Dental News Sept 2013

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64.

68.

Exposure of Dental Staff to Nitrous Oxide

Customizing Esthetic Complete Dentures

Management of Non-Vital Tooth Bleaching

Dr. Omar Mustafa

Dr. Nicole Harrak Jabbour, Pr. Carina Mehanna Zogheib

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

Lebanese Dental Association North Lebanon

Lebanese University International Convention 2013

ACE Surgical 41 ACTEON 47 A-DEC 49 AL TURKI 52 BA Intl 19BELMONT 18BIEN AIR 39 BISCO 62CARESTREAM 63 CAVEX 77 COLTENE 27E4D 17DENTSPLY 8DENTAURUM 29DISCUS PHILIPS 67 DURR 57EMOFORM 5 GC 33 GSK C3, 31, 51, 65 GENDEX 6HENRY SCHEIN 58HU FRIEDY 36ITENA 23

IVOCLAR 1, C4JDENTAL CARE 21KAVO C2 KERR 71LISTERINE 73MEDESY 30MICRO MEGA 53 MORITA 15NSK C1 ORMCO 70ORTHO ORGANIZERS 80PLANMECA 45 RITTER 43SCI CAN 13SIRONA 25SULTAN 59 SOREDEX 9TEBODONT 4 ULTRADENT 35 VITA 79 VOCO 7 W&H 69 ZHERMACK 2

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Dental News, Volume XX, Number III, 2013

Dr. Nazem Assaad, Dr. Najib Abou Hamra, Dr. Maha Ghotmi

Autotransplantation of Tooth in Children with Mixed DentitionDr. Abu-Hussein Mohamad, Dr. Abdulgani Azzaldeen Muhamad

May 30-31, June 1, 2013Las Salinas, Anfeh, Lebanon

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International Calendar 11

10th Annual Meeting of ESCD

16th International Dental Congress of the Egyptian Dental Association

The Lebanese Orthodontic Society

AEEDC

1st ORMCO MENA Symposium

Asia Pacific Dental Congress

GNYDM 2013

3rd Pan Arab Endodontic Conference

DFCIC 2013

The 10th congress of SENAME

National Guard Health Affairs

October 3 - 5, 2013 atCinema Lux Turin, ItalyWebsite: www.escdonline.eu

November 5 - 8, 2013at InterContinental Citystars Hotel, Cairo, EgyptWebsite: www.eda-egypt.org

September 27 - 29, 2013Hammamet, Tunisia Website: www.sename.eu

September 29 - October 1, 2013at the King Saud University, College of Medicine, RiyadhEmail: [email protected]

November 28 - 30, 2013at the Hilton Habtoor, Beirut, Lebanon Email: [email protected] Website: www.paec2013.org

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

December 6-7, 2013Emirates Towers, Dubai, UAEWebsite: www.ormcoeurope.com

June 17-19, 2014Dubai World Trade Center, UAEWebsite: www.apdentalcongress.org

November 29 - December 4, 2013570 Seventh Avenue, Suite 800 New York, NY 10018, USA.Email: [email protected] Website: www.gnydm.com

January 12-14, 2014Riyadh International Convention and Exhibition center, KSAWebsite: www.sds.org.sa

November 8 - 9, 2013at Jumeirah Beach Hotel, Dubai, UAE Website: www.cappmea.com

October 31 - November 3, 2013at Movenpick Resort Raouch, Beirut, Lebanon Email: [email protected] Website: www.leborthosoc.com

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

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

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

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12

Prosthetic DentistryComplete dentures

Customizing Esthetic Complete dentures

Dr. Nazem Assaad

Dr. Najib Abou Hamra

Dr. Maha Ghotmi

Introduction and Background Esthetic is a predominant factor for complete denture success (Carlsson et al. 1967). It is the most frequent complaints among complete denture patients (Jeganathan, 1993). Comfort-able but unaesthetic dentures seem to be unac-cepted by patients (Brewer, 1967). Compensat-ing alveolar bone loss, correctly supporting lips and reestablishing the correct vertical dimension of occlusion are basic steps for achieving pa-tient normal appearance. However, this is not sufficient to achieve individual denture esthet-ics. Denture esthetics has been defined as the cosmetic effect produced by a dental prosthesis that affects the desirable beauty, attractiveness, character and dignity of the individual (Glossary of Prosthodontic terms) which means proper form and shade of denture teeth and also in-dividual set up of the teeth in order to achieve individual esthetic. Classically, three esthetic concepts have been differentiated to achieve denture esthetics (Waliszewski et al. 2006)1- The denture look: an esthetic concept devel-oped mainly as a result of a functionally oriented tooth positioning as well as from common errors in fabrication and appearance for complete den-ture wearers (Fig. 1-2).

Fig.1 & 2 Regular arch form

Fig. 5: Male teeth setup based on criteria given by the natural look theory

Fig 1

Fig 2

2- The supernormal teeth: Shor and colleagues in 2005 defined the supernormal concept as “at-tractive, idealized, and above-average dental es-thetics. A custom made look to please the body image of the patient (Fig. 3-4).

3- The natural look : described by Frush and Fischer as a natural appearance related to ana-tomic determinants of gender, age and person-ality. It seeks to restore the most natural patient smile and its appearance (Fig. 5).

There is limited evidence-based information available when achieving dentate appearance in

Fig 3

Fig 4

Fig 5

[email protected]

Lebanese University,Beirut Arab University

Beirut, Lebanon

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2414

edentulous patients. However the natural con-cept of Frush and Fisher (Frush and Fisher, 1955) is still useful, and this will ensure a better psy-chological integration of the artistic prosthesis (Waliszewski M 2005).The aim of this paper is to develop the natural look theory and give a series of clinical examples.In order to look natural, denture teeth should be as close as possible and look as close as pos-sible to natural teeth. However there might be some discrepancies between the clinical situa-tion of the edentulous mouth and the look of the natural teeth before extractions occurred. It is therefore very important to find a reasonable compromise between the reality of the edentu-lous mouth and the position of the natural teeth as they should have been. The natural look the-ory is the way to achieve this goal. The mixture of personality look, gender and age in combina-tion with the clinical situation will determine the final look and position of teeth. To emphazise the personality, age and gender some specific characterization might be also needed to attain this result. Clinical examples will try to explain how this theory can be used (Fig.6-24).

Fig 6

Fig 9

Fig 10

Fig 11

Fig 12

Fig 13

Fig 6

Fig 6

Fig. 6: Rude and aggres-sive appearance due to the prominent position of the canine following to the strong retruded Position of the lateral incisors especially right side.

Fig. 9: As light rotation of the centrals accentuates the vigor look

Fig. 10: The projection of a prominent canine gives to the smile a more rugged and typically male ap-pearance.

Fig. 11: Female teeth set with a curved smile line.

Fig. 12: Regular arch and teeth with more rounded shape.

Fig 13: Anterior rotation mesial of the central incisor combined with cervical inclination express a female character.

Fig. 7: Aggression is rein-forced by the existence of the diastema.

Fig. 8: Male teeth setup: Free edges touching the horizontal plane, giving a vigorous male look.



16

Fig 14

Fig 20

Fig 21

Fig 22

Fig 23

Fig 24

Fig 15

Fig 16

Fig 17

Fig 18

Fig 19

Fig. 14: Lateral incisors over-lapping the central incisors, gives softness to smile.

Fig. 15: Feminine teeth setup: strong inclination and rotation of the lateral incisors, absence ofcanine prominent, a smile curved line, give softness to the over all smile.

Fig. 16: The difference in shape and size between the lateral and central incisor accentuates the feminine character.

Fig. 18: Teeth setup based on the photograph

Fig. 19: Dark teeth and gin-gival recession in the elderly patient.

Fig. 20: Crowding at the lower incisors especially in the elderly patients.

Fig. 21: Artifi cial teeth similar to natural teeth (overcrowding, abrasion).

A result close to the natural staining teeth to simu-late cracks in the enamel and other imperfections especially in case of unimaxillary edentulous patient.

Fig. 24: Covering the distal part of a tooth on the mesial side of its neighboring one gives an effect of crowding and smaller sized teeth.


ConclusionSome patients ask for a perfect denture look or for a supernatural teeth form, shade and ar-rangement; the majority prefer a natural look and smile. This implies an effort from the dentist and his technician to achieve this goal. The end result being an individualized esthetic denture.Achieving a natural look in complete dentures needs skills, scientific back up information re-garding the set up of teeth but most of all the collaboration between the dentist and his pa-tient to find a reasonable compromise between what is expected and what can be done.

References

1- CARLSSON GE, OTTERLAND A, WENNSTROM A, ODONT D. PATIENT FACTORS IN AP-PRECIATION OF COMPLETE DENTURES. J PROSTHET DENT 1967; 17:322-8.170.2- JEGANATHAN S, PAYNE JA. COMMON FAULTS IN COMPLETE DENTURES: A REVIEW.QUINTESSENCE INT. 1993 JUL;24(7):483-7. REVIEW.3- FRUSH JP, FISHER RD.INTRODUCTION TO DENTOGENICRESTORATIONS.JPROSTHET DENT 1955; 5: 586-95.4- BREWER A. SELECTION OF DENTURE TEETH FOR ESTHETICS AND FUNCTION. . J PROSTHET DENT 1970; 23: 368-734.5- WALISZEWSKI M, SHOR A, BRUDVIK J, RAIGRODSKIAJ. A SURVEY OF EDENTULOUS PATIENT PREFERENCE AMONG DIFFERENT DENTURE ESTHETIC CONCEPTS. J ESTHET RESTOR DENT. 2006;18(6):352-68; DISCUSSION 369.6- ACADEMY OF DENTURE PROSTHETICS: GLOSSARY OF PROSTHODONTIC TERMS. J PROS-THET DENT 1970; 38:81.7- WALISZEWSKI M. RESTORING DENTATE APPEARANCE: A LITERATURE REVIEW FOR MODERN COMPLETE DENTURE ESTHETICS. J PROSTHET DENT 2005 OCT-94 (4):4078- SHOR A, SHOR K, GOTO Y. THE EDENTULOUS PATIENT AND BODY IMAGE ACHIEVING GREATER PATIENT SATISFACTION. PRACT PROCED AESTHET DENT 2005;17:289–96.

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Autotransplantation

Oral Surgery

20

Dr. Abu-Hussein Muhamad

abuhusseinmuhamad@gmail

Dr. Abdulgani Azzaldeen

AbstractAutotransplantation of tooth in children is the surgical movement of a tooth from one place in the mouth to another in the similar individual. Once thought to be uncertain, Autotransplanta-tion has achieved high success rates and is an outstanding option for tooth replacement in children. Although the indications for autotrans-plantation are narrow, careful patient assort-ment coupled with a suitable method can lead to exceptional esthetic and useful results. One benefit of this procedure is that placement of an implant-supported prosthesis or other form of prosthetic tooth replacement is not needed. A review of the recommended surgical technique as well as success rates is also discussed.

Key Words; Autotransplantation, clinical indica-tions, healing factors, cryopreservation.

IntroductionThe age at which the first tooth appears differs very much from child to child. Very occasionally, children are born with one or more teeth. These may need to be removed if they are very loose, as there is a risk that the child could swallow them, or have difficulties with breastfeeding. Other children may not expand any teeth until they are more than a year old. Usually, however, the first tooth - which tends to be in the middle of the lower jaw - appears at around six months of age. The complete set of 20 primary teeth (baby teeth) is usually present by the age of two-and-a-half years. The first permanent teeth appear at around six years of age. These tend to be the incisors in the middle of the lower jaw and the first permanent molar teeth. The molars come up behind the primary teeth, they do not

replace them.1,2,3 As there are a lot of reasons for autotransplant-ing teeth in children, tooth defeat as a result of dental caries is the most common sign, par-ticularly when mandibular first molars are con-cerned. First molars erupt early and are often a lot restored. Autotransplantation in this situation involves the removal of a third molar which may then be transferred to the site of an unrestorable first molar. Extra circumstances in which trans-plantation can be careful include tooth agenesis (particularly of premolars and lateral incisors), shocking tooth loss, atopic outbreak of canines, root resorption, large endodontic lesions, cervi-cal root fractures, localized juvenile periodontitis as well as other pathologies (Alberg, 1999). Suc-cessful transplantation depends on specific re-quirements of the patient, the donor tooth, and the recipient site.3

Patient selection is very significant for the achievement of autotransplantation. Child must be in good health, able to follow post-operative instructions, and available for follow-up visits. They should also demonstrate a satisfactory level of oral hygiene and be agreeable to regular den-tal care. Most importantly, the child must have a suitable receiver site and donor tooth. Patient collaboration and comprehension are extremely important to ensure predictable result. 4

The most significant criteria for success connect-ing the recipient site are adequacy of bone sup-port. There must be enough alveolar bone sup-port in all dimensions with sufficient attached keratinized tissue to allow for stabilization of the transplanted tooth. In addition, the recipient site should be free from acute disease and chronic irritation.

Autotransplantation of Tooth in Children with Mixed Dentition

Athens University

Al Quds University


Autotransplantation

Oral Surgery

22

The donor tooth should be positioned such that extraction will be as atraumatic as possible. Ir-regular root morphology, which makes tooth removal very difficult and may involve tooth sec-tioning, is contraindicated for this surgery. Teeth with also open or closed apices may be donors; however, the most unsurprising results are ob-tained with teeth having between one-half to two-thirds finished root development. Surgi-cal treatment of teeth with less than one-half root formation may be too shocking and could compromise further root development, stunt-ing maturation or changing morphology. When root development is better than two-thirds, the increased length may cause infringement on vi-tal structures such as the maxillary sinus or the lesser alveolar nerve. Also, a tooth with total or near complete root configuration will usually re-quire root canal therapy, while a tooth with an open apex will remain vital and should carry on root development after transplantation. In the latter case, successful transplantation without the need for further endodontic therapy is usu-ally seen. (Jens, et al. 2001)The mixed dentition is the developmental pe-riod after the permanent first molars and inci-sors have erupted, and before the remaining deciduous teeth are lost. Treatment is usually done early in this period. The American Associa-tion of Orthodontists recommends all children should see an orthodontist by age 7. A favor-ably developing occlusion at this stage has these characteristics. 2,5

Mixed Dentition. In a longitudinal study, Moor-rees and Reed found that arch length decreases 2 to 3 mm between the ages of 10 and 14 years, when primary molars are replaced by permanent premolars. These authors also found a reduction in arch circumference of approximately 3.5 mm in the mandible in boys and 4.5 mm in girls dur-ing the mixed-dentition period. If crowding is evident in the early mixed-dentition years, it will not improve with further growth and develop-ment. (Moorrees & Reed, 2007)Mesial shift. In patients with a spaced primary dentition and a flush or straight terminal plane, the flare-up of the permanent mandibular first molars at approximately 6 years of age closes the space distal to the primary canines (primate space) and transforms the molar relationship into a Class I relationship. This has been referred

to as “early mesial shift.”9 In patients with a closed primary dentition (no primate space) and a straight terminal plane, the transformation into a Class I molar relationship may not occur until the exfoliation of the primary molars. At approximately 11 years of age, the permanent first molars migrate forward to close up the ex-cess leeway space provided by the difference in size between the primary molars and the suc-cedaneous premolars. This has been called “late mesial shift.”9 The transformation into a Class I molar relationship depends on a number of den-tal and facial skeletal changes, both genetic and environmental, that interact to achieve (or not achieve) a normal occlusion. Several factors may prevent the establishment of a normal posterior occlusion. Extensive interproximal caries or ecto-pic eruption of the maxillary first molars may re-sult in premature loss of primary second molars and a subsequent loss of arch length. Periapical pathology of primary teeth may hasten the erup-tion of their permanent successors. Tumors and supernumerary teeth may impede the course of eruption. Prolonged retention of primary teeth may disturb the eruption sequence. (Jens, et.al. 2001). Leeway space. The difference in size be-tween the primary molars and the succedaneous premolars is termed “leeway space.” This varies greatly from person to person, according to a longitudinal study by Bishara and colleagues.12

the average leeway space in that study was 2.2 mm in the maxilla and 4.8 mm in the mandible. The differences in the leeway spaces between the maxillary and mandibular arches were 1.3 mm for male subjects and 1.1 mm for female subjects. The range in the amount of leeway space between people is quite remarkable and can exceed the above amounts.Incisor liability. The size differential between the primary and permanent incisors is called “inci-sor liability.” In the anterior segment, the four permanent maxillary incisor teeth are, on aver-age, 7.6 mm larger than the primary incisors. In the mandibular arch, the permanent incisors are 6.0 mm larger than the corresponding primary teeth.13 Incisor liability varies greatly from person to person. The spacing of the primary anterior teeth; lateral and even possibly distal shifting of the primary canines; and facial positioning of the incisors all contribute to the incisor liability. All of these factors will increase the arch perimeter and


Autotransplantation

Oral Surgery

24

help the mouth accommodate the larger perma-nent teeth. Eruption sequence. In a study by Lo and Moyers,14 the most favorable sequence of eruption to obtain a normal molar relationship was as follows: first molar, central incisor, lateral incisor, first premolar, second premolar, canine, second molar in the maxilla and first molar, cen-tral incisor, lateral incisor, canine, first premolar, second premolar, second molar in the mandible. The most unfavorable sequence in the maxilla was that in which second molar erupted earlier than either the premolars. The most unfavorable sequence in the mandible was that in which the canines erupted later than the premolars.{Tab.1}

Treatment strategiesMixed dentition treatment goals often focus on skeletal rather than dental correction. To design a treatment plan, the clinician must understand the growth and development patterns, and the known effects of the chosen treatment modal-ity. Many dental development problems can be headed off in the mixed dentition; for example, anterior cross bites. In-time removal of a decidu-ous tooth could prevent a cross bite, but once the permanent upper incisor is caught on the lin-gual of the lower incisors, treatment is needed. The anterior cross bite can cause tissue damage around the affected lower incisor. Another ex-ample is the displaced lower midline as a result

of the early loss of a lower deciduous canine. 6,7

Auto-transplantationThis is a surgical procedure in which tooth from one part of the mouth is transplanted to anoth-er. Indications for such procedure are as below:1. Hypodontia – This is where there are missing tooth or teeth such as a missing central incisor, a premolar can be use as a substitute.2. Premature loss of tooth- especially true in first molar area where it may have been lost due to caries and the space is too great to be closed by the second molar. A third molar tooth is judi-ciously removed and a socket is prepared in the first molar area and molar is then placed and se-cured with 0.5 mm eyelet wire to the adjacent teeth. There are a lot of dental procedures be-ing utilized by consumers whether for aesthetic purposes or medical, and tooth transplantation is the most common one. Basically, this is done by moving a tooth from a site to another site of the mouth and rarely to another recipient. Stud-ies showed that implants utilized in filling gaps of missing front teeth are not the best alterna-tive since this can cause a considerable amount of bone loss and abrasion on neighboring teeth and surrounding gums. Auto transplantation is considered a better alternative in certain cases.1,4,7,8

Auto transplantation is a tooth surgical proce-dure in one location to another location within the same person. Before, this was considered experimental, but in present times auto-trans-plantation is a better alternative for tooth re-placement with high success rate. Indication for clients opted for this procedure is narrow {Tab.2}, and thorough patient selection added with appropriate technique leads to outstanding aesthetic and functional capabilities. One advan-tage of this procedure is that the placement of implant-supported prosthesis or other form of prosthetic tooth replacement is not essentially required. 9,10

Indications for auto-transplantation Usually, auto transplantation is done because of tooth loss due to dental caries, predominantly in the first molars of the lower jaws. Early eruption of first molars is frequently restored (Byers, et. al, 2002). In this case, the third molar is then re-moved via auto transplantation and then trans-

Criteria for success in autotransplantationRadiographic examination - No evidence of progressive

inflammatory root resorption

- Normal PDL space width around the transplanted tooth

- No disturbance in root development

- Lamina dura

- Healing of alveolar bone

Clinical examination - Normal tooth mobility and

normal tooth function

- Gingival healing and no indication of

marginal attachment loss, inflammation

- Healing of dental pulp

- No patient discomfort

- Normal percussion sound

Histological examination - The PDL fibers are aligned to

perpendicular, not parallel, to the root and alveolar bone

- However, without extraction, it is impossible to evaluate

clinical cases histologicallyTable 1

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Oral Surgery

26

Autotransplantation

ferred to the site of the first molar that is beyond saving. Transplantation can also be opted in cas-es like tooth agenesis (premolars and lateral inci-sors), traumatic tooth loss, canine atopic erup-tion, root resorption (body of the cells attack and destroy a part of a tooth), large endodontic lesions, cervical root fractures, and localized ju-venile periodontitis. 3,6,7,9,10

Transplant success depends primarily on the specified requirements from the client, donor tooth, and recipient site. Autotransplant success is based on how well the healing takes place af-ter the procedure (Czochrowska, et al. 2000). A healthy tooth with undamaged periodontal ligament will have higher degree of success. Before having this procedure, clients must have a good health and oral hygiene regimen. Most of all, a suitable donor tooth and recipient site are required so that tooth can be replanted ap-propriately. The site should be well prepared in receiving the tooth donor. Size should accom-modate a tooth, along with sufficient alveolar bone structure, which enables support. This should be free from inflammation and infection. The replanted Donor Tooth (the tooth) should be positioned to assist in easy removal with minimum trauma possible. Misshapen teeth or abnormal root morphology are not used in transplants 8,9.10,11

Tooth length and development stage is vital in determining the affectivity of a replantation wherein the tooth has between one-half to two-thirds complete root development. So, auto-transplantation of the premolars where there is half to two thirds completed root development have higher chances of pulp survival, with mini-mum chances of necrosis (cell death). (Krister-son, 1995). Another factor influencing tooth de-velopment is the status of epithelial root sheath or the covering. HERS or Hertwig’s epithelial root sheath has a continuous production of cells that separates a pulp to a dental follicle. HERS deter-mines the root growth by its degree of damage so the lesser the damage, the greater chance of root growth post transplantation. 2,7,9,10,12

Tooth cryopreservationTeeth auto-transplantation with cryopreserva-tion is an alternative currently utilized for clients in a few clinics. With cryobiology, cells or whole tissues are preserved by cooling it to sub-zero

Successful healing factors associated with autotransplantation of teeth

a. Patient related factors- Better results in younger patients- A patient free of major systemic and metabolic problems or specific habits (e.g., smoking)- Good oral hygiene and a cooperative attitude.

b. Donor tooth related factorsPeriodontal ligament (PDL)- The presence of intact and vital PDL attached to the root surface- Preservation of vital PDL when the tooth is outside the mouth using physiologic salt water or milk or preservation liquids and as short a surgery time as possible- Enhanced healing of the gingival tissue by placing a 1 mm band of PDLfibers on the root above the crest of bone- A major factor in the formation of alveolar bone- A chance of inadequate PDL development as an effective attachment with an impacted tooth (nonfunctioning tooth)Healing of dental pulp- The preservation of Hertwig’s epithelial root sheath (HERS)- Healing of the dental pulp occurs until Moorrees tooth development stage 5- When the diameter of the apical foramina is > 1 mm, there is more than an 87% chance the dental pulp will heal, Continuation of root development- Ideal timing of transplantation is when development of the donor tooth roots is 3/4 to 4/5 completeGingival adaptation- Tight flap adaptation prevents bacterial invasion into the recipient socketRoot morphology- Teeth with a single, cone-shaped root without concavity around the cervical area are most favorable.

c. Recipient site related factors- Bone width and height should be adequate to receive the donor tooth- Better healing can be expected if the PDL tissue is still attached- Transplantation should be performed the day of transplantation orwithin 1 month after extraction

d. Clinical factors- Surgery should be performed by a clinician with experience in such areas as Surgery should be performed by a clinician with experience in such areas as donor tooth extraction, preparation of the recipient site, and tissue management

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28

Autotransplantation

Oral Surgery

temperature at around 77K or -196°C (boiling point of liquid nitrogen). Low temperatures leads to prevention of cell death (necrosis) and ceasing of biological activities along with its biochemi-cal reactions. Experiments on mice showed ef-fectively of cryopreservation on the teeth, re-sulting to dental tissue survival even at below freezing point. (Cooke & Scheer, 2003). Teeth cryopreservation requires a wider understanding of cryoprotective mechanisms of co solvents like dimethylsulfoxide (DMSO) (Andreasen, 2007). Consequently, only a few clinics have the ex-pertise to do tooth cryopreservation and make it available to their clients. With cryopreserva-tion, elevated numbers of healthy teeth extrac-tions can be done for orthodontic purposes and it enables sufficient amounts of donor teeth in cases of extensive surgical reconstruction. Tissue banks for teeth tissues are regulated legally for quality control. 7,9,10,11,13

Surgical technique for tooth transplantationThe same amount of trauma is experienced by

the patients having a removal of impacted molars to that that underwent tooth transplanta-tion. Sedation along with lo-cal anesthesia is utilized in this case. Once the effect of anes-thesia is sufficient, then extrac-tion of the tooth at the recipi-ent site and recipient socket is prepared. Replantation of an acrylic replica of a tooth is done after an x-ray and donor tooth scan. This replica will guide the tooth technician to prepare a donor site for its dimension, etc {Tab.1}. Then, extraction of the donor tooth should have least damage on the periodon-tal ligament and positioned quickly on the recipient site. Instructions and follow-ups given to post operative clients are similar in that of removal of tooth impaction. 4,7,8,13,14,15,16 A soft diet is followed for several days post-surgery, and chew-ing on the transplant should be

avoided. Clients should always maintain good oral hygiene. (Jensen & Kreiborg, 1992)Auto transplantation: Surgical TechniqueThe surgical techniques used in autotransplan-tation have progressively been modeled and refined over the years. Good oral hygiene, self-motivation and a medical history that does not contraindicate transplantation (e.g. cardiac defects) are pre-requisites before this avenue of treatment is embarked upon. Andreasen et al. (1990) carried out a long-term study of 370 autotransplanted premolar teeth to determine a standardised surgical procedure which op-timised pulpal and periodontal healing.15,16,17

Although there is published variations for the surgical technique of auto-transplantation the consistent message is one of a careful atrau-matic surgical technique to maximally preserve an intact periodontal ligament. If Hertwig’s root sheath is traumatized then future root growth is limited or inhibited, according to the severity of this trauma (Andreasen, et al. 1990). Evidence based transplantation techniques are combined in a ‘protocol for transplantation’ included at the end of this paper. 2,13,14,18 In some cases au-totransplantation may not be possible as a one stage procedure. Two stage transplantation has been reported in which an ectopic canine was removed and initially stored in the buccal pouch whilst the recipient site was orthodontically re-opened (Tab.3). The potential problem of re-sorption of the transplanted tooth is minimized if contact between the tooth andperiosteum is avoided during storage. In some situations, there may be resorption of the alveolar ridge at the recipient site with insufficient bucco- palatal width to accommodate the transplant. In such cases, specialized investigative techniques (e.g. Scanora, CT tomography) may need to be car-ried out to ascertain the amount of bone pres-ent bucco-palatally. Alveolar bone grafting of the recipient site may be required prior to trans-plantation. 4,11,14,17,18,19.

Conclusion Although auto transplantation in children has not been established as a traditional means of replacing a missing tooth, the process warrants more reflection. New studies obviously show that auto transplantation of teeth in children is as successful as endosseous dental implant placement. Minimum acceptable success rates

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for endosseous titanium dental implants are 85% after 2 years and 80% after 5 years. For children, auto transplantation may also be con-sidered as a provisional measure. The transplant can replace missing teeth to make sure preserva-tion of bone until growth has ceased and then, if essential, the patient can become a candidate for implants. With suitable patient selection, and presence of a suitable donor tooth and recipient site, auto transplantation should be considered as a viable option for treatment of an edentu-lous space.

References

1. ANDREASEN JO, PAULSEN HU, YU Z, AHLQUIST R, BAYER T, SCHWARTZ O. A LONG-TERM STUDY OF 370 AUTOTRANSPLANTED PREMOLARS. PART I. SURGICAL PROCEDURES AND STANDARDIZED TECHNIQUES FOR MONITORING HEALING. EUR J ORTHOD. 1990;12:3-13. 2. TSUKIBOSHI M. AUTOTRANSPLANTATION OF TEETH: REQUIREMENTS FOR PREDICTABLE SUC-CESS. DENT TRAUMATOL. 2002;18:157-80. 3. ANDREASEN JO, PAULSEN HU, YU Z, BAYER T, SCHWARTZ O. A LONG-TERM STUDY OF 370 AUTO TRANSPLANTED PREMOLARS. PART II. TOOTH SURVIVAL AND PULP HEALING SUBSEQUENT TO TRANSPLANTATION. EUR J ORTHOD. 1990;12:14-24. 4. ANDREASEN JO, PAULSEN HU, YU Z, SCHWARTZ O. A LONG-TERM STUDY OF 370 AUTOTRANSPLANTED PREMOLARS. PART III. PERIODONTAL HEALING SUBSEQUENT TO TRANS-PLANTATION. EUR J ORTHOD. 1990;12:25-37. 5. ANDREASEN JO, PAULSEN HU, YU Z, BAYER T. A LONG-TERM STUDY OF 370 AUTO-TRANSPLANTED PREMOLARS. PART IV. ROOT DEVELOPMENT SUBSEQUENT TO TRANSPLANTA-TION. EUR J ORTHOD. 1990;12:38-50. 6. GARCÍA-CALDERÓN M, TORRES-LAGARES D, GONZÁLEZ-MARTÍN M, GUTIÉRREZ-PÉREZ JL. RESCUE SURGERY (SURGICAL REPOSITIONING) OF IMPACTED LOWER SECOND MO-LARS. MED ORAL PATOL ORAL CIR BUCAL. 2005;10:448-53. 7. CZOCHROWSKA EM, STENVIK A, ALBUM B, ZACHRISSON BU. AUTO TRANSPLANTA-TION OF PREMOLARS TO REPLACE MAXILLARY INCISORS: A COMPARISON WITH NATURAL INCI-SORS. AM J ORTHOD DENTOFACIAL ORTHOP. 2000;118:592-600. 8. ZACHRISSON BU, STENVIK A, HAANAES HR. MANAGEMENT OF MISSING MAXILLARY ANTERIOR TEETH WITH EMPHASIS ON AUTO TRANSPLANTATION. AM J ORTHOD DENTOFACIAL ORTHOP. 2004 ;126:284-8. 9. CZOCHROWSKA EM, STENVIK A, BJERCKE B, ZACHRISSON BU. OUTCOME OF TOOTH TRANSPLANTATION: SURVIVAL AND SUCCESS RATES 17-41 YEARS POST TREATMENT. AM J ORTHOD DENTOFACIAL ORTHOP. 2002;121:110-9.10. TEIXEIRA CS, PASTERNAK B JR, VANSAN LP, SOUSA-NETO MD. AUTOGENOUS TRANSPLANTATION OF TEETH WITH COMPLETE ROOT FORMATION: TWO CASE REPORTS. INT ENDOD J. 2006;39:977-85. 11. KALLU R, VINCKIER F, POLITIS C, MWALILI S, WILLEMS G. TOOTH TRANS¬PLANTATIONS: A DESCRIPTIVE RETROSPECTIVE STUDY. INT J ORAL MAXILLOFAC SURG. 2005;34:745-55. 12. CLOKIE CM, YAU DM, CHANO L. AUTOGENOUS TOOTH TRANSPLANTATION: AN ALTERNATIVE TO DENTAL IMPLANT PLACEMENT? J CAN DENT ASSOC. 2001;67:92-6. 13. BAUSS O, SCHILKE R, FENSKE C, ENGELKE W, KILIARIDIS S. AUTOTRANS PLANTATION OF IMMATURE THIRD MOLARS: INFLUENCE OF DIFFERENT SPLINTING METHODS AND FIXATION PERIODS. DENT TRAUMATOL. 2002;18:322-8. 14. DÍAZ JA, ALMEIDA AM, BENAVENTE AA. TOOTH TRANSPLANTATION AFTER DENTAL INJURY SEQUELAE IN CHILDREN. DENT TRAUMATOL. 2008;24:320-7. 15. BAUSS O, ZONIOS I, RAHMAN A. ROOT DEVELOPMENT OF IMMATURE THIRD MO-LARS TRANSPLANTED TO SURGICALLY CREATED SOCKETS. J ORAL MAXILLOFAC SURG. 2008;66:1200-11. 16. PAULSEN HU, ANDREASEN JO. ERUPTION OF PREMOLARS SUBSEQUENT TO AUTOTRANS-PLANTATION. A LONGITUDINAL RADIOGRAPHIC STUDY. EUR J ORTHOD. 1998;20:45-55. 17. CZOCHROWSKA EM, STENVIK A, ZACHRISSON BU. THE ESTHETIC OUT¬REFERENCES WITH LINKS TO CROSSREF - DOICOME OF AUTOTRANSPLANTED PREMOLARS REPLACING MAXILLARY INCISORS. DENT TRAUMATOL. 2002;18:237-45. 18. AKKOCAOGLU M, KASABOGLU O. SUCCESS RATE OF AUTOTRANSPLANTED TEETH WITHOUT STABILISATION BY SPLINTS: A LONG-TERM CLINICAL AND RADIO LOGICAL FOLLOW-UP. BR J ORAL MAXILLOFAC SURG. 2005;43:31-5. 19. ECKERT SE, CHOI YG, SÁNCHEZ AR, KOKA S. COMPARISON OF DENTAL IMPLANT SYSTEMS: QUALITY OF CLINICAL EVIDENCE AND PREDICTION OF 5-YEAR SURVIVAL. INT J ORAL MAXILLOFAC IMPLANTS. 2005;20:406-15.

30

Oral Surgery


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

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

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

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32

Nitrous Oxide Exposure

Paediatric Dentistry

Exposure of dental staff to NITROUS OXIDE

Dr. Omar Mustafa

[email protected]: Chronic exposure to nitrous oxide has been reported as a potential health hazard. Leakage from the mask delivery system and in-efficient scavenging can lead to significant pol-lution.Aims: to compare the nitrous oxide traces be-tween different dental procedures and to moni-tor the nitrous oxide traces in the working envi-ronment. Methods: Nitrous oxide was measured in 27 dental procedures according to two methods. First method, measurements were recorded ev-ery two minutes during the inhalational sessions. Second method measurements were recorded from different distances from the operation site.Results: 21 sessions used for the first method. No statistical difference was found between the means of the nitrous oxide traces through the extraction and conservative sessions. Age group from 6 to 8 years has the highest measured trac-es. High traces recorded during stressful events6 sessions were selected for the second method. The distance obeys the inverse square law.Conclusions: uncooperativeness would lead to excessive pollution. Patient conditioning to breathing through nose would be very helpful. Equipment to be checked for leaks and that the mask is of the appropriate size and tight fitting. Ensure that scavenging and surgery ventilation is adequate.- Keywords: chronic exposure, nitrous oxide, dentistry.

IntroductionAnxiety and fear of dental treatment in children is recognized as a problem in patient manage-ment. A variety of behavioural management techniques have been proposed to control these fear reactions.1 Management approaches to

anxiety vary according to its severity, the age of the patient, the degree of cooperation and the patient’s medical history.2 For some patients se-dation will be required, with inhalation sedation using nitrous oxide/oxygen commonly used. In-halation sedation with low to moderate concen-trations of nitrous oxide in oxygen has a remark-able safety record, in over 45 years of use there has not been any mortality or serious morbidity recorded.3 Inhalation of nitrous oxide is admin-istered via a special nosepiece. The gases are in-haled continually and the nitrous oxide ceases to have effect immediately after cessation of its administration. A patient recovers full conscious-ness within five minutes after administration of 100% oxygen.4

Chronic occupational exposure to trace concen-trations of nitrous oxide has been reported as a potential health hazard,5 though the available evidence is weak.6 Some authors report com-plications to range from haematological abnor-malities, neurological deficits or increased risk of spontaneous abortions in women.7,8 These effects may present a serious occupational haz-ard to dental surgeons and dental nurses who are regularly exposed to nitrous oxide when un-dertaking inhalation sedation. The British Health and Safety Commission advises that the maxi-mum exposure of clinical staff to nitrous oxide gas should be 100 ppm over an 8 hour time weighted average period.9 In the 1990s prac-titioners were educated in ways to effectively scavenge trace gas contamination, with the pri-mary method being the evacuation system and the scavenging nasal hood/mask in addition to regular monitoring programs.10 Leakage of gas from the mask delivery system and inefficient scavenging of waste gas from the surgery at-mosphere can lead to significant pollution of the

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dental surgery.9 There are many nitrous oxide analysers and dosimeters like the infrared nitrous oxide analyser which is used in many studies. Several types of dosimeters are available which can be worn as lapel badges during working hours.11 In order for dentists to feel comfortable that they are attaining safe levels of nitrous oxide within their surgeries they need to understand the risk of pollution from different procedures and also the risk to individuals within the sur-gery dependent on where they are placed rela-tive to the source of pollution. The purpose of this study was to compare the measured nitrous oxide traces between the different dental pro-cedures and to monitor the nitrous oxide traces in the working environment of the dental staff at variable distances at the paediatric dentistry department of Liverpool Dental Hospital.

Materials and MethodsThis was a cross sectional study, ethical approval was not required as regular monitoring is part of the safety routine. Measurement of nitrous oxide was done in a convenience sample of 27 child patients attending the Paediatric depart-

ment of the Liverpool Dental Hospital for den-tal treatment. The Department of Paediatric Dentistry is an open clinic design in which the dental units are separated by short partitions. The nitrous oxide machine used was the MDM Quantiflex which is a continuous flow type. The machine matches the universal safety mea-sures of the sedation machines. It has the main parts which are the flowmeter, circuit bag, air entrainment valve, scavenging nasal hood and expiratory valve, and the conducting tubes. It uses continuous gas flow and the rate can be adjusted. One examiner monitored the nitrous oxide traces, he was trained in the use of the ni-trous oxide analyser (the Medigas PM3010 N2O Analyser). The Medigas PM3010 N2O Analyser is a handheld infrared nitrous oxide monitor which can measure nitrous oxide concentrations in the range of 0-1,000 ppm with a resolution of 5 ppm. Readings can be displayed in real time or as an 8 hour TWA (Time Weighted Average). The analyser was calibrated and checked by the Medical Engineering Department at the Royal Liverpool Hospital.

The ProcedureBefore the start of each inhalation session, per-mission was taken from the operators. Also parents and patients were informed about the study and assured that there would be no any intervention with dental treatment.

Nitrous oxide traces were measured for two procedures

The First ProcedureIn the first procedure, measurements were re-corded every two minutes during 21 inhalational sessions as close as possible to the operation site within a circle of 20 cm diameter. A stop-watch was used from the time the mask was placed over the patient’s nose to the time it was removed, during this time nitrous oxide traces were recorded by the Medigas analyser.The following information was recorded:1- The patient’s age and sex.2- Nitrous oxide flow (litre per minute) and con-centration (in percentage).3- The nature of the dental treatment such as extraction, conservative, etc.4- General comments as to whether windows


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were opened or closed, fan was working or not, etc.5- In each 2 minute reading, a note was record-ed about the current dental procedure and the patient behaviour such as giving local anesthe-sia, cavity preparation, extraction, patient is talk-ing, crying, etc.

The Second ProcedureIn this procedure measurements were recorded in 6 sedation sessions from different distances from the operation site at zero, one, two, three, four and five metres.

Data ProcessingThe Analyser measured nitrous oxide traces in numbers in ppm (part per million). Outcomes were assessed using descriptive statistics and by t-test.

ResultsData was collected from 27 paediatric inhala-tional sessions. It was assumed that nitrous ox-ide traces will be more fluctuant and variable in the first measurement method than that in the second method, and therefore, 21 sessions were selected for the first procedure whereas only 6 sessions for the second procedure. In the 21 ses-sions, nitrous oxide traces were measured every 2 minutes throughout the session. In 6 sessions, nitrous oxide traces were measured from differ-ent distances from the operation site: at zero, one, two, three, four, and five meters. In all the nitrous oxide inhalation sessions a scavenging nasal mask was used and the fan was working.

A- Measurements taken every 2 minutes during inhalational sessions:In the 21 sessions the treatments were 12 extrac-tions (57%), 7 conservative treatments (33%), 1 fluoride application (5%) and 1 acclimatization (5%). The treatments were carried for 6 males (29%) and 15 female (71%) patients with age ranges from 6 to 17 years, mean is 9.9 years (SD 3.7). The mean nitrous oxide concentration was 30.7% (SD 5.1, ranged from 20% to 40%) and the mean flow rate was 6.6 l/min (SD 1.3, ranged from 5 l/min to 10 l/min). In all the ses-sions, sampling of the atmosphere was made at 20 cm from the patient in the horizontal plane.The mean of measured nitrous oxide traces was

compared in the extraction (91.7 ppm, SD 133.7) and conservative (32.4 ppm, SD 58.8) sessions and found to be not significant statistically (p>0.05). There was no relationship between age and measured nitrous oxide (p>0.05). In general, levels of nitrous oxide varied widely be-tween treatment sessions. In one fluoride appli-cation session it reached 2725 ppm (the patient was talking at the time); 4460 ppm in an ex-traction session (at the time the patient started to cry after being given local anesthesia); and 1975 ppm in an extraction session (at the time of tooth extraction). B- Measurements taken at various distances:Nitrous oxide traces were measured in 6 ses-sions, 4 sessions were conservative treatment and 2 sessions were extraction, 4 females and 2 males. The mean age of the patients was 10 years (SD 3.5, age range 6 to 14 years). The mean nitrous oxide concentration used during the sessions was 3.8% (SD 2.0) with a range from 30% to 35%, and the mean flow was 6.2 l/min (SD 1.1) ranges from 5 l/min to 8 l/min.The mean measured nitrous oxide traces were 602 ppm (SD 514) at zero distance, then de-creased by increase in distance from the operat-ing site (at 5 metre: 9 ppm, SD 17.5).

DiscussionThe importance of keeping pollution of nitrous oxide to the absolute minimum levels cannot be understated. The problem is of great concern to staff who have to work in such an environment constantly, rather than patients where exposure, although at a high level to produce the desired clinical effects, is only occasional. There may also be concerns in respect of accompanying adults, e.g. pregnant mothers who may be at the chair-side with their child. Problems of chronic expo-sure to nitrous oxide have been cited in the lit-erature review but the most important ones are haematological changes. Chronic occupational exposure to nitrous oxide may cause depression of vitamin B12 activity11 and altered DNA synthe-sis in the bone marrow and mild megaloblastic changes.12, 13 The aim of this study was to moni-tor as accurately as possible, the levels of nitrous oxide in the surgery under different conditions. These included continuous monitoring in the immediate vicinity of the operator and also at


38



varying distances. There was no significant dif-ference between the mean of the measured ni-trous oxide traces in the extraction sessions from that in the conservative sessions. There was also no relationship between age and nitrous oxide pollution, gender or with the concentration of nitrous oxide used and nitrous oxide air levels. There were a few sessions where nitrous ox-ide levels reached a very high level, sometimes exceeding 1000 ppm (0.01%). Donaldson and Meechan 10 suggested that when this occurred it was related to leakage of the nitrous oxide sedation machine or cylinders, poorly fitting masks, inadequate scavenging, patient mouth breathing, and poor surgery ventilation. In this study, where large variations in nitrous oxide lev-els were seen, this was associated with patients who were talking, crying etc. throughout the procedure. It may therefore be associated with pollution from expired air as a result of crying, talking, etc, or from leakage around the mask due to patient movement, etc. These findings are similar to those of Henry et al.14 who stated that patient behaviour can result in significant increase in nitrous oxide levels in the ambient air. Particular attention to these aspects is required to ensure pollution is significantly reduced to ac-ceptable levels. Given that the results showed that the higher nitrous oxide levels were re-corded at the time when patients were talking, laughing, crying, local analgesia administration, extraction, and rubber dam application, good sedation and behavior management is impor-tant. Relaxed and comfortable patients are less likely to talk, cry etc.The lack of observable differences found related to type of treatment or age could also be at-tributed to errors in the sampling such as the sample size, randomization, etc.It is obvious by looking at the results of the sec-ond part that the distance obeys the inverse square law: the nitrous oxide concentration decreases as the distance from working site in-creases. The greatest nitrous oxide concentra-tions was at zero metre from the working zone as described by Cleaton-Jonset et al.15 This is reassuring for other personnel in the surgery in-cluding accompanying parents who are approxi-mately 2 metres away with levels of 50 ppm. Conversely, concerns are raised in respect of the operator and assisting dental nurse who are in

the working zone during these administrations.There is no doubt that for many patients, nitrous oxide sedation provides a good quality of seda-tion for them to be able to cope with treatment. This study has highlighted potential problems in respect of nitrous oxide pollution which is of concern to all personnel in surgery during the sedation sessions.1. In this study the sample size was very limited. A future study with a larger cohort would be much more meaningful and would, hopefully, confirm the trends which I have found.2. Patient selection is of utmost importance as a struggling, crying child would lead to very exces-sive pollution.3. Patient conditioning to breathing through his/her nose at all times would be very helpful. Talk-ing to patients through (with the help of normal behavioural management techniques) stressful events e.g. local analgesia administration, ex-tractions, etc. would limit the amount of disrup-tion and the pollution at these times.4. Ensure equipment is checked for leaks and that the mask is of the appropriate size and tight fitting.5. Ensure that scavenging and surgery ventila-tion is adequate.

References

1. YAMADA MKM, TANABE Y, SANO T, NODA T. COOPERATION DURING DENTAL TREAT-MENT: THE CHILDREN’S FEAR SURVEY SCHEDULE IN JAPANESE CHILDREN. INT J PAED DENT 2002; 12: 404-409.2. COULTHARD P, CRAIG D. CONSCIOUS SEDATION. DENT UPDATE. 1997 NOV;24(9):376-81.3. ROBERTS GJ. INHALATION SEDATION (RELATIVE ANALGESIA) WITH OXYGEN/NITROUS OXIDE GAS MIXTURES: 1. PRINCIPLES. DENT UPDATE. 1990 MAY;17(4):139-42, 145-6.4. SZYMANSKA J. ENVIRONMENTAL HEALTH RISK OF CHRONIC EXPOSURE TO NITROUS OXIDE IN DENTAL PRACTICE. ANN AGRIC ENVIRON MED 2001,8,119-122.5. CARLSON P, HALLEN B, HALLONSTEN AL, LJUNGQVIST B. THERMOCAMERA STUDIES OF NITROUS OXIDE DISPERSION IN THE DENTAL SURGERY. SCAN J DENT RES 1983 JUNE; 91(3): 224-30.6. BURM AG. OCCUPATIONAL HAZARDS OF INHALATIONAL ANAESTHETICS. BEST PRACT RES CLIN ANAESTHESIOL 2003 MAR; 17(1): 147-61.7. SMITH DA. HAZARDS OF NITROUS OXIDE EXPOSURE IN HEALTHCARE PERSONNEL. AANA J 1998 AUG; 66(4): 390-3.8. SHORTRIDGE-MCCAULEY LA. REPRODUCTIVE HAZARDS: AN OVERVIEW OF EXPOSURES TO HEALTH WORKERS. AAOHN J 1995 DEC; 43(12): 614-21.9. STERLING PA, GIRDLER NM. INVESTIGATION OF NITROUS OXIDE POLLUTION ARISING FROM INHALATIONAL SEDATION FOR THE EXTRACTION OF TEETH IN CHILD PATIENTS. INT J PED DENT 1998;8: 93-102.10. CLARK MS AND BRUNICK AL. HANDBOOK OF NITROUS OXIDE AND OXYGEN SEDA-TION, 1999.11. DONALDSON D, MEECHAN JG. THE HAZARDS OF CHRONIC EXPOSURE TO NITROUS OXIDE: AN UPDATE. BDJ 1995 FEB;11: 95-100.12. SWEENY B, BINGHAM RM, AMOS RJ, PETTY AC, COLE PV. TOXICITY OF BONE MARROW IN DENTISTS EXPOSED TO NITROUS OXIDE. BMJ 1985, 291 (6495): 567-9.13. GUIDELINES FOR THE SAFETY OF EMPLOYEES EXPOSED TO ANAESTHETIC GASES AND VAPOURS, UNIVERSITY OF WALES, COLLEGE OF MEDICINE, 2002.14. HENRY RJ, PRIMOSCH RE AND COURTS FJ. THE EFFECTS OF VARIOUS DENTAL PROCE-DURES AND PATIENT BEHAVIOUR UPON NITROUS OXIDE SCAVENGER EFFECTIVENESS. PEDIATRIC DENT 1992; 14 (1): 19-25.

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Esthetic Dentistry Tooth Bleaching

Dr. Nicole Harrak Jabbour

Pr. Carina Mehanna Zogheib

AbstractNoticeable discoloration of permanent teeth can impact on a person’s self-image, self-confidence, physical attractiveness and employability. Success in bleaching a non-vital discolored tooth varies by depending on the etiology, appearance, localization, severity, and adhesion to tooth structure. It can be defined as being extrinsic or intrinsic on the basis of localization and etiology. Moreover, the success of bleaching depends on several factors, where the most important are the cause of the discoloration of the tooth, the adequate diagnosis of the problem and the proper choice of the bleaching technique. Different phenomena can ensure that endodontically treated teeth become darker. Although there is a deficiency of evidence-based science in the literature that addresses the prognosis of bleached non-vital teeth, it is important to always be aware of the possible complications and risks that are associated with the different bleaching techniques and agents. This present article aims to emphasize on the different procedures to bleach a non-vital tooth in order to get the best results.Key Words: Devitalized tooth, Tooth discoloration, Bleaching agents, Tooth bleaching techniques

Management of Non-Vital Tooth Bleaching

40

IntroductionBleaching discolored non-vital teeth has been described for the first time in 1864.1 A variety of bleaching agents were then used, such as chlorite, sodium hypochlorite, sodium perborate and hydrogen peroxide, alone or in combination, with or without heat activation.2 Different techniques were described such as the walking bleach technique, the thermocatalytic and in-office techniques. Each one of these procedures has its own positive and negative points. Before proposing any treatment to the patient in a way to correct the discoloration of his or her devitalized tooth, it is essential to determine the exact cause of the color change. Discoloration of a tooth can occur during or after the formation of dentin and enamel, and can be associated with the patient himself or with a treatment performed by the dentist. Discolorations associated with the patient himself may be superficial or incorporated within tooth structure. Regarding the discolorations associated with the dentist, they are usually predictable and should be avoided.3,4 Tooth discoloration varies in etiology, appearance, location, severity, and affinity to tooth structure. It can be classified as intrinsic, extrinsic, or a combination of both, according to its location and etiology5 (Table 1).

Causes of dental dicoloration

wine, coffee, tea, chocolate, tobacco, bacterial plaque, mouth rinses

Pulp Necrosis, Intrapulpal Hemorrhage, Pulp Tissue Remnants, Endodontic Materials, Coronal Filling Materials, Root Resorption, Aging

Drug-related (Teracycline) Metabolic (Dystrophic calcification, Fluorosis) Genetic: Amelogenesis imperfecta, Dentinogenesis imperfecta

Extrinsic

Intrinsinc Local

Systemic Table1: Extrinsic and Intrinsic Causes of Teeth Discolorations

[email protected]

St. Joseph University, Beirut, Lebanon

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Esthetic Dentistry

Tooth Bleaching

Bleaching Agents for whitening Devitalized TeethThe most commonly products used for bleaching are carbamide peroxide, sodium perborate and hydrogen peroxide.6 The teeth whitening is now based on the use of hydrogen peroxide as an active agent. Hydrogen peroxide can be applied alone or produced by a chemical reaction of the sodium perborate or carbamide peroxide. Regarding the carbamide peroxide (CH6N2O2), upon reaction, it dissociates into hydrogen peroxide (H2O2) and urea (CH4N2O).7 Other whitening products use rather sodium perborate as the active ingredient. In the reaction, complex oxygen is created during removal of the sodium perborate. A peroxide gel is then released. This gel interacts with the tooth structure and becomes activated. Oxygen complex interacts with the tooth, saturates and modifies the amino acids. Double bonds of the oxygen are responsible for the discoloration of the tooth. Hydrogen peroxide, in turn, is used in different proportions in most bleaching products and dissociates in water and long chain molecules of dark colored chromophores.8 The tooth thus finds its original color or at least a lighter color. It should also be noted that the success of bleaching depends primarily on the ability of the agent to penetrate deeply into the dentinal tubules. The success of the treatment also depends on the concentration of the whitening agent and on the period during which the agent is in contact with the molecules. The bleaching agents are available in several concentrations, but different studies do not agree on the ideal concentration in terms of whitening power and preservation of oral tissues.9 Carrasco et al. found that the ideal product for whitening is carbamide peroxide 37%.10 According to Lim et al. carbamide peroxide 35% and hydrogen peroxide 35% are most effective for whitening, but the first one is preferable to the second, because it is less offensive to the tissues.11 The reason which hydrogen peroxide is harmful to tissues is that it releases free radicals toxic anions (perhydroxyl). While for Kinomoto et al. the sodium perborate 2 grams/ml is preferable to hydrogen peroxide 30%.12 In short, the authors conclude that hydrogen peroxide is too harmful to tissues and it is recommended to use an alternative product, preferably peroxide

carbamide, otherwise sodium perborate. However, we know that sodium perborate contains hydrogen peroxide because it is a by-product of the dissociation of sodium perborate, as is also the case of carbamide peroxide as mentioned above. Hydrogen peroxide is the main constituent of either bleaching agent or the product of dissociation of carbamide peroxide or perborate sodium and it acts as an oxidizing agent by causing the formation of free radicals. Other studies (Weiger 1992) found that sodium perborate mixed with distilled water in a ratio of 2: 1 (g/ml) is a bleaching agent and prevents or at least minimizes the external cervical resorption of the root, an important consequence, although rare in internal bleaching, compared with a bleaching agent not combined with water.13 In cases of severe discoloration, hydrogen peroxide (H2O2) 3% can replace water. The use of 30% H2O2 is not recommended, always due to the risk of external resorption. Other authors have focused their research on the comparison between the hydrogen peroxide and carbamide peroxide. They concluded that in fact, as previously mentioned, these two products contain hydrogen peroxide and both work well. It appears, however, that H2O2 gives the desired results faster and requires a shorter treatment and a less exposure time than solutions of carbamide peroxide. In addition, there is less chance that dehydration occurs in hard tissues of the tooth treated with H2O2 as this system is based on aqueous gel, unlike carbamide peroxide gel based on anhydride. Carbamide peroxide seems to be softer on tissues, possibly due to the fact that the concentration of hydroxyl ion, acid, urea ammonium or carbonic acid is lower. In all whitening products, you can find other substances such agent thickener like Carbopol. This substance allows a slower reaction, but a longer period by altering the rate of release of oxygen. In addition, the urea produced by salivary glands can also be found in the whitening agents. The urea dissociates to ammonia and carbon dioxide. In addition to stabilizing the hydrogen peroxide, it has properties such as anticariogenic raising the pH of the solution and stimulating salivation. The high pH also facilitates whitening procedures.14 This is explained by the fact that in basic solution, a smaller amount of energy is required


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Esthetic Dentistry

Tooth Bleaching

for the formation of free radicals from hydrogen peroxide and level of reaction is higher, which leads to a better performance, in comparison with a bleach acid environment. It also contains glycerin due to its properties to increase the viscosity of the product and to facilitate handling thereof. However, it can cause tooth dehydration. A surfactant is also used to allow the hydrogen peroxide to diffuse into the tooth. Pigment dispersants, meanwhile, have the function to keep the pigments in suspension.15

Techniques and tips to follow to ensure the success of treatmentThe most commonly methods used to whiten endodontically treated teeth are the walking bleach technique and the thermocatalytic technique. The thermo / photo and internal / external techniques are also used for whitening devitalized teeth. The walking bleach is preferable because this technique requires less time in the office and is safer and more comfortable for the patient.16

Walking Bleach TechniqueThe first description of the walking bleach technique with a mixture of sodium perborate and distilled water was mentioned in a congress report by Marsh and published by Salvas.17

In this procedure, the mixture was left in the pulp cavity for a few days, and the access cavity was sealed with provisional cement. The mixture of sodium perborate and water was reconsidered by Spasser18 and modified by Nutting and Poe19, who advocated the use of 30% hydrogen peroxide instead of water to improve the bleaching effectiveness of the mixture. A mixture of sodium perborate and water or hydrogen peroxide continues to be used today and has been described many times as a successful technique for intracoronal bleaching. There are numerous studies that have reported the successful use of the walking bleach technique for correction of severely discolored teeth caused by incorporation of tetracycline.20

This procedure starts with intentional devitalization and root canal treatment of the tooth to enable application of the bleaching agent into the pulp chamber. Because the methods of intentional devitalization and root canal treatment have risks, the advantages and disadvantages of this therapy should be

assessed. Restorative treatment options such as ceramic veneers should be considered as an alternative procedure. Furthermore, there is now evidence that prolonged bleaching with carbamide peroxide can also reach the desired results.21

A: Left maxillary incisor showing severe discoloration due to a trauma

B: After endodontic treatment, In-office internal and external bleaching was per-formed followed by a walking bleaching technique

C: Result 3 days after

D: Another session of internal and exter-nal bleaching was performed followed by a walking bleaching technique

Fig 1: In -office internal and external bleaching was performed to the left central incisor followed by walking bleaching technique

Fig 1.D

Fig 1.C

Fig 1.B

Fig 1.A

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46

Case report

Tooth Bleaching

E: Esthetic restoration was completed 10 days after bleaching

Fig 1.E

Before starting the treatment, the patient should be informed about the technique, the expected results and the possibility of a recurrence of the coloration.1. Periapical radiographs should be taken to assess the status of periapical tissues and the quality of endodontic obturation. If it is unsatisfactory or questionable, it is imperative to retreat the tooth prior to the bleaching treatment.2. Evaluate the quality and color of the restorations on the discolored tooth and replace if defective, because the discoloration of the tooth is often the result of a leak. In such cases, you only have to clean the pulp chamber and replace the defective restoration.3. Evaluate the tooth shade with a shade guide, if possible, take photographs at the beginning and during the treatment, as this will be a reference point for any comparison. Clean and polish the tooth to be treated to remove any extrinsic stains.22

Preparation of the Pulp CavityBefore preparation of the access cavity, rubber dam should be applied to protect the adjacent structures. After that, restorative materials closing the access to the pulp cavity should be removed. Then, check that the entire pulp chamber is adequately accessible and cleaned. All remnants of restorative materials and necrotic pulp tissue must be removed completely.

Cervical SealRegarding the root canal filling material ending up inside the pulp chamber, it must be removed to a depth of 1-2 mm (a periodontal probe can be used to be sure of the length) below the CEJ with a Gates-Glidden or a Largo bur. A pulp chamber completely sealed with aesthetic ma-

terial presents technical difficulties because the composite is difficult to distinguish from the tooth itself. A root filling does not adequately prevent diffu-sion of bleaching agents from the pulpal cham-ber to the apical foramen.24 Hansen- Bayless and Davis 24 indicated that a base is required to pre-vent radicular penetration of bleaching agents. Therefore, sealing the root filling with a base is essential, for which a variety of dental materials such as glass-ionomer cements, intermediate re-storative material (IRM), hydraulic filling materi-als (Cavit®, Coltosol®), resin composites, photo-activated temporary resin materials (Fermit®), zinc oxide– eugenol cement, and zinc phosphate cement have been suggested as an interim seal-ing agent during bleaching techniques. McIner-ney and Zillich 25 found that Cavit® and IRM pro-vided better internal sealing of the dentin than did zinc phosphate cement, whereas Hansen-Bayless and Davis 26 reported that Cavit® was a more effective barrier to leakage than IRM. Fur-thermore, hydraulic filling materials (Cavit® and Coltosol®) provided the most favorable cavo-surface seal when they were firmly packed into the cavity space to prevent microleakage, when compared with a photoactivated temporary resin material (Fermit®), zinc oxide– eugenol cement, and a zinc oxide phosphate cement.27 Temporary sealing materials need to be removed before providing the final restoration of the access cav-ity. Rotstein et al. 28 demonstrated that a 2-mm layer of glass-ionomer cement was effective in preventing penetration of 30% hydrogen perox-ide solution into the root canal. Thus, the use of this material as a base during bleaching presents the additional advantage that it can be left in place after bleaching and can serve as a base for the final restoration. The sealing material should reach the level of the epithelial attachment or the CEJ, respectively, to avoid leakage of bleach-ing agents into the periodontium. The shape of the cervical seal should be similar to the external anatomic landmarks, thus reproducing CEJ posi-tion and interproximal bone level. A flat barrier, leveled with the labial CEJ, leaves a large portion of the proximal dentinal tubules unprotected. Therefore, the barrier should be determined by probing the level of the epithelial attachment at the mesial, distal, and labial aspects of the tooth. The intracoronal level of the barrier is placed 1


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Esthetic Dentistry

Tooth Bleaching

mm incisal to the corresponding external prob-ing of the attachment. With this method the coronal outline of the attachment defines an internal pattern of the shape and location of the barrier. However, the impact of the bleaching agents on the discolored dentin should not be hampered by the cervical seal. Dentin tubules at the coronal third of the root run in an oblique direction from the apex to the crown, so that the tubules at the CEJ are originating more apically inside the root canal. If bleaching of the cervical region of the tooth is required, a stepwise reduc-tion of the labial part of the seal and use of a mild bleaching agent are recommended for the final dressings. The placement of a piece of rub-ber dam has been suggested to act as a further barrier to isolate filling material from the bleach-ing agent. However, Hosoya et al. 29 reported no significant differences between the groups with and without the placement of this barrier.

Application of the Bleaching AgentThe bleaching agent can be applied with an amalgam carrier or plugger or with the syringe and should be changed every 3–7 days. Success-ful bleaching becomes apparent after 2– 4 visits, depending on the severity of the discoloration. The patients should be instructed to evaluate the tooth color on a daily basis and return when the bleaching is acceptable to avoid “over-bleach-ing”.

Temporary FillingA temporary filling (Cavit®, Coltosol®) will be applied to the outer periphery of the cavity, Then the access of the cavity will be sealed with composite. The patient should be informed that the bleaching works slowly and that the results should be visible a few days later. Every week the patient must show up to the clinic to repeat the procedure.30

Restoration of the Access Cavity and Postoperative RadiographsWhen the devitalized tooth reaches the desired color, the access cavity will be sealed with a composite.To obtain optimal adhesive bond between the restorative material and hard tissues of the tooth, it is advisable to proceed with the estab-lishment of the permanent restoration after a

period of approximately 10 days after the last bleaching therapy. Whitening the tooth leaves supersaturated oxygen, which inhibits the po-lymerization of the resins. A radiograph of the bleached tooth will be taken on all annual ap-pointments to diagnose the earliest possible cer-vical resorption.31

Thermocatalytic TechniqueIt is a technique where the hydrogen peroxide 30-35% is placed in the pulp chamber and ac-tivated by a heating source, either with an elec-tric heating devices (Touch’ n Heat, System B) or especially designed lamps. The steps for placing the bleaching agent and sealing the pulp cham-ber are similar to the walking bleach technique. Heat application is repeated 3 or 4 times at every appointment. When heat is applied, a reaction produces foam and releases the oxygen present in the preparation.32 The major risk of this tech-nique is the external root resorption due to the excessive heat applied on the tooth.33

Combined TechniqueWhen an agent fails to remove a stain complete-ly or when multiple patches of different origins are present on the same tooth, a combination of whitening techniques can be used. The tech-nique combines external / internal bleaching, so the patient can do it at home. This technique is both simple and effective. It consists of putting the whitening gel in a tray especially customized for the patient and placed directly on the tooth. There are certain risks with this technique, in that an unsealed access opening enables bac-teria and stains to penetrate into dentin. There-fore, a restorative material such as glass-ionomer cement or resin composite should be used to seal the root filling at the orifice.34

DiscussionDespite many clinical reports, there are few scientific evidence based studies on devitalized tooth whitening.35 Most reports present optimal initial results after bleaching, with complete col-or matching of the bleached tooth (teeth) with the adjacent one(s). However, occasionally dark-ening after internal bleaching can be observed,36 which is presumably caused by diffusion of staining substances and penetration of bacteria through marginal gaps between the filling and


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Esthetic Dentistry

Tooth Bleaching

the tooth. It is worth noting that the opinion of the patient regarding the success of the therapy is often more positive than the opinion of the dentist. One study reported an 80% rate of success after 1 year and 45% after 6 years of 20 cases that were chemically bleached by us-ing the thermocatalytic technique.37 Some au-thors have suggested that teeth that have been discolored for several years do not respond as well to bleaching as teeth that are stained for a short period of time. Furthermore, it is uncertain whether darkening after bleaching is more likely when the tooth is heavily or mildly discolored.38

Discoloration caused by restorative materials has a dubious prognosis. Certain metallic ions (mer-cury, silver, copper, iodine) are extremely dif-ficult to remove or alter by bleaching. Brown39 reported that trauma- or necrosis-induced dis-coloration can be successfully bleached in about 95% of the cases, compared with lower per-centages for teeth discolored as a result of me-dicaments or restorations. There is a difference in opinion as to whether teeth that respond rap-idly to bleaching have a better long-term color stability prognosis. Some studies have reported that stained teeth in young patients are easier to bleach than discoloration in older patients, presumably because the wide open dentinal tu-bules in young teeth enable a better diffusion of the bleaching agent. However, not all stud-ies are in agreement with age related success of bleaching. Teeth with internal discoloration caused by root canal medicaments, root-filling materials, or metallic restorations such as amal-gam have a poor prognosis, because this type of discoloration is difficult to bleach and tends to reappear over time because of the tenacity of the oxidizing products to dental tissues. Anterior teeth with interproximal restorations occasion-ally show less optimum results than teeth with a palatal access cavity only. This might be attrib-uted to the fact that resin composites cannot be bleached.40 In these cases, replacement of exist-ing restorations after the whitening treatment is recommended to get optimal results.

ConclusionToday, the causes of discoloration of endodon-tically treated teeth are well recognized, and techniques of bleaching that have proved their efficacy over the years, yield optimal results if

the cases have been selected appropriately and if the dentist and the patient are aware of the remote risks of dental bleaching. Therefore, we can successfully treat tooth discoloration that has undergone a root canal using the walking bleach technique. Bleaching is done by tempo-rarily placing a mixture of perborate (tetrahy-drate) of sodium and water in the pulp chamber. This releases the mixture H2O2 which is capable of reacting with the coloring substances. The use of thermocatalytic method by heating a solution of 30% H2O2 is not recommended as this method increases the risk of external cervi-cal resorption. For the same reason, the dentist should not use either 30% H2O2 for the walk-ing bleach technique. To avoid leakage of the bleaching agent into the dentine, it is necessary to place a compact filling material, that is to say, gutta percha, and an additional cervical barrier, before beginning the bleaching technique. For a long-term success, it seems important to restore the access cavity with an adhesive filling materi-al, which prevents the infiltration of bacteria and stains. The fact of following these procedures provides a much safer bleaching technique in the course of maintaining the integrity of the tooth and above the surrounding tissue, while maintaining an optimum result goal. Neverthe-less, this treatment involves minimal risk. It is therefore desirable to have a product providing the benefits of effective bleaching agent while eliminating the associated risks.

REFERENCES

1. TRUMAN J. BLEACHING OF NON-VITAL DISCOLORED ANTERIOR TEETH. DENT TIMES1864;1:69 –72.2. WATTS A, ADDY M. TOOTH DISCOLORATION AND STAINING: A REVIEW OF THE LITERA-TURE. BR DENT J 2001;190:309-16.3. MATIS BA, MOUSA HN, COCHRAN MA, ECKERT GJ. CLINICAL EVALUATION OF BLEACHING AGENTS OF DIFFERENT CONCENTRATIONS. QUINTESSENCE INT 2000;31: 303-310.4. FOR THE DENTAL PATIENT: TOOTH WHITENING – WHAT YOU SHOULD KNOW. JADA 2009;40:384.5. MANUEL ST, ABHISHEK P, KUNDABALA M. ETIOLOGY OF TOOTH DISCOLORATION- A REVIEW. NIG DENT J 2010; 18(2): 56-63.6. FAUNCE F. MANAGEMENT OF DISCOLORED TEETH. DENT CLIN NORTH AM 1983;27: 657–670.7. PLOTINO G, BUONO L. NON-VITAL TOOTH BLEACHING: A REVIEW OF LITERATURE AND CLINICAL PROCEDURES. J ENDOD 2008;34(4):394-407.8. ROSTEIN I. TOOTH DISCOLORATION AND BLEACHING. IN: INGLE JI, BAKLAND LK, EDS. ENDODONTICS.5TH ED. HAMILTON, ONTARIO, CANADA: BC DECKER INC, 2002:845– 60.9. J.E DAHL ET U. PALLESEN. TOOTH BLEACHING – A CRITICAL REVIEW OF THE BIOLOGI-CAL ASPECTS 2003;14 (4): 292.10. L.D. CARRASCO, I.C. FRÖNER ET AL. EFFECT OF INTERNAL BLEACHING AGENTS ON DENTINAL PERMEABILITY OF NON-VITAL TEETH : QUANTITATIVE ASSESSMENT. DENTAL TRAUMATOLOGY 2003(19) :85-89.11. M.Y. LIM, S.O.Y. LUM ET AL. AN IN-VITRO COMPARISON OF THE BLEACHING

fits inThis is where


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EFFICACY OF 35% CARBAMIDE PEROXIDE WITH ESTABLISHED INTRACORONAL BLEACHING AGENTS.INT J ENDO 2004(37):483-488.12. Y. KINOMOTO, D.L. CARNES ET S. EBISU.CYTOTOXICITY OF INTRACANAL BLEACHING AGENTS ON PERIODONTAL LIGAMENT CELLS IN VITRO. J ENDOD 2001(27):574-577.13.R. M. WAITE, D. L. CARNES JR, W. A. WALKER. «MICROLEAKAGE OF TERM USED WITH SODIUM PERBORATE/WATER AND SODIUM PERBORATE/SUPEROXOL IN THE « WALK-ING BLEACH » TECHNIQUE», J ENDOD 1998(24):648-650.14. ZABOKOVA BILBILOVA E, SOTIROVSKA IVKOVSKA A, AMBARKOVA V.CORRELATION BE-TWEEN SALIVARY UREA LEVEL AND DENTAL CARIES. PRILOZI. 2012 JUL;33(1):289-302.15. L. GREENWALL, G. FREEDMAN ET AL. BLEACHING TECHNIQUES IN RESTORATIVE DEN-TISTRY : AN ILLUSTRATED GUIDE, THEME MEDICAL PUB 2005.16. P.CARROTTE. «ENDODONTIC PROBLEMS», BRITISH DENTAL JOURNAL. 2005; 198:127-133.17. SALVAS CJ. PERBORATE AS A BLEACHING AGENT. J AM DENT ASSOC 1938;25:324.18. SPASSER HF. A SIMPLE BLEACHING TECHNIQUE USING SODIUM PERBORATE. N Y STATE DENTLJ 1961;27:332– 4.19. NUTTING EB, POE GS. A NEW COMBINATION FOR BLEACHING TEETH. J SOUTH CALI-FORNIAN DENTASSOC 1963;31:289.20. ABOU-RASS M. LONG-TERM PROGNOSIS OF INTENTIONAL ENDODONTICS AND IN-TERNAL BLEACHING OF TETRACYCLINE-STAINED TEETH. COMP CONTIN EDUC DENT 1998;19:1034 –50.21. BARATIERI LN, RITTER AV, MONTEIRO S JR, CALDEIRA DEANDRADA MA, CARDOSO VIEIRA LC. NON-VITAL TOOTH BLEACHING: GUIDELINES FOR THE CLINICIAN. QUINTESSENCE INT 1995; 26:597– 8.22. ATTIN T, PAQUE F, AJAM F, LENNON AM. REVIEW OF THE CURRENT STATUS OF TOOTH WHITENING WITH THE WALKING BLEACH TECHNIQUE. INT ENDOD J. 2003 MAY;36(5):313-29.23. SMITH JJ, CUNNINGHAM CJ, MONTGOMERY S. CERVICAL CANAL LEAKAGE AFTER INTERNAL BLEACHING PROCEDURES. J ENDOD 1992;18:476–81.24. HANSEN-BAYLESS J, DAVIS R SEALING ABILITY OF TWO INTERMEDIATE RESTORATIVE MATERIALS IN BLEACHED TEETH. AM J DENT 1992;5:151– 4.25. MCINERNEY ST, ZILLICH R. EVALUATION OF INTERNAL SEALING ABILITY OF THREE MA-TERIALS. J ENDOD 1992;18:376–8.26. HANSEN-BAYLESS J, DAVIS R. SEALING ABILITY OF TWO INTERMEDIATE RESTORATIVE MATERIALS IN BLEACHED TEETH. AM J DENT 1992;5:151– 4.27. HOSOYA N, COX CF, ARAI T, NAKAMURA J. THE WALKING BLEACH PROCEDURE: AN IN VITRO STUDY TO MEASURE MICROLEAKAGE OF FIVE TEMPORARY SEALING AGENTS. J ENDOD 2000;26:716–8.28. ROTSTEIN I, ZYSKIND D, LEWINSTEIN I, BAMBERGER N. EFFECT OF DIFFERENT PROTEC-TIVE BASE MATERIALS ON HYDROGEN PEROXIDE LEAKAGE DURING INTRACORONAL BLEACHING IN VITRO. J ENDOD 1992;18:114 –7.29. HOSOYA N, COX CF, ARAI T, NAKAMURA J. THE WALKING BLEACH PROCEDURE: AN IN VITRO STUDY TO MEASURE MICROLEAKAGE OF FIVE TEMPORARY SEALING AGENTS. J ENDOD 2000;26:716–8.30. HOSOYA N, COX C F, ARAI T, NAKAMURA J: THE WALKING BLEACH PROCEDURE: AN IN VITRO STUDY TO MEASURE MICROLEAKAGE OF FIVE TEMPORARY SEALING AGENTS. J ENDOD 2000,26: 716–718.31. MÜLLER ARCARI G, ARAÙJO E, BARATIERI L N, LOPES G C: MICROTENSILE BOND STRENGTH OF A NANOFILLED COMPOSITE RESIN TO HUMAN DENTIN AFTER NONVITAL TOOTH BLEACHING. J ADHES DENT 2007 (9): 333–340.32. DALHSTROM S,HEITHERSAY G, BRIDGES T.HYDROXYL RADICAL ACTIVITY IN THER-MOCATALYTICALLY BLEACHED ROOT-FILLED TEETH. ENDODONTIC DENTAL TRAUMATOLOGY 1997;13:119-125.33. MACISAAC AM, HOEN CM. INTRACORONAL BLEACHING: CONCERNS AND CONSID-ERATIONS. J CAN DENT ASSOC. 1994 JAN; 60(1):57-64 .34. TRONSTAD L. BLEACHING OF DISCOLORED TEETH. CLINICAL ENDODONTICS. STUTTGART,GERMANY. 2003; 236-241.35. NIEDERMAN R, FERGUSON M, URDANETA R. EVIDENCE BASED ESTHETIC DENTISTRY. J ESTHET DENT 1998;10:229 –34.36. CARRASCO L.D., FRONER I.C ET AL. EFFECT OF INTERNAL BLEACHING AGENTS ON DENTINAL PERMEABILITY OF NON-VITAL TEETH : QUANTITATIVE ASSESSMENT. DENTAL TRAUMATOLOGY 2003; 19:85-89.37. AUSCHILL T M, HELLWIG E, SCHMIDALE S, SCULEAN A, ARWEILER N B: EFFICACY, SIDE EFFECTS AND PATIENTS ACCEPTANCE OF DIFFERENT BLEACHING TECHNIQUES (OTC,

IN-OFFICE, AT-HOME). OPER DENT 2005,30: 156–163.38. DIETSCHI D, ROSSIER S, KREJCI I: IN VITRO COLORIMETRIC EVALUATION OF THE EFFICACY OF VARIOUS BLEACHING METHODS AND PRODUCTS. QUINTESSENCE INT 2006,37: 515–526.

39. BROWN G: FACTORS INFLUENCING SUCCESSFUL BLEACHING OF THE DISCOLORED ROOT-FILLED TOOTH. ORAL SURG ORAL MED ORAL PATH 1965; 20: 238–244.40. DELIPERI S, BARDWELL D N: TWO-YEAR CLINICAL EVALUATION OF NON-VITAL TOOTH WHITENING AND RESIN COMPOSITE RESTORATIONS. J ESTHET RESTOR DENT 2005;17: 369–378.


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54

Lebanese University International Convention 2013

PR. MOUNIR DOUMIT DEAN OF THE SCHOOL OF DENTISTRY

DABKE PERFORMANCE FOR THE OPENING CEREMONY

LEFT TO RIGHT: DRS. RAHIL DOUEIHY, KASIM HASHEM, ELIE MAALOUF, MOUNIR DOUMIT, FATMEH HAMASNI, JOSEPH CHAER, ESSAM OSMAN

DR. ZIAD NOUJEIM, CHAIRPERSON SCIENTIFIC COMMITTEE

DR. MOHAMAD RIFAII, GENERAL COORDINATOR

DR. KHALDOUN RIFAII, WELCOMING DR. KASIM HASHEM

LEFT TO RIGHTDR. TONY DIB, PR. MOUNIR DOUMIT, PR. NADIM BABA

PR. MOTLU OZCAN AND DR. ARZU NAIPOGLU DURING THE BREAK AT THE TENT

LEFT TO RIGHT DRS. ANTOINE SAADE, ZIAD SALAME, CHARLES SFEIR

LEFT TO RIGHT MR. ANTOINE BARAKA, DR. JEAN MARIE MEGARBANE, DR. CEDRIC HADAD


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unbelievably quiet and powerful compressor for dentistry in the form

of the new “Made in Germany“ Tornado.

▪ Oil-free, dry, and hygienic

▪ One of the quietest of its kind

▪ Dust- and Sandresistant

▪ Antibacterial inner tank coating

▪ Low-maintenance thanks to membrane-drying unit

Duerr Dental Middle East, P.O.Box: 87355, Al Ain - U.A.E.,

Mobile: +971 (0) 50 - 550 84 12, Fax: +971 (0) 3 767 - 5615,

email: [email protected]

HENRY SCHEIN BRAND Beyond Satisfaction!Henry Schein Brand products offer our clients maximum value withoutcompromising on quality. We offer quality products you can trust to fulfill your practice merchandise needs—each bearing the Henry Schein Seal of Excellence, your guarantee of satisfaction.

Henry Schein, Inc. is the world’s largest provider of healthcare products and services to office-based dental, medical,and animal health practitioners.


Lebanese Dental Association North Lebanon

www.facebook.com/dentalnews1

More PicturesAvailable OnMay 30-31, June 1, 2013

Las Salinas, Anfeh, Lebanon

DR. RAHIL DOUEIHY, PRESIDENT OF LDA-TRIPOLI

TROPHY TO PR. MOUNIR DOUMIT DEAN OF THE LU

TROPHY TO DR. MOHAMAD BOUKANAAN

TROPHY TO DR. ELIE MAALOUF PRESIDENT OF THE LDA

TROPHY TO DR. HASSAN ALLOUL

TROPHY TO NASSIF KALOUCH-PRESIDENT OF THE REPUBLIC REPRESENTATIVE

. . . z

.

LEFT TO RIGHT: DR. WALID NEHME, DR. RAHIL DOUEIHY, PR. ANTOINE KHOURY, DR. JALAL KASSAB

DR. ILIA ROUSSOU FOR HER LECTURE ON OCCLUSION

DR. EHAB HEIKAL LECTURING ON MANAGEMENT

DR. HALA ABBOUD FOR HER LECTURE ON PROSTHETICS

LEFT TO RIGHT: DR. CHRISTIAN MAKARI, DR. RAHIL DOUEIHY, PR. NADA NAAMAN-DEAN ST. JOSEPH DENTAL SCHOOL, PR. ANTOINE KHOURY

PR. ESSAM OSMAN-DEAN BAU DENTAL SCHOOL, DR. DOUEIHY, DR. RAFEH JOBOURI-PRESIDENT OF THE IRAK DENTAL ASSOCIATION

RECOGNITIONS TO:


1mm layer TheraCal LC

Regenerative layer stimulates hydroxyapatite

stays where it is placed

calcium hydroxide and RMGI

technique

TheraCal LC is an internal flowablepulpal protectant material knownas Resin Modified Calcium Silicates(RMCS).

Surrounding enamel is etched

All-Bond Universal single-bottlelight-cured adhesive can be usedfor any dental procedure.

Core-Flo DC is a radiopaquedual-cured flowable materialideal for core build-up, postcementation and dentin replacement.

To learn more e-mail [email protected] visit www.bisco.com

TheraCal LC

NEW Products from BISCO

All-Bond Universal Core-Flo DC

PICTURES FROM THE EXHIBITION FLOOR

08-09 November 2013Jumeirah Beach HotelDubai UAE

5th Dental - Facial CosmeticInternational Conference

AMERICAN ACADEMY OF IMPLANT DENTISTRY

Joint Meeting with

Centre for Advanced Professional Practices (CAPP) is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals

in identifying quality providers of continuing dental education. ADA CERP does not ap-

prove or endorse individual courses or instructors, nor does it imply acceptance of credit

hours by boards of dentistry.

Platinum Sponsor Gold Sponsors

Organizers

2nd Global Conference

The #1 patient-requested professional whitening system*

is now better than ever.

New Philips Zoom offers advanced light technology that gives you more control and your patients even greater results. And with a worldwide public awareness campaign to drive patients to you and new programs to help you easily integrate Philips Zoom WhiteSpeed light-activated whitening into your practice, you’ll have the answer to the confident, beautiful smile your patients are asking for.

Ask about the new Philips Zoom WhiteSpeed today. Visit philipsoralhealthcare.com. For more information, contact your local sales representative or call +971 50 643 1707.

*In the United States. Philips is a registered trademark of Koninklijke Philips Electronics N.V. ©2012 Discus Dental, LLC. All rights reserved. To be dispensed by or on the order of a dental professional only. ADV-3545ARA 101912

EGYPT Elsafaa Tel: 2 (0) 10 1466997

JORDAN Al Ghad Medical Supplies Tel: +962 6 552 6358

KUWAIT Alpha Medical Co. Tel: +965 2247 8611

LEBANON G. Tamer Holding Tel: 961 1 694000

MOROCCO Ortho-Rama +21 2 22862086

SAUDI ARABIA Bashir Shakib Al Jabri & Co. Tel: +966 26700430

TUNISIA MSI Tel: +216 73 449 401

UNITED ARAB EMIRATES Al Hayat Pharmaceuticals Tel: +971 6 5592 481

OptiBond™ XTR Unmatched power for all your direct and indirect restorations.

OptiBond XTR Self-Etch, Light-Cure Univesal Adhesive.

Extraordinary performance for long-lasting restorations.

Minimizes post-operative sensitivity, maximizes patient comfort.

A true universal adhesive.

Enables use with all cements, core build-up materials and substrates.

For more information visit:

Your practice is our inspiration.™ KerrHawe SA P.O. Box 268 6934 Bioggio Switzerland Freephone: 00800 41 05 05 05 Fax: ++41 91 610 05 14 www.kerrdental.eu

Clear, long resin tags with penetration intolateral dentin tubule branches (2,000x).

OptiBond XTR Self-Etch, Light-Cure Universal Adhesive.


One Shape® Paper Points Shaping

Impression materials and especially alginates are core products for Cavex Holland BV. Ongoing research and development are key in the structural outperformance of Cavex alginates compared to the competition. In 2001 we already improved dimensional stability of Cavex ColorChange up to 5 days. This means that when properly stored, an impression with Cavex ColorChange can still be perfectly poured (at least twice) after 5 days. Impressive, but by no means a reason to stop further improvements. In our continuous strive of improving Cavex products we accumulated unparalleled knowledge on the chemistry of the ingredients used in our alginates. This has lead up to the point that evaluation by the department Dental Material Science at ACTA, shows that the quality of Cavex ColorChange permits for an astounding dimensional stability of 9 days. This puts Cavex ColorChange in a whole different league than the competition, making Cavex ColorChange the absolute number 1 alginate in the world. For more information please visit www.cavex.nl.

Advantages of the One Shape® Paper Points Shaping by Micro Mega: Quick and efficient drying.Shaped for easy and reliable penetration to the apex.Easy-to-identify thanks to the coloured tip.One Shape® Paper Points Shaping are available in length 29 mm.Packaging: 60 points per box.For any further information please E-mail us at [email protected]

#76

Cavex ColorChange – 9 days dimensionally stable!

The award winning A-dec LED light is now available to existing A-dec light users.Replacing your current A-dec light head with the new A-dec LED light is quick, easy and entirely hassle-free. Upgrade to 20% more luminance while consuming one-fifth of the power needed for halogen bulbs. Are you eligible for an upgrade? As long as you have a working flexarm on an A-dec light manufactured after 1993, you can upgrade it to an A-dec LED light.For more information please visit www.a-dec.com

Henry Schein® introduces the new Natural Elegance® Universal Bond featuring a single-component, light-cure system that primes and bonds in one easy step. The total-etch system, responsive to all curing lights, provides an excellent bond to both dentin and enamel. The etching-required seal helps prevent recurrent decay and has low postoperative sensitivity. The Natural Elegance® Universal Bond is available in individual 5 mL bottle or 50 unit dose packages. For more information please visit www.henryscheindental.com

Upgrade to Brilliance

Natural Elegance® Universal Bond For Improved Sealing

Cavex ColorChangeThe best - got even better!

CAVEXYOUR IMPRESSION IS OUR CONCERNOngoing research and development are key in the structural outperformance of Cavex alginates

compared to the competition. In 2001 we already improved dimensional stability of Cavex

ColorChange up to 5 days. Impressive, but by no means a reason to stop further improvements.

In our continuous strive of improving Cavex products we accumulated unparalleled knowledge

on the chemistry of the ingredients used in our alginates. This has lead up to the point that

evaluation by the department Dental Material Science at ACTA, shows that the quality of Cavex

ColorChange permits for an astounding dimensional stability of 9 days. This puts Cavex

ColorChange in a whole diff erent league than the competition, making Cavex ColorChange the

absolute number 1 alginate in the world.

Cavex Holland BV, P.O. Box 852, 2003 RW Haarlem, The Netherlands. Tel +31 23 530 77 00 Fax +31 23 535 64 82 [email protected] www.cavex.nl

9 days dimensionally stable

Exceptional tear resistance

Can be poured at least twice

25 micron detail reproduction

Chromatic

5 year shelf life


New features and improvements to Planmeca ProMax® 3D X-ray units

Scalpel handle for micro blades entirely made in pure titanium

TOTALCEM, THE ALL-IN-ONE CEMENT

Planmeca ProMax® 3D is a family of true all-in-one X-ray units that provide digital panoramic, cephalometric and CBCT imaging, 3D face photos and 3D model scans, i.e. impression and plaster cast scans. Planmeca constantly develops its state-of-the-art imaging units and is now proud to introduce new features that further improve their image quality, patient comfort and usability. In addition to their wide selection of volume sizes and optimal patient doses, the Planmeca ProMax 3D family units are known for their simple and effortless patient positioning offering an unrestricted view of the patient and easy side entry access. Planmeca now introduces to the units a new adjustable and autoclavable patient support that helps to keep the patient better in place and thus also improves patient comfort. Planmeca’s user interface designers have also designed a completely new graphical user interface to all Planmeca’s 2D and 3D X-ray units. The big interface guides the user to a fluent workflow with clear and explicit texts and preprogrammed target sites and exposure values. For more information please visit www.planmeca.com

The manufacture of large and most complex tools in titanium is obtained only by means of technologically advanced machineries. - This new titanium scalpel handle is the result of one among many other investments that Medesy has recently made on the most modern last generation technological equipment. - An excellent ergonomic design specifically conceived to guarantee the utmost comfort and safest handling.- Nothing lighter than titanium! - High precision non-slip knurling. - Medesy special design which assures maximum comfort, and secure grip For more information please visit www.medesy.it

Itena, the French dental product manufacturer and restoration expert; presents TotalCem, a self-etching and self-adhesive permanent resin cement.TotalCem provides a strong adhesion to the dentine, enamel, porcelain, zirconium, composites, ceramic or metal for the cementation of posts, inlays, onlays, crowns and bridges. The procedure is very simple. All is done in one step: etching, primer, bonding and cementation. The product can be kept at room temperature; there is no need to refrigerate. As it is a dual-cure cement, the polymerization is guaranteed, even for areas with limited light penetration. Furthermore the excess can be easily cleaned thanks to a gel phase. The cement can also be used on vital teeth. The comfort of the patient is still ensured as the product gives no post-operative sensitivities. With the Automix syringe, the base and the catalyst are perfectly proportioned and mixed. As you can choose between, three different types of intra-oral tips (fine, extra-fine and ultra-fine) the placement of TotalCem is extremely easy. The film thickness gives a perfect marginal integrity. TotalCem radiopacity also allows a visual confirmation.For more information please visit www.itena-clinical.com

#78

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E

VITA shade, VITA made.

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

mind, the time has come to leave shade sticks behind and

to move ahead with VITA Easyshade Advance 4.0. Whether

it‘s VITA SYSTEM 3D-MASTER or VITA classical A1–D4, this

digital measuring device determines and verifies all tooth

shades in a matter of seconds and with absolute precision.

Automatic activation, Bluetooth®, bleaching mode and a whole

range of other innovations guarantee maximum precision for

even greater reliability and comfort. www.vita-zahnfabrik.com

facebook.com/vita.zahnfabrik

Determine and verify tooth shades with digital precision.

VITA Easyshade® Advance 4.0Analog goes digital.

New! Automatic activation

guarantees optimal shade determination

Turn Complex Class II into Simple Class I Cases

* Images courtesy of Dr. Clark Colville.

© 2012 Ortho Organizers, Inc. All rights reserved.

With its non-invasive design, the Carriere Distalizer Appliance corrects Class II malocclusion at

the beginning of treatment, prior to bracket placement when patient motivation is highest.

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

Carriere Ortho 3D A FREE App. for iPads, iPhones, and

Android tablets and phones

Carriere

Self-Ligating Bracket

* Typical case: Patient 16 years

Start of treatment, prior to placement

of Carriere Distalizer Appliance 5.10.10

Class II to Class I achieved, and

Carriere Distalizer Appliance treatment

completed 8.30.10

Total orthodontic treatment

completed 3.7.12

SHIFTING THE WAY YOU THINK ABOUT ORTHODONTICS.The Carriere®

Distalizer™ Appliance

Documents

Dental News Sept 2013