Volume 7 Issue 4

Smile Dental Journal - December 2012 - Volume 7, Issue 4 - www.smiledentaljournal.
com - Distributed free of charge
Dental Journal
Eruption of Oral Lichen
Planus After InterferonTherapy for Hepatitis C Infection
Longevity
for Dental Career
Yoga
Cleft Lip
and Palate: The Multidisciplinary Management
Disinfection Methods on Surface Roughness and Hardness of Type III Dental Stone
ISSN: 2072-473X
The Effect of Two
AEEDC
BOOTH No. 370
Editorial Review Board

Endodontics
Dr. Ali Abu Nemeh BDS, NDB, MSc Dr. Muna Al-Ali BDS (Uni Jordan), MFDS (RCSI), DClinDent (Melbourne) Endodontics Dr. Hani Al Kadi BDS, Dip ODONT, MDS Dr. Muayad Assaf BDS, MSc
International Advisory Board

Prof. Rafi Aljobory / Iraq BDS, MSc, PhD Periodontics, President of the Iraqi Dental Association Prof. Abdullah Al-Shammery / KSA BDS, MS Restorative Dentistry / Rector, Riyadh Colleges of Dentistry & Pharmacy Prof. Magid Amin Ahmed / Egypt Oral & Maxillo-Facial Surgery / Vice President MSA University Dean, Faculty of Dentistry MSA University Prof. Jamal Aqrabawi / Jordan DDS, DSc, DMD Endodontics / Dental Faculty, University of Jordan Prof. Nabil Barakat / Lebanon DDS, MSc, FICD Maxillo-Facial Surgery / President of LAO & EMAO Prof. Stephen Cohen / USA MA, DDS, FICD, FACD, Diplomate, American Board of Endodontics Prof. Azmi Darwazeh / Jordan BDS, MSc, PhD Oral Pathology Oral Medicine / Former Dean, Faculty of Dentistry JUST / Examiner, Faculty of Dentistry RCS Ireland Prof. Mohamed Sherine Elattar / Egypt BDS, MSc, PhD Prosthodontics / Former Dean, Faculty of Dentistry, Pharos University / President of AOIA Prof. Fouad Kadim / Jordan BDS, MSc, PhD Conservative Dentistry / Vice Dean, Faculty of Dentistry, University of Jordan Prof. Howard Lieb / USA DMD General Dentistry & Management Sciences / College of Dentistry, New York University Prof. Edward Lynch / UK PhD (Lon), MA, BDentSc, TCD, FDSRCS (Ed), FADFE, FDSRCS (Lon) Head of Dental Education and Research Warwick University Prof. Lamis D. Rajab / Jordan DDS, PhD, Pediatric Dentistry / Former Dean, Faculty of Dentistry, University of Jordan Prof. Issam Shaaban / Syria BDS, PhD, Maxillo-Facial Surgery / Former Dean, Faculty of Dentistry Damascus University / President of Syrian OMFS Society Prof. Yousef Talic / KSA BDS, MSc, DASO, FICOI, FICD, Consultant in Prosthodontics & Implantology, College of Dentistry, King Saud University Prof. Abbas Zaher / Egypt BDS, MS, PhD Orthodontics, Professor of Orthodontics / ViceDean, Alexandria University / Vice-President, World Federation of Orthodontists Prof. Carina Mehanna Zogheib / Lebanon DDS, PhD Restorative and Esthetic Dentistry, FICD Head of Restorative and Esthetic Dentistry Department, SaintJoseph University Dr. Nadim Abou-Jaoude / Lebanon CES, DU, FICD Prosthodontics, Lecturer, Lebanese University / Clinical Associate, American University of Beirut Dr. Hasanen H. Al-Khafagy / UAE BDS, MSc, PhD Conservative Dentistry, Ajman University of Science & Technology Dr. Jaser Al-Maitah / Jordan BDS, MSc Oral Surgery, Head of Dental Department, Jordanian Royal Medical Services Dr. Maher Almasri / UK DDS, MSc, PhD, FADFE, Director of Oral Surgery Courses, Bone Graft Modules Leader, Warwick University / President of the Syrian Section of IADR Dr. Abdelsalam Elaskary / Egypt BDS, FICOI, President of ASOI Dr. Yasin El-Husban / Jordan DDS, MSc Prosthodontics, Former Minister of Health Former Head of Dental Department & King Hussein Hospital Dr. Zbys Fedorowicz / Bahrain Director, The Bahrain Branch of the UK Cochrane Centre Dr. Wolfgang Richter / UK DDS, PhD, Restorative Dentistry, President of ESCD Dr. Mohammad Sartawi / Jordan / UK BSc, BDS, MSc, FFDRCSI (OSOM) Senior Consultant Maxillo-Facial Surgeon
Maxillofacial Surgery
Dr. Hazem Al-Ahmad BDS, MSc, FDSRCS Dr. Faaiz Yaqub Al-Hamadani BDS, MSc Dr. Raed Al-Jallad BDS, MSc, FFDRCS, FDSRCS Dr. Alan Al-Qassab BDS, HDD (Ortho), MSc, MOMS RCPS(Glasg) Dr. Hatem Al-Rashdan BDS, MSc Dr. Kamis Gaballah BDS, MSc, FDS RCS, PhD
Smile Dental Journal December 2012 Volume 7, Issue 4 Quarterly Issued Distributed Free of Charge
Jordan: +962 7 96367954 Lebanon: +961 70 32 32 75 sola@smiledentaljournal.com www.smiledentaljournal.com
Oral Medicine
Dr. Suhail H. Al-Amad D.Clin.Dent (Melb), FRACDSOral Med, GradDip ForOdont (Melb), JMC
Orthodontics Founder & Editor-in-Charge Dr. Issa S. Bader Director Dr. Mamoon A. Salhab Editorial Director Dr. Hassan A. Maghaireh Associate Editors Prof. Marco Esposito Dr. Wesam A. Aleid Assistant Editors Dr. Aveen K. Aljaff Dr. Mohammad A. Abu Khalifeh Dr. Mohanad M. Ali Al-Janabi Marketing Director Solange R. Sfeir Art & Design Yazid M. Masa Stephanie Moufarrej
Dr. Feras Abed Al Jawad DDS, NBDE, MSc, PhD Dr. Eyas Abu-Hijleh DDS, PhD Dr. Samer Sunna BDS, MSc, M.Orth, RCS
Paediatric Dentistry
Dr. Hani Abudiak BDS, MFDS RCSFRCD, PhD Dr. Majd Al-Saleh BDS, DDS, MSc Dr. Ghada Karien BDS, JDB Dr. Jumana Sabbarini BDS, MSc Dr. Leema Yaghmour BDS, DUA, DUB
Periodontics
Dr. Manal Azzeh BDS, MSc Dr. Edgard El Chaar DDS, MS Dr. Marwan Qasem DDS, PG
Prosthodontics
Dr. Layla Abu-Nabaa BDS, MFD, RCS, PhD Dr. Ahmad Kutkut DDS, MS Dr. Yousef Sadik Marafie BDS, MSD Dr. Thamer M. Theeb BDS, MSc
Published by MENA Co. for Dental Services Jordanian National Library Registration # 3954/2008/P ISSN 2072-473X Printed By: Ad-Dustour Commercial Printing Press Amman, Jordan
Restorative Dentistry
Prof. Louis Hardan DDS, DEA, PhD Dr. Maher M. Abdeljawad BDS, MDentSci Dr. Mohammad Al-Rababah BDS, MFD RCSIre, MRD(Pros), RCSEd, JB(Cons) PhD Dr. Hakam Mousa BDS, MSD
Mission Statement
Bridging the gap between advanced upto-date peer-reviewed dental literature and the dental practitioners enabling them to do their jobs better- is our ultimate target. Besides, Smile provides readers with information regarding the available dental products, armamentarium, news and proceedings of dental symposia, workshops and conferences.
Disclaimer
Smile Dental Journal makes every effort to report clinical information and manufacturers product news accurately, but cannot assume responsibility for the validity of product claims or typographical errors. Opinions or interpretations expressed by the authors are their own and do not necessarily reflect nor hold Smile team responsible for the validity of the content.
14
Maxillofacial Cleft Lip and Palate: The Multidisciplinary Management
08
Debate in Focus
By Emad Hussein, John Van Aalst, Alev Aksoy, Libby Wilson, Khaled Abughazaleh, Nezar Watted
46
24
Dental Materials The Effect of Two Disinfection Methods on Surface Roughness and Hardness of Type III Dental Stone
By Suha Fadhil Dulaimi
The Retention of Complete Crowns Prepared with Three Different Tapers and Luted with Four Different Cements
Research Summaries in Focus
30
Oral Medicine Eruption of Oral Lichen Planus After Interferon Therapy for Hepatitis C Infection: Case Report
By Wafa Al-Shamali, Mohamed El-Khalawany, Rasha Al-Shemmari, Saqer Al-Surayei
Effect of Working Length Measurement by Electronic Apex Locator or Radiography on the Adequacy of Final Working Length: A Randomized Clinical Trial Microleakage in Class II Composite Resin Restorations: Total Bonding and Open Sandwich Technique
36
Dentist Health Yoga for Dental Career Longevity

By Tetyana Ratushnyak
Bahrain: Bahrain Dental Society +973 17723767, bahds@batelco.com.bh Egypt: Alexandria Oral Implantology Association +203 5451277, www.aoiaegypt.com Iran: Shayan Simin Teb Co. +98 21 66380364/5, info@shayansiminteb.com Iranian General Dental Association +98 2188287794/5, info@igda.ir Iraq: Iraqi Dental Association +964 015379267, info@iraqidental.org Kurdistan Dental Association +964 7504510315, dara_saeed@yahoo.com Pro Health Line Company +964 7504544479, www.prohealthline.com Emirates Scientific Bureau +964 771 0131978, www.prohealthline.com Jordan: Jordanian Dental Association (JDA) +962 6 5665520, info@jda.org.jo Basamat Medical (Pharmadent) +962 6 5605395, www.basamat.com Kuwait: Kuwait Dental Association +965 5325094, www.kda.org.kw Lebanon: Lebanese Dental Association +961 1 611555, www.lda.org.lb Lebanese Dental Laboratory Association (OPDL) +961 5955 151, www.opdlb.com Richa Dental Store +961 5 452555, www.richadental.com Oman: Oman Dental Society +968 95769039, omandent@omantel.net.om Palestine: Palestinian Association of Implant Dentistry (PADI) +970 2 2954545, www.implant.ps Qatar: Qatar Dental Society +974 4393144, www.qatardentalsociety.org Ali Bin Ali Medical The i-partner +974 4867871 ext. 247, www.alibinali.com Saudi Arabia: Saudi Dental Society +966 1 4677743, www.sds.org.sa Sudan: Sudanese Dental Association +249 83 779769, sdaassnan@hotmail.com Syria: Najjar Trading Est. +963 (11) 2244140, najjest@scs-net.org United Arab Emirates: Noble Medical Equipment +971 4 3255046, imad.kafity@noblemedical.ae Dubai Medical Equipment L.L.C. +971 6 554 0206, www.mamut-dental.com
Affiliation & Distributors
50 54 60
Ask the Experts Flash News Two Minutes with
Our objective is to publish a dental journal of consistent high quality and help to increase the exposure of literature written by dental professionals from our region at a global level. Literature review, original research, clinical case reports, case series, short communication, randomized clinical trials, and book reviews are among our scope of published material, where the clinical aspect of dentistry is presented in a scientific way, starting each article with an abstract, backed up by references in accordance with the Vancouver citation style. The journal encourages the submission of papers with a clinical approach, practical or management oriented, besides papers that bridge the gap between dental research and clinical application. Received manuscripts are first revised by the editor to check if it is appropriate for publishing in Smile and that it complies with the authors guidelines. The manuscript is then forwarded to two or more professional reviewers. Anonymity of both the author and reviewer is preserved (double blinded peer-review process). Our editorial policy which controls the quality of articles and assures their accuracy, clarity, and smooth readability through high level enthusiast regional and international team of experts is our golden key for success. Finally, we believe that a controlled content of advertisements could be informative and beneficial especially in dentistry, where the armamentarium and pharmaceuticals are a major and integral part of the dental science.
Editorial Policy
Dental Conferences in the Arab World & the English Language

On an ongoing basis, experts in dental health in various fields of dentistry keep on doing their researches and studies. They present their key research findings at international conferences and events around the globe. Organizers of dental conferences in the Arab world quite often have a tendency to invite prolific world known international speakers in the field to enrich their conferences scientific programs giving the way to present the latest advancements and developments in different fields of dentistry. In addition to the distinguished speakers, dental conferences in the Arab world are being held in a very elegant atmosphere, usually in luxurious hotels as the meeting ground of industrial leaders and professional practitioners. The professional practitioners are not only dentists from different specialties, but dental assistants and dental technicians surprisingly seem also to have a considerable portion of the specialty representation chart of various dental conferences. In a recent international dental conference in the Middle East, the specialty representation charting revealed only 47% of the participants were general dental practitioners, while 20% of the participants were dental assistants, 19% were dental technicians, and the rest were dental specialists in different fields. They all have enjoyed the high level of the scientific program and have had the opportunity to meet the top industrial players in the field. No doubt that English is the dominant universal language of science, technology, and many other fields of human knowledge. And so it is, English is the main language used in dental conferences, dental research, and dental articles. However, the use of English as the de facto global language of science creates distinct challenges for those who are not native speakers of English or those who have limited knowledge of English. It is estimated that less than 15% of the worlds population speaks English, with just 5% being native speakers. This extraordinary imbalance emphasizes the importance of recognizing and alleviating the difficulties faced by nonnative speakers or those having limited command of English if we are to have a truly global understanding and world openness in our dental conferences. In this regard, considering that I am writing in English at a dental journal styled in English, in spite of the fact that considerable amount of its readers come from the Arab world, I would like to emphasize on the point that as far as I am concerned Arabic is our beloved language and we should cherish it, live with it in weal and woe. Though in this I may be going at odds with many opinions, I know I would provoke none of our readers if I call for some Arabic inserts in Smile Dental Journal. Maybe an editorial, description of journal contents, some of the advertisements, and if possible the abstracts of certain articles to say the least. This hybridization of the Journals content between Arabic and English in my opinion will add to the glamour of Smile Dental Journal and bridge the gap between Smile Dental Journal and the Arabic speaking colleagues. In conclusion, and back to the subject of this editorial, it is very important for the organizers of dental conferences in the Arab world to give extra attention to the subject of translation and simultaneous interpreting of conference lectures to and from the Arabic language. The type of language used in dental conference lectures is highly specialized, and thus the translators and interpreters hired in these conferences should have the specialized knowledge in different fields of dentistry in order to give translations that are linguistically correct, scientifically accurate, and terminologically consistent.
Dr. Amjad Khoury BDS, MA amjadkhoury@gmail.com
| 4 | Smile Dental Journal | Volume 7, Issue 4 - 2012
International Calendar
January, 22 - 25
3rd International Dental Congress of the Faculty of Oral & Dental Medicine Cairo, Egypt www.dentistry.cu.edu.eg
January, 28 - 30
24th Saudi Dental Society International Dental Conference Riyadh, KSA www.sds.org.sa
February, 5 - 7
AEEDC 2013 Dubai, UAE www.aeedc.com
February, 27 - 28
Oman International Dental Conference 2013 Muscat, Oman www.omanidc.com/2013/
March, 12 - 16
IDS 2013 Cologne, Germany www.ids-cologne.de
April, 4 - 6
Dubai Implantarium Dubai, UAE www.dubaiimplantarium.com
April, 6 - 8
MedExpo Saudi Arabia Jeddah, KSA www.medexposaudi.com
April 11 - 12
18th Irbid International Congress Irbid, Jordan
April, 24 - 26
2nd IQDAC (International Quintessence Dental Arab Congress) Riyadh, KSA www.iqdac.org
May, 1 - 4
LUSD 13th International Convention Rac Hariri Campus, Beirut, Lebanon congresul@ul.edu.lb
May, 2 - 3
8th CAD/CAM Dubai, UAE www.cappmea.com/cadcam8/
May, 14 - 15
3rd International Dental Conference & Exhibition Tripoli, Libya
May, 17 - 18
Iraqi Dental Reunion (IDR 2013) Erbil, Iraq
August, 28 - 31
FDI 2103 Istanbul, Turkey www.fdiworldental.org
For more dental events please visit www.smiledentaljournal.com or our page on Facebook
Smile Dental Journal | Volume 7, Issue 4 - 2012 | 5 |
Smile Message
The Battle Against Cancer
The fight against cancer is one of the most challenging issues facing humankind today. According to the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute and Based on rates from 2007-2009, 41.24% of men and women born today will be diagnosed with cancer at some time during their lifetime. This fight has never been easy; nevertheless we will always stand tall and try by all means to defeat this disease. One of the leading organizations fighting cancer in the Middle East is the King Hussein Cancer Foundation (KHCF), the legal umbrella organization responsible for the King Hussein Cancer Center (KHCC). KHCF is a free-standing independent non-governmental not-for-profit institution founded in 1997 by a Royal Decree to combat cancer in Jordan and the Middle East region and is dedicated entirely to cancer care. KHCF undertakes many fundraising activities to help support cancer patients and maintain KHCC as a comprehensive cancer care center of excellence and its life-saving work has gained the widespread support of many members of the community. This upcoming spring, Mostafa Salameh, the first Jordanian to climb Mount Everest, is leading an expedition from the lowest point on Earth, the Dead Sea, to the highest point on Earth, Mount Everest base camp. The aim of this expedition, which is named From the Lowest Point to the Highest Point for Cancer, will be to raise funds to support the New King Hussein Cancer Center Expansion Project. The expedition will begin with a symbolic walk along the shores of the Dead Sea, after which the team will visit the children receiving cancer treatment at KHCC and collect the childrens wish flags that will accompany the team on their journey. The team will then trek to the Mount Everest Base Camp at the end of March 2013. During this journey, a team of prominent Jordanians will take part, including our colleague Dr. Samer Sunna. Dr. Sunna a consultant orthodontist at the Sunna Orthodontist Center was awarded in 2004 the Royal Jordan First Award for Excellence in Medicine and Dentistry and four years later was awarded Man of the Year in Dental Health by the American Bio Society. Dr. Sunna is also one of the pioneer supporters of Smile Dental Journal since its launch back in 2006 and a prominent member of our editorial board. Miss Iman Al-Majali, an International Development Coordinator at KHCF and a news anchor at Jordan TVI, urged everyone in the community to support this historic initiative as it not only raises awareness about one of the most important causes we deal with on a daily basis but it will also support a much needed expansion project that will allow KHCC to absorb the increasing number of cancer patients seeking life-saving treatment and not turn them away due to lack of space. Miss Al-Majali who works on various grants from international donors stated that the new KHCC expansion will be a state-of-the-art facility to complement the existing center. This project will consist of two new buildings three times the size of KHCCs current premises, thus increasing its capacity to absorb in-patients from 3,500 to over 7,000 per year and increase the number of outpatient visits from 100,000 to over 150,000 visits, as well as reduce the number of patients on the waiting lists. We believe that the battle against cancer should be everybodys concern. Donations in the expeditions name can be made in person at the office of the KHCF, by calling (+962-6)554490, or by visiting the pledge page: www.cancerpledges.com/SelectPledge.aspx?P_ID=35
Dr. Issa Salem Bader Founder & Editor-in-Charge Smile Dental Journal
| 6 | Smile Dental Journal | Volume 7, 6, Issue 4 1 - 2012 2011
Flapless Implant Dentistry: Evidence Based Debate

Hassan Maghaireh, BDS, MFDS(Ed), MSc Implants Department of Oral and Maxillofacial Surgery, School of Dentistry, The University of Manchester, Manchester, UK Clarendon Dental Spa, Leeds, UK
ABSTRACT This mini review is based on a Cochrane systematic review entitled Interventions for replacing missing teeth: management of soft tissues for dental implants published in The Cochrane Library. Clinicians are under pressure to meet patients expectations to provide them with naturally looking teeth, and while dental implants are very predictable nowadays, the challenge has shifted to the peri-implant soft tissue level, shape, thickness and contour. Many soft tissue manipulation techniques including flap designs and placing dental implants flapless have been promoted by different clinicians, each group of them defending their technique and/or approach. On the other hand, clinicians area subjected to information overload, and evidence based answers are needed when ever they are faced with a clinical intervention question at their daily practice, rather than relying on opinion based information. This mini review aims to answer two main questions:1 Is flap elevation necessary in implant dentistry?2 What is the best flap design in implant dentistry? Relying on up-to-date random controlled trials. KEYWORDS Flapless, Flap design, Soft tissue management. INTRODUCTION Traditionally, dental implant surgery starts with raising flap procedures for implant placement. However, in recent years there has been some interest in developing techniques that can provide function, advanced aesthetics, comfort and long lasting prognosis with as minimally invasive surgery as possible. To fulfil these requirements flapless surgery has been advocated by many clinicians. In return many flap design variations have strong proponents with surgeons claiming that a particular design offers improved implant success. However, there is frequently disagreement and this area is controversial. Numerous techniques have been proposed to design flaps aiming to preserve or rebuild the interdental papillae, but it is still unclear which ones achieve the best results. This interesting subject is as important as the debate on various flap designs while placing dental implants. HISTORY OF DENTAL IMPLANTS Dental implants started to be offered as an option to replace missing teeth in the mid-1960s, however, implants were being used in very small numbers. Typical designs were sub-periosteal frames, blade vents or trans-mandibular devices, none of which was properly documented clinically. In general, only poor clinical results had been recorded even though allegedly successful cases were occasionally presented at meetings by the few academic outcasts who used the devices. Per-Ingvar Brnemark placed his first clinical root form dental implant in 1965.1 In the following 5 years, his clinical results were also unacceptably poor, with success rates of about 50%. Brnemarks early results seemed
to confirm that foreign materials did not work in the oral cavity for a number of reasons including the risk of infection.2 During the 1970s clinical outcomes for patients with Brnemarks implants have clearly improved, not as a result of traditional controlled trial studies but in an empirical way with the simultaneous changing of a great number of parameters. Implants were made wider with some design changes, implant healing time was prolonged and changes were made to the surgical and prosthodontic routines. Brnemark published an experimental study which mentioned the term osseointegration,1 but it was till the late 1970s when he published a retrospective clinical study which further discussed and confirmed the concept of osseointegration of dental implants , which was described as direct structural and functional connection between living bone and implant surface.3 Since that time, the revolutionary concept of osseointegration is now considered highly predictable. Today the implant-supported dental restorations are among the most accepted treatment options for treating edentulous and partially edentulous patients Flap Design The term flap been used to indicate a section of soft tissue that is outlined by a surgical incision, carries its own blood supply, allows surgical access to underlying tissues, can be replaced as required on its original position, maintained with sutures and is expected to heal.4
Implants are usually placed after soft tissue flap elevation to visualize better the bone sites where the implant(s) will be placed. Flap elevation ensures that some anatomical landmarks (e.g. foramina, lingual undercuts or maxillary sinuses) are clearly identified and protected. When the amount of available bone is limited, flap elevation will facilitate implant placement maximizing bony contact while minimizing the risk of bone fenestrations. However, flaps are associated with some degree of morbidity and discomfort, and require suturing. There are situations, where flap elevation may not be necessary since the amount of bone is more than adequate and the risk of complications is minimal. Under these circumstances, flapless implant placement may be indicated, but when placing implants with a flapless procedure the surgeon is working blindly and care must be taken to avoid any complications such as bone perforations. Guided surgery aided with customized surgical templates derived from CT scans can help clinicians to minimize the risk of perforation and incorrect implant alignment.5 When dental implants are placed after reflecting soft tissue flaps, there generally is some bone resorption. During the initial phase of healing, bone resorption of varying degrees almost always occurs in the crestal area of the alveolar bone.6 The extent of alveolar height reduction resulting from this resorption is related to the bone thickness at each specific site.7 When teeth are present, blood supply to the bone comes from three different sources: from the connective tissue above the periosteum, from the periodontal ligament, and from inside the bone. When a tooth is lost, blood supply from the periodontal ligament disappears, so that blood now only comes from soft tissue source through the connective tissue above the periosteum and from the bone. Cortical bone is poorly vascularised and has very few blood vessels running through it, in contrast to soft cancellous bone. When soft tissue flaps are reflected for implant placement, this will disturb the periosteal layer; hence, the blood supply from the soft tissue to the bone (supra-periosteal blood supply) is removed, thus leaving poorly vascularised cortical bone without a considerable part of its vascular supply, prompting bone resorption during the initial healing phase. Another major function of the periosteum which will be badly affected is the venous blood drainage, therefore after raising a surgical flap and disturbing the periosteum, the amount of resulting post operative oedema is usually considerable due to lack of proper drainage. There is some swelling, pain, and discomfort associated with every surgical procedure. With a flapless approach, surgical trauma is minimal because the punch or circular cut is very small, usually 1mm wider than the implant to be placed, so that postoperative pain, swelling, and discomfort related to soft tissue trauma are greatly minimized.
(Case 1) Astra Tech dental Implant placed at the upper left central incisor flapless and restored 3 months afterwards with a CAD CAM Atlantis titanium abutment and porcelain fused to metal crown. A B
(Case 2) Astra Tech dental Implant placed at the upper right central incisor immediately with flap elevation, guided bone regeneration and soft tissue grafting and restored with porcelain fused to metal crown.
There are many advantages for the patient as well as for the surgeon, since the procedure is less time consuming, bleeding is minimal, implant placement is expedited, and there is no need to place and remove sutures. However, since flapless implant placement generally is a blind surgical technique, care must be taken when placing implants. Angulation of the implants affected by drilling is critical so as to avoid perforation of the cortical plates, both lingual and buccal, especially on the lingual side of
was sutured back in place. The rationale for this incision was to keep the incision line away from the implants, thereby possibly preventing infection. In a retrospective study,9 it has been demonstrated that there was no difference in the implant success rates when implants were placed with a mid-crestal incision, however, they concluded that it was far more advantageous to use a mid-crestal incision since the swelling and the postoperative pain were greatly minimized. THE EVIDENCE Is flap elevation necessary? Lindeboom et al. in their random controlled trail10 ompared flapless versus flap elevation to place at least 6 implants in fully edentulous maxillae. The flapless surgery procedure was performed using individually customised surgical templates fabricated with CAD/ CAM technology planned with the Procera Software 3D Planning Program (Nobel Biocare AB, Goteborg, Sweden). In the flapless group, soft tissues were punched away and after implant installation, the punch wounds were sutured. Data were reported in the publication up to 1 month after implant placement, however, the authors provided data up to 6 months after loading. At baseline, the patients who were going to receive flapless surgery were less satisfied. There were no withdrawals or complications up to 6 months. Two implants were lost in the flapless group versus none in the flap elevation group but this difference was not statistically significant. In another random controlled trial on flapless dental implant, Fortin et al.11 compared a flapless versus a conventional flap elevation procedure to place dental implants in partially or fully edentulous patients in a randomised controlled trial. The flapless surgery procedure was performed using an image-guided system (CAD Implant, Medfield, Ma, USA) based on a template. After a 6 day follow up, thirty patients were included in each group and it was reported that less patients subjected to the minimally invasive surgery experienced postoperative pain than those patients subjected to conventional flap elevation. Cannizzaro et al.12, and compared a flapless versus a conventional flap elevation procedure to place dental implants in partially edentulous patients. Templates were used for both groups. The flapless surgery procedure was performed based on intra oral, panoramic or CT scan information. Implants that obtained a primary stability >45 Ncm (all but one) were functionally loaded the same day. Implants in the control group were placed after mid-crestal incision and flap elevation following the manufacturer instructions. Twenty patients were included in each group with no apparent baseline differences between the two groups. No withdrawals after 3 years. In one patient of the flapless group, a flap had to be elevated to properly evaluate the direction of the drill. No prosthesis or implant failed.
(Case 3) JD Evolution dental implant placed at lower right 2nd premolar flapless with minimal post operative bruising and swelling. A B
D C
(Case 4) White Zirconia dental implant placed at upper right lateral incisor area, with minimal post operative bruising and swelling.
the mandibular anterior area. In a 10 year retrospective review,8 a 3% fenestration of the implants placed flapless was reported due to incorrect bur angulation. However, there should be no problem if the patient has been appropriately selected and an appropriate width of bone is available for implant placement. From all the above, we can tell that whether to raise a flap or not while placing dental implants is a very controversial subject, and this is going to be the first question in our systematic review. In connection to the above subject, another question which clinicians face is what the best flap design is. The surgical placement of dental implants has undergone changes since the beginning of placement of root-form implants. Initially, using the Brnemark protocol,1 an incision in the mucosa or the muco-buccal fold was made, and then a flap was reflected to expose the underlying bone. The implants were placed and the flap
Five patients had complications in each group: transient disturbance of the alveolar inferior nerve (one patient), maxillary sinus membrane perforation (one patient), periimplant mucositis (one patient) and perimplantitis (two patients) in the flapless group; and wound dehiscence (two patients), peri-implant mucositis (one patient) and perimplantitis (two patients) in the conventional flap group. Less patients subjected to a flapless procedure experienced postoperative pain than those patients subjected to conventional flap elevation. Canizzaro et al. reported that patients of the flapless group suffered significant less oedema and consumed less analgesics than those in the conventional flap group. Cannizzaro et al.13 in a more recent study, compared flapless versus flap elevation implant placement in partially edentulous patients following a split-mouth design random controlled trial. All implants were placed with an insertion torque >48Ncm and were immediately functionally loaded. Forty patients were included and two prostheses and two implants failed in each group, all in different patients. Once more, there were no statistically significant differences for prosthesis/ implant failures or biological complications between the two groups. However, it is worth mentioning that one patient had one biological complication (peri-implantitis with purulent discharge) in the flapless group versus four complications in three patients (one intrasurgical haemorrhage, one intrasurgical fracture of the buccal bone plate, one case of peri-implant marginal bone loss exceeding 4mm and one patient experiencing pain on chewing) in the flap elevation group. Fewer patients subjected to a flapless procedure experienced postoperative pain than those subjected to flap elevation. An interesting finding was that there were no differences for peri-implant marginal bone levels between the flapless and the conventional flap groups. Thirty-one patients preferred the flapless intervention; three patients preferred flap elevation and six patients had no preference. This difference was statistically significant. In this study, it was also reported that patients of the flapless group suffered significantly less postoperative swelling and consumed less analgesics than those in the flap elevation group and that the flapless procedure was significantly shorter. In a recent systematic review, Esposito et al.14 reported that there is limited weak evidence suggesting that flapless implant placement can cause less postoperative pain, oedema and consumption of analgesics than flap elevation. Flapless surgery performed by skilful clinicians in properly selected cases can be as successful and complication-free as conventional flap elevation. Further more, it was recommended that clinicians should select patients for flapless implant placement with a great deal of caution with respect to their own clinical skills and experience. One interesting finding at the same systematic review was that the safety and efficacy of customised surgical templates created with the help of planning software on CT scans to facilitate flapless
placement of dental implants still needs to be assessed, especially for fully edentulous patients where it might be more difficult to correctly position the stent. Which is the most effective flap design/ technique? A randomised controlled trial by Hunt et al. in 199615 compared the vestibular incision with the crestal incision using a split-mouth design of fully and partially edentulous patients. Patients were examined at 1, 7, 14 and 30 days, as well as at abutment connection 4 to 6 months after. The authors reported no significant differences for pain and oedema. Furthermore, there were no statistically significant differences for biological complications (wound dehiscence) which occurred in two sites of the crestal and three sites of the vestibular incision. In another random controlled study, Heydenrijk et al.16 compared crestal versus vestibular incisions to place one-stage dental implants with five patients were included in each group. There were no statistically significant differences for prosthesis/im-plant failures and complications between the groups. However, it was reported that four patients from the crestal group and one from the vestibular group suffered from hyperplastic tissue covering the healing abutment after surgery. Arnabat-Dominguez17 compared Erbium: YAG laser with flap elevation at implant exposure to connect abutments. Ten patients were included in each group, once more, no withdrawal or implant failures occurred up to 6 months after abutment connection. Patients treated with laser did not receive local anaesthesia, though two patients had to be anaesthetised during the procedure: one due to pain and one due to profuse bleeding (complication). Fewer patients treated with laser experienced postoperative pain than those treated with conventional flap elevation. In the article, it was also reported that patients of the laser group consumed significantly fewer analgesics and more interestingly, the prosthetic procedures could start earlier (after 7.3 days) than in patients of the conventional flap group (after 13.6 days). CONCLUSION There is evidence suggesting that flapless or miniinvasive procedures can cause less postoperative pain, oedema and consumption of analgesics than conventional flap elevation. Flapless surgery performed by skilful clinicians in properly selected cases can be as successful and complication-free as conventional flap elevation. However, there is still insufficient evidence regarding a potential increased risk of complications/ failures using a flapless approach. Clinicians should select patients for flapless implant placement with a great deal of caution in relation to their own clinical skills and experience. The safety and efficacy of customized surgical templates created with the help of planning software on CT scans to facilitate placement of dental implants needs still to be assessed.
Very little well conducted studies were found on the best flap design for implant dentistry, although it is a major issue for every implant dentist, since the high number of complications may have occurred simply by chance. It would be prudent not to extrapolate any conclusions from any short term studies with few number of patients, not to mention case reports as larger random controlled multicentre trials are needed to answer this question. More research (properly designed and conducted randomised controlled trials) is needed to evaluate the potential risks/ advantages of flapless procedures and the safety and efficacy of implant planning software based on CT scans. REFERENCES
1. Brnemark PI, Hansson BO, Adell R, Breine U, Lindstrm J, Halln O, Ohman A. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl. 1977;16:1-132. Albrektsson T. & Wennerberg A. Oral implant surfaces: Part 2-review focusing on clinical knowledge of different surfaces. International Journal of Prosthodontics. 2004;17:544-64. , Breine U, Adell R, Hansson B, Lindstrom J, Ohlsson Brnemark P A. & Wennerberg. Intraosseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg. 1969;3(1):81100. Jephcott A. The surgical management of the oral soft tissue: 1. flap design. Dental updates. 2007;34:518-22. Van Steenberghe D, Glauser R, Blomback U, Andersson M, Schutyser F & Pettersson A. A computed tomographic scanderived customized surgical template and xed prosthesis for apless surgery and immediate loading of implants in fully edentulous maxillae: a prospective multicenter study. Clinical Implant Dentistry and Related Research. 2005; 7(1):S11120. Ramfjord Sp & Costich Er . Healing after exposure of periosteum on the alveolar process. J Periodontol. 1968;38:199207. , Donnenfeld O & Rosenfeld L. Alveolar crest Wood D, Hoag P reduction following full and partial thickness flaps. J Periodontol. 1972,42:1414. Dominguez Campelo L & Dominguez Camara J. Flapless Implant Surgery:A 10-year Clinical Retrospective Analysis. int J Oral Maxillofac Implants. 2002;17:2716. Sharf D & Tarnow D. Modified Roll Technique for localized alveolar ridge augmentation. Int J Periodontics Restorative Dent.1992;12:415-25. Lindeboom JA, vanWijk AJ. A comparison of two implant techniques on patient-based outcome measures: a report of flapless vs. conventional flapped implant placement. Clin Oral Implants Res. 2010;21:366-70. Fortin T, Bosson JL, Isidori M, Blanchet E. Effect of flapless surgery on pain experienced in implant placement using an imageguided system. Int J Oral Maxillofac Implants. 2006;21:298-304. Cannizzaro G, Leone M, Consolo U, Ferri V, Esposito M. Immediate functional loading of implants placed with flapless surgery versus conventional implants in partially edentulous patients. A 3-year randomized controlled clinical trial. Int J Oral Maxillofac Implants. 2008;23:867-75. Cannizzaro G, Felice P , Leone M, Checci V, Esposito M. Flap- less versus open flap implant surgery in partially edentulous patients subjected to immediate loading: 1-year results from a split-mouth randomised controlled trial. Eur J Oral Implantol. 2011;4:177-88. Esposito M, Maghaireh H, Grusovin G, Ziounas I, Worthington H. Soft tissue management for dental implants: what are the most effective techniques? A Cochrane systematic review. Eur J Oral Implantol. 2012;5(3):22138 Hunt BW, Sandifer JB, Assad DA, Gher ME. Effect of flap design on healing and osseointegration of dental implants. Int J Periodontics Restorative Dent. 1996;16:582-93. Heydenrijk K, Raghoebar GM, Batenburg RHK, Stegenga B. A comparison of labial and crestal incisions for the 1-stage placement of IMZ implants: a pilot study. J Oral Maxillofac Surg. 2000;58:1119-23. Arnabat-Domnguez J, Espaa-Tost AJ, Berini-Ayts L, GayEscoda C. Erbium:YAG laser application in the second phase of implant surgery: a pilot study in 20 patients. Int J Oral Maxillofac Implants. 2003;18:104-12.
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6. 7. 8. 9. 10.
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Cleft Lip and Palate: The Multidisciplinary Management

Emad Hussein - BDS, MSc, Associate Professor Former chairman, Department of Orthodontics, Faculty of Dentistry, Arab American University, Palestine - emadhussein@rocketmail.com John Van Aalst - Associate Professor Director, Pediatric/Craniofacial Plastic Surgery, School of Medicine, University of North Carolina, USA - john_vanaalst@med.unc.edu Alev Aksoy - Associate Professor Sleyman Demirel University, Faculty of Dentistry Department of Orthodontics, ISPARTA-TURKEY - alevak2000@yahoo.com Mahmoud Abu Mowais - Professor Arab American University, Jenin, Palestine - sarda@aauj.edu Libby Wilson - MD, Program Director Craniofacial/Cleft Palate Program at Orthopaedic Hospital, Los Angeles, USA - lwilson@laoh.ucla.edu Khaled Abughazaleh Diplomate American Board Oral and Maxillofacial Surgery Private Practice, Chicago, IL, Adjunct Assistant Professor Department Oral and Maxillofacial Surgery, University of Kentucky Chicago, USA - kabughazaleh@hotmail.com Nezar Watted - Professor Department of Orthodontics, University of Wurzburg, Germany nezar.watted@gmx.net
ABSTRACT Patients with cleft lip and palate usually face a multitude of problems, esthetic compromise being the most noticeable, malocclusion, missing teeth, oronasal fistula, speech and hearing pathology are also present in most cleft patients; this necessitates a multidisciplinary treatment across various medical and dental specialties that extends from birth to adulthood but in separate stages. A protocol for the treatment of cleft patients should followed by the healthcare providers, and coordination amongst them is a major contributor to success in cleft treatment. KEYWORDS Cleft patients, Treatment protocol, Teamwork management. INTRODUCTION Cleft lip and/or palate are the most common craniofacial anomalies, occurring disproportionately across the world. Cleft anomalies affect several organs and functions within the human body, necessitating multidisciplinary treatment across various specialties. This article gives a brief comprehensive overview of cleft lip and palate, including the embryology and etiology of cleft formation, the incidence of clefting, and the contemporary multidisciplinary treatment approach of cleft lip and palate. Embryology of cleft formation The critical period for proper intrauterine development of the face is between the fifth and seventh weeks of gestation, with the sixth week being the most important. During this time, the morphodifferentiation and orientation of the unpaired frontonasal process, which includes the medial and lateral nasal processes, occur simultaneously with progressive medial migration and growth of the paired maxillary processes (Fig. 1).1
(Fig. 1) Formation of lip and primary palate
The palate is formed in two stages: In the first stage, the primary median palatal triangle is formed, derived from the merging of the two mesial processes originated from the median frontonasal process. This is completed by the eighth intrauterine week. In the second stage, shelf-like outgrowths known as lateral palatine processes, derived from the maxillary processes, grow horizontally above the tongue to form the secondary palate.
Additionally, adult patients with cleft anomalies may also suffer from marital problems. These and other scenarios all require psychosocial support for the cleft patient as well as his/her family.5 By improving a childs social skills, educational pursuit, both the child and his/her parents may be able to overcome the issues that stem from the childs physical appearance.5 Other associated abnormalities include oronasal fistula, speech and hearing pathology, malocclusion, which is always present in cleft lip and palate patients. Anterior and posterior crossbites due to anteroposterior and transverse deficiency of the maxilla, rotation of the incisors due to muscle pull, lateral incisors at the cleft site are frequently missing and supernumerary teeth may be present at the non-cleft side. Carious teeth and periodontal inflammation are often present due to dental neglect (Figs. 3-5).6,7
(Fig. 2) Formation of secondary palate
The merging or fusion of these processes is completed by the twelfth intrauterine week (Fig. 2). Any insult to the fusion process between the fifth and seventh intrauterine weeks leads to the formation of clefts. This may lead to irritation of the nasal septum, causing repeated respiratory tract and middle ear infections. Additionally, the tongue may be postured in the cleft space during swallowing, which may further widen the cleft space. Etiology of cleft Lip and Palate The etiology of cleft remains unclear. It is presumed to be multifactorial, with various contributing environmental and genetic factors.2 Toxin exposure during the antenatal period is more likely to be present in developing countries due to poor sanitation, inadequate infrastructure, and political instability. For many of the same reasons, metabolic disorders and malnutrition are also more likely to be an issue for pregnant women in developing countries. Genetic factors and consanguinity are also major potential risk factors for birth defects.3 Problems Associated With Clefts Patients with cleft lip and palate usually face a multitude of problems, esthetic compromise being the most noticeable. The esthetic obstacle in children with cleft lip and palate may often lead to various types of psychosocial distress. For example, patients may feel that there is a stigma attached to their appearance. They often perceive themselves as unattractive, which may influence their psychological behavior and lead to problems with communication.4 Esthetic issues can also limit a childs life prospects. Some affected children may not attend school regularly, due to teasing, bullying, speech difficulty, and hearing problems.6
(Fig. 5) Repaired oronasal fistula during alveolar bone graft
(Fig. 3) Skeletal and Dentoalveolar irregularities associate with cleft lip and palate
(Fig. 4) Oronasal fistula associated with cleft palate
TREATMENT TIMING & PROTOCOL The First Closure: Lip The first procedure that cleft patients receive is surgical closure of the lip. Following the rule of 10s, a patient admitted for lip closure should be 10 weeks of age, weigh at least 10 pounds, have a hemoglobin 10mg/100ml, and have aWBC count <10.000cu/mm in order to withstand surgery and anesthesia (Figs. 6,7).8, 9
closure surgery can be performed 10 weeks later, thereby decreasing the psychological distress of the family as they witness the correction of their childs cleft. Hard & Soft Palate Surgical Repair Speech is learned by hearing, which can be aided by surgical repair of the hard and soft palate. This surgery is performed around 12-18 months of age, when children first begin to talk. The surgery is also performed at this age with airway considerations in mind, as it benefits dentition eruption.9 Palatal repair is done in a single stage using the Vomer flap for anterior palate closure, in addition to the Bardach two-flap palatoplasty with soft closure into both alveolar clefts (Fig. 9).
(Fig. 6) Bilateral Complete Cleft lip and palate before lip repair
(Fig. 7) Bilateral Complete Cleft lip and palate after lip repair
(Fig. 9) Surgical repair of the palate
Neonatal orthopedic correction is still used in several cleft lip and palate centers around the world, despite several reports questioning its effectiveness. In patients with wide bilateral cleft lip and/or a severely protruding premaxilla, surgical taping as an alternative method for neonatal orthopedics has many benefits: it is easy to use, does not require several visits to pediatric dentists or orthodontists over a period of months, and the results are often successful. When used, this taping is worn for two weeks prior to the Von Langenbeck lip orMillard forked flap surgery (Fig. 8).9
Treatment in the Primary Dentition Stage In the primary dentition stage, focus is on restoration of the primary dentition using mainly fillings, stainless steel crowns, and oral hygiene rather than orthodontics or surgery (Fig. 10).
(Fig. 10) Dental management in the primary dentition stage (Fig. 8) Surgical lip repair
In this approach, physiological forces will enhance palatal molding and will bring the premaxilla backwards. This in turn shortens the time for lip closure. When surgical taping is used rather than lengthy neonatal orthopedics, lip
Sometimes, expansion by a removable appliance is used in cross bites with functional shifts of the mandible upon closure. At this young age, cooperation of the patient remains a factor. This further necessitates delay of treatment to the mixed dentition stage.7
Treatment Principles in the Mixed Dentition Stage The main objective during the mixed dentition stage is to prepare the cleft patient for a bone graft. The collapsed (overlapped) alveolar segments may be impeded in their growth. It is important that these segments be unlocked by expansion during the early stages of development when growth is most rapid. Orthodontic expansion of collapsed buccal segments will also facilitate the pushback of the premaxilla to restore a favorable arch form, which was initially interrupted by the lack of alveolar bone continuity on the cleft side. Expansion is carried out successfully by a quadhelix expansion appliance (Fig. 11), giving the surgeon a more favorable surgical field to perform the bone graft. Expansion devices should be used for at least four months after the bone graft, as freshly grafted bone is unable to maintain the expansion (Fig. 12).7
(Fig. 13) Post orthodontic expansion of collapsed buccal segments
The central incisor is usually distolabially rotated and inclined due to muscular pull (Fig.14). Care should be taken while leveling this incisor and other teeth, so as not to push the roots of these teeth into the cleft space. Following a successful graft placement, it is preferable to keep the incisor roots invested in bone at the pregrafting stage while the correct tooth angulation is achieved at least 2 months after grafting (Figs.15,16).7
(Fig. 11) A quadhelix expansion appliance (Fig. 14) The central incisor is usually distolabially rotated and inclined in a cleft palate patient
(Fig. 15) Corrected position of the central incisor (Fig. 12) Collapsed buccal segments in unilateral cleft palate patient before expansion
Crowding is usually present on the non-cleft side in unilateral cleft patients, and should also be relieved during the mixed dentition stage. At the crowding site, serial extractions can sometimes be carried out to provide space for eruption of the canine, while lateral incisors are usually missing at the cleft side. Supernumerary teeth should be extracted during the bone graft surgery and primary teeth adjacent to cleft should be extracted at least two months prior to surgery (Fig. 13).10
(Fig. 16) A successful bone graft placement appearing by a periapical X-ray
Bone Graft at the Cleft Side Bone grafting has several advantages. It is performed to support the long-term expansion of the dental arch, maintaining arch continuity and form while also providing bone for the passage of the erupting canine through the graft.6 A bone graft will also support the teeth adjacent to the cleft site, ensuring orthodontic movement of these teeth without periodontally compromising them. The bone graft will also improve facial esthetics by providing support to the base of the nose, which is lacking due to the cleft space (Figs. 17-19).
The bone graft is usually taken from the cancellous bone of the iliac crest. Other donor sites that provide cancellous bone include the mandibular symphysis and the skull. Timing of alveolar bone graft relates to tooth development and is carried out between the ages of 6-9 years, using the stage of root formation of the maxillary canine as a guide for the proper timing for bone graft is better than just following chronological age, when one third of the canine is formed viewed by a periapical x-ray is the best time to consider bone graft. . This may lead to spontaneous canine eruption through the graft and healthy gingiva surrounding the graft, with normal bone height.6, 9 Orthopedic Mid Face Growth Enhancement Maxillary hypoplasia is a well-known feature of cleft lip and palate patients. It may be due to scarring from the surgical repair of the cleft lip and/or palate, which may cause lip tightness and palatal scarring that restricts the growth of the maxilla. Studies by Ross et al. showed that untreated cleft patients exhibited normal maxillary growth, further supporting this hypothesis. Orthopedics applies interrupted forces which can aid maxillary sutures. However, the success of maxillary orthopedic advancement remains limited due to the tightness of the lip and palatal scarring. The decision to use a face mask or to undergo orthognathic surgery should be made early during treatment planning for patients with mild to moderate skeletal discrepancies (Fig. 20).11,12
(Fig. 17) Alveolar bone exposed at cleft side
(Fig. 20) Orthopedic treatment using a facemask
(Fig. 18) Cancellous bone packed into cleft
Orthognathic surgery Cleft patients will usually have jaw disharmony at the end of their facial growth period, manifested by mid-face deficiency. Growth of the maxilla is impaired in sagittal, transverse and vertical dimensions, evident in the form of anterior and posterior cross bites. Mandibular overclosure is also apparent due to maxillary deficiency in the vertical dimension.
(Fig. 19) Incisor roots invested in bone at the pregrafting stage while the correct tooth angulation can be achieved after successful graft placement | 18 | Smile Dental Journal | Volume 7, Issue 4 - 2012
Orthognathic surgery is required in about 25% of adult cleft patients according to the severity of skeletal features. The most commonly affected jaw in cleft patients is the upper jaw. Thus, in most cases,
the orthognathic procedure performed involves the advancement of the upper jaw (Le Fort I) rather than setting the mandible back. When the reverse overjet is severe, a two-jaw surgery may be required, impacting breathing and esthetics (Figs. 21-24).7
Orthodontic preparation for the orthognathic surgery aims to correct dental compensation due to the skeletal discrepancy. Other goals of pre-surgical orthodontics include arch coordination and removal of any occlusal prematurity. Relapse in the upper jaw position is possible due to the scar tissue resulting from the upper lip and palate repair. Distraction osteogenisis enables the gradual advancement of the hypoplastic maxilla with corticotomy cuts that will allow expansion of the scar tissue (Figs. 21,22). This decreases the possibility of relapse and allows for a longer-term correction over orthognathic surgery. Distraction ostegenesis has recently benefited from major advances in instrumentation, especially regarding the materials used to create instruments and the creation of bidirectional instruments. This has improved results and further decreased the need for more orthognathic surgery.12 SUMMARY Patients with cleft lip and palate require a team approach for their treatment, comprised of several specialists. This multidisciplinary care starts from birth and continues into adulthood, and coordination amongst specialists is a major contributor to success in cleft treatment. ACKNOWLEDGMENTS The Authors thank Sonya Patel and Hala Borno from the medical school at The University of North Carolina for their participation to the editing of this article REFERENCES
1. Moore KL. The Developing Human: Clinically Oriented Embryology. Philadelphia, PA: Saunders, 1977. 2. Malcolm C, Johnston P . Embryogenesis of cleft lip and palate, In: McCarty JG, editor. Plastic Surgery, vol 4. Cleft Lip and Palate and Craniofacial Anomalies. Saunders, Philadelphia, PA, 1990:2532. 3. Persaud TVN, Chudley AE, Skalko BG. Basic Concepts in Teratology. New York: Alan R. Liss, 1985. 4. Marcusson A. Adult patients with treated complete cleft lip and palate. Methodological and clinical studies. Swed Dent J Suppl 2001;145:1 57. 5. Mars M, Sell D, Habel A (2008) Management of cleft lip and palate in the developing world. GBR, Chichester. 6. Peter D. Waite and Daniel E. Waite, Bone Grafting for the Alveolar Cleft Defect Seminars in Orthodontics, Vol 2, No 3 (September), 1996:192-6. 7. Christos C. Vlachos. Orthodontic Treatment for the Cleft Palate Patient Seminars in Orthodontics, Vol 2, No 3 (September), 1996:197-204. 8. Black PW, Scheflan M. Bilateral cleft lip repair: putting it all together. Ann Plast Surg. 1984;12:118127 23. 9. Samuel Berkowitz, A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure Seminars in Orthodontics, Vol 2, No 3 (September), 1996:169-18. 10. Carla A. Evans, Orthodontic treatment for patients with clefts Clin Plastic Surg 31 (2004;27190. 11. Rygh P , Tindlund R. Orthopedic expansion and protraction of the maxilla in cleft palate patientsa new treatment rationale. Cleft Palate J 1982;19:104-112. 12. Graber L , Vanarsdall R, Vig K. Orthodontics Current principles and Techniques, 5th edition, Elsevier. 2011;965-89.
(Fig. 21) Cephalometric X-ray for adult cleft patient before surgery
(Fig. 22) Surgical advancement of the upper jaw (Le Fort I) for the same patient in Figure 21
(Fig. 23) Lateral facial view of a cleft patient before orthognathic surgery
(Fig. 24) Lateral facial view of the same cleft patient in Figure 23 after maxillary advancement and mandibular set back
The proper timing of orthognathic surgery is when facial growth has ended. A hand and wrist radiograph can help determine the end of facial bone growth.
The Effect of Two Disinfection Methods on Surface Roughness and Hardness of Type III Dental Stone
Suha Fadhil Dulaimi BDS, Msc. Conservative Dentistry Lecturer, Dental Technologies Department, College of Health & Medical Technologies, Foundation of Technical Education, Ministry of Higher Education & Scientific Research, Baghdad Iraq sf_dulaimi@yahoo.com
ABSTRACT Dental stone casts are often heavily contaminated with microorganisms from saliva and blood. The aim of this study is to evaluate the surface properties (roughness and hardness) of dental stone type III subjected to two different disinfection methods. Materials & Methods: Thirty specimens of type III dental stone were prepared and divided into three groups: control group (10 specimens without disinfection), Sodium hypochlorite group (10 specimens immersed in 0.525% NaOCl for 10 min), and microwave group (10 specimens subjected to microwave irradiation at 650 watt for 10 min). Surface roughness was tested by two dimensional profilometrer and Shore D hardness test was carried out. Results: dental stone specimens immersed in 0.525% NaOCl for 10 min resulted in surface roughness and hardness values comparable to control group P values (0.657, 0.591 respectively) using Student t-test. While microwave irradiation at 650 watt for 10 min produces smoother casts (mean 0.816) with reduced hardness (mean 68.8). Conclusion: Disinfection of type III stone casts with immersion in 0.525% NaOCl for 10 min did not affect surface roughness and hardness, while microwave irradiation at 650 watt for 10 min result in smoother surface with reduced hardness. KEYWORDS Disinfection, Microwave irradiation, Dental stone, Sodium hypochlorite.
INTRODUCTION Controlling the risk of bacteriological and viral transmission from the dental clinic to the dental laboratory and vice versa has been of interest to staff at dental clinics and dental laboratories for several years.1 Dental prosthesis, appliances, impressions and casts are heavily contaminated with micro-organisms from saliva and blood.2 Recommendations exist for the use of safety measures, as well as for the disinfection techniques required after impression making.3,4 Because of difficulties associated with impression disinfection and sterilization an alternative method would be cast sterilization or even disinfection.5 Another indication for cast sterilization or disinfection, when laboratory has no assurance that an appropriate disinfection protocol was followed.6 Also disinfection of impression materials hinders possible cross-contamination only at the time the cast is poured. Because prosthesis are tried in the patients mouth, they must be regarded as the major vehicle for cross contamination.7,8 Sodium hypochlorite is one of the worlds oldest and most widely used disinfectants, it is effective against HIV and hepatitis virus.9 Many researchers recommended using sodium hypochlorite for impression and cast disinfection.10 Microwave energy has been suggested for drying and disinfection of gypsum cast and authors found that it is effective for sterilization of casts after
24hrs and does not affect strength of cast,11 but the effect of microwave energy or chemical disinfection on physical properties has not thoroughly examined. The purpose of this study is to evaluate the surface properties (roughness, hardness) of dental stone Type III subjected to microwave energy or chemical disinfection with sodium hypochlorite. MATERIALS & METHODS In this study Type III dental stone (Geastone Type III Zeus Seri Loc. Tamburino 58036 Roccastrada GR Italy) was evaluated. Thirty specimens were prepared from mixing dental stone Type III with distilled water according to manufacturer instructions (powder/water ratio 100gm/30ml). The recommended powder was added to the water in a rubber bowel and mixed by hand to a smooth consistency. Mixed dental stone were poured down the side of 7cm diameter and 1cm thickness mold, which was vibrated using vibrator (Bego, Germany) during filling to draw out air bubbles from the mixture and reduce porosity. Then all specimens were stored in air at room temperature range of 232C for 1hr., after that all specimens were removed from the mold and left to dry for 24hrs at room temperature.
The thirty specimens were divided into three groups: Group I (control group) 10 specimens without disinfection Group II (microwave group) 10 specimens were disinfected using microwave irradiation with household microwave oven (LG Electronics, Korea, LG Microwave oven) at 650 watt out put power and 2450 MHz for 10 min.12,13 A cup with 200ml water was placed in the microwave oven to protect magnetron.14 Group III (sodium hypochlorite NaOCl 0.525%) 10 specimens were disinfected by immersion in 0.525% NaOCl solution (Fas 6.4% Babel company, Baghdad, Iraq diluted to 0.525%) for 10 min.5 Surface roughness: Surface roughness was tested using a 2-dimensional profilometer (Talysurf 4 profilometer, Taylor Hobson, USA). For accuracy, roughness average of the surface of each specimen was measured in 3 different directions, and the mean roughness average was then calculated for each group.15 Surface hardness: Shore D hardness test was performed on the same specimens using Shore D hardness digital tester (shore D Durometer TH 210, Time group Inc.).15 For each specimen hardness was measured at 4 points in different positions. The average hardness number for each specimen was then calculated separately and same procedure was conducted for the remaining tested specimens. Statistical analysis: Surface roughness and hardness data were analyzed using one-way analysis of variance (ANOVA) at the 95% confidence level. Students t-test used to compare between individual groups. RESULTS Descriptive statistics of result of surface roughness values (in m) are illustrated in Table 1, Fig 1. Microwave irradiation causes significant reduction in surface roughness even less than control group mean (0.816 m). One way ANOVA showed significant difference among groups P-value 0.0093 (Table 2). Comparison among groups using Students t-test showed no significant difference between control group immersed in NaOCl 0.525% for 10 min P-value = 0.657. While microwave group showed significant difference when compared with control group P-value = 0.049 and highly significant difference when compared with NaOCl 0.525% group P<0.01 (Table 3). For the hardness test descriptive statistics showed in Table 4, Fig 2. One way ANOVA showed highly significant
(Table 1) Descriptive statistics results of surface roughness
Control group Min Max Mean SD SE 1,3 1,45 1,38 0,069 0,022 Microwave 0,71 0,93 0,816 0,084 0,026 NaOCl 525% group 1,32 1,45 1,385 0,068 0,021
difference among groups P<0.01 (Table 5). While Student t-test between individual groups showed that immersion of stone in NaOCl 0.525% for 10 min results in surface hardness values comparable to that of control
1.385 1.38 1.4 1.2 1 0.816 0.8 0.6 0.4 0.2 Naocl5%group Microwave Control group 0
(Fig. 1) Bar chart of surface roughness results (Table 2) ANOVA one way among groups for surface roughness test
F-test Among groups *P<0.05 Significant 6.137 P-value 0.0093 Sig S*
(Table 3) t-test between groups for surface roughness test

t-test Control & Naocl5% group Control & Microwave Microwave & NaOCl 525% group *P<0.05 Significant **P>0.05 Non significant ***P<0.01 High significant 0.459 2.211 16.511 P-value 0.657 0.049 P<0.01 Sig NS** S* HS***
(Table 4) statistics of Shore D Hardness test

Control group Min Max Mean SD SE 73 76 75,4 1,264 0,4002 Sodium hypochorite 0,525% group 73 77 75 1,885 0,596 Microwave group 68 70 68,8 1,032 0,326 77 75 75.4 75 73 71 68.8 69 67
Microwave group Sodium hypochorite 0.525% group Control group
65
(Fig. 2) Bar chart of surface hardness results
(Table 5) ANOVA one way among groups for hardness test

F-test among groups 62.452 P<0.01 High significant P-value P<0.01 Sig HS
explanation for (sodium hypochlorite group) could be related to time of disinfection after 24hrs from initial set means that stone cast has reached complete set and immersed once for 10 min (not repeated immersion) that do not cause any effect on surface roughness.16 For the microwave group after 24hrs from mixing, dental stone cast still contain excess water so microwave irradiation lead to rapid evaporation of excess water.11,18 Microwaving is energy conversion and not conduction heating as in a conventional oven. Microwave absorbent materials such as dental stone convert this energy into endothermic heat because of molecules friction with a short time.18 The presence of excess water in the cast material weakens the structure. During the drying process after the last traces of water disappear, fine crystals of gypsum precipitate.14 The lower power level used in this study 650 watt suggested by Tuncer et al. 199319 because high power lead to rapid escape of water from dental stones and may be harmful to the material, causing holes and cracks on the outer surface which may lead to fracture during handling.19 In our study microwave disinfection was performed after 24hrs from initial set, because microwaving of extremely wet casts may crack the casts due to rapid boiling of the free water.20 Microwave irradiation not only disinfects the cast but produce dry cast with increased strength in order to be handled without damage.14 Disinfection of dental stone casts with microwave energy can be repeated after trail procedure of the prosthesis.21 Increasing time of microwave irradiation more than 10 min had no additional antimicrobial effect as concluded by the study of Abass et al. 2011.22 For the surface hardness the present study found that chemical disinfection with immersion in NaOCl 0.525% did not affect surface hardness as compared with control group P value = 0.591. This finding agrees with Abdleziz et al. 2002,15 a study which concluded that using aqueous solutions of chemical disinfectant in mixing dental stones does not reduce the surface hardness of stone cast with respect to differences between both studies. However it was surprising to find that microwave disinfection significantly reduce surface hardness of dental stone casts compared to the control group and NaOCl 0.525% (Table 6). The result agree with those of Luebke and Chan 1985,23 a study stated that microwave drying of stone cast after 24hrs from pouring cause reduction in surface hardness. The causative factor is the rapid removal of uncombined water from the casts leaving holes and cracks in the surface.23 This is in agreement with the study of Abass et al. 2011.22 This study found that microwave irradiation of stone casts significantly increase surface porosity that eventually leads to reduction in surface hardness.22 Disinfection procedures mentioned in the present study need more research to evaluate their effect on other mechanical and physical properties of dental stone casts.
(Table 6) t-test between groups for surface roughness test

t-test Control group & Sodium hypochorite 0,525% group Control group & Microwave group Sodium hypochorite 0,525% group &Microwave group *P>0.05 Non significant **P<0.01 High significant 0.557 10.104 10.147 P-value 0.591 P<0.01 P<0.01 Sig NS* HS** HS**
(Table 6) P- value = 0.591, no significant difference in comparison with control, while microwave irradiation group showed highly significant difference in comparison with control and NaOCl group P<0.01. Microwave disinfection causes highly significant reduction in surface hardness (mean 68.8) as compared with control and NaOCl group mean (75.4), mean (75) respectively.
DISCUSION Dental gypsum casts are possible routes of transmission of pathogenic microorganisms for at least the first 24hrs This is the period of time during which the cast are most likely to be handled by dental and laboratory personnel.10 Therefore all the dental gypsum casts arriving at dental laboratory should be disinfected before handling. Immersion method of dental stone cast in NaOCl 0.525 % for 10 min is a well established method to disinfect dental stone cast that provide high antimicrobial activity.5 However repeated immersion of dental stone casts in 0.525% NaOCl and subsequent drying could affect the mechanical and physical properties of dental stone cast.16 Microwave irradiation was introduced as an alternative effective disinfection method which could be used in the dental office and dental laboratory.12 In the present study disinfection procedure was performed after 24hrs from the initial set of dental stone, because the first 24hrs the cast is still wet did not reach sufficient strength and hardness for best manipulation of gypsum cast17. It was surprising to find that microwave irradiation of dental stone for 10 min at 650 watt resulted in surface roughness significantly lower than control group P- value (0.049) and highly significantly lower than group immersed in NaOCl 0.525% for 10 min P-value (P < 0.01) (Tables 1,2,3). While chemical disinfection methods in the present study NaOCl 0.525% group result in surface roughness value comparable to control group, the microwave disinfection lead to smoother surface of gypsum cast than control group. This is better than using aqueous solutions of chemical disinfectants in mixing dental stones which adversely affect surface roughness.15 The scientific
As conclusion, disinfection of dental stone casts with immersion in 0.525% sodium hypochlorite for 10 min resulted in surface roughness and hardness values comparable to that of control group. However disinfection with microwave irradiation at 650 watt for 10 min leads to smoother casts with reduced hardness. REFERENCES
1. Sofou A, Larsen T, wall B, Fiehn N-E. In vitro study of transmission of bacteria from contaminated metal models to stone models via impressions. Clin Oral Invest. 2002;6:166-70. 2. Verran J, Kossar S, McCord JF. Microbiological study of selected risk areas in dental technology laboratories. Journal of Dentistry. 1996;24:77-80. 3. Taylor RL, Wright PS, Maryan C. Disinfection procedures: their effect on the dimensional accuracy and surface quality of irreversible hydrocolloid impression materials and gypsum casts. Dental Materials. 2002;18:103-10. 4. Rentzia A, Coleman DC, ODnnell MJ, Dowling AH, OSullivan M. Disinfection procedures: their efficacy and effect on dimensional accuracy and surface quality of an irreversible hydrocolloid impression material. Journal of Dentistry. 2011;39:133-40. 5. Tarik EM, Al-Ameer SS. The effect of storage time and disinfection method on the activity of some dental stone disinfectants. Journal of Baghdad Dentistry College. 2005;17(3):8-12. 6. Anusavice KJ. PHILLIPS Science of Dental Materials. Tenth edition W.B. Saunders company Philadelphia Pennsylvania USA. 1996:208. 7. Berg E, Nielsen , Skaug N. Highlevel microwave disinfection of dental gypsum casts. International Journal of Prosthodontics. 2005;18(6):520-5. 8. Berg E, Nielsen , Skaug N. Efficacy of high level microwave disinfection of dental gypsum casts: the effects of number and weight of casts. International Journal of Prosthodontics. 2007;20(5):463-4. 9. Schwartz RS, Hensly DH, Bradley DV. Immersion disinfection of irreversible hydrocolloid impressions in PH-adjusted sodium hypochlorite Part 1: microbiology. Journal of Prosthodontics. 1996;9(3):217-22. 10. Ivanovski S, Savage NW, Brockhurst PJ, Bird PS. Disinfection of dental stone casts : antimicrobial effects and physical property alterations. Dental Materials. 1995;11:19-23. 11. Hassan RH. The effect of microwave disinfection on tensile strength of dental gypsum. Al- Rafidain Dental Journal. 2008;8(2):213-8. 12. Rohrer MD, Bluard RA. Microwave sterilization. Journal of American Dental Association. 1985;110(2):194-8. 13. Abdelaziz KM, Hassan AM, Hodges JS. Reproducibility of sterilized rubber impressions. Brazilian Dental Journal. 2004;15(3):20913. 14. Hersek N, Canay , Aka K, ifti Y. Tensile strength of type IV dental stones dried in a microwave oven. The Journal of Prosthetic Dentistry. 2002;87(5):499-502. 15. Abdleaziz KM, Combe EC, Hodges JS. The effect of disinfectants on the properties of dental gypsum, Part 2: surface properties. Journal of Prosthodontics. 2002;11(4):234-40. 16. Abdulla MA. Surface detail, compressive strength, and dimensional accuracy of gypsum casts after repeated immersion in hypochlorite solution. The Journal of Prosthetic Dentistry. 2006;95(6):462-8. 17. Craig RG. Restorative dental materials. 10th edition Mosby St. Louis Missouri USA.1997:334-44. 18. Hasan RH, Mohammad K. The effects of drying techniques on the compressive strength of gypsum products. Al-Rafidain Dental Journal. 2005;5(1):63-8. 19. Tuncer N, Tufekioglu HB, Calikkocaoglu S.. Invetigation on the compressive strength of several gypsum products dried by microwave oven with different programs. The Journal of Prosthetic Dentistry. 1993;69:(3)333-9. 20. Luebke RJ, Schneider RL. Microwave oven drying of artificial stone. The Journal of Prosthetic Dentistry. 1985;53:(2)261-5. 21. Kumar RN, Karthik KS, Maller SV. Infection control in Prosthodontics. Journal of Indian Academy of Dental Specialist. 2010;1(2):22-4. 22. Abass MS, Mahmood MA, Khalaf BS. Effect of microwave
irradiation on disinfection, dimensional accuracy, and surface porosity of dental casts. Mustansiriyah Dental Journal. 2011;8(2):177-87. 23. Luebke RJ, Chan KC. Effect of microwave oven drying on surface hardness of dental gypsum products. The Journal of Prosthetic Dentistry. 1985;54(3):431-5.
Eruption of Oral Lichen Planus After Interferon Therapy for Hepatitis C Infection: Case Report
Wafa Ali Al-Shamali - BDS, MFDS-RCSI, FRCD (C) Specialist in Oral Medicine and Pathology, Farwaniya Dental Specialty Center - Kuwait wshamali2@yahoo.com Mohamed Ahmed El-Khalawany - MD, ICDP Specialist, Farwaniya Hospital- Dermatological Department - Kuwait Rasha Matter Al-Shemmari - MD, MRCGP (INT) Specialist Family Medicine, Dasman Center - Kuwait Saqer Abdulrahman Al-Surayei - MD, FRCP Gastro-Canada Senior specialist, Farwaniya Hospital, Department of Gastroenterology - Kuwait
ABSTRACT Background: The association between oral lichen planus (LP) and hepatitis C virus infection (HCV) has been discussed in several papers worldwide. The exact pathogenesis of oral LP in HCV-positive patients is still uncertain. There are several studies, which highlight the role of alpha-interferon (INF) being used for treatment of HCV- positive patients, resulting in eruption or exacerbation of oral LP . Case description: We present a case of erosive LP limited to oral cavity in a 44-year-old Egyptian man with chronic HCV infection who was treated with INF and ribavirin. Despite an extended period of treatment, there was no significant effect on the viral activity (viral load). Interestingly, following five months of termination of anti-hepatitis therapy, there was recurrence of oral LP lesions which was confirmed histopathologically. His condition improved dramatically by Protopic cream 0.1%. Conclusion: Altered immunogenicity of HCV appears to be the likely explanation, hence understanding the importance of follow-up of the patient post anti-hepatitis C therapy. KEYWORDS Oral lichen planus, Hepatitis C infection, Alfa-interferon. INTRODUCTION Oral lichen planus (LP) is a relatively common chronic inflammatory condition that affects the oral mucous membrane with variable clinical traits. Since the first description of oral LP associated with hepatitis C infection was reported in 1991,1 there have been several reports suggesting the association between HCV infection and oral LP .2 Many studies have showed higher prevalence (1.6-20%) of oral LP in HCV-positive patients.2-7 In contrast, some researchers found weak or no correlation between chronic HCV infection and LP .8-11 A region-based correlation between HCV infection and LP has been described by some researchers worldwide.12 However, the possible etiopathogenic mechanism that links the two diseases remains unclear. Immunogenic dysregulation of host infected with HCV, reaction to anti-hepatitis medications particularly alpha-interferon or viral infection are considered to be the current acceptable etiopathogenic factors causing oral LP .12-13
The clinical and histological features of oral LP associated with hepatitis C infection subjects are no different from the control patients. Although, erosive form of oral LP is common clinical phenotype noted in seropositive hepatitis C individuals, the management of oral LP in patients with or without hepatitis remains the same. CASE REPORT A 44-year-old Egyptian male was referred from dermatology department at Farwaniya hospital to oral medicine clinic, who presented with painful and swollen ulcerated lower lip on March 2010. On examination, there was apparent swollen lower lip with central erosive areas oozing fresh blood from the eroded surfaces on light palpation, and there were white fine and coarse lace-like mucosal changes abutting the eroded lesions (Fig. 1). Also, there was bilateral lymphadenopathy with mobile, tender lymph nodes palpable in the submandibular triangular region.
lesions were seen on the rest of oral cavity mucosa. The clinical presentation of the lip and oral cavity lesions were consistent with LP . On reviewing his medical history, he had been diagnosed with hepatitis due to HCV infection (genotype 4) in 2008 for which he received combined therapy of pegylated interferon-alpha (180mcg SC, weekly for 48 weeks) and ribavirin (1000mg PO daily for 48 weeks). The patient reported an oral soreness and burning sensation after one month of the anti-hepatitis therapy inception for the first time. The exact diagnosis of oral lesion and subsequent therapy provided by dermatology department had not been known to us. Nevertheless, oral condition was quiescent through the period of the therapy. The oral symptoms reappeared five months following discontinuation of anti-hepatitis therapy with increased severity resulting in severe pain, difficulty in eating, swallowing and speaking. In addition, he noticed progressive swelling of the lower lip with bleeding ulcers over the next 6 weeks. Besides his known medical condition, he is on insulin to manage his diabetes (type II). Furthermore, he is not a cigarette smoker and he does not drink alcohol. An incision biopsy of lower lip lesion revealed interface dermatitis confirming our clinical provisional diagnosis. Microscopically, the specimen exhibited ortho-keratosis with prominent granular layer, intense band-like lymphohistiocytic infiltrate with plasma cell predominance and hydropic degeneration of basal cell layer with scattered Civatte bodies. (Figs 4-6)
(Fig. 1) shows a swollen lower lip with central erosive and hemorrhagic areas
(Figs 2-3) Exhibit lichenoid changes reticular pattern on right (A) and left (B) buccal mucosae
Intra-oral examination revealed bilateral white and red lesions on posterior part of the buccal mucosa. These lesions had striking reticular pattern (reminiscent of LP) centered on erythematous mucosal areas. The lesion on right buccal mucosa was found rubbing against heavily restored molar tooth with amalgam (Figs 2,3). No other
(Fig. 4) reveals interface dermatitis (Hematoxylin and eosin stain at lower magnification 4X plain)
The patient was treated with protopic cream 0.1% three-four times daily for 2 weeks. The lower lip status improved dramatically. (Fig. 7)
DISCUSSION Among viruses, human herpes viruses, human papilloma virus and hepatitis viruses have been linked with oral LP , albeit on the basis of equivocal data.12 There have been several studies, which suggest an association between LP and HCV infection.3-7 In a recent review the pooled data from all studies revealed a statically significant difference in the population of HCV seropositive subjects among LP patients when compared with the controls. Interestingly, geographic heterogeneity seems to play an important role in this LP-HCV association. As indicated by studies from the Mediterranean basin showing a significant association whereas studies from Northern Europe did not present any such association. Furthermore, in studies from countries with high prevalence such as Egypt, negative or insignificant association between HCV infection and oral LP has been reported.12,14 The discrepancy may be explained by genetic differences among the population studies and this may possibly be the reason for development of LP in our patient. The exact etiopathogenesis of oral LP in HCV-positive individual is still uncertain. Nonetheless, eruption of oral LP in our case could have resulted from a lichenoid reaction to the medication used in the treatment of hepatitis C, particularly alpha-interferon. This hypothesis (i.e. drug reaction) was plausible in some studies.15-20 Most of these case reports demonstrate the aggravating effect of the interferon rather than causative effect for the development of oral LP in patient with HCV infection. Besides, in our case, reappearance of severe erosive oral LP while not receiving INF therapy, suggests that it may not have played a significant role in its pathogenesis. Nonetheless, this may be viewed as it having more aggravating rather than causal effect. Therefore, it would be a good practice to screen the oral cavity of HCV-positive patients prior to initiating antiviral therapy. So, the possible eruption of oral LP can be anticipated and managed appropriately especially in those with quiescent LP . Besides INF therapy, other confounding factors appeared to have contributed to the possible initiation or aggravating already present of oral LP in our case, such as presence of amalgam on right mandibular molar and chronic rubbing of buccal mucosa. Unfortunately, we are not aware of the intra-oral examination findings of the patient prior to anti-hepatitis treatment. Also, there is plethora of literature suggesting role of immune dysregulation in the pathogenesis of oral LP involving the cell-mediated immunity. However, viral factors, such as genotypes of HCV and HCV-RNA levels, are less important pathogenic cause.12
(Fig. 5) Reveal hydropic degeneration with intense lymphohistoicytic infiltrates. (Hematoxylin and eosin stain at higher magnification 20X)
(Fig. 6) Shows prominent Civatte body (*)
(Fig. 7) shows dramatic improvement of lower lip lesion after two weeks of topical tacrolimus use
Why oral mucosa is most frequently affected is still unknown. Several experimental studies conducted proposing a theory of compartmentalization of mucosa that still does not give a clear explanation to this phenomenon.21,22 In HCV seropositive subjects, erosive oral LP is commonly prevalent lesion.23,24 Mega et al.25 noted three types of OLP . He found lymphocytic inflammation deeply infiltrating lamina propria in OLP associated with a HCV infection and that could be associated with the erosive trait, as noted in our case. Management of HCV associated oral LP lesion is no different from oral LP in HCV-negative subjects. Since there is no cure different therapies are aimed primarily to ameliorate the signs and symptoms of oral LP . Although corticosteroids have been the mainstay of management, other immunosuppressant and immunomodulatory agents have also contributed significantly towards treatment of the disease.12,26-28 A comparative systemic review of 28 randomised controlled clinical trials of therapy for symptomatic oral LP has concluded that there is insufficient evidence to support the effectiveness of any specific treatment as being superior.26,29 A plausible therapeutic approach should be guided by severity of the patients condition. In our case, tacrolimus cream (0.1%) was prescribed and used three to four times daily for 2 weeks. Some studies recommend use of tacrolimus as second line of treatment especially in reluctant lesion. We preferred to use it due to severity of the lesion, which is found to be effective in other studies.12,26 In order to prevent a flare up of the condition, we avoided use of systemic immunosuppressant therapy. Up to the time of writing this case report, his oral condition is fairly controlled with topical steroids in addition to tacrolimus. Due to chronicity of LP , relapses of his oral condition did occur but with lesser frequency and severity. The potential for malignant transformation of OLP is still controversial. The frequency ranges from 0.4% to 6.25% with the highest rates in the erythematous and erosive lesions.30-32 Follow up is mandatory not only to control his oral LP but also to detect early malignant transformation. REFERENCES
1. Mokni M, Rybojad M, Puppin D. Lichen planus and hepatitis C virus. J Am Acad Dermatol. 1991;24(5 Pt 1):792. 2. Nita Chainani-Wu, Francina Lozada-Nur, Norah Terrault. Hepatitis C virus and Lichen planus: a review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004; 98(2):171-83. 3. LC Figueiredo, F Carrilho, HF De Andrade, DA Miglian. Oral Diseases. 2002;8(1):42- 6. 4. Ghaderi R, Makhmalbaf Z. Shiraz E-Medical Journal. 2007;8(2):72-9.
5. Sanchez-Perez J, De Castro M, Buezo GF, Fernandez-Herrera J, Borque MJ, Garcia-Diez A. Lichen planus and hepatitis C virus: prevalence and clinical presentation of patients with lichen planus and hepatitis C virus infection. Br J Dermatol. 1996;134(4):715-9. 6. Thais Dias Tavares Guerreiro, Marilia Moura Machado, Thais Helena Proenca de Freites. Association between lichen planus and hepatitis C virus infection: a prospective study with 66 patients of the dermatology department of the hospital Santa Casa de Misericordia de Sao Paulo. An Bras Dermatol. 2005;80(5):475-80. 7. Nima Mahboobi, Farzaneh Aga-Hosseini, Kamran Bagheri Lankarani. Hepatitis C virus and lichen planus: the real association. Hepat Mon. 2010;10(3):161-4. 8. Simon C, Tucker and Ian H. Coulson. Lichen planus is not associated with hepatitis C virus infection in patients from North West England. Acta Derm Venereol. 1999;79:378-9. 9. Karin Soares Goncalves Cunha, Angela Correa Manso, Abel Silveira Cardoso, Jacqueline Bittencourt Althoff Paixao, Henrique Sergio M. Coelho, Sandra Regina Torres, and Rio de Janeiro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:330-3. 10. Yu Zhou, Lu Jiang, Jie Liu, Xin Zeng, Qian-ming Chen. The prevalence of hepatitis C virus infection in oral lichen planus in an ethnic Chinese cohort of 232 patients. Int J Oral Sci. 2010;2(2):90-7. 11. Del Olmo JA, Pascual I, Bagan V, Serra MA, Escudero A, Rodriguez F, Rodrigo JM. Prevalence of hepatitis C virus in patients with lichen planus of the oral cavity and chronic liver disease. Eur J Oral Sci. 2000;108(5):378-2. 12. Giovanni Lodi, Crispian Scully, Marco Carrozzoo, Mark Griffiths, Philip B. Sugerman, and Kobkan Thongprasom. Current controversies in oral lichen planus: report of an international consensus meeting. Part1. Viral infections and etiopathogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:40-51. 13. A. A. Al Robaee and A. A. Al Zolibani, et al. Oral lichen planus and hepatitis C virus: is there real association? Acta Dermatoven APA. 2005;15(No1):14-9. 14. G. Lodi, M. Giuliani, A. Majorana, A. Sardella, C. Bez, F. Demarosi, A. Carrassi, et al. Lichen planus and hepatitis C virus: a multicentre study of patients with oral lesions and a systematic review. British journal of drematology. 2004;151(6):1172-81. 15. Nagao Y, Sata M, Ide T, Suzuki H, Tanikawa K, Itoh K, Kameyama T. Development and exacerbation of oral lichen planus during and after interferon therapy for hepatitis C. Eur J Clin Invest. 1996;26(12):1171-4. 16. Nagao Y, Kawaguchi T, Ide T, Kumashiro R, Sata M. Exacerbation of oral erosive lichen planus by combination of interferon and ribavirin therapy for chronic hepatitis C. Int J Mol Med. 2005;15(2):237-41. 17. Grossmann Sde M, Teixeira R, de Aguiar MC, do Carmo MA. Exacerbation of lichen planus lesions during treatment of chronic hepatitis C with pegylated interferon and ribavirin. Eur J Gastroenterol Hepatol. 2008;20(7):702-6. 18. Barreca T, Corsini G, Franceschini R, Gambini C, Garibaldi A, Rolandi E. Lichen planus induced by interferon-alpha-2a therapy for chronic active hepatitis C. Eur J Gastroenterol Hepatol. 1995;7(4):367-8. 19. Protzer U, Ochsendorf FR, Leopolder-OchsendorfA, Holtermuller KH. Exacerbation of lichen planus during interferon alfa-2a therapy for chronic active hepatitis C. Gastroenterology. 1993;104(3):903-5.
20. Areias J, Velho GC, Cerqueira R, Barbedo C, Amaral B, Sanches M, Massa A, Saraiva AM. Lichen planus and chronic hepatitis C: exacerbation of the lichen planus under interferon-alpha-2a therapy. Eur J Gastroenterol Hepatol. 1996;8(8);825-8. 21. Carrozzo M, Quadri R, Latorre P , Pentenero M, Paganin S, Bertolsso G. Molecular evidence that the hepatitis C virus replicates in the oral mucosa. J Hepatol. 2002;37:364-9. 22. Pilli M, Penna A, zerbini A, Vescovi P , Manfredi M, Negro F. Oral lichen planus pathogenesis: a role for the HCV-specific cellular immune response. Hepatology. 2002;36:1446-52. 23. Carrozzo M, Grandolfo S, Carbone N, Colombatto P , Broccoletti R, Garzino-Demo P , Ghisetti V. J Oral Pathol Med. 1996;25(10):52733. 24. Michele D, Mignogna MD, Lucio Lo Russo, et al. Oral lichen planus: different clinical features in HCV-positive and HCVnegative patients. Int J Dermatol. 2000;39(2):134-9. 25. Mega H, Jiang W, Takagi M. Immunohistochemical study of oral lichen planus associated with hepatitis C virus infection, oral lichenoid contact sensitivity reaction and idiopathic oral lichen planus. Oral diseases. 2006;7(5):296-305. 26. Thongprasom K, Carrozzo M, FurnessS, Lodi G. Intervension for treating oral lichen planus. Cochrane Database of Systemic Reviews 2011, Issue 7. 27. N Lavanya, P Jayanthi, Umadevi K Rao, K Ranganathan. Oral lichen planus: An update on pathogenesis and treatment. J Oral Maxillofac Pathol. 2011;15:127-32. 28. Mahnaz Sahebjamee, Fatemeh Arbabi-Kalati. Management of oral lichen planus. Archives of Iranian Medicine. 2005;8(4):52-6. 29. Analia Veitz Keenan and Debra Ferraiolo. Insufficient evidence for effectiveness of any treatment for oral lichen planus. Evidence-based dentistry. 2011;12:85-6. 30. Giovanni Lodi, Crispian Scully, Marco Carrozzoo, Mark Griffiths, Philip B. Sugerman, and Kobkan Thongprasom. Current controversies in oral lichen planus: report of an international consensus meeting. Part1. Viral infections and etiopathogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:164-78. 31. Atessa Pakfetrat, Abbas Javadzadeh-Bolouri, Samira BasirShabestari, Farnaz Falaki. Oral lichen planus: A retrospective study of 420 Iranian patients. Med Oral Patol Oral Cir Bucal. 2009;14(7):E315-8. 32. Marija Bokor-Bratic, Ivana Picuric. The prevalence of precancerous oral lesions. Oral lichen planus. Archive of oncology. 2001;9(2):107-9.
Yoga for Dental Career Longevity

Tetyana Ratushnyak Certified full time Yoga Teacher and Fitness Class Instructor Amman - Jordan / Shenzhen China 4mywork2011@gmail.com
ABSTRACT Dental professionals are always at high risk for musculoskeletal disorders and mental stress due to the nature of their work. This article will discuss work related injuries among dentists and will introduce Yoga Techniques to prevent and recover from these injuries; specifically designed postures will be described to practice in-office time between appointments, as well as breathing techniques and relaxation. Aim: To introduce Yoga practice to Dental Professionals and discuss techniques that are able to prevent and treat common injuries at work. To aquante dental professionals with Meditation, Pranayama (breathing) & Relaxation techniques for their own and their patients benefit. Conclusion: Several studies and tests have shown great improvement implementing Yoga practice into daily life among dental practitioners with different work related health issues. Physical Yoga practice improved postures and strength of the musculoskeletal system, mental relaxation and meditation helps to reduce work related stress and breathing techniques helped to calm and focus the mind. Better health better productivity at work and a better, longer life. KEYWORDS Dentist, Work-related injury, Musculoskeletal Disorder (MSD), Yoga, Stretching.
INTRODUCTION Being a dentist for a while, how often have you noticed headaches, back and neck pain, or stiffness in your arms? How many colleagues have complained of serious spine injuries or joint pain? Working full day, without brakes, trying to accept as many clients a day as possible, treating their health problems, often you neglect your own health by focusing on your work? Musculoskeletal disorders (which include repetitive-motion disorders and conditions such as carpal tunnel syndrome and hand-arm vibration syndrome) are among the most common medical problems, affecting at least 7% of the population and accounting for 14% of all doctor visits. Work-related musculoskeletal disorders make up 34% of lost workday injuries. These are the injuries that result from repetitive work, awkward or constrained postures, heavy lifting, pinching grasps, forceful movements, and vibrating tools. Work-related musculoskeletal disorders are the nations leading job-safety problem, causing more than 600,000 workers to lose work time each year and costing an estimated $15 to $20 billion in worker compensation costs and lost productivity.1 Musculoskeletal pain is more frequently noted by oral health providers than any other occupational hazard, including communicable diseases and other physical and emotional disorders. A survey published in the Journal of the California Dental Association in February 20022 found that 61% of dentists surveyed said they had
experienced work-related neck pain during the year; 51% reported lower-back problems; 44% said they had shoulder pain; 43% had upper-back pain; 38% reported hand pain; 30% mentioned mid-back pain; 14% indicated arm pain; and 10% reported leg pain. Dentists lose millions of dollars a year because they have to cancel patient appointments or cant work due to musculoskeletal pain. In 1987, dentists had to cancel 1.3 million patient appointments and lost income amounting to $41 million more than $65 million in todays dollars.3 (At present time, more recent statistics could not be located. Obviously there is need for additional study in this area). There have been a number of studies done on dental hygienists, a population that is overwhelmingly female. Although the tasks performed by hygienists are different, studies of this group may be a good indication both of the risks involved with the types of motions female dental professionals make and of the effects on women of using dental tools in a work environment designed primarily for men.4 A study published in September 2002 issue of the American Journal of Industrial Medicine5 found that a large percentage of dental hygienists reported workrelated musculoskeletal disorders, especially in the wrist, neck, and upper back. In fact, more than 90% had experienced at least one musculoskeletal complaint in a 12-month period.
According to the number of participants in those studies and the amount of work dentist loose due to their health issues caused at work, we can definitely say that it is a major problem business wise as well as health wise. And what could be more important than your own health after all? METHOD I am sure you have heard about Yoga, maybe have seen the practice or tried Yoga before. Yoga is an ancient (5000 years old) form of mind and body discipline. Originally Yoga teachings were a path towards enlightenment and purity of the soul. Yoga has entered the western world around 200 years ago and became a very unique form of physical therapeutic exercises for the body, which occupied most of the western gyms nowadays. Yogic breath is used to relieve symptoms of anxiety and panic attacks, relaxation techniques are used to let go of physical stress and meditation is used to free and focus the mind. The number of yoga practitioners is growing every day. Yoga practice entered corporate groups and offices, cancer patients, schools and army. In the United States yoga practice has also entered Dental Offices as remedy against work related injuries, that are developed day after day and appearing as threatening towards business and dentists health. I would like to introduce five common work related injuries and health complications among dentists, developed by working posture, tools and general environment at the office: 1. Vision Problems 2. Chronic Back Pain 3. Tension Neck Syndrome 4. Carpal Tunnel Syndrome 5. Stress Taking each of these injuries separately one by one, like the complications in a dentist life or their health & business being affected by their work related injuries are growing daily by big numbers. You may avoid working in pain and discomfort; have an early retirement, and never with poor health conditions by living through your daily routine with Yoga practise and philosophy. Off course its impossible to see changes within your body after the first, second or even the 10th practice; but bit-by-bit, your body will build a strong foundation for a better healthier life through years of practice. VISION The fastest way to bring the mind into concentration is through the eyes -Swami Sitaramananda.6 It is said, the face is the index of the mind and the eyes are the windows of the soul. On a tangible level, eyes are our only windows to the world.
Dentist eyes need care and attention. As years go by, the muscles around the eyes lose their tone. Eyesight becomes weak after the muscles around the eyes lose their elasticity and become rigid, thereby reducing the power to focus on different distances. In addition, tension around the eyes affects the brain causing stress and anxiety. Poor lighting, concentration on a small object on a short distance, and mental stress are playing big role in loosing healthy vision. What can a dentist do without great sharp vision at work? Not much, and the sad thing is that in daily life it can become frustrating. Here are some tips that you can try at the office today that may save your eyesight tomorrow. Eyesight is dramatically improved when the muscles of the eyes are relaxed. There is a deep correlation between the eyes and the mind. It is said that vision occupies 40% of the brains capacity. Therefore, when we close our eyes, relaxation is induced in the brain. Eye health corresponds to the level of relaxation it experiences. Eye on yoga Yoga plays a significant role in promoting eye health. A yoga routine replete with asanas, pranayama and meditation helps in achieving peace and tranquility. Yogic eye exercises strengthen the muscles of the eyes and thus help in curing many ailments of the eyes. Certain eye exercises are known to completely rectify eye problems. With yoga, people begin treating their eyes with care, which reflects in good eye health. The renowned late William H. Bates,7 an ophthalmologist, claimed that vision could be improved with eye exercises like palming and eyeball rotations. So, eye exercises are important to any individual and should be incorporated into the regular yoga routine. These exercises can be performed at any time of the day. Before beginning the eye exercise, sit up tall at your desk, with your forearms on the desk. Palming 1. To do this pose, sit at your desk with elbows supported and close your eyes. 2. All the body parts from the toes to the head should be in a relaxed state. 3. In this relaxed posture, total calmness, and peace is felt when the whole body and mind have taken complete rest. 4. Warm up your palms by rubbing them tightly, to bring positive warm energy up to awakening in between your palms. 5. Breathe easily; try not to force your breath at any point. 6. Gently cover your eyes with palms and imagine complete darkness. Let your muscles and nerves rest, letting go from any tension from your eyes, relax for a couple of minutes during your work day.
Chronic Back Pain Around 80% of dentists suffer from back pain during their career and of those who retire prematurely, 30% do so because of persistent back pain.8 Chronic back pain management can have physical and emotional benefits. Chronic pains emotional effects include depression, anger, anxiety, and fear of re-injury, which may hinder the ability to return to work or once enjoyable activities. The emotional toll of chronic pain also can make pain worse. Anxiety, stress, depression, anger, and fatigue interact in complex ways with chronic pain and may decrease the bodys production of natural painkillers; moreover, such negative feelings may increase the level of substances that amplify sensations of pain, causing a vicious cycle of pain. Allow yourself to twist and bend forward every 2 hours. This will bring more blood and fluids into your stiff muscles and mobilize the spine it self. Back pain is one particularly crucial problem that is in a dentists best interest to avoid. A good seating position and correct posture is vital for the efficient practice of dentistry and to avoid chronic back pain. In order to do this, it is important to begin learning the correct posture to use while treating. Recent study has however concluded that body pain is prevalent even among dental students.9 It has been found that the constant replication of certain movements, such as the many movements that a dentist will perform whilst treating patients in general practice, can contribute to chronic body pain and bad posture. Head posture should be 0-20 degrees, forearms parallel to the floor or angles upward 0-10 degrees and reach 0-25 degrees, hip angle 105 125 degrees, feet flat on the floor and spread apart slightly, back supported by the stool.
Palming Relaxes More Than Your Eyes You may find that palming relaxes more than your eyes. Notice if your shoulders, neck, and other tight spots start to let go while you palm. This would be no surprise to Dr. Bates. He observed that eyestrain can go hand in hand with rigidity all through the body. Many yoga teachers also note this connection of eyestrain with other body tensions. You dont need to compete with the man who palmed 20 hours in one sitting. Palming just a few minutes in the morning, at night, or while at work can be very restful. Many people report clearer vision and a reduction of symptoms such as headaches and dry eyes with regular palming. These days it is often associated with doing eye exercises. This is not what Dr. Bates taught. He recommended not eye exercises but the use of relaxed natural vision habits all day long. Eyeball Rotation 1. Sit up tall at the desk, with your forearms on the table. 2. Close your eyes for a moment and take couple of natural, deep breaths. 3. Gently open up your eyes and roll the eyeball in a slow circular motion for 10 times in one direction and then the other. You should be able to see your eyebrows, corners of the eye and cheeks (can be done with your eyes closed). 4. Than close your eyes and take couple of breaths.
A bad posture equals bad health. Shoulder, back pain, reduced lung function and capacity 30% with head leaning forward, gastrointestinal pains, vital organ compression and weakening of abdominal muscles. Try these easy steps while you are on a break or in between changing shifts. Spinal Twist 1. Sit up tall, slide to the edge of the chair slightly, feet right under your knees, thighs parallel to the floor (adjust your stool upwards or downwards). 2. Cross left leg over your right. 3. Cross right arm over your left knee & hold on onto the back of your stool/chair with your left arm. 4. Twist to your left side, helping the rotation with your arms. Gently rotate to the maximum to your left side and slightly turn your head over the left shoulder. 5. Take 5-10 deep and easy breaths, with every inhalation lifting up through your spine, with every exhalation relaxing the back muscles. Do not perform if you have severe disc case. Do not perform if not advisable by your physician. Cat Cow Spinal Stretch 1. Stand on your hands and knees, each arm directly under the shoulder, each knee directly under your hip. 2. Flex your feet by curling toes under. 3. On inhalation drop the spine down, rotating shoulders back, pointing head and tailbone upwards. 4. On exhalation round your spine by arching upwards, squeeze your belly button in and press into the floor firmly. 5. Repeat slowly up to 10 times. Forward Bend Stretch 1. Sit down on the floor or a chair with both legs together, straight knees and feet flexed. 2. With straight spine, reach
down your legs as far as you can go and stop at the level where you feel nice and relaxing stretch in your hamstrings and back. 3. Take up to 5-10 relaxing breath and come back up to seating straight. 4. Repeat for several times. Tension Neck Syndrome Consequently it is unsurprising that more than 70% of dentists suffer from neck ache as a direct result of their jobs, often leading to conditions such as TNS (tension neck syndrome, a major cause of headaches and arm and shoulder pain) and cervical disc degeneration or spondylosis.10 Unnatural and static positions of the arms with raised elbows and shoulders, as well as the need for excessive force increase the static muscular load. Mental strain such as monotonous work conditions, need for concentration and much responsibility, together with poor illumination and noise, were characteristic of most of the occupations. Both the psychological and, partially, physiological constitution of the worker may contribute to the development of the syndrome, External work factors, such as static loading of the shoulders and arms, and repetitive, high speed motions in connection with mental stress can lead to muscle in-coordination and spasm. These investigations also promise, however, that by work design and exercise at work the morbidity of this syndrome can be decreased.11 Common Causes for Neck Tension Syndrome: Sitting unsupported and leaning forward in chair for prolonged periods Anxiety, stress, and fear Insufficient back support from chair Working with your client with your elbows and forearms unsupported can create neck muscle Fatigue Repetitive head tilting and bending over the patient Common Solutions for Neck Tension Syndrome: Take regular breaks every 30-40 minutes and stretch neck muscles. Neck Rolls 1. Sit up straight at the end of the chair. 2. Place both palms onto your lap and relax your arms. 3. Gently drop your head forward exhaling. 4. On inhalation lift your chin up towards right shoulder. 5. On exhalation roll
your head back down, chin towards your chest. 6. On inhalation roll over towards your left shoulder 7. Repeat up to 10 times. Do not perform if you have had neck surgery or cervical disc herniation. Balasana or Child Pose
4. Allow all your body to relax, close your eyes and take a moment to connect to your breath. 5. After couple of moments, gently help your knees to come back up, by raising them with your arms. 6. Roll onto your side and gently come up to sitting. You may place a small pillow under your head if you feel uncomfortable in your neck. Capral Tunnel Syndrome Carpal tunnel syndrome is a condition in which there is pressure on the median nerve - the nerve in the wrist that supplies feeling and movement to parts of the hand. Carpal tunnel syndrome is caused by an inflammation or collapse of the carpal tunnel that allows nerves to pass through the wrist. It can lead to numbness, tingling, weakness, or muscle damage in the hand and fingers. The median nerve provides feeling and movement to the thumb side of the hand (the palm, thumb, index finger, middle finger, and thumb side of the ring finger). The area in your wrist where the nerve enters the hand is called the carpal tunnel. This tunnel is normally narrow, so any swelling can pinch the nerve and cause pain, numbness, tingling or weakness. This is called carpal tunnel syndrome. Carpal tunnel syndrome is common in people who perform repetitive motion of the hand & wrist using tools (especially hand tools or tools that vibrate), which is very common in dentistry. The condition occurs most often in people 30 to 60 years old, and is more common in women than men. Symptoms: Clumsiness of the hand when gripping objects. Numbness or tingling in the thumb and next two or three fingers of one or both hands. Numbness or tingling of the palm of the hand. Pain extending to the elbow. Pain in the wrist or hand in one or both hands. Problems with fine finger movements (coordination) in one or both hands. Weak grip or difficulty carrying bags (a common complaint). Weakness in one or both hands. Symptoms often improve with treatment, but more than 50% of cases eventually require surgery. Surgery is often successful, but full healing can take months. If the condition is treated properly, there are usually no complications. If untreated, the nerve can be damaged, causing permanent weakness, numbness, and tingling.12 Dental health workers reported a high incidence of work related musculoskeletal disorder (WRMD). In dental professionals, hand/wrist complaints and Carpal Tunnel Syndrome (CTS) are the most common distal upper extremity disorders in comparison with other human service
1. Sit on the floor on your heels, knees bend and slightly spread apart. 2. Lean over your knees extending through arms and even fingers forward. 3. Place your forehead on the floor(if your head doesnt reach to the floor, fold you arm placing one forearm over the other and rest your head on your arms). 4. Take a moment in this position, with every new exhalation relaxing through the whole back, shoulders and neck. This restorative pose helps to relax the body and relieve your neck. Do not perform if you have knee problems, or seat up on a pillow and than bend forward. This will elevate your bottom and change knee angle. Bharadvajas Twist 1. Gently come up from child pose 2. Place your left arm over the right knee. 3. Right arm onto your right foot from the back, and gently turn your torso to the right, twisting around the spine gently. 4. Take couple of easy breaths, lengthening through the spine with every inhalation, letting go of tension with every exhalation. 5. Repeat on the left side. Supta Baddha Konasana or Reclining Bound Angle Pose 1. Lie down on your back with your legs bend slightly. 2. Find comfortable position for your head, neck and shoulders. 3. Open up your knees to the sides and join soles of your feet together.
workers. A study was preformed to assess the efficacy of a comprehensive exercise program as an ergonomic educational program for CTS in young dentists;10 Eighty six dentists from both genders (41 females and 27 males) with age ranged from 29 to 40 years were selected according to self-administered questionnaire covering personal, symptomatic and functional information. All dentists were suffering from CTS and were classified randomly into two equal groups. The study group received a comprehensive exercise program in the form of active range of motion of the wrist\hand joints, stretching of the wrist flexors and extensors, tendon glides and strengthening exercises five days per week with ten repetitions for each exercise for six weeks. The control group did not receive any treatment program except wearing night splint when symptomatic. Pain intensity, handgrip and pinch strengths, symptom severity as well as functional status for both groups were evaluated before starting the study and after six weeks. The results revealed significant improvement in both groups regarding pain and functional scores. The improvement is more prominent in the group treated with a comprehensive exercise program in comparison to the non-exercise group. The results of the study group showed additional improvement in handgrip and pinch strengths. The finding of this study reflects the importance of using comprehensive exercises in reducing the incidence of WRMD, particularly CTS in young dentists. Because the nerves of the carpal tunnel run through the neck and arms before reaching the wrist, tension in the neck and shoulders can also aggravate carpal tunnel syndrome. Below are five tips for using basic stretches to help prevent carpal tunnel syndrome. Stretch Your Wrists and Hands13
Heres another basic stretch for your hands and arms: 1. Inhale to lift both arms out to the side and up over your head. 2. Interlace your fingers. 3. Turn your palms up to the sky and straighten your arms. As you straighten your arms and reach for the sky, be sure to draw your shoulders down away from your ears. Mudras, or yogic hand gestures, can also be good hand stretches to prevent carpal tunnel syndrome. My favorite Mudra is Pran Mudra: 1. Extend your index finger and middle finger. 2. Bring the finger pads of your ring and pinkie fingers to touch the finger pad of your thumb. Do this with both hands and then sit quietly and feel the effects of the hand stretch. Explore other Mudras to see which stretches feel best. Stretch Your Neck and Shoulders14 Tightness in the neck, chest and shoulders may be a contributing factor to carpal tunnel syndrome, and stretching these areas may help prevent carpal tunnel syndrome. The arm positions for Garudasana (Eagle Pose) and Gomukasana (Cow-Face Pose) are excellent shoulder openers. For Garudasana Arms
Incorporating hand, wrist and arm stretches into your everyday life can help prevent carpal tunnel syndrome. 1. Extend one arm out in front of you, palm facing up 2. With your other hand, guide the fingers of the extended hand down toward the ground until you feel a gentle stretch through the wrist Always repeat each stretch on both sides.
1. Wrap one arm under the other, first crossing at the elbows and then again at the wrists. 2. Lift your elbows up and draw your shoulders away from your ears. 3. After several breaths, unwrap and repeat with the other arm underneath.
For Gomukasana Arms
To enjoy satisfying professional and personal lives, dentists must be aware of the importance of maintaining good physical and mental health. A large part of effective practice management is to understand the implications of stress. Almost 1,000 American dentists attending the 1982 Association annual meeting completed a selfadministered questionnaire on sources of stress in dental practice. Most respondents identified dentistry as more stressful than other occupations.17 However, most believed that other dentists were under more stress than themselves. Dentists use a variety of ways to cope with their stress. The stressors particularly noted include falling behind schedule, striving for technical perfection, causing pain or anxiety in patients, cancelled or late appointments, and lack of cooperation from patients in the dental chair. However, all of the 25 listed during the study stressors were endorsed by at least some dentists. Among the stressors lowest in the composite ratings included: isolation from fellow practitioners, competition, monotony, lack of acceptance by patients of the preferred treatment plan, and lack of appreciation. An exploratory factor analysis leads us to hypothesize six sources in dentists stress: problems of patients compliance, pain and anxiety; interpersonal relations; the physical strain of work; economic pressures, and the strain of perfectionism and seeking ideal results. As the well-being of the dentist and that of the staff and patients are dependent on successful management of occupational strains, this topic deserves more empirical study than it has so far received. We strongly suggest more studies dealing with stresses that occur daily in the immediate environment of office, waiting room, and operatory.17 Stress management through Meditation and Yogic breath are very effective remedies against stress. These techniques are being used for cancer patients in the hospitals and for people with severe depression and anxiety. These techniques do not require any special knowledge or background anyone can do it. Breathing is a physical exercise, which can be improved with practise and afterwards done mindfully. By moving your abdominal muscles, diaphragm, lung capacity increases with proper practise, bringing more oxygen into the body. We can affect our state of the mind through breath, same way as our mind affects our breath. As we get stressed out, angry, or scared, our breath becomes short, shallow, fast an uneasy which affects our heart rate and blood pressure, leading to health complications if being affected by stress for a long period of time. As we are calm and relaxed, sleeping or awake, or we are having a walk by the side of the river or listening to
1. Extend one arm out in front of you with the palm facing up. 2. Bend your elbow and reach your palm to your upper back, pointing your elbow toward the sky. 3. With the other arm, face your palm down 4. Bend your elbow and try to bring the back of your hand to your mid-back. 5. Hook the fingers of both hands. Repeat on the other side. If you struggle with either of these shoulder stretches, use a strap to extend your reach. Be careful not to overstretch or hold your breath. Take Regular Stretch Breaks at Work15 Most yoga stretches to prevent carpal tunnel syndrome can be done discreetly while seated at your desk, and each stretch only needs to be held 15-30 seconds at a time. Taking regular stretch breaks during the day can help prevent a variety of discomforts in addition to preventing carpal tunnel syndrome. Stress Stressed out by fear and pain patients carry a lot of negative energy which of course affects dentists as well. This stress can have a negative impact on dentists personal and professional life. Dentists are faced every day with many stressors; as a result, you are subjected to many symptoms of stress that must be identified and managed in the early stages before serious physical and psychological consequences develop.16 Dentists are prone to professional burnout, anxiety disorders and clinical depression, owing to the nature of clinical practice and the personality traits common among those who decide to pursue careers in dentistry. Fortunately, breathing techniques and relaxation are the prevention strategies that can help dentists conquer and avoid these disorders.
beautiful piano music, our breath is equal, deep and relaxed. And the state of our mind is calm and relaxed. Try this Simple Technique of Pranayama 1. Seat up tall, with your spine being straight and back supported. 2. Rest your arms on your lap, shoulders relaxed and close your eyes gently. 3. Bring your attention to your breath, notice if you breathe shallow or fast. 4. Try to clear up your mind and for a moment be present with your natural breath. 5. On inhalation count 1,2,3,4 hold your breath for a second, and on exhalation count 1,2,3,4,5,6,7,8. Repeat up to 10 rounds. 6. After you reached last round take a moment in silence to just observe the state of your mind and your breath after this exercise and notice any differences, if your mind became a bit calmer, if your breath became deeper and less anxious. This type of breath brings concentration to the mind. Helps to lower blood pressure and reduce stress. A handful of scientists (and a boatload of yogis) have studied this 1-to-2 ratio breathing pattern (here we did 4 to 8 same ratio), and what theyve discovered is that by simply extending exhalations, it stimulates vagus nerve and immediately has a calming effect on the body. Diaphragmatic Breathing
4. Try not to move your chest and the palm on your chest, let the air go deep down through your chest into the abdomen. 5. Take up to 10-20 relaxed breaths and then place your hands on the side of the rib cage. Inhale, lifting the lower belly noticing the air expanding the ribs, exhale and feel rib cage contracts in. 6. Repeat for a few breaths. Practicing Diaphragmatic Breathing reduces stress and brings greater mindfulness to the body. Diaphragmatic breath stimulates the parasympathetic nervous system, which works in the opposite way to the sympathetic nervous system. Parasympathetic nervous system slows your cardiovascular system and relaxes your muscles. Diaphragmatic breathing relaxes the muscles, massages the internal organs, and allows more oxygen to flow through your body. Try out simple relaxation technique to calm your body & mind after a busy exhausting working day before you fall asleep. Progressive Muscle Relaxation
This technique is often most useful when you tape the instructions beforehand. You can tape these instructions, reading them slowly and leaving a short pause after each one. 1. Lie on your back, close your eyes. 2. Feel your feet. Sense their weight. Consciously relax them and sink into the bed. Start with your toes and progress to your ankles. 3. Feel your knees. Sense their weight. Consciously relax them and feel them sink into the bed. 4. Feel you upper legs and thighs. Feel their weight. Consciously relax them and feel them sink into the bed. 5. Feel your abdomen and chest. Sense your breathing. Consciously will them to relax. 6. Deepen your breathing slightly and feel your abdomen and chest sink into the bed. 7. Feel your buttocks. Sense their weight. Consciously relax them and feel them sink into the bed. 8. Feel your hands. Sense their weight. Consciously relax them and feel them sink into the bed. 9. Feel your upper arms. Sense their weight. Consciously relax them and feel them sink into the bed. 10. Feel your shoulders. Sense their weight. Consciously
1. Sit up tall or lie down on your back, using folded blankets to support the spine and head if necessary, chin should be slightly elevated. 2. Place your left palm on your belly above the navel and your right on your chest closer to the heart. 3. Inhale through your nose, expanding the belly in all directions, and exhale contracting the lower abdomen push the air out.
relax them and feel them sink into the bed. 11. Feel your neck. Sense its weight. Consciously relax it and feel it sink into the bed. 12. Feel your head and skull. Sense its weight. Consciously relax it and feel it sink into the bed. 13. Feel your mouth and jaw. Consciously relax them. Pay particular attention to your jaw muscles and unclench them if you need to. Feel your mouth and jaw relax and sink into the bed. 14. Feel your eyes. Sense if there is tension in your eyes. Sense if you are forcibly closing your eyelids. Consciously relax your eyelids and feel the tension slide off the eyes. 15. Feel your face and cheeks. Consciously relax them and feel the tension slide off into the bed. Mentally scan your body. If you find any place that is still tense, then consciously relax that place and let it sink through the bed into the floor. Let go from any physical or mental tension and accept who you are and where you stand today. Giving yourself half an hour a day with stretches and relaxation will definitely improve your mental and physical state.
Namaste.
REFERENCES
1. Ergonomics, the study of health article OSHA 3125, Feb 2000. 2. Rucker LM, Sunell S. Ergonomic risk factors associated with clinical dentistry. Calif Dent Assoc. 2002;30(2):139-48.
3. Shugars, et al. Musculoskeletal pain among general dentists. Gen Dent. 1987 Jul-Aug; 35(4):272-6. 4. Marshall ED et al. Musculoskeletal symptoms in New South Wales dentists. Aust Dent J. 1997;42(4):240-6. 5. Anton D, Rosecrance J, Merlino L, Cook T. Prevalence of Musculoskeletal Symptoms and Carpal Tunnel Syndrome Among Dental Hygienists. Am J Ind Med. 2002;42(3):248-57. 6. Swami Sitaramananda, Yoga Farm Director, http:// sivanandayogafarm.org/swami_sitaramananda. 7. William H. Bates 18601931, creator of Bates method, an alternative therapy aimed at improving eyesight. http://www. encyclopedia.com/doc/1G2-3435100076.html. 8. A study of a back pain in Dentistry pdf, 2005, Page 4. 9. Rising DW, Bennett BC, Hursh K, Plesh O. Reports of body pain in a dental student population. J Am Dent Assoc. 2005;136(1):81-6. 10. Valachi B. Magnification in Dentistry: How ergonomic features impact your health. Dent Today. 2009;28(4):132,134,136-7. 11. Indian Journal of Physiotherapy and Occupational Therapy. 2010;4(3). 12. Keith MW. Clinical practice guidelines on the treatment of carpal tunnel syndrome. J Bone Joint Surg Am.2010;92(1):218-9. 13. My Yoga Online; Remedies for Carpal Tunnel Syndrome; Dr. Carla Cupido; http://www.myyogaonline.com/videos/workplacewellness/remedies-for-carpal-tunnel-syndrome. Jan 2010. 14. My Yoga Online; Wrist Safety in Yoga Poses; Jesse Enright;http:// www.myyogaonline.com/videos/workshops/wrist-safety-in-yogaposes. March 2009. 15. Yoga Journal; Carpal Tunnel Cure; Angela Pirisi; http://www. yogajournal.com/health/128. 16. King Abdulaziz Medical City Dental Center, Riyadh, Saudi Arabia. 2004 Sep-Oct. 17. American Dental Association 1984 July,109(1):48-51. http://www. ncbi.nlm.nih.gov/pubmed/6589290.
Summarized & Presented by:

Mohammad Adnan Abu Khalifeh BDS
Dentist and Oral Surgeon Assistant Editor Smile Dental Journal Health Editor, UMEN MAGAZINE Co-Owner, Dental Lounge/Smile Studio, Amman Jordan harper2003@gmail.com
The Retention of Complete Crowns Prepared with Three Different Tapers and Luted with Four Different Cements
Zidan O, Ferguson GC School of Dentistry, University of Minnesota, Minneapolis, USA J Prosthet Dent. 2003 Jun;89(6):565-71
STATEMENT OF PROBLEM The role of adhesive properties of cements on the retentive strength of crowns with different degrees of taper is not clear. PURPOSE This study evaluated the retention of full crowns prepared with 3 different tapers and cemented with 2 conventional and 2 adhesive resin cements. MATERIAL & METHODS One hundred twenty sound human molar teeth were assigned randomly to 1 of 12 groups, (n=10). The groups represented the 4 cements: zinc phosphate (Flecks), a conventional glass ionomer (Ketac-Cem); 2 adhesive resin cements (C&B Metabond and Panavia); and 3 tapers of 6-degrees, 12-degrees, and 24-degrees within each cement. Crowns were cast with a high noble alloy. The 6-degree taper was considered the control within each cement group. Retention was measured (MPa) by separating the metal crowns from the prepared teeth under tension on a universal testing machine. Analysis of variance was used to test the main effects on the retentive strength of full crowns, namely cements, tapers, and failure modes. The Fishers multiple comparison test was used to evaluate the source of the differences. The chi(2) analyses were used to examine
the relationships between failure types, cements, and tapers. All statistical tests were conducted at alpha=.05. RESULTS There was a significant difference in the main effect cement (P<.0001) and taper (P=.0002). The mean retentive strength values of both Flecks and Ketac-Cem were significantly lower than the mean retentive strength values of both C&B Metabond and Panavia (P<.0001). The retention of crowns prepared with 6-degree taper was not significant from the 12-degree taper (P=.0666). The difference in retention was significant between the 6-degree taper and the 24-degree taper (P<.0001) and between 12-degree taper and 24-degree taper (P=.0178). The types of failure were adhesive in the cement (65%), cohesive in the tooth (31%), and assembly failure (fracture of embedding resin) (4%). The type of failure was dependent on the degree of taper (P<.0001) and on the type of cement (P<.0042). CONCLUSION Within the limitations of this study, the retentive values of the adhesive resins at 24-degree taper were 20% higher than the retentive values of the conventional cements at 6-degree taper. The use of resin luting agents yielded retention values that were double the values of zinc phosphate or conventional glass ionomer cement.
Microleakage in Class II Composite Resin Restorations: Total Bonding and Open Sandwich Technique
Effect of Working Length Measurement by Electronic Apex Locator or Radiography on the Adequacy of Final Working Length: A Randomized Clinical Trial
Shohreh Ravanshad DDS, MSD - Alireza Adl DDS, MSD, and Javad Anvar DDS, MSD JOE Volume 36, Number 11, November 2010
Loguercio AD, Alessandra R, Mazzocco KC, Dias AL, Busato AL, Singer M, Rosa P . J Adhes Dent. 2002 Summer;4(2):137-44
PURPOSE The objective of this in vitro study was to evaluate gingival microleakage in Class II total bond resin restorations in comparison to open sandwich technique restorations using different materials. MATERIALS & METHODS Forty-eight human molar teeth were disinfected and stored in a 0.9% saline solution. In each tooth, two standardized Class II cavities (3 mm x 6 mm x 2 mm) were prepared with the gingival cavosurface margins located 1 mm below the cementoenamel junction. The teeth were divided into 4 equally sized groups (n = 12), and the proximal boxes were treated as follows: In Group 1, no base material was used and the cavity was restored using SyntacSprint (SS) and Tetric Ceram (TC); in Groups 2, 3, and 4 the gingival portion of the cavity was restored with different base materials (Group 2, Dyract; Group 3, Vitremer; Group 4, Chelon-fil) prior to the placement of the composite resin. After a storage time of 7 days, the restorations were finished and polished. Then, specimens were submitted to thermocycling (500 cycles, 5 degrees C to 55 degrees C, 15 s dwell time) and immersed in a 0.5% methylene blue solution for 24 h. After washing, they were sectioned in a mesio-distal direction. Each restoration was evaluated under a stereomicroscope at 20x by 2 examiners and scored on a 0 to 3 scale according to the marginal leakage. Kappa statistics were used to evaluate the agreement between the examiners. Given the ordinal nature of the scoring system, data were submitted to nonparametric repeated measures ANOVA. The results were confirmed with parametric repeated measures ANOVA. RESULTS Significant differences (p < 0.001) among the four groups with respect to dye penetration were detected, with the association Vitremer/Tetric showing the best results. CONCLUSION The use of Vitremer in the open sandwich technique presents the lowest degree of microleakage among the treatments considered in this study.
INTRODUCTION Obtaining a correct working length is critical to the success of endodontic therapy. The aim of this clinical study was to compare the effect of working length determination using electronic apex locator or working length radiograph on the length adequacy of final working length as well as the final obturation. METHODS A total of 84 patients with 188 canals were randomized into two groups; in group 1, the working length was determined by working length radiograph, whereas in group 2, it was determined by the Raypex5 electronic apex locator (VDW, Munich, Germany). Length adequacy was assessed in each group for master cone and final obturation radiography and categorized into short, acceptable, and over cases. RESULTS There was no statistically significant difference between the rates of acceptable (master cone radiography: group 1 = 82.1% and group 2 = 90.4%; final radiography: group 1 = 85.7% and group 2 = 90.4%) and short cases (master cone radiography: group 1 = 7.1% and group 2 = 8.7%; final radiography: group 1 = 1.2% and group 2 = 1%) between the two groups. Over cases in master cone radiography were significantly more in group 1 (10.7%) than group 2 (1%) (c2, p = 0.00). However, this category did not show a significant difference for final obturation between group 1 (13.1%) and group 2 (8.7%). CONCLUSION The results of endodontic treatment using the Raypex5 electronic apex locator are quite comparable, if not superior, to radiographic length measurement regarding the rates of acceptable and short cases. Furthermore, in addition to reducing the radiographic exposure, electronic apex locators are superior in reducing overestimation of the root canal length.
DECEMBER EXPERT PANEL

Ahmad A. Jumah BDS (Hons), MSc (Dist) Rest Dent, PhD(Clin) Majed Abu Arqub BDS, MSc
Restorative Dentistry
Department, Leeds Teaching Hospital Trust, Leeds Dental Institute University of Leeds, UK dnaahj@leeds.ac.uk
BDS, Aden Uni-Yemen MSc, Periodontics Just Resident in Royal Private SectorMedical Service University
Mohd Hammo BDS, DESE
BDS, Jordan University Higher Education in
majed_aa@yahoo.com
Madaba, Jordan
Endodontics, USJ, Lebanon Immediate former President of Scientific Committee of Jordan Dental Association Endodontic Referral Practice, Amman, Jordan dentist_h@yahoo.com
Do we really need an adjunct or alternative material to titanium in implant dentistry?

Answer: Ahmad A. Jumah
Implant treatment is currently overriding other prosthetic solutions especially in the case of replacing anterior teeth in the aesthetic zone. Commercially pure titanium earned an exclusive recognition as the gold standard material for osseointegrated dental implants. The outstanding long-term serviceability of this material has been proved by high quality experimental and clinical research that is well documented in the dental literature. Recently, titanium implants were challenged by newly emerging issues which in turn, made researchers investigate other biomaterials to compensate for potential inadequacies of titanium. The aesthetic complications associated with titanium implants were among the most important factors driving this trend. In fact, there is currently significant concerns regarding stability and longevity of soft tissue aesthetics surrounding titanium dental implantswhich adversely affects the treatment outcome and patient satisfaction. Health related issues with titanium such as, ion release due to corrosion and wear and subsequent allergies and sensitisation have been raised recently. High concentrations of titanium ions were detected locally, i.e. bone in the vicinity of implants, and systemically as in regional lymph nodes, internal organs, serum and urine which is potentially hazardous to human body and can account for the unexplained Fig. 1: Peri-implant soft tissue recession around titanium implant jeopardising the aesthetic outcome of the treatment and patient satisfaction as well delayed failure of dental implants. Advances in biomaterial science and ceramic manufacturing technology have allowed production of high strength and biocompatible ceramics that can be used as dental implants that potentially can substitute titanium. The introduction of Yettria- Partially Stabilized Tetragonal Zirconia Polycrystals, Powder Injection Moulding and Hot Isostatic Pressing techniques were the hallmarks of this development. To conclude, titanium is still and will remain the gold standard material for dental implants, however other materials can be used such as zirconia in order to avoid the aforementioned complications especially in aesthetically and functionally demanding cases. References:
Andreiotelli M, Wenz HJ, Kohal R-J. Are ceramic implants a viable alternative to titanium implants? A systematic literature review.Clinical Oral Implants Research. 2009;20:32-47. Cosyn J, De Bruyn H, Cleymaet R. Soft Tissue Preservation and Pink Aesthetics around Single Immediate Implant Restorations: A 1-Year Prospective Study. Clinical Implant Dentistry and Related Research 2012. Evard L WD, Parent D. Allergies to dental metals. Titanium: a new allergen. Rev Med Brux. 2010;31(1):44-9
Fig. 2: Non-restorable UR1 extracted and immediately replaced using zirconia implant. A: Frontal view pre-op, B: temporary bridge in place, C: permanent crown in place and D: situation on 5-years review, note the appealing aesthetic outcome and stable peri-implant soft tissues
Does the crown/root ratio of 1:1 apply to crown/ implant? Is there a recommendation for crown/implant ratio?
2.0:1 and even greater can produce a stable favorable outcome. Crown to-implant ratios do not affect the success of short-length plateaudesign implants. Short implants are a much less complex and less invasive treatment than placement of longer implants in clinical sites where prior adjunctive ridge augmentation, localized bone grafting, inferior mandibular nerve repositioning or maxillary sinus elevation would be required. They also result in the removal of less bone than with longer implants and are less invasive compared to these and therefore probably less traumatic. In the case of the natural dentition a low crown-to-root ratio is a contraindication for an indirect restoration. In contrast, no such restriction applies in the case of crown-to-implant ratio, and the ideal crown-to-implant ratio has not been established Tawil et al. in their study of short implants with a crown-toimplant ratio of less than 1 to greater than 2 concluded that these were a viable solution long-term, as long as force orientation and load distribution were favorable. They also found no difference statistically between bruxers and nonbruxers. Factors related to the success of short implants 1. Osseointegration 2. Macro-geometric design 3. Physics and the distribution of forces 4. Diameter CONCLUSION The success and survival rates for short and long implants are equivalent. In a 10-year prospective study of implants, Blanes et al. concluded that a crown-to-implant ratio of 2 to 3 was acceptable. Implant success or failure was not related to variations in the crown-toimplant ratios.
Does the mechanical action of rotary files cause root cracks or micro-fractures?
Answer: Mohd Hammo
The goals of endodontic instrumentation are to completely remove microorganisms, debris, and tissue by enlarging the canal diameter and create a canal form that allows a proper seal. Preparation procedures could damage the root dentin resulting in fractures or craze lines. Rotary instrumentation requires less time to prepare canals as compared with hand instrumentation but result in significantly more rotations of the instruments inside the canal. This may cause more friction between the files and the canal walls. Wilcox et al.1 speculated that the stresses generated from inside the root canal are transmitted through the root to the surface where they overcome the bonds holding the dentin together. Carlos et al.2 concluded that the use of some rotary NiTi instruments could result in an increased chance for dentinal defects. References 1. Wilcox LR, Roskelley C, Sutton T. The relationship of root canal enlargement to finger-spreader induced vertical root fracture. J Endod. 1997;23:533 4. 2. Carlos Alexandre Souza Bier, Hagay Shemesh. The Ability of Different Nickel-Titanium Rotary Instruments To Induce Dentinal Damage During Canal Preparation, J Endod. 2009;35:236 8.
Answer: Majed Abu Arqub

The use of endosseous dental implants as tooth replacements has become an accepted treatment modality in dentistry today. Implants increasingly became available that were shorter or longer and with wider or narrower diameters, as well as with varying macrogeometric designs. Anatomical considerations may exist that require either adjunctive treatment prior to implant placement or, instead, the placement of short implants. Recent research has found that: Length, macro-geometric design and diameter, influence the amount of bone that osseointegrates due to differences in surface area, as well as the distribution of forces and resulting stresses. With appropriate selection, high success rates can be enjoyed for both long and short implants where indicated. As a result, clinicians often use certain guidelines associated with natural teeth and apply them to implant dentistry. One of these guidelines is: crown-toroot ratio. The crown-to-root ratio is defined as: the physical relationship between that portion of the tooth within the alveolar bone and that portion not within alveolar bone, as determined by a radiograph. Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis, Mo: Elsevier;2008:2646. States that the crown-to-implant ratio should not be considered the same way as a crownto root ratio crown-to-implant ratio of
Visit Us During AEEDC Piro Trading Intl Booth #208
G-aenial The art of Creating Beautiful Smiles

Announcing the First Crosslinked Gutta Percha Obturator
Were revolutionizing obturation technology right now to its core. Introducing GuttaCore. The first gutta percha obturator thats crosslinked. Crosslinking is not only breakthrough technology. Its superior performance. Crosslinking is a process that bonds a stabilizer to the molecular structure of guttapercha. This gives GuttaCore unique inner strengththe way a web of fibers becomes stronger than the individualfibers themselves. That means GuttaCore can deliver a consistent fill of warm guttapercha right down to the apex-assuming an absence of voids and a stable, secure fit. And because the strong core is guttapercha, its easier to re-treat. If youre looking for the next generation in bturation technology, youve found it! All the Benefits You Expect from the Obturator Leader: No plastic core remaining in the root canal Fast, efficient and heats in seconds Safe and biocompatible Superior 3D fills with the ease of a single insertion Continually tapered design matches the shapes created by todays files Product sizes: 20,25,30,35,40,45,50,55,60,70,80,90 Product Ref: A1702-B: blister of 5 obturators& 1 size Verifier A1702-P: pack of 5 blisters GuttaCore is used with the Thermaprep2 Oven for GuttaCore www.dentsplymea.com G-aenial family is especially designed and developed in a way to ensure nice and predictable results in an easy and simple way. Aesthetics is definitely made easy. Available are three different materials that offer the highest performance in terms of physical properties but yet different handling characteristics in order to satisfy the dentists needs and demands. G-aenial Anterior & Posterior An all-round restorative for effortless invisible restorations. Your aesthetic skills are matched by G-nials superior characteristics which allow it to match every restoration with nature. G-aenial Anterior is a smooth material for an easy contouring offering a viscosity that is very much appreciated by all users. Trying is adopting. G-aenial Poserior is a more packable material fulfilling the requirements of a placement in the posterior area. G-aenial Universal Flo An innovative concept in composite restorative. Its high physical properties allow it to behave like a conventional restorative material in all classes (from Cl I to V). It benefits from a unique handling; it is directly injected from the syringe into the cavity. It is not runny; it has a nice thixotropic viscosity allowing it to be dispensed in a precise manner. www.gceurope.com
Retragyl (ATO ZIZINE)

Chemical Dental Dam_ Thermogelifiable Gel for Gingival Preparation. INDICATIONS Sulcus opening and control of bleeding prior to impression taking and in the preparation of Class II, III and V cavities. FEATURES & BENEFITS Thermogelifiable properties to ensure no mechanical trauma to the periodontium, to control application without excessive hand pressure and to facilitate placement and rinsing, Retragyl does not run or drip. 25% Aluminium Chloride for optimal and fast control of bleeding and gingival oozing. Orange color to easily visualize Retragyl during placement and rinsing. Thin, pre-bent needle tips for better placement even in hard-to-reach areas. Raspberry aroma for patient comfort. PRESENTATION 3 x 1.4g syringe + 30 pre-bent tips. www.prohealthline.com
Congratulations for Dr. Bilal El-Dhuwaib

Winner of: Dentistry Awards 2012 & Overall Best Young Dentist UK & Best Young Dentist East
The first Middle East/Africa Ivory Implant Symposium

The first Middle East/ Africa Ivory Implant Symposium took place in Beirut on November 23 - 24, 2012 where Dr. Alexander Khairallah; Clinical Instructor at the Department of Dento Maxillo Facial Imaging, Lebanese University, School of Dentistry described that due to the computers revolution during the past years, the dental radiological means had encountered a huge progress (digital radiology, dentascan, cone beam CT...). The radiological diagnosis and planning can now be very accurate. Virtual surgery can even be performed directly on computers (virtual implant placement, virtual MaxilloFacial surgeries). Dr. Elie Abdo; Clinical Instructor at the Department of Dento Maxillo Facial Imaging, Lebanese University, School of Dentistry continued: Resorption of the edentulous or partially edentulous alveolar ridge or bone loss due to periodontitis or trauma frequently compromises dental implant placement in a prosthetically ideal position. Therefore, augmentation of an insufficient bone volume is often indicated prior to or in conjunction with implant placement to attain predictable long-term functioning and an esthetic treatment outcome Autogenously bone grafts are still considered the gold standard in bone regeneration procedures. Dr. Wael Hassan Khalil; Clinical Instructor at the Department of Periodontology; Lebanese University, School of Dentistry described From a scientific point of view, the criteria of choosing implant must be based on some more objective criteria: mainly the surface architecture which could enhance the process of osseointegration and increase then secondary stability especially in critical cases (type IV bone, short implant, early loading). As for Dr. Youssef Khalifeh, he showed Clinical cases with the Ritter Ivory implant, as he was considered an early user & a supporter of the Ivory system worldwide.
CGF: Concentrate Growth Factor from Tissue Regeneration

The ability to regenerate tissues and organs is a topic of great scientific, social and ethical interest Tissue engineering and regenerative medicine have made and continue to make great progress identifying new strategies in the field of tissue regeneration, such as the use of platelet concentrate which constitutes a relevant and innovative clinical approach. From years Silfradent deals with the study of platelet concentrates and, in particular, with CGF (Concentrated Growth Factors) and LPGF (Liquid Phase Growth Factors) that represent a new generation of platelet concentrates able to hold inside a higher concentration of autologous growth factors. CGF, like other platelet concentrates, is isolated from blood samples through a simple and standardized separation protocol, which is performed by a specific centrifuge device (Medifuge MF200, Silfradent srl, Forl, Italy) without the addition of exogenous substances. A study made in the Laboratory of Organ and Tissue Regeneration, headed by Professor Luigi F. Rodella of the Section of Human Anatomy, Department of Biomedical Sciences and Biotechnologies of the University of Brescia and published in the international journal Microscopy Research and Technique has highlighted some of its main features: the CGF consists of an organic matrix rich in fibrin that is able to trap a greater amount of growth factors (TGF-1 and VEGF); moreover, it contains CD34 positive stem cells, which are known to be recruited from blood to injured tissue and play a role in vascular maintenance, neovascularisation and angiogenesis.1 In addition, another study underlined the need to establish a standardized protocol for preparing CGF (also said PRF-Platelet Rich Fibrin) membranes for clinical use.2 Form a clinical point of view, some recent studies about the use of CGF in maxillofacial surgery showed the efficacy of CGF in guided bone regeneration before dental implant placement.3-5 In particular, there are satisfying results about the use of CGF as alternative to bone substitutes for sinus augmentation.4,5 However, its features make it suitable for its use, alone or with other biomaterials, in other fields where tissue regeneration and remodeling is required. To date, the research continue and is addressed to evaluate in vitro the ability of CGF of stimulate cellular proliferation and to test the efficacy of CGF in different clinical applications ranging from oral surgery, dermatology and cosmetic surgery. References:
Rodella LF, Favero G, Boninsegna R, Buffoli B, Labanca M, Scar G, Sacco L, Batani T, Rezzani R. Growth factors, CD34 positive cells, and fibrin network analysis in concentrated growth factors fraction. Microsc Res Tech. 2011; 74:772-7. Kobayashi M, Kawase T, Horimizu M, Okuda K, Wolff LF, Yoshie H. A proposed protocol for the standardized preparation of PRF membranes for clinical use. Biologicals 2012;40:323-9. Sohn DS, Moon JW, Moon YS, Park JS, Jung HS. The use of concentrated growth factors (CGF) for sinus augmentation. Implant Journal. 2009;38:25-35. Sohn DS. The use of concentrated growth factors as alternative to bone substitutes for sinus augmentation. Dental Inc. 2009;Marc/Apr:2-7. Sohn DS. The effect of concentrated growth factors on ridge augmentation. Dental Inc. 2009;Sep/Oct:34-40.
Visit Sultan Healthcare at AEEDC 2013

Sultan Healthcare is proud to be hosting a booth at the AEEDC Dubai Conference from 5th-7th February, 2013. Dr. Khaled Teleb and the Sultan Healthcare team will be delighted to discuss and demonstrate our wide product portfolio including: Materials and Restoratives, Infection Prevention and Preventives. Please visit the team at Booth Number 371. Sultan Healthcare is dedicated to providing the global healthcare community with quality products and a fast, reliable service. Our on-going commitment to research and development allows us to constantly offer exciting new products. To solidify our presence in the market, we have global distribution centres located in the United States, Canada and Europe for fast, efficient product delivery as well as a global sales team in place to support our customer needs. Over the course of our 135 year history, Sultan Healthcare has grown to be one of the worlds leading manufacturers of infection control products, dental materials, preventives and oral therapeutics. Our distribution partners, dental and healthcare practitioners worldwide count on us for quality products, excellent customer service, strong marketing support and continuous profitability. www.sultanhealthcare.com
MICRO-MEGA new Discovery kit One Shape and Endo kit One Shape!
Each kit compiles One Shape files, the one and only NiTi instrument in continuous rotation for quality root canal preparations: Discovery kit One Shape: * 5 blisters of 5 One Shape instr. * 1 pack of 4 G-Files instr. * 1 watch REF . 51400091 One Shape, THE new asset in endodontic instruments. Simplicity and safety Quality root canal shaping in a single instrument with remarkable design. Use your existing equipment: no need to buy an additional specific motor. Sterile instrument: time savings, Facilitated handling for assistants, Controls risk of infections: safety for patients and staff. www.micro-mega.com Endo kit One Shape: * 10 blisters of 5 One Shape instr. * 1 AXS ENDO 04 contra-angle REF . 51400092
Dr. Elie Azar Malouf

Ass. Prof. Dr. Elie Azar Maalouf, DDS, DSO
President of the Lebanese Dental Association Chairman of the department of Periodontology at the Lebanese University Founding member and former president of the Lebanese Society of Periodontology Elie graduated with honors in dentistry at Saint Joseph University of Beirut, in 1985 and was awarded a Certificat dtudes suprieures de biologie de la bouche option Anatomophysiologie (CES) at Paris V in 1987, and a CES in Periodontology in1988 in addition to a CES in Fixed Prosthesis in 1988, and a Doctorate (DSO) in Periodontology from the Lebanese University in 2009. Since 1988, He has a teaching responsibility at the Lebanese University in the Department of Periodontology, director of the post-graduate program from 2005 to 2008 and Chairman of the department since 2008. He organized the 2009 Dental Meeting of the Faculty of Dental Medicine as the chairman of the scientific committee. He Accomplished more than 200 lectures in Periodontolgy and Implantology localy and internationally. As well as: - Lecturer in continuing education in Zimmer Institute in Implantology from 2007 till 2011 Zurich SWITZERLAND - Lecturer in continuing education in Implantology at Lebanese University from 2008 till now - Lecturer in continuing education at ITI team in LEBANON from 2000 till now - The President of the Lebanese Dental Association since December 9, 2012 Dr. Elie authored many scientific publications in international peer-reviewed journals and he directed a large number of dissertations and researches.
Two Minutes with
WHY DID YOU CHOOSE TO BE A DENTIST? I like very much biology and precision. I can mix both in dentistry. I really like what I am doing as a clinician and as an academic WHAT ARE THE BEST/WORST ASPECTS OF YOUR JOB? Best aspect: the feeling when people appreciate your work and then you for that especially in the case of sophisticated surgeries/implants. Worst aspect: when patients do not follow the recommendations and instructions that help achieve the best results WHERE DO YOU LIVE? Jounieh - Lebanon WHAT DO YOU DRIVE? Sport car WHAT DRIVES YOU? Honesty YOUR FAVORITE FOOD? Lebanese food YOUR HOBBY? Sports YOUR FAVORITE FILM? Taxi driver (Robert De Niro) FAVORITE HOLIDAY DESTINATION? Paris WHAT INSPIRES YOU? Wisdom WHAT REALLY ANNOYS YOU? Ignorance
WHAT KEEPS YOU AWAKE AT NIGHT? Unclear situations WHAT MAKES YOU SMILE? I like very much good jokes. But really good jokes! YOUR BEST CHARACTERISTIC? Communication WORST FAULT? Maybe honesty CAN YOU DESCRIBE YOURSELF IN THREE WORDS? Honest, hard worker, efficient WHAT DO YOU DO TO RELAX? I like to play football with my old friends and even with my students. When I have enough time I play also tennis IF YOU WERENT A DENTIST, WHAT WOULD YOU HAVE LIKED TO HAVE BEEN? Hospital manager DO YOU READ AND RECOMMEND SMILE DENTAL JOURNAL REGULARLY? I found Smile Journal in 2009 when I was preparing the Lebanese University meeting. At that occasion I met Mrs Solange and Dr. Maghaireh who presented two interesting lectures at the congress. Since then, I regularly follow all the issues and I found many interesting articles. So yes I recommend Smile Dental Journal for GPs and specialists WHAT WOULD BE YOUR MOTTO IN LIFE? Nothing is impossible, just persevere - La science a fait de nous des dieux avant mme que nous mritions dtre des hommes - Jean Rostand
The science made us Gods before we deserve to be men Smile Dental Journal | Volume 7, Issue 3 - 2011| 61 |
AEEDC BOOTH No. 371
BAIRD COMMUNICATION
Dbayeh / Lebanon: Sinus Grafting Course

The Evidence, Clinical Skills & Managing Complications By The British Academy of Implant & Restorative Dentistry (BAIRD), a PreCongress Course at The 22nd Annual Scientific Congress of the Lebanese Dental Association, September 19, 2012. This unique workshop which was delivered by Prof. Marco Esposito, the current president of BAIRD, and Dr. Hassan Maghaireh, the head of the scientific committee at BAIRD, presented lectures covering the latest evidence based data on sinus grafting, maxillary sinus anatomy, sinus augmentation materials, contraindications and prevention & management of sinus grafting complications, as well as some clinical tips & hints during the hands on training sessions. The 22 delegates who were a group of experienced implant dentists from Lebanon, Jordan, Iraq and Saudi Arabia had the opportunity to learn different sinus grafting techniques during the hands on training which was on maxillary dry models, eggs and sheep heads, in addition to discussing the pros and cons of different sinus grafting materials. Mrs. Solange Sfeir-Aswad, the marketing director at BAIRD, reported that this one day course was completed successfully receiving good appreciation from participants, tutors and observers. Throughout this Course, all participants have shown their great interest, enthusiasm, active participation, full energy and effort as well as willingness to adopt the new techniques in sinus grafting learnt in this advanced evidence based & clinical course. Mrs. Sfeir-Aswad also thanked the course main sponsors; Tecnoss - OsteoBiol Bone Material" and their office in Lebanon,Provis Ltd. for their great efforts in providing all the required equipments and materials.
Tripoli / Libya: "Is Quicker Always Better?" Monday 22

Treatment planning in advanced Implant Cases, Immediate post-extractive implants: the up to date evidence, Immediate loading: the up to date evidence, Immediate loading: Tips and Hints for successful restorations and Avoiding Restorative Complications in advanced implant cases.
nd
October 2012
These were among the main topics covered in the 1st BAIRD symposium in Tripoli, held on 22nd of October 2012 in the luxurious five star Al Mahary Radisson Blue Hotel, in Tripoli, where 110 dentists from all around Libya had a full day of clinical lectures from three of BAIRD main speakers; Prof. Marco Esposito, Dr. Thamer Theeb and Dr. Hassan Maghaireh who presented clinical lectures on post extractive placement and immediate loading in dental implants. In her address to the symposium dentists, Dr. Awatef Nuri, the chairperson of Alazhar Company for Dental Services, the main sponsor of this symposium, praised the Libyan dentists for their great interest in continual education. She has also thanked Tripoli Dental Association for their support in organizing this event, which has brought together world-renown academics and clinicians. She added that this symposium is an indicator of the implementation of the continuing dental education policy in the Libya to
keep dentists abreast of the latest developments in all areas of dentistry. Dr. Maghaireh; The Head of The Scientific Committee of BAIRD, commended the constructive partnership between The British academy of Implant dentistry and the Libyan dental community, stating that BAIRD believes in the effectiveness of such events, as they promote clinical excellence by presenting evidence based data combined with cutting edge practices and techniques in dental healthcare, which will contribute to providing better and advanced dental treatment services for the Libyan community. The symposium was extremely well supported by the dental implant industry in Libya, as beside the main sponsor; Alazhar Company for Dental Services, 10 more local companies and 2 International companies were represented in the dental exhibition which took place in conjunction with the BAIRD symposium in Implant Dentistry in Tripoli.
Baghdad / Iraq 7 - 8 December 2012

BAIRD was present as a main partner with The Iraqi Dental Association at the 1st Baghdad International Cosmetic & Implant Dental Conference, 7-8 Dec 2012. BAIRD is proud to be the scientific and organizing partner at The 1st Baghdad International Conference, which was organized by The Iraqi Dental Association in Baghdad for the first time for the last 20 years. The British Academy keynote speakers, along with their Iraqi colleagues presented the latest evidence based data and clinical tips and hints on various clinical topics in cosmetic and implant dentistry presented at more than 24 sessions including lectures, round tables, hands-on workshops and seminars, which focused on the treatment planning, clinical advances, prognosis of cosmetic & implant dentistry, and aimed to address the challenges and problems facing the dentist in her or his daily cosmetic & implant practice. Participants welcomed the 16 international speakers who came from Europe, Asia, Africa and the USA to lead the Congress, in addition to 6 respectful speakers from Iraq. In this respect and expressed their full interest in continuing these events into the future. Mrs. Solange Sfeir Aswad, the Marketing director at BAIRD and the head of the Congress Marketing and Exhibition Committee reported that the Congress has successfully gathered for the first time since 1995, international dental companies in the Exhibition Area, where visitors had the chance to learn about state-of-the-art dental equipments, services, products and more. Dr. Rafi Al-Jobori; the president of the Iraqi Dental Association and the president of the congress offered his gratitude to the Scientific Committee at The British Academy of Implant & Restorative Dentistry who has worked closely with The Scientific committee at the Iraqi Dental Association to plan the congress so meticulously in every small detail, from the choice of experts to developing highly focused learning objectives for each lecture and constantly negotiating with our speakers to ensure coherency and consistency throughout the congress. In return, Prof. Marco Esposito; the President of BAIRD, who presented BAIRD Appreciation Plaque to Iraq's Deputy PM Saleh Al-Mutlaq and another one to Dr. Rafi Al-Jobori; The President of The Iraqi Dental Association, thanked the Iraqi dentists for showing such enthusiasm for continual education. He has also congratulated the Iraqi Dental Association for organizing this congress so meticulously in every small detail and thanked them for their great efforts in raising the level of dentistry in Iraq.
BAIRD COMMUNICATION
Erbil / Iraq One year course
In October The British Academy of Implant & Restorative Dentistry (BAIRD) in collaboration with The European Society of Cosmetic Dentistry (ESCD) teamed up with the Iraqi Dental Association in organising the 1st Cosmetic Professional Diploma One Year Part Time Course. This Course aims to offer its 105 attendees who came from all around Iraq an all-in-one comprehensive package in cosmetic and restorative dentistry ranging from Principles of Veneers restoration to Full Mouth Rehabilitation and Facial Aesthetics . Dr. Rafi Al-Jobory, welcomed this unique collaboration between the Iraqi Dental Association and both of BAIRD & ESCD and stated in his welcoming message that clinical training and education must keep up with the times, and such a comprehensive clinical course will provide the Iraqi dentist with the up to date in cosmetic and restorative dentistry which will reflect on the level of dentistry provided in all around Iraq. Dr. Al-Jobory, expressed his thanks to Smile Dental Journal for their role in promoting clinical education and for being the media partner of this one year part time course. Prof. Wolfgnag Richter, the course director, stated that the first four modules of this one year course, (October, November, December and January) have recieved a fantastic feedback form our delegates who not only had the opportunity to listen to prominent speakers in the field of cosmetic and restorative dentistry from BAIRD & ESCD such as Dr. Julian Caplan, Dr. David Bloom, Dr. Ahmed Al-Ani, Dr. Hassan Maghaireh from England as well as Dr. Gregory Brambilla from Italy, Dr. Joseph Sabbagh, Dr. Johnny Haddad, Prof. Dr. Louis Hardan, Prof. Dr. Alexandre Khairallah and Dr. Johnny Haddad from Lebanon and Dr. Thamer Theeb from Jordan, in addition to many other speakers covering different branches of cosmetic and restorative dentistry, but also had more than ten hands on workshops under the direct supervision of a very professional team of clinical mentors from the Iraqi Dental Association and its two partners; BAIRD & ESCD. Dr. Hassan Maghaireh, the head of the scientific committee at The British Academy of Implant & Restorative Dentistry and the course co-director, confirmed in his message to to the course delegates that UCLan University is interested in accrediting this course towards the first year of MSc course, which will offer the cosmetic course delegates a similar opportunity to their colleagues form the BAIRD implant course who have already started accrediting their training towards the first year of the Implant MSc course at UCLan University. He added, that this accreditation process is a proof of the high standards of the seminars, workshops and the meticulous organization of this course by the IDA and its two partners; BAIRD & ESCD. Mrs. Solange Sfeir, the marketing and administrative director of this one year course, has expressed her gratitude to the International and the Iraqi companies for supporting the Iraqi dentists and sponsoring the clinical hands-on workshops which have all received a very positive feedback form all the course delegates. Furthermore, she has promised the Iraqi dentists more of these well conducted long term and short courses by The Iraqi dental Association and The British Academy of Implant & Restorative Dentistry all around Iraq.
19 - 22 September 2012 | Dbayeh, Lebanon
BIDM 2012
The Lebanese Dental Association (LDA) has organized yearly scientific congresses since 1991. In September 19 - 22 / 2012, the LDA held its 22nd Beirut International Dental Meeting (BIDM 2012) in at the Congress Palace, Dbayeh, Beirut, Lebanon. As usual, this meeting has again confirmed quality and innovation of a rich scientific program, and a remarkable audience, from the region. Dr. Ghassan Yard; president of the Lebanese Dental Association welcomed the participants and guests wishing them a nice stay in Beirut. The 4 day-scientific-program handled general dental topics given by more than 80 local, regional and foreign speakers. In addition, the scientific program included more than 10 pre and post congress courses. Alongside the congress, state of the art devices and materials were presented in the exhibition, in which more than 60 companies and representatives participated.
Sebtember 2012 | Beirut, Lebanon
Celebrating 50 Years in Dentistry & A New Association Birth

During the 22nd Beirut International Dental Meeting (BIDM), September 2012, The members of Middle East Managers Association (MEMA) from more than 20 countries, came together to celebrate the golden Jubilee of Mr. Lazar Piro in appreciation to his Regional & International achievements in the world of dentistry for the last 50 years. Lazar Piro Mr. Piro, as a graduate from Pigier School (Beirut, Lebanon) in Business Administration started his carrier by managing one of the largest dental companies in Lebanon for 17 years; Tamer Depot, and thus the celebration was in Beirut, sponsored by Mr. Gabi Tamer; CEO of Tamer Holding. After moving to the USA, he worked as a Middle East and North Africa sales representative for Syntex Dental (Des Moines, Lowa). In 1984, Mr. Piro started Piro Trading International, specialized in marketing and sales of American & European dental manufactures for the Middle East and Africa. MEMA The MEMA was a dream since many years back, but this was the first gathering, gathering all friends and at the same time, noble competitors together, sharing experience, and uniting together in one organization. Members of the MEMA are all Middle East managers for dental manufacturers, as well as other identities covering the Middle East region like dental journals and magazines.
28 29 September 2012 | Nicosia , Cyprus
International Conference of Imlantology & Esthetic Dentistry

OMNIPRESS has been in the scientific dental information and education services consistently and responsibly for the last 30 years. By publishing 9 different journals addressed both to the general and specialist dentists, brings together the continuous evolution in the field of oral health. OMNIPRESS, in a continuous effort to upgrade its quality services to the dentists, went another step ahead and became active in organizing specialized dental courses, congresses, and further training programs in the field of esthetic dentistry, implantology, endodontics, etc. In September 2012, OMNIPRESS organized the International Conference of Imlantology and Esthetic Dentistry in Nicosia, Cyprus. Famous foreign and Greek speakers awarded in their respective fields were sharing their knowledge at the conference. The choice was made carefully in order to create a program that will deal with everyday clinical concerns. Esthetic Dentistry is an area that is evolving. New materials, adhesives and techniques were constantly presented. The general dentist is not always able to follow this development that is why our effort focuses on creating a program that will give answers. Additionally, nowadays treatment plans frequently include the placement of implant retained restorations. The osseointegration itself is no longer the only factor needed for success. The restorations have to be esthetic and a functional part of the oral and maxillofacial system. The selected speakers reported on contemporary surgical and prosthetic techniques.
Report by Ilia Roussou
AEEDC Booth 14 IDS Hall 11.2, Stand N010, O019, N020, O021
9 12 October 2012 | Amman, Jordan
23rd Jordanian International Dental Conference

Under the auspices of Her Royal Highness Princess Muna Al Hussein, the 23rd Jordanian International Dental Conference was held under the slogan Dentistry, Much Is Possible in Landmark HotelAmman during the period from 9-12 October 2012. More than 1500 local and international participants had the chance to attend this very well organized conference, with its rich scientific program presented by some of the worlds most renowned figures including several well-known regional specialists. 83 scientific papers were presented and eight specialized workshops covering different aspects of Dentistry were held during the conference. Local and International dental companies had the chance to present their most up to date products and armamentarium to the participants during one of the biggest exhibitions held in Amman so far.
7 11 November 2012 | Alexandria, Egypt
18th Alexandria International Dental Conference AIDC 2012

The faculty of dentistry held its 18th Alexandria International Dental Conference AIDC 2012 from the 7th till the 11th of November 2012 in the HILTON Green Plaza Hotel, Alexandria - Egypt. The conference started with an extra ordinary opening ceremony with a performance given by the dental students of the faculty, and ended with a gala dinner with a performance given by one of the top singers. Over the last 36 years the faculty of Dentistry - Alexandria University had been holding this conference in the Middle East region for the sake of enhancing the dental practice and highlighting both the recent and ongoing dental researches and developments all over the world. SCIENTIFIC PROGRAM: The conference had a unique scientific program including lectures, poster sessions, in addition to a number of crash courses and hands-on courses held pre, during & post conference. The scientific content was given by a group of keynote speakers from all over the world to share their experience and knowledge with their colleagues. TRADE SHOW: As usual the conference held one of the biggest dental equipments exhibition; almost 100 exhibitors represented well known national and international dental companies.
09 - 10 November 2012 | Dubai, UAE
4th Dental - Facial Cosmetic International Conference

Dubai gathered for the fourth time the world experts of Dental - Facial Cosmetic on 09th - 10th November 2012, an international conference, open to all aspects and specialists working in the field of aesthetic dentistry and implantology. With the excellent ambiance and cozy atmosphere the conference again provided warm exceptional networking opportunities while connecting the leaders in the field of Aesthetic Dentistry & Implantology practitioners, researchers and industry players. Prolific world known International speakers joined forces to present the full two-day Scientific Program to the dental delegates at the astonishing Jumeirah Beach Hotel in Dubai. Under the Chairmanship of the experienced and charismatic Dr. Munir Silwadi, all sessions of the program were presented smoothly with sharp discussions and beneficial feedback to take dentistry forward. Jumeirah Beach Hotel hosted 886 participants Dentists, Dental Technicians, Dental Industry and Dental professionals in the very elegant atmosphere. Bringing together industrial leaders and professional practitioners, the conference not only delivered extensive scientific knowledge from across the globe but gave way for an excellent opportunity to present the latest advancements and developments within the Dental Facial Cosmetics practice. The introduction of the new Dental Technicians Parallel Session last year has seen a vast improvement in the interest to improve the skills of the technicians at the conference.
7 8 December 2012 | Baghdad, Iraq
1st Baghdad Cosmetic & Implant International Dental Conference

2012 was a special year for the continual education for the Iraqi dentists due to the Iraqi Dental Association (IDA) hosting the 1st Baghdad Cosmetic & Implant International Dental Conference. This conference took place at the Ishtar hotel, Baghdad, a glamorous five star resort in the heart of Baghdad, the capital city of Iraq, the home to the Sumerian civilization, which arose in the fertile TigrisEuphrates river valley. This conference was organized in collaboration with The British Academy of Implant & Restorative Dentistry (BAIRD) who together with the IDA have successfully put a very attractive clinical timetable of lectures and workshops delivered by the fourteen of the worlds most eminent cosmetic & implant dentists from Europe, Asia, Africa and the USA, in addition to a very respectful speakers from The Iraqi Universities. For the first time in Baghdad for the last twenty years, all areas of Iraq were represented by over 900 dentists who engaged in lectures and clinical workshops aimed to enhance current knowledge and clinical skills in Aesthetic Restorative Dentistry & in Implant Dentistry ensuring functional and long lasting dental care. Professor Wolfgang Richter, The Cosmetic Chairperson at The British Academy of Implant & Restorative Dentistry (BAIRD) commented following the conference that He and his team are proud to see the IDA collaborating with BAIRD and Smile Dental Journal to organize such a remarkable scientific meeting in Baghdad, which he fully trust will add a lot to the clinical daily practice of the Iraqi dentists. He added that all the thanks go to the IDA conference committee for their hard work and unique efforts in finalizing this very successful conference and serving the dental community in Iraq. Dr. Rafi Al-Jobory, the president of the Iraqi Dental Association, during the closing ceremony has thanked the Iraqi dentists for supporting their dental association and has confirmed the main reason for the great success of the 1st Baghdad International Cosmetic conference is the Iraqi dentist himself, who has shown great interest in improving his and her clinical skills and shown an great keenness in continual education and raising the level of dentistry in Iraq. Dr. AlJobory has also thanked the British Academy of Implant & Restorative Dentistry for delivering high quality innovative dental courses in Iraq aiming to bridge the gap between Evidence Based Practice and the day to day clinical practice in restorative and implant dentistry in Iraq. Finally, he promised his Iraqi colleagues more regular conferences and continual education courses covering various aspects of dentistry in the different cities of Iraq. Dr. Abo-Baker Al-Rawi, the head of the organization committee has expressed his gratitude to all the international and Iraqi dental companies who supported the very dynamic and vibrant dental exhibition organized by Mrs. Solange Sfeir Aswad which took place on the side of the 1st Baghdad International Cosmetic conference, with more than 20 Iraqi and International suppliers showcasing the very latest dental products, services and technology. Dr. Al-Rawi confirmed that this dental trade exhibition provided the Iraqi dentist for the first time in Baghdad, with the opportunity to access the best deals, compare prices, get advice and try before buying any of the dental products.
Platinum Sponsor: Tamer Levant
Gold Sponsor: Alfiras Scientific Bureau
Gold Sponsor: Osseolink Implant System
Official Sponsors
AEEDC booth number 178/179, 202/203
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Smile Dental Journal - December 2012 - Volume 7, Issue 4 - www.smiledentaljournal.

com - Distributed free of charge

for Dental Career

and Palate: The Multidisciplinary Management

The Effect of Two

BOOTH No. 370

Editorial Review Board

International Advisory Board

Maxillofacial Cleft Lip and Palate: The Multidisciplinary Management

Research Summaries in Focus

Dentist Health Yoga for Dental Career Longevity

Affiliation & Distributors

Ask the Experts Flash News Two Minutes with

Dental Conferences in the Arab World & the English Language

Dr. Amjad Khoury BDS, MA amjadkhoury@gmail.com

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Flapless Implant Dentistry: Evidence Based Debate

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Cleft Lip and Palate: The Multidisciplinary Management

(Fig. 1) Formation of lip and primary palate

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(Fig. 2) Formation of secondary palate

(Fig. 4) Oronasal fistula associated with cleft palate

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(Fig. 9) Surgical repair of the palate

(Fig. 13) Post orthodontic expansion of collapsed buccal segments

(Fig. 16) A successful bone graft placement appearing by a periapical X-ray

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(Fig. 17) Alveolar bone exposed at cleft side

(Fig. 20) Orthopedic treatment using a facemask

(Fig. 18) Cancellous bone packed into cleft

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(Table 3) t-test between groups for surface roughness test

(Table 4) statistics of Shore D Hardness test

(Fig. 2) Bar chart of surface hardness results

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(Table 5) ANOVA one way among groups for hardness test

(Table 6) t-test between groups for surface roughness test

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(Fig. 6) Shows prominent Civatte body (*)

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Yoga for Dental Career Longevity

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For Gomukasana Arms

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Summarized & Presented by:

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DECEMBER EXPERT PANEL

Mohd Hammo BDS, DESE

BDS, Jordan University Higher Education in