dental news dec 2013

Dental News, Volume XX, Number IV, 2013

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ARTICLES CONGRESSES

64.

68.

52.

68.

68.

Replacement of a Missing Maxillary Central Incisor

Effect of irrigation solutions on adhesion of EndorezTM sealer to root canal dentin

Dr. Badry Meouchy, Dr. Fady Abillamaa,Dr. Elie Azar Maalouf, Dr. Fatmé Mouchref Hamasny, Dr. Ramzi Abou Arraj

Novermber 5 - 8, 2013Cairo City Stars International Hotel, EYGPT

National Guard Health Affairs

BIDM 2013

Lebanese Orthodontic Society

Dental Facial Cosmetic International Conference

Egyptian Dental Assosiation

ACE Surgical 41 ACTEON 47 A-DEC 49 BA Intl 69BELMONT 18BIEN AIR 39 BISCO 61CARESTREAM 63 CAVEX 21 COLTENE 27CREST 10DENTSPLY 8DISCUS PHILIPS 6 DURR 23EMOFORM 5 E4D 17 FKG 29GC 33, 40 GSK C3, 31, 51, 76 GENDEX 31HENRY SCHEIN 59HU FRIEDY 37ITENA 13

IVOCLAR 1, C4KAVO C2 KERR 71LISTERINE 73MEDESY 34MICRO MEGA 55 MORITA 15NSK C1 ORTHO ORGANIZERS 80PLANMECA 45 RITTER 43SIRONA 25SULTAN 57 SOREDEX 9TEBODONT 4 ULTRADENT 35 VITA 79 VOCO 7 W&H 67 ZHERMACK 2ZIRLUX 19

24.

12.

38.


Dr. Chems BelkhirDr. Saida SahtoutDr. Latifa BerrezougaDr. Mohammed Semir Belkhir

Dealing with Airway and Dentofacial Development In ChildrenDr. Derek MahonyDr. George Meredith

September 29- October 1, 2013 King Saud Bin Abdulaziz University for Health Sciences, Riyadh, KSA

September 25-28, 2013 School of Dentistry, Hadath, Lebanon

October 31 - November 3, 2013Movenpick Resort, Raouche, Lebanon

Novermber 8 - 9, 2013 Jumeirah Beach Hotel, DUBAI

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International Calendar

11

The Tunisian Dental Association Congress

2nd International Scientific Conference Of The Jordan University Of Science And Technology In Irbid

Stars Meeting

The 18th Kuwait Dental Association Dental Conference

FDI Annual World Dental Congress

36Th Asia Pacific Dental Congress

Journées Odontologiques

CAD/CAM and Digital Dentistry

Saudi Orthodontic Society

AEEDC

February 7 – 8, 2014 [email protected]

May 7 - 8, 2014The faculty of Dentistry at JUST, JORDANEmail: [email protected]: www.just.edu.jo/jidc

January 28 - 29, 2014Park Hyatt, Jeddah, KSAWebsite: www.sos.sa

February 4 – 6, 2014at the state-of-the-art Dubai International Convention & Exhibition Centre, DUBAIWebsite: www.aeedc.com

May 28 - 30, 2014at the Saint Joseph University Dental School, Beirut, LEBANONRegistration: 00961 1 421282Email: [email protected]

November 20-22, 2014KUWAITEmail: [email protected] Website: www.kda.org.kw

September 11 - 14, 2014at the India Expo Mart, New Delhi, INDIAWebsite: www.fdi2014.org.in

June 17 - 19, 2014at the World Trade Center, Dubai, U.A.EWebsite: www.apdentalcongress.org

September 18 - 20, 2014in Beirut, LEBANONWebsite: www.bidm-lda.com

May 8 - 9, 2014at the JW Marriott Marquis Hotel Dubai, UAEEmail: [email protected] Website: www.cappmea.com

April 2 - 4, 2014Alexandria, EYGPTEmail:[email protected]

DENTAL NEWS – Sami Solh Ave., G. Younis Bldg.POB: 116-5515 Beirut, Lebanon.Tel: 961-3-30 30 48Fax: 961-1-38 46 57Email: [email protected]: www.dentalnews.comwww.facebook.com/dentalnews1

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DENTAL NEWS IS A QUARTERLY MAGAZINE DISTRIBUTED MAINLY IN THE MIDDLE EAST & NORTH AFRICA IN COLLABORATION WITH THE COUNCIL OF DENTAL SOCIETIES FOR THE GCC.Statements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the Editor(s) or publisher. No part of this magazine may be reproduced in any form, either electronic or mechanical, without the express written permission of the publisher.

Alfred Naaman, Nada Naaman,Jihad Fakhoury, Dona Raad, Antoine Saadé, Lina Chamseddine, Tarek Kotob, Mohammed Rifai, Bilal Koleilat, Mohammad H. Al-JammazSuha NaderIbrahim MantoufehMicheline Assaf, Nariman NehmehJosiane YounesAlbert SaykaliGisèle Wakim, Marielle KhouryTony Dib1026-261X

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Volume XX, Number IV, 2013w w w. d e n t a l n ew s . c o m

BIDM 2014



12

EndodonticsEffect of irrigation solutions

Effect of irrigation solutions on adhesion of Endorez sealer to root canal dentin

Dr. Chems Belkhir

Dr. Saida Sahtout

Dr. Latifa Berrezouga

AbstractIntroduction: The objective of this work is to study the influence of the different irrigation so-lution combinations: Sodium hypochlorite (NaO-Cl), EDTA and chlorhexidine (CHX) on the seal-ing of the root canal obturation using Endorez® sealing cement.

Materials and methods56 incisors were endodontically prepared with the Protaper® system and were irrigated with Sodium hypochlorite at 2.5%. These teeth were divided into four groups depending on the fi-nal irrigation used. Group 1: 17% EDTA and 2.5% NaOCL, Group 2: 17% EDTA and 0.2% CHX, Group 3: 17% EDTA, 2.5%NaOCI and 0.2% CHX and Group 4: Only 2.5% NaOCI. All the canals were obturated with Endorez® and a gutta percha cone. After coronal obtura-tion with composite resin, infiltration with china ink and diaphanisation, each tooth was ob-served using a stereo microscope and the dye ascent was calculated. Statistical analysis was performed using Post Hoc Test. Results: The irrigation associating EDTA and CHX showed less infiltration than that associating EDTA and NaOCI; (P=0.024). The group irrigated using the association EDTA and CHX gave infiltration rates inferior to those observed in the group irrigated with NaOCI (P=O). The group irrigated using the association EDTA, NaOCI and CHX showed in-filtration rates weaker than the group irrigated with only NaOCL (P=0.04). Non significant dif-ferences were observed between groups 1 and 3 (P=0.68), groups 1 and 4 (P=0.1) and groups 2 and 3 (P=0.06).

ConclusionsThe sealing of root canal obturation with En-dorez® is sensitive to the last irrigation solution used. The best results were observed in the as-

[email protected]

Dr. Mohammed Semir Belkhir

sociations EDTA/CHX and EDTA/NaOCI/CHX.Key words: Endorez, Sodium hypochlorite, EDTA, chlorhexidine, adhesion, root canal dentin

Introduction The success of root canal therapy depends on the quality of several factors, including the in-strumentation, irrigation, disinfection, and 3-di-mensional obturation of the root canal.1 The ability to bond to radicular dentin has been perceived as beneficial for establishing a du-rable, impervious seal to prevent colonization of microbial biofilms and reinfection of filled canal spaces2 There has been a continuous quest throughout the history of endodontics for sealing materials that bond to instrumented canal walls.3 Resin-based sealers have gained popularity with the recent growing interest in adhesive endodontics. However, several factors make adhesion to the root canal system a chal-lenge, such as chemical substances used dur-ing the biomechanical preparation, volumetric changes that occur in resin-based sealers during polymerization, bonding of the sealer because of polymerization shrinkage stresses, and vari-ous geometric factors.4 The irrigation solutions could alter the physicochemical characteristics of dentin3 and may have an adverse effect on ad-hesion to root canal dentin5 Endorez® (Ultradent Products Inc, South Jordan, UT) is a dualcured radiopaque hydrophilic methacrylate sealer that might be used in the wet environment of the root canal system.6 Endorez® required removal of canal wall smear layers to facilitate resin tag formation by hydrophilic resins.2 According to the manufacture, Endorez® can be used either with conventional gutta percha or with specific Endorez® point. In this work, we opted for con-ventional gutta percha as it represents the refer-ence material for canal obturation and it is the

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most used by the majority of practitioners. The objective of this work was to study the influence of the varioust most used irrigation solution combinations (sodium hypochlorite, EDTA and chlorhexidine) on the sealing of canal obturation using Endorez®.

Materials and MethodsSamples preparationFifty-six extracted mature human incisors with single straight canals and patent apices were se-lected. These teeth were stored in KCL at 0.9% until the operative procedures. After performing access cavities, Canals preparation were per-formed by the ProTaper Universal Series Rotary System according to the manufacturer’s recom-mendations using a crown-down technique. Irri-gation was performed with sodium hypochlorite at 2.5%7 before and after the passage of each instrument. These teeth were randomly divided into 5 groups, each comprising 14 teeth. Each group underwent a final rinsing according to the following protocol.

After rinsing, the canals were dried with paper points. The obturations were performed with En-dorez® (methacrylic resin-based sealing cement) and with one gutta-percha cone according to the protocol recommended by the manufacturer (mono cone obturation). The master-cone (non-standardized medium size VENTURA) of each canal was adjusted with visual and tactile tests. (Control of Tug Back).A coronal obturation with composite resin (SWISS TEC®) was performed in order to obtain a maximal airtight and to avoid any infiltration risk of the dye through the coronal cavity.Infiltration (leakage) with china ink:All the teeth were immersed in china ink. Each tooth was placed, apex downward, in a Pyrex test tube half-filled with china ink. Each test tube was placed in a water bath, all placed in an agitator for 10 minutes. The water bath tem-perature was maintained at 37°C. After immer-sion, the teeth were left to dry in the open air for 24h. The dye deposit to the root surface of each tooth was carefully eliminated with the help of a Soflex disc of fine granulometry.

DiaphanisationThe crowns were sectioned and eliminated,

maintaining only the roots in order not to rap-idly exhaust the acid solution. Only the roots underwent the diaphanisation stage. The teeth were placed for 12 days in nitric acid at 5% un-der continuous agitation and room temperature. The acid solution was daily renewed. To carry out progressive and complete dehydration, the roots were placed in growing concentrations of ethanol solutions (75%, 85%, and 95%, pure) for 24 hours each. The teeth were made trans-parent through immersion in methyl salicylate for 24 hours.Observation with stereo-microscopeThe stereo microscope was used to directly evaluate the dye recovery. The different samples of the five groups were photographed with the stereo microscope in two views (sections): ves-tibular and proximal. The measurements of the dye recovery were taken under an enlargement of 0,75, through unity of microscopic scale. (Fig-ures 1, 2, 3 and 4) The Post Hoc Test was used to conduct a multiple comparison between groups 1, 2, 3 and 4. The value p is considered as signifi-cant when it is inferior to 0.05.

ResultsInfiltration scores are shown in figure 5. The sig-nificant differences were observed between:- Groups 1 (17% EDTA and 2.5% NaOCL) and 2 (17% EDTA and 0.2% CHX) (P=0.024). The irrigation associating 17% EDTA and 0.2% CHX shows less infiltration than that associating 17% EDTA and 2.5% NaOCL.- Groups 2 (17% EDTA and 0.2% CHX) and 4 (2.5% NaOCL) (p=0). The group irrigated us-ing the association 17% EDTA and 0.2% CHX shows infiltration values of china ink clearly infe-rior to those observed at the level of the group irrigated with 2.5% NaOCL.- Groups 3 (17% EDTA, 2.5% NaOCL and 0.2% CHX) and 4 (2.5% NaOCL) (p=0.04). The group irrigated with the association 17% EDTA, 2.5% NaOCL and 0.2% CHX gives infiltration values weaker than the group irrigated with only 2.5% NaOCL. No significant differences were observed between groups 1 and 3 (P=0.68), groups 1 and 4 (P=0.1) and groups 2 and 3 (P=0.06). (Fig.1)

DiscussionThe methods used to evaluate the root canal leakage are numerous and the results are of-

Group 2

Group 1

Group 4

Group 3

- Suction of sodium

hypochlorite from the

canal.

- Irrigation with 17%

EDTA for one minute.

- Neutralization with

3cc of distilled water

for one minute.

- Final rinsing with 3cc

of chlorhexidine at

0.2% for one minute.

- Suction of sodium


canal.


EDTA7 for one minute

and neutralization with

3cc sodium hypochlo-

rite at 2.5% for one

minute.

- Irrigation with sodium

hypochlorite at 2.5%

for one minute.

- Suction of sodium


canal.


EDTA for one minute.

- Neutralization with

3cc of sodium

hypochlorite at 2.5%

for one minute.

- Rinsing with distilled

water for one minute

(in order to avoid the

formation of precipitate

rust)

- Final rinsing with 3cc

of chlorexidine at 0.2%

for one minute.


GROUP BGROUP A

16


ten contradictory.7 Dye penetration study is fre-quently used as it presents a good correlation with the other techniques.8

Many researches on Endorez® cement have been interested in its adhesion to the dentine when comparing it to other sealing cements9,10

but few works have studied the effects of the irrigation solutions on the cement bonding.Endodontic irrigation can result in an alteration of the chemical and structural composition of the human dentin modifying its permeability and its solubility, and affecting adhesion of ma-terials to dentin surfaces.11 According to Xiaoli study, the irrigation solutions act on the physico-chemical properties of the dentin surface, mainly on its wetness and durability.1

Optimum adhesion requires intimate contact be-tween the adhesive material and the substrate to facilitate molecular attraction and allow ei-ther chemical adhesion or penetration for mi-cromechanical surface interlocking. Therefore, adhesion processes are mainly influenced by the relative surface energy (wetting ability) of the solid surface which, in turn, is affected by the

internal dentin wetness resulting from dentin permeability provided by water in the dentinal tubules. This wetness is a consequence of dentin permeability provided by water in the dentinal tubules.11

In this study, we tested the effect of the various most currently-used irrigation solution combi-nations (NaOCl, EDTA, CHX) on the leakage of Endorez® canal filling. We noticed that the final irrigation with only sodium hypochlorite gave the most significant infiltration values. Sodium hypochlorite is the base irrigation solution that allows canal disinfection and the elimination of the organic fraction from the smear layer.12 So-dium hypochlorite is a powerful oxidizing agent that allows the formation of an oxygen-enriched layer to the dentinal surface. According to Mor-ris et al. NaOCL leads to the oxidation of certain components of the dentinal matrix.13 It also leads to the formation of protein free radicals that gets into competition with the vinyl free radi-cals generated by the photo activation of resin sealer. This leads to an incomplete polymeriza-tion that affects the obturation quality.14 Oxygen

sample without infi ltration



sample without infi ltration sample with infi ltration

sample with infi ltration



Figure 1group 1 (EDTA and NaOCl)

Figure 2group 2 (EDTA and CHX)

Figure 3group 3 (EDTA NaOCl CHX)

Figure 4group 4 (NaOCl)

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is considered among the substances that inhibit the polymerization of resin-based sealers. 3, 15 According to Ari et al. the formation of oxygen bubbles in the resin dentin interface will interfere with resin infiltration at the level of the tubules.15 Irrigation with sodium hypochlorite also causes a reduction in the calcium and phosphorus rates of dentin surface14, 16, thus modifying certain me-chanical properties of this tissue, such as elastic-ity, flexion and micro hardness. This contributes to the decrease of the micro mechanical interac-tion between the resin sealing cements and the dentin. All these points explain the bad results obtained in this study.14 The final irrigation as-sociating EDTA and NaOCI did not give better results than the final irrigation with only hypo-chlorite. EDTA removes the mineral fraction from the smear layer exposing the dentinal tubules17 It is generally used in the final rinsing following the end of shaping.12 This irrigation sequence allows the total elimination of the smear layer (organic and mineral fractions) but it can be at the origin of certain problems for the exposed root dentin.EDTA can cause severe erosion to the dentin if it exposed for a long time or if EDTA is not neutral-ized. Calt and Serper suggest that EDTA should be used for less than a minute in the canal to avoid any risk of erosion.18 Dogan and Semra showed that the irrigation associating NaOCI and EDTA alter the mineral of the root dentin.17,18 Several other studies showed that the use of so-dium hypochlorite in the final flush after EDTA increases dentinal erosion.19 NaOCI attack the collegen exposed.20 Although we had aspired NaOCI before using EDTA and we neutralized the latter with distilled water, the results were not better. This is explained by the oxidizing action of hypochlorite which was lastly used. Eldeniz study which used the final irrigation pro-tocol (EDTA, NaOCl) showed a bad adhesion of Endorez® to the dentin compared to the other sealing cements.10 According to Doyle study, when EDTA is used in final rinsing following Na-OCI, the adhesion of Endorez® to the dentin is not altered by the latter.21 The final irrigation as-sociating EDTA and CHX showed better results with the weakest infiltration values. The absence of NaOCI ameliorates the quality of the canal fill-ing (or of adhesion). In our study, we noticed that the neutralization of EDTA with CHX had ameliorated the obtura-

tion leakage. Erdemir et al. noticed that CHX significantly increases the adhesion force of the resin sealers to the radicular dentin. This phe-nomenon could be explained by the adsorption of CHX to the dentin surface which is in favor of resin infiltration at the dentinal tubules.5

We noted that there are no significant differ-ences between the irrigation associating EDTA and NaOCI and that associating EDTA, NaOCI and CHX. CHX managed to neutralize the ef-fect of NaOCI. According to Santos et al, CHX used alone does not affect adhesion of the self-etching adhesives to the dentin as it is an anti-oxidizing agent. It is the same when CHX is as-sociated with EDTA.14

It is worth noting that a white precipitate is formed when these two products are associ-ated.15 When CHX is associated with sodium hypochlorite, a brown orange (parachloramine) is formed at the canal surface and it affects the canal obturation with the resin cements.4, 22 It is for these reasons that we performed rinsing with distilled water before the use of CHX.22

According to Wachlarowicz, the different irriga-tion solutions have little effect on the dentinal adhesion of epiphany-based sealers. The adhe-sion of epiphany to the dentin is comparable to other sealing cements. The negative effect of NaOCl on adhesion was not confirmed by Wachlarowichz study.24

Based on this study, the best leakage results were obtained with the following combinations “EDTA and CHX” and “EDTA, NaOCl and CHX”.The association EDTA, NaOCI and CHX allows a rigorous final disinfection thanks to the com-bined action of sodium hypochlorite and CHX without an alteration of Endorez sealer adhe-sion. This irrigation protocol could be indicated in case of infected canals.

20

Prosthetic DentistryEffect of irrigation solutions

1. HU X, LING J, GAO Y. EFFECTS OF IRRIGATION SOLUTIONS ON DENTIN WETTABILITY AND ROUGHNESS. J ENDOD 2010; 36:1064-67.2. MAI S, KIM YK, HIRAISHI N , LING J, PASHLEY DH, TAY FR. EVALUATION OF THE TRUE SELF-ETCHING POTENTIAL OF A FOURTH GENERATION SELF-ADHESIVE METHACRYLATE RESIN–BASED SEALER. J ENDOD 2009; 35:870-74.3. SCHWARTZ RS. ADHESIVE DENTISTRY AND ENDODONTICS. PART 2: BONDING IN THE ROOT CANAL SYSTEM. THE PROMISE AND THE PROBLEMS: A REVIEW. J ENDOD 2006; 32:1125-34.4. BELLI S, COBANKARA FK, OZCOPUR B, ELIGUZELOGLU E, ESKITASCIOGLU G . AN ALTERNATIVE ADHESIVE STRATEGY TO OPTIMIZE BONDING TO ROOT DENTIN. J ENDOD 2011; 37: 1427-32.5. ERDEMIR A, ARI H, GÜNGÜNES H, BELLI S. EFFECT OF MEDICATIONS FOR ROOT CA-NAL TREATMENT ON BONDING TO ROOT CANAL DENTIN. J ENDOD 2004; 30: 113-16.6. KIM YK, GRANDINI S, AMES JM, GU LS, KIM SK, PASHLEY DH, GUTMANN JL, TAY FR. CRITICAL REVIEW ON METHACRYLATE RESIN–BASED ROOT CANAL SEALERS.

References:

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Effect of irrigation solutions

Oral Surgery

22

J ENDOD 2010; 36:383-99.7. HERBERT J, BRUDER M, BRAUNSTEINER J, ALTENBURGER MJ, WRBAS KT. APICAL QUALITY AND ADAPTATION OF RESILON, ENDOREZ, AND GUTTAFLOW ROOT CANAL FILL-INGS IN COMBINATION WITH A NONCOMPACTION TECHNIQUE. J ENDOD 2009; 35:261-64.8.ZMENER O, PAMEIJER CH, ALVAREZ SERRANO S, VIDUEIRA M, MACCHI RL.SIGNIFICANCE OF MOIST ROOT CANAL DENTIN WITH THE USE OF METHACRYLATE-BASED ENDODONTIC SEALERS: AN IN VITRO CORONAL DYE LEAKAGE STUDY. J ENDOD 2008; 34:76-79.9. FISHER MA, BERZINS DW, BAHCALL JK. AN IN VITRO COMPARISON OF BOND STRENGTH OF VARIOUS OBTURATION MATERIALS TO ROOT CANAL DENTIN USING A PUSH-OUT TEST DESIGN. J ENDOD 2007; 33:856-58.10. UNVERDI ELDENIZ A, ERDEMIR A; BELLI S. SHEAR BOND STRENGTH OF THREE RESIN BASED SEALERS TO DENTIN WITH AND WITHOUT THE SMEAR LAYER. J ENDOD 2005; 31:293-96.11. HASHEM AAR, GHONEIM AG, LUTFY RA, FOUDA MY. THE EFFECT OF DIFFERENT IRRIGATING SOLUTIONS ON BOND STRENGTH OF TWO ROOT CANAL–FILLING SYSTEMS. J ENDOD 2009; 35: 537-540.12. ZEHNDER M. ROOT CANAL IRRIGANTS. J ENDOD 2006; 32: 389-98.13. MORRIS MD, LEE KW, AGEE KA, BOUILLAGUET S, PASHLEY DH.EFFECTS OF SODIUM HYPOCHLORITE AND RC-PREP ON BOND STRENGTHS OF RESIN CEMENT TO END-ODONTIC SURFACES. J ENDOD 2001; 27:753-57.14. SANTOS N J, ROCHA DE OLIVEIRA CARRILHO M, DE GOES MF, ZAIA AA, FIGUEIRE-DO DE ALMEIDA GOMES BP, DE SOUZA-FILHO FJ, RANDI FERRAZ CC.EFFECT OF CHEMICAL IRRIGANTS ON THE BOND STRENGTH OF A SELF-ETCHING ADHESIVE TO PULP CHAMBER DENTIN. J ENDOD 2006; 32: 1088-90.15. ARI H, YASSAR E¸ BELLI S. EFFECTS OF NAOCL ON BOND STRENGTHS OF RESIN CEMENTS TO ROOT CANAL DENTIN. J ENDOD 2003; 29:248-51.16. ARI H, ERDEMIR A. EFFECTS OF ENDODONTIC IRRIGATION SOLUTIONS ON MINERAL CONTENT OF ROOT CANAL DENTIN USING ICP-AES TECHNIQUE. J ENDOD 2005; 31: 187-189.17. DOGAN H, CALT S. EFFECTS OF CHELATING AGENTS AND SODIUM HYPOCHLORITE ON MINERAL CONTENT OF ROOT DENTIN. J ENDOD 2001; 27:578-80.18. ÇALT S, SERPER A. TIME-DEPENDENT EFFECTS OF EDTA ON DENTIN STRUCTURES. J ENDOD 2002; 28:17-19. 19. GRANDE NM, PLOTINO G, FALANGA A, POMPONI M, SOMMA F . INTERACTION BETWEEN EDTA AND SODIUM HYPOCHLORITE: A NUCLEAR MAGNETIC RESONANCE ANALYSIS. J ENDOD 2006; 32: 460-464.20. QIAN W, SHEN Y, HAAPASALO M. QUANTITATIVE ANALYSIS OF THE EFFECT OF IRRIGANT SOLUTION SEQUENCES ON DENTIN EROSION. J ENDOD 2011; 37: 1437-41.21. DOYLE MD, LOUSHINE RJ, AGEE KA, GILLESPIE WT, WELLER RN, PASHLEY DH, TAY FR. IMPROVING THE PERFORMANCE OF ENDOREZ ROOT CANAL SEALER WITH A DUAL-CURED TWO-STEP SELF-ETCH ADHESIVE. I. ADHESIVE STRENGTH TO DENTIN. J EN-DOD 2006; 32:766-770.22. BUI TB, CRAIG BAUMGARTNER J, MITCHELL JC. EVALUATION OF THE INTERACTION BETWEEN SODIUM HYPOCHLORITE AND CHLORHEXIDINE GLUCONATE AND ITS EFFECT ON ROOT DENTIN. J ENDOD 2008; 34:181-85.23. BASRANI BR, MANEK S, SODHI RNS, FILLERY E, MANZUR A. INTERACTION BETWEEN SODIUM HYPOCHLORITE AND CHLORHEXIDINE GLUCONATE. J ENDOD 2007; 33:966-69.24. WACHLAROWICZ AJ, JOYCE AP, STEVEN ROBERTS, PASHLEY DH. EFFECT OF ENDODONTIC IRRIGANTS ON THE SHEAR BOND STRENGTH OF EPIPHANY SEALER TO DENTIN. J ENDOD 2007; 33:152-55. ACKNOWLEDGEMENTS THE AUTHORS THANK MISTER SAMIR BOUKOTTAYA FOR REVISION OF THE MANUSCRIPT.

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48

Case Report

Implant Dentistry

Replacement of a Missing Maxillary Central Incisor

Dr. Fady Abillamaa

Dr. Badry Meouchy

Dr. Elie Azar Maalouf

Dr. Fatmé Mouchref Hamasny

Dr. Ramzi Abou Arraj

AbstractBackground: An 18 year old female patient pre-sented for implant placement at the site of a congenitally missing right maxillary central inci-sor. The clinical examination revealed an insuf-ficient bucco-lingual width of the edentulous ridge, requiring a horizontal bone augmentation procedure prior to implant placement.Methods: An autogenous bone block graft was harvested from mandibular symphysis, fixed on buccal aspect of edentulous crest with titanium miniscrews, covered first by autogenous bone chips and xenograft particles, and second with a resorbable barrier membrane. Four months later, an Astra Tech® implant was placed in the grafted site, surrounded by a thick buccal bony wall, demonstrating excellent primary stability and guaranteeing a better esthetic outcome. Impressions for prosthetic work were taken and final restoration cemented 3 months following implant placement.

DiscussionAutogenous bone block grafting is regarded as a predictable procedure, especially in horizontal bone augmentation from intra-oral sites. Many requirements have to be respected however in order to achieve this purpose. In addition, tim-ing of implant placement with autogenous block grafts is a subject of controversy. Finally, implant placement in anterior maxilla has to meet guide-lines proposed in the literature to avoid esthetic shortcomings. Conclusion: This case report describes the suc-cessful replacement of an anterior missing tooth with an Astra® implant after a bucco-lingual augmentation of the edentulous ridge.

IntroductionThe ability to successfully replace single or mul-tiple missing teeth with osseointegrated dental implants has revolutionized dentistry over the past four decades. Consistent long-term results have been reported in the literature (Adell et al., 1990; Albrektsson et al., 1986; Lekholm et al., 1994). Nevertheless, dental implant therapy can be complicated by numerous local factors, namely the anatomy of the edentulous ridge. An inadequate bone volume, either in height or in width, renders the placement of implants rather difficult, especially in areas of high esthetic de-mands. Various bone augmentation techniques have been described in the literature in order to reconstruct deficient alveolar ridges such as particulate bone grafting, guided bone regen-eration, autogenous bone block graft, ridge ex-pansion, and alveolar distraction osteogenesis (McAllister and Haghighat, 2007; Chiapasco et al., 2006 & 2007; Esposito et al., 2006). The pur-pose of this clinical report is to describe a case of single implant placement in maxillary right central incisor region following horizontal bone augmentation using an autogenous block graft in a young female patient.

Case ReportAn 18 year old female patient was referred by the Department of Orthodontics to the Depart-ment of Periodontology (at the Lebanese Uni-versity School of Dentistry) because of a missing maxillary right central incisor.

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Case Report

Implant Dentistry

Fig. 1: Extra-oral examina-tion showing smile line, symmetry and missing right central incisor.

Fig. 2: Maxillary retainer in place.

Fig. 4: Peri-appical radiograph of the edentulous site.

Fig. 3: Insuffi cient bucco-lingual width of the edentu-lous ridge.

Fig 1

Fig 4

Fig 2

Fig 3

The patient had just completed her orthodon-tic treatment and a removable maxillary retainer was fabricated to maintain the space as well as to temporarily replace the missing tooth (Fig. 2).

In addition, the Department of Orthodontics and Dentofacial Orthopedics approved the initiation of surgical procedures after examining a hand wrist radiograph in order to confirm the end of growth. The questionnaire and the patient’s file revealed that this central incisor was congenitally missing. An extra-oral examination was first car-ried out, demonstrating a low lip line, facial sym-metry and a well aligned dental midline. Then, intra-oral examination of the edentulous space showed a well managed space to symmetrically replace the missing right central incisor accord-ing to the left central incisor, a narrow alveolar crest indicating a horizontal bone loss at the site of the missing tooth (Fig. 3).

A periodontal probe (Michigan probe, Hu-Friedy, IL, USA) was then used under local analgesia to assess bucco-lingual width of bone crest, after subtracting the thicknesses of buccal and lingual soft tissues from total bucco-lingual width of the ridge at top of the crest. These measurements displayed an approximate horizontal bone thick-ness of 3 mm. However, optimal implant place-ment required a buccal bone thickness of at least 1 mm to avoid esthetic shortcomings, i.e. gingival recession (Belser et al., 1998; Chiapasco et al., 1999; Buser et al., 2004). Therefore, it was decided to perform a horizontal bone augmen-tation procedure using an autogenous block graft prior to implant placement in a staged ap-proach. Moreover, a peri-apical radiograph re-vealed a sufficient height of bone (Fig. 4).

Onlay Bone Block GraftingPatient was instructed to perform a mouthrinse with a 0.12% solution of chlorhexidine-diglu-conate for 1 minute with a 10 ml solution im-mediately prior to surgery. Local analgesia (2% lidocaine with 1:100000 epinephrine) was ad-ministered in the area of the maxillary edentu-lous crest as well as in the interforaminal region of anterior mandible. Full-thickness buccal and palatal mucoperios-teal flaps with 2 buccal vertical releasing inci-sions were first raised at the recipient site. The direct measurement using a periodontal probe (Michigan probe, Hu-Friedy, IL, USA) confirmed the pre-operative bucco-lingual width evalua-tion. Then, a template was used and adjusted at the recipient bed to assess the dimensions of the block graft to be harvested (Fig. 5). Subsequently, a horizontal incision was made at muco-gingival junction from cuspid to cuspid at mandibular symphysis region and a full-thick

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28

Case Report

Implant Dentistry

ness (mucoperiosteal) flap was raised (Fig. 6).

Right and left mental nerves were identified and protected and the adjusted template was used to outline the cortico-cancellous block with a fissure bur used on a straight handpiece, under copious irrigation with sterile saline (Fig. 7).

Following ostectomy, a 14x6x5 mm bone block was removed with fine straight chisels while preserving the lingual cortex. Further cancellous bone chips were harvested with surgical curettes and the donor site filled with haemostatic mate-rial (Cutanplast®, Milan, Italy) (Fig. 8)

to minimize hematoma formation. Next, the flap was sutured back to its original position using an interlocked continuous suture technique. At the recipient site, the block graft was adjusted to achieve better adaptability and decrease micro-movements. A round bur was used to perforate the buccal cortex of the recipient bed in order to promote bleeding and the block was fixed with 2 titanium miniscrews (Straumann®, Switzer-land) after smoothening of its sharp edges.

Cancellous bone chips collected from donor site were mixed with xenograft bone particles (Bio-Oss®, Geistlich, Switzerland) and were used to fill the gap around the bone block (Fig. 10).

Then, a resorbable membrane (Bio-Gide®, Geistlich, Switzerland) was placed in a double layer technique to cover both the block graft and bone particles (Fig. 11).

Fig 5

Fig 9

Fig 10

Fig 6

Fig 7

Fig 8

Fig 11

Fig. 10: cancellous bone chips and Bio-Oss® particles fi lling the defects around the bone block.

Figure 11: (Note the prominent antegonial notch on the lower border of the mandible)

Fig. 7: Use of the template to outline the block graft.

Fig. 5: Adjustment of a template of the graft at the recipient site.

Fig. 6: Incision and fl ap at mandibular donor site.

Fig. 8: Cancellous bone chips after block harvesting.

Fig. 9: Fixation of the block graft with 2 titanium miniscrews.

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Periosteal releasing incisions allowed a coronal displacement of the buccal flap enough to close the wound, using mattress and tension-free sim-ple interrupted resorbable sutures (3/0 Vicryl®) (Fig. 12).

Antibiotic (Augmentin® 625mg TID for one week) and anti-inflammatory (Brufen® 400mg TID in case of pain) drugs were administered fol-lowing surgery. Mouthrinses with a 0.12% solu-tion of chlorhexidine-digluconate were started again 24 hours after surgery and continued for 2 weeks. The maxillary removable retainer was ad-justed to avoid pressure over the grafted site and sutures were removed 10 days post-operatively.Implant Placement Four months later, patient re-turned to the Department of Periodontology for implant placement (Figs. 13 & 14)

Immediately prior to starting surgery, patient

Fig 12

Fig 15

Fig 16

Fig 13

Fig 14

Fig. 12: Horizontal mattress and simple interrupted sutures.

Fig. 15: Bone resorption at the level of the more coronal miniscrew.

Fig. 16: Direction indicator in place to verify the ideal position.

Fig. 13: Recipient site 4 months after bone grafting (Note that 1 of the minis-crews is showing through the alveolar mucosa).

Fig. 14: Occlusal view of the edentulous crest 4 months after bone grafting.

was asked to use a mouthrinse (Chlorhexidine digluconate 0.12%) for 3 minutes, and local an-algesia (2% lidocaine with 1:100000 epineph-rine) was administered in the grafted maxillary area. Similar to the previous procedure, crestal, intra-sulcular and vertical releasing incisions were made and full-thickness buccal and palatal mucoperiosteal flaps were raised. The grafted region demonstrated an adequate horizontal bone augmentation of approximately 7 mm with some resorption at coronal level with no considerable effect on the outcome of therapy (Fig. 15).

Next, the 2 titanium miniscrews were removed, a 2mm twist drill was then used to the length of 13mm followed by verification with the direction indicator (Fig. 16).

Then, the 2.5 mm Tiger drill was used to the length of 13 mm, followed by the intermediate Pilot drill, and finally the 3.2 mm Tiger drill fol-lowed by the 3.5mm cortical drill. The Direction Indicator was used at all times to guide implant positioning both mesio-distally and bucco-lin-gually (Fig. 17).

30

Case Report

Implant Dentistry


Fig 17

Fig 18

Fig 21

Fig 22

Fig 20

Fig 19

Fig. 17: Occlusal view of the Direction Indicator.

Fig. 18: Frontal view of the implant showing its corono-apical position.

Fig. 19: Occlusal view of the implant showing the pres-ence of 2mm thickness.

Fig. 20: Flap Closure.

Fig. 21: Final cemented restoration.

Fig. 22: Peri-apical radiograph of the implant/crown connection.

The 3-dimensional implant placement was per-formed in respect to the guidelines proposed in the literature (Buser et al., 2004). Subsequently, a 3.5 x 13 mm Astra Tech® implant was re-moved from its sterile container and delivered to the drilling site by first using the Delivery Cap and later the Torque Wrench until its rough sur-face was fully submerged in bone (Figs. 18 & 19).

The implant carrier was released using the Torque Wrench in a counterclockwise direction with the Combination Wrench and a 3.5 mm cover screw placed on top of the implant. Finally, the mucoperiosteal flaps were sutured in their original position (Fig. 20). Post-operative medications were prescribed similarly to previous surgery and sutures were removed 1 week after.

Crown PlacementThree months after implant placement, uncover-ing of the implant was performed and a healing screw replaced the cover screw. Three weeks later, abutment choice and impressions were made for prosthesis fabrication at the Leba-nese University School of Dentistry Department of Prosthodontics. After another 3 weeks, the crown was cemented in place demonstrating an excellent immediate esthetic outcome and after a follow-up period of 1 month and 2 years (Figs 21, 22 & 23).

DiscussionInsufficient width of alveolar crest has led to the application of different grafting techniques.

32

Case Report

Implant Dentistry

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Fig 23

Autogenous block grafting is a well documented procedure, either from intra-or extra-oral sites (McAllister and Haghighat 2007; Chiapasco et al., 2006). Horizontal bone augmentation, in particular, is considered a predictable approach with onlay bone grafts (Buser et al., 1996; Misch, 1997). Available intra-oral donor sites in-clude mandibular symphysis, mandibular ramus and mandibular external oblique ridge (Prous-saefs et al., 2002; Misch, 2000). Pre-requisites for the success of this therapy are the intimate contact and stabilization of the block graft to the recipient bed (de Carvalho et al., 2000; Ur-bani et al., 1998), and the cortical perforation with intra-marrow penetration of the defect site to increase the rate of re-vascularization and re-modeling (Majzoub et al., 2000; de Carvalho, 2000). The amount of bone resorption of intra-oral (chin and mandibular ramus) onlay block grafts has been reported to vary between 5 and 10% (Chiapasco et al., 1999; Raghoebar et al., 2000; Jemt and Lekholm, 2003). However, the use of barrier membranes in combination with block grafts seems to minimize the rate of bone resorption (McAllister and Haghighat, 2007; Chiapasco et al., 2006). The timing of implant placement in grafted sites has been a subject of controversy. Many authors24,25 advocated an immediate implant placement in conjunction with intra-oral onlay grafting procedure in order to reduce the risk of bone resorption that occurs, for the most part, shortly after graft fixation. Other authors22,23 recommended implant placement after a wait-ing period of 4 to 5 months of the grafting pro-cedure to permit a better primary stability and integration of the implant in a re-vascularized bone and to avoid an implant loss due to expo-sure or infection of the block graft (Chiapasco et al., 2006). Therefore, in areas of esthetic con-cern, it would be wiser to place the implants in a delayed approach for more predictable results.

ConclusionLateral bone augmentation of a narrow eden-tulous ridge, using autogenous block grafts, has shown to be a successful technique. Fur-thermore, if guidelines for implant placement in anterior maxilla are respected, excellent esthetic outcomes can be achieved. This case report demonstrated the ability to replace a congenital-

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IMPLANTS 1990;5:347-359.

2. ALBREKTSSON T, ZARB G, WORTHINGTON PMD, ERIKSSON AR. THE LONG-TERM EFFICACY OF CUR-

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IMPLANTS 1986;1:11-25.

3. BELSER UC, BUSER D, HESS D, SCHMID B, BERNARD JP, LANG NP. AESTHETIC IMPLANT RESTORA-

TIONS IN PARTIALLY EDENTULOUS PATIENTS-A CRITICAL APPRAISAL. PERIODONTOL 2000 1998;17:132-150.

4. BUSER D, DULA K, HIRT HP, SCHENK RK. LATERAL RIDGE AUGMENTATION USING AUTOGRAFTS AND

BARRIER MEMBRANES: A CLINICAL STUDY WITH 40 PARTIALLY EDENTULOUS PATIENTS. J ORAL MAXILLOFAC

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PL):43-61.

6. CHIAPASCO M, ABATI S, ROMEO E, VOGEL G. CLINICAL OUTCOME OF AUTOGENOUS BLOCK GRAFTS OR

GUIDED BONE REGENERATION WITH E-PTFE MEMBRANES FOR THE RECONSTRUCTION OF NARROW EDENTULOUS

RIDGES. CLIN ORAL IMPL RES 1999;10:278-288.

7. CHIAPASCO M, ZANIBONI M, BOISCO M. AUGMENTATION PROCEDURES FOR THE REHABILITATION OF

DEFICIENT EDENTULOUS RIDGES WITH ORAL IMPLANTS. CLIN ORAL IMPL RES 2006;17(SUPPL. 2):136-159.

8. CHIAPASCO M, ZANIBONI M, RIMONDINI L. AUTOGENOUS ONLAY BONE GRAFTS VS. ALVEOLAR DISTRAC-

TION OSTEOGENESIS FOR THE CORRECTION OF VERTICALLY DEFICIENT RIDGES: A 2-4-YEAR PROSPECTIVE STUDY

ON HUMANS. CLIN ORAL IMPL RES 2007;18:432-

9. DE CARVALHO PS, VASCONCELLOS LW, PI J. INFLUENCE OF BED PREPARATION ON THE INCORPORATION OF

AUTOGENOUS BONE GRAFTS: A STUDY IN DOGS. INT J ORAL MAXILLOFAC IMPLANTS 2000;15:565-570.

10. ESPOSITO M, GRUSOVIN MG, COULTHARD P, WORTHINGTON HV. THE EFFICACY OF VARIOUS BONE

AUGMENTATION PROCEDURES FOR DENTAL IMPLANTS: A COCHRANE SYSTEMATIC REVIEW OF RANDOMIZED

CONTROLLED CLINICAL TRIALS. INT J ORAL MAXILLOFAC IMPLANTS 2006;21:696-710.

11. JEMT T, LEKHOLM U. MEASUREMENTS OF BUCCAL TISSUE VOLUMES AT SINGLE-IMPLANT RESTORATIONS

AFTER LOCAL BONE GRAFTING IN MAXILLAE: A 3-YEAR CLINICAL PROSPECTIVE STUDY CASE SERIES. CLINICAL

IMPLANT DENTISTRY RELATED RESEARCH 2003;5:63-70.

12. LEKHOLM U, VAN STEENBERGHE D, HERMANN I, BOLENDER C, FOLMER T, GUNNE J, HENRY P,

HIGUCHI K, LANEY WR. OSSEOINTEGRATED IMPLANTS IN THE TREATMENT OF PARTIALLY EDENTULOUS JAWS; A

PROSPECTIVE 5-YEAR MULTICENTER STUDY. INT J ORAL MAXILLOFAC IMPLANTS 1994;9:627-635.

13. MAJZOUB Z, BERENGO M, GIARDINO R, ALDINI NN, CORDIOLI G. ROLE OF INTRAMARROW PENETRA-

TION IN OSSEOUS REPAIR: A PILOT STUDY IN THE RABBIT CALVARIA. J PERIODONTOL 1999;70:1501-1510.

14. MCALLISTER BS, HAGHIGHAT K. BONE AUGMENTATION TECHNIQUES. J PERIODONTOL 2007;78:377-

396.

15. MISCH CM. COMPARISON OF INTRAORAL DONOR SITES FOR ONLAY GRAFTING PRIOR TO IMPLANT PLACE-

MENT. INT J ORAL MAXILLOFAC IMPLANTS 1997;12:767-776.

16. MISCH CM. USE OF MANDIBULAR RAMUS AS A DONOR SITE FOR ONLAY BONE GRAFTING. JOURNAL OF

ORAL IMPLANTOLOGY; VOL.XXVI/NO. ONE/2000.

17. PROUSSAEFS P, LOZADA J, KLEINMAN A, ROHRER MD. THE USE OF RAMUS AUTOGENOUS BLOCK

GRAFTS FOR VERTICAL ALVEOLAR RIDGE AUGMENTATION AND IMPLANT PLACEMENT: A PILOT STUDY. INT J ORAL

MAXILLOFAC IMPLANTS 2002;17:238-248.

18. RAGHOEBAR GM, BATENBURG RHK, MEIJER HJA, VISSINK A. HORIZONTAL OSTEOTOMY FOR RECON-

STRUCTION OF THE NARROW EDENTULOUS MANDIBLE. CLIN ORAL IMPL RES 2000;11:76-82.

19. SCHWARTZ-ARAD D, LEVIN L, SIGAL L. SURGICAL SUCCESS OF INTRAORAL AUTOGENOUS BLOCK ONLAY

BONE GRAFTING FOR ALVEOLAR RIDGE AUGMENTATION. IMPLANT DENT. 2005 JUN;14(2):131-8.

20. URBANI G, LOMBARDO G, SANTI E, TARNOW D. LOCALIZED RIDGE AUGMENTATION WITH CHIN GRAFTS

AND RESORBABLE PINS: CASE REPORTS. INT J PERIODONTICS RESTORATIVE DENT 1998;18:363-375.

21. VON ARX T, BUSER D. HORIZONTAL RIDGE AUGMENTATION USING BLOCK GRAFTS AND THE GUIDED BONE

REGENERATION TECHNIQUE WITH COLLAGEN MEMBRANES: A CLINICAL STUDY WITH 42 PATIENTS. CLIN ORAL

IMPLANTS RES. 2006 AUG;17(4):359-66.

22. JEMT T, LECKHOLM U. MEASUREMENTS OF BUCCAL TISSUE VOLUMES AT SINGLE-IMPLANT RESTORATIONS

AFTER LOCAL BONE GRAFTING IN MAXILLAE: A 3-YEAR CLINICAL PROSPECTIVE STUDY CASES SERIES. CLINICAL

IMPLANT DENT REL RES. 2003;5:63-70.

23. BECKTOR JP, ECKERT SE, ISAKSSON S, KELLER EE. THE INFLUENCE OF MANDIBULAR DENTITION ON

IMPLANT FAILURES IN BONE-GRAFTED EDENTULOUS MAXILLAE. INT J ORAL MAXFAC IMPL. 2002;17:69-77.

24. NYSTRÔM E, AHLQVIST J, GUNNE J, KAHNBERG KE. 10-YEAR FOLLOW-UP OF ONLAY BONE GRAFTS AND

IMPLANTS IN SEVERELY RESORBED MAXILLAE. INT J ORAL MAXFAC IMPL. 2004;33:258-262.

25. VAN DER MEJJ EH, BLANKESTIJN J, BERMS RM, BUN RJ, JOVANOVIC A ET AL. THE COMBINATION OF

TWO ENDOSTEAL IMPLANTS AND ILIAC CREST ONLAY GRAFTS IN THE SEVERELY ATROPHIC MANDIBLE BY A MODI-

FIED SURGICAL APPROACH. INT J ORAL MAXFAC SURG. 2005;34:152-157.

ly missing tooth using an Astra Tech® implant, 4 months following a ridge augmentation with an onlay block graft from mandibular symphysis.

Authors declare that they do not have financial ar-

rangement or interest in Astra Tech® implant system.

Fig. 23: Peri-apical radio-graph (2 years follow-up).

34

Case Report

Implant Dentistry

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On 30th October 2013 Carestream Dental hosted the official opening of the Ajman University Dental Centre for Care in Shar-jah, UAE.Dr. Aisha Sultan, Director of Dental Services, MOH, UAE was the Guest of Honor.The event was opened with a warm welcome by Dr. Mohamed Kashif Shafiq of Ajman University Dental College who intro-duced Dr. Aisha Sultan Alsuwaidi, Director of Dental Services at the Ministry of Health in UAE alongside several Deans from Den-tal Colleges across the UAE as well as regional opinion leaders.Carestream Dental has partnered up with Ajman University to combine academia and business through the opening of the new Carestream Dental Training Centre. According to Fritz Dit-tman, Regional Sales and Service Director “Next to the fact that the University has a great team, being able to take X-Rays and constantly have our equipment in use are the main reasons behind this partnership. The benefits are clear; this is a unique opportunity which will lead to great things. We can train our customers, their technicians, dealer engineers and in the future application training for dentists and clinicians as the equipment evolves. Customers from the Middle East no longer have to travel to USA or Europe to be trained how to use our technologies.”The Ajman University Dental College is one of the pioneers of oral and dental healthcare education in the UAE with well-structured and accredited programs. Under the leadership of Prof. Salem Abu Fanas, Dean of Ajman University of Science & Technology the college has produced 12 batches of quality dental graduates who are already very well received by the dental industry. Prof.

Salem Abu Fanas, Dean of Ajman University Dental College further explained “Our vision at the Ajman University Dental College is clear, we are catering for 130 clinics and until today we have treated over 40,000 patients coming to Ajman from all over the UAE” Prof. Abu Fanas further commented on the partnership with Carestream as “a new landmark for the col-lege”. The University is very pleased with these new facilities. “I would like to express my sincere gratitude to those who made it possible. Thank you to Carestream for enabling this project to take place namely Mr. Fritz Dietman and Montessar Ben Tili together with their fantastic team who did their best to see the success of it”.After the ceremony, the delegates were taken for a tour of the new facilities witnessing the ribbon-cutting of the new Training Centre.For more information contact:Martin Serck +971 55 1093485

Inauguration of Carestream Dental Training Centre for Knowledge and Care in Ajman UAE

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Part7one

Airway and Dentofacial Development In Children

Dr. George Meredith

Dr. Derek Mahony

[email protected]

Like so many things in life, timing is everything. Parents, family physicians, pediatricians, family dentists, pediatric dentists, ear nose and throat surgeons, friends, family and, especially ortho-dontists find themselves, in a unique situation where they can change a child’s quality of life, literally for the rest of that child’s life. Mouth breathing, snoring, excessive daytime sleepiness, obstructive sleep apnea, esthetically unpleas-ing facial features, narrow dental arches, need for future jaw surgery, recurring nasal and sinus infections, sinus pressure headaches, dry raw pharynx, post nasal drip and life long nasal ob-struction are some of the quality of life issues that a child or teenager, with a developing long face syndrome, will have to deal with for the rest of his adult life. Especially if the developing long face syndrome is not intercepted.

The child, who has a developing long face syn-drome, can have that pathological process inter-cepted through the use of some unusually simple procedures. Tonsillectomy and adenoidectomy, partial resection of the inferior turbinates, max-illary expansion, upper lateral cartilage lateral (alar) rotation and use of a Vertical Chin Cup are some of the simple procedures that can, when done in a timely manner, be utilised to intercept the developing long face syndrome. And at the same time we can greatly improve that child’s quality of life.

Unfortunately current internet websites, as well as the government run pubmed.com, offer little in depth information re: the diagnosis of the developing long face syndrome, and virtu-ally nothing regarding interceptive treatment of the developing long face syndrome. However, the research is definitely out there. A few days spent in a good medical school, or dental school library, under the direction of an experienced li-

brarian, can rectify this. Then the clinician needs to find knowledgeable practitioners who can implement the same, and your paediatric pa-tients will thank you for the rest of their life.

Figure 1: Lateral cephalometric radiograph of a high angle patient)

Figure 2; (Note the prominent antegonial notch on the lower border of the mandible)

38

Fig 1

Fig 2

Orthodontics

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40

Dentofacial DevelopmentOrthodontics

Effects of Nasal Airway Obstruction on Facial GrowthIn 1872, CV Tomes1 described the dentofacial changes associated with nasal airway blockage. He used the term “adenoid facies” because he believed enlarged adenoids were the principle cause of the obstruction. Over one hundred years later, numerous reports concerning this observation have appeared in the dental and medical literature, but the issue still remains controversial. In 1982, O’Ryan et al.2 critically reviewed the possible relationship between na-sorespiratory function and dentofacial morphol-ogy, and concluded that they were unable to demonstrate a consistent relationship between obstructed nasorespiratory function, and the adenoid facies in a “long-face” syndrome. We have attempted to review the available evidence on both sides of this question and propose an aetiologic rationale for the findings. We will also describe a cooperative protocol between pri-mary care physicians and dentists, allergists, oral myologists, otorhinolaryngologists (ENT doc-tors), and orthodontists for the management of young patients with increased nasal airway resistance.

Literature ReviewThe initial views of Tomes were later supported by many leading orthodontists, in the 1930s, including Todd et al.3 and Balyeat and Bowen.4 Angle5 included airway obstruction as an impor-tant aetiologic agent in malocclusion and Ket-cham6 indicated that patients were not receiving the full benefits of medical and dental therapy unless they were fully evaluated by both a rhinol-ogist and an orthodontist. McCoy7 regarded na-sopharyngeal obstruction as an important cause of malocclusion, noting an increase in Class III malocclusion, in his sample with an open mouth posture, and large tonsils.Moss8, in developing a “functional matrix” the-ory (originally proposed by van der Klaauw9), presented a logical rationale for the findings seen in nasally obstructive patients. His view held that bone responded to the influences of function, and adjoining soft tissue. This ex-plained the narrow palate, and long face, seen in some chronic mouth-breathers. In contrast, Hawkins10, Howard11, and Leech12 found no rela-tionship between malocclusion and mouth

breathing. However, a serious flaw in their stud-ies was the use of Angle’s horizontal classifica-tion system, to incorrectly assess vertical dento-facial dysplasias.

In the 1950s, Subtelny13 and Ricketts14 examined the effect of nasal airway on facial growth, and concluded that airway obstruction had an im-portant influence on facial form. In recent years, reports by Linder-Aronson and Woodside,15 Quinn,16, Rubin,17 McNamara,18 Bushey,19 and Harvold21 concluded that objective measure-ments have, in fact, substantiated the finding of chronic mouth-breathing as a casual factor in orthodontic anomalies. In 1968, Ricketts22 used the term respiratory obstructive syndrome to de-scribe a constellation of findings, seen in chronic mouth breathers. Subtelny23, in 1974, also indi-cated that adenotonsillar hypertrophy (marked enlargement of the tonsils and adenoids) could influence facial growth. Marks24 studied the role of allergy in orofacial deformities and concluded that nasal obstruction was a significant cause of altered facial growth. Similar findings were reported by Shapiro and Shapiro.25 Quinn16 has cited nasal airway obstruction as the major cause of mandibular prognathism (forward pro-jecting lower jaw), facial asymmetries, and verti-cal dysplasias.Linder-Aronson26 also was able to show that a group of post adenoidectomy patients, who became nasal breathers, had significant cranio-facial changes, toward normal. Conversely, per-sistent mouth-breathers, and the un-operated controls, showed no changes. Harvold20 has shown skeletal changes in primates, secondary to experimentally produced nasal blockage. Af-ter removal of the obstruction, changes toward normality became apparent. Hannuksela27 com-pared 39 Finnish children, with moderate or se-vere allergic disease, with a control group. She found significantly steeper mandibular (lower jaw) plane angles in the allergic group. This group included children with allergic dermatitis, bronchial asthma, and allergic rhinitis. Hannuk-sela noted that children with documented ade-noidal hypertrophies (on lateral headplates), had steeper mandibular plane angles. Recently, Long and McNamara28 reported 17 cases that devel-


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Dentofacial Development

Tooth Bleaching

42

eral cephalometric x-ray, of the head, provides an excellent view of any adenoid tissue in the epipharynx.

Septal surgery is rarely indicated in the child, but should be considered in the presence of a marked nasal septal deflection with impaction. Cottle 35, Jennes36, and Farrior and Connolly37 have demonstrated that conservative septal surgery, in growing patients, will not have an adverse effect on growth of the boney and cartilaginous nasal vault. Rapid or semi-rapid maxillary expansion (RME), an orthodontic pro-cedure38, is effective in improving the airway by widening the nasal vault.

Objective improvement, in the cross-sectional area of the nasal vault, can be documented by pre- and post-expansion PA tomograms or CAT scans.

Rhinometric data has supported the efficiency of maxillary expansion in treating nasal obstruc-tion in a child, with a narrow maxilla. In our experience, nonsurgical expansion can be per-formed between the ages of 3 and 19 years. The rate of expansion is reduced in the older individual/patient.

Figure 3: 60% adenoid obstruction

Figure 4:80% adenoid obstruction

Figure 5:Banded hyrax

Figure 6: Bonded hyrax

Figure 7: (PA tomogram)

Figure 8: (CT scan)

Fig 3 Fig 6

Fig 7

Fig 8

Fig 4

Fig 5

Orthodontics

Fig 6


44


Orthodontics

Figure 9:(Lateral movement of the inferior turbinates)

Figure 10:(Improvement in septal deviation post maxillary expansion therapy)

Figures 13:

Figure 11,12: Partial resection of enlarged inferior turbinates

The inferior turbinates move laterally, as the maxillary expansion device expands the maxilla, over a period of 3 weeks. Accordingly, the cross sectional area of the nasal vault is significantly improved.

When the cause of nasal obstruction is allergic rhinitis (with associated hypertrophied tonsils, adenoids and inferior turbinates), a systematic programme of treatment is indicated. In these patients, adenoidectomy is frequently consid-ered; however, removal of the adenoidal pad alone, in cases of untreated nasal allergy, will yield disappointing results because the anterior nasal vault will remain obstructed from inferior turbinate hypertrophy. Long-standing nasal air-way obstruction can lead to a “disuse” atrophy of the lateral crus of the lower lateral cartilage.30 The result is a slit-like external nares associated with a narrow nasal vault and a constricted up-per dental arch.

The septum straightens and the cross sectional area of the nasal vault increases, over a three week period of time, as the maxilla is expanded by the maxillary expansion device. The condi-tions of patients with vasomotor rhinitis can be improved with cryosurgery or electrosurgery.39

Chronically enlarged inferior turbinates can be reduced by electrocoagulation,40-41 or by partial resection.42-46

Narrow nares and a high palatal vault

Photo of High Palate

Fig 9

Fig 10

Fig 11

Fig 12

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Orthodontics

oped increased lower facial height following pal-atopharyngoplasty (flap at the back end of the soft palate used to correct hypernasal voice ). They concluded that the pharyngeal flap proce-dure increased nasal airway resistance.Disagreeing with this etiologic contention, Vig29

stated that, in the absence of documented total nasal obstruction, surgical or other treatment to “improve” nasal respiration remains purely empirical, and difficult to justify from an orth-odontic viewpoint. O’Ryan et al.2 reviewed the available literature and found no support for the contention that mouth breathing is a ma-jor aetiologic factor in the development of the long-face syndrome (LFS). Although the primate experiments performed by Harvold obviously cannot be performed on human subjects, tech-nologic advances have permitted the develop-ment of sophisticated devices to simultaneously measure nasal and oral resistances. Prospective studies, as performed by Linder-Aronson,25 are still necessary for a more objective analysis of mode of respiration, and its influences on fa-cial growth. Establishing a cause-and-effect relationship, between nasorespiratory function, and dentofacial development, is not simple. A dolichocephalic (long narrow face) pattern may be conducive to mouth-breathing, rather than mouth-breathing causing a dolichocephalic ap-pearance. The studies by Shapiro and Shapiro,26 and Hanuksela,27 on patients with (nasal) allergy avoid this enigma.

Normal Nasal RespirationThe nose filters, warms, and humidifies the air in preparation for entry into the bronchi and lungs. The functioning nasal airway may also create a certain degree of nasal resistance to fa-cilitate the movements of the diaphragm, and intercostal muscles, in creating negative intra-thoracic pressure that, in turn, promotes airflow into the alveoli.30 (final branchings of the respira-tory tree…the primary gas exchange units of the lungs). Appropriate nasal resistance is 2 to 3.5 cm H2O/L/sec and produces high tracheobron-chial airflow, which improves the oxygenation of the most peripheral pulmonary alveoli. Mouth breathing results in a lower velocity of incoming air, and also eliminates nasal resistance. Subop-timal pulmonary compliance (the ability of the lungs to stretch in a change in volume relative

to an applied change in pressure) is the result. Blood gas studies have revealed that advanced mouth-breathers have 20 percent higher par-tial pressures of carbon dioxide, and 20 percent lower partial pressures of oxygen in the blood, associated with their lower pulmonary compli-ance and reduced velocity.31 Obstructive sleep apnea is regarded as a complication of nasal and oropharyngeal obstruction. Another less com-mon complication of upper airway compromise is functional pectus excavatum. Upper airway compromise can also cause cor pulmonale as the result of pulmonary hypertension with as-sociated right ventricular hypertrophy.32

History and Physical ExaminationThe patient should be observed, as he enters the examining room, and sits in the chair. The facial posture should be noted to see if the lips are closed during respiration. Allergic “salutes” and “shiners” are seen commonly in patients expe-riencing allergic rhinitis. The patient may also give a history of frequent “colds” or “sinus.” A family history for allergy is likewise important. If either parent or a sibling has an allergic history, there is a 40 percent chance that the patient is allergic.33 One parent may have eczema alone and then transmit the allergic tendency in the form of allergic rhinitis. Any history consistent with obstructive sleep apnea or loud snoring should be explored, in detail, and parents should be asked about the sleep patterns of their chil-dren. An open mouth posture, while sleeping, may be a supporting sign. The child should be asked to seal his lips. It should be noted if the child has difficulty breathing through the nose. One nostril can be occluded and the response noted. The same procedure is followed for the other nostril. The one-to-four hour nasal cycle results in the inferior turbinate on one side be-ing engorged for a time, followed by engorge-ment of the other side. This produces increased nasal resistance in one side of the nasal vault at a time.34 Patients with septal deviations may be totally obstructed when the nasal cycle occludes the contralateral side.

Treatment of Nasal ObstructionAdenoidectomy, with or without tonsillectomy, is indicated if enlarged adenoids (and tonsils) are the cause of upper airway obstruction. The lat-


48


Orthodontics

After the airway obstruction is corrected, and a normal nasal airway is established, certain patients may still experience nasal collapse on inspiration. These patients could benefit from reconstructive surgery and/or alar dilators.

Note: Excising an ellipse of skin, and subcutane-ous tissue, in the nasofacial fold, in these cases, can open the nasal valve by rotating the upper lateral cartilage laterally. The nasofacial fold is highly vascular. It is recommended that infiltration of ½ % Xy-locaine with epinephrine 1:200,000 is placed both superficially, as well as down onto the periosetium, of the nasal bone, and ascending process of the maxilla. Then wait a full 7 minutes (while doing some other part of the operative sequence). Return to the nasaofacial fold, ex-cise a long ellipse of skin, subcutaneous tissue and fascia. Then immediately place a Weck Cell Sponge soaked in 2% Xylocaine with epineph-rine 1:5,000 for topical anesthesia and hemo-stasis, color coded with methylene blue to pre-vent inadvertent injection, in the wound. And replace the same, several times, as the sponge becomes saturated with blood. Next apply suc-tion to the Weck Cell Sponge and then lightly electrofulgurate specific bleeding points (fourth photograph). Finally do a two layered closure, and apply an ice pack.

Figure 14:Infi ltration injection

Figure 15:Excise skin, subcutane-ous tissue and fascia

Figure 16:Placement of a WeckCell Sponge

Figure 17:Two layered closure

Figure 18:Apply ice pack

Figure 19: Variation for advanced alar collapse …employing a laterally based nasofacial fold interposi-tion fl ap…lower right

Fig 14 Fig 15 Fig 16 Fig 17

Fig 19

References1. TOMES CS: ON THE DEVELOPMENTAL ORIGIN OF THE V-SHAPED CONTRACTED MAXILLA. MONTHLY REVUE OF DENTAL SURGERY 1872:1.2-5.2. O’RYAN FS, GALLAGHER DM, LABLANC JP, ET AL: THE RELATION BETWEEN NASO-RESPIRATORY FUNCTION AND DENTOFACIAL MORPHOLOGY: A REVIEW. AM J ORTHOD 1982; 82:403-410.3. TODD TW, COHEN MD, BROADBENT BH: THE ROLE OF ALLERGY IN THE ETIOLOGY OF ORTHODONTIC DEFORMITY. J ALLERGY 1939;10:246-249.4. BALYEAT RM. BOWEN R: FACIAL AND DENTAL DEFORMITIES DUE TO PERENNIAL NASAL ALLERGY IN CHILDHOOD. INT J ORTHOD. 1934;20:445-449.5. ANGLE EH: TREATMENT OF MALOCCLUSION OF THE TEETH, ED 7. PHILADELPHIA, SS WHITE DENTAL MANUFACTURING CO, 1907.6. KETCHAM AH: TREATMENT BY THE ORTHODONTIST SUPPLEMENTING THAT BY THE RHI-NOLOGIST. LARYNGOSCOPE 1912;22:1286-1299.7. MCCOY JD: APPLIED ORTHODONTICS. PHILADELPHIA, LEA AND FEBIGER, 1935.8. MOSS ML: THE FUNCTIONAL MATRIX: FUNCTIONAL CRANIAL COMPONENTS IN KRAUS BS, REIDEL R, (EDS): VISTAS IN ORTHODONTICS. PHILADELPHIA, LEA AND FEBIGER, 1962, PP 85-90.9. VAN DER KLAAUW CJ: SIZE AND POSITION OF THE FUNCTIONAL COMPONENTS OF THE SKULL. ARCH NEERL ZOOL, 1948;9:1-559.10. HAWKINS AC: MOUTH-BREATHING AS THE CAUSE OF MALOCCLUSION AND OTHER

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50


Orthodontics

FACIAL ABNORMALITIES. TEXAS DENTAL JOURNAL 1965; 83:10-15.11. HOWARD C: INHERENT GROWTH AND ITS INFLUENCE ON MALOCCLUSION. J. AM DENT. ASSOC 1932;19;642-651.12. LEECH HI: A CLINICAL ANALYSIS OF OROFACIAL MORPHOLOGY AND BEHAVIOR OF 500 PATIENTS ATTENDING AN UPPER RESPIRATORY RESEARCH CLINIC. DENTAL PRACTITIONER 1958;9:57-91.13. SUBTELNY JD: THE SIGNIFICANCE OF ADENOID TISSUE IN ORTHODONTIA. ANGLE ORTHOD 1954;24:59-69.14. RICKETTS RM: RESPIRATORY OBSTRUCTIONS AND THEIR RELATION TO TONGUE POSTURE. CLEFT PALATE BULL, 1958;8:3-6.15. LINDER-ARONSON S, WOODSIDE D: THE CHANNELIZATION OF UPPER AND LOWER ANTERIOR FACE HEIGHTS COMPARED TO POPULATION STANDARDS IN MALES BETWEEN AGES 6 TO 20 YEARS. EUR J ORTHOD, 1979;1:25-40.16. QUINN GW: AIRWAY INTERFERENCE AND ITS EFFECT UPON THE GROWTH AND DEVELOPMENT OF THE FACE, JAWS, DENTITION, AND ASSOCIATED PARTS. NORTH CAROLINA DENTAL JOURNAL 1978;60:28-31.17. RUBIN RM: MODE OF RESPIRATION AND FACIAL GROWTH. AM J ORTHOD 1980;78-504-510.18. MCNAMARA JA, JR.: INFLUENCE OF RESPIRATORY PATTERN ON CRANIOFACIAL GROWTH. ANGLE ORTHOD 1981;51:269-299.19. BUSHEY RS: ALTERATIONS IN CERTAIN ANATOMICAL RELATIONS ACCOMPANYING THE CHANGE FROM ORAL TO NASAL BREATHING, THESIS. UNIVERSITY OF ILLINOIS, CHICAGO, 1965.20. HARVOLD EP, CHIERCI G, VARGERVIK K: EXPERIMENTS ON THE DEVELOPMENT OF DENTAL MALOCCLUSIONS. AM J ORTHOD 1972;61:38-44.21. HOROWITZ SL, HIXON EH: THE NATURE OF ORTHODONTIC DIAGNOSIS. ST. LOUIS, CV MOSBY, 1966.22. RICKETTS RM: RESPIRATORY OBSTRUCTION SYNDROME (IN FORUM ON THE TONSIL AND ADENOID PROBLEMS IN ORTHODONTICS). AM J ORTHOD 1968;54:495-514.23. SUBTELNY JD: WORKSHOP ON TONSILLECTOMY AND ADENOIDECTOMY. ANN OTOL RHINOL LARYNGOL 1974;84:250-254.24. MARKS MB: ALLERGY IN RELATIONS TO OROFACIAL DENTAL DEFORMITIES IN CHILDREN: A REVIEW. J ALLERGY 1965;36:293-302.25. SHAPIRO GC, SHAPIRO PA: NASAL AIRWAY OBSTRUCTION AND FACIAL DEVELOPMENT. CLIN REV ALLERGY 1984;2:225-235.26. LINDER-ARONSON S: EFFECTS OF ADENOIDECTOMY ON THE DENTITION AND FACIAL SKELETON OVER A PERIOD OF FIVE YEARS, IN COOK JT (ED): TRANSACTIONS OF THE THIRD INTERNATIONAL ORTHODONTIC CONGRESS. ST. LOUIS, CV MOSBY, 1975, PP. 85-100.27. HANNUKSELA A: THE EFFECT OF MODERATE AND SEVERE ATOPY ON THE FACIAL SKELETON. EUR J ORTHOD 1981;3:187-193.28. LONG RE, MCNAMARA JA: FACIAL GROWTH FOLLOWING PHARYNGEAL FLAP SURGERY: SKELETAL ASSESSMENT ON SERIAL LATERAL CEPHALOMETRIC RADIOGRAPHS. AM J ORTHOD 1985;87:187-196.29. VIG PS, SARVER DM, HALL DJ, ET AL: QUANTITATIVE EVALUATION OF NASAL AIRFLOW IN RELATION TO FACE MORPHOLOGY. AM J ORTHOD 1981;79:263-272.30. ADAMS GL, BOIES LR, JR., PAPARELLA MM: BOIES’ FUNDAMENTALS OF OTOLARYNGOLOGY. PHILADELPHIA, WB SAUNDERS, 1978.31. OGURA JH: PHYSIOLOGIC RELATIONSHIPS OF THE UPPER AND LOWER AIRWAYS. ANN OTOL RHINOL LARYNGOL 1970;79:495-501.32. MENASHE WD, FARRHEI C, MILLER M: HYPERVENTILATION AND COR PULMONOLAE DUE TO CHRONIC UPPER AIRWAY OBSTRUCTION. J PEDIATR 1965;67:198-203.33. NELSON WE, VAUGHAN VC, MCKAY RJ: TEXTBOOK OF PEDIATRICS PHILADELPHIA, WB SAUNDERS, 1969, PP 23-42.34. PRINCIPATO JJ, OZENBERBER JM: CYCLICAL CHANGES IN NASAL RESISTANCE. ARCH OTHOLARYNGOL 1970;91:71-77.35. COTTLE MH: NASAL SURGERY IN CHILDREN. EYE, EAR, NOSE, AND THROAT MONTHLY 1951;30:32-38.36. JENNES MI: CORRECTIVE NASAL SURGERY IN CHILDREN: LONG TERM RESULTS. ARCH OTOLARYNGOL 1964; 79:145-151.37. FARRIOR RT, CONNOLLY ME. SEPTORHINOPLASTY IN CHILDREN. OTOLARYNGOL CLIN NORTH AM 1970;3:345-364.38. GRAY LP, BROGAN WF: SEPTAL DEFORMITY MALOCCLUSIONS AND RAPID MAXILLARY EXPANSION. ORTHO-DONTIST 1972;4:1-13.39. PRINCIPATO JJ: CHRONIC VASOMOTOR RHINITIS: CRYOGENIC AND OTHER SURGICAL MODES OF TREATMENT. LARYNGOSCOPE 1979;89:619-638.40. DEVGAN BK: SUBMUCOSAL DIATHERMY OF INFERIOR TURBINATES. EYE, EAR, NOSE, AND THROAT MONTHLY 1976;55:19.41. BECK JC: PATHOLOGY OF INTRAMURAL ELECTROCAOGULATION OF THE INFERIOR TURBINATE. ANN OTOL RHINOL LARYNGOL 1930;39:349.42. FRY HJH: JUDICIOUS TURBINECTOMY FOR NASAL OBSTRUCTION. AUST NZ J SURG 1973;42-291.43. SHEEN JH: AESTHETIC RHINOPLASTY. ST. LOUIS, CV MOSBY, 1978, PP 184-194.44. SPECTOR M: PARTIAL RESECTION OF THE INFERIOR TURBINATES. EAR, NOSE, AND THROAT J 1982;61:28-32.45. POLLOCK MD: INFERIOR TURBINATE SURGERY. PLAST RECONSTR SURG 1984;74:227.46. COURTISS EH: RESECTION OF OBSTRUCTING INFERIOR NASAL TURBINATES. PLAST RECONSTR SURG 1978;62:249.47. ALEXANDER C: THE EFFECTS OF TOOTH POSITION AND MAXILLOFACIAL VERTICAL GROWTH DURING SCOLIOSIS TREATMENT WITH THE MILWAUKEE BRACE: AN INITIAL STUDY. AM J ORTHOD 1966;52:161-189.48. MOLLER E: THE ACTIVITY OF THE MUSCLES OF MASTICATION AS RELATED TO THE MORPHOLOGY OF THE FACIAL SKELETON. ACTA PHYSIOL SCAND 1966;69:280-284.49. SASSOUNI V, FORREST EJ: ORTHODONTICS IN DENTAL PRACTICE, ST. LOUIS, CV MOSBY, 1971.50. HARVOLD E: NEUROMUSCULAR AND MORPHOLOGICAL ADAPTATIONS IN EXPERIMENTALLY INDUCED ORAL RESPIRA-TION IN MCNAMARA JA, JR. (ED): NASO-RESPIRATORY FUNCTION AND CRANIOFACIAL GROWTH, CRANIOFACIAL GROWTH SERIES NO. 9 ANN ARBOR, THE UNIVERSITY OF MICHIGAN, 1979.51. BELL WH: CORRECTION OF SKELETAL TYPE ANTERIOR OPEN BITE. J ORAL SURG 1971;29:706-714.52. BERMAN C: PREFACE. JOURNAL OF PREVENTIVE DENTISTRY 1978;5:8.

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fits inThis is where

More PicturesAvailable OnSeptember 25-28, 2013

Lebanese University, Hadath, Lebanon www.facebook.com/dentalnews1

52 BIDM 2013

PR. ELIE MAALOUF, PRESIDENT OF THE LDA AND PRESIDENT OF ARAB DENTAL FEDERATION

DR. ZIAD NOUJEIM EDITOR IN CHIEF JLDA

DR. WALID KHATTAR GENERAL SECRETARY OF THE LDA

DR. MOHAMED BINHAFEED PAST PRESIDENT OF THE ADF

DR. HABIH NADER, PRESIDENT OF THE SCIENTIFIC COMMITTEE

TO DR. KESHTBAN TO DR. ARAMOUNY

TO DR. DACCACHE TO PR. CHEMALY

TO DR. REHAYEL TO DR. KATAYA

TROPHY DISTRIBUTION:

The 23rd Beirut International Dental Meeting (BIDM 2013), taking place 25-28 September 2013 in Lebanese University Rafic Hariri Campus, Hadat, will be an exciting event that prom-ises great communications and enjoyable scientific debates. On behalf of the Lebanese Den-tal Association (LDA), it is my great pleasure to invite you to joinus at this occasion.Through the theme “Sharing Solutions” you will hear cutting-edge dental presentations. The organizers of this meeting have prepared a three-day program that will feature leading experts and world-renowned speakers who will share the most up-to date developments in dentistry and related disciplines. Participants will enjoy the learning opportunities in various plenary, symposia, panel discussion sessions that will be put in place.I also strongly encourage you to take advantage of the presence of over 90 exhibiting com-panies to keep up to date with evolving technologies of equipment and the latest dental materials.I hope that you find this meeting beneficial to your career, where you can take advantage of the innumerable learning and networking opportunities this meeting will provide.I’m looking forward to meeting with you all.Sincerely,

Prof Elie Azar Maalouf

PICTURES FROM THE

EXHIBITION FLOOR

PICTURES FROM DENTAL NEWS

BOOTH

Pr. Elie Maalouf graduated with honors in Dentistry at Saint Joseph University of Beirut, in 1985 and was awarded a “Certificat d’études supérieures de biologie de la bouche” (CES) at Paris V in 1987 France, and a CES in Periodontology in 1988, in addition to a CES in Fixed Prosthesis in 1988, and a Doctorate (DSO) in Periodontology from the Lebanese University in 2009.

His professional achievements:

لثالث سنوات مقبلة؟ و السبل املنوي إعتامدها لتطوير املهنة؟

نسعى إىل توفري الفرص لجميع أطباء األسنان يف لبنان بهدف رفع مستوى مهاراتهم عرب برامج

تنطوي عىل جميع املبادئ النظرية و ورش عمل، يف مراكزنا يف السوديكو، و بعلبك، و زحلة،

و صور، و صيدا، و الشوف. يف النهاية، متنح شهادات الجدارة ألطباء األسنان املشرتكني يف هذه

الدورات، كام تعطى نقاط اإلعتامد إىل الذين تابعوا املؤمترات و املحارضات الطبية و العلمية. هذا من ناحية، أما من ناحية أخرى فإّن مهمتنا

املحافظة أيضاً عىل آداب طبابة األسنان و كرامتها، و عىل مصالح أطباء األسنان املعنوية و املادية

وصوالً إىل أفضل الخدمات للمرىض. كام هنالك مرشوع أسايس، و هو تحديث الربنامج اإللكرتوين للموقع الرسمي العائد ألطباء األسنان يف لبنان. و

هذا سيسمح لألعضاء اإلستفادة من بريد إلكرتوين خاص بهم. إىل جانب منتدى يفسح لهم بتبادل األفكار و مختلف الحاالت عىل املستوى املهني،

إضافًة إىل خدمات و مزايا أخرى. يجري طبعاً تدريب املوظفني ملجاراة هذا التحديث.

يجري العمل عىل تحسني قيمة الراتب التقاعدي و تقدميات صندوق التعاضدي بإرشاف هيئة

إدارية مختصة. سنقوم أيضاً بتنفيذ مرشوع قروض مرصفية للمرىض، و برنامج متكامل لتغطية تأمني

األسنان.

Dental تم التوقيع عىل إتفاق رشاكة حرصية معOnline College األملانية عىل التواصل املستمر،

ليتمكن جميع أطباء األسنان يف لبنان من مشاهدة مجاناً فيديوهات تعليمية خالل العامني املقبلني.

العرشينBIDM ٢٠١٣ لطب األسنان ؟ من الالفت أن مؤمتر بريوت الدويل الثالث و

العرشين لطب األسنان لهذا العام حقق نجاحاً باهراً رغم األوضاع األمنية الحذرة يف املنطقة،

بحضور ما يزيد عىل األلفي مشرتك و ٧٧ عارض مثلوا أكرب الرشكات اإلقليمية، إضافًة إىل ٧٠٠ زائر

توافدوا إىل الخيمة التي أقيمت خصيصاً لهذا املعرض و التي بلغت مساحتها ٢٠٠٠ مرت مربع.

أما بالنسبة للمبيعات، فوصل حجمها ثالثة أضعاف عن السنة املاضية.

إنجاح هذا املؤمتر؟القت الخيمة إستحساناً واسعاً كونها شملت ألول مرة يف نفس املساحة جميع املشاركني و العارضني

يتحدث يف هذه املقابلة الخاصة مع مجلة Dental News، الدكتور و الربوفيسور إييل معلوف، نقيب أطباء األسنان يف لبنان و ،BIDM رئيس إتحاد أطباء األسنان العرب، عن أسباب نجاح مؤمتر بريوت الدويل الثالث و العرشين لطب األسنان لعام ٢٠١٣

و عن أهمية النتائج التي صدرت عنه. و باملناسبة شاركنا أيضاً مبشاريعه و مواقفه املستقبلية لتحديث هذه املهنة.

P r e s i d e n t o f t h e L e b a n e s e D e n t a l A s s o c i a t i o nP r e s i d e n t o f t h e A ra b D e n t a l F e d e r a t i o n

Pr. Elie Azar MaaloufINTERVIEW

الذين طالبوا بتوسيعها للسنة املقبلة لتضم عدد أوفر من السنة الحالية.

بصفتك رئيساً لإلتحاد العريب لطب األسنان؟

لدينا جدول أعامل مهم يتضمن إحياء املجلة و تنظيم برامج للتعليم املستمر بني البلدان لكافة

مجاالت طب األسنان، و توحيد مصطلحات طب األسنان يف الدول العربية.

لقد تجاوز عدد املتخرجني من كليات طب األسنان يف لبنان الحد املطلوب، و قد عزمنا عىل إقامة محارضات توجيهية يف املدارس لتوعية الطالب

إىل صعوبة املهنة كونها ال تقف فقط عىل املبادئ النظرية بل إنها تتطلب أيضاً مهارات يدوية.

مع ذلك، إّن العديد من أطباء األسنان اللبنانيني هم من املهرة، و يف طليعة املتفوقني يف لبنان و

الخارج.

تاال فاخوري

More PicturesAvailable On

September 29- October 1, 2013King Saud Bin Abdulaziz University, for Health Sciences, Riyadh, KSA www.facebook.com/dentalnews1

58

National Guard Health Affairs

DR. ABDULRHMAN AL FAYEZORGANIZING COMMITTEE CHAIRMAN

PROF RALPH SMEETS LECTURING ON AUTOGENOUS BONE GRAFTS

DR. ALI AL EHAIDEBDEAN COLLEGE OF DENTISTRY

I would like to welcome you all on the 4th New Dental Era International conference. The three years of implementation of this conference were all successful and hopefully will still continue to be organized by our very active continuing education committee members. This year conference is hosting the 4th International College of Dentists meeting for district 2 of Middle East section, our continuing collaboration with them is another mark of excel-lency to our program. This conference will feature different presentation series highlighting the progress and challenges in all dental care specialties, e.g. bone graft and dental implant, Botox, treatment of dentofacial deformities, all-on-4 concept that allows for the rehabilitation of fully edentulous patients in just a few hours with no need for bone grafting technique, etc.There is no question that science will lead to new technologies for diagnosing, preventing and treating oral and craniofacial diseases and disorders. However, given the complexities of our health care delivery system and the economic and cultural differences in our society, practi-tioners, policymakers and dental educators must make a substantive and concerted effort to apply these new discoveries in ways that improve the oral health of all. It is in this light that we are very happy that experts in this field are attending here. Our institute is pleased to hold this 4th international conference. We hope that this conference will lead to more studies and contribute to further methodological developments in dentistry.DR. ALI AL EHAIDEB

DEAN COLLEGE OF DENTISTRY

PROF IBRAHIM NASSEH FOR HIS LECTURE ON CBCT IN ORAL HEALTHCARE

DR. RIAD BACHO FOR HIS LECTURE ON PULP REGENERATION

DR. NADIM ABOUJAOUDEH FOR HIS LECTURE ON SMILE ENHANCEMENT

DR. JEREMY MAOFOR HIS LECTURE ON STEM CELLS

ICD INDUCTIONICD INDUCTION

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ICD INDUCTION CEREMONY FOR DR. MOHAMAD AL DARWISH, DR. AZIZA AL JOHAR, DR. ABEER AL SUBAIT

DENTAL STUDENTS SURROUNDING THEIR DEAN DR. ALI AL EHAIDEB

4TH INTERNATIONAL COLLEGE OF DENTISTS MEETING FOR DISTRICT 2 OF MIDDLE EAST SECTION

DR. ALI AL EHAIDEB

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More PicturesAvailable OnOctober 31 - November 3, 2013

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Arab Orthodontic Meeting &Lebanese Orthodontic Society

Dear friends and colleagues,It’s my pleasure to welcome you to the 11th Arab Orthodontic Congress held jointly with the 12th Lebanese Orthodontic Congress in Beirut, Lebanon. I would like to express my deep satisfaction of sharing together this important moment for the development of our specialty of Orthodontics.This congress is one of the largest and most prestigious event in our area and has been devot-ed to the theme “New perspectives in Orthodontics: clinical expertise or evidence based?” Your presence confirms that these issues are ones of our utmost importance in today’s world.The valuable scientific contribution of our eminent speakers, as well as, the motivation of our delegates and all participants coming from all over the world has enabled us to uphold our meeting even though the delicate situation that our country is going thru. I am greatly hon-ored to receive you in the capital of Lebanon, Beirut, the intersection of the East and West and to have you here with us. Enjoy your presence in Lebanon, the country of Alphabet’s origin and let’s advance together towards excellence in Orthodontics…

Dr. Fadi GhaithPresident of the Arab Orthodontic Society

President of the Lebanese Orthodontic SocietyDR. SAMI SAMAWI. GENERAL SECRETARY OF

ARAB ORTHODONTIC SOCIETY

DR. FADI GHAITHPRESIDENT OF THE ARAB ORTHODONTIC SOCIETY

PRESIDENT OF THE LEBANESE ORTHODONTIC SOCIETY

TROPHY DISTRIBUTION TO:

DR. ABBAS ZAHER. PRESIDENT OF EGYPTIAN ORTH-ODONTIC SOCIETY WITH THE EGYPYION DELIGATION

DR. MAHFOUZ FARAJ AL-ATY, DELEGATE OF THE LIBYAN ORTHODONTIC SOCIETY

DR. FATMA SAIDI. PRESIDENT OF THE TUNISIAN ORTHODONTIC SOCIETY

DR. AYMAN SADIK TAHA, DELEGATE OF THE SUDANESE ORTHODONTIC SOCIETY

DR. HALA HALLAK, DELEGATE OF PALESTINIAN ORTHODONTIC SOCIETY

DR. NAWAL BOUYAHYAOUI, DELEGATE OF MOROCCAN ORTHODONTIC SOCIETY

DR. FAWAZ AL ROSAIES, DELEGATE OF SAUDI ORTHODONTIC SOCIETY

DR. AKRAM AL-HUWAIZI, GENERAL SECRETARY OF IRAQI ORTHODONTIC SOCIETY

DR. STATHIS EFSTATHIOU, PRESIDENT OF CYPRUS ORTHODONTIC SOCIETY

Date of preparation: June 2012

Speak and prevent

References 1. Data on file, GSK, June 2012. 2. Global Segmentation Study. Europe – Learnings from Research, Oct 2007. 3. NHS Adult Dental Health Survey 2009. http://www.ic.nhs.uk/webfiles/publications/007_Primary_Care/Dentistry/dentalsurvey09/AdultDentalHealthSurvey_2009_Theme2_Diseaseandrelateddisorders.pdf. Accessed April 2012. 4. Data on file, GSK TN06-003, April 2006. 5. Data on file, GSK Armstrong J, March 2003. 6. Data on file, GSK E5931015, January 2011. 7. Data on file, GSK E5930966, January 2011. 8. Yankell SL et al. J Clin Dent 1993; 4(1):26-30. 9. Saxer U et al. J Clin Dent 1994; 5(2): 63-64. 10. Arweiler NB et al. J Clin Periodent 2002; 29: 615-621. 11. Data on file, GSK. Russian market research, June 2007. 12. Data on file, GSK. French market research, November 2011. 13. FDA U.S. Food & Drug Administration. Health Claim Notification for Fluoridated Water and Reduced Risk of Dental Caries. http://www.fda.gov/Food/LabelingNutrition/LabelClaims/FDAModernizationActFDAMAClaims/ucm073602.htm. Accessed April 2012. 14. ten Cate IM. Euro J Oral Sciences 1997; 105(5): 461-465. http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0722.1997.tb00231.x/abstract. Accessed April 2012. 15. Willershausen B et al. J Clin Dent 1991; 2(3): 75-78.

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DR. AND MRS. EDMOND CHAPTINIDR. KHALIL GHOSSOUB AND DR. MONA SAYEGH GHOSSOUB

DR. FADI DAHBOUL AND DR. ALAIN TAWK

DR. AND MRS. JOSEPH BOUSERHAL

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68

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www.facebook.com/dentalnews1

On behalf of myself and all EDA board members, I extend a very welcoming hand to all our colleagues, our participants and our visitors. We are all very proud and happy to have you with us here in Cairo. Our last meeting was a very successful one, both scientifically and socially, and we promise you at least an equally successful, or an even more enterprising meeting. The quality of the scientific papers to be presented in this conference is extremely high, and we promise you that the social program accompanying and following the congress will appeal to you all.The EDA board and members are very happy to have you all with us, and we wish you a very pleasant stay and hope to see you all in Cairo in the next EDA meetings. Professor Salah H. Sherif, General Secretary of the EDA, Dean of Faculty of Dentistry MIU

November 5 - 8, 2013Cairo City Stars International Hotel, EGYPT

Egyptian Dental Association

EGYPTIAN DENTAL ASSOCIATION BOARD MEMBERS

LEFT TO RIGHT: PR. NOUR HABIB AND PR. SALAH H SHERIF

DR. MAALOUF, PRESIDENT OF THE LDA RECEIVING THE TROPHY FROM PR. HABIB

DR. RAHEEL PRESIDENT OF THE LDA - TRIPOLI, BETWEEN MEMBERS OF THE EDA

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Dental Facial Cosmetic International Conference

It is my honor and pleasure to welcome you all to our 5th Dental - Facial Cosmetic Interna-tional Conference. Our specialized conferences are evolving into land marks in the field of Continuous Dental Education. We offer a unique blend of Science, Clinical Knowledge, and Cutting Edge Technology in the field of Dentistry and beyond. All of us, organizers, speak-ers, and sponsors spare no time or effort to put bring to you the most up to date develop-ments in various fields of Dentistry. This 5th edition of our DFCIC features a joint meeting with the American Academy of Implant Dentistry. During this session, the AAID will share with us their vast knowledge and experience as well as the latest in the field of Implant Den-tistry. I am sure that this conference will be of the greatest help to develop our knowledge

and sharpen our skills in pursuing the goal that we all share, to provide our patients with the best possible solutions for their esthetic needs.

Dr. Munir SilwadiConference Chairman

PICTURES FROM

THE EXHIBITION

FLOOR

DR. MUNIR SILWADI

DR. DIB, DEAN HAMED, DR. NAHASS

REFERENCES

1. Data on file A, McNEIL-PPC.Inc. 2. Sharma C. Naresh et al. superiority of an essential oil mouthrinse when compared with a 0.05% cetylpyridinium chloride containing mouthrinse: a six month study. International Dental Surgeon,

2010;175-180. 3. N. Sharma et al. Adjunctive benefit of an essential oil–containing mouthrinse in reducing plaque and gingivitis in patients who brush and floss regularly A six-month study. J Am Dent Assoc, 2004;135:496-504.

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LEFT TO RIGHT; DRS KAZI, BANDAY, SHAMMERY, DIB, SHAKER AND ABOUJAOUDEH

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GROUP PICTURE WITH DR. NABEEL OFFERING THE TROPHY TO DR. MAALOUF, PRESIDENT OF THE LEBANESE DENTAL ASSOCIATION

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firmly binds to dentine6,7 and is resistant to daily oral challenges3,8,9,10

Think beyond pain relief and recommend Sensodyne Repair & Protect

References: 1. Greenspan DC. J Clin Dent 2010; 21(Spec Iss): 61–65. 2. LaTorre G, Greenspan DC. J Clin Dent 2010; 21(3): 72-76. 3. Burwell A et al. J Clin Dent 2010; 21(Spec Iss):

66–71. 4. West NX et al. J Clin Dent 2011; 22(Spec Iss): 82-89. 5. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 62-67. 6. Efflandt SE et al. J Mater Sci Mater Med 2002; 26(6): 557-565. 7. Zhong JP et al. The kinetics of bioactive ceramics part VII: Binding of collagen to hydroxyapatite and bioactive glass. In Bioceramics 7, (eds) OH Andersson, R-P Happonen, A Yli-Urpo,

Butterworth-Heinemann, London, pp61–66. 8. Parkinson C et al. J Clin Dent 2011; 22(Spec Issue): 74-81. 9. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 68-73. 10. Wang Z et al. J Dent

2010; 38: 400−410. Prepared December 2011, Z-11-516.OH/CA/01/13/001


#78

The Cavex Bite&White Ready 2 Use professional home whitening system is a fast, safe (pH-neutral) and above all very simple whitening system for use at home. After a consultation your patient will simply open the packaging, place the pre-filled tray in their mouth and enjoy the result after only 30 to 60 minutes. The highly viscous Cavex Bite&White Ready 2 Use whitening gel contains 6% hydrogen peroxide (partly as carbamide peroxide), a sustainable and active combination of effective whitening substances with a proven reputation worldwide as an effective whitening agent. Adding potassium nitrate avoids sensitivity. The unique ‹one-size-fits-all› Dryflex® whitening tray is made of a special type of plastic which the mouth tolerates well. Thanks to its 95% compatibility, the whitening tray is suited to almost everyone. Cavex Bite&White Ready 2 Use complies totally with new European legislation for teeth whitening website: www.cavex.nl

You want to watch the world’s famous experts performing their surgery without travelling all over the world? You want to learn from the best without having to waste time and money on airports and highways? Join the Dental Online College: Numerous German/Swiss and international experts give you lectures about the hottest dental topics. Look them over the shoulder while treating the most difficult cases. High resolution videos streamed directly to your home PC allow you to share all the experts knowledge. Visit us on www.dental-online-college.com

With Fuji IX GP Extra in powder-liquid, GC, the glass ionomer world leader, is providing the most advanced GI technology to Powder Liquid users.Actually, advances in glass technology have resulted in the development of GC Fuji IX GP EXTRA, a high strength glass ionomer cement with a new generation of glass filler which gives the restorations a very high translucency that changes little over time. The result is natural aesthetics never before achievable with conventional glass ionomer. GC special glass filler used in GC Fuji IX GP EXTRA releases three times more fluoride than conventional glass ionomers so it provides even better protection against caries. The comfortable working time combined with a fast setting time mean you can start finishing and polishing just two and a half minutes after mixing.website: www.gc-dental.com

NEW! Cavex Bite&White Ready 2 Use ‘pre-filled whitening trays’

Dental Online College

GC Fuji IX GP EXTRA from GC

3452

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VITA shade, VITA made.

At VITA, we see progress as self-improvement. With this in

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Determine and verify tooth shades with digital precision.

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SHIFTING THE WAY YOU THINK ABOUT ORTHODONTICS.

Turn Complex Class II into Simple Class I Cases

* Images courtesy of Dr. Clark Colville.© 2013 Ortho Organizers, Inc. All rights reserved.

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

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

Visit us on line at OrthoOrganizers.com or contact your exclusive O2’s partner listed below:

Works great with our Cu Nitanium® Archwires!

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The Carriere® Distalizer™ Appliance

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* Typical case: Patient 16 yearsStart of treatment, prior to placement of Carriere Distalizer Appliance 5.10.10

Class II to Class I achieved, and Carriere Distalizer Appliance treatment completed 8.30.10

Total orthodontic treatment completed 3.7.12

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