
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Intercontinental Hotel - Cairo - City Stars
Email: eda@internetegypt.com.eg
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November 29 December 2nd, 2009
Greater New York Dental Meeting
Tel: 212-398-6922
Fax: 212-398-6934
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March 9 - March 11, 2010
AEEDC Dubai
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OPERATIVE DENTISTRY
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Abstract
Minimum Intervention (MI) in dentistry aims to empower
patients through information, skills, and motivation to take
charge of their own oral health and consequently require only
minimum intervention from the dental profession. Although MI
in dentistry has until now focused mainly on caries-related topics,
it follows the 3-step philosophy of disease risk assessment, early
disease detection and, if required, minimally invasive treatment.
This philosophy is applicable to any type of disease. The subsequent
benefit of MI is its focus on disease causes and ultra-conservative,
patient-friendly treatment. Successful diffusion of MI depends
on substantiation of its beneficial claims through low-bias evidence.
Such evidence provides the first step for a wider adoption which,
furthermore, depends on complex factors related to adopter
behavior.
Introduction
Since the beginning of this millennium information about the
procedures and benefits of minimum intervention, an innovative,
modern healthcare approach for dentistry, has been increasingly
disseminated
1-8
. As with any innovation, wide adoption of minimum
intervention by the dental profession is reliant upon factors related
to the process of diffusion
9
. This paper aims to contribute to the
discussion of this topic by highlighting the role, which both bias
and scientific evidence can play in this process.
Minimum intervention
Minimum Intervention (MI) in dentistry aims to empower
patients, through information, skills and motivation, to take
charge of their own oral health in order to require only minimum
intervention from the dental profession (Hien Ngo, National
University of Singapore; oral communication, September 2004).
Although the focus of MI in dentistry has so far been on caries-
related topics
10
, the approach follows the 3-step philosophy of
disease risk assessment; early disease detection and possible
minimally invasive subsequent treatment. Such philosophy is
applicable to any type of disease
2
. MI enables the healthcare
provider to advise healthy patients about their risks regarding
possible future ailments
11
. Such risks may be due to aspects related
to a patient's lifestyle or to other factors with the potential to
have an impact upon health
12
. These aspects are then assessed
to determine the basis on which addressing the identified risk
factors with targeted prevention is possible
13
.
Patients with manifest disease are helped by as early as possible
identification of such manifestation
14-16
. As disease at an early
stage is often relatively contained, treatment can consequently
be simple, very conservative and minimally invasive
1
.
Laboratory findings, clinical considerations and protocols, materials
and technologies for all three steps of MI in dentistry have been
reported elsewhere
3-6,17
. Patients benefit from MI because of its
focus on the cause of disease instead of on merely addressing
disease symptoms
7
. A further benefit for patients is its patient-
friendly nature, due to its minimally invasive treatment options.
MI procedures are considered to be atraumatic, since patients
experience less discomfort and pain than traditional treatment
options incur
8
. Experience and expectation of pain and discomfort
during dental treatment has been associated with dental fear
18
.
A study investigating the dental fear levels of children and adults
during atraumatic restorative treatment (ART), in comparison to
those receiving traditional restorative treatment using high-speed
drilling, found patients treated with ART to be significantly less
fearful than the others
19
. Patients with low levels of dental fear
are more cooperative during treatment than those with high fear
levels
20
. Positive patient attitude and cooperation resulting from
reduction of fear during treatment sessions may further benefit
the healthcare provider, as a direct correlation between dental
fear and operator stress in daily dental practice has been
observed
21
.
The MI benefits for patients, attributable to addressing causes
of disease and to the reduced discomfort, and the benefits for
healthcare providers, resulting from stress reduction through
reduced patient fear and consequent higher patient coopera-
tion, have been stated as reasons for adopting MI into daily
dental practice.
Adopting minimum intervention in dentistry:
Diffusion, bias and the role of scientific evidence
Dr S Mickenautsch, BDS, PhD
Division of Public Oral Health, University of the Witwatersrand, 7 York Rd, 2193
Parktown/Johannesburg, South Africa
Email: neem@global.co.za
OPERATIVE DENTISTRY
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Diffusion of innovation
Despite its stated benefits the still new philosophy of MI faces,
as most innovations commonly do, the process of diffusion.
Rogers
9
(2003) defined innovation as an idea, practice or
object that is perceived as new, and diffusion as the process
through which innovation spreads. Diffusion comprises (i) innovation
itself; (ii) the type and availability of channels through which the
innovation is communicated to others; (iii) time and (iv) the
prevailing social system
9
.
The social system constitutes the community of potential adopters
of innovation, categorized as follows: the innovators themselves,
early adaptors, early majority, late majority and laggards
9
. Rogers
(2003) estimated the percentage distribution of these groups as
being 2.5%, 3.5%, 34%, 34% and 16%, respectively
9
. Except
for the innovators themselves, these adopter groups' responses
to innovation can vary between adoption, non-adoption or
rejection
22
. An innovation is considered self-sustaining once it
has been accepted by 10-20% of all potential adopters
9
. As well
as adoption of an effective innovation, rejection and resistance
against such an innovation are possible.
Research bias
One of the factors governing the response to an innovation by
potential adopters is insecurity concerning uncertainties about
the advantages of new ideas, practices or objects as compared
to those of current ones
22
. Doubts regarding claims of superiori-
ty of, for example, new products or clinical procedures are justi-
fied if these are based on studies containing high degrees of bias
or systematic error. Bias has been defined as any process at any
stage of inference tending to produce results that differ system-
atically from the true values
23
. The most important types of bias
in clinical studies are selection-, performance-, detection-and
attrition bias (Table 1)
24
.
Bias may affect studies by causing either an over-or under estimation
of the treatment effect of an investigated clinical procedure. This
may lead to a situation where a new ineffective treatment procedure
is presented as effective or an effective treatment is presented as
ineffective. The overestimation of a treatment effect through
bias has been observed to be the most common
25
, thus providing
the rationale for late adopters to doubt superiority claims at the
onset. Schulz et al. (1995) reported a 41% treatment effect over-
estimation due to selection bias alone
26
. Such overestimation
would mean that a study comparing the treatment effect of a
new clinical procedure against a standard one would report a
Risk ratio (RR) of 0.82 while the true RR would only be 1.13. The
term Risk (R) describes the number of patients having an
event (e.g. remaining ill after treatment) (nill) divided by the total
number of patients treated (ntotal)
27
.
R = n
ill
: n
total
If the effect of treatment with a new procedure is compared
with the effect of a conventional, standard procedure, a Risk
ratio (RR) can be calculated by dividing the patient Risk of
remaining ill after treatment with the new procedure (R
new
) by
the patient Risk of remaining ill after treatment with the standard
procedure (R
old
)
28
.
RR = R
new
: R
old
The so calculated RR indicates whether treatment with the new
procedure, in comparison to treatment with the standard procedure,
increases or decreases the risk (or chance) that patients may
remain ill
28
. A presented RR of 0.82 would imply that the new
procedure has reduced the chance of remaining ill for 18% of
patients. (A risk ratio of 1.00 would indicate no difference in risk
between the two procedures.) However, in a case of a 41%
overestimation through bias, a real RR of 1.13 would mean that
Selection bias
Performance bias
Detection bias
Attrition bias
Bias
New clinical procedures are usually tested in clinical trials consisting of 2 groups of patients: One group,
forming the control group, is treated with a conventional, most commonly used procedure being considered as
currently accepted standard of care. A second group (test group) is treated with the new procedure. At
the end of the study the success (or failure) rates of both procedures are compared. Selection bias occurs
when patients are selected into the 2 groups with known or unknown different characteristics. For example,
if patients in the test group have conditions, which favor the success of treatment and which are lacking
in patients of the control group then the new clinical procedure cannot be credited with the treatment
success
43
.
Similar to selection bias, performance bias leads to wrong study results if the characteristics of patients in
one group of a clinical study support or hinder the treatment effect of a clinical procedure. However,
unlike in selection bias, performance bias is induced through active intervention, e.g. through additional
treatment during the study in preference to one group only
44
.
Detection bias is created if the outcomes of both test-and control group are assessed differently. In other
words, if the outcome of one group is assessed more favorably then the other
44
.
Attrition bias occurs when patients allocated to either test-or control group are excluded from the outcomes
assessment. For example, if patients in the control group are excluded for whom the standard clinical procedure
lead to a treatment success. In such case the overall success rate of the standard treatment would be com-
parable lower than the new clinical procedure, thus falsely indicating that the later is superior
24
.
Description
Table 1. Types of bias in clinical trials
OPERATIVE DENTISTRY
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the new procedure has in fact increased by 13% the chance of
patients' remaining ill. If such new clinical procedure were to be
adopted into daily practice on the basis of the biased overesti-
mated results, then 13 out of 100 patients treated with the new
procedure would have been worse off than they would have
been if treated with the standard procedure.
Negative experiences of early adopters of an apparently ineffective
innovation, as shown in the example above, would in time lead to
its rejection. Early adopters have been described as interacting more
frequently with peers than late adopters
9
. Therefore, negative expe-
riences of an innovation by early adopters would be communicated
to other adopter groups and this would prevent further diffusion.
In that case, the critical mass of 10-20% of adopters
29
would not
be reached and the innovation would thus remain unsustainable.
Evidence and diffusion
To avoid negative feedback from early adopters during the diffu-
sion process, an innovation needs to be based on low-bias
research because high internal validity of research provides the
prerequisite for the successful generalization and adoption of
the innovation
24
. Bias reduction in clinical studies focused on
treatment is realized through a range of interventions (Table 2)
to be considered while planning and conducting a study
24,29,30
.
In addition, it has been acknowledged that various study designs
contain various degrees of bias
31-33
. For that reason an 'evidence
hierarchy' of study designs has been established (Table 3)
31-33
.
It also has been recommended that once a study is conducted,
its reporting should follow guidelines in order to assure recognition
of study quality
34
. Such guidelines include the CONSORT statement
for randomized control trials
35
and the STROBE statement for
observational studies, such as Cohort and case-control studies
36
.
Studies with low bias are identified through systematic reviews,
using explicit, systematic methods designed to limit bias and the
chance effects
37
. Where possible the results of the identified
studies are statistically combined, using META analysis and thus
providing more precise estimates of healthcare effects
37
.
Despite the value of low-bias evidence, it has been shown that
on its own this is not sufficient to facilitate diffusion of innova-
tion
38
. Nevertheless, diffusion of innovation is more likely if the
evidence supporting it is regarded as being strong
38,39
.
Furthermore, it has been observed that clinicians do recognize a
hierarchy of evidence and most frequently regard randomized
control trials (RCT) as the gold standard
38
. Locock et al. (1999)
described RCTs as providing the only form of evidence that may
convince clinicians to adopt change
40
. Therefore strong evidence
is an important prerequisite for achieving wider adoption of an
innovation. Once strong positive evidence regarding an innova-
tion is available, further aspects of diffusion need to be consid-
ered. These are related to complex factors of adopter behavior.
According to Morris et al. (1989), they may include past educa-
tional and professional experiences, work environment and pro-
fessional and personal aspirations
41
. Fitzgerald et al. (2002) add
further considerations related to whether the innovation threat-
ens the established skill base and, consequently, the status and
professional position of potential adopters, and to the impact of
financial incentives which may facilitate or inhibit adoption of an
innovation
42
. The latter may be further reinforced by perceptions
of potential adopters as to whether the innovation offers advan-
tages that the current methods do not
22
.
MI Evidence
The need for strong (low-bias) evidence as an important prerequisite
for wide adoption of innovation
38-40
applies also to MI. The Cochrane
library (online: www.cochrane.org) and Midentistry's compendium
database (online: www.midentistry.com/compendium.html) are
known sources for evidence generated through systematic
reviews and META analysis and cover aspects of disease risk
assessment; early disease detection and minimally invasive treatment.
The compendium database follows Cochrane recommendations
and guidelines regarding the conduct of systematic reviews and
META analysis but focuses exclusively on MI topics, including disease
treatment and etiology, prognosis and diagnosis.
Conclusions
Minimum intervention (MI) in dentistry focuses on causes of dis-
ease and allows for ultraconservative treatment that is more
patient-friendly than traditional dentistry. Successful diffusion of
MI requires substantiation of its beneficial claims through low-
bias evidence. Such evidence provides the first step for a wider
adoption, which furthermore depends on complex factors of
adopter behavior.
(a) Selection of study subjects using a random allocation
sequence
(b) Concealment of allocation sequence from investi-
gators
24
Blinding (masking) of study subjects and care providers as
to the differences per test-or control group
24
Blinding (masking) of study assessors as to the differences
per test-or control group
24
Inclusion of all randomized study subjects into the
analysis regardless of their adherence to the study
protocol, thus following intention-to-treat principle
29,30
Selection bias
Performance bias
Detection bias
Attrition bias
Intervention Bias
Table 2. Bias-reducing interventions
Large randomised trials with clear results
Small randomised results with unclear results
COHORT studies
Case-control studies
Case series and reports
Expert reports
Highest evidence
value / lowest bias
Lowest evidence
value / highest bias
Study Design
Table 3 - Evidence hierarchy
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27: 35-47.
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40. Locock L, Chambers D, Surender R, Dopson S, Gabbay J. Evaluation Of The
Welsh Clinical Effectiveness Initiative National Demonstration Projects: Final Report.
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Health Research and Development, University of Southampton, 1999.
41. Morris A, Vito A, Bomba M, Bentley J. The Impact Of A Quality Assessment
Program On The Practice Behaviour Of General Practitioners: A Follow Up Study. J
Am Dent Assoc 1989; 119:705-9.
42. Fitzgerald L, Ferlie E, Wood M, Hawkins C. Interlocking Interactions, The
Diffusion Of Innovations In Health Care. Human Relations 2002; 55:
14: 29-49.
43. Altman DG, Bland JM. Statistic notes. Treatment Allocation In Controlled Trials:
Why Randomize? Br Med J 1999; 318: 1209.
44. Noseworthy JH, Ebers GC, Vandervoorst MK, Farquhar RF, Yetsir E, Roberts R.
The Impact Of Blinding On The Result Of A Randomized, Placebo-Controlled
Multiple Sclerosis Clinical Trial. Neurology 1994; 44: 16-20.
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left lips and cleft palates are among the most common
of birth defects and if left untreated can lead to serious
medical and concurrent speech and language problems.
However, while the consequences of cleft lips and
palates can be severe and long-lasting, these can be averted by
medical intervention, especially if it is done as early as possible.
This paper explores the various options for surgical, medical,
dental, and speech and audiological management of cleft of the
secondary palates in children with Apert's syndrome and the
ways in which these interventions can help children with these
particular birth defects.
We should begin this discussion by establishing what a cleft palate is,
in medical terms. Per the Cleft Palate Foundation website (accessed
August 17, 2007) a cleft palate occurs when the palatal plates
of an individual (which lie in the roof of the mouth) for various
reasons fail to come together or close during the second month
of fetal development. From an early age and up to adulthood,
the skull, face, jaws, hands and feet undergo frequent surgical
correction. These operations require planning and coordination
amongst various specialists, including a neurosurgeon, a craniofacial
plastic surgeon, an anesthesiologist, a maxillofacial oral surgeon,
an orthodontist, a dentist, an orthopedist and an orthopedic surgeon.
Continuing care throughout the first twelve years of a child with
Apert's life (as well as past the first twelve years) is facilitated by
a social worker, psychologist, audiologist and speech language
pathologist. In addition to the planning and performance of
many operations at specialist clinics, each child and his or her
family should have regular contact with the craniofacial team.
There will often be meetings with several members of the mul-
tidisciplinary craniofacial team as well as other medical profession-
als: the occupational therapist, the pediatrician, the nutritionist,
the guidance counselor, the psychologist and the physiothera-
pist. For the purposes of this research paper there will be a
focused discussion of six medical professionals' roles on the
craniofacial team in the first twelve years of a child with Apert's
life. These professionals are: geneticist, speech language pathol-
ogist, audiologist, plastic surgeon, dentist and orthodontist.
Role of the Geneticist
Consultation with a geneticist is crucial in order to do a DNA test
of the child with Apert's as well as the parents of the child. Per
the Mountain States Genetics Regional Collaborative Center's
website (accessed August 11, 2007) in Apert's syndrome, there
is bicoronal synostosis, midface retrusion, and symmetric syndactyly
(webbing of the digits) in both the hands and feet. The cranio-
facial dysostosis syndromes are inheritable. Per Carinci et al (2005 ),
the gene mutation for each syndrome has been identified.
Apert's syndrome is inherited in an autosomal dominant fashion,
meaning that there is a 50% likelihood of recurrence of the syn-
drome in the offspring of the affected individual. Often, the parents
of these children are not affected, and the gene mutation arises
spontaneously during development. However, the severity of
the syndrome may vary from one generation to the next. The
researchers state that the gene encoding for FGFR2 is mutated,
and this results in a wide spectrum in the expression of phenotype
and making anomalous development more complicated.
Furthermore, Apert's may not have been detected in a parent,
until a child with more remarkable Apert's traits was born.
Therefore DNA testing is of the utmost importance to give par-
ents the data to make informed decisions about the odds of
bearing another child with Apert's or other genetically inherited
disorders. Lastly, it is of great importance to determine the co-
occurrence of other congenital and genetic anomalies that may
affect the progression of the child's development.
Role of the Speech Language Pathologist
Therapy and follow-up care is coordinated with the speech language
pathologist (SLP). Per Shipster et al (2002), a cohort of ten children
with Apert's syndrome was studied and a thorough analysis of
their speech and language characteristics was done. They often
have hyponasal resonance due to an under-developed midface,
small nose, and excessively long soft palate. If there is a cleft
palate, they may also have hypernasal resonance. Articulation of
speech sounds is often distorted due to the malocclusion and high
arched palate. Impaired hearing or a general developmental
Cleft Lips and Palates;
The Roles Of Specialists
DR. ABU-HUSSEIN MUHAMAD - DDS, MScD
Limited to Pediatric Dentistry
Athens-GREECE
Abu-hus@hotmail.com
C
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delay will also affect speech and language development.
Individuals with Apert's Syndrome often require glasses to correct
near- or long-sightedness and thus the Speech Language Pathologist
must bear this in mind when doing drills using written media.
The researchers state that there are specific areas requiring therapy
based on their examination and standardized testing of these
children. Resonance and voice are at issue due to marked nasal
obstruction, affecting the nasality of words produced by the chil-
dren. Diplophonia and wet voice quality were apparent in the
cohort's voice and resonance. As a result therapy must focus on
nasality and voice therapy as well. Testing of the cohort deter-
mined severely impaired receptive and expressive language skills
in nearly 50% of the group. This involves an approach to ther-
apy which must address these issues to strengthen receptive and
consequently receptive abilities. Attention was delayed by 2;0 to
3;0 chronological years. The cohort displayed single channel
attention control that lags behind normal children. This means
that therapy must focus on eye contact, pragmatics and posture
issues. There were delays in the phonetic and phonological skills
of these children. Phonetic errors mainly involved blade production
of alveolar consonants as well as some lateralization of alveolar
fricative and affricates. While these issues mostly would be
helped by alveolar ridge surgery, in the meantime therapy may
focus on proper articulation of these phonemes. Phonologically
problems involved stopping of fricatives and affricates, final con-
sonant deletion, voicing of voiceless consonants, and fronting of
velars and palatoalveolar sounds. These are all major areas for
work on the part of the SLP. It is important to note that areas of
therapy for the cohort members during earlier years of life were:
Portage and Makaton signing (which was relinquished to instead
work on spoken language).
Role of the Audiologist
Per Rajenderkumar, Bamiou and Simimanna (2005), the major
concern related to audiological treatment of Apert's is the risk of
hearing impairment caused by repeated infections in the middle
ear. However, the researchers point to the significant debate
regarding the efficacy of repeated pressure equalization tube
insertion vs. the efficacy of amplification to ensure hearing ability.
Otoloaryngologists will handle the middle ear infections by
inserting pressure equalization tubes into the eardrum to equalize
middle-ear air pressure and drain liquid. The audiologist will
check the ears for placement of the tubes as they often fall out
of place.
Per the researchers, some individuals may require hearing aids, as a
hearing impairment will affect speech and language development.
They argue based on their data from a cohort of seventy cases
that hearing aids are more effective than tube insertion in the
long run. Hearing impairments caused by sensorineural damage
(the inability of the nervous system to mediate sound impulses)
are uncommon. Further impairments of hearing that are monitored
and managed by the audiologist (with consultation with a
Otoloaryngologist) are: low-set ears, microtia, macrotia, posteriorly
rotated external ears, ossicular fixation, wide cochlear aqueduct,
and abnormal surface configuration of the pinna. Regular audi-
ological testing is done according to schedule in order to assess
ongoing changes in the child's hearing.
Role of the Plastic Surgeon
Per the Children's Craniofacial Association website (accessed
August 19, 2007) the physical characteristics of Apert's include
defects of the skull, eyes, and face. The skull is: short from back
to front, wide on the sides. The eyes are: bulging, eyelids tilt
downward abnormally at the sides. The face is: mid-face has a
sunken-in appearance, the upper jaw slopes backward, lower
teeth project in front of the upper teeth. Early surgery relieves
the pressure on the brain and eyes by allowing the bone plates
of the skull to be detached from one another. Even in severe
cases of Apert's syndrome a significant cosmetic and functional
improvement is possible and a decreased risk of optic difficulties
or blindness secondary to orbital hypoplasia can be achieved.
Per Paravatty et al (1999) plastic surgery procedures include
release of the prematurely fused sutures; the traditional surgery
involves advancing the frontal bones, correcting the bulging eyes
and upper facial deformities including the retrusion or hypoplasia
of the midface. Depending on the severity of Apert's syndrome
and the associated congenital abnormalities, other operations
such as rhinoplasty - plastic surgery of the nose, genioplasty -
plastic surgery of the chin, eye muscle surgery to correct strabis-
mus or eyelid surgery to correct the abnormal downward tilt,
and surgical separation of the fingers and/or toes are performed
according to a staged treatment plan. To give the brain space to
grow and to improve the shape of the head, the fused bones are
subjected to early surgery, often when the child is six months old.
Corrections of the midface and jaws are currently not undertaken
until adolescence, when all the permanent teeth are in place. It
is also important to note that plastic surgery of the hand in
Apert's syndrome often has to be started early, to allow the child
to develop a grip.
Per the Mountain States Genetics Regional Collaborative
Center's website (accessed August 11, 2007), the fingers are all
separated and shaped, using skin and possibly also bone transplants.
This may enable the child to have three to five fingers on each
hand. After such surgery, the child will require training under the
supervision of an occupational therapist to develop grip and
coordination; the Speech Language Pathologist will work on
similar issues of tone and articulation related to muscle strength
in the speech mechanism.
Per Sadove, Van Aalst, and Culp (2004) the plastic surgeon is
involved in early repair of the cleft lip in the first few months of
life and works with the dentist and orthodontist to manage
appliances to close the cleft in the secondary palate. The surgeon
also is involved with surgery to the hands and feet to create digits.
Regarding the secondary palate surgery, there are a number of
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approaches. These include the von Langenbeck repair, the Veau-
Wardill-Kilner palatoplasty, two-flap palatoplasty, vomer flap surgery,
Z-furlow (Z-plasty), and four-flap palatoplasty surgeries. It is
important to note that the researchers report the discussion
between two schools of thought on repair timing. One is to
repair early in life to accommodate the onset of speech at 1 year
of age, vs. delaying repairs to allow for maxillo-facial growth
with a complete transverse facial growth at 5 years of age. The
current approach stated by the researchers, is to do the soft
palate repair at 0;3 to 0;6 and the secondary hard palate by 1;6 CA.
Role of the Dentist
Dental treatment is necessary in the case of Apert's syndrome.
Per Kaloust, Ishii, and Vargervik (1997) the oral cavity of these
children is characterized by supernumary teeth, missing teeth,
impaction and crowding, and delayed eruption. The maxilla is
affected and the mandible has an abnormal shape and size.
The dentist works closely with the orthodontist to time adjustments
to the oral cavity and dentition. The researchers point to two sig-
nificant findings: a delay of 0.96 years vs. a normal timeline of
dentition, as well as a marked slowdown in dental maturity that
slows more notably with age. This means that the dentist must
time their involvement with the patient along these parameters.
They will work on extraction of supernumary teeth and impaction
and crowding, but the work is done at different ages as normal
children. The dentist also works closely with the orthodontist
and plastic surgeon to assess dentition all the while that process-
es are worked on for closing the alveolar ridge after age 5;0 as
well as palatal closure and velopharngeal port surgeries.
Per Shipster et al (2002), there are a remarkable number of
cases that present with Class III malocclusion, specifically Class III
incisor relationship, anterior bite and bilateral posterior crossbite.
The degree of incisor crowding and irregularity is variable among
cases. The dentist considers how difficult it is for the child to
maintain good oral hygiene owing both to crowded teeth and to
restrictions in fine motor skills. An electric toothbrush may be a
useful aid. Frequent appointments with the dentist and/or a den-
tal hygienist are important and, as there is an increased risk of
caries, preventive fluoride treatment should be given.
Role of the Orthodontist
Orthodontists play a significant role in the treatment of a child
with Apert's syndrome. Per Kuijpers-Jagtman (2006) there are
four distinct processes that the orthodontist will participate in up
to and beyond the child's twelfth year of life. The orthodontist
will confer with the dentist and plastic surgeon that care for a
child with Apert's. This is to determine proper timing for the
implementation of orthodontic treatment.
The first process begins from 0;0 to 7;0 years, after the initial
treatment plan is devised with the craniofacial team. This is the
period during which the orthodontist constructs neonatal maxil-
lary orthopedics for the child ages infant through elementary
school age. The purpose of this device is to bring the maxilla in
alignment with the rest of the head, with consideration of the
mandible and dentition in the process of the orthopedic treatment.
There is debate as to the proper timing for orthopedics and the
efficacy of using extra-oral pin-retained appliances versus passive
appliances. Per the researchers 54% of craniofacial centers use
neonatal maxillary orthopedics.
The second process involves orthodontic treatment of the decid-
uous dentition stage, which the researchers state has a direct
correlation with the patency of circummaxillary sutures. This
occurs in the latter period of 5;0 to 7;0 years. It is significant to
reiterate the research of Kaloust, Ishii, and Vargervik (1997),
bearing in mind once again that there is a 0.96 year delay in
dentition of Apert's vs. normal children's dentition. Treatments
are needed for the lack of deciduous dentition in the area of the
alveolar cleft, and these treatments may include a face mask to
protract growth. Treatment to manage crossbite includes equili-
bration for occlusal interference.
The third process is in the mixed dentition period in the 9;0 to
11;0 years age range. This is concurrent with alveolar bone
grafting, 6 months prior to graft insertion with fixed appliances
placed on the maxillary arch. The researchers explain that this
eliminates crossbite and other unfavorable consequences of mal-
positioned incisors, and helps with dental aesthetics.
Eruption of the canine adjacent to the cleft of the secondary
palate is of importance as this will control the timing for further
orthodontic treatment. The researchers point to evidence that
the canines erupt in synchronicity with bone graft placement.
The fourth process is in the permanent dentition stage, anywhere
from 10;0 to 13;0 years of age or even older. In this period there
is a determination whether orthognathic surgery is indicated.
The researchers state that there is a high percentage of patients
that require this surgery vs. the general population, but that it is
not needed in more than 10% of the Apert's and cleft palate
patients. This is particularly relavent in Apert's patients as they
have a high incidence of Class III skeletal issues and thus the
orthodontist carefully exams the other evidence from the cranio-
facial team in order to determine candidacy for treatment.
Conclusion
There is clearly a need for further and more controlled research
on the disciplines involved in the craniofacial teams. There is a
need for larger cohorts to gather more data specific to Apert's
syndrome as this will give better evidence about treatment efficacy
and treatment outcomes. The craniofacial teams should be
advised to produce studies that have to do strictly with Apert's
syndrome so that the body of research regarding genetics in par-
ticular so that models for future treatment can be perfected even
more for the benefit of these patients.
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REFERENCES
Cleft Palate Foundation (2007). About Cleft Lip and Palate. Retrieved August 13,
2007, from http://www.cleftline.org/parents/about_cleft_lip_and_palate.
Carinci, F., Pezzetti, F., Locci, P., Becchetti, E., Carls, F., Avantaggiato, A., Becchetti,
A., Carinci, P., Baroni, T., & Bodo, M. (2005). Apert and Crouzon's Syndromes:
Clinical Findings, Genes and Extracellular Matrix. The Journal of Craniofacial
Surgery, 16(3), p. 361-368.
Children's Craniofacial Association (2007). A guide to understanding Apert's Syndrome.
Retrieved August 19, 2007, from http://www.ccakids.com/Syndrome/Apert.PDF.
Kaloust, S., Ishii, K., & Vargervik, K. (1997). Dental development in Apert
Syndrome. Cleft Palate-Craniofacial Journal, 34(2), p. 117-121.
Kuijpers-Jagtman, A. (2006) The orthodontist, an essential partner in CLP treatment.
B-ENT, 2(4), p. 57-62.
Mountain States Genetics Regional Collaborative Center (2007). What to Expect
from a Genetics Consultation. Retrieved August 11, 2007, from
http://www.mostgene.org/dir/expect.htm.
Paravatty, R., Ahsan, A., Sebastian, B., Pai, K., Dayal, P. (1999). Apert syndrome: A
case report with discussion of craniofacial features. Quintessence International,
30(6), p. 423-426.
Rajenderkumar, D., Bamiou, D., & Sirimanna, T. (2005). Management of hearing
loss in Apert syndrome. The Journal of Laryngology and Otology, 119, p. 385-390.
Sadove, A., Van Aalst, J., & Culp, J. (2004). Cleft palate repair: art and issues.
Clinics in Plastic Surgery, 31, p. 231-241.
Shipster, C., Hearst, D., Dockrell, J., Kilby, E., & Hayward, R. (2002) Speech and language
skills and cognitive functioning in children with Apert syndrome: a pilot study.
International Journal of Language and Communication Disorders. 37(3), p. 325-343.
ESTHETIC DENTISTRY
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Lumineers, The easy, painless way
to transform patients smiles.
he hottest craze in dentistry has been Esthetic
Dentistry. It has been taught by many dentists around
the world. However, it is still not a main topic in the
dental school curriculum. Many continuing education
programs are teaching different techniques to give the patient
the same result; a beautiful smile. This result can be done with
Orthodontics, Crowns, Composite Bonding or Veneers. Each of
these categories has its benefits, but when it is said and done,
which procedure would you like to get done.
Orthodontics has come along way. In the seventies, it was routine
to extract premolars and align teeth. The use of extra oral appa-
ratology was routinely used as an adjunct and patient compliance
was very low. Today, Orthodontist use digital radiography to assist
them in diagnostic and treatment planning. We even have comput-
er programs that can predict orthodontic results, like invisalign.
Composite bonding for esthetics reasons is a good fix. However,
these restorations stain easily and dont last as long as we would
like. Porcelain and Porcelain fused to metal crowns give an
excellent esthetic result. However, they are far too aggressive in
their preparation. Needing anywhere between 1.5-2.0 mm of
sound tooth structure to place these restorations, normally that
reduction is sound tooth structure. Veneers started as a conservative
alternative cosmetic restoration. These porcelain restorations
were minimally invasive. However, at some point, dentist started
complaining of failures or bulky restorations. Porcelain manu-
facturers and dental technicians came up with a conservative
preparation that would lead to a long lasting esthetic veneer.
Hence, the prepped veneer. This preparation resembled a three
quarter crown.
Dental technicians loved it, because they always say, they can
give you a beautiful restoration if you give them space. So, they asked
for 1.0-2.0 mm of buccal and incisal reduction. They also asked
for the doctors to open the interproximal contacts. Once again,
all this required the removal of solid, sound tooth structure. This
preparation led to some postoperative sensitivity and a weaker
bond between the tooth and the veneer. Both of the above
were due to exposed dentin. Instead of bonding to Enamel, now
they were bonding to dentin. Dentin is a weaker bond, hence
the increase in failures.
Again; dental manufacturers and technicians looked for different
alternative for the esthetic treatment. Enter pressed porcelains,
which can be strong and thin at the same time. Lumineers,
which are made of Cerinate pressed porcelain, can be as thin as
0.3 - 0.5mm. At this thickness, it maintains beauty and strength.
There are many dental laboratories that promote minimal prepa-
ration or no preparation veneers. However, you must read the
guidelines; many require some sort of tooth alterations.
Lumineers is the only no preparation porcelain veneer that has
studies showing its longevity.
With the advent of the internet, patients are becoming more
educated and asking wiser questions. They want to know that
they have options when selecting an esthetic restoration. If the
doctor doesnt give them options they will find one that does.
Case in point, patient MT had been to a handful of dentist to
correct the irregularities that he notices on his incisal edges. He
claims that nobody has given him options. One doctor offered
composite bonding, another ortho the other offered veneers.
The complimentary smile consultation is done in our treatment
plan room, where the patient has no dental distractions. The
patients smile consultation begins with him filling out Denmats
smile evaluation. It gives the patient the opportunity to state
what he likes about his smile and what he doesnt like. This is a
good conversation piece. I tell him about his options; he opted
for Lumineers because he was a minimal preparation candidate.
The thought of shots and the sound of the drill were not his
favorite. They always want to know if they are candidates for the
no preparation procedure.
To determine if the patient is a candidate for no preparation
David Silber, DMD
doctor@davidsilber.com
2800 Routh Street - Suite 255
Dallas, TX 75201, USA
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ESTHETIC DENTISTRY
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Lumineers we go to the dental chair. There I do a quick evaluation
to see if I can deliver what they WANT and how I can do it. They
must understand that they have options, so now I educate. They
are told that they can correct their smile by the use of orthodontics,
Porcelain fused to metal crowns, all porcelain crowns, veneers
and Lumineers. I make sure they understand each one, making
them more educated and once they decide they have really had
informed consent of the procedure.
At this juncture the patient has made the decision for WANTING
Lumineers. He wants to know what would be the steps required
for the procedure. I make sure they understand that they need
a full set of radiographs, complete oral exam and an oral prophylaxis.
This is done to ensure the predictability of Lumineers; absence of
decay and disease. No surprises in the near future. At this point,
I am looking for a solid foundation; absence of decay and dis-
ease. All periodontal, functional and restorative issues should be
taken care of, prior to any esthetic treatment.
If you have not done many Lumineers smile makeovers and are
unsure if the case is a preparation case or no preparation case,
you may simply take alginate study models and ship them to the
studio for evaluation. If there are no modifications to be done,
you will receive your models with a note stating that, where all
that is left is a good final PVS impression. If some work is to be
done, they will return your model with another model and red
lines showing you were to make the modification. You can also
ask for a prep guide, where they can actually show you where
to make those modifications.
The final impression, from which the Lumineers would be made,
was then created with Lumineers Impressions (Den-Mat
Holdings, LLC). This Polyvinylsiloxane material reproduces margins
with great accuracy. This is especially important for no-prep
veneers that are placed supragingivally. The patient then left the
practice with my favorite anterior provisionals his own teeth.
Two weeks later, he returned for the Lumineers placement.
However, before we brought him into the operatory, we verified
that the Lumineers had been etched by the Cerinate Smile
Design Studios. We then treated the inner surface of the
Lumineers with Porcelain Conditioner (Den-Mat) for 30 seconds,
rinsed and air-dried. This citric acid conditioner prepares the
porcelain for the silane. Applied next, Cerinate Prime (Den-Mat)
was left on for 30 seconds and air-dried. The surface of the
Lumineers looked glossy as a result of this layer of lightcure
unfilled resin. Since the Lumineers porcelain veneers were now
ready for placement, each was gently placed back in the original
box to shade them from the light. Finally, I carefully considered
the surfaces I was planning to bond to (enamel and cementum)
and arranged to have all the necessary materials readily available.
In order to do the try in procedure we must clean all the teeth
that we are going to bond to. This is done by using denmats
porcelain polishing paste on a dialite cup, this will remove all the
organic materials that lie on top of the tooth, thus maximizing
our bond. Next we will do our try in procedure. The try in is
done for the patients final shade selection. We know patients
want WHITE, MONOCHROMATIC teeth. I do the try in to satisfy the
patients intrigue for, Did I pick the right color?
For the try in procedure, I use denmats Ultrabond try in paste.
This try in paste has the same shade characteristics as the actual
ultrabond Plus, resin cement. However, it has no curing charac-
teristics. I Place Ultrabond try in paste in both central incisors. I
use two different shades; A-1, the same as the lumineers and B-O.
I now give the patient a mirror and allow him to pick which
shade he prefers. He picks shade B-O. We now clean the teeth
and Lumineers with a dry cotton applicator and apply tenure s
to the Lumineers. This step reactivates your bond. We must
keep the Lumineers clear of any contaminants and away from
any light because Tenure S Is a light cured bond enhancer.
Before
Resin luting
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Finally you can achieve
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structure AND to aesthetic
restorations, especially zirconium.
ESTHETIC DENTISTRY
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We are now ready to start preparing our intraoral surfaces. First
we apply paint-on dental dam, to protect the palatal surface
from any excess resins during the procedure. This makes the
clean up and finishing much faster. All the surface that are covered
with the paint-on dental dam will be as clean as when we started,
therefore we like to cover the occlusal surfaces, to protect them
from any excess resin or Ultrabond. At this point we clean all the
teeth that are to be bonded to with porcelain polishing paste on
a dialite cup, to ensure the cleanest possible surface to bond.
Now, we are ready to prepare the teeth for bonding, I recom-
mend the total etch technique. I use denmats etch and seal for
10 seconds and rinse for 20. Then apply 5 coats of tenure A/B
to all the surface that you have etched. I use the low speed suc-
tion on the lingual surfaces of the teeth to create a glossy sur-
face. By using the suction, this evaporates the acetone carrier
leaving a stronger base for bonding. If you air dry, you will
remove all the resin from the surface that you prepared. Proceed
to add a coat of Tenure S to all the teeth that have been pre-
pared. At this point I have just re-activated the bond, so I must
keep the teeth clean and avoid any moisture. Now the entire
surfaces are ready for bonding.
I began the actual placement of the Lumineers by loading
each Lumineer with Ultrabond Plus, shade B-O and transport-
ing them to the corresponding tooth. Our practice has recent-
ly begun using the LUMIgrip, which greatly simplifies the
process of transferring veneers. It utilizes suctioning forces to
hold the veneers and I can easily grasp the handle from my
assistant.
The excess cement was cleaned off with Tenure S. I took spe-
cial care to wipe the brush towards the gingival margin to pre-
vent the removal of too much cement and the unintentional
creation of a void. The Lumineers were tacked into place using
the Sapphire Supreme Plasma Arc Light with a 2mm tip for two
seconds. With the Lumineers firmly in place, I returned with
the Tenure S to remove extruded cement without the fear of
dislodging the veneers. The final cure was completed with the
Sapphire lights 9mm collimating tip. With this high intensity
plasma arc light, I was able to cure each veneer for only five sec-
onds, thereby curing all 10 Lumineers in less than a minute.
After
ESTHETIC DENTISTRY
The finishing technique for Lumineers is markedly different from
that of standard veneers. We are used to modifying the teeth
for traditional veneers and with Lumineers we dont remove
much tooth structure. We must tell our patients that we are
going to use the drill to clean and polish the margins and make
the Lumineers look good, we will be polishing and adjusting the
bite on the teeth. They must understand that even though you
are using the drill you are not doing any excessive tooth removal;
just cleaning and polishing. The clinician should also understand
this, as this is the major difference between prepping and
Lumineers. Traditional veneers have a subgingival margin that is
finished by the ceramist.
After placement, the clinician must only clean up the resin
cement. With Lumineers, the clinician creates a supragingival
margin chairside. The Cerinate porcelain and cement is
smoothed to the tooth to create a stress-resistant, non-
microleaking margin. The finishing was accomplished with the
carbide and diamond burs in the Lumineers Finishing Kit (Den-Mat).
These burs were used with a high-speed handpiece and a lot of
water. Any cement still remaining was removed with a 12-fluted
flame-shaped bur and a Schure 349 instrument.
A medium grain needle bur was used to the slight porcelain
ledge at the gingival margin. This was further smoothed with an
extra-fine needle diamond to create a seamless emergence profile.
I defined the interproximal margins with the mosquito bur.
Occlusion was checked with articulating paper. Slight adjustments
were made using the American football-shaped bur where the
opposing dentition contacted the porcelain.
The interproximal contacts were opened by gently rocking a
CeriSaw (Den-Mat) between the teeth. These were then
smoothed with the CeriSander (Den-Mat).
Four days later, he returned for the final finish. The interproximal
contacts were verified and smoothed. I also reviewed the look of
the porcelain and further defined a few areas with the interprox-
imal mosquito diamond. I again verified the occlusion. Satisfied
with the final result, I polished the restorations with Porcelain
Polishing Paste in a polishing cup.
If you are considering doing more cosmetic dentistry and hate
removing healthy tooth structure to place porcelain, consider
this; patients want to have a beautiful smile but many would
rather avoid a painful dental experience. The minimally-invasive
dentistry that the Lumineers system makes possible gives these
patients the smile makeovers they have dreamed of. He is
thrilled with his new smile and greatly appreciative that I did not
hurt him. Most important of all I have made another friend who
admires me for the procedure that I painlessly performed.
The best of
two worlds.
Identium
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Utilizing the best characteristics of two well-known

impression materials, Kettenbach has developed an
entirely new one: Vinylsiloxanether

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especially for the one-step impression technique: Identium.
www.kettenbach.com
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ENDODONTIC DENTISTRY
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here is confusion amongst many clinicians regarding
which failed clinical endodontic cases should be
retreated and which may need endodontic surgery.
ES carried out on a tooth that should ideally have OR
(or vice versa) has a direct impact on the long-term success of
treatment. For either of these treatments to have clinical success,
they must be carried out with the correct indications and avoided
where contraindicated. Several important treatment planning
principles that should be considered when choosing between
these two options are provided below:
Endodontic surgery is the answer when a condition can be
corrected, repaired and remedied only by gaining access to the
problem surgically. Few circumstances can be called outright
endodontic surgical indications. However conservative treatment
plans meet with difficulties and frustrations that defy conven-
tional methods of therapythe only difference between surgery
and conventional therapy is the approach; the principles of
cleaning, shaping, sterilizing, filing and sealing the canal are the same.
In Endodontic surgery, these procedures are simply conducted at
the end of the root instead of through the crown. Ref. 1.
A surgical approach is only indicated when it is agreed that
orthograde retreatment is either not possible or will not solve
the problem. Ref. 2.
Retreatment is usually initiated if the original treatment appears
inadequate, if the initial treatment has failed, or if microorgan-
isms from the oral environment have contaminated the root
canal. Ref. 3.
|Management of these "failed" cases is a challenge to the
clinician, at the levels of diagnosis, case selection, communica-
tion and decision, and that is even before techniques are consid-
ered. Ref. 4.
surgery is a compromise unless the microorganisms are
assumed to be harbored periapically, retreatment is unfeasible or
restricted, or a retreatment attempt has failedretreatment
offers a greater benefit-a better ability to eliminate root canal
infection with minimal invasionsmaller risk, significantly less
post operative discomfort and a lesser chance of injuring nerves,
sinuses or other structuresCase selection is based on consider-
ations that either preclude retreatment or restrict its feasibility in
a way that decreases the potential benefits and increases the
potential risks Ref 5.
Endodontic surgery (ES) and orthograde retreatment (OR) are
very different treatment modalities. Each has its own technical
difficulty, risk factors, degree of invasiveness, prognosis, expected
outcome for the patient and each requires a different and
unique set of equipment and skills. This said, the needed clinical
examination and decision making required for ES or OR are very
similar irrespective of the final treatment rendered. Such universal
treatment planning considerations should include, at a minimum:
1) All of the various indications and contraindications for either
treatment should be mentally taken into account given the clin-
ical situation at hand.
2) The medical and dental history of the patient and the pres-
ence of coronal leakage and/or the quality of the existing coro-
nal seal.*
3) Root length
4) Periodontal status including bone height, tissue contours and
health, probings, etc
5) The bone anatomy including the external oblique ridge, sinus
and root proximity.
6) Post presence and type.
7) Presence of a paste root canal filling and/or warm gutta per-
cha carrier based device.
8) The tooth's strategic value, restorability, and expected func-
tionality after treatment.
9) Proximity of vital structures (nerve bundles, arteries, etc).
Endodontic Surgery Versus Retreatment:
Assessing Options in Treatment Planning Decisions
Richard E. Mounce, DDS
Lineker@comcast.net
Vancouver, WA, USA
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10) Previous endodontic and surgical history of the tooth.
*As a full time endodontist, it is commonplace to observe overt
coronal leakage under crowns. Empirically, in my practice,
99.9% of the restorations accessed for endodontic treatment
show such leakage in the form of unset restoratives, purulence,
caries, voids, and moisture. Interestingly, these findings are ubiq-
uitous in teeth that appear to have acceptable restorations both
clinically and radiographically. In addition, these findings are
common where the patient is asymptomatic.
ES includes a number of procedures in addition to root resection
and root end filling, these include:
1) biopsy
2) root amputation
3) hemisection
4) perforation repair
5) trephination
6) apical curettage almost always coincident with a biopsy
7) intentional replantation
8) attainment of surgical drainage
It is noteworthy that several of these procedures may be carried
out at the same time on the same tooth depending on the clin-
ical indication.
The indications for ES (in the presence of a periapical lesion
and/or symptoms which have developed subsequent to root
canal treatment or retreatment) include:
1) apical blockage
2) iatrogenic apical events including severe transportation, per-
foration, canal zipping
3) non negotiable calcified canals
4) severe extrusion of filling materials
5) establishment of drainage through trephination
6) patient convenience
7) saving costly restorations where previous root canal therapy
has failed but has already been retreated. In such cases, the cli-
nician must be sure that the coronal seal is intact. In essence, dis-
assembly is unwarranted.
8) Retreatment is not possible, for example, the previous filling
materials cannot be removed despite the best attempt of the cli-
nician. Such materials might include unremovable silver points,
pastes, and warm carrier based devices.
9) Irretrievable posts or posts whose removal would risk iatro-
genic outcomes
10) Iatrogenic outcomes such as separated files or metallic
objects which despite all efforts resist removal and whose
removal is predictable and indicated by root resection and root
end filling procedures.
11) Anatomy that cannot be addressed by typical means of
cleaning, shaping and obturation. For example, a blunderbuss
canal, depending on the clinical indication might be better treat-
ed by orthograde treatment and surgical means to provide a pre-
dictable apical seal.
12) Resorptive defects that cannot be managed through
orthograde endodontic therapy.
13) Biopsy
14) Exploratory surgery that is carried out for diagnostic reasons
or teeth that remain symptomatic despite what appears to be
adequate treatment
15) Clinical cases where teeth have had endodontic therapy
and/or retreatment and either symptoms or evidence of long
term radiographic healing are not evident.
Contraindications to ES include the following:
1) Medical conditions including significant disease states such
uncontrolled diabetes, heart disease, clotting abnormalities,
amongst others.
2) Individuals who are poor behavioral candidates for surgery.
Such patients might be considered for ES with IV sedation or
other sedative means.
3) Surgical inexperience on the part of the clinician
4) Lack of equipment and needed materials to carry out the sur-
gery out to the highest level of care.
5) Teeth that can be retreated predictably should be retreated.
ES should never be used as a cover for poor quality orthograde
first time endodontic therapy.
Common contraindications to both Endodontic
Surgery and Orthograde Retreatment
Treating teeth with either modality that are unrestorable should
be avoided at all costs. It is noteworthy that the clinical dogma
and beliefs of what constitutes restorability is highly variable
amongst different clinicians. In any event, the clinician should be
absolutely certain that the proposed treatment will give the
patient the best possible chance to retain the tooth after either
ES or OR. It is incumbent on the clinician to determine if the
anticipated procedure will leave the tooth with the needed
crown/root ratio and resistance to vertical fracture to function in
the intended manner after the treatment. Such an approach can
go far to prevent vertical fracture as well as subsequent loss of
function. If the comprehensive picture of the long-term clinical
case is considered, it may be better, in the particular situation to
remove the tooth and place an implant.
Indications for OR include teeth that:
1) Show evidence of coronal microleakage.
2) Show evidence of a lesion of endodontic origin where one
was not previously evident.
3) Show evidence of a lesion of endodontic origin that has not
resolved after a period in which it predictably should have (12-
48 months).
4) Are symptomatic to one degree or another or have symptoms
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that are growing more acute in nature after a suitable period of
observation. In addition, a tooth that has developed symptoms
where symptoms were not initially evident before is a strong sign
that treatment is failing and retreatment should be considered.
5) Show evidence of a chronic sinus stoma where one was not
evident before.
6) Show evidence of swelling where it was not evident before.
7) If there is any evidence of coronal leakage with bacterial con-
tamination of the obturation and the tooth is treatment planned
for a new coronal restoration, especially if the new restoration
will be a bridge or a tooth of high strategic value.
8) Clinical cases where, even if the tooth is asymptotic and does
not show evidence of failure, the long-term success of the case
is not predictable based on the evidence. These factors include
singularly or in combination the following: missed canals, calcified
or otherwise, ledges which can be bypassed, separated files and
metal objects which can be removed of all types, and perforations
which can be repaired with OR procedures.
Endodontic healing, like success and failure, is not always clear-cut.
For example, a tooth may appear to be well sealed, asymptomatic,
radiographically within normal limits and yet be filled far short of
the apex. In such clinical cases, it is advisable to watch and
observe such teeth for evidence of continued long term healing.
Another interesting diagnostic dilemma is the tooth that initially
has a lesion of endodontic origin and which resolves to some
degree but which does not resolve entirely despite what should
be an adequate period of time for its healing. It is a matter of clinical
opinion what is the optimal treatment in such cases.
The indications and contraindications for endodontic surgery
and orthograde retreatment have been reviewed. Emphasis has
been placed on a comprehensive analysis of the clinical case
prior to starting either OR or ES. The skill of the clinician blended
with performing treatment where indicated on restorable teeth is
predictive of long-term clinical success. I welcome your feedback.
Figure 1-2A-B: Cases that were retreated using the Twisted File*
and RealSeal* bonded obturation material. Treatment strategies
in all cases were designed to disassemble the previous treat-
ment, remove the gutta percha, achieve patency and create a
coronal and apical seal.
*SybronEndo, Orange, CA, USA
Dr. Mounce lectures globally and is widely published. He is in
private practice in Endodontics in Vancouver, WA, USA.
REFERENCES
1: Practical Lessons in Endodontic Surgery, Quintessence Books, 1998, p. 3.
2: A Clinical guide to Endodontics, BDJ Books, 2003, p. 83.
3: Color Atlas of Endodontics, WB Saunders Company, 2002, p. 117
4: Aust Endod J. 2000 Dec; 26(3): 104-9. Friedman S.
5: Shimon Friedman, Chapter 20, p. 346-347, Orthograde Retreatment Principles
and Practice of Endodontics, 3rd ed. 2002
Fig. 1A Fig. 1B
Fig. 2A Fig. 2B
Theres one thing
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Only Colgate Total
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antibacterial protection and fight gingival inflammation.
Provides 12-hour antibacterial action
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3,4
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5
In 44 controlled clinical studies in more than
100 publications including 58 scientific posters
and 56 scientific articles
1
No other toothpaste can provide the antibacterial and anti-inflammatory protection of Colgate Total
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-10
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Plaque
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-60
-70
-80
-90
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Gingivitis
0.0
0.4
0.8
1.2
1.0
0.6
0.2
1.6
1.4
Control
Baseline 6 Months 12 Months 24 Months
Colgate Total
G
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Reduction in severity index vs. ordinary toothpaste.

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2
Amornchat C, et al. Mahidol Dental Journal. 2004;24:10311.
3
Volpe AR, et al. J Clin Dent. 1996;7(suppl):S1S14.
4
Davies R, et al. J Clin Periodontol. 2004;31:10291033.
5
Kerdvongbundit V, et al. J Clin Periodontol. 2003;30:10241030.
2007 Colgate-Palmolive Company. All rights reserved.
12-hour Antibacterial Protection Plus Fights Gingival Inflammation.
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TEBODONT:
Successful against oral microorganisms
Dr. Knig, how did you discover Tea Tree Oil?
We received samples of TEBODONT Gel two years ago.
Clinically, I noticed quickly that it is less irritating than
Chlorhexidin. In addition, and very important for us: it does not
produce any discolorations.
This plays an important role to our patients who notice even
smallest discolorations on their bleached teeth. Another advan-
tage of Tea Tree Oil: it acts successfully against Candida albicans.
Nowadays, I don't use Chlorhexidin anymore.
When do you use Tea Tree Oil products?
Always after surgical interventions. And always after implanta-
tions: the parts to be screwed on the implants are soaked in Tea
Tree Oil before. We also use it in case of troubles after the treat-
ment - in Candidiasis. Our Dental Hygienist gives it in cases of
periodontitis. And, since a few patients told us that they could
significantly reduce their aphtae problem with the Tea Trea Oil
toothpaste, we also recommend it for this indication.
Tea Tree Oil has become an universal remedy in our Clinic. The
Gel is primarily used during the treatment and postsurgical, the
other products are given to the patients for home care.
How do your patients react on Tea Tree Oil?
There are patients who do not like the taste of Tea Tree Oil.
Others, like myself, appreciate the refreshing taste. The positive
feedback we get from the patients:
In contrast to Chlorhexidin, Tea Tree Oil does neither discolour
the teeth, nor change the sense of taste.
Tea Tree Oil is an universal remedy in our Clinic.
Dr. med. dent. Arno Knig, Head of the Medical Dental Clinic
Bethanien, Zurich/Switzerland
The essential oil of the australian tea tree (Melaleuca Alternifolia) is more
and more used in oral hygiene with a remarkable success. In the Medical
Dental Clinic of Bethanien (Professor Sailer) in Zurich / Switzerland it has
become an universal remedy within a short lapse of time.
I don't use Chlorhexidin anymore said the Head of the Clinic, Dr. Arno
Knig, who uses above all the Gel and the Mouthrinse out of the different
Tea Tree Oil products (TEBODONT).
Tea Tree Oil is an universal
remedy in our Clinic
ADVERTORIAL
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Diamond instruments for veneer
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IMPLANT CONTINUUM 2010
THE LEBANESE UNIVERSITY IS ORGANIZING
THE 2
nd
COURSE IN IMPLANT DENTISTRY
LUSD-School of dentistry- Lebanese
University-Choueifat.
15 days - 3 days per month- 120
Credit Hours .
Faculty Members of the Postgraduate
Periodontology,
Oral Surgery, Radiology and
Prosthodontics Departments.
Delivered by the Lebanese University.
The overall educational goals of this
program are:
1) To acquaint the participant with
the biologic scientific and clinical
bases for dental implant therapy
2) To develop an understanding of
diagnosis, treatment planning, main-
tenance procedures and complica-
tions in implant dentistry.
3) To acquaint the participant with
clinical; surgical and prosthetic proce-
dures through hands-on sessions,
live surgery and case treatment.
Participants bring their own cases for
review, treatment planning, and dis-
cussion and will have the opportunity
to treat their patients.
Tel: 00961 1 694888
Fax: 00961 1 694222
Email: sales@3i-mena.com
andree.chidiac@tamerholding.com
Location:
Certificate:
Course Description:
For more information:
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Inauguration de lEspace Fawzi Tamer de soins
dentaires et de vido transmission la Facult de
Mdecine Dentaire de l'Universit Saint-Joseph
Cest lors d'une crmonie spciale et conviviale qua eu lieu linauguration de lEspace Fawzi Tamer de soins dentaires et de vido
transmission la Facult de Mdecine Dentaire de l'Universit Saint-Joseph.
Il sagit dun espace quip dune technologie de pointe et de cameras haute performance par la Fondation Fawzi Tamer, une
salle de chirurgie bucco-dentaire spcialement conue pour la diffusion directe et instantane des oprations vers les salles den-
seignement et les salles de confrence de l'universit.Par cette contribution, la Fondation Fawzi Tamer, a voulu rendre hommage
aux 90 ans d'change entre lUSJ et la Droguerie Tamer, premier fournisseur depuis 1920 dquipements et de produits dentaires
de lUniversit Saint Joseph.
LInauguration a eu lieu en prsence du Professeur Ren Chamussy, recteur de luniversit, du professeur Antoine Hokayem, Vice
recteur aux relations internationales, du professeur Khalil Karam, vice recteur au dveloppement, de Madame le Doyen professeur
Nada Naaman entoure du conseil dadministration de la Facult de mdecine dentaire et du corps professoral. Parmi lassistance
des personnalits mdicales et conomiques comme les Prsidents Roger Nasnas, Camille Menassa et Selim Zeeni. M. Nicolas Nahas,
Matre Choucri El Khoury et Matre Alexandre Sakr, M. Raffy Boutros et la famille Tamer dont Gaby Tamer, prsident de la Fondation,
et PDG de la Socit Droguerie Tamer sal- Membre de G. Tamer Holding, Mimi Tamer, vice prsidente de la Fondation Fawzi Tamer,
Maya, Raya, Youmna, Fawzi et Elias Tamer. Dans son allocution Gaby Tamer a remerci le Professeur Chamussy et les professeurs
Hokayem et Naaman pour leurs inestimables apports la facult et luniversit et leur dcerna pour cette occasion au nom de la
Fondation des plaques commmoratives.
Finalement, tous les invits ont bu un toast la sant des relations distingues entre lUSJ et la Fondation Fawzi Tamer, relations que
la famille Gaby Tamer a promis de perptuer.
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Commemorial picture of the Heads of Departments at the Saint Joseph University Dental School
From left to right: Pr. Antoine Hokayem, Pr. Ren Chamussy, Mr. Gaby Tamer, Pr. Nada Naaman and Mrs. Mimi Tamer
From left to right: Mr. Camille Menassa, Mr Roger Nasnas, Mrs. Mimi Tamer, Pr. Ren Chamussy, Pr. Nada Naaman, Mr. Gaby Tamer, Mr Salim Zeeni
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The XI
th
International Meeting
& 25
th
Anniversary
School of Dentistry - Lebanese University
June 19 - 21, 2009
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The XI
th
& 25
th
Anniversary
June 19 - 21, 2009
Pr. Elia Sfeir President of the organizing committee Dr. Antoine Berberi, Chairperson Scientific committee
Dr. Bassel Doughan Chairperson Audio Visual committee Classical music performance for the opening ceremony
Picture from the opening ceremony that took place at the main auditorium of the Rafic Hariri campus
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The XI
th
& 25
th
Anniversary
June 19 - 21, 2009
Dr. Fadia Bou Dagher Pr. Mounir Doumit
Pr. Nabil Barakat Dr. Khaldoun Rifai
Sister Adrienne Aoun Dr. Jean-Marie Megharbaneh
Pr. Ibrahim Nasseh Dr. Ghassan Oueni
DR. ZOUHAIR CHOUCR PRESIDENT OF THE LU DISTRIBUTING TROPHIES TO
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The XI
th
& 25
th
Anniversary
June 19 - 21, 2009
Recipients of the trophies posing for a commemorial picture
Faculty of the LU Dental School. Left to right: Elia Sfeir, Ibrahim Nasseh, Georges Tehini, Edmond Koyess, Hani Hasbini, Antoine Berberi,
Elie Maalouf, Jean-Claude Fahed and Antoine Cassia
Millennium: the safest, complete and most rapid
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The XI
th
& 25
th
Anniversary
June 19 - 21, 2009
Picture of the deans of Arab Dental Schools
Chairpersons of the session
Picture from the audience
Mr. Luca Graziani from Italy lecturing on sterilization
STERILIZATION
LECTURE
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The XI
th
& 25
th
Anniversary
June 19 - 21, 2009
EXHIBITION FLOOR
In the frame of Straumann continuous education in the Middle East
region, several events were organized in the first half of 2009.
The first event took place after the AEEDC congress in Dubai on
March 13th and 14th at the University of Sharjah. This was the first
ITI Esthetic Master course in the Middle East conducted by Prof. Dean
Morton from Louisville University and Assistant Professor William
Martin from Florida University.
The course covered the state of the art techniques in the treatment
of high end esthetic implant situations.
Besides receiving high level theoretical tuition based on the ITI con-
sensus and treatment planning approach through beautifully docu-
mented clinical guidelines and cases from Dr. Martin's and Dr.
Morton's remarkable experience, the 30 participants had the oppor-
tunity to exercise these often advanced techniques during clinically
based practical sessions.
Procedures such as making provisional restorations for optimal soft
tissue forming, esthetic surgical templates and customizing impres-
sion transfers for post mucosa forming impression taking were per-
formed.
Due to the success that this course obtained, these two remarkable
speakers will be returning next year to conduct another ITI Esthetic
Master course.
For the second event we were proud to receive one of the world's
most notorious experts in the field of oral surgery and implant den-
tistry, Prof. Daniel Buser, Chairman of the Department of Oral
Surgery at the University of Bern, Switzerland.
Prof Buser was an invited speaker to Saudi Arabia's National
Congress organized by the Saudi Dental Society and the Saudi
National Guard, where he conducted a 1 day lecture about the
importance of Guided Bone Regeneration surgical techniques in deal-
ing with highly demanding esthetic implant cases in compromised
Straumann continuous education
in the Middle East
hard and soft tissue sites.
The participants were exposed to proven methods and techniques on
how to achieve best results from his long clinical and research expe-
rience.
Professor Buser then continued to Abu Dhabi in the UAE where he
lectured to 150 dental clinicians on the same topic. This event was
organized in collaboration with the Health Authorities from Abu
Dhabi in their premises.
This was Professor Buser's first visit to the Middle East. He was
impressed and expressed the wish to return, therefore, next year a 2
day course with Professor Buser and Professor Belser from Geneva
University is already been discussed and should take place in Dubai in
the First half of 2010.
Professor Buser's visit to the region also coincides with the develop-
ment of the ITI foundation in the region as the Middle East ITI section
is in the process of being created and soon will be able to provide the
highest level of continues education through activities such as study
clubs and mentoring programs for the local ITI members.
With all these events, Straumann and the ITI foundation continue to
assure their commitment to the development of training and educa-
tion for the advancement of excellence in implant dentistry in the
Middle East.
For more information on the upcoming courses in the Middle East
region please contact:
David Dias
Head of Regional Education - Middle East
David.dias@straumann.com
We ihvite you to behet from the T's rehowhed ih-depth expertise ahd experi-
ehce by takihg advahtage of the comprehehsive educatioh offer presehted here.
h keepihg with the T philosophy, this course illustrates the cohcepts of proper
diaghosis, case selectioh, treatmeht plahhihg ahd cohduct of treatmeht ih the
eld of implaht dehtistry.
This course addresses the geheral practitioher as well as the specialist clihiciah.
A cohcept of comprehehsive treatmeht plahhihg as well as case presehtatiohs
will be presehted durihg this course. Peer-to-peer discussiohs, practical exercises
ahd live surgeries will help to acquire ih-depth khowledge ih implaht dehtistry's
clihical applicatioh, usihg the Straumahh
Dehtal mplaht System.

A licehsed certicatioh from the UAE Mihistry of Health will be awarded upoh
passihg the hal examihatioh.
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Professor U. Brgger
Assistaht Professor C. Salvi
Departmeht of Periodohtology ahd
Prosthodohtics, Uhiversity of Berh
Switzerlahd
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BdYjaZ&/ Jahuary 17 - 19, 2010
BdYjaZ'/ May 1 - 3, 2010
BdYjaZ(/ Dctober 31 - November 2, 2010
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:VgangZ\^higVi^dcjci^aCdkZbWZg&*!'%%.
CHF 3S00.-
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CHF 3700.-
80 CE credit hours awarded by Abu Dhabi's Health Authority
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Mihistry of Health
Uhited Arab Emirates
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Dr. Khaled Ayyoub: Phohe +971S06284429
Dr. Mohammad Hussaih: Phohe +971S07211878
Mrs Deborah Michiehzi : Phohe +49172797S38S
email: deborah.michiehzistraumahh.com
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Dr. B. El Dakr - Abu Dhabi, UAE
Dr. N. Saab- Abu Dhabi, UAE
The CLCC 2010
Comprehensive Licence CHUWLFDWLRQ
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Franais
ONE, you shoot
TWO, you scan
No more over-exposed X-ray images thanks to
Safer for the patient
An outstanding image quality
Two sensor sizes to improve patient comfort
So easy to use
So easy, so safe
PSP!X is designed to make intra-oral imaging
in the dental office easier and more efficient:
Reusable imaging plates
Readout process of 4.3 to 7.5 seconds
Consistent image quality
Smart and compact
Time to see what was once invisible!
With SOPROLIFE, diagnose occlusal or interproximal caries...
differentiate with outstanding accuracy healthy tissue from
infected tissue, so as to excavate only the decayed area.
Time has come for SOPROLIFE!
www.soprolife.com
Discover the blue revolution
Numan Center 1st Floor No 111 Gardens Str. PO Box 468 11953 Amman JORDAN Tel +962 6 553 4401 Fax +962 6 553 7833 E-mail: info@me.acteongroup.com www.acteongroup.com
We to create
A sign of quality and
durability
PRODUCT NEWS
7
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For the highest standards in aesthetic dentistry, Amaris Gingiva is the only
restorative that permits chair side gingival shade matching. This new gin-
giva-shaded, composite-based restoration system facilitates individual
shade-matching using a combination of a base shade (nature) with three
mixable opaque shades in white, light and dark. The result is a represen-
tation of the gingiva that appears natural. Through this principle, behind
which the proven Amaris-know how stands, extensively exposed cervical
areas caused by gingival recession and wedge-shaped defects in the cer-
vical area can be controlled in the future, both functionally and aestheti-
cally. With Amaris Gingiva, the high standard placed on the capacity of
modern composites no longer has to end at the cervical boundary. This
new material permits the reconstruction of the "red-white" boundary
with a predictable result.
Suitable for multiple indications
Amaris Gingiva is also suitable for other indications. Reconstruction with
gingiva-shaded composite thus represents an important extension of ther-
apeutic measures after muco-gingival surgery. In addition, the so-called
'black holes" induced by the loss of interdental papillae as a consequence
of periodontitis or gingival recession can be quickly and easily treated with
Amaris Gingiva to provide an aesthetic restoration. Amaris Gingiva can
also be used to significantly extend the lifespan of in situ crowns with vis-
ible and exposed edges caused by natural gingival shrinkage.
Outstanding material and handling properties
Amaris Gingiva is not only impressive with its material properties, but also
by its handling. It models extremely well and can be polished to high
gloss. And thanks to the new non-dripping, non-running NDT syringe
from VOCO, applying the material is just as economical as it is hygienic.
For more info: www.voco.com
Amaris Gingiva - Naturally, a beautiful smile
Highly aesthetic, light-curing restorative in gingiva shades
The innovative suspended chair of the E70 offers incomparable leg room
for the user. The newly developed operation logic with direct keys is intu-
itively designed so that the dentist and assistant can reliably access every
function. Integrated in the dentist unit, the brushless, sterilisable KL702
motor with an endodontic function renders additional endodontic instru-
ments superfluous and enhances the practice workflow.
In addition, the individual equipment and expansion options such as the
USB interfaces or the differentiated system of headrests and backrests
maximise investment security.
The automated, standardised and time-saving hygiene functions of the
E70 make intensive and permanent sterilisation, cleaning and disinfection
of the suction and drain system and suction hoses (Hydroclean) comfort-
able and efficient. The optionally available ERGOcom light multimedia sys-
tem allows you to easily incorporate practice components such as an
intraoral camera, microscope or x-ray and portray the required informa-
tion directly on the unit's monitor.
With the ESTETICA E70, the user experiences superior comfort and func-
tionality!
Email: info@kavo.com
World premiere at the IDS 2009
KaVo ESTETICA E70:
Simply comfortable! Comfortably simple!
What is ACP?
Chemical Makeup
ACP is an abbreviation for Amorphous Calcium
Phosphate. ACP is created when dissolved calci-
um ions and phosphate ions react to form a
non-crystalline insoluble salt. Due to the reactive
nature of the chemicals involved, the calcium
and phosphate must be stored separately until
they are applied to the tooth surface.
Patented Technology
Discus Dental, LLC. has licensed patented tech-
nology from the ADA Foundation allowing Discus
Dental to incorporate ACP technology in profes-
sionally dispensed whitening gels.
How ACP Works
Tooth demineralization from acid results in
dulling, loss of tooth luster, and a higher suscep-
tibility to caries. The oral environment can natu-
rally rebuild enamel, through a process called
remineralization, to some extent on its own, but
the extent of remineralization is controlled by
pH and the amount and availability of calcium
and phosphate ions present in the mouth.
Remineralization can easily be reversed in an
under-saturated environment.
The natural rebuilding of enamel is a slow kinetic
reaction which can be rapidly sped up by the
addition of ACP-forming components into the
oral environment. Amorphous Calcium
Phosphate (ACP) is the reacted complex of calci-
um and phosphate ions that precipitate and can
grow on tooth surfaces in the oral environment.
These initial ACP complexes are thermodynamically
unstable under the conditions normally prevalent in
the oral environment; pH, temperature, etc.
Over time, these unstable compounds will
undergo further reactions as well as phase
transformation into other more stable forms of
calcium phosphate. The precise path of the complex
transformation is not fully understood, but the
final form has been shown to be hydroxyapatite,
a large constituent of the normal, mineralized
structure of healthy teeth. In practice, introduc-
ing ACP onto a tooth surface will lead to rapid
deposition of a new coating of hydroxyapatite
over the original tooth surface.
1,2
At normal oral pH and temperature, the addi-
tion of ACP-components to the salivary system
can cause the hydrolysis of ACP into apatite
within a few minutes, which is roughly 20,000
times faster than normal, physiologic formation
of apatite.
3
Besides adding to the external resistance of the
teeth by building a barrier of acid resistant
hydroxyapatite, ACP also biases the remineral-
ization-demineralization equilibrium by releas-
ing essential ions that favor remineralization by
increasing the degree of saturation with respect
to hydroxyapatite. Furthermore, calcium and
phosphates can bind with other ions such as flu-
oride, and other proteins in saliva, to form com-
plexes that can be stored in plaque and saliva,
ready to release calcium, fluoride, and phos-
phate ions in response to acid challenges.
4
coat-
ing of hydroxyapatite. Hydroxyapatite rebuilds
enamel and fills surface defects.
ACP Benefits
Rebuilds Enamel
The deposition of hydroxyapatite onto teeth
rebuilds enamel and restores luster through a
process called remineralization. Preliminary
research by Flaitz & Hicks at the University of
Texas, Houston, showed that, The addition of
calcium phosphate to whitening agents reduces
the susceptibility of enamel to
in-vitro lesion initiation and progression.
5
Effective Desensitizer
ACP mimics the natural desensitizing process by
eliminating the source of sensitivity by plugging
dentinal tubules with calcium phosphate, the
tooth mineral. This is similar to the process of
sclerosis, where salivary mineral precipitates
slowly over time in these tubules and reduces
sensitivity. ACP simply speeds this process con-
siderably with the same mineral at much higher
concentrations.
ACP has been clinically shown to dramatically
reduce dentinal hypersensitivity by occluding
dentinal tubules.
6
Discus Dental whitening gels,
such as Nite White ACP, are the only profession-
al take-home whiteners to combine patented
ACP technology with the proven effectiveness
of Potassium Nitrate to establish a new standard
for patient comfort in professional take-home
whitening.
7
Improved Appearance - Restores Enamel Luster
ACP has been clinically shown to improve the
smoothness and luster of teeth8 by filling super-
ficial tooth defects and improving the overall
smoothness and luster of patients' smiles.
3
Lasting Results
In clinical studies, patients who used a take-
home dental tooth whitener containing ACP
experienced less fadeback six months after
treatment compared to patients who used an
identical take-home whitener without ACP.
9
ACP is a revolutionary chemistry that
goes beyond traditional restorative
materials by using the body's own
building blocks to desensitize the den-
tition through remineralization.
Alan Boghosian, D.D.S.,
Assistant Professor of Clinical Surgery,
Department of Surgery, Division of Dental
Surgery, Northwestern University Feinberg
School of Medicine
References
1 Tung, M.S., Eichmiller, F.C. Amorphous Calcium
Phosphate for tooth mineralization. Compend
Contin Educ Dent, Vol 25, No 9 Suppl 1, Sep
2004, pp 9-13. Journal Code 9600713, Journal
Subset MEDJSD, ISSN 1548-8578. Corporate
Author: American Dental Association Foundation.
2 M. Markovic, B.O. Fowler And M.S. Tung.
Preparation and Comprehensive Characterization
of a Calcium Hydroxyapatite Reference Material.
Journal of Research of the National Institute of
Standards and Technology, Volume 109, Number
6, November-December 2004.
3 Tung, M.S., Eichmiller, F.C. Amorphous Calcium
Phosphate for tooth mineralization. Compend
Contin Educ Dent, Vol 25, No 9 Suppl 1, Sep
2004, pp 9-13. Journal Code 9600713, Journal
Subset MEDJSD, ISSN 1548-8578. Corporate
Author: American Dental Association Foundation.
4 Grant LP, Thompson A, Tanzer JM. Caries
inhibition in rats by a remineralizing toothpaste.
Journal of Clinical Dentistry. 1999;10(1 spec
no):30-33.
5 Flaitz C, Hicks J. Whitening Agent Effects on
Enamel Caries Formation and Progression. IADR
Unpublished Abstract #73739.
6 M. Cherng, S. Takagi And L.C. Chow. Reduction
in Dentin Permeability Using a Calcium Phosphate
Slurry. Journal of Dental Research 83 (Special
Issue A); IADR CD-ROM Abstract No. 0119, 2004.
7 Giniger, MacDonald, Ziemba, Felix. The Clinical
Performance of Professionally Dispensed Bleaching
Gel with Added Amorphous Calcium Phosphate.
Jada Vol. 136, March 2005.
8 Giniger M, Spaid M, Felix M, MacDonald J,
Ziemba S. Tooth Surface Enhancement by a 16%
Carbamide Peroxide Take-Home Bleaching Gel
Containing ACP. Journal of Dental Research.
84(Spec Issue A): 1793,2005.
.
9 Giniger M, Spaid M, Felix H, MacDonald J. A
180-Day Clinical Investigation of the Tooth
Whitening Efficacy of a Bleaching Gel with Added
Amorphous Calcium Phosphate. Journal of
Clinical Dentistry, Volume XVI, No. 1, 2005.
2009 Discus Dental, LLC. All rights reserved.
Visit: www.discusdental.com
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PRODUCT NEWS
New, individually configurable diode laser facilitates an intuitive mode of
working.
Sirona's new SIROLaser Advance combines state-of-the-art laser technol-
ogy with outstanding user-friendliness. The color touchscreen, clearly
structured menus and self-explanatory symbols provide the ideal basis for
easy operation.
The SIROLaser caters for a broad spectrum of applications. The preset
programs ensure quick and effective therapy in the area of periodontics,
endodontics, surgery, and pain relief. If required the dentist can view
additional information about each individual preset in a help menu.
The dentist is free to adapt the SIROLaser Advance to his or her individ-
ual mode of working. Up to 24 different applications can be pro-
grammed; twelve favorites are available at the touch of a button. In his
role as system administrator the dentist can also configure profiles for five
additional users, each protected by its own PIN code. In addition, the
SIROLaser Advance anonymously stores the parameter data relating to
each treatment session. For patient documentation purposes this data can
be easily transferred to a PC with the aid of a USB flash drive.
The SIROLaser Advance is operated via the light-touch finger switch (inte-
grated directly into the handpiece) or via the optional foot control.
For more info: www.sirona.com
SIROLaser Advance sets new standards
of user-friendliness and flexibility
Starting today, dentists can count on an innovative new impression
material: Hydrorise, the first hyperhydrophilic A-silicone that adapts to
any kind of impression technique in all clinical conditions.
Hyperhydrophilic technology has been exclusively developed by
Zhermack research, making hydrorise extremely flowable.
With a contact angle less than 10 and thanks to the effects of the
AMDA System (Advanced Moisture Displacement Action), Hydrorise is
able to remove fluids from the gingival sulcus and reproduce impression
margins with maximum precision, like no other material on the market.
The attention paid by researchers in the Zhermack impression materials
development phase is focused on the company's aim to create clinically rel-
evant products. An impression material must guarantee extremely accu-
rate and reliable results, even in particularly difficult clinical situations.
The perfect synergy between physical and mechanical properties found
in Hydrorise ensures clinical success at each use.
Zhermack offers the chance to pair the new conditioner range
Hydrosystem to optimise preparation surfaces, creating ideal conditions
for use of the Hydrorise.
Hydrorise is available in different viscosities: putty - heavy body - regular
body - light body - extra light body - monophase, each of which comes
both in normal set or fast set.
for more info: www.zhermack.com
Hydrorise, the innovation that did not exist
PRODUCT NEWS
7
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The technical and hygienic advantages of the TwinPower Turbine by J.
Morita have recently been confirmed by the independent American test-
ing institute Reality. They gave the turbine the highest number of
points and awarded it the Five Star Award for 2008. The TwinPower
Turbine was able to score points on its compact design and its light-
weight, 50 gram handpiece. The turbine has such sophisticated
ergonomics that it mitigates the strain experienced after several hours
of intensive work. There are three different head sizes available depend-
ing on the application so that even regions which are difficult to access
can be easily reached with the smallest size.
The main reason the Turbine is attractive, says Morita, is its world-wide
unique double-impeller system which is driven by three drive nozzles
and the generated exhaust air. The result is a continuous, low-vibration
and as much as 50 % greater torque, which practitioners experience as
very pleasant. The frequent sterilisation processes, says the manufactur-
er, in no way limit the Turbine's usability. Moreover, both - practitioners
and patients - alike benefit from this new technology. The zero suck-
back technology was developed especially by Morita to reduce the like-
lihood of patient infections.
Morita says that the zero suck-
back system of the TwinPower
Turbine family enables it to satisfy
the hygienic requirements and
provide the necessary assurance
that current hygiene regulations
are met.
For further information from:
J. Morita Europe GmbH
Justus-von-Liebig-Strae 27a
63128 Dietzenbach - Germany
Phone: +49 (60 74) 8 36-0
Fax: +49 (60 74) 8 36-299
info@jmoritaeurope.com
www.jmoritaeurope.com
The TwinPower Turbine by J. Morita:
Test the Best

InLine
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InLine I
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Conventional Metal-Ceramic InLine PoM I
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Press-on-Metal Ceramic
www.ivoclarvivadent.com
Ivoclar Vivadent AG Technical
Bendererstr. 2 | FL 9494 Schaan | Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60
IPS InLine PoM the new press-on-metal technology
based on the proven press technique, popular alloys
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IPS InLine the leucite metal-ceramic featuring
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Make it InLine!

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I

The nano-optimized composite system

proved to have superior flow.*Isnt it time

, contact your dental supply

superior flow for incredible impressions, every time.

Utilizing the best characteristics of two well-known

with triclosan is proven to provide

Reduction in severity index vs. ordinary toothpaste.

is lhe lirsl non-healed lree-llow gulla-percha lhal does nol shrink

FEEL THE COMFORT

Dehtal mplaht System.

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