vol. 10 no. 2 in this issue

Transcription

COVER AUS_Vol10 No2_new contents 2015/04/23 2:18 PM Page 1
VOL. 1 0 NO. 2
IN THIS ISSUE
Crispian Scully
Making sense of mouth ulceration: part five
Marga Ree
Vital pulp therapy with Biodentine™
in two immature, traumatized teeth
Johan Hartshorne
Which non-surgical treatment protocol
should I use as first-line intervention
against peri-implantitis?
Walter Denner
High quality restorations
Modern nanohybrid composites –
an alternative for all cavity classes
Crispian Scully
Making sense of mouth ulceration: part six
Sigal Jacobson
Direct veneers just got a whole lot easier
Richard Bassed
Forensic odontology – broader than just
identification
Michael L. Young
A minimally invasive approach according
to biomechanical principles of teeth
AUS_Vol10No2_IFC_Apr2015_Layout 1 2015/04/23 2:17 PM Page 1
ID-Aus_Vol10-No2_1-16_Layout 1 2015/04/23 2:22 PM Page 1
8
Contents
Volume 10 No. 2
4
Clinical
8
Clinical
24
Making sense of mouth ulceration: part five
Crispian Scully
Vital pulp therapy with Biodentine™ in two immature, traumatized teeth
Marga Ree
16 Clinical
Which non-surgical treatment protocol should I use as first-line intervention
against peri-implantitis?
Johan Hartshorne
24 Case Report
36
Modern nanohybrid composites – an alternative for all cavity classes
Walter Denner
30 Clinical
Making sense of mouth ulceration: part six
Crispian Scully
34 Clinical
Sigal Jacobson
44
36 Clinical
Forensic odontology – broader than just identification
Richard Bassed
44 Clinical
A minimally invasive approach according to biomechanical principles of teeth
Michael L. Young
62 Products
VOL. 10, NO. 2 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION 1
Common Ground Community
Outreach Clinic – bringing
dental care to Adelaide’s
homeless poputation
Vol. 10 No. 2
ISSN 2071-7962
PUBLISHING EDITOR
Ursula Jenkins
EDITOR-IN-CHIEF
Imagine being on the streets at just 9 years old, on a cold rainy day and not
yet even a teenager, you would wonder why life has dealt you such a bad
hand. Melyssa, now 19, found herself in exactly that position and has
struggled for the last 10 years on the streets. Going to see a dentist is not a
priority or a possibility for someone like Melyssa. Thanks to the people at
Common Ground in co-operation with doctors and staff at the Youth
Homeless Centre – Street Link, Adelaide, Melyssa was given access to much
needed dental care. She is no longer in pain and working to get her life on
track.
Common Ground provides tiered accommodation for people who are
residentially and socially disadvantaged, providing an opportunity to rebuild
healthy communities with specific support systems in place. In September
2011, they opened a Community Outreach Dental Clinic. Working in
conjunction with the University of Adelaide, the clinic runs using a core group
of volunteers as well as undergraduates from the dentistry, oral health,
medicine and nursing departments. The significant experience gained by the
students sets them up for a future career, while at the same time treatment
is offered to people who would not otherwise get access to care.
Since the opening in 2011, the clinic has seen over 750 patients with
numerous repeat visits. They have provided basic restorative and preventative
services and acrylic dentures for those who have been without teeth for
many years. They are now partnering with several dental laboratories and in
collaboration with TAFE prosthodontic students, providing fabrication of
dentures and night guards.
Common Ground aims to extend their service more broadly to Inner City
Agencies to include underserved suburban areas. They plan to increase their
portable equipment and require sstorage facilities in order to better service
more remote areas. To help them achieve these goals, Henry Schein Halas,
through the Henry Schein Cares Foundation, will be supporting a fundraising
event in Adelaide in October.
Prof Dr Marco Ferrari
ASSOCIATE EDITORS
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Prof Andre van Zyl
EDITORIAL REVIEW BOARD
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Prof Roberto Giorgetti
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Prof Dr Reinhard Hickel
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Prof Edward Lynch
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Prof Franklin R Tay
Prof Manuel Toledano
Dr Bernard Touati
Prof Laurence Walsh
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2 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 10, NO. 2
CLINICAL
Making sense of mouth ulceration:
part five
Crispian Scully1
In the fifth part of the series, Crispian Scully looks at the issue of gastrointestinal disorders
and mouth ulceration.
The clinical appearance of an oral ulcer on its own is rarely diagnostic. Any ulceration
with other orofacial or extraoral lesions may be suspect.
In the light of multiple causes, some systematic way of dealing with ulceration is
needed, such as my system of splitting causes into:
• Systemic
• Malignancy
• Local
• Aphthae
• Drugs.
Gastrointestinal disorders
This article discusses the third of the systemic causes – gastrointestinal disorders.
The main gastrointestinal disorders that may present with mouth ulceration include
coeliac disease, and Crohn’s and related diseases.
Coeliac disease
1
Professor Crispian Scully CBE
FMedSci DSc FDS MD is
professor emeritus at UCL,
London, King James IV
professor at the Royal College
of Surgeons, Edinburgh,
Harley Street Diagnostic
Centre, 16 Devonshire Street
and 19 Wimpole Street,
London.
Coeliac disease (gluten sensitive enteropathy) is usually an inherited disorder. People
with the disease have sensitivity to gluten, a protein found mainly in wheat, and patients
suffer small intestinal disease leading to malabsorption. This manifests in many ways,
especially:
• Haematinic deficiency
• Failure to thrive
• Infertility.
Oral lesions may include mouth ulceration (ulcers mimic aphthae) and enamel
hypoplasia in early onset coeliac disease.
Coeliac disease is frequently under-diagnosed and we still see older people (even
in their 60s and 70s) whose diagnosis has been missed. Diagnosis is typically
confirmed by:
• Anti-endomysial antibodies
• Transglutaminase
• Small bowel (jejunal) biopsy.
Management is by antigen exclusion – a gluten-free diet.
Crohn’s disease
Crohn’s disease is a heterogeneous group of chronic inflammatory disorders mainly
causing regional enteritis (ileitis).
CLINICAL
Figure 1: Lip swelling.
Figure 2: Ulceration.
Seen mainly in Caucasians, it is increased in Ashkenazi
Jews and 20% of people with Crohn’s disease have a blood
relative with inflammatory bowel disease (IBD).
The cause is unclear but the inflammatory response is
probably mediated by factors such as tumour necrosis factor
alpha (TNFα) and there are non-caseating granulomas in
submucosa and lymph nodes.
Microorganisms have been implicated but some may
simply take advantage of damaged mucosa and inability to
clear bacteria from the intestine.
Crohn’s disease can affect any part of the digestive tract,
from mouth to anus – as well as producing extraintestinal
disease in some patients.
Manifestations depend on the severity and sites affected,
but typical features include:
• Abdominal pain
• Anaemia
• Arthralgia
• Diarrhoea (repeated episodes)
• Non-specific constitutional signs and symptoms
• Weight loss.
Orofacial involvement is common and can precede
intestinal symptoms. It includes:
• Lip or face swelling (Figure 1)
• Ulceration (may be linear) (Figure 2)
• Gingival swelling (Figure 3)
• Mucosal ‘cobblestoning’ and tags
• Angular cheilitis (stomatitis) and split lips (Figure 4).
However, because of vague and protean manifestations,
Crohn’s disease is often under-diagnosed. There are no
specific assays or diagnostic analyses – it is a diagnosis by
exclusion. Tests include:
• Faecal calprotectin (often raised)
• Blood count (anaemia common)
• Serum potassium, zinc and albumin (often reduced)
• Erythrocyte sedimentation rate (ESR), C-reactive protein
Figure 3: Gingival swelling.
(CRP), anti-Saccharomyces cerevisiae antibodies, antineutrophil
cytoplasmic antibody (ANCA) and seromucoid (often raised)
• Small bowel MRI or CT; plain-film and contrast
radiography
• Endoscopy (sigmoidoscopy, colonoscopy)
• Ultrasound
• Mucosal biopsy (for granulomas).
Diagnosis of intestinal Crohn’s disease can be fraught –
not least because of patchy distribution, and is sometimes
only confirmed after intestinal resection and histopathological
examination of specimen late in the course of disease.
Repeated evaluations (including sequential colonoscopies)
may be required to establish the diagnosis.
Treatment is by specialists with a high-fibre diet and
sometimes:
• Aminosalicylates (ASA), or newer 5-aminosalicylates
(mesalazine, olsalazine)
• Antimicrobials (metronidazole, ampicillin, ciprofloxacin,
others)
• Immune modifiers: corticosteroids locally (prednisolone,
budesonide) or systemic corticosteroids, azathioprine, 6mercaptopurine (6-MP), or methotrexate and biologics
(anti-TNFα agents [adalimumab, certolizumab pegol or
infliximab])
• Thiopurines (eg, 6-MP, azathioprine) can increase risk of
non-Hodgkin’s lymphoma.
Up to 60% of patients with Crohn’s disease require surgery
at some point.
Orofacial granulomatosis
Some patients with clinical evidence consistent with oral Crohn’s
disease have no intestinal symptoms of the disease and, while
some may have evidence of Crohn’s disease in the intestine,
others do not. Orofacial granulomatosis (OFG) is the term
coined for those with no detectable gastrointestinal involvement.
Orofacial lesions mimic those in Crohn’s disease and may
S C U L LY
Figure 4: Split, swollen lip and palatal lesions.
Figure 5: OFG facial swelling.
Orofacial lesions mimic those in Crohn’s disease and may
include:
• Facial or labial swelling (Figure 5)
• ‘Cobblestone’ proliferation of mucosa or mucosal tags
• Ulcers.
Variants include:
• Miescher, or granulomatous cheilitis
– Lip swelling alone
• Melkerrson-Rosenthal syndrome
– Lip swelling
– Fissured tongue
– Facial palsy.
OFG may sometimes result from reactions to foods or
additives – most commonly:
• Cinnamaldehyde
• Benzoates.
Like Crohn’s disease, OFG is often under-diagnosed
because of vague and protean manifestations. Again, it is a
diagnosis by exclusion – there are no specific diagnostic
tests. Reactions to foods should be excluded by antigen
exclusion/allergy tests. Gastrointestinal and other
investigations are often indicated to exclude Crohn’s disease
and other conditions that can produce granulomas (notably
tuberculosis and sarcoidosis).
If systemic Crohn’s disease can be excluded, patients still
need to be kept under observation for possible Crohn’s
disease development later.
Management is challenging. Exclusion of offending
substances may help facial swelling resolve. Topical or
intralesional triamcinolone acetonide alone or in combination
with topical pimecrolimus or tacrolimus may be trialled but
systemic clofazimine, dapsone, methotrexate, tacrolimus,
thalidomide, other immunosuppressants or anti-TNF biologics
(under physician guidance) may be needed.
References
Gandolfo S, Scully C, Carrozzo M (2006) Oral medicine.
Elsevier Churchill Livingstone (Edinburgh and London). ISBN
13: 29780443100376
Scully C, Almeida ODP, Bagan J, Diz PD, Mosqueda A
(2010) Oral medicine and pathology at a glance. WileyBlackwell (Oxford) ISBN 978-1-4051-9985-8
Scully C, Flint S, Bagan JV, Porter SR, Moos K (2010) Oral
and maxillofacial diseases. Informa Healthcare (London and
New York). ISBN-13: 9780415414944
Scully C, Bagan JV, Carrozzo M, Flaitz C, Gandolfo S
(2012) Pocketbook of oral disease. Elsevier, London. ISBN
978-0-702-04649-0
Scully C (2013) Oral and maxillofacial medicine. 3rd
edition. Churchill Livingstone (Edinburgh). ISBN
9780702049484
Scully C (2012) Aide memoires in oral diagnosis:
mnemonics and acronyms (the Scully system). Journal of
Investigative and Clinical Dentistry 3(4): 262-3
Published with permission by Private Dentistry May 2014
CLINICAL
Vital pulp therapy with Biodentine™
in two immature, traumatized teeth
Marga Ree1
Introduction
1
Marga Ree DDS, MSc
Private Practice limited to
Endodontics, Purmerend,
Netherlands
If pulp vitality in a young, permanent tooth is lost before root formation is completed,
the clinician is confronted with a tooth that is more prone to fracture in case of a trauma,
due to the presence of a root with very thin dentinal walls. In addition, the affected
tooth might exhibit a poor crown-root ratio. Therefore, it is of utmost importance that
pulp vitality should be preserved in an immature tooth with pulp involvement.
According to the definition of the AAE, the American Association of Endodontists,
vital pulp therapy is a procedure to encourage apexogenesis.
The requirements for a successful vital pulp therapy are a the presence of a noninflamed or a reversibly-inflamed pulp, the ability the control the hemorrhage, the use
of a biocompatible and bioactive pulp capping material and the creation of a bacteriatight seal.
Over the course of time, several materials have been used as pulp capping agents.
Calcium hydroxide has traditionally been the material of choice, followed by Mineral
Trioxide Aggregate (MTA). MTA is described as a first generation bioactive material.
It has many advantages, but also some disadvantages.1, 2 The initial setting time is at
least 3 hours. It is not easy to manipulate, resulting in considerable wasted material,
and is hard to remove. Clinically, both gray and white MTA stain dentin, presumably
due to the heavy metal content of the material or the inclusion of blood pigment while
setting.3, 4 Efforts have been made to overcome these shortcomings with new
compositions of MTA5-7 or with additives.8, 9 However, these formulations affect MTA’s
physical and mechanical characteristics.
Bioceramics are inorganic, non-metallic, biocompatible materials that have similar
mechanical properties as the hard tissues they are replacing or repairing. They are
chemically stable, non-corrosive, and interaction well with organic tissue. Bioceramic
materials used in endodontics can be categorized by composition, setting mechanism
and consistency. There are sealers and pastes, developed for use with gutta-percha,
and putties, designed for use as the sole material, comparable to MTA. Biodentine™
is a calcium silicate cement that was developed as a dentine substitute in deep cavities.
CLINICAL
1a
1b
Figure 1a: Preoperative radiograph of #21 showing an immature tooth with an open apex and a
complicated crown fracture.
Figure 1b: Clinical picture showing a complicated crown fracture in #21.
Comparable to MTA, Biodentine™ is biocompatible and
in contact with vital tissues it has been demonstrated to be
bioactive and suitable to be used as a pulp capping
agent.10, 11, 12 It has a higher compressive strength than
MTA12 and most glass ionomer cements, a higher flexural
strength and flexural modulus than MTA Angelus12 and can
be applied in a bulk on dentin without any conditioning.13,
14
The material sets in 12 minutes and is capable to
withstand deterioration when used as a temporary filling for
up to 6 months.15
In the opinion of the author, bioceramic materials have
several advantages over MTA. In general, bioceramic
materials have better clinical handling properties. The
difficulties in handling of MTA have been frequently reported
by clinicians.16 Another drawback of MTA is the potential for
staining dentin, which has been shown in several in vitro
studies,4, 17, 18 clinical investigations19, 20 and case reports,3,
21
which have shown that both white and gray MTA cause
Figure 1c: The palatal aspect of the fracture site, covered with
plaque.
Figure 1d: Photograph of the fragment, showing an oblique
fracture line with the palatal outline below the gum line
REE
1e
1f
1g
Figure 1e: After a partial pulpotomy was carried out, a cotton pellet soaked in NaOCl 5% was applied to the pulp stump to stop the bleeding.
Figure 1f: Clinical picture showing the hemorrhage was controlled.
Figure 1g: Biodentine was used as a pulp capping material.
1h
1i
1j
Figure 1h: Postoperative radiograph of the pulp cap with Biodentine, showing a material with moderate radiopacity.
Figure 1i: After one week, the Biodentine had not washed out.
Figure 1j: A retraction cord was packed into the sulcus to obtain a dry field and expose the subgingival margin of the palatal fracture site.
1k
1l
1m
1n
Figure 1k: Postoperative radiograph showing the teeth restored with composite resin.
Figure 1l: Clinical picture of the restoration of composite core material layered with a micro-filled composite at the buccal site.
Figure 1m - n: Recall radiograph at 6 and 12 months, showing continued root formation.
discoloration. To date, there have been no reports of staining
of dentin by Biodentine™ or comparable bioceramic
products, which has also been the experience of the author.
Several studies report that bismuth oxide, which acts as a
radiopacifier in MTA as a radiopacifier,22, 23 may increase
the cytotoxicity of MTA, because bismuth oxide does not
encourage cell proliferation in cell culture.24 Biodentine™
contains zirconium oxide as opacifier.
REE
2a
2b
2c
Figure 2a: Preoperative radiograph of 21 showing a class IV restoration of composite resin and an immature root with an open apex.
Figure 2b: After a partial pulpotomy was carried out, a cotton pellet soaked in NaOCl 5% was applied to the pulp stump to stop the bleeding.
Figure 2c: After a couple of minutes, the bleeding had stopped, which is indicative of healthy pulp tissue.
2d
2e
2f
Figures 2d - e: Biodentine was used as a pulp capping material.
Figure 2f: Photograph of the set Biodentine.
2g
2h
Case reports
Patient #1 was a 7-year old female who suffered a
traumatic dental injury to tooth #21 three days earlier. Her
main complaints were sensitivity to warm and cold, and
2i
Figure 2g: Postoperative radiograph showing
the pulp-capped tooth restored with a
composite resin.
Figure 2h-i: At 6 and 18 months respectively,
the patient was asymptomatic and the recall
radiographs
showed
continued
root
development.
her medical history was noncontributory. Clinical
examination revealed a crown fracture with pulp exposure
of tooth #21 (Fig. 1a). Radiographically, #21 had an
open apex and no peri-apical pathosis (Fig. 1b). The
REE
diagnosis was a complicated crown fracture with
reversible pulpitis of tooth #21
Treatment options were discussed with the patient and
her parents, and a partial pulpotomy was selected as the
treatment of choice. The fragment was stored by her
parents, but due to the subgingival fracture site (Fig. 1c)
and missing tooth structure in the fragment itself (Fig. 1d), it
was not possible to re-attach the fragment to the tooth. Local
anesthesia was administered (Septanest N, Septodont,
Saint-Maur-des-Fossés, France) and a partial pulpotomy
was carried out with a new diamond bur in a high speed
handpiece with copious water cooling. Since it was not
possible to apply a rubber dam, utmost care was taken to
keep a dry field and prevent saliva to contaminate the pulp
tissue after the Cvek pulpotomy. A cotton pellet soaked in
sodium hypochlorite 5% was applied on the pulp stump
with moderate pressure (Fig. 1e). After five minutes, the
bleeding had stopped (Fig. 1f), and Biodentine™
(Septodont, Saint-Maur-des-Fossés, France) was applied as
a pulp capping material to a thickness of approximately 3
mm with a Dovgan MTA carrier (Hartzell and Son,
Concord, CA) (Fig. 1g-h). After the material had set in
approximately 20 minutes, it was used as a temporary
restoration. This is one of the advantages of the use of
Biodentine™ over MTA, and makes it the material of choice
in these type of cases. The patient was rescheduled for a
second visit. After one week, the patient returned and was
asymptomatic. The Biodentine™ had fully set and had not
washed out (Fig. 1i). A gingivectomy was carried out, and
a retraction cord (Gingibraid, van R, Oxnard, CA, USA)
was packed into the sulcus (Fig. 1j). Then a build-up of
composite core material was placed (Luxacore; DMG,
Hamburg, Germany), which was cut back on the buccal
site and layered with a micro-filled composite (Filtek
Supreme Ultra Universal Restorative, 3M ESPE, St. Paul,
MN, USA) (Fig. 1k-l). Follow-up after 6 (Fig. 1m) and 12
months (Fig. 1n) showed a healthy tooth in full function with
continuous root development.
Patient #2 was an 8-year old male who was referred for
advice and possible treatment of tooth #21. His medical
history was noncontributory. Some months ago, he sustained
an uncomplicated crown fracture of # 21. His dentist made
a restoration of composite resin, that had to be replaced 5
times, because it came loose every single time. For one
week, the patient had experienced severe sensitivity to hot
and cold food and drinks. Clinical testing confirmed that
tooth #21 was very sensitive to cold. A radiographic
examination revealed that #21 had an open apex and no
peri-apical pathosis (Fig. 2a). The diagnosis was an
uncomplicated crown fracture with a reversible pulpitis in
tooth #21.
Treatment options were discussed with the patient and his
parents, and a partial pulpotomy was selected as the
treatment of choice. Local anesthesia was administered
(Septanest N, Septodont, Saint-Maur-des-Fossés, France),
rubber dam was applied (Optradam, Ivoclar Vivadent,
Schaan, Lichtenstein) and a partial pulpotomy was carried
out with a new diamond bur in a high speed handpiece with
copious water cooling. A cotton pellet soaked in sodium
hypochlorite 5% was applied on the pulp stump with
moderate pressure (Fig. 2b). After five minutes, the bleeding
had stopped (Fig. 2c), and Biodentine™ (Septodont, SaintMaur-des-Fossés, France) was applied as a pulp capping
material to a thickness of several mm with a Dovgan MTA
carrier (Hartzell and Son, Concord, CA) (Fig. 2d-e). A moist
cotton pellet was introduced on top of the Biodentine™, the
access cavity was filled with a temporary filing, and the
patient was rescheduled for a second appointment. After a
week the patient returned asymptomatic. The Biodentine™
had fully set (Fig. 2f) and a build-up of composite core
material was placed in the endodontic access cavity
(Luxacore; DMG, Hamburg, Germany), with a top layer of
a hybrid composite (Tetric Ceram, Ivoclar Vivadent, Schaan,
Lichtenstein) (Fig. 2g). At the 6-month (Fig. 2h) and 18-month
recall (Fig. 2i), the tooth was asymptomatic and showed
apical maturation and continuous root development.
Conclusion
The author has presented 2 cases in which Biodentine™ was
successfully used as a pulp capping material in an immature
tooth with pulp involvement. In both cases, treatment
provided elimination of symptoms and continuation of root
formation. In addition, no signs of discoloration were noticed
after 6, 12 and 18 months respectively.
REE
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2006;54:258–261.
21. Jacobovitz M, de Lima RK. Treatment of inflammatory
internal root resorption with mineral trioxide aggregate: a
case report. Int Endod J. 2008 Oct;41(10):905-12.
22. Camilleri J, Montesin FE, Brady K, Sweeney R, Curtis
RV, Ford TR. The constitution of mineral trioxide aggregate.
Dent Mater. 2005 Apr;21(4):297-303.
23. Park JW, Hong SH, Kim JH, Lee SJ, Shin SJ. X-Ray
diffraction analysis of white ProRoot MTA and Diadent
BioAggregate. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2010 Jan;109(1):155-8.
24. Camilleri J, Montesin FE, Papaioannou S, McDonald
F, Pitt Ford TR. Biocompatibility of two commercial forms of
mineral trioxide aggregate. Int Endod J. 2004
Oct;37(10):699-704
CLINICAL
Which non-surgical treatment protocol should I use
as first-line intervention against peri-implantitis?
Johan Hartshorne1
A critical appraisal of a systematic review and meta-analysis: Faggion CM, Listl S, Frühauf N, Chang H-J, Tu Y-K.
(2014) A systematic review and Bayesian network meta-analysis of randomized clinical trials on non-surgical treatments
for peri-implantitis. Journal of Clinical Periodontology, Accepted article, doi: 10.1111/jcpe.12292
Summary
Systematic review conclusion: All combinations of non-surgical approaches for treating
peri-implantitis showed small but more significant probing pocket depth reduction than
debridement only. There is insufficient evidence to rate any particular non-surgical
treatment for peri-implantitis as providing significantly better performance than
debridement alone.
Critical appraisal conclusion: Removal of biofilm by means of mechanical or automatic
debridement and reducing bacterial load with adjunctive use of antimicrobial agents,
without altering the implant surface, remains the standard of care for first-line intervention
to any non-surgical treatment approach for peri-implantitis. At this stage of time the
efficacy and validity of mechanical or automatic debridement methods for removing
biofilm as well as adjunctive antimicrobial therapies remain unknown and needs to be
tested by properly executed RCT’s.
Implications for clinical practice: Currently there is no gold standard non-surgical
treatment protocol. Clinicians, however, should be committed to monitoring and
maintaining peri-implant health through continuous assessment and the provision of
individualized supportive care. Patient motivation and proper oral hygiene practices to
limit infection is very important.
Clinical question
“In patients with peri-implantitis, what is the clinical effect of other non-surgical
approaches in comparison to sub-gingival scaling in terms of clinical attachment level
and pocket depth changes compared?”
Review methods
1
Johan Hartshorne B.Sc.,
B.Ch.D., M.Ch.D, M.P.A. Ph.D.
(Stell), FFPH.RCP (UK),
Visiting Professor, Department of
Periodontics and Oral Medicine,
University of Pretoria, Pretoria,
South Africa.
E-mail:
jhartshorne@kanonberg.co.za
Methodology
The reviewers conducted the systematic review of the literature according to the
PRISMA1 and AMSTAR 2 guidelines. The network meta-analysis was conducted
in accordance with the guidelines for good research practices for indirect
treatment comparisons. 3
Search strategy and study selection
Two independent reviewers searched the following electronic databases: [MEDLINEPubmed, SCOPUS, CINAHL, DARE, Biosis Preview and Web of Knowledge, up to
and including 1 January 2014 to identify articles that met the inclusion criteria. In
addition they searched for grey literature (IADR meetings, clinical trials.gov,
CLINICAL
controlledtrials.com, Pro-Quest Dissertation Abstracts and
Thesis database and Opengrey (http://www.opengrey.eu)
for potential studies and clinical trials in progress. They also
conducted a manual search of relevant journals from January
2000 to January 2014. No language restrictions were
used. The two independent reviewers assessed the full-text
of potential articles for inclusion into the study. Disagreements
on inclusion of a study were resolved by discussion between
the reviewers until consensus was achieved. They also
screened the reference lists of included randomized
controlled trials (RCT’s) for relevant studies. The investigators
recorded all studies that were rejected as well as the reason
for exclusion.
Eligibility and exclusion criteria
The reviewers searched for RCT’s in humans and non-surgical
approaches for treating peri-implantitis. RCT’s without any
intervention or with treatment outcomes other than clinical
attachment level (CAL) and probing pocket depth (PPD)
changes were excluded. All other study designs, animal, and
in-vitro studies were excluded. Studies investigating surgical
approaches and those with duplicated data were also
excluded.
Outcome measures and data extraction
The reviewers used two endpoints to assess the clinical effect
of non-surgical peri-implantitis therapies: CAL and PPD. Two
independent reviewers extracted the data from the included
studies. Data was double-checked and any disagreement on
data extraction was resolved by discussion between
reviewers until consensus was achieved. They contacted the
authors of the original studies for clarification of dubious data
and request for unpublished data.
Data analysis
Network meta-analysis (NMA) was conducted using the
Bayesian random-effects hierarchical model that incorporates
information from both direct and indirect comparisons of
multiple therapies in a single analysis. Standard metaanalysis of direct pair-wise comparisons were also performed
and compared to results from the NMA. To be valid,
interventions in a NMA should be connected. The NMA
based on CAL was not connected, and therefore its
assessment was not feasible. Therefore, only results in PPD
changes were reported.
Studies with split-mouth design were separated from those
with parallel group design in order to take account of
potential correlation between treatment effects of treatment
groups with split-mouth RCT’s. The reviewers also made
adjustments for studies that reported results from site level
data analysis by calculating appropriate standard errors
using the number of patients. Consistency amongst the
network was statistically investigated. They also used a
comparison-adjusted funnel plot to assess whether smaller
studies produced larger treatment effects. The treatments
were ordered by defining the comparisons of an active
treatment versus placebo (debridement) only.
Risk of bias of the included RCT’s was assessed according
the Cochrane Collaboration risk of bias assessment tool.4
Three reviewers were subjected to a training phase prior to
the risk of bias assessment. The overall quality of the
evidence within the pair-wise meta-analysis was graded
using the GRADE approach.5
Main results
The search process yielded 11 RCT’s studies eligible for the
NMA. Ten of the RCT’s had a parallel group design and one
study used a split-mouth design. The NMA compared the
PPD between 8 different treatments namely: (i) debridement
+ chlorhexidine, (ii) photodynamic therapy, (iii) debridement
and antibiotics, (iv) air abrasive system, (v) Vector ultrasonic
system, (vi) debridement and periochip, (vii) Er:YAG laser
monotherapy, and (viii) debridement alone (control). Overall,
the examined combinations of therapeutic approaches
generated greater PPD reduction than isolated debridement
(control) alone. The differences between the combinations
however, were very small. The reviewers ascribed the small
differences in outcomes between therapies to heterogeneity
amongst RCT’s.
The results from the NMA indicated that debridement in
conjunction with antibiotics achieved the greatest
additional PPD reduction in comparison to debridement
only (0.490 mm 95% Credible Intervals [CrI]: -0.647 to
1.252). The second greatest additional PPD reduction
was provided by the combination of debridement and
periochip (0.400 mm 95% CrI: -0.843 to 1.629) more
PPD reduction than debridement only. Debridement and
antibiotics achieved greater PPD reduction (0.262 mm
95% CrI: -1.260 to 0.771) than debridement combined
with a chlorhexidine gel. Large CrI indicated considerable
uncertainty. Results from the NMA were in general
comparable to those from the pair-wise meta-analysis. The
network funnel plot showed only small study bias. No
inconsistency was found within the network.
In general there was a low to moderate risk of bias across
all included studies. Three studies were considered to be at
HARTSHORNE
high risk of bias, because one of the authors was working
for a company supporting the respective study. Seven studies
were industry supported. Overall, the quality of the evidence
was considered very low by the GRADE assessment. The
main reasons for grading the evidence as very low were the
risk of bias limitations and imprecision within the included
studies. A statistically significant heterogeneity was found
amongst the RCT’s (p= 0.046; I2 = 46.1%)
Conclusion
The authors of this review concluded that all combinations
of non-surgical therapies for treating peri-implantitis
generated small but more significant PPD reduction than
debridement alone. However, they also stated that the
results should be interpreted with caution due to the large
credit intervals. They also pointed out that currently
available evidence does not support the valuation that
any particular non-surgical treatment for peri-implantitis
performs better than debridement alone.
The authors received financial support and declared no
potential conflict of interest with respect to the authorship
and/or publication of this review.
Commentary
Background and importance
Peri-implantitis is an inflammatory lesion of the surrounding
peri-implant tissues with loss of supporting bone and clinical
signs of inflammation (bleeding and/or suppuration on
probing)6, primarily caused by bacteria from dental
biofilm.7,8 The prevalence of peri-implantitis is estimated to
be in the order of 10% of implants and 20% of patients 5 to
10 years after implant placement.9 The high prevalence rate
and the lack of standard mode of care make it an important
disease entity.10
Currently the basis for non-surgical peri-implantitis therapy
is mechanical or automatic debridement of the implant
surface to remove the adhered biofilm and chemical
decontamination to reducing the bacterial load below the
threshold level for causing disease.11 Various debridement
protocols in combination with adjunctive therapy have been
proposed to achieve the abovementioned goal. Generally
they involve mechanical or automatic debridement of the
implant surfaces using either curettes (i.e. carbon fibre or
titanium), ultrasonic or air abrasive devices or lasers. These
treatment modalities are either used alone or in combination
with an antimicrobial therapy based on antibiotics (locally
or systemically) or antiseptics such as chlorhexidine.12
Successful peri-implantitis treatment outcome is considered as
absence of PPD ≥ 5mm, no BoP with light pressure and no
suppuration, in addition to no further bone loss.8 The latter
authors proposed that if these criteria can be met, no further
intervention other than non-surgical maintenance care would
be required. If the latter criteria cannot be met, surgical
intervention is required.
This study is the first attempt to combine and compare the
data of available RCT’s of different non-surgical therapeutic
protocols for peri-implantitis in a meta-analysis.
Are the results valid?
The methodological rigor of this review was excellent and in
a class of its own. However, the methodological quality of
the individual RCT’s included in this review had several basic
limitations and weaknesses that affected the quality of the
evidence presented. Overall, there was marked variability
and inconsistencies between the studies for all outcomes
measured. This is likely due to differences in the sample
population characteristics, definition of peri-implantitis,
characteristics of the interventions used, and inconsistencies
with measurement of primary and secondary outcomes.
Various risk factors were excluded from the study including
smoking, poor oral hygiene, untreated periodontal disease,
and diabetes that could modify both initial outcome of
treatment as well as the long-term outcome.9,13
Some of the studies were lacking information on the
presence or absence of clinical inflammation (bleeding or
suppuration on probing) in the inclusion criteria and therefore
had to be discarded as an outcome measure in the metaanalysis. Consequently the only clinical endpoint used in this
meta-analysis was PPD. This raises some concern because
reduction of PPD might not indicate that therapies will be
effective in the long-term neither is there any proof of
evidence that reduction of PPD after non-surgical therapy will
reduce implant failure.14
Overall, there was a lack of uniformity in the assessed
treatment regimens. Some interventions simultaneously
involved both mechanical and chemical treatment of implant
surfaces in order to remove bacterial plaque, whilst other
therapies were based on single or repeated application.
Another potential limitation of the present meta-analysis is
the short follow-up (up to 12 months) as this hinders more
definitive conclusions about the efficacy of therapies. Whilst
clinical healing could be expected to be complete by 3
months following cause related therapy15 (i.e removal of the
HARTSHORNE
biofilm), detectable changes in radiographic marginal bone
levels may not be apparent at this time.8 Long-term RCT’s
remain desirable. The number of studies included in the
review were relatively insufficient, potentially leading to
fragile probabilities.16 Adding on a study to the meta-analysis
could tip the probability scale in any direction.
Most domains presented a low risk of bias. However,
one domain (allocation concealment) was considered a
high or unclear risk of bias in 9 of 11 RCTs assessed.
Estimates of treatment effects may be inflated when
allocation concealment is not preserved. 17 Additionally,
three of the RCTs included in the meta-analysis were
considered at high risk of reporting bias because authors
involved in the studies were working for the companies
supporting the study at the time of the study and the
findings from these studies suggest more positive or
favourable results for therapies supported by industry.
The high level of variability, lack of consistency, and risk
of bias, does not lend support to the validity of the results.
However, the results of the NMA were consistent to those
from pair-wise meta-analysis, thus supporting the validity of
the results. Additionally, the comparison-adjusted funnel did
not support biases towards larger effects in smaller trials.
Overall, the weaknesses of the study were greater than its
strengths, thus questioning the validity of the results.
What were the key findings?
All the combinations of therapeutic approaches generated
greater PPD reduction compared to using debridement alone.
The differences between the combinations however ranged
between small and considerable uncertainty, and therefore
may not be clinically relevant, thus indicating that any
decision-making regarding choices for best treatment
approach should be done with caution.
The Vector ultrasonic system had the greatest probability
to be ranked as the best non-surgical therapeutic approach
for peri-implantitis. However, two other approaches,
debridement with periochip and photodynamic therapy,
presented with similar probabilities. Although ranking of
therapies are helpful in practical decision-making, caution
should be exercised due to sparse evidence and limitations
in the included studies.
How are the results of this review applicable in clinical
practice?
Treating peri-implantitis effectively through a non-surgical
approach has great significance to the patient because this
could mean saving or losing an implant. A non-surgical
approach as opposed to a surgical approach also means
less discomfort, less morbidity and reduced cost. Postoperative complications and early implant failures are
important patient outcomes because of health,
inconvenience and cost implications thereof. As a general
rule, antibiotic prophylaxis is always indicated when there
is an important risk of infection, either because of the
characteristics of the surgical procedure (i.e. type and
duration of surgery), because of the patient’s local or
systemic infection risk (i.e. diabetes, immunodeficiency’s,
inflammatory arthropathies), or for patients with postbacteraemia focal infection risk factors (i.e. infectious
endocarditis, infection of joint prostheses).
Most of the individual studies had specific exclusion
criteria, including patients who smoked, patients with full
mouth plaque scores or full mouth bleeding scores above
20%, pregnant or lactating women, patients who had taken
systemic antibiotics in recent months prior to treatment,
patients with implants with < 2mm keratinized mucosa or no
keratinized mucosa. Consequently, the results reported
should be interpreted with caution and may not apply to all
patients in the practice situation. Availability and accessibility
to the technologies assessed in this review may also be
limited due to high cost of equipment and skills training
required.
Clinical resolution
Clinicians involved with dental implant treatment must have
a comprehensive understanding of the need for on-going
maintenance and peri-implant health, peri-implant disease,
the assessment thereof, and correct diagnosis and early
interception of disease, as well as appropriate skills and tools
for managing these complications.
Non-surgical peri-implantitis therapy as first line treatment
plays a pivotal role in the treatment of peri-implant disease.
Removal of biofilm by means of mechanical or automatic
debridement, and reducing bacterial load to levels
compatible with peri-implant health by means of adjunctive
use of antimicrobial agents without altering the implant
surface, remains the standard of care for first-line intervention
to any non-surgical treatment approach for peri-implantitis.
At this stage of time the efficacy and validity of mechanical
or automatic debridement protocols for removing biofilm as
well as adjunctive antimicrobial therapies for reducing
bacterial load remain unknown and needs to be tested by
properly executed head-to-head RCT’s.
HARTSHORNE
Disclosure
Dr Johan Hartshorne is trained in clinical epidemiology,
biostatistics, research methodology and critical appraisal of
research evidence. This critical appraisal is not intended to,
and do not, express, imply or summarize standards of care,
but rather provide a concise reference point for dentists to
aid in understanding and applying research evidence from
referenced early view or pre-published articles in top ranking
scientific publications and to facilitate clinically sound
decisions as guided by their clinical judgement and by
patient needs.
References
1. Liberati A, Altman DG, Tetzlaff J, Mulrow C,
Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ,
Kleijnen J, Moher D. The PRISMA statement for reporting
systematic reviews and meta-analysis of studies that
evaluate healthcare interventions: explanation and
elaboration. Brit Med J 2009; 339: b2700.
2. Shea BJ, Grimshaw JM, Wells GA, Boers M,
Andersson N, Hamel C, Porter AC, Tugwell P, Moher D,
Bouter LM. Development of AMSTAR: a measurement tool
to assess the methodological quality of systematic review
BMC Med Res Methodol 2007; 7: 10.
3. Jansen JP, Fleurence R, Devine B, Itzler R, Barret A,
Hawkins N, Lee K, Boersma C, Annemans L. Interpreting
indirect treatment comparisons and network meta-analysis for
health care decision making: Report of the ISPOR task force
on indirect treatment comparisons good research practices:
Part 1. Value in Health 2011; 14: 417-428.
4. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D,
Oxman AD et al. The Cochrane Collaboration’s tool for
assessing risk of bias in randomised trials. B Med J 2011;
343: d5928.
5. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y,
Alonso-Coello P, Schunemann HJ and GRADE Working
Group. GRADE: an emerging consensus on rating quality of
evidence and strength of recommendations. Brit Med J 2008;
336: 924- 926.
6. Lindhe J, Meyle J. Peri-implant diseases: Consensus
report of the Sixth European Workshop on Periodontology. J
Clin Periodontol 2008; 35: 282-285.
7. Lang NP, Berglundh T. Peri-implant diseases: where
are we now? – Consensus of the Seventh European
Workshop on Periodontology. J Clin Periodontol 2011:
38(Suppl): 178-181.
8. Heitz-Mayfield LJ, Mombelli A. The therapy of
peri-implantitis: A systematic review.
Int J Oral
Maxillofac 2014; 29(Suppl): 325-345.
9. Mombelli A, Muller N,Clonca N. The epidemiology
of peri-implantitis. Clin Oral Implants Res 2012;
23(suppl. 6): 67-76.
10. Renvert S, Roos-Jansaker AM, Claffey N. Non-surgical
treatment of peri-implant mucositis and peri-implantitis: A
literature review. J Clin Periodontol 2008; 35: 305-315.
11. Tomasi C, Wennstrom JL. Full mouth treatment vs
the conventional staged approach for periodontal
infection control. Periodontol 2000 2009; 51: 45-62.
12. Fuguero E, Graziani F, Sanz I, Herrera D, Sanz M.
Management of peri-implant mucositis and peri-implantitis.
Periodontology 2000 2014; 66: 255-273.
13. Heitz-Mayfield LJ. Peri-implant diseases: Diagnosis and
risk indicators. J Clin Periodontol 2008; 35: 292-304.
14. Faggion CM Jr, Listl S, Tu YK. Assessment of
endpoints in studies of peri-implantitis treatment – a
systematic review. J Dentistry 2010; 38: 443-450.
15. Heitz-Mayfield LJ, Salvi GE, Mombelli A, Faddy
M, Lang NP. Implant complications research. Antiinfective surgical therapy of peri-implantitis. A 12-month
prospective clinical study. Clin Oral Implants Res 2012;
33: 205-210.
16. Mills EJ, Thorlund K, Ioannidis JP. Demystifying
trial networks and network meta-analysis. Br Med J
2013; 346: f2914.
17. Schultz KF, Chalmers I, Hayes RJ, Altman DG.
Empirical evidence of bias. Dimensions of methodological
quality associated with estimates of treatment effects in
controlled trials. J Amer Med Assoc 1995; 273: 408-412.
CASE REPORT
Modern nanohybrid composites – an
alternative for all cavity classes
Walter Denner1
Tooth-coloured, direct restorations play an indispensable role in dental treatment today.
Apart from the clinical advantages of restorative composite, such as minimally invasive
preparation and stabilisation of the tooth by adhesive bonding of the restoration, it is
primarily patients’ demands for “invisible” restorations that have led to this material
becoming the restorative material of choice today. Initially, restorative composites were
used only in the anterior region. Since then however their use has become state of the
art in the posterior region as well. The positive results achieved in recent years in
numerous long-term studies, particularly with hybrid composites, speak for themselves.1,
2
The reason for these positive clinical results, apart from the improvement in adhesive
bonding techniques, is the significant improvement in the physical properties of the
hybrid composites compared with the older microfilled and macrofilled composites.
Nanohybrid composites were developed from microhybrid composites by the use of
nanofillers, a step which led to a significant increase in the filler content of the materials
and a considerable improvement in their physical properties.3, 4 Since then very
promising clinical data for these nanohybrid composites has become available for the
posterior region as well.5 –7 The restorative material GrandioSO (VOCO), which has
only recently been launched on the market and which is to be used in this clinical case,
is one of the latest nanohybrid composites to be developed.
1
Dr Walter Denner
Contact:
Dr Walter Denner
Flemingstr. 5
36041 Fulda, Germany
E-Mail: praxis@dr-denner.de
Clinical case
A 33-year-old female patient presented at our practice, expressing the wish to have
the old, inadequate amalgam restorations and inlays in the aesthetically relevant area
replaced by “invisible” restorations. Following a clinical assessment, the taking of
bitewing X-rays and a detailed examination of the situation, it was decided to replace
the amalgam restorations and non-precious metal inlays in the maxillary premolars (Figs.
1, 9) by composite restorations. Since neither the clinical nor the X-ray findings gave
Figure 1: Extensive amalgam restorations on 14, 15.
Figure 2: Placement of rubber dam and removal of the old
restorations.
CASE REPORT
Figure 3: Attachment and wedging/bracing the sectional
matrices. Application of the bonding agent to tooth 15.
Figure 4: Building up the mesial marginal ridge; 1st occlusal
increment.
Figure 5: Precontoured restoration on tooth 15.
Figure 6: Attaching the sectional matrices to tooth 14.
Application of the bonding agent.
any indications that complications were likely, it was possible
to restore both quadrants at the same time at one session.
Before treatment was carried out, the shade of the teeth
was compared in daylight with the shade guide included
with the system. The shade was determined before
(completely) isolating the operating site because the moisture
loss makes the teeth appear unnaturally bright and,
moreover, the contrasting colour of the rubber dam gives a
false impression of the tooth shade. The isolation of the area
to be treated by the rubber dam neatly shields the operating
site from the oral cavity, enabling the dentist to work
effectively and tidily. This separation of the operating site is
an enormous benefit both for the dentist and the patient,
especially for larger restorations.
The 1st quadrant was restored first. In order to do this, the
rubber dam was secured on tooth 16 by means of a clamp
and the old amalgam restorations and inlays were removed
(Fig. 2). The sectional matrices used (Compositight, Garrison)
were secured by a clamping ring (Palodent, Dentsply) and
adapted with wooden wedges. Great care should be taken
in adapting the matrices accurately because this will minimise
excesses. This will pay off later because less time and effort
will have to be spent finishing the restoration.
The application of the bonding agent (Futurabond DC,
VOCO) was followed by the incremental filling of the cavity
in tooth 15 with the nanohybrid composite GrandioSO in
shade A3. To do this, the Class II cavity was initially
transformed into a purely occlusally limited cavity by building
up the distal (Fig. 4) and mesial marginal ridges. The
pleasant, non-sticky consistency of GrandioSO facilitates the
adaptation of the material and the contouring of the proximal
walls in this procedure. After completion of the proximal walls
it was possible to remove the matrices and the clamping
rings for a better overview. The composite GrandioSO was
placed in individual increments into the cavity, which was
now purely occlusal, with each increment being polymerised
DENNER
for ten seconds by blue light. The individual layers are
formed anatomically correctly in this process, i.e. following
the occlusal relief as closely as possible. This saves much
time in the subsequent finishing. Figure 5 shows the
precontoured restoration of tooth 15 after it had been
placed. A similar procedure was then carried out in tooth
14. The sectional matrices were attached and wedged (Fig.
6), the bonding agent applied, dried with an air stream and
polymerised. The proximal walls were again reconstructed
initially, and the occlusal restoration was then incrementally
filled and precontoured (Fig. 7). Figure 8 shows the
completed restoration after polishing and checking the
occlusion.
After the restorations had been completed in the 1st
quadrant, the rubber dam was secured on tooth 26 to
restore the 2nd quadrant and the old restorations in tooth
24 and tooth 25 were excavated (Fig. 10). Caries Marker
(VOCO) was used to ensure a complete excavation of
caries. Sectional matrices were attached to tooth 25 and
the self-etch adhesive Futurabond DC was then applied to
both cavities and cured. After the distal marginal ridge on
tooth 25 had been built up, the mesial wall was
reconstructed and the deep distal box was filled in several
horizontal layers. At the same time, the buccal followed by
the palatal part of the occlusal cavity in tooth 24 was
restored with GrandioSO A3. The cavity in tooth 25 was
filled with additional increments of GrandioSO to match the
tooth’s anatomy and was then finished (Fig. 11). After the
restorations had been completed, the rubber dam was
removed, the static and dynamic occlusion checked and
finally all restorations were polished with silicone polishers
to a high-lustre. Figs. 8 and 12 show the completed,
aesthetically attractive restorations.
Modern nanohybrid composites enable the dentist to
carry out restorations which are both minimally invasive and
durable, and which combine the necessary stability with the
optimum aesthetic effect required by the patient, especially
for the posterior tooth.
Figure 7: Precontoured restorations before finishing.
Figure 8: Completed restorations of the 1st quadrant.
Figure 9: Restorations to be replaced (amalgam, non-precious
metal inlay) on 24, 25.
Figure 10: Placement of rubber dam and excavation of the old
restoration.
DENNER
Figure 11: Placement of additional increments of GrandioSO
into the cavities of 24, 25.
Figure 12: Completed, highly aesthetic restorations of the 2nd
quadrant.
Bibliography
or Traditional Microhybrid Resins
Oper. Dent. 34, 551-557 (2009)
5. Celik, C., Arhun, N., Yamanel, K.: Clinical Evaluation
of Resin-based Composites in Posterior Restorations: Two
Year result
Oper. Dent. 35, 399-406 (2010)
6. Krämer, N., Reinelt, C., Richter, G., Petschelt, A.,
Frankenberger, R.: Nanohybrid vs. fine hybrid composite in
Class II cavities: clinical results and margin analysis after four
years.
Dent. Mater. 25, 750 – 759, (2009)
7. Garcia-Godoy, F., Krämer, N., Feilzer, A.J.,
Frankenberger, R.:
Long-term degradation of enamel and dentin bonds:
6-year results in vitro vs. in vivo.
Dent. Mater. 26, 1113-1118 (2010)
1. Hickel, R., Heidemann D., Staehle H.J., Minnig P.,
Wilson N.H.: Direct composite restorations: extended use in
anterior and posterior situations.
Clin. Oral. Invest. 8, 43-44 (2004)
2. Manhart, J., Chen, H. Y., Hamm G. und Hickel, R.:
Review of the clinical survival of direct and indirect
restorations in posterior teeth of the permanent dentition
Oper. Dent. 29, 481-508 (2004)
3. Beun, S., Glorieux, T., Devaux, J., Vreven, J., Leloup,
G.: Characterization of nanofilled compared to universal
and microfilled composites
Dent. Mater. 23, 51-59 (2007)
4. Moraes, R.R., Goncalves, L.S., Lancellotti, A.C.,
Consani, S., Correr-Sobrinho, L., Sinhoreti, M.A.:
Nanohybrid Resin Composites: Nanofiller Loaded Materials
CLINICAL
Making sense of mouth ulceration:
part six
Crispian Scully1
Skin disorders
The main skin disorders that may present with mouth ulceration include particularly
lichen planus, but also:
• Pemphigus
• Pemphigoid
• Dermatitis herpetiformis
• Linear IgA disease
• Epidermolysis bullosa
• Erythema multiforme.
Lichen planus
1
Professor Crispian Scully CBE
FMedSci DSc FDS MD is
professor emeritus at UCL,
London, King James IV
professor at the Royal College
of Surgeons, Edinburgh,
Harley Street Diagnostic
Centre, 16 Devonshire Street
and 19 Wimpole Street,
London.
This article discusses lichen planus – the most common skin disease with oral lesions,
and the last group of the systemic causes of mouth ulceration (skin disorders).
Lichen planus (LP) is a common mucocutaneous disorder; an inflammatory
autoimmune-type of disease that can affect stratified squamous epithelia – the skin, oral
mucosa and genitalia.
Lichen planus usually affects persons aged between 30 and 65 years, with a slight
female predisposition.
Tumour necrosis factor-alpha (TNFα) homozygous polymorphisms may cause
cutaneous lesions. The antigen(s) responsible are unknown and studies looking for any
causal bacteria, fungi and viruses have proved negative. Antigen-processing cells
(Langerhans cells) appear first and lead to a mononuclear inflammatory cell infiltrate,
in the upper lamina propria, mainly of CD8+ T-cells that release T-cell cytokines such
as TNFα and interferon-γ (IFNγ), cause apoptosis and vacuolar degeneration in basal
keratinocytes, and lysis in the epithelial basement membrane zone (EBMZ).
The clinical appearance of an oral ulcer on its own is rarely diagnostic though in
lichen planus, white lesions are typically also seen (Figure 1).
Lichen planus is often asymptomatic but may cause mild oral discomfort or burning
sensations especially when eating or drinking substances that are acidic or spicy. For
some, discomfort can be severe.
Lichen planus presents orally mainly with bilateral white lesions – of which there are
six clinical types, often mixed (Figure 2):
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Figure 1: White lesions are invariably seen in lichen planus.
Figure 2: Lichen planus reticular and erosive.
Figure 3: Lichenoid reaction to amalgam.
Figure 4: Lichen planus and cancer.
• Reticular, network of raised white lines (striae)
• Papular
• Plaque-like, white patches simulating leukoplakia
• Red atrophic areas – or desquamative gingivitis
• Erosive/ulcerative – persistent, irregular
• Bullous (rare; possibly superficial mucoceles).
The rash, if present, is characterised by lesions, which are:
• Purple
• Polygonal
• Pruritic (itchy)
• Papules – often crossed by fine white lines (Wickham’s
striae).
Lichen planus may also involve:
• Anogenital mucosae:
– ‘Vulvovaginal-gingival syndrome’ (Pelisse)
– Peno-gingival syndrome
– Anal LP
• Nails: uncommon ridging, shedding or destruction
• Scalp: uncommonly affected
• Eyes: rare conjunctival involvement.
Lesions that are clinically and histologically similar to lichen
planus – termed ‘lichenoid lesions’ – are sometimes
caused by:
• Drugs, especially NSAIDs
• Dental restorative materials (Figure 3)
• Chronic graft-versus-host disease
• Infection with hepatitis C virus
• Other systemic disorders (eg, hypertension, diabetes).
Lichenoid reactions may be unilateral.
Differential diagnosis includes:
• Lupus erythematosus
• Chronic ulcerative stomatitis
• Keratosis
• Carcinoma.
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A firm diagnosis of LP relies on lesional biopsy and
histopathological examination.
A physician opinion is indicated if:
• There is HCV infection
• There is other systemic background
• Drugs are implicated
• There is skin, genital or ocular involvement.
In the management of lichen/lichenoid lesions, it may be
wise to consider removal of amalgams, but no tests (eg,
patch tests) will reliably help guide this decision.
Symptoms can often be controlled with topical medications
such as benzydamine hydrochloride (0.15%) spray or
mouthrinse and 2% lidocaine gel.
There is no evidence base for many of the therapies
associated with lichen planus:
Mild lichen planus
• Topical aloe vera may help symptomatically
• Topical corticosteroids are the mainstay
• Initial use of a high potency drug such as clobetasol,
fluocinonide or fluticasone, followed by a lower potency
drug (eg, hydrocortisone hemisuccinate, betamethasone,
triamcinolone acetate or fluocinolone).
Moderate lichen planus (severe or extensive oral
involvement)
• Topical ciclosporin along with a high or super potent t
opical corticosteroid
• Topical tacrolimus.
Severe lichen planus (in multiple sites)
• Systemic corticosteroids (prednisolone, deflazacort), or
other immunomodulatory agents (eg, mycophenolate mofetil
or biologics).
Lichen planus, and especially lichenoid lesions, have a
small malignant potential – probably in less than 1-3% and
predominantly in non-reticular lesions and on tongue
(Figure 4).
NICE guidelines clearly state that patients with oral lichen
planus should be monitored for oral cancer as part of the
routine dental examination.
References
Gandolfo S, Scully C, Carrozzo M (2006) Oral medicine.
Elsevier Churchill Livingstone (Edinburgh and London). ISBN
13: 29780443100376
Scully C, Almeida ODP, Bagan J, Diz PD, Mosqueda A
(2010) Oral medicine and pathology at a glance. WileyBlackwell (Oxford) ISBN 978-1-4051-9985-8
Scully C, Flint S, Bagan JV, Porter SR, Moos K (2010) Oral
and maxillofacial diseases. Informa Healthcare (London and
New York). ISBN-13: 9780415414944
Scully C, Bagan JV, Carrozzo M, Flaitz C, Gandolfo S
(2012) Pocketbook of oral disease. Elsevier, London. ISBN
978-0-702-04649-0
Scully C (2013) Oral and maxillofacial medicine. 3rd
edition. Churchill Livingstone (Edinburgh). ISBN
9780702049484
Scully C (2012) Aide memoires in oral diagnosis:
mnemonics and acronyms (the Scully system). Journal of
Investigative and Clinical Dentistry 3(4): 262-3
Scully C (2013) RULE for cancer diagnosis. British Dental
Journal 215: 265-6
Published with permission by Private Dentistry June
2014
CLINICAL
Sigal Jacobson1
Many of us still remember the past generation composites. Reproduction of the natural
characteristics of a tooth was difficult because of the lack of available shades as well
as the less-than ideal physical qualities of the materials. Since that time, various aesthetic
composite resin materials have been introduced that possess exceptional colour
characteristics and improved physical qualities.
Given a composite’s advantages, why is direct composite veneering of teeth so
frequently overlooked in favor of the porcelain veneer option? One would first assume
that the artistic ability needed to reproduce the correct contour, shape, and shine would
pose a major deterrent in participating in the process. Dentists will often state that
composite veneering is time-consuming and cost-ineffective, with results that are not
predictable and sometimes disappointing.
This author is happy to report that Dental Art innovations, an Australian company,
has recently introduced a unique product called Uveneer. The Uveneer system is a
complete set of translucent templates that allows easy and fast reproduction of anterior
tooth anatomy in the form of a composite veneer. The Uveneer uses innovative
technologies that help the dentist to achieve a refined, anatomically correct, high-gloss
restoration in a fraction of the time than if done freehand. Results are both reproducible
and predictable. The operator needs to press the clear template onto the composite
that has been applied to the prepared tooth, cure, and remove the Uveneer template.
The result will be a shiny and anatomically correct tooth surface. The Uveneer kit
includes all anterior teeth and premolars in both upper and lower arches. Two sizes,
large and universal, are provided, according to research on smile design sizes and
proportions. The Uveneer is made from a medical-grade translucent plastic that does
not adhere to the composite resin and is both reusable and autoclavable.
Technique
1
Sigal Jacobson, DMD
This young woman was embarrassed to show her teeth. Tooth No. 10 is an implant
crown restoration with poor match to the rest of the dentition (Figure 1).
The treatment option she was offered by another dentist to get satisfactory cosmetic
results was a porcelain work on all 4 incisors. This approach proved to be beyond her
budget, since her resources were diminished by her implant treatment. The treatment
plan offered in this case by the dentist was 3 composites veneers on teeth Nos. 9, 8,
and 7 with Uveneer system.
The correct template is chosen (Figure 2). Note that its size and shape corresponds
nicely to the tooth to be veneered, No. 9. The teeth to be veneered required little
preparation as they are retroclined.
After the insertion of retraction cord and sectional matrixes, the tooth was etched for
15 seconds (Figure 3).
The tooth is sprayed with water for 5 seconds and gently dried. The adhesive system
is then applied and cured for 20 seconds. (This was done with VOCO America’s
Futurabond U.)
A composite resin is then applied to the tooth labial surface without curing yet. (This
was done with Danville Materials’ ZNano. Figure 4).
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Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Figure 6.
Figure 7.
Figure 8.
Figure 9.
A small amount of flowable composite is applied into the
template by using VOCO America’s GrandioSO and
pressed onto the uncured composite that has been laid on
the tooth. Excess is removed from the periphery using a
probe.
Then light cure throughout the template while pressing for
30 seconds by using Ultradent Products’ VALO LED curing
light (Figure 5). The template is then removed.
Retraction cord and separators are also removed. Residual
excess is cleaned from the periphery with flame-finishing
diamond burs (Figure 6).
The Uveneer template will generate the shine (also assisted
by the blocking the oxygen-inhibiting layer) and the correct
anatomy of the tooth (Figure 7). The same procedure was
repeated for teeth Nos. 7 and 8 (Figure 8).
Three composite veneers with the Uveneer system were
completed on 3 teeth—Nos. 7, 8, and 9—in less than an
hour. Everyone was very excited by the results (Figure 9).
Conclusion
By combining today’s improved composite materials with the
Uveneer’s innovative and unique delivery technique, dentists
can now create smile solutions that were not possible before.
The result is conservative, functional restorations with excellent
aesthetics in a fraction of the time that it previously took.
For additional information, call Dental Art innovations at
(888) 771-0479 or visit uveneer.com.
Dr. Sigal Jacobson, DMD is the inventor of the Uveneer
system. She is based in Melbourne, Australia, and has run
her private clinic.
Published with permission by Dentistry Today 8/14
CLINICAL
Forensic odontology – broader than just
identification
Richard Bassed1
Nowadays, most people will associate forensic dentistry primarily with identification and
bite mark analysis. These areas do indeed form the majority of an odontologist’s
workload. There are, however, other aspects of the discipline that are just as important
but perhaps less well known. These include cranio-facial trauma analysis, age estimation
for both living and deceased individuals, dental manifestations of child abuse, dental
malpractice investigations, as well as dental insurance fraud.
Forensic odontology is an integral part of the medico-legal process. With this comes
a responsibility borne by forensic odontology practitioners for the requisite education,
qualifications and ongoing training. Courts and legal institutions now require that we
have evidence-based research upon which we can rest our findings and conclusions. In
addition to knowledge of the law, we have to have knowledge of human anatomy and
its relationship to injury patterns and interpretation. Knowledge of bite mark patterns due
to assault, trauma and sexual abuse, as well as child abuse injury manifestations, is also
required, as is knowledge of assessment techniques used when the age of an individual
is unknown. Finally, there is a need to have knowledge of human identification methods,
principles and practices, as well as mass disaster identification procedures and protocols,
and the ethical issues involved in the examination and management of dead bodies,
and to have an understanding of human rights issues involved in war crimes investigations.
All of these require thorough knowledge of cranio-facial anatomy, dental anatomy,
dental and skeletal development, injury interpretation and medico-legal report writing. It
is also important to have a good understanding of the law relating to the practice of
dentistry, the coronial system, and the criminal justice system. As the majority of the
forensic odontology caseload concerns the identification of unknown deceased
individuals, most discussion in this article will concentrate on this.
Honouring the dead is a fundamental precept in all societies. The extent of this
communal attention to the deceased varies across the world, but in essence every person
hopes that his or her remains will be treated with respect after death. This respect for the
dead includes, for many societies, robust identification of the deceased so that relatives
and friends are able to treat the remains with appropriate ceremony and are able to visit
the resting place of the deceased whenever they wish. So important is the perception of
personal identification in almost all societies that authorities will go to extraordinary lengths
1
Dr Richard Bassed
is a senior forensic odontologist
and Head of Human
Identification Services at the
Victorian Institute of Forensic
Medicine in Melbourne in
Australia.
Figure 1: Comparison of ante-mortem (AM) and post-mortem (PM) radiographs, leading to
a positive identification.
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to ensure that deceased individuals are not interred in
unmarked graves, or cremated without a name.
To be buried anonymously goes against all of our religious,
cultural and ethical belief systems, and implies that a life
unremembered and unmourned was really a life without
consequence. William Gladstone, Prime Minister of Britain in
the mid-1800s, encapsulated this sentiment better than most
when he said, “Show me the manner in which a nation cares
for its dead and I will measure with mathematical exactness
the tender mercies of its people, their loyalty to high ideals,
and their regard for the laws of the land.”
Hal Hallenstein, the Victorian State Coroner from 1986 to
1994, also had firm views concerning the importance of
human identification, articulated in the following quotation: “It
is a hallmark of our civilisation that we regard it as an affront,
an indignity, an abrogation of our responsibilities, that a person
could live amongst us, die and be buried without a name.” In
fact, the importance of identification of the deceased is
enshrined in the Victorian Coroners Act 2008 (Section 67),
which states “A coroner investigating a death must find, if
possible, the identity of the deceased, the cause of death, and
the circumstances in which the death occurred.”
Positive identification of the deceased not only satisfies a
commitment to probity, but also resolves many legal issues
surrounding an individual’s death, such as inheritance and life
insurance. If a deceased person remains unidentified, then
technically he or she will not be declared dead for a number
of years, thus creating further distress to families who not only
are unable to put their lost loved one to rest, but may suffer
financially as well.
Personal identification of the deceased, and occasionally
the living, is achieved through a variety of scientific and
sometimes unscientific methods. Practitioners from forensic
science, forensic medicine, law enforcement and coroners’
offices apply their own particular set of skills to an identification
problem in order to arrive at an answer. The most common
2b
2a
Figures 2a–c: A more difficult case highlighting that sometimes
a degree of interpretation is required.
method used to identify the deceased in all jurisdictions is
undoubtedly visual recognition by a relative or close friend.
There is continual debate concerning the veracity of this
method, given the propensity for error, which has been well
documented, especially in mass casualty events and in
situations in which the deceased has suffered trauma to the
face. From the forensic medical/scientific perspective, visual
recognition is not proof of identity, but is only presumptive.
Theory of human identification
Methods used to achieve positive human identification can be
separated into two broad categories. The first consists of those
methods that are presumptive for identification, such as
circumstantial evidence, property associated with the body,
and visual recognition. These methods involve a high degree
of subjectivity and rely on identifiers that are not intrinsic to the
body itself, are dependent on lay interpretation, and therefore
can be falsified or mistaken (commonly known as secondary
identifiers). The second category relies on scientific analysis
of identifiers that are intrinsic to the body, such as dental
restorations, fingerprints, DNA, and verifiable medical records
(primary identifiers). These involve characteristics that can be
2c
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Figure 3: An example of cranio-facial trauma in a homicide
case. Accurate injury description can be vital in these cases.
objectively appraised and compared to ante-mortem
exemplars in both a quantitative and a qualitative way and
that are difficult or impossible to falsify.
Of all the scientific methods, molecular biology is the only
method that can mathematically quantify the degree of
certainty for a particular match, with the other methods
(including odontology) being somewhat dependent on more
subjective methodology and expert opinion. This reliance on
even a small level of subjectivity can raise issues in courts
when lay people do not have a deep understanding of the
methods employed in an expert’s conclusion.
Confusion can arise from the fact that there is often no
unanimous indication regarding which and how many
characteristics are necessary in order to achieve a positive
identification. The recurrence of discordant features excludes
identity; the occurrence of several concordant features
commonly observed within the population does not allow a
final judgment on identification, whereas even a few features
rarely observed can lead to a positive match. An example of
this is a case in which the written dental chart describes
amalgam restorations in each first molar. If the same is found
in the deceased, is this sufficient evidence to confirm identity?
Definitely not, as many people share this restoration pattern.
If, however, we also have ante-mortem radiographs of those
restorations displaying the exact shape, size and location
within each tooth, and these compare favourably with the
post-mortem radiographs, then few would argue that a
positive match cannot be confirmed. There is, however, still
no way to quantify this match, to put a probability ratio or a
percentage certainty to it.
It may be necessary in some cases to compare all of the
teeth in a mouth in order to arrive at a match. In other cases,
a single tooth with an unusual or complex restoration may be
sufficient. It has long been the wish of identification experts to
be able to quantify such matches, but no reliable method has
yet been devised and so a degree of expert subjectivity is still
required.
Prior to the availability of scientific methods applicable to the
issue of positive human identification, the only real option for
relatives and friends to recover the mortal remains of their loved
ones was to visually examine them, and make a decision
regarding whether the person before them was indeed who they
believed him or her to be. On the face of it, positive human
identification by visual recognition would seem to be a fairly
simple matter, as long as the deceased has undamaged facial
features. We can all recognise people who are well known to
us by their facial features and mannerisms, even in poor light
and at odd angulations. This has been shown to be true in many
studies concerning the recognition of living people via CCTV
security footage. Why then are there documented cases of
misidentification through visual recognition of the deceased,
even of intact and undamaged faces?
The process of visual recognition is complex and until quite
recently not well understood. Clues as to the identity of an
individual, either living or deceased, rest not only with the
physical structure of the face, but also with the variety of facial
expressions, the display of various mannerisms, and the
context in which the individual is seen.
A deceased person has lost all facial expression, animation,
and context and simply looks different from when he or she
was alive. Incipient decomposition changes may also be
present and go unrecognised. Couple this with the stress and
trauma being experienced by the identifier, who may well
have never seen a dead body before, and it is easy to see
how someone may make a mistake. This is compounded by
the way visual identifications are often performed, in that the
deceased is presented to the identifier to confirm what the
authorities already believe they know.
Identification methods
Visual recognition, despite the lack of scientific validity and
the propensity for error, will for all practical purposes remain
as a major method for positive human identification. When it
is determined that visual recognition is not an option, usually
because of trauma, incineration, decomposition, or multiple
deaths resulting from a single incident, then forensic
practitioners are able to rely on more scientific means to
BASSED
determine identity. The common methods employed include
molecular biology, medical record comparison, fingerprints,
and dental record comparison.
DNA profiles are encrypted sets of numbers that reflect a
person’s DNA make-up, which can also be used as the
person’s identifier. Although 99.9% of human DNA sequences
are the same in every person, enough of the DNA is different
to distinguish one individual from another, unless they are
monozygotic twins. DNA profiling uses repetitive sequences
that are highly variable, called variable number tandem
repeats (VNTRs), particularly short tandem repeats. VNTR loci
are very similar in closely related humans, but so variable that
unrelated individuals are extremely unlikely to have the same
VNTRs. In situations in which a full nuclear DNA profile is not
attainable, for example in ancient or degraded remains,
mitochondrial DNA analysis may be used, although with less
certainty. Identification using DNA evidence relies on the
comparison of an ante-mortem sample (reference sample) with
a post-mortem sample, and may include direct comparison of
the decedent’s DNA (e.g. Guthrie cards or an ante-mortem
blood sample), or a comparison with relatives’ DNA (parents,
children or siblings), to arrive at a conclusion. The conclusions
of molecular biologists are expressed as a probability ratio
and are thus scientifically quantifiable as to the strength of the
match. With any DNA technique, the cautious juror should
not convict on genetic fingerprint evidence alone if other
factors raise doubt. Contamination with other evidence
(secondary transfer) is a key source of incorrect DNA profiles,
and raising doubts as to whether a sample has been
adulterated is a favourite defence technique.
Identification using fingerprints (friction ridges) relies on an
examination of ante-mortem prints already on file with
authorities (exemplars), or more commonly comparison with
latent prints retrieved from an object the subject of the
examination was known to have touched. Fingerprint
identification involves an expert, or an expert computer system
operating under threshold scoring rules, determining whether
two friction ridge impressions are likely to have originated from
the same finger or palm (or toe or sole). The validity of forensic
fingerprint evidence has been challenged by academics,
judges and the media. While fingerprint identification was an
improvement on earlier anthropometric systems, the subjective
nature of matching (especially when incomplete latent prints
are used), despite a very low error rate, has introduced an
element of controversy.
Medical record comparison can be used for identification
purposes when there is sufficient ante-mortem evidence of
unique medical intervention or disease. Examples include the
discovery of medical prostheses, such as pacemakers and
Figure 4: Age estimation using a standard atlas of development
results in an age range that can either lead to identification or
help police in limiting their search criteria for a missing person
in the case of discovered unknown remains.
prosthetic hips, which will have engraved on them serial
numbers, which can then be reconciled with ante-mortem
surgical notes.
Dental identification
When good quality ante-mortem dental records are available
for comparison with post-mortem examination findings, positive
identification is a relatively simple matter (Figs. 1a & b). For
many cases, however, such a simple resolution is not so easily
achieved. Often ante-mortem dental records are incomplete or
many years old or there are no radiographs. Couple this with
incomplete remains or remains damaged by fire and/or
trauma and the difficulties are magnified (Figs. 2a–c).
Reproducing the exact angulation and aspect of an antemortem radiograph in a post-mortem radiograph, taken in less
than ideal circumstances, can also be challenging. In order to
reach conclusions to these difficult identification puzzles, the
forensic dentist not only needs a solid grounding in all of the
techniques available, but also requires a level of experience
and, in the early years, a degree of mentoring.
Dental identification is not only achieved using comparison
of restorations; other features of the teeth and maxillofacial
skeleton may also be employed. Root morphology, sinus
configuration, unusual crown shape, and pulp chamber
morphology are all factors that can be considered in the
absence of restorations, as long as there are high-quality antemortem images with which to make a comparison. Study
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5a
Figures 5a–c: Multiple development sites used for age estimation
of late teenage individuals: in this case, the third molar, the
medial clavicular epiphysis, and the spheno-occipital
synchondrosis, all of which are useful age indicators in the late
teenage years.
models, sport mouth guards, partial dentures, orthodontic
appliances and photographs of the dentition are all useful aids
for a forensic odontologist and are employed with varying
degrees of certainty, depending on the circumstances of the
case.
Personal identification via dental record comparison is
similar to fingerprint analysis in that there is, as discussed
above, an element of subjectivity involved in the matching
process. Where dental identification differs, and is perhaps
easier to comprehend for lay people, is in the nature of the
evidence being compared. With dental evidence, matches
are commonly assessed by comparing both ante-mortem and
post-mortem radiographs of easily identifiable man-made (and
most often handmade) restorations. Unlike the minute nature
of the whorls and swirls of fingerprint evidence, dental
radiograph comparisons are often so obviously similar that
any reasonable person is able to say that the images belong
to the same person.
Other aspects
Aside from identification case work, odontologists are asked
to provide medico-legal opinions on a variety of topics as
outlined in the introduction. Bite mark interpretation is probably
the most recognisable of these to the lay audience and
involves the assessment of injuries to the skin that are suspected
of being caused by human teeth. This area of forensic practice
is fraught with difficulty, as the highly subjective nature of the
conclusions reached is almost completely based upon opinion
rather than scientific research. There are so many problems
associated with the interpretation of bite marks that to describe
them all here is beyond the scope of this introductory article.
Cranio-facial trauma analysis is a growing area of forensic
odontology practice, and involves examination of both living
and deceased individuals and the provision of opinions
concerning accurate anatomical description of the injuries
(Fig. 3), degree of force (mild, moderate severe), and
direction of force application. Occasionally, opinions are also
sought regarding the exact nature of the weapon used,
although caution needs to be exercised in this regard, as
unless the implement bears unique characteristics that are
imparted to the body interpretation will be very difficult. This
area of odontology practice predicates a thorough knowledge
of cranio-facial anatomy, the biomechanics of bone, and the
effect on anatomical structures of various degrees of force.
Age estimation has always been a function of the forensic
odontologist, and traditionally has been based upon
interpretation of dental development and comparison with
published standards for tooth development (Fig. 4). The
majority of age estimation work has concentrated on the
ageing of children up to 15 years. Beyond this age, dental
development becomes relatively unreliable, as only the third
molar is available for assessment, and this tooth is notoriously
variable in its development. It has been recognised recently,
however, that published standards for tooth development may
not be as accurate as assumed, owing to the fact that they
were constructed many decades ago and in other parts of the
world, and therefore may bear little resemblance to modern
populations. Considerable work is currently underway to
address this issue, with new population datasets being
established around the world.
Odontologists are also researching the ability to estimate
more accurately the age of older individuals, around the
adult/child demarcation age of 18 years. This is being
achieved through the use of multifactorial approaches, where
the third molar and various other skeletal development sites
are assessed together in order to arrive at an estimate (Figs.
5a–c). This is seen as important research in light of the
increasing need to determine the legal status of individuals
such as asylum seekers, accused human traffickers who may
be children and risk being incarcerated in an adult prison,
child soldiers, and victims of sexual assault in developing
countries, all of whom are unlikely to possess proof of age
documentation.
It has been shown that more than half of all cases of child
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5b
5c
abuse involve cranio-facial injuries, perhaps owing in part to
the significance of the face and mouth in communication and
nutrition. Forensic odontologists are rarely involved in these
difficult cases, but despite this play an important role in injury
description and providing help with determination of
causation. All of the principles involved in cranio-facial trauma
analysis for adults are applicable here, but with emphasis on
the developing anatomy and different biomechanical
characteristics of the child facial skeleton.
Dental malpractice and insurance fraud investigations are
increasing, partly owing to greater public awareness of what
constitutes a dentist’s duty of care and responsibility to patients,
and partly owing to our increasingly litigious society. For this
aspect of practice, the odontologist requires thorough
knowledge of the various pieces of legislation relating to
dental practice, the professional codes of conduct, and the
latest information on treatment modalities, as well as good
medico-legal report writing skills.
Conclusion
Forensic odontology is capable of providing rapid and
relatively cost-effective identification of the deceased, as long
as reasonable ante-mortem dental records are available. In
countries such as Australia, the laws concerning medical
record-keeping ensure that dental records are, in the main, of
good quality and easily retrieved in the event they are
required.
In other countries, this may not be the case, and
identification of the deceased in some parts of the world
represents a serious and ongoing issue for governments and
humanitarian organisations. Good record-keeping is not only
of benefit to forensic practitioners, but also relevant to
improved health services and outcomes for patients in general,
so part of the work of odontologists includes educating health
authorities in less developed parts of the world to encourage
good record-keeping. The benefit of good record-keeping can
be seen in recent mass fatality incidents, such as the Victorian
Black Saturday bushfires, where, despite the availability of a
well-resourced DNA capability, more than half of all victims
were identified by dental record comparison.
The scope of forensic odontology is broader than
identification alone and encompasses a range of activities,
anything in fact where the practice and theory of dentistry
intersect the law. To be a competent practitioner in this
discipline requires not only a comprehensive understanding of
odontology theory and technique, but also a degree of
knowledge and experience in a variety of forensic fields,
including law, pathology, clinical forensic medicine, molecular
biology and anthropology. The forensic odontologist
encounters all of these disciplines in different case scenarios,
and in order to understand how the odontologist can
contribute best to an investigation he or she needs to
comprehend the capabilities and limitations of these fields.
Editorial note: A list of references is available from the
publisher.
Reprinted with permission by Cone Beam 1/2015
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A minimally invasive approach according
to biomechanical principles of teeth
Michael L. Young1
Introduction
Traditionally, the practice of dentistry has been a reparative model. We have waited
for disease to express itself, and then repaired it. What if we could predict who would
express a disease and prevent it from happening in the first place? How would this
approach affect the long-term oral and overall health of the dental patient?
Many of our patients tell us, “If it’s not broken, don’t fix it.” Patients are often unaware
of the conditions in their mouths because there isn’t an associated disability, and they won’t
accept a solution to a problem they don’t have. Thus teeth at risk may remain untreated
until a quality of life issue has occurred, such as pain, infection or a fractured tooth.
According to Geurtsen, Schwarze, & Gunay (2003), root fractures are the third
leading cause of tooth loss.
Tooth loss is a quality of life issue. Loss of a tooth ideally requires replacement,
which necessitates further expenditures and procedures.
Failure to replace the tooth has consequences, which may lead to further cost and
need for treatment or loss of additional teeth. The consequence of the reactive approach
to dental care is, at best, a lesser prognosis for the tooth and, at worst, loss of the tooth.
This may be avoidable with a paradigm shift to a wellness model of practice. A
wellness model is proactive and preventative. If we can identify a dental condition that
increases risk to the tooth and patient, and treat the condition prior to its consequence,
we’re effectively reducing risk. The effect is an improved prognosis. Subsequently,
health-care costs will be reduced and quality of life improved.
Biomechanical principles
Tidmarsh said in 1979 that teeth are like prestressed laminates. They flex but can return
to their natural state. However, under prolonged loading, teeth can permanently deform.
Grimaldi said in 1979 that there is a relationship between how much tooth structure
has been lost and deformation.
Cavity preparation or endodontic access destroys the pre-stress state. Teeth can then
1
Dr. Michael L. Young
Private Practice, Sterling
Heights, Mich, USA
1a
Figure 1a: Pre-operative photo: Diagnosis of structurally compromised teeth. Figure 1b: Pre-op:
Measuring intercuspal distance of filling #3. Figure 1c: Pre-op: Measuring intercuspal distance
of filling #4.
1b
1c
CLINICAL
2a
2b
2c
3a
3b
4
5
6
7
Figures 2a–c: Depth cut bur #3. Figures 3a: Final depth cuts. Figures 3b: Final depth cuts, occlusal view. Figures 4 & 5: Gross occlusal
reduction with KS7 #3. Figures 6 & 7: Gross occlusal reduction with KS7 #4.
deform greater and are more susceptible to fracture. Too much
flexing makes them crack.
Larson, Douglas and Geistfield (1981) showed that a
restoration that takes up just one-third of the intercuspal distance
is less than one-half of the strength of an unrestored tooth. The
load required to fracture a tooth was the same if the restoration
involved only the occlusal surface or included the mesial and
distal surfaces as well.
Geurtsen, Schwarze and Gunay (2003) agreed that the
risk of cuspal fracture increases considerably when the
isthmus width of a restoration is 50 per cent of the
intercuspal distance. They stated that amalgam or resin
composite restorations should not exceed one-fourth to onethird of the intercuspal distance. The more tooth structure that
is removed in cavity preparations, the more the tooth flexes
under increasing loads.1
Teeth with cuspal fractures may still be restored; however,
the prognosis will be lower and less than ideal because
there is less remaining natural structure to retain a crown
and withstand the flexing from functional and non-functional
forces. These teeth may last for years. However, they may
eventually fracture at the gingival crest or below, because
8a
Figure 8a: Final occlusal reduction frontal view.
8b
Figure 8b: Final occlusal reduction occlusal view.
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9a
9b
9c
10
11
12
Figure 9a: Measuring remaining enamel ring after occlusal reduction #4. Figure 9b: Measuring remaining enamel ring after occlusal reduction
#3. Figure 9c: Occlusal reduction lateral view. Figures 10–12: Breaking contacts and removing remainder of existing filling.
of further cracks and propagation of those cracks.
Teeth with history of endodontic treatment are at an
increased risk of subgingival fracture, rendering the tooth
non-restorable or with a poor prognosis.2 Therefore, it’s
important to prevent these cracks from forming at all.
How do we prevent too much flexing in these teeth and prevent
cracking? Some have wondered whether a bonded inlay
restoration would strengthen the tooth and prevent cuspal fracture.
A study of bonded inlay restorations under static load
testing in maxillary premolars with large MOD preparations
concluded that bonding ceramic or composite will not
strengthen the tooth.3 A bonded resin or ceramic inlay will
not prevent cuspal deformation and fracture. However,
bonded ceramic onlays have been shown to be an effective
answer in restoring posterior teeth.4,5
Bakeman and Kois (2009) stated that all porcelain,
13
14a
14b
15a
15b
15c
Figure 13: Blending occlusal and interproximal #4. Figures 14a & b: Blending occlusal and interproximal #3. Figures 15a & b: Final
preparations occlusal views. Figure 15c: Final preparations lateral view.
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16
17
18
19
20
Figures 16 & 17: Tissue management with Viscostat. Figures 18–21a: Gingival retraction.
adhesively retained restorations offered the possibility of
limited or no removal of tooth structure on the axial wall,
while covering the cusps.
The result is a tooth with more remaining original structure,
less flexure under force and thus less risk of permanent
deformation and fracture.
It is important to preserve as much enamel as possible, as
failure rates of adhesively retained restorations increase the
more the tooth preparation involves the dentin.6 In addition,
the size of the remaining enamel ring after occlusal reduction
is an important determinant between an adhesively or
cohesively retained approach in tooth preparation.
21a
21b
22a
22b
Figure 21b: Final gingival retraction, occlusal view. Figure 22a: Scanning preparations. Figure 22b: PlanScan screenshot of scanning
preparations.
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23
24a
24b
24c
Figure 23: Scanning preparations. Figure 24a: Scanning opposing teeth. Figure 24b: PlanScan screenshot of scanning opposing teeth.
Figure 24c: Opposing model screenshot.
Increased occlusal reduction, or occlusal reduction on a
worn tooth, results in a preparation with a reduced enamel
ring width. A decrease in the size of the enamel ring
thickness from 1.5 mm to 1 mm increased the failure rate
dramatically. An enamel ring of less than 1 mm in width
would be a contraindication for an adhesively retained
25a
25b
26a
26b
26c
26d
26e
26f
26g
Figure 25a: Scanning buccal bite. Figure 25b: Screenshot of scanning buccal bite. Figure 26a: Screenshot of buccal bite. Figure 26b: Screenshot
of occluded models. Figure 26c: Screenshot of preparations in density view. Figure 26d: Screenshot of orientation of preparation model. Figure
26e: Tracing margins. Figure 26f: Tracing margins in ice view. Figure 26g: Initial proposal of restoration for #4.
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26h
26i
26j
26k
Fig. 26l
26m
Figures 26h & i: Initial proposal of restorations for #3 and #4. Figure 26j: Restorations #3 and #4, checking material thickness in occlusal
view. Figure 26k: Checking material thickness of #4 in facial view. Figure 26l: Using rubber tooth tool to adjust the anatomy of #4. Figure
26m: Using rubber tooth to adjust the distofacial cusp height of #3.
restoration, and a cohesively retained restoration would then
be required.7 A restoration bonded to enamel also provides
a margin with reduced or no microleakage.8
Summary
Aminian and Brunton (2003) stated: “The removal of sound
tooth structure is an unfortunate biological compromise. The
conservation of sound tooth structure, therefore, represents
an appropriate strategy to minimize biologic risk.”
Adhesively retained restorations offer the possibility to be
more minimally invasive while restoring a tooth to natural
appearance and function. More conservative removal of
tooth structure also means there is less risk to the pulp.
The converse is true in that cohesively retained
restorations are more invasive. Removal of more structure
increases pulpal risk, decreases strength and increases
tooth flexure, which may lead to fracture.
Tooth preparation is also more important as retention and
resistance form is essential to retain the crown.
A laboratory can fabricate minimally invasive, adhesively
26n
26o
26p
26q
26r
26s
Figure 26n: Using rubber tooth tool to adjust the distal marginal ridge height of #4. Figure 26o: Using smooth tool to smooth the facial of
#3. Figure 26p: Using smooth tool to smooth the facial of #3. Figure 26q: Checking occlusal contacts, location and strength, #3. Figure
26r: Checking interproximal contact strength #4. Figure 26s: Final restorations, occlusal view in PlanScan.
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26t
26u
26w
26v
26x
Figure 26t: Final restorations, lateral view in PlanScan. Figure 26u: Final restorations #3, slice view facial to lingual. Figure 26v: Final
restoration #4, slice view facial to lingual. Figure 26w: Final restorations, lingual view. Figure 26x: Milling preview.
retained restorations. However, chairside CAD/CAM
technology can fabricate excellent restorations of the same
quality in the same visit. This means the challenge of
fabricating a provisional for a tooth preparation that lacks
retention and resistance form is eliminated.
In addition, it has been shown that patients prefer a
digital impression technique in lieu of the traditional
impression method.9–13
Yuzbasioglu, et al (2014), also determined that the
digital impression method was faster than
26y
the traditional method. This finding was also verified by
Patzelt, Lamprinos, Stampft and Att (2014), who indicated
that workflow efficiency was improved using a digital
impression technique.
Case report
This patient presented for restorations of teeth #3 and #4
(Fig. 1a). Because of the size of the existing restorations,
these teeth were diagnosed as structurally compromised
(Figs. 1b, c). The prognosis without treatment was fair.
26z
Figure 26y: Try-in of restorations, occlusal view. Figure 26z: Try-in of restorations lateral view.
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27
28
29
30
Figure 27: Isolation for seating of restorations using Isolite. Figures 28 & 29: Application of Mulitlink Automix Primer. Figs. 30 & 31:
Application of Liquid Strip.
The restorations were to be completed with PlanScan
chairside CAD/CAM technology in the same visit.
Local anesthesia was achieved with 1.7 cc 2 per cent
Lidocaine with 1:100,000 epi, buffered with Onset sodium
bicarbonate inj., 8.4 per cent, USP neutralizing additive
solution.
Depth guide cuts were made using a 330 bur, which has
a 2 mm cutting surface (Figs. 2a–3b). This ensures 2 mm of
31
33a
Figure 32: Curing restorations. Figures 33a–c: Checking occlusion.
32
33b
33c
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34
35a
35b
Figure 34: Polishing. Figures 35a & b: Final restorations occlusal view.
occlusal reduction to accommodate 2 mm of material
thickness on the occlusal surface of the restoration.
Gross occlusal reduction was completed using a KS7 bur
to the depth cuts (Figs. 4–8b, 9c). Adequate clearance was
verified with a 2 mm prep check from Common Sense
Dental Products.
After gross occlusal reduction was completed, the
remaining enamel ring was measured (Figs. 9a, b). The
enamel rings were noted to be 1.5 mm, and the teeth were
prepared for adhesively retained restorations. If the enamel
rings were less than 1 mm, the teeth would have been
prepared on the axial walls to create retention for
cohesively retained crowns.
The remainder of the existing composite resin in #3 and
the amalgam in #4 were removed. The occlusal surfaces of
the preparations were blended into the interproximal areas
using a KS2 bur to create smooth preparations (Figs. 10–
15c). There was no retention or resistance form prepared to
retain the restorations.
Tissue management was obtained with ViscoStat Clear,
gingival haemostatic gel, 25 percent (m/m) aluminum
chloride (Figs. 16 & 17). Gingival retraction was obtained
using a two-cord system. First, a #00 size cord from
Ultradent was placed on the mesial and distal of both
preparations (Figs. 18 & 19).
Additional haemostatic gel was used prior to the second
cord. The second cord was #2 size cord from Ultradent
(Figs. 20 & 21a). A minimum of four minutes with both
cords in place is needed for adequate retraction of the soft
tissue (Fig. 21b).
While waiting four minutes for gingival retraction, the
opposing teeth were scanned with the PlanScan wand to
create a digital model (Figs. 22a–24c). The buccal
surfaces were then scanned with the teeth fully occluded in
maximum intercuspal position. This scan was used along
with the scan of the preparations and the opposing teeth to
create a model for the occlusion (Figs. 25a–26c).
Prior to scanning the prepared teeth, the second cords
were rinsed and removed. The cords were left wet to lower
the risk of disturbing the tissue upon removal.
The #00 cords were left in place during the scanning of
the preparations, and the teeth were dried to allow
accurate scanning.
The preparation model was examined in data density
view to verify adequate data was obtained during the
scanning of the preparations (Fig. 26c).
Any areas lacking adequate data were scanned further
until adequate data was obtained. Next, orientation of the
preparation model was performed (Fig. 26d). Orientation is
for optimal design, not path of insertion. The margins were
then traced and viewed in ICE mode, which provides a
rendering of the scanned images for a clear view of the
margins, teeth and tissues (Figs. 26e, f).
The initial proposals for the restorations were made using
Library A and autogenesis, which is morphogenesis of the
library tooth with the neighbouring teeth (Figs. 26g–i).
Material thickness of the proposed restorations was
checked (Fig. 26j, k). Tools were then utilized to improve
the initial proposal to the desired result. The rubber tooth
tool was used to make minor adjustments to the anatomy
(Figs. 26l–n). The smooth surface tool was used to smooth
the surfaces (Figs. 26o, p).
The location and strength of the occlusal contacts were
checked and adjusted (Fig. 26q). Interproximal contact
strength and location was then verified and adjusted as
needed (Fig. 26r).
The final proposals were then verified prior to milling
(Figs. 26s, t, w). The slice plane view was used to check
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36a
36b
Figures 36a & b: Final restorations, lateral view.
the space between the tooth preparation and the restoration
(Figs. 26u, v).
This is done to check for possible areas that may prevent
the final restoration from completely seating on the
preparation or for areas that may be over milled. Overmilling reduces the thickness of the material. This view also
illustrates the lack of preparation on the axial wall and the
minimally invasive approach taken. The location of the
sprues were noted and adjusted as needed in the milling
preview (Fig. 26x).
The fit of the restorations was then verified intraorally prior
to final seating (Figs. 26y, z). Occlusion can be verified
intraorally with e.Max CAD prior to crystallization and any
staining and glazing. Checking occlusion with Empress
CAD blocks prior to bonding in place is not recommended.
The restoration for #3 was then glazed and crystallized in
a Programmat CS2 furnace (Ivoclar Vivadent). The restoration
was allowed to cool to room temperature upon completion of
glazing and crystallization. The restoration was then cleaned
with a steam cleaner. Five percent hydrofluoric acid was used
to etch the e.max restoration for 60 seconds. The Empress
restoration was etched for 20 seconds.
The etchant was rinsed with a steam cleaner. Ivoclean
(Ivoclar Vivadent) was applied for 20 seconds on both
restorations to clean their internal surfaces. Monobond Plus
primer (Ivoclar Vivadent) was applied to the internal surface
of the restorations for 60 seconds. The primer was lightly air
dried after 60 seconds, taking extra care not to allow
primer on the outside surfaces of the restorations.
The teeth were isolated using Isolite (Fig. 27). Multilink Primer
A/B was scrubbed onto the entire bonding surfaces using a
microbrush for 30 seconds. Excess material was dispersed
with blown air until the mobile liquid film was no longer visible,
leaving a glossy appearing surface (Figs. 28 & 29).
An OptraStick Application Aid (Ivoclar Vivadent) was
used to seat the restorations on the teeth because onlays
and partial crowns can be difficult to handle. Initial tack
curing was completed using a Bluephase curing light
(Ivoclar Vivadent) for three seconds at each interproximal
area. The resin was then removed easily using a 36/37
scaler from Brasseler. Liquid Strip (Ivoclar Vivadent), a
glycerine gel that prevents an oxygen-inhibited layer of the
resin cement, was applied to the margins prior to final
curing (Figs. 30 & 31).
Final curing of the restorations was then completed (Fig.
32). The initial #00 cords were removed after final curing
so proper tissue management could be maintained until
curing was completed.
Occlusion was checked with the patient chair at a 45degree angle. Bausch articulating paper, horseshoe shape,
200 microns thick, was used first, and the patient was
instructed to chew on the paper as if chewing gum. Next,
the patient was instructed to tap straight up and down on
red Troll Foil articulating foil. Any marks from the chewing
strokes that weren’t covered by the red paper were
removed to eliminate interferences and reduce the risk of
material fracture (Figs. 33a–c).
The restorations were then polished (Fig. 34). For #3
e.max restoration, the burs were NTI Cera Glaze - green,
blue and yellow, in order. The green prepolisher was not
used on the Empress restoration for #4.
The final result was minimally invasive restorations that
appear and function naturally, while decreasing risk of tooth
fracture, and minimize further risk to the teeth. (Figs. 35a–36b).
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Editorial note: This article was published in CAD/CAM
C.E. Magazine No. 01/2014.
References
1. Gonzalez-Lopez S, DeHaro-Gasquet F, VilchezDiaz MA, Ceballos L, Bravo M. Oper Dent. 2006;
31(1):33–38.
2. Fennis WM, Kuijs RH, Kreulen CM, Roeters FJ,
Creugers NH, Burgersdijk RC. Int J Prosthodont. 2002;
15(6):559–563.
3. St-Georges AJ, Sturdevant JR, Swift EJ Jr, Thompson JY.
J Prosthet Dent. 2003; 89:551–557.
4. Magne P, Belser UC. Porcelain Versus Composite
Inlays/Onlays; Effects of Mechanical Loads on Stress
Distribution, Adhesion, and Crown Flexure. Int J Periodontics Restorative Dent. 2003; 23:543–555.
5. Bakeman E, Kois J, Posterior, All-Porcelain, Adhesively
Retained Restorations. Inside Dentistry. 2009: 20–33.
6. Dumfahrt H, Schaffer H. Porcelain Laminate Veneers.
A Retrospective Evaluation After 1 to 10 Years of Service:
Part II—Clinical Results. Int J Prosthodont. 2000;
13(1):9–18.
7. Kois DE, Chaiyabutr Y, Kois JC. Comparison of Load-
Fatigue Performance of Posterior Ceramic Onlay
Restorations Under Different Preparation Designs.
Compendium Contin Educ Dent. 2012; 33(3):2 –9.
8. Tjan AH, Dunn JR, Sanderson IR. Microleakage
Patterns of Porcelain and Castable Ceramic Laminate
Veneers. J Prosthet Dent. 1989;61(3):276–282.
9. Yuzbasioglu E, Kurt H, Turunc R, Bilir H. Comparison
of Digital and Conventional Impression Techniques:
Evaluation of Patient’s Perception, Treatment Comfort,
Effectiveness and Clinical Outcomes. BMC Oral Health.
2014. 30;14:10.
10. Patzelt SB, Lamprinos C, Stampf S, Att W. The Time
Efficiency of Intraoral Scanners: An In Vitro Comparative
Study. J Am Dent Assoc. 2014; 145(6):542–551.
11. Geurtsen W, Schwarze T, Gunay H. Diagnosis,
Therapy, and Prevention of the Cracked Tooth Syndrome.
Quintessence Int. 2003;34(6):409–417.
12. Aminian A, Brunton PA. A Comparison of the Depths
Produced Using Three Different Tooth Preparation
Techniques. J Prosthet Dent. 2003;89(1):19–22.
13. Larson TD, Douglas WH, Geistfeld RE. Effect of
Prepared Cavities on the Strength of Teeth. Oper Dent.
1981;6(1):2–5.
ADVERTORIAL
Admira® Fusion – the first purely
ceramic-based restorative material
With Admira Fusion VOCO presents the worldwide first purely ceramic-based universal
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ORMOCER®-based restorative system, as early as 1999, and having followed it up
with Grandio, the first nanohybrid composite, in 2003, intensive research has now
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Admira Fusion, not only for the fillers but also – and this represents the innovative
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The ORMOCER®s (”Organically Modified Ceramics“) used in the manufacture of
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Fusion’s particularly high colour stability gives it an additional edge and allows its
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Being a very homogeneous material, it offers outstanding handling and is compatible
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increments of up to 4 mm in thickness while delivering absolutely identical physical
values. The fast-track version also has a convincing, low level of volume shrinkage, as
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Admira Fusion, the worldwide first purely ceramic-based restorative material.
ADVERTORIAL
Highly aesthetic restorations in the anterior and posterior region with Admira Fusion
Figure 1: Enamel-dentine fracture on tooth 21.
Figure 2: Aesthetic result after polishing.
Figure 3: Insufficient amalgam restorations in teeth 46 and 47.
Figure 4: Finished, polished restorations (clinical photos: Dr
Sanzio Marques, Passos/Brazil).
Indications
• Thanks to the most innovative ORMOCER® technology
– by far the lowest polymerisation shrinkage (1.25 % by
volume) and particularly low level of shrinkage stress in
comparison to all conventional restorative composites
– inert, so highly biocompatible and extremely resistant to
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– perfect coordination of translucence with opacity for
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• Excellent handling, simple high-lustre polishing procedure
coupled with high surface hardness guarantee first-class
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• Compatible with all conventional bonding agents
• Class I to V restorations
• Base in class I and II cavities
• Reconstruction of traumatically damaged anteriors
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• Correction of shape and shade for improved aesthetic
appearance
• Locking, splinting of loose anteriors
• Repairing veneers, small enamel defects and temporary
C&Bmaterials
• Restoration of deciduous teeth
• Core build-up
• Composite inlays
Advantages
• The worldwide first purely ceramic-based restorative
material
– pure Silicate Technology, i.e., fillers and resin matrix
based purely on silicon oxide
– contains no classic monomers
Manufacturer: VOCO GmbH, P.O. Box 767, 27457
Cuxhaven, Germany, www.voco.com, info@voco.com
Contact VOCO Australia & New Zealand:
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KURARAY NORITAKE
ZIRLUX
CLEARFIL MAJESTY ES FLOW
ZIRLUX® ST1
CLEARFIL MAJESTY™ ES Flow is
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CLEARFIL MAJESTY™ ES Flow
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Zirlux ST1 is a high translucency, strong, aesthetic Zirconia material
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well as 89 x 71mm puks and Cerec mandres blocks.
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VHF N4 IMPRESSION
MODELLING FLUID RS
The Art of Wet Grinding
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Ceramic materials that support longer
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MODELLING FLUID RS surpasses these
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GC
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The EQUIA Forte system consists of
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CLEARFIL™ Universal Bond
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new standards around the world.
Root Canal Shaping - Innovative and accurate
The CanalPro Apex Locator is characterized by its brilliant, coloured
3D panel and its accuracy of measurement. The ergonomic design
and easy operation allow comfortable use.
• Virtual Apex Function to mark
a predetermined position at
the required distance from
the apex
• Audio feedback with volume
control
• Built-in demo mode
• Auto-off after 5 min. without
use
• Built-in self-test for a fast
function control
• Rechargeable battery
ISOLITE SYSTEMS
COLTENE
ISOVAC
FILL-UP!
The Isovac dental isolation adapter is
perfect for rounding out other
operatories with easy-to-use oral control.
Like the Isolite and Isodry you can take
advantage of all the benefits of our
award winning Mouthpieces. The strong,
ultra lightweight Control Head Assembly
is constructed of an easy-to-clean
autoclavable polymer. Dual vacuum
controls enable the operator to focus
continuous hands-free vacuum suction
either in the upper or lower quadrant, allowing better control
moisture and oral humidity. The adapter quickly attaches to Saliva
Ejector line in the operatory. The Isovac is the perfect solution for
practices to add an affordable and versatile alternative for oral control.
This tooth coloured, fluorescent and
radiopaque bulk composite provides a
perfect amalgam replacement and
alternative to glass ionomer cements,
compomers and conventional filling
therapy. Owing to its dual curing
properties, fillings with Fill-Up! can be
administered in arbitrary filling depth
without the need of an additional
covering layer.
Fill-Up! is applied in only one single layer and finished with rotary
instruments. The material is easy and quickly polishable to high gloss and
is therefore your perfect choice for all Class I and II fillings, cavity lining and
core build-ups – every time when a fast and aesthetic restoration is needed.
Fill-Up! Deep, Fast, Perfect!
GC
COLTENE
MI VARNISH
AFFINIS BLACK
MI Varnish™ is a 5% NaF varnish enhanced with 2% RECALDENT
(CPP-ACP) to give an exceptional fluoride varnish that releases more
bio-available fluoride, calcium and phosphate.
Perfect brush, optimum flow Packaged with the “perfect application
brush”, MI Varnish gives clinicians the smoothest and easiest fluoride
varnish application experience. Smooth, translucent and tasty. Once
applied, MI Varnish has a beautiful smooth consistency and a neutral
shade with natural translucency. The great tasting strawberry and mint
flavours mean MI Varnish will be your patient’s first preference as well.
Visible precision with
attention to detail
High contrast AFFINIS heavy
body BLACK EDITION, offers
optimal stability with fast
pressure build-up, ideal for an
excellent die effect. The
impression can be read exceptionally well in combination with gold
or silver AFFINIS PRECIOUS. This unique colour and contrast
combination presents details precisely and supports the qualitative
assessment of the impression result.
AFFINIS PRECIOUS impression materials have an innovative and
unique surface affinity, thus wetting tooth and gingiva quickly. The
excellent flow properties of AFFINIS PRECIOUS captures all critical
surface details of the preparation, even under the most difficult
moist conditions. The self-contouring consistency prevents air
pockets and virtually excludes any air voids or distortions.
All products available from: HENRY SCHEIN HALAS • Tel: 1300 65 88 22 • www.henryschein.com.au
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