incisal index.pdf

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30 NYSDJ AUGUST/SEPTEMBER 2005

The clinical significance is that anterior tooth fractures can

be predictably restored using contemporary small particle

hybrid composite resin systems with the aforementioned

restorative techniques. These placement techniques when

used with proper attention to preparation design, adhesive

protocol and finishing and polishing procedures, allow the

clinician to successfully restore form, function and esthetics

to the single anterior tooth replacement.

THE SINGLE ANTERIOR TOOTH replacement remains a complexaesthetic challenge for technicians and clinicians in restorativedentistry. This challenge exists in either composite restorative sys-tems or porcelain systems while attempting to achieve true harmo-nization of the primary parameters in aesthetics (that is, colorshape, texture). While porcelain designing relies on stone modelsphotographs and the clinician’s narrative description to the labora-tory technician, direct restorative resin reconstruction relies on thesurrounding dentition for correlation. The proximate environmentcommands the appearance of any restoration. Increased patientdemand for aesthetic dentistry with minimal invasive procedureshas resulted in the extensive use of freehand bonding of compositeresin to address this challenge.

Achieving a restorative result with optimal physical andmechanical characteristics often required the use of a combinationof hybrid and microfill. The hybrid provided the strength andsculptability, and the microfill furnished the polish and durabilityof the restoration.An incremental layering technique with compos-ite resin resulted in an optimal depth of cure while reducing theeffects of shrinkage and stress forces during the polymerizationprocess.1, 2 Yet, when different restorative composites of varyingrefractive indexes, shades and opacities were stratified, clinicians

Abstract

Restorative dentistry evolves with each development of

new material and innovative technique. Selection of

improved restorative materials that simulate the physical

properties and other characteristics of natural teeth, in

combination with restorative techniques such as the prox-

imal adaptation and incremental layering, provide the

framework that ensures the optimal development of an

esthetic restoration. These advanced placement tech-

niques offer benefits such as enhanced chromatic inte-

gration, polychromatism, ideal anatomical form and func-

tion, optimal proximal contact, improved marginal integrity

and longer lasting directly placed composite restorations.

The purpose of this article is to give the reader a better

understanding of the complex restorative challenge in

achieving true harmonization of the primary parameters in

esthetics (that is, color, shape and texture) represented by

the replacement of a single anterior tooth. The case pre-

sented demonstrates the restoration of a Class IV fractureintegrating basic adhesive principles with these place-

ment techniques and a recently developed nanoparticle

hybrid composite resin system (Premise, Kerr/Sybron,

Orange, CA) . The clinical presentation describes preopera-

tive considerations, tooth preparation, development of the

body layer, internal characterization with tints, develop-

ment of the artificial enamel layer, shaping and contouring,

and polishing of a Class IV composite restoration.

Restoring the Incisal EdgeDouglas A. Terry, D.D.S.


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NYSDJ • AUGUST/SEPTEMBER 2005 31

observed a “polychromatic effect.”3 However, by using an anatomicstratification with successive layers of dentin, enamel and incisalcomposite, a more realistic depth of color could be achieved, as wellas surface and optical characteristics that mimic nature.4-5

The development of the polychromatic restoration from theinequities of the different composite resin systems (hybrid andmicrofill) stimulated scientists, researchers, clinicians and manu-

facturers to explore and develop restorative materials that are notonly applied in relationship to the natural tissue anatomy, but alsohave similar physical, mechanical and optical properties of thetooth structure.

In the past decade, aesthetic dentistry has continued to evolvethrough innovations in restorative materials, bonding systems,function-based treatments, conservative preparation design andadhesive placement techniques. Such advances have increased therestorative opportunities available for discriminating patients, andhave provided solutions to many of the aesthetic challenges facedby clinicians. Increased use of composite materials to restore theanterior dentition has drawn increased attention to contemporary

technological advances in restorative and aesthetic dentistry.

Contemporary Technological

Advances: Nanotechnology

In composite resin technology,particle size and the amount of par-ticles represent crucial information in determining how best to usethe composite materials.Alteration of the filler component remainsthe most significant development in the evolution of compositeresins,7 because filler particle size, distribution and the quantity incorporated dramatically affect the mechanical properties and theclinical success of composite resins.8 In general, mechanical andphysical properties of composites improve in relationship to the

amount of filler added. Many of the mechanical properties dependupon this filler phase, including compression strength and/or hard-ness, flexural strength, the elastic modulus, coefficient of thermalexpansion, water absorption and wear resistance.

Nanotechnology or molecular manufacturing9 may providecomposite resin with filler particle size that is dramatically smallerin size, can be dissolved in higher concentrations and polymerizedinto the resin system with molecules that can be designed to be com-patible when coupled with a polymer, and provide unique charac-teristics (physical,mechanical and optical). In addition, optimizingthe adhesion of restorative biomaterials to the mineralized hard tis-sues of the tooth is a decisive factor in enhancing the mechanicalstrength and marginal adaptation and seal, while improving the reli-ability and longevity of the adhesive restoration.

Currently, the particle sizes of conventional composites are sodissimilar to the structural sizes of the hydroxyapatite crystal, den-tal tubule and enamel rod, there is a potential for compromises inadhesion between the macroscopic (40 nm to 0.7 um) restorativematerial and the nanoscopic (1 nm to 10 nm in size) tooth struc-ture.10 However, nanotechnology has the potential to improve thiscontinuity between the tooth structure and the nano-sized fillerparticle and provide a more stable and natural interface between

the mineralized hard tissues of the tooth and these advancedrestorative biomaterials.

The following clinical presentation describes the use of a nanopar-ticle hybrid composite resin system (Premise,Kerr/Sybron,Orange,CA).

Preoperative Considerations

Prior to initiating the restorative procedure, an occlusal analysis o

the anatomical morphology of the tooth is performed and trans-ferred to a hand-drawn diagram. This diagram acts as a restorativeroadmap for the clinician and can include such information asdentin and enamel intercolor contrasts; translucency patternscrazing; hypocalcification spots; incisal and gingival blending; andstain patterns. Also, a preoperative selection of composite resinsand tints and modifiers with their shade and orientation is record-ed. Shade selection should be accomplished prior to rubber damplacement to prevent improper color matching as a result of dehy-dration and elevated values.11 When teeth dehydrate, the airreplaces the water between the enamel rods, changing the refractiveindex that makes the enamel appear opaque and white.12

In addition, the preoperative occlusal stops and excursiveguiding planes can be recorded with articulation paper and can betransferred to a hand-drawn occlusal diagram, recorded on anintraoral or digital camera or indicated and reviewed on a stonemodel. This initial registration is valuable in preparation designwhen determining placement of centric stops beyond or within theconfines of the restoration, in determining the proper restorativematerial thickness of the artificial enamel and artificial dentin, andin minimizing finishing procedures.13

Restoration of Anterior Fracture:

Class IV Restoration

A 35-year-old male patient presented with a fractured maxillaryleft central incisor (Figure 1). Upon self-assessment the patientrequested the most conservative and aesthetic restorative proce-dure available. Shade determination was accomplished by customfabricated shade comparison (Figure 2) and instrumental shadeanalysis (ShadeScan, Cynovad, Montreal, Canada), and a previsualized

Figure 2. Custom-fabricat

shade tabs were developedfrom composite material and

compared to existing tooth

structure.Figure 1. Preoperative facial view of fractured

maxillary left central incisor.


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32 NYSDJ • AUGUST/SEPTEMBER 2005

margins to improve sealing, this excess should be removed duringfinishing procedures to avoid adverse periodontal sequellae.

Proximal Adaptation Technique

Since composite does not have hydroxyapatite crystals, enamerods and dentinal tubules, the final composite restorationrequires the clinician to develop an illusion of the way light isreflected, refracted, transmitted and absorbed by these micro-structures of the dentin and enamel. Therefore, in recreating theproximal surface, a similar orientation of enamel and dentin isrequired. Since a silhouette of the cavity form is highlighted bythe darkness of the oral cavity, which is described as “shinethrough,” it is necessary to use an opacious dentin replacementwith higher color saturation. This ensures that when light strikesthe optically denser dentin with more color saturation, more lightis reflected back to the eyes. To reproduce the optical effects of the

enamel, a translucent composite encapsulates the inner dentincore and alters the quantity and quality of the light as it is reflect-ed back to the eyes.

An infinitesimal amount of glycerin was applied to the mesiasurface of the maxillary right central with unwaxed floss (Figure 8)The proximal adaptation technique was used because it allowsoptimal adaptation of the initial composite layer to the adjacenttooth without using a mylar plastic strip.Although studies indicatea smooth surface can be attained with the mylar strip, improperproximal adaptation can result in inadequate contact, improperanatomical form and shape, and surface defects.

Opacious dentin replacement was selected for strength andcolor, and the most suitable restorative materials for the core othese restorations were the hybrids and the microhybrids.Because these small-particle hybrids have refractive propertiesand a variety of color selections similar to that of dentin, theyimitate the natural tooth structure extremely well and haveenough resistance for most occlusal stress-bearing regions inthe anterior segment. (Premise, Kerr/Sybron, Orange, CA; Venus, HeraeusKulzer, Armonk, NY; Gradia, GC America, Alsip, IL; Vitalescence, Ultradent, Salt

Lake City, UT; Filtek Supreme, 3M ESPE, St Paul, MN; Point 4, Kerr/Sybron

Orange, CA).

color mapping (hand-drawn diagram and computer diagram) weredeveloped to anticipate the final result as previously indicated inthe preoperative considerations.

To facilitate access to the cervical region of the tooth, the field

was first isolated with a rubber dam using a modified technique.This process involved creation of an elongated hole that allowedplacement of the rubber dam over the retainers to achieve adequatefield control.14,15 Once the extent of the preparation was determined,a cervical chamfer 0.3 mm in depth was placed 2 mm long aroundthe entire margin to increase the enamel–adhesive surface and toprovide a sufficient bulk of material at the margins.16

A “scalloped”bevel on the chamfer was placed to break up thestraight chamfer line with a long tapered diamond (6850, Brasseler USA, Savannah, GA) (Figure 3). Since the margin was on enamel, a 0.5mm bevel was placed on the gingival margin to reduce microleak-age with a needle-shaped fine diamond (DET-9, Brasseler, USA,

Savannah, GA) (Figure 4). The lingual aspect of the chamfer wasextended 2 mm onto the lingual surface, but not onto the occlusalcontact area. The margin should not end on the occlusal contactarea unless relocating it to a contact free area would require exces-sive reduction of healthy tooth structure.

The preparation was completed with a finishing disk and pol-ished with rubber cups that contained a premixed slurry of pumiceand 2% chlorhexidine (Consepsis, Ultradent, South Jordan, UT) (Figure 5).The preparation was rinsed and lightly air dried, and a soft metalstrip was placed interproximally to isolate the prepared tooth fromthe adjacent dentition.

The “total etch” technique was used because of its ability tominimize the potential of microleakage and to enhance bondstrength to dentin and enamel.17-19 The preparation was etched for15 seconds with 37.5% phosphoric acid semi-gel (GEL-Etchant,Kerr/Sybron,Orange,CA), rinsed for five seconds and gently air dried forfive seconds (Figure 6). Once a hydrophilic adhesive agent (Optibond Solo Plus, Kerr/Sybron, Orange, CA) was applied for 20 seconds with aMicrobrush (Microbrush, Grafton, WI) disposable applicator using con-tinuous motion, the excess was removed with the same applicator,and the agent was light cured for 20 seconds (Figures 7 A-C).Although a small amount of excess adhesive can be applied over the

Figure 3. Chamfer0.3 mm in depth was

placed 2 mm long

around entire margin.

Figure 4. 0.5 mmscalloped bevel was

placed with long,

tapered diamond bur.

Figure 5.

Preparation wascleaned with 2%

chlorhexidine.

Figure 6. Prepar-ation was etched for

15 seconds with 37.5%

phosphoric acid (Gel Etchant, Kerr/Sybron,

Orange, CA).

Figure 7. (A) Single component adhesive (OptiBond SOLO plus,Kerr/Sybron, Orange, CA) was applied in continuous motion for 20

seconds. (B) Air thinned for 5 seconds. (C) Light cured for 20 seconds

A B C


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ization technique uses color variation to emphasize the nuances ocolor in the incisal edge and instill the restoration with a three-dimensional effect.

“Artificial Enamel” Layer

The enamel or artificial enamel layer is the principal determinantof the value of tooth or the restoration;21 this can be varied by thethickness of this layer. The enamel is colorless, but through its net-work of rods acts as a fiber optic conduit and projects the underly-ing color found in the dentin. The nanoparticle hybrid (PremiseKerr/Sybron, Orange, CA) used in developing this restoration has fourtranslucent shades: super clear, clear, amber and gray.

A super clear translucent-shaded hybrid composite wasapplied and contoured with a long-bladed composite instrument.A precut mylar strip was placed and adapted over the facial surfaceand light cured from the facial and the lingual aspects for 40-sec-ond intervals, respectively (Figures 13 A,B).Developing the restora-

tion in increments and considering the occlusal morphology andocclusal stops allows the clinician to minimize finishing proceduresand results in a restoration with improved physical and mechanicalcharacteristics with less microfracture.

After placing the last layer of composite and prior to final curean oxygen inhibitor, Glycerin (Insure, Cosmedent, Chicago, IL) or De-OxTM (Ultradent, South Jordan, UT), is applied in a thin layer with abrush to the surface of the restoration and light cured for a two-minute post cure.22


“Artificial Dentin” Layer

The initial artificial dentin body layer of opacious B-1 shadedhybrid composite resin (PremiseTM Kerr/ Sybron,Orange CA) was applied,adapted and contoured to the proximal surface of the contralateralcentral incisor with a long-bladed interproximal instrument,smoothed out with a sable brush and light cured for 40 seconds,which allowed placement of subsequent increments without

deforming the underlying composite layer (Figure 9). An ellipticalincrement of opacious B-1 shaded hybrid composite resin wasplaced from the incisolingual aspect to form an incisal matrix.

While the material was still soft, vertical and horizontal invagi-nations were placed with a long-bladed composite instrument,smoothed with a sable brush, and light cured for 40 seconds fromthe facial and lingual aspects (Figure 10). It was crucial to maintaina smooth internal surface, since surface irregularities could haveinterfered with placement of the tints for internal characterization.In addition, these invaginations created translucency and providedregions for placement of tints. In order to prevent overbuilding of the artificial dentin layer, it is imperative to monitor the composite

from the incisal aspect to provide adequate space for the final “arti-ficial enamel layer.”

Internal Color Characterization

A thin layer of resin can be applied and cured to create a “light dif-fusion layer” and provide an illusion of depth for restorations of limited thickness. This translucent layer will cause an internal dif-fusion of light and control luminosity within the internal aspect of the restoration.20 A white tint (Kolor Plus, Kerr/Sybron, Orange, CA) wasplaced along the fracture line and on specific regions in the verticalinvaginations corresponding to the schematic color mapping dia-gram of the contralateral central and light cured for 40 seconds(Figure 11). A gray tint (Kolor Plus, Kerr/Sybron, Orange, CA) was placedon specific regions in the vertical invaginations corresponding tothe schematic color mapping diagram of the contralateral centraland light cured for 40 seconds (Figure 12). This internal character-

Figure 8. Glycerinwas applied to proximal

surface of maxillary

right central usingun-waxed floss as

separating medium.

Figure 9. First layer

of artificial dentinbody, opacious B-1

shaded hybrid com-

posite was appliedand contoured to

proximal surface of

contralateral centralincisor with long-

bladed instrument.

Figure 10. Increment

of composite was

added to incisoligualaspect and contoured,

followed by placement

of vertical and horizon-tal invaginations.

Restoration wasthen light cured

for 40 seconds.

Figure 11. Diluted white tint was applied in vertical

and horizontal invaginations and placed alonginterface to disguise fracture line.

Figure 12. Diluted gra

tint was applied verticalcorresponding to contra

eral central and to crea

illusion of translucency.

Figure 13. (A) Super-clear translucent shaded hybrid was placed at the incisal

third of tooth. (B) Precut mylar strip was placed and adapted over facial sur faceto achieve smooth surface and light cured.

A B


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The rubber dam was removed, and the patient was asked to per-

form closure without force and then centric, protrusive and lateralexcursions.Any necessary occlusal equilibration was accomplishedwith a 30-micron, egg-shaped finishing diamond bur, and the finapolish was repeated.

The surface quality of the composite is influenced not only bythe polishing instruments and polishing pastes, but also by thecomposition and filler characteristics of the composite.27 The newerformulations of nanocomposites with smaller particle size, shapeand orientation, and increased filler concentration provideimproved physical, mechanical and optical characteristics. Althoughclinical evidence of polishability with these new nanoparticlehybrids appears promising, the long-term durability of the polish

will need to be evaluated in future clinical trials.The completed restoration reveals the harmonious integration

of composite with natural tooth structure that can be achievedwhile developing an optimal proximal contact and marginalintegrity in the interproximal zone through the use of incrementalayering of composite resin and the proximal adaptation technique(Figures 19 A,B).

Conclusion

This article has reviewed the advances in composite resin technol-ogy and provided a detailed description of the preparation designrestoration and finishing protocol for a Class IV fracture on a max-illary left central incisor using a nanoparticle composite resin sys-tem, Premise.


Finishing and Polishing Procedure

Finishing focuses on contouring, adjusting, shaping and smooth-

ing the restoration, while polishing concentrates on producing asmooth surface luster and highly light-reflective surface.23 Thefinal restorative phase was achieved by contouring and finishingthe restoration, which remains critical to the enhancement of esthetics and the longevity of the restored teeth.24,25 To reproducethe shape, color and gloss of the natural dentition, while enhanc-ing the esthetics and longevity of the restoration, the followingprotocol was implemented.

Surface texture of composite restorations is relatively hard toachieve, demanding intensive training and meticulous attention totechnique coupled with very attentive observation of natural teeth.In this case, particular attention was given not only to the relationship

between the expanse and direction of the marginal ridge, lingualfossa and the anatomic variations of the teeth that will be adjacentto the restoration,but also to the light refraction and surface reflec-tion resulting from microstructure of the tooth surface.26

The initial contouring was performed with a series of finishingburs to replicate form and texture. The facial contouring was initi-ated with #30 fluted, needle-shaped burs (BluWhite Diamonds and Carbides,#7714, Kerr/Sybron,Orange, CA) (Figure 14).The lingual surfaceswere contoured with #30 fluted, football-shaped burs (BluWhiteDiamonds and Carbides, #9406, Kerr/Sybron, Orange, CA) (Figure 15).Finishing the proximal, facial and incisal angles was performedwith aluminum oxide disks and finishing strips (Figure 16). Thesewere used sequentially according to grit, and ranged from coarse toextra fine. For characterization, finishing burs, diamonds, and rub-ber wheels and points were used to create indentations, lobes andridges (Figure 17).The definitive polish and high luster was accom-plished with a soft white goat hair brush with composite polishingpaste (Diamond Polishing Paste, Kerr/Sybron, CA) and a cloth wheel usingstaccato motion (Figures 18 A,B).

The contact was tested with unwaxed floss to ensure theabsence of sealant in the contact zone, to verify adequate contactand the absence of a gingival overhang, and to inspect the margins.

Figures 19 A, B. Postoperative facial view of restored central incisor. Note har-

monious integration of composite with natural tooth structure in interproximal zone

Figure 14. To repro-

duce natural formand texture, initial

contouring was

performed with #30fluted, needle-shaped

finishing bur.

Figure 15. Contour-

ing and finishing of

lingual aspect wereaccomplished with

#30 fluted, egg

shaped finishing bur.

Figure 16. Inter-

proximal region wasfinished with aluminum

oxide finishing stripsthat were used

sequentially according

to grit and ranged fromcoarse to extra fine.

Figure 17. Final

polish was performedwith silicone points

to eliminate surface

defects.

Figure 18. (A) Definitive polish and high luster were accomplishedwith soft goat hair bush with composite polishing paste. (B) With

cloth wheel using staccato motion.

A B

A B


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11. Fahl N Jr., Denehy GE, Jackson RD.Protocol for predictable restoration of anterior teethwith composite resins.Pract Perio Aesthet Dent 1995;7(8):13-21.

12. Winter R.Visualizing the natural dentition. J Esthet Dent 1993;5(3):102-117.13. Liebenberg WH. Successive cusp build-up: an improved placement technique for poste

rior direct resin restorations. J Canad Dent Assoc 1996;62(6):501-507.14. Liebenberg WH. General field isolation and the cementation of indirect restorations

Part 1.J Dent Assoc of South Afr 1994; 49(7): 349-353.15. Croll TP. Alternative methods for use of the rubber dam. Quint Int 1985;16:387-392.16. Bichacho N. Direct composite resin restorations of the anterior single tooth: clinica

implication and practical applications. Compend 1996;17(7): 796-802.

17. Kanca, J III. Improving bond strength through etching of dentin and bonding to wedentin surfaces.J Am Dent Assoc 1992(123):35-43.18. Nakabayashi N,Nakamura M,Yasuda, N. Hybrid layer as a dentin-bonding mechanism

J Esthet Dent 1991;3(4):133-138.19. Kanca J III. Resin bonding to wet substrate. II. Bonding to enamel. Quint Int

1992;23(9):625-627.20. Vanini L. Light and color in anterior composite restorations. Pract Periodont Aesthe

Dent 1996;8(7):673-682.21. Muia PJ. Esthetic Restorations: Improved Dentist-Laboratory Communication. Caro

Stream, IL: Quintessence Publishing 1993: 86-87.22. Sturdevant CM, Roberson TM, Heymann HO, et al. The Art and Science of Operative

Dentistry. 3rd Ed. St.Louis: Mosby-Year 1995: 592.23. Schwartz RS, Summitt JB, Robbins JW. Finishing and Polishing. In: Fundamentals o

Operative Dentistry: A Contemporary Approach. Carol Stream, IL:QuintessencePublishing Co. Inc. 1996:201-205.

24. Jefferies SR,Barkmerier M, Gwinnett AJ.Three composite finishing systems: a multisitein vitro evaluation. J Esthet Dent 1992;4(6):181-185.

25. Goldstein RE.Finishing of composites and laminates.Dent Clin North Am 1999;33(2): 305-318.26. Hegenbarth EA. Teeth and Esthetics. In: Creative Ceramic Color: A Practical System

Chicago,IL: Quintessence 1989:9-36.27. Jefferies Sr, Smith RL, Barkmeier WW, et al. Comparison of surface smoothness o

restorative resin materials. J Esthet Dent 1989; 1(5): 169-175.

Although the long-term benefits of this material remain to bedetermined, the use of an optimized particle composite in theaforementioned patient demonstrated enhanced sculptability, thepolishability of a microfill, the strength of a hybrid and the ability to simulate the optical properties of the natural tooth.

While the evening news may fail to report the technologicaladvancements that led to the development of the optimized parti-

cle composite, another milestone in the practice of dentistry hasoccurred in the endless quest for the ideal composite.■

REFERENCES1. Tjan AHL,Glancy JF. Effects of four lubricants used during incremental insertion of two

types of visible light-activated composites.J Prosthet Dent 1988;60:189-194.2. Kovarik RE, Ergle JW. Fracture toughness of posterior composite resins fabricated by

incremental layering. J Prosthet Dent 1993;69:557-560.3. Dietshi D. Free-hand composite resin restorations: a key to anterior aesthetics. Pract

Periodont Aesthet Dent 1995;7(7):15-25.4. Jefferies SR The art and science of abrasive finishing and polishing in restorative den-

tistry.Dent Clinic North America 1998;32(4):613-627.5. Donly KJ, Browning R.Class IV preparation design for microfilled and macrofilled com-

posite resin. Pediatric Dentistry January/February 1992;14(1): 34-36.6. Kim HS,Um CM.Color differences between resin composite and shade guides. Quint Int

August 1996;27(8):559-567.7. Roulet JF. Degradation of Dental Polymers.1st ed.Basel,Switzerland: S.Karger AG,1987.8. Leinfelder KF. Composite resins: properties and clinical performance. In: O’Brien WJ,

and Powers, JM, ed. Dental Materials: Properties and Selection. Chicago, IL:Quintessence Publishing Co. 1989:139-57.

9. Kirk RE,Othmer DF, Kroschwitz J, Howe-Grant.Encyclopedia of Chemical Technology.4th ed. New York: Wiley. 1991:397.

10. Muselmann M. Composites make large difference in “small” medical, dental applica-tions. Comp Tech December 2003:24-27.


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There is a wide range of reported incidences of unilateral pos-terior crossbite (UPXB) in the primary and mixed dentition. Theincidence of UPXB has ranged from 7% to 23%.1-7 Posterior cross-bites have been reported to develop between 19 months and 5 yearsof age, with approximately 80% of UPXBs being accompanied by

functional shifts of the mandible.8

The posterior crossbite with functional shift of the mandibleshould be differentiated from posterior dental crossbites withoutfunctional shifts. Figure 3 is a posterior dental crossbite caused byan individual tooth malposition of the maxillary left molar. Notethat the maxillary and mandibular dental midlines coincide. Thistype of crossbite can be treated by moving the tooth (or teeth) incrossbite into normal position.

However, the situation in Figure 4 is quite different. Theobserved crossbite relationship in the maximum intercuspationposition appears to be identical to the dental crossbite anomaly. Acloser look, however,reveals a notable disparity between the maxil-lary and mandibular dental midlines. The mandible has shifted (tothe side of the observed crossbite) as it encountered prematuritiesupon closure. If we were to place the mandible in its normal trans-verse position (lining up the true maxillary and mandibular dentamidlines), we would observe the actual transverse relationshipbetween the maxillary and mandibular posterior teeth (Figure 5). Itbecomes apparent that both the right and left sides of the maxillaryposterior segments are lingually displaced. Consequently, the func-tional crossbite (even though it resembles the dental posteriorcrossbite in the maximum intercuspation position) is a result of a

Abstract

The unilateral posterior crossbite (UPXB) with functional

shift of the mandible is commonly encountered in young

children and adolescents. Differential diagnosis and the

impact this type of malocclusion might have upon the

growth and development of dental and facial components

are discussed.

Impaired function and compromised facial esthetics may

be consequences of untreated UPXBs with functional shifts.

Appropriate treatment protocols and specific orthodontic

appliances intended to correct these problems are presented.

POSTERIOR CROSSBITES in the mixed or permanent dentition repre-sent deviations from normal bucco-lingual occlusal relationships.Posterior crossbites can be caused by malpositions of individual orgroups of posterior teeth (dental crossbites),malpositions of posteriorteeth accompanied by a functional shift of the mandible (functionalcrossbites), or transverse disharmonies of the maxilla and mandible(skeletal crossbites). Frequently, posterior crossbite relationships may be caused by a combination of the aforementioned factors.

Posterior crossbites are frequently observed as lingual cross-bites (Figure 1), but may also be found in buccal crossbite relation-ships (Figure 2).

The Unilateral Posterior Functional Crossbite

An Opportunity to Restore Form and Function

Elliott M. Moskowitz, D.D.S., M.Sd


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bilateral constriction or narrowness of the maxillary dental archand, therefore, requires bilateral posterior expansion.

The young patient, R.G., in the composite intraoral photograph(Figure 6) has UPXB in the mixed dentition with functional shift of the mandible. Note that the left side is observed in crossbite and the

right side appears “normal” in the maximum intercuspation posi-tion. The maxillary and mandibular dental midlines are significant-ly disparate. In cases of functional crossbites, the mandible shifts tothe side of the observed crossbite (Figure 7).Facial asymmetries canbe either subtle or significant. Figure 8 reveals patient R.G.’s facialasymmetry,caused by a lateral or transverse shift of the mandible.

Need for Orthodontic Treatment

Posterior crossbites with functional mandibular shifts should betreated earlier rather than later.9 In general, the mixed dentitionstage is an ideal time to treat UPXBs with functional shifts; howev-er, they may be treated in the primary dentition as well. The denti-tional status (presence of permanent maxillary and lateral incisorsand first permanent molars) and important management consider-ations are usually favorable during the mixed dentition. From apractical perspective,few patients in the primary dentition are seenby most orthodontists on a routine basis.

There is ample empirical and evidenced-based information tosupport the need for treatment while skeletal and dental growthand development are relatively active. Pinto, et. al.10 found bothpositional and morphological changes in young patients with pos-terior functional crossbites. Condylar position and length of the

mandibular skeletal structures,particularly the mandibular ramusdiffered when bilateral structures were compared. Interestingly, itwas also found that compensatory growth during and after maxil-lary expansion eliminated positional and morphological asymme-tries observed before treatment. Simply stated, both form and func-

tion were restored via maxillary expansion and elimination of thefunctional shift of the mandible.

Sonneson, et al.11 measured the bite force of patients with andwithout posterior functional crossbites with pressure transducersThey found a significant increase in muscle tenderness and otherTMD symptomology in the crossbite sample. Additionally, biteforce was also decreased in patients with crossbites. These investi-gators concluded, “The early treatment of unilateral posterior cross-bites was advisable to optimize conditions for function.”

Figure 9 shows a composite photograph of an adult patientG.W., with a longstanding left side crossbite relationship and func-tional shift of the mandible to the left side. The facial asymmetry isnotable. The anteroposterior cephalometric radiograph (Figure 10)confirms the asymmetric mandibular skeletal structures as a resulof continued differential growth and development while the mandiblewas positioned in an abnormal transverse relationship.

Several viable treatment options were offered to the patientThese options included a combined orthodontic/orthognathic sur-gical protocol (which might have fully corrected the skeletal dishar-monies) and a sole conventional orthodontic treatment intended tomerely “improve” the mandibular asymmetry by allowing themandible to assume a more normal transverse position after func-

Figure 1. Most posteriorcrossbites are observed

as lingual crossbites.

Maxillary left molar issituated lingual to its

normal position.

Figure 2. Although lessfrequently encountered,

some posterior crossbites

are buccal crossbites.Maxillary molar is

positioned buccally,and mandibular molaris positioned lingually.

Figure 3. Posteriordental crossbite: definite

occlusal stop in position

of maximum intercuspa-tion. Normal bucco-

lingual inclinations ofopposing molars on rightside. Abnormal tipping

on left side. Maxillary

and mandibular dentalmidlines coincide.

Figure 4. Posteriorfunctional crossbite: with

teeth in maximum inter-

cuspation, unilateralcrossbite is seen.

Opposite side appearsto occlude normally.

Mandibular midline is

shifted toward cross-bite side.

Figure 5. Functional crossbite on left displaysmandibular transverse shift to patient’s left side as

result of occlusal prematurities. Lining up true uppe

and lower dental midlines (by shifting mandible topatient’s right side) reveals actual transverse rela-

tionship between maxillary and mandibular dentalarches. Maxillary dental arch is now seen as beingconstricted bilaterally.

Figure 6. Patient R.G. has unilateral posterior crossbite with functional shiftof mandible (to patient’s left side). Upper and lower dental midlines are

characteristically disparate.

Figure 7. Diagrammaticdepiction of transverse shifting

of mandible associated with

unilateral posterior crossbites.

Figure 8.

Patient R.G.displays facial

asymmetry asresult of trans-

verse shift of

mandible uponclosure.


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crossbite relationship from the maxillary right primary canine tothe maxillary right first permanent molar. The mandible has shift-

ed to the patient’s right side as a result of prematurities caused bythe malpositions of the teeth and constriction of the maxillary den-tal arch. The maxillary and mandibular dental midlines do notcoincide. The early effects of the transverse malpositioning of themandible in the lower third of the face can be seen in Figure 13. Afixed palatal expander (Figure 14) was placed, and the parent wasinstructed to activate the expansion screw with a “key”once a dayThis early or “phase I” treatment extended approximately ninemonths. Figure 15 shows the composite post-treatment outcomeNote the elimination of crossbites, dental midline coincidence andimprovement in facial symmetry (Figure 16).

The 9-year-old patient in Figure 17 has UPXB with functionalshift (to the patient’s right side) in the mixed dentition. The dentamidlines do not coincide.A removable expansion appliance was pre-scribed (Figure 18) to effect bilateral dental expansion. The patientor parent activated the expansion screw placed in the palatal portionof the appliance.Note that the occlusal acrylic portion of the remov-able appliance covers the buccal surfaces of the posterior teeth tominimize occlusal interferences and unwanted tipping of the buccasegments. The crossbite and functional shift were corrected in lessthan six months. Figure 19 shows the correction as the patient con-tinues to develop into the permanent dentition.

tional interferences were removed. The patient rejected orthog-nathic surgery and opted for conventional orthodontic treatment,

which entailed maxillary dental expansion and the use of fixedorthodontic appliances to improve inter- and intradental relation-ships. Figure 11 is a post-treatment composite showing significantinter- and intradental arch corrections. The facial asymmetry hasbeen reduced as the mandible assumed a more normal transverserelationship. The remaining asymmetry is due to unchanged bilat-eral morphological mandibular structural differences that natural-ly would not be expected to fully correct without the assistance of asurgical procedure.

Treatment

The treatment of posterior crossbites with functional shifts gener-ally entails use of an orthodontic appliance that is capable of effecting bilateral expansion of the maxillary dental arch and/orexpansion of the palate via sutural disjunction. The clinicianshould assess the level of orthodontic correction that is neededbeyond the mere elimination of the functional shift using the samecriteria that are appropriate for the diagnosis, treatment planning,choice of appliance(s) and retention requirements of any prospec-tive orthodontic patient.

E.H. is an 8-year-old female with UPXB with functional shift inthe mixed dentition (Figure 12). The right side displays a complete

Figure 9. Adult patient, G.W., displays facial

asymmetry as result of longstanding functional

crossbite that persisted during growth.

Figure 10. Anterior-posterior

cephalometric radiograph con-firms mandibular asymmetry.

Figure 11. Post-orthodontic treatment compos-

ite illustrating dental and facial improvement.

Figure 12. E.H. is 8-year-old female displaying

“classic” UPXB in mixed dentition.

Figure 13. Facial asymmetry of E.H. as

result of functional shift of mandible.

Figure 14. Fixed palatal expansion device used in

treatment of E.H’s functional crossbite.


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REFERENCES1. Kutin G, Hawes RR. Posterior crossbites in the deciduous and mixed dentition. AM

Orthod 1969;56:491-504.2. Day AJ, Foster TD. An investigation into the prevalence of molar crossbite and somassociated etiological conditions.Dent Pract. 1971;21:402-10.

3. Infante PF. An epidemiologic study of finger habits in preschool children as related tomalocclusion, socioecononomic status, race, sex, and size of community. J Dent Child1976;1:33-8.

4. de Vis H, de Boever JA, van Cauwenberge P. Epidemiologic survey of functional conditions of the masticatory system in Belgian children aged 3-6 years. Comm Dent OraEpidemiol 1984;12:203-207.

5. Heikinheimo K, Salmi K. Need for orthodontic intervention in five-year-old Finnishchildren.Proc Finn Dent Soc 1987;83:165-9.

6. Hannuksela A, Laurin A,Lehmus V, Kouri R. Treatment of crossbite in early mixed dentition. Proc. Finn Dent Soc.1988;84:175-82.

7. Kurol J, Bergland L. Longitudinal study and cost-benefit analysis of the effect of earlytreatment of posterior crossbites in the primary dentition. Eur J Orthod 1992;14:173-9

8. Thilander B,Wahlund S, Lennartsson B.The effect of early interceptive treatment in children with posterior crossbite. Eur J Orthod 1984;6:25-34.

9. Gottlieb Eugene, Moderator, JCO Roundtable, Early Orthodontic Treatment, Part 2.Clinical Orthod March,Volume XXXVIII,Number 3:135-154.10. Pinto,AS,Buschang, PH,Throckmorton GS,Chen P. Morphological and positional asym

metries of young children with functional unilateral posterior crossbite.Am. J. Orthod2001;20:513-520.

11. Sonnesen L, Bakke M, Solow B. Bite force in pre-orthodontic children and unilateracrossbite Eur. J.Orthod. 2001;23:741-749.

12. Moskowitz E. Orthodontics in the Progressive Dental Practice. In Essential DentaHandbook. Tulsa, OK: PennWell Corp.2 003:387-430.


P.C. is a 16-year-old female in the permanent dentition withUPXB and functional shift of the mandible to the right side (Figure

20). A fixed palatal expander with occlusal acrylic coverage was bond-ed to the maxillary dental arch (Figure 21). This type of fixedexpander can eliminate occlusal interferences during treatment,min-imize unwanted vertical changes that sometimes accompany palatalexpansion,and obviate the need for separation and banding of poste-rior teeth. Treatment extended approximately 16 months and includ-ed a brief period of conventional fixed orthodontic appliances to coor-dinate inter- and intradental relationships. Figure 22 shows the post-treatment outcome, in which the functional crossbite was eliminated.

Conclusions

UPXB with functional shift of the mandible is a type of malocclu-sion that can impair both form and function in growing individ-uals. Pediatric dentists and other clinicians who choose to treatchildren and adolescents should be keenly aware of the diagnos-tic features of UPXB with functional shifts and recommend ortho-dontic corrective procedures earlier rather than later. The mixeddentition is an ideal stage to consider beginning orthodontictreatment in these types of cases.

The successful resolution of UPXB with functional shift rep-resents a valuable and conservative dental health service forindividual patients with this type of malocclusion. ■

Figure 22. Correction of functional crossbite and improvement in inter- and

intradental relationships.

Figure 15. Post “phase I” treatment demonstrating

return to dentofacial harmony in mixed dentition.

Figure 16. Facial asymmetry of

E.H. eliminated.

Figure 17. UPXB with functional shift in mixed dentition.

Figure 18. Removable dentalexpansion appliance with

occlusal coverage. Figure 19. Correction of UPXB.

Figure 20. Patient P.C. with UPXB and functional shift in permanent dentition.

Figure 21. Bonded

palatal expandingdevice with occlusalcoverage.


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ALTHOUGH ORAL PIERCING IS POPULAR among certain cul-tures and in some developing countries, only recently has it gainedpartial acceptance in Western society.1-3 Body beautification, deco-ration and body art are ancient practices that have been exercisedby humans across cultures for centuries. Intentional, irreversiblechanges to the human body have been practiced by older,as well asmodern, civilizations for a variety of reasons.The most common ofthese are expressing spiritual devotion or dedication to magic, ful-filling social demands, making a personal statement or enhancingindividual sex appeal. A multitude of body beautification proce-dures were in use by older civilizations and are commonly seentoday, especially in developing countries.Among these are skin tat-tooing, branding and piercing of ear lobes and the nose.4

Oral body art, as it is referred to, usually involves piercing of thetongue,cheeks, lips or uvula. The lip is the most commonly piercedsite,but tongue piercing is becoming more prevalent.With the grow-ing number of oral piercings being performed, it is vital that dentistsare aware of the risks, complications and dental implications associ-ated with such procedures.1 This article includes a case report ontongue piercing, periodontal trauma and its surgical managementAnd it presents the topic of oral piercing with special emphasis oncomplications and ethical considerations for dental professionals.

Abstract

Body piercing has grown in popularity among teenagers

and young adults. Dating back to antiquity, piercing is a

cultural practice used in ceremonial or religious rites; how-

ever, today, it is commonly exercised as a method of self-

expression. Different complications and side effects are

associated with intraoral piercing, including pain, swelling,

infection, gingival trauma, chipped or fractured teeth,

increased salivary flow, calculus buildup, and interferencewith speech and swallowing. We present a case report of

periodontal treatment of traumatized gingival tissue

caused by a tongue stud. The step-by-step periodontal

surgical management of the case has been elaborated.

The role of oral and dental health care professionals in

managing the growing problem of tongue piercing as a

periodontal risk factor has also been highlighted.

TONGUE PIERCING

Risk Factor to Periodontal Health

Jennifer Choe, D.D.S.; Khalid Almas, B.D.S., M.Sc., FRACDS, FDSRCS, FICD; Robert Schoor, D.D.S.


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Case Report

A 26-year-old Caucasian male patient was referred to the New York University College of Dentistry Department of Periodontics for eval-uation of the lingual aspect of tooth #25. An initial clinical and radi-ographic evaluation was performed.A periapical radiograph revealedlocalized horizontal bone loss associated with tooth #25. Clinicalevaluation of the midlingual aspect of the tooth illustrated isolated 5

mm of gingival recession,a probing pocket depth of 4 mm and local-ized inflammation. No other sites displayed any loss of attachment.

The patient had scaling and root planing performed by hisdentist one week before visiting the department, and there was noevidence of supragingival plaque or calculus.There was no mobili-ty associated with any of the teeth, and there was an absence of occlusal interferences. The localized gingival defect was directly opposed to the location of the patient’s tongue stud (Figures 1-4).Ingeneral, the patient’s oral hygiene was good.

Periodontal Treatment

After a complete intraoral examination and periodontal charting, a

treatment plan was formulated that included removal of the tonguestud and a subepithelial connective tissue graft on the lingualaspect of tooth #25. As the probing pocket depths ranged from1 mm to 3 mm in other areas of the mouth, and the patient hadmaintenance prophylaxis prior to his examination, supragingivalscaling was not performed.

Surgical Procedure

Following local anesthesia on the lingual aspect of teeth #22-27 andon the palatal aspect of teeth #12-15, using two carpules of lido-caine with 1:100,000 epinephrine, the area affected by the tongue

stud was accessed by a lingual full thickness mucoperiosteal flapreflection using sulcular incisions. Care was taken to conserve thepapilla between the adjacent teeth (Figures 5-7).

Apical to the 5 mm of gingival recession on the lingual aspectof tooth #25, a split thickness flap was reflected to accommodate aconnective tissue graft from the palatal site. Approximately 80% of the attachment loss was localized to the lingual aspect of tooth #25.The circumferential osseous defect was consistent with the inferiorball of the tongue stud, extending more than 6 mm apical to thecemento-enamel junction (CEJ). The connective tissue graft washarvested from the palatal aspect of tooth #14, using an 8 mm long

Figure 1. Metallic tongue stud opposing lingualaspect of tooth #25.

Figure 2. Occlusal view of tooth #25 with gingivalcleft on lingual aspect.

Figure 3. V-shaped cleft (gingival recession).

Figure 4. Tooth #25

with circumferentialosseous defect.

Figure 5. Local anes-thesia infiltration given.

Figures 6 & 7.

Lingual full thicknessflap reflection from

tooth #25.

Figure 6.

Figure 7.


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horizontal incision at a perpendicular angle to the palatal vault. Asecond horizontal incision was placed parallel to the palatal vault todissect the connective tissue from the donor site.

An 8 x 5 mm piece of connective tissue with approximately

1 mm band of epithelium was yielded from the site (Figure 8). Thelingual surface of tooth #25 was swabbed with 10% tetracyclinesolution, and the area was rinsed with sterile saline after oneminute. The enamel matrix derivative (Emdogain 0.3 ml, StraumannBiologics Co., Waltham, MA 02451) was placed on the lingual aspect oftooth #25, and the connective tissue graft was placed over theexposed root surface. The epithelial aspect of the donor graft wasplaced at the level of the CEJ.

The connective tissue was sutured with 5.0 vicryl interruptedsutures placed on mesial and distal sides of tooth #25. The epitheliaflap was also sutured with 5.0 vicryl interrupted sutures to the mesialand distal of tooth #25.The area was inspected for flap stability and

adequate tension relief. Additional Emdogain was placed over theflap and the donor site. The metal tongue stud was removed. Thedonor site was also sutured with the same material (Figures 9, 10).

Postop Instructions and Follow-up

Postoperative instructions included 500 mg Amoxicillin tabletsthree times daily for one week, 800 mg Motrin (analgesic) as need-ed for pain, and rinsing with Chlorhexidine mouthrinse twice a dayfor two weeks. The 10-day postoperative evaluation revealedremarkable healing.The patient said he had minimal postoperativediscomfort (Figure 11).At our 4-month follow-up visit, the patient’soral hygiene had improved and attachment loss appeared to have

stabilized (Figure 12 ).

Discussion

The patient in this case report represents a situation that will occurmore frequently as the popularity of tongue piercing increases.Andwhile tongue piercing is gaining in popularity, it does not appear tobe a harmless fad. On the contrary, there is a risk of infection andedema, which could cause a hazard to the airway.2 Consequently,warnings have appeared in the popular press. And, according to arecent report, experts from the Academy of General Dentistry havewarned that implanting jewelry in the tongue may lead to numbnessloss of taste and mobility, and even a life-threatening blood clot.5

According to a recent report, common complications andpossible adverse consequences of oral piercing can be summa-rized as follows:1

● Oral pain● Edema● Infection● Disease transmission● Airway obstruction secondary to swelling● Prolonged bleeding● Chipped or fractured teeth

Figure 8. Palatal

donor site of connective

tissue graft.

Figure 9. Connectivetissue (8 x 5 mm)

placed at defect site.

Figure 10. Connectivetissue graft sutured with

5.O vicryl sutures.

Figure 11. Post-

operative healingafter 10 days.

Figure 12. Post-operative healing

after four months.


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Conclusion

Determination of the periodontal treatment for a localized mucos-al or gingival defect resulting from disease or trauma in a mouth iscase dependent. Generally, the goals of periodontal treatment are to

restore the function and esthetics of periodontium and long-termmaintenance of teeth and gingival tissues.The periodontal surgical procedure with connective tissue

graft has predictable outcome in the absence of causal traumaDental professionals should be aware of oral and perioral piercingand should be able to talk with their patients about these issues andprovide sound advice and comprehensive care for soft and hard tis-sue damage caused by oral piercing jewelry.■

REFERENCES1 . Farah CS, Harmon DM.Tongue piercing:case report and review of current practice.Aus

Dent J 1998;43: 387-389.2. Scully C,Chen M. Tongue piercing (oral body art).Br J Oral Maxillofac Surg 1994;32:37-38

3. Maibaum WW, Margherita VA. Tongue piercing: a concern for the dentist. Gen Den1997; 45:495-497.4. Bassiouny MA, Deem LP., Deem TE. Tongue piercing: a restorative perspective

Quintessence Int 2001; 32: 477-481.5. Jones HE.Are they just skin deep? RDH 1996;16:38-44.6. American Dental Association. ADA statement on intraoral/perioral piercing. Available

at: http://www.ada.org/prof/resources/positions/statements/piercing.asp. January 20037. Dunn WJ, Reeves TE. Tongue piercing: case report and ethical overview. Genera

Dentistry May-June 2004; 244-247.


● Mucosal or gingival trauma● Interference with mastication and swallowing● Speech impediment● Hypersalivation●

Hyperplastic or scar tissue formation● Nerve damage and paraesthesia● Aspiration of specific piercing jewelry● Foreign body incorporation into site of piercing● Obstruction of radiographic images● Calculus formation on metal surfaces● Metal hypersensitivity

The presence of a piercing in the oral cavity should be evaluat-ed with its surrounding structures as a regular parameter whenperforming an initial examination. The question about intraoralpiercing should also be incorporated into a questionnaire providedfor new patients in the dental practice.

In the patient described here,the trauma to the periodontal struc-ture on the lingual surface of tooth #25 appeared to be directly causedby the lower ball of a lingual stud, as no other patterns of attachmentloss were present in any other areas of the oral cavity. These findingsstrongly implicate the piercing as the primary factor in this localizedtraumatic periodontitis. It was recommended to our patient that heremove the tongue stud as part of the treatment plan. The patientagreed as he was well informed of the situation. Oral hygiene instruc-tions were provided for long-term maintenance of the tooth and mouth in general.

Of primary interest to the dentist are perioraland intraoral piercings.These expressions of body art

became a dental concern over the past few yearsbecause of the increased frequency of their use andtheir influence on the health,function and esthetics of oral tissues.Management of the consequences,eitherdirect or indirect, of oral piercing represents a basicfunction in modern dental practices. Hence, an inte-gral part of emergency procedures is to treat postop-erative and latent complications and to perform com-prehensive treatment planning, including restorativetreatment and periodontal follow-up care.4

The ADA opposes the practice of intraoral/perioral piercing and supports legislation requir-ing parental consent of minors who want to bepierced because of the potential for numerous neg-ative sequelae.6 Each state has the opportunity toconsider legislation regarding the issue of minorsand the regulation of piercing parlors, whichwould mandate the use of sterile equipment aswell as submission to OSHA guidelines andinspections. The process starts at the local levelwith dental professionals who can educate theirpatients about the risks of piercing.7


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AN INTERDISCIPLINARY APPROACH taken by a restoring dentistperiodontist, dental laboratory and digital imaging technicians tore-establish esthetics in a case of severe occlusal wear is presentedDigital imaging is used during treatment planning to increasepatient acceptance and to facilitate communication among therestorative and surgical dentists and dental laboratory.1 Using digi-

tal simulations,the planned prosthesis can be viewed in the contextof the surrounding soft tissues in a life-like manner. The rationalefor selecting digital imaging as a consultation tool was to betterdescribe the proposed treatment, making it easier to visualize theproposed goals and enhancing the ability to share the anticipatedresults with friends and family.

Often, crown-lengthening procedures are necessary for re-establishing esthetics. The rationale for a crown-lengthening pro-cedure is to increase the apico-coronal height of the clinical crownfor a clinically acceptable prosthetic restoration.2-4 For a successfultreatment outcome, the dimension of the attachment apparatusneeds to be considered. To achieve stable soft-tissue levels and gin-giva that is healthy in appearance, it is important to respect theattachment apparatus. Unfortunately, it is common to violate theattachment apparatus with restorative materials.5-9

After the crown-lengthening procedure, the surgical site maybe closed with a variety of suture techniques, such as single inter-rupted and continuous suture. The surgical approach that is pre-sented in this case report includes use of subsidiary tacks to stabi-lize and position the tissues without the use of sutures. Tacks havebeen used previously in surgical techniques for membrane stabi-lization and have been shown to be biologically compatible.10-11

Abstract

Managing crown lengthening in cases of attrition (wear or

loss of tooth substance) and achieving desired esthetic

outcomes, especially in the esthetic zone, is challenging.

This case report presents an interdisciplinary approach to

case management.

Concomitant use of digital imaging, along with model

wax-ups and surgical guide, were used to enhance patient

acceptance during treatment planning and to facilitate

communication and treatment implementation among den-

tal professionals and laboratory technicians.

Resulting surgical template was used for crown

lengthening to apically position the gingival zenith (mar-

gin) to a predetermined level, crown preps and final

restorations, respectively, ultimately improving esthetics

and patient satisfaction.

Supplementing esthetic treatment planning with digital

imaging, model wax-ups and a surgical template allows a

dentist to carry information into the mouth and incorporate

it into the surgical procedure, crown preps, temps and,

ultimately, the final restoration.

Use of Interdisciplinary Team Approachin Establishing Esthetic Restorative Dentistry

Dov M. Almog, D.M.D.; Sean W. Meitner, D.D.S.; Neer Even-Hen, D.D.S.; Joshua P. Grant, D.D.S.; James L. Soltys, D.D.S.


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This article and case study illustrate a multidisciplinary teamapproach to the esthetic and prosthetic rehabilitation of the maxillary ante-rior region,using consultation adjuncts like digital imaging, model wax-ups and surgical templates,including subsidiary use of surgical tacks.

Case Report

A 53-year-old Caucasian male patient was evaluated for estheticsconcerns involving severe anterior occlusal wear. His chief com-plaint was that we “fix his short front teeth.”

His medical history revealed myocardial infarction five years ago;the patient is taking medications to control hypertension and elevatedserum cholesterol.Following a full-mouth radiographic survey,an intra-oral exam revealed dental restorations on all posterior teeth, including afixed partial denture from teeth #3-6 (of five years duration), and animplant-supported crown on tooth #12 (of three years duration). Allanterior teeth from canine to canine in both the mandible and maxillapresented with extreme wear to the incisal edges.Canine guidance did

not exist, as all anterior teeth contacted during excursive movements.With the exception of marginal redness and swelling around teeth # 6and 9, the patient’s gingiva was pink, firm and healthy in appearance(Figure 1A).No radiographic evidence of bone loss was visible.

In order to obtain optimum therapeutic results and to executeinterdisciplinary care for this complex esthetic abnormality case, ateam of providers gathered to develop a consistent treatment phi-losophy, including diagnostic and treatment planning procedures.

Digital Imaging

Following a preoperative consultation among a team made up of a

Figure 1. Before (A) and computer-simulated after (B) close-up photographs.

A

B


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prosthodontist, periodontist and laboratory technician, it wasdetermined by the team that the patient would benefit from digitalimaging simulations. After a detailed treatment plan was pre-scribed, preoperative facial and close-up digital photographs wereacquired with a digital camera (DX4900 Dental Digital Camera Kit,

Eastman Kodak Co., Rochester,NY).Facial and close-up digital images of the patient were down-

loaded to a computer. Simulation of esthetic values of crown widthand height was achieved using a specialized dental imaging soft-ware (PracticeWorks/DICOMTM Cosmetic Imaging Software, Version 1.73 Eastman Kodak, Atlanta, GA). Before and after 8-inch x 11-inch printoutputs were produced using a desktop printer (Kodak Personal Picture Maker 200 by Lexmark, Eastman Kodak, Co., Rochester, NY) and glossy pho-tographic paper (Kodak Desktop Medical Imaging Paper, Eastman Kodak, Co.Rochester, NY). The consultation adjunct output included a personal-ized before and after facial and close-up digital photograph(Figure 1).

Diagnostic Wax-up/Surgical Template

Impressions were made of both arches using stock trays and irre-versible hydrocolloid. These were then cast in stone. The castswere articulated in a semi-adjustable articulator (Hanau H2Waterpik Technologies, Fort Collins, CO). Concomitant with the digitalimaging output, using average values of crown width and heightthe gingiva was scalloped on the casts to achieve desired crownlength. A diagnostic wax-up was then completed to visualize thefinal outcome. It is important to stress that the extra length wasachieved in a gingival direction almost exclusively, with only 1mm added to the incisal edge. This is done both for esthetic rea-

sons and to avoid excessive restorative materials from interferingduring function.

The diagnostic wax-up was duplicated and poured in dentalstone. A .020-inch vacuum plastic form was made over this castthen trimmed to the scalloped outline of the gingival zenith on theteeth scheduled to have crown-lengthening surgery (Figure 2).Thisvacuum-formed tray was designed to serve as a surgical guide tem-plate during the crown-lengthening procedure. Tooth #6 was notincluded, as this was part of a fixed partial denture that was notbeing replaced.

During the surgical visit, the mucoperiosteal flap was elevat-ed beyond the mucogingival junction, allowing apical displace-ment of the gingiva. The surgical guide was then placed over theteeth and used to position the gingival tissues to the apical mar-gin of the planned prosthesis (Figure 3A). Subsidiary surgicaltacks, 5 mm in length, were then driven through the marginagingival tissues into the interproximal bone to stabilize the mar-ginal tissue at the desired level as indicated by the surgical guide(Figure 3B).

After four weeks of tissue maturation, teeth #7-11 were pre-pared for full coverage porcelain-fused-to-metal crowns. Full archImpergum-polyether impressions were taken (3M-ESPE, St. Paul, MN)

Figure 3. A) Surgical template is placed over epically positioned flap to confirm

desired gingival margin. B) Surgical tacks are used to stabilize soft tissues.

Figure 4. Intraoral anterior view of maxillary anterior dentition 6 weeks after final

restorations have been delivered.

A

B

Figure 2. A .020-inch vacuum plastic form was made over the stone cast duplicate

of the diagnostic wax-up, then trimmed to the scalloped outline of the gingival zenith

on the teeth.


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and poured in die stone. Acrylic temporaries were fabricated(Coldpack, Motloid of Chicago, IL) using the diagnostic wax-up as a tem-plate. The patient returned four weeks later for crown placementwith provisional cement (Zone Non Eugenol, CADCO-VanR, Oxnard, CA).

After six weeks the crowns were cemented with a resin-

reinforced glass ionomer (FujiPlus, GC Corp., Tokyo, Japan)(Figure 4).

Discussion

Good team communication is critical to patient satisfaction inesthetic dentistry. This article and case study illustrate a multidis-ciplinary team’s role in the prosthetic and esthetic rehabilitation of the maxillary anterior region. Digital imaging and diagnostic wax-up enable both clinicians and patients to view the desired final out-come of their teeth and soft tissue at the preoperative stage.In morecomplex treatment plans, the dentist can convey a treatment con-cept to the patient more easily and realistically when using digitalimaging.1,12-14

Additionally, esthetics is subjective and can vary considerably between individuals. It is important to illustrate the planned out-come to the treating team members and to the patient, and toreceive feedback. The surgical guide template in particular enabledthe team to transfer information into the mouth and incorporate itinto the surgical procedure,crown preps, temps and,ultimately, thedesired final restoration.

This case study also illustrates the subsidiary use of surgicaltacks (IMTEC Tac System, New York, NY). Crown lengthening for anesthetic procedure requires stabilization of the soft tissues for themost predictable results, and the ability to achieve adequate exten-sion of the clinical crown is often difficult.15 The purpose of the tack

is to provide immediate stabilization at a predictable level. Tackswere originally developed in Europe for the stabilization of mem-branes in ridge preservation and ridge augmentation proce-dures.10,11 If sutures alone are used to stabilize the flaps, by pullingthe flaps up against the teeth, their final position is not as pre-dictable, as the tissues may still shift. Periodontal pack is often usedwith sutures to stabilize the tissues. The tacks must be placed in theinterproximal bone between adjacent teeth to avoid contact withthe roots.The tacks can be covered with periodontal pack if there isany question or fear of them being lost and swallowed during thehealing period.

Although the gratifying esthetic outcome in this particular casepresentation tends to support an interdisciplinary approach and theuse of treatment planning adjuncts,the authors strongly encourageconducting more comprehensive investigations with larger study populations and numerical data to support success-to-failure ratiofollowing the concomitant use of digital imaging, model wax-upsand surgical templates during esthetic procedures. ■

This study was supported by the divisions of Prosthodontics and Periodontics at the University of

Rochester Eastman Dental Center.

REFERENCES1. Goldstein C,Goldstein RE,Garber DA. Computer imaging:an aid to treatment planning

J Calif Dent Assoc 1991;19:47-51.2. Kois JC.Altering gingival levels: the restorative connection,part 1: biologic variables.

Esthet Dent 1994;6:3-9.3. Garguilo AW. Dimensions and relationships of the dentogingival junction in humans. J

Periodontol 19 61;32:261-7.4. Ingber JS, Rose LF, Coslet JG. The “biologic width”- a concept in periodontics and

restorative dentistry.Alpha Omegan 1977;70(3) :62-5.5. Maynard JG, Wilson RD. Physiologic dimensions of the periodontium fundamental to

successful restorative dentistry.J Periodontol 1979;50 :107.6. Nevins M, Skurow HM.The intracrevicular restorative margin, the biologic width, and

the maintenance of the gingival margin.Int J Periodont Rest Dent 1984;4(3):31-49.7. Kaldahl WB,Becker CM,Wentz FM. Periodontal surgical preparation for specific prob

lems in restorative dentistry. J Prosthet Dent 1984;51(1):36-41.8. Parma-Benfenati S, Fugazzotto PA, Ruben MP. The effect of restorative margins on the

postsurgical development and nature of the periodontium. Part I. Int J Periodont ResDent 1985;5(6):31.

9. Oakley E, Rhyu IC,Karatzas S,Gandini-Santiago L, Nevins M, Caton J. Formation of thebiologic width following crown lengthening in nonhuman primates. Int J PeriodonticRestorative Dent 1999 Dec;19(6) :529-41.

10. Block MS.Preserving alveolar ridge anatomy following tooth removal in conjunction withdelayed implant placement.Atlas Oral Maxillofac Surg Clin North Am 1999;7(2):61-77.

11. Guided Tissue Regeneration, The Final Mechanical Stabilizer. http://www.imtec.comdemo/gtr_product.php (last viewed 10/13/04).

12. Grubb JE, Smith T, Sinclair P. Clinical and scientific applications/advances in videoimaging.Angle Orthod 1996; 66: 407-16.

13. Papasotiriou OS, Nathanson D, Goldstein RE. Computer imaging versus conventionaesthetic consultation: a prospective clinical study.J Esthet Dent 2000;12(2):72-7.

14. Almog DM, Sanchez Marin C, Proskin HM, Cohen MJ, Kyrkanides S, Malmstrom HChoice for utilization of esthetic services following four different esthetic consultationmethods: pilot study. J Dent Res 2003,Vol. 82, Special Issue A.

15. Herrero F, Scott JB, Maropis PS,Yukna RA. Clinical comparison of desired versus actuaamount of surgical crown lengthening.J Periodontol 1995;66:568-571.


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Plasma cell gingivitis has been described in the literature sincethe late 1960s.1,4,6 It has a unique histopathologic presentation witha dense chronic inflammatory infiltrate, predominantly plasmacells.5 The clinical appearance is typically seen as a generalized

enlargement of the free and attached gingiva with bright erythemaand loss of normal stippling. In some cases, the condition alsoincludes the tongue, buccal and labial mucosa, and vermilion bor-der of the lip. Patients are often symptomatic, complaining of arapid onset of soreness,bleeding gums and cracked lips.

Several well-studied cases have shown a true hypersensitivi-ty reaction leading to the plasmacytosis of the gingiva.Kerr et al.in 1971, described eight cases of habitual gum chewers whosesigns and symptoms resolved once the allergen (the gum) wasremoved. They used various laboratory tests, including completeblood counts, blood chemistry, smears, blood agar aerobic andanaerobic cultures, viral cultures, cultures for Candida and biop-sy with tissue fixed for electron microscopic studies. Serio et al.,in 1991, reported a case related to the use of fresh and dried redpeppers and chili peppers in cooking. Once these allergens wereremoved from the patient’s diet, the lesions improved. Lubow etal., in 1984, presented a case well shown to be caused by the use ofmint candies.

This report presents an unusual case of soft tissue plasma-cytosis in a totally edentulous patient, which may have beenrelated to the use of a household and kitchen cleaning solutionon the prostheses.

Abstract

Plasma cell gingivitis was identified during the early 1970s

as an allergic reaction to a component in a chewing gum.

The clinical picture was described as bright erythema of

the entire gingiva, loss of stippling and generalized swelling.

Today, many allergens appear to be responsible for this

problem. This report presents an unusual case of soft-

tissue plasmacytosis in a totally edentulous patient, which

may have been related to the use of a household and

kitchen cleaning solution on the prostheses.

THE CONDITION called plasma cell gingivitis may also be known asatypical gingivostomatitis, soft tissue plasmacytosis, allergic gin-givostomatitis,stomatitis venenata or irritant contact stomatitis.Theetiology is often found to be a hypersensitivity reaction to a flavoringagent in food or chewing gum, such as cinnamon or mint.1,2 Othercases have been traced to the use of red peppers in cooking.3 Still oth-ers have been deemed idiopathic,with no allergen identified.4

It is important to diagnose this condition properly. The appear-ance of the gingiva may be similar to that of a neoplastic processsuch as multiple myeloma5 or leukemia. Other conditions, such asdiscoid lupus, lichen planus, cicatricial pemphigoid or HIV-relatedgingivitis, should also be considered.3

Soft Tissue PlasmacytosisA Case Report

Inés Vélez, D.D.S., M.S.; Sheldon M. Mintz, D.D.S., M.S.


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Case Report

In January 1996, a 57-year-old white female was admitted to theOral and Maxillofacial Surgery Department at ICHILOV Hospital inTel Aviv, Israel, for evaluation of a sore mouth. Her medical history was unremarkable except for hypertension, which was controlledwith diuretics and calcium channel blockers. Physical examinationwas within normal limits. The personal history of the patient dis-closed the habit of cleaning her dentures every day with a house-

hold and kitchen cleaner.Oral examination revealed an edentulous patient using full, ill-

fitting dentures. A diffuse erythema, fissuring and scaling of thevermillion border of the upper and lower lips with pronouncedangular cheilitis were present. The inner surface of the upper lipalso presented an erythematous, exophytic lesion covered by anirregular and pebbled surface,showing fissures, nodules and ulcer-ation with focal white areas.

The dorsal surface of the tongue appeared brilliantly erythe-matous with diffuse atrophy of the papillae. Fissures and papuleswere also noted.

The buccal mucosa presented an edematous and erythematous

lesion with a ragged white surface suggestive of a lupus-like reac-tion. The edentulous alveolar ridge was normal.

Several incisional biopsies were taken. Microscopic examina-tion revealed H & E sections showing superficial squamous epithe-lium with hyperparakeratosis, elongated thin rete ridges, exocytosisand microabscesses. The principal feature of the tissue was anintense inflammatory infiltrate of predominantly plasma cellsimmediately subjacent to the epithelium and extending downwardinto the reticular dermis. Numerous dilated blood vessels were pre-sent. Candida was not identified.

To rule out the possibility of a plasma cell neoplasm, the clon-ality of the plasma cell infiltrate was investigated. B-lymphocyteswith differentiation toward plasma cells have immunoglobulinmolecules in their cytoplasm. Each normal plasma cell producesimmunoglobulin of a single light chain type: Kappa (K) or Lambda(L). Normally, populations of human B cells carry K or L lightchains in approximately a 2:1 ratio. Neoplastic populations arisingfrom a single progenitor cell should contain only a single lightchain: K or L.Polyclonal light chain population is indicative of non-neoplastic disease.

Using tonsil tissue as a control, immuno-stains,anti Kappa andanti Lambda chains were performed, and a polyclonal population

Figure 1. Diffuse erythema, fissuring and scaling of

vermillion border of lips and pronounced angular cheilitis.

Atrophy of lingual papillae and fissures of dorsal tongueare also seen.

Figure 2. Edematous and erythematous buccal mucosawith white areas and fissures.

Figure 3. Exophytic lesion of upper labial mucosa,fissures, nodules and ulceration.

The personal history of the patient disclosed the

habit of cleaning her dentures every day with a

household and kitchen cleaner.


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was identified. In this way the non-tumoral nature of the lesionswas confirmed.

DiscussionThe prevalence of contact dermatitis (both allergic and irritant)has been estimated at between 1% and 10% of the population.7

Many cases are probably unreported.As mentioned above, many agents placed in the mouth can be

allergens, e.g., various foods, spices and flavorings. Chemicals in

Figures 5A and B. Biopsy specimens with special stains (A) anti-kappa light chain and (B) anti-lambda lightchain, demonstrating polyclonal population of plasma cells.

Figure 4. Biopsy specimen showing hyperparak-eratosis, exocytosis and microabscesses. Intense

inflammatory infiltrate, basically composed of

plasma cells, is present down into connectivetissue (H & E stain).

A B

oral care products,nicotine, thermal injury or metals may be chem-ical or mechanical irritants.7 In the case presented here, the condi-tion resolved completely in approximately three weeks after cessa-

tion of using the household cleaning product.There may have been some mechanical injury to the mucosa

because of the poor-fitting prostheses, but the most exuberant lesionwas found on the upper labial mucosa. Speculation as to the allergenincludes sodium hypochlorite, sodium lauryl sulfate, some coloringagent or a fragrance. The household cleaner was not analyzed.

Conclusion

This case presents a plasma cell infiltration of the soft tissuethroughout the oral cavity except for the edentulous alveolar ridgeIf an allergic reaction is suspected, then it is important to investi-gate the patient’s diet and habits to determine the possible causes.

A diary should be kept listing all things that enter the mouth,including foods, dentifrice, mouthwash, tobacco, alcohol, chewinggum, candy and medications (prescription and over-the-counter).Any habits such as chewing fingernails, pens or pencils may intro-duce other allergens.8 Sometimes even careful patch testing by adermatologist may not reveal the allergen. Occasionally, topical orsystemic steroids may be helpful for improving symptoms. ■

REFERENCES1. Sollecito TP, Greenberg MS.Plasma cell gingivitis; Report of two cases.Oral Surg Ora

Med Oral Pathol 1992;73:690-693.2. Lubow RM, Cooley RL, Hartman KS, McDaniel RK. Plasma-cell gingivitis; Report of a

case. J Periodontol 1984;55:235-241.

3. Serio FG, Siegel MA, Slade B.Plasma cell gingivitis of unusual origin.A case report.Periodontol 1991;62:390-393 .4. Silverman S Jr, Lozada F. An epilogue to plasma-cell gingivostomatitis (allergic gin

givostomatitis). Oral Surg Oral Med Oral Pathol 1977;43:211-217.5. Neville B,Damm D,Allen C, Bouquot J, editors.Oral and Maxillofacial Pathology, 1st Ed

Philadelphia:W.B.Saunders.1995; pp.126-127.6. Kerr DA,McClatchey KD, Regezi JA.Idiopathic gingivostomatitis: cheilitis,glossitis,gin

givitis syndrome, atypical gingivostomatitis, plasma cell gingivitis, plasmacytosis ogingiva. Oral Surg Oral Med Oral Pathol 1971;32:402-423.

7. Davis CC, Squier CA, Lilly GE. Irritant contact stomatitis: a review of the condition.Periodontol 1998;69:620-631 .

8. Millard HD, Mason D, editors.Perspectives on the World Workshop on Oral Medicine III1998.Ann Arbor:University of Michigan.2000; pp 52-57.

9. Henry K, Farrer-Brown G.A Color Atlas of Thymus and Lymph Node HistopathologyLondon:Wolfe Medical Publications Ltd. 1981; pp.263 -276.


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services in private dental offices. And the average income of den-tists was almost $13,000.(1)2

Early Years of Hospital Dentistry

Dental departments first appeared in some hospitals in the 1920s.Efforts were made to provide services that “were commensurate

with the needs, facilities and personnel of the local communities.”In the late 1930s and early 1940s,a number of dental services wereavailable in many government, voluntary and for-profit hospitals.

Hospital Dentistry in the 1950sBy the late 1950s, most dental schools had hospital affiliationsDental students received as much as 50 hours of training and expe-rience in ward walking, history taking, operating room proceduresand hospital decorum. In general,the dental schools of the far westand the eastern regions offered more extensive programs than didschools in other sections of the country.

Dental internship and residency programs were available inonly about half of the hospitals that had received approval by theCouncil on Hospital Dental Services of the ADA for such programsThe number may have been so small, “…because there had notbeen a great demand for dental internships.”2

Abstract

Dental programs have evolved from an occasional com-

ponent of hospitals to fully recognized departments within

the structure of most institutions. A review is presented of

some of these developments, including the initiation of

general practice residency (GPR) programs and training

in a residency program as a substitute for the standard

licensing examination.

TRY TO IMAGINE THE SETTINGin which hospital dentistry exist-ed when I began my dental education more than 50 years ago.Dentists (virtually all of whom were white males) stood while usingbelt-driven drills that ran about 7,500 rpm. Discs were used to pre-pare crowns, because the steel burs couldn’t cut through enamel.The dental office staff answered phones and cleaned up betweenpatients; they seldom worked at chairside.More than 55% of dentaloffices had only one full-time auxiliary staff member. (New York State had the smallest proportion of dentists who used auxiliaries;it was somehow related to the fact that the average age of New York dentists was the highest in the nation.) Gloves were used only dur-ing surgical procedures. Third party insurance schemes wereextremely limited. Medicaid was off somewhere in the distantfuture.Dental care in hospitals often was a sporadic reality in many facilities. All too often, hospital dental care consisted of emergency and surgical care for the poor, who were unable to secure needed

Hospital Dentistry and GPRsA Relationship with a Past

H. Barry Waldman, D.D.S., M.P.H., Ph.D.

1 Unless otherwise stated, all material on the history of hospital dentistry was

drawn from the publication, Survey of Dentistry 2

2 The median number of dentists (including both house and attending staff)

in hospitals with a dental staff was: 2 dentists in governmental (nonfederal)hospitals; 6 dentists in federal hospitals; 9 dentists in voluntary hospitals; 3

dentists in proprietary hospitals.2


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About one-third(2,323) of the 6,818 hospitals listed by theAmerican Hospital Association had dental services. There was awide range in the reported number of staff dentists, but the largestnumber (18%) of hospitals had only one dentist.(2)

Eighty-five percent of the hospitals with a dental staff had nodental interns. Most of the hospitals with interns had 500 or more

beds. There were an average 0.3 dental interns per hospital in theUnited States.

Among nonsalaried dentists, half of dental specialists re-ported having a hospital staff appointment (ranging from 98% of oral surgeons to 26% of orthodontists) and 31% of general practi-tioners. The proportion of dentists with hospital staff appoint-

“…the most striking example of professional insularity

today is the practice of dentistry…the dentist practices

as an individual in the four walls of his office. He is not

integrated into the hospital, the institution which represents

the centricity in our society in the delivery of health care.

…The dentist too often looks at the mouth as if there

were no man. In the hospital, too often is the man

looked at as if there were no mouth.” — 1960 1

ments was highest in New England (49%) and lowest in theCentral region (25%).

More than 90% of the dental department was under a den-tist’s direction.

Hospital Dentistry Post-1950

During the 1970s and 1980s, there were major increases in thenumber of postdoctoral general dentistry programs and resi-dents. The first effort to codify curricula for postgraduate gen-eral dentistry programs came in 1972 in the form of accredita-tion guidelines for general practice residency (GPR) programsfrom the ADA Council on Dental Accreditation. During the1970s, the number of programs and the number of residentsincreased with funding from the Health Professions EducationAssistance Act and the Robert Wood Johnson Foundation.Hospital sponsorship of the GPR programs (supported by feder-al graduate medical education [GME] funds) provided themajor impetus for the growth in graduate general dentistry pro-

grams during this period.Since 1981, the major source of growth of postdoctoral edu-

cation in general dentistry was in advanced education in generadentistry (AEGD) programs sponsored by dental schools andsupported with federal GME funds.3,4

By the academic year 2001/02, there were 956 first-year resi-


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dents enrolled in the 208 GPR programs. There were 898 graduatesfrom the 30 dental school-sponsored GPR and 178 hospital-sponsored GPR programs.5

Since 1987, hospitals have been allowed to receive GME fund-ing for resident training in non-hospital settings. The Centers for

Medicare and Medicaid Services (CMS) (previously named theHealth Care Financing Administration) worked with dental schools,hospitals and others to facilitate the creation of dental residencyprograms in non-hospital settings that would qualify for GMEfunds. However, in 2003, CMS took the position that GME fundingfor dental residencies in non-hospital settings, which it had sanc-tioned and supported since 1997, was no longer appropriateFunding for these programs continued only for those residents whohad commenced their postdoctoral training prior to the ruling.6 Asa result, at many dental schools, efforts are being made to transferAEGD-sponsored programs to GPR arrangements and formats.

Types of Dental ServicesThe limited availability of hospital dental services in the past hasbeen replaced by a full range of needed services for the increasingnumber of individuals with medically, physically and intellectuallycompromised conditions, as well as individuals with limited finan-cial resources who live in

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