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BALKAN JOURNAL OF STOMATOLOGY
Official publication of the BALKAN STOMATOLOGICAL SOCIETY Volume 16 No 2 July 2012
ISSN 1107 - 1141
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ISSN 1107 - 1141
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Editor-in-Chief
Ljubomir TODOROVI, DDS, MSc, PhD Faculty of Dentistry University of Belgrade Dr Subotia 8 11000 Belgrade Serbia
Editorial board
ALBANIA Ruzhdie QAFMOLLA - Editor Emil KUVARATI Besnik GAVAZI BOSNIA AND HERZEGOVINA Maida GANIBEGOVI - Editor Naida HADIABDI Mihael STANOJEVI BULGARIA Nikolai POPOV - Editor Nikola ATANASSOV Nikolai SHARKOV FYROM Julijana GJORGOVA - Editor Ana STAVREVSKA Ljuben GUGUEVSKI GREECE Anastasios MARKOPOULOS - Editor Haralambos PETRIDIS Lambros ZOULOUMIS Address: Dental University Clinic Tirana, Albania Address: Faculty of Dentistry Bolnika 4a 71000 Sarajevo, BIH Address: Faculty of Dentistry G. Sofiiski str. 1 1431 Sofia, Bulgaria Address: Faculty of Dentistry Vodnjanska 17, Skopje Republika Makedonija Address: Aristotle University Dental School Thessaloniki, Greece ROMANIA Alexandru-Andrei ILIESCU - Editor Victor NAMIGEAN Cinel MALITA SERBIA Dejan MARKOVI - Editor Slavoljub IVKOVI Zoran STAJI TURKEY Ender KAZAZOGLU - Editor Pinar KURSOGLU Arzu CIVELEK CYPRUS George PANTELAS - Editor Huseyn BIAK Aikaterine KOSTEA Address: Faculty of Dentistry Calea Plevnei 19, sect. 1 70754 Bucuresti, Romania
Address: Faculty of Dentistry Dr Subotia 8 11000 Beograd, Serbia
Address: Yeditepe University Faculty of Dentistry Bagdat Cad. No 238 Gztepe 81006 Istanbul, Turkey Address: Gen. Hospital Nicosia No 10 Pallados St. Nicosia, Cyprus
International Editorial (Advisory) Board

Christoph HMMERLE Barrie Kenney Predrag Charles LEKIC Kysti OIKARINEN Switzerland USA Canada Finland George SANDOR Ario SANTINI Riita SUURONEN Michael WEINLAENDER - Canada - Great Britain - Finland - Austria
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President: Past President: President Elect: Vice President: Secretary General: Treasurer: Editor-in-Chief: Prof. H. Bostanci Prof. P. Koidis Prof. N. Sharkov Prof. D. Stamenkovi Prof. A.L. Pissiotis Prof. S. Dalampiras Prof. Lj.Todorovi
Members: R. Qafmolla P. Kongo M. Ganibegovi S. Kostadinovi A. Filchev D. Stancheva Zaburkova M. Carev A. Minovska T. Lambrianidis S. Dalambiras
A. Adi M. Djurikovi N. Forna A. Bucur M. Carevi M. Barjaktarevi E. Kazazoglu M. Akkaya G. Pantelas S. Solyali
The whole issue is available on-line at the web address of the BaSS (www.e-bass.org)

Official publication of the BALKAN STOMATOLOGICAL SOCIETY Volume 16 No 2 July 2012
ISSN 1107 - 1141
GI CA L SOCIETY
ISSN 1107 - 1141
LO TO STOMA
VOLUME 16
NUMBER 2
july 2012
PAGES 65-128
Contents
LR P. Papadopoulos OP

Langerhans Cell Histiocytosis: 69 Its Oral and Maxillofacial Dimension Effects of Local Application of Ascorbic Acid and 74 Glutathione by Iontophoresis on Gingival Inflammation
M. Pandilova A. Ugrinska S. Georgieva M. Popovska L. Kanurkova K. Smilevska L. Gavriliuc E. Stepco I. Lupan N. Sevcenco I. Spinei A. Dimkov E. Gjorgievska A. Fildishevski E. Boteva D. Yovchev T.T. Akbay M. Guvercin O. Gonul A. Yarat S. Akyuz R. Pisiriciler K. Gker D. Veleski B. Pejkovska M. Antanasova K. Tolidis P. Gerasimou C. Boutsiouki B. Vanlolu Y. zkan Y. Kulak-zkan
OP

Salivary Glutathione-Dependent Enzymes in Patients with 79 Dental Fluorosis Treated by Complex Antioxidant Therapy
OP OP

Release of Antimicrobial Agents from 84 Glass Ionomer Cements
Efficacy of Working Length Detection and 90 Irrigation during Preparation of Curved Root Canals Salivary Thromboplastic Activity May Indicate 94 Wound Healing after Tooth Extraction
OP

OP CR

Biophysical Principles of the AcryLock Attachments Use in 98 Contemporary Prosthetic Dentistry
Intraoral Ceramic Restoration Repair Techniques: Report of 3 Cases 103
CR

A Multidiscipline Approach to Improve Aesthetics in a Patient with 109 High Lip Line: A Clinical Report
Balk J Stom, Vol 16, 2012
67
CR CR

L. Mavriqi E. Baca A. Vjeshta S. Karamanis D. Tsoukalas A. Traskas N. Parissis S. Dalampiras C. Boutsiouki B. Evrosimovska B. Velickovski Z. Menceva
The Use of Advanced Technology to Avoid Injury of the 112 Inferior Alveolar Nerve during Implant Surgery
Bony Lid Approach in Dentoalveolar Surgery: Report of 2 Cases 116
CR CR
Technique of Frenectomy of Labial Fraenum with 122 Combined Osteotomy at Intermaxillary Suture Fracture of the Maxillary Tuberosity: A Case Report 125
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Langerhans Cell Histiocytosis: Its Oral and Maxillofacial Dimension

SUMMARY
Petros Papadopoulos Private Practice
This paper reviews clinical, histological and pathological characteristics of Langerhans Cell Histiocytosis (LCH) in relation to its oral and maxillofacial interest. For purposes of better examination, LCH is differentiated into 3 syndromes: Hand-Sculler-Cristian (HSC) disease, Letterer-Siwe (LS) disease and Eosinophilic Granuloma (EG). Abnormal proliferation of histiocytic cells with Birbeck granules is found in all 3 of them. The cause of LCH is related to abnormal proliferation of Langerhans Cells (LCs) which are mononuclear phagocyte system cells concentrated in oral gingival sulcular and junctional epithelium. LCH appears to attack patients of any age, especially young children. Its predilection sites are the maxilla and the mandible. In LS disease, ulceration of oral mucosa, premature loss of teeth, suppuration or haemorrhage, all are common symptoms. Moreover, in HSC soreness, generalized stomatitis and bone destruction are found. EG preserves all the above characteristics and underlines a delayed healing after extraction and pathologic fractures. The diagnosis is served by radiographic images, which show solitary intraosseous lesions, defined periphery and multiplicity of alveolar bone lesions, bone sclerosis or root resorption. Early diagnosis improves the prognosis and effectiveness of the treatment. The weapons against LCH are: surgery, corticosteroids and alkylating agents.
Keywords: Langerhans Cell Histiocytosis; Hand-Sculler-Cristian Disease; Letterer-Siwe Disease; Eosinophilic Granuloma; Alveolar Bone; Bone Destruction
LITERATURE REVIEW (LR) Balk J Stom, 2012; 16:69-73
Introduction
The term Histiocytosis X was introduced by Lichten stein in 1953 for a group of diseases that produce 3 syndromes with similar clinical and histopathological features1: Hand-Sculler-Cristian (HSC) disease, LettererSiwe (LS) syndrome and Eosinophilic Granuloma (EG). Since all 3 diseases have an abnormal proliferation of histiocytic cells with characteristic Birbeck granules, a differentiation between them has been abandoned and the term Langerhans Cell Histiocytosis (LCH) is commonly used nowadays2. LCH develops in childhood as well as in adulthood3. It can involve many organ systems but primarily affects bone, skin, lymph nodes, lung, liver and spleen, endocrine glands and nervous system4.
Its dental interest derives from its special histo pathological characteristics referring to the oral and maxillofacial region, as well as its relationship to certain dental pathologies. This comprises the reason of a review of all the aforementioned syndromes, which can be proven useful either for general dentists or for specialized ones.
Role of Langerhans Cells in Oral Pathology

Langerhans Cells (LCs) are bone marrow derived cells that belong to the mononuclear phagocyte system and (or) dendritic system5. In gingiva they are present in 3 areas: (1) the oral gingival epithelium; (2) the sulcular
70 Petros Papadopoulos
epithelium; (3) the junctional epithelium. They are located in the suprabasal and spinous layers of the oral gingival and sulcular epithelium. In the junctional epithelium, 2 types of Langerhans cells can be observed. The first type with a spherical morphology possesses a few short dendrites and is weakly stained for Castlemans Disease (CD) 1a Thymocyte (T) 6 antigen. The other type exhibits dendrites of moderate length and number with varied fluorescence intensity against CD1a T6 antigen6. These heterogeneities could represent different stages of a dynamic process leading to an accumulation in number of LCs7. Much experimental evidence has shown that there are differences both in LC numbers and in surface antigen expression between healthy and diseased gingiva. Consequently, LC could represent key cells in pathogenesis and development of periodontal disease8. Moreover, the relationship between an increased number of LCs and plaque accumulation was demonstrated in men during experimental gingivitis. More LCs were found in the inflamed gingiva in comparison to healthy gingiva from the same patients. Many studies also suggested an increase of the LCs in moderate gingival inflammation, but a decreased number of LCs in periodontitis compared with the controls. The numerical diminution of LCs in the passage from gingivitis to periodontitis reveals an important role of these cells in the pathogenesis of gingival disease. In contrast to gingivitis and periodontitis, a satisfactory explanation of the proliferation of LCs in the lesions of LCH is still missing, although its appearance is definitely related to this proliferation9.
nodular foci. Oral manifestations such as gingivitis and ulcers as well as oral bleeding and eventual loss of teeth are present10. 3. Eosinophilic granuloma of bone (chronic focal): It can be solitary or multifocal11. LCs are associated with eosinophils and often other types of granulocytes in variable number. LCs have pale, vesiculated, weakly eosinophilic cytoplasm and nuclei that appear folded or lobulated. Mitotic activity is typically absent. Eosinophils may be scattered among the LCs or histiocytes. By electron microscopy, Birbeck granules may be seen in LCs. They appear as lamellar plates with a central striated line. They occasionally have a terminal vesicular dilatation giving them a racquet shape.
Incidence and Dental Predominant Sites

LCH is considered a childhood disease, but the diagnosis is often made in adults as a likely evolution of the juvenile form12. It seems to be more frequent in males than in females, with a reported ratio ranging from 1:1 to 4:113. In adults, there is a much greater variation with a slight predominance of female patients12. It is very interesting to notice that in a review of 1120 patients, Hartman reported oral involvement in 10% of the cases. a. LS disease: There is no special information about the incidence of the LS disease. It particularly affects infants or young children, under the age of 2 years, predilection sites being the alveolar parts of the maxilla and the mandible; b. HSC disease occurs mainly in children or adults. The maxilla and the mandible may be the first structures to show signs of this condition14. It commonly affects older children, between ages of 5 and 10, but may be seen in any group; c. EG constitutes about 50% to 60% of all Histiocytosis X cases15. It is a disease with an incidence of 1 new case/350000-2 million per year16, 17. Approximately 75% of all patients are below 20 years of age2. Predominant locations are the flat bones, with frequent involvement of the mandible in patients less than 20 years old. Individuals over the age of 50 are uncommonly affected.
Histology (Microscopy)
For purposes of a better examination of the histology of the disease, its differentiation into the 3 syndromes we mentioned in the introduction could be critical. Consequently: 1. Hand-Schuller-Cristian disease (chronic disseminated) comprises of multiple lesions in the bones and soft tissues initially, with some visceral lesions developing later8. Except of the skin lesions, which are typical nodules in flexures, a crusted scalp rash mimicking seborrheic dermatitis may also be seen. Oral lesions include gingivitis, ulcerations and destructive granulomas involving the mandible and the maxilla. Gingival tissue shows a dense infiltrate (histiocytic) throughout most of the connective tissue. The nuclei of the histiocytes are, for the most part, regular with some vacuolisation. There is a significant number of eosinophils scattered throughout much of the infiltrate. 2. Letterer-Siwe disease (acute disseminated): It demonstrates an excessive proliferation of histiocytes that accumulates in tissues. It can also include
Oral Manifestations
In case of the LCH, the first manifestations and symptoms occur in the mouth5 and identification is necessary for the diagnosis of the disease. The leading
Langerhans Cell Histiocytosis 71
symptom of the LCH within mandibular and maxillary bones is pain, which sometimes is misdiagnosed as a marginal infection2. There is also loosening of teeth, as common presenting complains of the patients, as well as necrotising and ulcerating defects of the mucosa and jaw swelling5. The ulcerations are accompanied by granulomatous exophytic tissue in the areas of the attached gingiva in the maxilla, extending to the palate anteriorly and posteriorly18. In clinical cases without bone involvement, palatal, lingual and vestibular bilateral ulcerations were recorded in molar maxillary and mandibular regions. Submucosal nodules were also recorded in the superior and inferior frontal gums19. Except from pain,, a burning sensation and spontaneous and mechanically induced bleeding during oral hygiene procedures were noticed. The upper and lower third molar regions were more inflamed and painful19. More specifically referring to each entity of the disease separately, we can look into the following signs and symptoms of oral involvement of the LCH: (1) The LS syndrome -ulcerations of oral mucosa, diffuse destruction of bone, premature loss of teeth, haemorrhage, foul breath, suppuration; (2) The HSC disease - generalised stomatitis, soreness, haemorrhage from the gums, ulceration and necrosis of the oral mucosa, progressive bone destruction of the alveolar process, loosening and premature loss of teeth, facial asymmetry; (3) The EO - periodontitis localised in an otherwise healthy dentition, loss of alveolar bone with the area of destruction replaced by soft tissue, delayed healing after extraction teeth, premature loss of teeth, foul breath, solitary soft tissue involvement may affect the tongue and may also be confused with traumatic granuloma20. In the EO, pathologic fractures may occur especially in the long bones15. It is also useful to underline the fact that in the HSC disease, typical lesions of the disease involve the cranial bones, the eyes (exophthalmia) and the pituitary gland (diabetes insipidus), whereas in the LS disease, the syndrome is characterised by lymph node, spleen and liver involvement, with a severe clinical course12.
the borders of the lesions are mostly well delineated, whereas in the HSC disease the lesions appear as round, oval or irregular areas with sharp margins. In the jaws, these areas look like cysts. Concentrically, several studies showed at least 7 radiographic characteristics occurred frequently with LCH of the jaws, such as the solitary intraosseous lesions that are located outside the alveolar process, the multiplicity of alveolar bone lesions or the well defined periphery. The periphery of the lesions of LCH in the jaws is considered to be well defined but uncorticated. Another radiographic characteristic is the scooped out shape. This occurs because bone destruction starts below the crest of the alveolar process. Usually, a portion of the superior aspect of the crest of the alveolar bone is maintained at the mesial and distal margins of the area of destruction and produces the scooped out appearance. Bone sclerosis is a common observation in inflammatory lesions of the jaws, and the fact that it appears frequently in the alveolar bone lesions might be explained by communication of the lesions with the oral cavity, that results in a superimposed infection. Periosteal new bone is observed in intraosseous lesions. The identification of the presence of this thin layer of bone is highly dependent on the projections available for study. Finally, root resorption associated with lesions of the LCH is always very slight22. It is necessary to notice the need of biopsies along with immunohistochemistry to confirm the diagnosis of the LCH and ascertain the nature of cells involved in the lesions detected18. The infiltration cells in LCH are S-100, CD1, CD4 and Human Leukocyte Antigen (HLA)-DR positive. Electron microscopy will also detect the presence of Birbeck granules23.
Differential Diagnosis
The puzzle of a successful diagnosis is completed by the fulfilment of the differential one: clinically, the LCH is difficult to be distinguished from bone metastases, osteomyelitis or even malignant tumours. The final diagnosis of the LCH can be made only by histology. Morphologically, the cells are characterised by lobulated nuclei, basophilic nuclei and eosinophilic cell plasma. By immunohistochemistry, tumour cells usually express S-100 and CD-1a. The detection of cytoplasmic inclusion bodies known as Birbeck-Breatuach granules is a typical characteristic of the LCH24. Besides histopathologic diagnosis, a bone scintigraphy is mandatory to exclude or to detect additional lesions. A common extraosseus manifestation can be found in the lungs25. The clinical appearance and course of the presenting lesions usually suggest a differential diagnosis including other causes of chronic ulceration, such as trauma, necrotizing sialometaplasia, tuberculosis or deep fungal
Diagnosis - Radiographic Image

An effort to find out the diagnosis of LCH would be surely incomplete and insecure without taking into consideration the radiographic image of the disease. LCH presents as localised punched out radiolucencies with no calcification and no sign of sclerosis or reaction at the borders. There may be severe alveolar bone resorption producing an appearance of teeth floating in space. Panoramic radiograph and computerised tomography is used for this purpose21. Moreover, in the EO of the jaws,
72 Petros Papadopoulos
infection. Although T-cell lymphoma might manifest as an ulcer, growth is very rapid and progressive, with destruction of underlying bone. In contrast, in the LCH, the ulcer may maintain the same appearance for months. Another differential diagnostic possibility is melanoma, although the presence or not of pigmentation allows clinically to distinguish it from the LCH. As mentioned above immunohistochemistry is very useful to confirm diagnosis. S-100 positivity might prove sufficient, in the appropriate light microscopic setting and with negative immunohistochemical studies for Human Melanoma Black (HMB)-45, leukocyte common antigen (LCA) or CD3026.
Prognosis
Generally, the prognosis for patients with the various forms of LCH has improved steadily with the advent of an early and successful diagnosis and the evolution of a more effective treatment. However, clinical prognosis of patients will become worse with the growing number of involved organs, with growing number of oral dysfunctions27, with rapid disease progression, with limited treatment response and decreasing age of the first disease manifestation22. Early onset is associated with bad prognosis. In younger children, before the age of 3, the disease progresses rapidly and is fatal. Late onset is associated with milder forms of the disease. Prognosis is excellent in isolated EO of bone, which may heal spontaneously. There is a 90-95% recovery. Prognosis is also good to very good in multiple EOs restricted to bone15. Moreover, soft tissue involvement is associated with bad prognosis. In bone and soft tissue involvement, the mortality rate is 50%. In HSC disease the mortality rate has been estimated to be 30%. In LS disease the outcome is usually fatal. Death usually ensues within 1-3 years from bone marrow depletion, toxicity, septicaemia haemorrhage and exhaustion. In HSC death usually ensues from opportunistic infections, intracranial extension and anaemia. Long survival is an exception in LS disease. In infants, it is very acute and rapidly fatal.
In some large or multifocal lesions, it is necessary to follow surgical curettage with radiation therapy. Oral lesions are treated by topical corticosteroids (betamethasone dipropionate 0.05% and sometimes in combination with topical antifungals (miconazole oral gel) to avoid oral Candida infections. The patient undergoes frequent oral professional hygiene sessions to minimize mucosal and periodontal damage. Particularly, in the LS disease with a poor prognosis, therapy consists of steroids used in conjunction with a cytotoxic drug. Alkylating agents provide a more definite suppressing action. Vinblastin has proved to be a medication of value. Moreover, in recent years, drug treatment, especially in cases of multiorgan involvement, gains more and more importance. Such drugs are 2-deoxycoformin, etoposide, vinblastin28-30, mercaptopurine, methotrexate, predisolone, interferon31 and interleukin14.
Concluding Remarks
As it is well understood, the most important parameter in the analysis of a disease as a scientific issue is its cure. Generally speaking about cure of the LCH, not only in jaws but as a multi-system threat, very interesting questions are born such as: is LCH a malignant or an inflammatory disorder? Should all LCH patients receive therapy? Concerning the first question, clinical data is ambigual. Clonal expansion of LC, but not lesional T-cells, was defined by the human androgen receptor (HUMARA) DNA assay as well as T-cell receptor analysis32. These findings have led many aficionados of LCH to strongly state that it is a malignant proliferation. Given certain CGH/LOH results from clonal versus nonclonal LCH, the controversy on the malignant nature of the LCH seems far from settled33,34. About the second question (whether should all LCH patients receive therapy), the studies show distinct conclusions. The simple answer is no when including single skull lesions in the frontal, parietal or occipital areas and other skeletal lesions. However, it would be a mistake to say that LCH is a slowly progressive disease in which a wait and see approach should be adopted. This is especially true of pulmonary, jaw and skin disease of adults. Smoking cessation may be effective in some patients with lung disease, but they need to be monitored carefully since the insidious progression of cystic changes and fibrosis can rob the patients of vital lung function. Heroic surgery for jaw disease results in disfigurement and loss of teeth, whereas a 6 month course of viblastine and prednisone can cure the disease and allow reformation of the bone with no loss of dentition. Finally, painful and disturbing perineal ulcers
Treatment
The treatment of LCH is dependent on the lesion size and the degree of tissue involvement, and thus differs from unifocal or multifocal (monostotic or polyostotic) presentations26. Surgery, in particular for solitary bone lesions, is still the treatment of choice. Following radiation therapy, patients frequently experience pain relief; however a complete remission is seldom achieved2.
Langerhans Cell Histiocytosis 73 18. Bottomley WK, Gabriel SA, Corio RL, et al. Histiocytosis X: Report of an oral soft tissue lesion without bony involvement. Oral Surg Oral Med Oral Pathol, 1987; 63:228-231. 19. Manfreddi D, Corradi V, Vescovi P. Langerhans cell histiocytosis: A clinical case without bone involvement. J Periodontol, 2005; 76:143-147. 20. Zachariadis N, Anastasea-Vlachou K, Xypolyta A, et al. Uncommon manifestations of histiocytosis X. Int J Oral Maxillofac Surg, 1987; 16:355-362. 21. Kelly KM, Pritchard J. Monoclonal antibody therapy in Langerhans cell histiocutosis -feasible and reasonable? Br J Cancer, 1994; 70(23):54-55. 22. Dagenais M, Pharoah MJ, Sikorski PA. The radiographic characteristics of histiocytosis X: A study of 29 cases that involve the jaws. J Oral Surg Oral Pathol, 1992; 74:230-236. 23. Odam RB, James WD, Berger TG. Andrews Disease of the skin. 9th ed. Philadelphia: WB Saunders Co, 2000; pp 913-917. 24. Chu T, Taffe R. The normal Langerhans cell and the Langerhans cell histiocytosis cell. J Cancer, 1994; 23:4-9. 25. Malpas TS, Norton AJ. Langerhans cell histiocutosis in the adult. J Med Pediatr Oncol, 1996; 27:540-546. 26. Milian MA, Bagan JV, Jimenez Y. Langerhans cell histiocytosis restricted to the oral mucosa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2001; 91:76-79. 27. Giona F, Caruso R, Testi AM, et al. Langerhans cell histiocytosis in adults. A clinical and therapeutic analysis of eleven patients from a single institution. J Cancer, 1997; 80:1786-1791. 28. Basade MM, Nair CN, Kurkure PA, et al. Etoposide in Langerhans cell histiocytosis in children: a preliminary experience. Med Pediatr Oncol, 1996; 13:159-162. 29. Gadner H, Heitger A, Grois N, et al. Treatment strategy for disseminated Langerhans cell histiocytosis. Med Pediatr Oncol, 1994; 23:72-80. 30. Ladisch S, Gadner H, Aric M, et al. LCH-I: a randomized trial of etoposide vs. vinblastine in disseminated Langerhans cell histiocytosis. The Histiocyte Society. Med Pediatr Oncol, 1994; 23:107-110. 31. Hirose M, Saito S, Yoshimoto T, et al. Interleukin 2 therapy of Langerhans cell histiocytosis. Acta Paediatr, 1995; 84:1204-1206. 32. William CL, Busque L, Griffith BB, et al. Langerhans cell histiocytosis (histiocytosis X) - a clonal proliferative disease. N Engl J Med, 1994; 331:154-160. 33. Murakami I, Gogusev J, Fournet JC, et al. Detection of molecular cytogenetic aberrations in Langerhans cell histiocytosis of bone. Hum Pathol, 2002; 33:555-560 34. Dacic S, Trusky C, Bakker A, et al. Genotypic analysis of pulmonary Langerhans cell histiocytosis. Hum Pathol, 2003; 34:1345-1349. 35. Mc Clain KL, Natkunam Y, Swerdlow SH. Atypical cellular disorders. Hematology, 2004; pp 283-296.
of LCH in women are best treated with chemotherapy or thalidomide, not radiation. This whole description reveals the importance of the existence of such questions as the above. These prove to be the basis of further evolution of scientific studies about certain subjects of great medical concern35.
References
1. Lichtenstein L. Histiocytosis: Integration of eosinophilic granuloma of bone, Letterer-Siwe disease and Hand -Schuller-Cristian disease as related manifestations of a single nosologic entity. Arch Pathol, 1953; 56:89-102. 2. Eckardt A. Schultze A. Maxillofacial manifestations of Langerhans cell histiocytosis: A clinical and therapeutic analysis of 10 patients. J Oral Oncology, 2003; 39:687-694. 3. Howarth DM, Gilchrist GS, Mullan PB, et al. Langerhans cell histiocytosis: Diagnosis, natural history management and outcome. Cancer, 1999; 85:2278-2290. 4. Mortazavi H, Ehsani A, Namazi MR, et al. Langerhans cell histiocytosis. Dermatol Online J, 2002; 8(2):18. 5. Schepman KP, Radden BG, Van der Waal I. Langerhans cell histiocytosis of the jaw bones. Report of 11 cases. Austr Dent J, 1998; 43(4):000-000. 6. Lombardi T, Hauser C, Budtz-Jorgensen E. Langerhans cells: structure, function and role in oral pathological conditions. J Oral Pathol Med, 1993; 22:193-202. 7. Sagredo E, Pino A, Ibanez P. Evaluation de letat gingival par la quantification desantigenes T6 (CD1a) et HLA-DR. J Biol Buccale, 1990; 18:163-168. 8. Jenney MEM. Langerhans cell histiocytosis: Where do we go from here? Lancet, 1994; 344:1717-1718. 9. Chen HC, Shen WC, Chou DY, et al. Langerhans cell Histiocytosis of the skull complicated with an Epidural Hematoma. AJNR Am J Neuroradiol, 2002; 23(3):493-495. 10. Strodel BJ. Letterer-Siwe disease: Report of Case. ASDC J Dent Child, 1977; 44(4):310-313. 11. Landrito J, Sakurai K, Ohshima K. Use of the ultrasonic surgical aspirator in the treatment of the solitary eosinophilic granuloma of the mandible: A case report. J Oral Maxillofac Surg, 1990; 48:855. 12. Muzzi L, Pini Prato GP, Ficarrat G. Langerhans cell histiocytosis diagnosed through periodontal lesions: A Case report. J Periodontol, 2002; 73:1528-1533. 13. The French Langerhans cell histiocytosis study group. A multicentre retrospective survey of Langerhans cell histiocytosis: 348 cases observed between 1983 and 1993. Arch Dis Child, 1996; 75:17-20. 14. Thoma KH. Oral Pathology. 4th ed. St Louis: CV Mosby, 1954; pp 666-672. 15. Uckan S, Gurol M, Durmus E. Recurrent multifocal Langerhans cell, Eosinophilic Granuloma of the jaws: Report of a case. J Oral Maxillofac Surg, 1996; 54:906-909. 16. Libicher M, Roegen I, Troeger. Localised Langerhans cell Histiocytosis of bone; treatment and follow-up in children. J Pediatr Radiol, 1995; 25:134-137. 17. Mc Cowage GB, Frush DP, Kurtzberg J. Successful treatment of two children with Langerhans cell histiocytosis with 2-deoxycoformycin. J Pediatr Hematol Oncol, 1996; 18:154-158.
Correspondence and request for offprints to:

Petros Papadopoulos Th. Sakellaridi 25a 542 48 Thessaloniki, Greece E-mail: peterpap77@yahoo.gr
GI CA L SOCIETY
ISSN 1107 - 1141
LO TO STOMA
Effects of Local Application of Ascorbic Acid and Glutathione by Iontophoresis on Gingival Inflammation
SUMMARY
Management of gingival inflammation is always a priority in dental practice, regardless the possible involvement of other periodontal tissues. Besides the use of systemic medical therapy, such as antibiotics, vitamins are also recommended as a complementary therapy. Nutritional vitamin intake has been proven effective on gingival inflammation. The aim of this study was to evaluate the effects of local application of glutathione and ascorbic acid by iontophoresis on gingival tissue inflammation. 60 patients with periodontal disease were divided into 2 groups: the control group was treated by conservative treatment of periodontal disease only, and the study group was treated by ascorbic and glutathione, applied with iontophoresis in 10 sessions, besides conservative treatment. Values for gingival inflammation and gingival bleeding on probing were noted. The obtained results showed significant differences for both gingival inflammation and gingival bleeding between the examined groups, with significant decrease in index values for gingival bleeding after 3 months in the study group.
Keywords: Gingival Inflammation; Iontophoresis; Ascorbic Acid; Glutathione
Maja Pandilova1, Ana Ugrinska2, Silvana Georgieva1, Mirjana Popovska1, Lidija Kanurkova1, Katerina Smilevska1 Dental Clinical Centre St. Pantelejmon 2Faculty of Medicine, Institute of Pathophysiology and Nuclear Medicine Akademik Isak Tadzer Skopje, FYROM
1University
ORIGINAL PAPER (OP) Balk J Stom, 2012, 16:74-78
Introduction
Managing gingival inflammation is one of the first challenges that every peridontologist faces, no matter if the process is located only in the gingival tissue, or severe periodontal destruction had taken place. Furthermore, control of infection and gingival inflammation is necessary regardless the following course of periodontal therapy, conservative or surgical. Keeping inflammation under control is even more important in the maintenance period. The methods used for dealing with gingival inflammation are various, such as: removal of local irritations, training the patients to maintain optimal plaque control, and applying different kinds of medication. Besides the antibiotic therapy, which in certain cases is applied, for control of inflammation and creating better conditions for managing microorganism challenge, vitamins are often used as a supplemental therapy. The effects of vitamins on the gingival tissue are confirmed
when taken in natural forms, like fruits and vegetables14. Receiving vitamins as supplements in a chemical way (pills, tablets), according to our previous examinations15 did not show measurable results. Therefore the aim of this study was to verify the effects, if any, of topical appliance of ascorbic acid and glutathione delivered by iontophoresis in the gingival tissue, on gingival inflammation.
Material and Methods

For realization of our goal 60 patients with periodontal disease, randomly selected, participated in the study. The selected patients met the following criteria: None of the patients had attachment lost on probing greater then 5 mm; None of the patients had any systematic disease, or was receiving any drugs;
Application of Ascorbic Acid and Glutathione by Iontophoresis 75 Table 2. Average index values for gingival bleeding for the control group X Before therapy After therapy 3 months after therapy 2.76 1.56 2.20 Sd Se t 11.39 4.26 p <0.001 <0.001
All patients had forefeel the conditions for iontophoresis (patients with heart disease and pregnant women were excluded from the study); All patients were between 35 and 45 years of age; All patients, according to their history, brushed their teeth twice a day and occasionally used additional products for inter-dental cleaning. Patients were separated in 2 different groups, 30 patients each: The control group, treated only with conservative treatment; The study group, treated by iontophoresis with ascorbic acid and glutathione beside the conservative treatment. Ascorbic acid was applied by all standard procedu res, depending on the individual patients sensitivity of current strength and the transportability of molecules of the applied solution. After a 30 min break, to each patient of the study group, glutathione was applied as solution on the electrodes covered with sterile gaze soaked in solution of distilled water and 0.9% NaCl. The iontophoresis of glutathione was performed from the active electrode with negative charge for a period of 15 minutes. Both glutathione and ascorbic acid were applied every day during period of 10 days. All patients were trained to maintain oral hygiene and were called 3 months later for a control visit. Gingival inflammation and gingival bleeding were noted according to the criteria proposed by Silness and Loe22, for each patient on his/her first visit, after the treatment, and on the recall visit after 3 months. Data were statistically processed by the computer programme Statistics 5.
0.55 0.11 0.72 0.09
The study group also had a significant decrease of gingival inflammation and gingival bleeding after the performed therapy (inflammation went from 2.30 to 0.93 and gingival bleeding went from 2.66 to 0.77). Nevertheless, the index values after the 3-month period showed bigger stability for the study group compared with the control group (Tabs. 3 and 4).
Table 3. Average index values for gingival inflammation for the study group X Before therapy After therapy 3 months after therapy 2.30 0.93 1.01 Sd 0.61 0.70 Se t p
0.11 12.17 <0.001 0.09 10.30 <0.001
Table 4. Average index values for gingival bleeding for the examined group X Before therapy After therapy 3 months after therapy 2.66 0.70 0.86 Sd 0.66 0.61 Se t p
0.11 16.10 <0.001 0.09 16.15 <0.001
Results
After processing the data we gained the following results: both groups expressed excellent results during therapy according to the given criteria. The control group had a significant decrease of gingival inflammation index and gingival bleeding after initial therapy: inflammation went from 2.46 to 0.83 and gingival bleeding from 2.76 to 1.56. However, on the control visit after 3 months, gingival inflammation was 1.40, while gingival bleeding was almost at the start point (Tabs. 1 and 2).
Table 1. Average index values for gingival inflammation for the control group X Before therapy After therapy 3 months after therapy 2.46 0.83 1.40 Sd 0.80 0.86 Se 0.11 0.09 t 11.06 6.71 p <0.001 <0.001
Discussion
The general idea of our study was to administrate ascorbic acid and glutathione directly in gingival tissue in order to accomplish favourable ratio between over-generated reactive oxygen species (ROS) and antioxidants. ROS are highly reactive molecules which in their last electron circle have the ability to gain or lose 1 electron. This kind of structure makes them highly unstable, so they persist only a very short period of time (a nanosecond or less). Even so, they can cause serious damages on the cellular level. They are taught to be responsible for autoimmune diseases, atherosclerotic changes and cancerous growth. Once created, ROS can interact among themselves, which is most preferred outcome, yet less likely to happen considering their brief life time. As long as the production of ROS is in physiological range, the organism ties them up in order to make them stable. But when their production is increased or when the antioxidant system is exhausted, then the increased presence of ROS
76 Maja Pandilova et al.
start a chain reaction of creating more free radicals, even more reactive and damageable from the initial one. The chain reaction will run until the one of the antioxidant mechanisms stops it. ROS production is inevitable in all aerobic organisms, including humans, who necessarily posses a complex system of antioxidant defence8,21. If homeostasis is interrupted in favour of ROS, an oxidative stress situation is created21. Oxidative stress processes and alterations in the immune system are closely related and have been described in different diseases, thus both the aspects also seem to be linked to the pathogenesis of periodontal disease, and can also be detected in plasma of patients with periodontal disease8,16,21. However, the extent to which ROS over-generation influences the initiation and progression of periodontal diseases is still unknown. The strong evidence linking ROS to the pathological destruction of the connective tissue during periodontal disease rests on the presence of neutrophil infiltration as the main event in the host's response to bacterial invasion1,2,10,19. The hydroxyl radical is able to initiate a classical chain reaction, known as lipid peroxidation, leading to vasodilatation and rat bone reabsorption8. An example of the damage caused by hydrogen peroxide is stimulation of phosphorylation of the NFkB-kB complex, activating the NK-kB and facilitating nuclear translocation and downstream of pro-inflammatory cytokines, including IL-2, IL-6, IL-8, -interferon and TNF-, that are very important in the pathogenesis of periodontal disease9. Experiments concerning the effects of ROS are generally focused on the effects of gingival inflammation. Such experiments, conducted on lab animals treated with pesticides, and given food with lowered elementary antioxidant, showed desquamation of the epithelium, swelling, elasticity loose and breaking of the collagen, bone resorption and lowered speed of C prolin incorporation, thickening of the blood vessels and thrombosis with all its consequences5. On the contrary, in another study, the lab animals were treated with ascorbic acid, tocopherol and biophlavonides. In this experiment, less inflammatory-destructive process was noticed12. Mentioned data raises the questions on developing pharmaco-prophylactic measures with bio antioxidants and other bio-regulatives as an addition to the primary and preventive treatment of periodontal disease. The chain of inhibition of ROS: glutathione - ascorbic acid - tocopherol, with transportation of electrons from pironucleotides (NAD NADF) towards ROS, guarantees permanent low level of free radicals in the cells. Applying glutathione at periodontal disease has proven to be effective in the early stages of the disease. Beside glutathione, other antioxidants can be used with good results such as: tocopherol or ascorbic acid12,13. Glutathione (GSH) is a tripeptide of glutamine, glycine, and cysteine. It is not an essential nutrient, since
it can be synthesized in the body from the amino acids L-cysteine, L-glutamic acid, and glycine, and acts directly as a generic ROS scavenger of the so-called Phase II reactions17. GSH has multiple functions: it is the major endogenous antioxidant produced by cells, participating directly in neutralization of free radicals and reactive oxygen compounds, as well as maintaining exogenous antioxidants, such as vitamins C and E, in their reduced active forms20. It is used in metabolic and biochemical reactions, such as DNA synthesis and repair, protein synthesis, prostaglandin synthesis, amino acid transport, and enzyme activation. Some periodonto-pathogenic bacteria deplete GSH, and this may explain why the amount of this antioxidant was not elevated in the gingival tissue of patients with periodontal disease1,2,10. A similar result was obtained in gingival tissue and blood, and lower levels of GSH were detected in the crevicular gingival fluid of patients with chronic periodontal disease, when compared to normal subjects1,2. Systemic depletion of antioxidants clearly indicates that in chronic periodontal disease the antioxidant system is affected by a relatively strong oxidation insult, which can deplete nutritional antioxidants, such as vitamin E and C in plasma, and also vitamin E in red cell membrane16. According to the literature data on the positive effect of this kind of additional therapy with vitamins, and in our previous studies, we confirmed that individuals which on regular daily base use citrus and citrus like fruits have less gingival inflammation and gingival bleeding from those who never use it, or use it occasionally14. But in our further studies we got to the conclusion that if the vitamins are received chemically (as pills) the significant results were not achieved15. In order to be able to get better topic apply of antioxidants, directly in the gingival tissue, we decided to use permeability of the oral mucosa and enhance the drug appliance by electric current using iontophoresis. The permeability barrier in oral mucosa is believed to be the result of intercellular material derived from the so-called membrane coating granules (MCG)6. MCG start forming through cell differentiation and at the apical cell surfaces they fuse with plasma membrane. This barrier is present in the outermost 200 m of the superficial layer. Permeation studies have been performed using a number of very large molecular weight tracers, such as horseradish peroxidase and lanthanum nitrate3. After being applied to the outer surface of the epithelium, these tracers penetrate only through outermost layer of cells. When applied to the submucosal surface, they permeate up to the top cell layers of the epithelium. While the basement membrane may present some resistance to permeation, the outer epithelium is considered to be the rate limiting step to mucosal penetration11. There are 2 permeation pathways for passive drug transport across the oral mucosa: paracellular
Application of Ascorbic Acid and Glutathione by Iontophoresis 77
and transcellular routes4. These 2 routes can be used simultaneously, but 1 route is usually preferred over the other, depending on the physicochemical properties of the drug. Since the intercellular spaces and cytoplasm are hydrophilic in character, lipophilic compounds would have low solubility in this environment. The cell membrane is lipophilic in nature and hydrophilic solutions will have difficulty permeating24. Iontophoresis is a procedure based on the use of galvanic electricity and provides easy, fast and effective absorption of different kinds of substances in the tissue. Iontophoresis accomplishes faster metabolism of cells by movement of ions in the bodily fluids and opening on canals in the cells membrane which create possibilities for easer absorption of different liquid substances in the tissue. Iontophoresis enhances drug delivery by 3 mechanisms: ion-electric field interaction provides an additional force that drives ions through the tissue, the flow of electric current increases the permeability of the mucosa, and electro-osmosis produces bulk motion of solvent that carries ions or neutral species with the solvent stream. Electro-osmotic flow occurs in a variety of membranes and is in the same direction as the flow of counter-ions. It may assist or hinder drug transport18,23. Iontophoresis can also enhance mucosa delivery by a possibly dependant pore formation in the upper stratum cell layer, attributed to a flip-flop gating mechanism that occurs due to restructuring of the polypeptide helices on application of electric current. Iontophoretic transport is capable of producing a 100 fold enhancement relative to passive diffusion7,23. The achieved effects from our study were expected. Inflammation and gingival bleeding showed significant decrease of the average index values for both groups after the therapy without noticeable difference between the groups. Noticeable data were achieved for the average index value for gingival bleeding after 3 months had passed. Since our study design didnt include methods of tracing the given medicaments into the tissue, the concentration they achieve and length of their permeability, the prolonged improvement of clinical parameters may convince us that we had created better host environment. It is worth mentioning that during our study same problems occurred. Convincing the patients from the study group to undertake the procedure was an issue, since applied at the way we did the procedure, it was rather time consuming for both patient and doctor. So further work might be focused towards developing a hydro-gel containing these or some other drugs and, using iontophoretic enhancers, the time of appliance could be shortened. Discoloration of the mucosa did not appear in any of the patients, since both agents are used in dermatology as blanching agents.
The achieved results of this study speak in favour of applying ascorbic acid and glutathione by iontophoresis in everyday clinical practice, especially for a long term maintenance on once achieved results of periodontal therapy.
References
1. Chapple ILC, Brock G, Eftimiadi C, Matthews JB. Glutathione in gingival crevicular fluid and its relation to local antioxidant capacity in periodontal health and disease. J Clin Pathol, 2002; 55(6):367-373. 2. Chapple ILC. Role of free radicals and antioxidants in the pathogenesis of the inflammatory periodontal diseases. J Clin Pathol, 1996; 49:247-255. 3. Collins LMC. The Surface Area of the Adult Human Mouth and Thickness of the Salivary Film Covering the Teeth and Oral Mucosa. J Dent Res, 1987; 66:1300. 4. DeVries ME, Verhoef JC, Junginger HE. Developments in buccal drug delivery. Crit Rev Ther Drug Carr Sys, 1991; 8:271. 5. Enwonwu C. Cellular and molecular effects of malnutrition and their relevance to periodontal diseases. J Clin Periodontol, 1994; 21:643-657. 6. Gandhi RE. Indirect atomic absorption determination of atropine, diphenhydramine, tolazoline, and levamisole based on formation of ion-associates with potassium tetraiodometrcurate. Ind J Pharm Sci, 1988; 50:142. 7. Gangarosa LP, Sr. Iontophoresis in dental practice. Chicago: Quintessence Publ Co Inc, 1983; p 40-52. 8. Halliwell B, Gutteridge JMC. Free Radicals in Biology and Medicine. Oxford: Clarendon Press, 1998; pp 617-783. 9. Honda T, Domon H, Okui T, Kajita K, Amanuma R, Yamazaki K. Balance of inflammatory response in stable gingivitis and progressive periodontitis lesions. Clin Exp Immunol, 2006; 144(1):35-40. 10. Katsuragi H, Ohtake M, Kurasawa I, Saito K. Intracellular production and extracellular release of oxygen radicals by PMNs and oxidative stress on PMNs during phagocytosis of periodontopathic bacteria. Odontology, 2003; 91(1):13-18. 11. Lee JW, JHP, Robinson JR. Bioadhesive-based dosage forms: The next generation. J Pharm Sci, 2000; 89:850. 12. Meydani SN, Meydani M, Blumberg JB, Leka LS, Siber G, Loszewski R, Thompson C, Pedrosa MC, Diamond RD, Stollar BD. Vitamin E supplementation and in vivo immune response in healthy elderly subjects. A randomized controlled trial. JAMA, 1997; 277(17):1380-1386. 13. Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M, Genco RJ. Dietary vitamin C and the risk for periodontal disease. J Periodontol, 2000; 71(8):1215-1223. 14. Pandilova M, Ivanovski K, Ugrinska A, Minovska A, Radojkova V, Ristoska S. The effect of nutritional vitamin intake on periodontal health. Abstract Book of the 9th Congress of the Balkan Stomatological Society, Ohrid 2004; p 97. 15. Pandilova M, Ugrinska A, Ivanovski K. Effects of nutritional tocopherol intake on periodontal health. Mak Stom Pregl, 2009; 33(1-2):95-101.
78 Maja Pandilova et al. 16. Panjamurthy K, Manoharan S, Ramachandran CR. Lipid peroxidation and antioxidant status in patients with periodontitis. Cell Molec Biol Letters, 2005; 10(2):255-264. 17. Pompella A, Visvikis A, Paolicchi A, De Tata V, Casini AF. The changing faces of glutathione, a cellular protagonist. Biochemical Pharmacology, 2003; 66(8):1499-1503. 18. Rai R, Srinivas CR. Iontophoresis in dermatology. Ind J Dermatol Vener Leprol, 2005; 71:236-241. 19. Sakalliolu U, Aliyev E, Eren Z, Akimek G, Keskiner I, Yavuz . Reactive oxygen species scavenging activity during periodontal mucoperiosteal healing: an experimental study in dogs. Arch Oral Biol, 2005; 50(12):1040-1046. 20. Scholz RW. Graham KS, Gumpricht E, Reddy CC. Mechanism of interaction of vitamin E and glutathione in the protection against membrane lipid peroxidation. Ann NY Acad Sci, 1989; 570:514-517. 21. Sculley DV, Langley-Evans SC. Salivary antioxidants and periodontal disease status. Proc Nutr Soc, 2002; 61(1):137-143.
Balk J Stom, Vol 16, 2012 22. Silness P, Loe H. Periodontal disease in pregnancy. Acta Odontol Scand, 1964; 22:121. 23. Semalty A, Semalty M, Singh R, Saraf SK, Saraf S. Iontophoretic drug delivery system: A review. Technology and Health Care, 2007; 15(4):237-245. 24. Wertz PW. The physical, chemical and functional properties of lipids in the skin. Chemistry and Physics of Lipids, 1998; 91:85.
Correspondence and request for offprins to:

Pandilova Maja University Dental Clinical Centre St. Panteleimon Department of Oral Pathology and Periodontology Skopje FYR Macedonia E-mail: mpandilova@yahoo.com
GI CA L SOCIETY
ISSN 1107 - 1141
LO TO STOMA
Salivary Glutathione-Dependent Enzymes in Patients with Dental Fluorosis Treated by Complex Antioxidant Therapy
Introduction. Fluorosis, caused by long-term intake of high levels of fluoride, is characterized by clinical manifestations in teeth. Although fluorosis is irreversible, it could be prevented by appropriate and timely intervention through understanding the process at biochemical and molecular levels. Increased production of reactive oxygen species (ROS) and lipid peroxidation has been considered to play an important role in the pathogenesis of chronic fluoride toxicity. Saliva as a biological liquid of the human organism may be a reflection of the metabolic state, and salivary parameters are clinical-diagnostic means. Aim. The aim was to examine comparatively activities of glutathionedependent enzymes, glutathione reductase and glutathione-S-transferase, and contents of glutathione, calcium and protein in the saliva of adult patients with dental fluorosis, before and after complex antioxidant therapy. Material and Methods. 26 patients (19-30 years old) with mild and moderate dental fluorosis (Deans classification: 3 and 4) and 20 healthy subjects (20-30 years old) were examined. Patients were treated with complex therapy, which included Opalescente Whitening gel (Ultradent products, USA), calcium gluconate and vitamins-antioxidants A, E, D and C. The activities of glutathione-dependent enzymes and contents of glutathione, calcium and protein were determined in the saliva of the patients using spectrophotometric methods. Results. Chronic fluoride intoxication led to the imbalance of antioxidative glutathione-dependent defense system in the patients with dental fluorosis. The results reflected dose-dependent fluoride intoxication and metabolic imbalance. The results suggest that complex antioxidant therapy was effective and partially restored imbalance of the anti-oxidative defense of saliva in patients with fluorosis. Conclusion. Non-invasive methods of the glutathione-dependent enzymes examination may be used in dental practice for estimation of the degree of metabolic disturbances in patients with dental fluorosis.
Keywords: Glutathione; Glutathione reductase; Glutathione-S-transferase; Fluorosis
SUMMARY
Ludmila Gavriliuc1, Elena Stepco2, Ion Lupan2, Nina Sevcenco2, Iurii Spinei2 State University of Medicine and Pharmacy Nicolae Testemitanu, Chisinau Republic of Moldova 1Biochemistry and Clinical Biochemistry Department 2Department of Oral-maxillofacial Surgery and Orthodontics of Children Dentistry
ORIGINAL PAPER (OP) Balk J Stom, 2012; 16:79-83
Introduction
Dental fluorosis, caused by long-term intake of high levels of fluoride, is characterized by clinical manifestations in teeth1. Fluorosis is a serious public health problem in
many parts of the world (India, China, Canada, USA, France, Bulgaria, Romania, etc.) where drinking water contains more than 1 ppm of fluoride5. In certain regions of the Republic of Moldova people use drinking water with high level fluoride, from 0.8 mg/L to 14.0 mg/L (Tab. 1).
80 Ludmila Gavriliuc et al. Table 1. Fluoride concentration in drinking water in different regions of Moldova Regions Anenii Noi Cimislia Orhei Floresti Chiadir-Lunga C= mg/L 1.7-3.0 1.78-3.2 2.1-3.7 3.21-3.7 2.6-4.7 Regions Hincesti Glodeni Ungheni Falesti Pirlita C= mg/L 2.0-5.5 2.0-8.16 5.7 3.2-8.7 9.0-14.0
The aim of this investigation was to examine comparatively activities of glutathione-dependent enzymes, glutathione reductase and glutathione-Stransferase, and the content of glutathione in saliva of adult patients with dental fluorosis, before and after complex antioxidant therapy.

26 patients (19-30 years old) with mild and moderate dental fluorosis (Deans classification: 3 and 4) and 20 healthy subjects (20-30 years old) were examined. Patients were treated with complex therapy, which included Opalescente Whitening gel (Ultradent products, USA), calcium gluconate (1.5 g/day) and vitamins-antioxidants A (retinol palmitate -100000 U/ day), E (alfa-tocopherol acetate -100mg/day), D3 (600 U/ day) and C (ascorbate - 100mg/day). The first course of antioxidant therapy (AOT) was during 30 days, the second AOT course was repeated 1 year after the first AOT. The salivary parameters (indices) were examined 3 times during the treatment: before the therapeutic course and twice after the AOT processes. Saliva was collected in the morning, before breakfast (8 am), and centrifuged at 600 g for 10 min. After centrifugation saliva was examined using SP Humalyzer 2000 (Germany). The contents of glutathione, protein, calcium, activities of glutathione reductase and glutathione-S-transferase were determined in saliva by spectrophotometric methods. Glutathione reductase (GR, E.C. 1.6.4.2) activity was determined with the method already described9. Glutathione-S-transferase (GST, E.C. 2.5.1.18) activity was determined with the method described by Habig and Jacoby10. Glutathiones content14, calcium-ions (Ca2+) content2 were determined by corresponding methods, and protein content by pyrogallol photometric test19. The results were statistically analyzed with Students t-test and Microstat: Microsoft Excel 2003 programme.
Dental fluorosis is a developmental disturbance of dental enamel caused by successive exposures to high concentrations of fluoride during tooth development, leading to enamel with lower mineral content and increased porosity. This subsurface porosity or hypomineralization is most likely caused by a delay in hydrolysis and removal of enamel proteins, particularly amelogenin, as the enamel matures4. The severity of dental fluorosis depends on when and for how long the overexposure to fluoride occurs, the individual response, weight, physical activity, nutritional factors and bone growth5,17,20. The risk period for aesthetic changes in permanent teeth is between 20 and 30 months of age20. The recommended level for daily fluoride intake is 0.05-0.07 mg F/kg/day, which is considered of great help in preventing dental caries, acting in remineralisation. A daily intake above this safe level leads to an increased risk of dental fluorosis. The effects of fluoride on enamel formation suggest that fluoride affects the enamel-forming cells, the ameloblasts3. Fluor is the most active halogen, which is widespread. Intoxication by fluoride leads to chronic oxidative stress and numerous pathological consequences: DNA damage, inhibition of type I collagen synthesis, altered activities of enzymes and metabolic lesions14,18. Increased free radical generation and lipid peroxidation (POL) are proposed to mediate the toxic effects of fluoride on soft tissues and teeth. Oxidative stress was evaluated by the assays of malondialdehyde and antioxidants in patients with fluorosis. Increased POL and altered levels of antioxidants were observed in the blood of children with endemic skeletal fluorosis14. Many results are about investigation of POL and antioxidant defense system in human blood and urine. Data of examinations of salivary components in patients with fluorosis are not numerous and contradictory12,14. Saliva, as a biological liquid of human organism, may be a reflection of the metabolic state. Salivary components (indices) have clinical-diagnostic means11,16. Non-invasive methods of the salivary parameters examination may be used in dental practice for estimation of the degree of metabolic disturbances in patients with dental fluorosis.
Results
Examination of patients with dental fluorosis showed the sufficient difference between contents of their salivary indices and the control group (healthy subjects). Results of the comparative examination of the slivery parameters are shown in figure 1. The content of protein determined in saliva of patients with fluorosis before treatment was 1.40 g/L (152.5%; p<0.001) in comparison with the healthy subjects (0.920 g/L). Concentration of salivary calcium (Ca2+) in patients was 1.428 mmol/L (59.9%; p<0.001) in comparison with healthy subjects (2.383 g/L).
Complex Antioxidant Treatment of Dental Fluorosis 81
Figure 1. Contents of protein (g/L and calcium (mmol/L) in the saliva of patients with dental during complex antioxidant therapy (AOT) courses (1 - protein, left - healthy, right - before treatment; 2 - protein, left - 1st AOT, right - 2nd AOT; 3 and 4 - calcium)
comparison with the healthy individuals - 240 mcmol/L). After the first AOT, its content increased to 173 mcmol/L (72.08%; p<0.05) and after the second course of AOT it increased to 274 mcmol/L (114.17%, p>0.05). In saliva of the patients with dental fluorosis the glutathione reductase activity was 130.9 U/L (78.3%; p<0.01 in comparison with the healthy individuals - 167.1 U/L). After the first AOT, the activity of glutathione reductase was 101.6 U/L (60.8%; p<0.01) and after the second AOT course it increased to 121.6 U/L (72.8%; p<0.05). Glutathione-S-transferase activity in saliva in patients with fluorosis was increased before treatment (3598 U/L), i.e. 122.9% (p<0.05 in comparison with healthy subjects - 2927 U/L). After the first AOT course it decreased to 3450 U/L (117.87%; p<0.05), and even more after the second AOT (2801 U/L), which is 95.7% of the values of healthy subjects (p>0.05).
The first AOT course decreased the protein content to 1.065 g/L (116.0%; p>0.05) and increased calcium content to 2.042 mmol/L (85.69%; p>0.05). The second AOT decreased the protein content to 1.016 g/L (110.7%; p>0.05) and increased calcium concentration to 2.117 mmol/L (88.8 %; p>0.05).
Discussion
The long-term intake of high levels of fluoride with drinking water leads to dental fluorosis. Fluorosis is a serious public health problem in many countries where drinking water contains high level of fluorides. Treatment of patients with fluorosis, which affects both young and old alike, has posed a daunting task of the medical fraternity. Children have been affected by fluorosis of teeth that is one of the clinical manifestations of the disease and metabolic disturbances. Saliva as a biological liquid of the human organism may be a reflection of the metabolic state. Also, salivary components have clinical-diagnostic means. Our results point out that parameters of saliva in patients with dental fluorosis differ from the same parameters of the control group (healthy persons). In saliva of our patients with dental fluorosis the content of protein was increased, which may confirm the dentinal-enamel porosity and removal of enamel proteins to patients saliva. AOT courses decreased its content in saliva of the patients. Our yearly results of creatinine, urea, proline and hydroxyproline determination in saliva of the patients with dental fluorosis were also different from the same parameters of healthy persons7. The described parameters of saliva in the patients with dental fluorosis reflect disturbance of the protein metabolism. Mineral components of saliva constitute one third of all salivary substances, which play an important role for teeth, soft tissues and mouth enzymes. Calcium (Ca2+) is one of the main elements necessary for bones and teeth formation. It is also needed for many processes in
Figure 2. The content of glutathione (1) in saliva of patients with dental fluorosis after complex AOT, and activities of glutathione reductase (2), glutathione-S transferase (3). The first column - before treatment, the second - after the 1st AOT, the third - after the 2nd AOT (healthy subjects - 100%)
The results of the activity of glutathione-dependent enzymes and content of glutathione in saliva in patients with dental fluorosis during antioxidant therapeutic courses are shown in figure 2. Results are the evidence that in patients before the treatment the salivary glutathione content was 89 mcmol/L (37.08%; p<0.01 in
82 Ludmila Gavriliuc et al.
human organism: moving of nerve impulse, contraction and tonus of muscles, blood clotting (the IV plasmatic factor), stabilizer of -amylase, etc. Determination of Ca2+-ions concentration in saliva in the patients with fluorosis showed its decreasing value. It is logical to assume that all the above-mentioned processes with Ca2+ions participation may be changed in patients with dental fluorosis as well6. Both courses including complex AOT and calcium gluconate increased its concentration in saliva of the patients. Main biological role of glutathione reductase is based on the reduction of oxidized glutathione (GSSG) to its reduced form (GSH) with utilization of NADPH+. Hydrophilic antioxidant glutathione is the main component of redox-buffer system of the intracellular medium. Glutathione-associated metabolism is a major mechanism for cellular protection against agents which generate oxidative stress and POL. Recent genetic and biochemical evidence has demonstrated that glutathione and glutathione-dependent enzymes play a central role in the cellular defense against toxic agents. Enzyme glutathione-S-transferase catalyzes the conjugation of GSH with different toxic and mutagenic compounds, which are generated during POL processes. Chronic intoxication by fluoride leads to metabolic imbalance of antioxidant enzymes and reflects the decrease of glutathione content and activity of glutathione reductase in saliva of patients with dental fluorosis. Also, intoxication leads to the increase of of glutathione-Stransferase activity in saliva of the patients. Complex therapy, including AOT and calcium gluconate, increased content of glutathione and decreased activity of glutathione-S-transferase in saliva of patients with dental fluorosis. We found negative correlation between the content of glutathione and clinically manifested characteristics of the disease in patients with dental fluorosis8. There was a direct relationship between the activity of glutathione-S-transferase and clinical manifestations. We found the direct correlation between clinical characteristics, reflecting the level of the pathological process, and metabolic imbalance, which can allow more correct estimation of the intoxication degree caused by fluoride intake (Invention G2 MD, 2006)8.
chronic intoxication with fluoride content in drinking water. The imbalanced salivary components - calcium, protein and glutathione-dependent enzymatic defense system, including glutathione, glutathione reductase and glutathione-S-transferase, were partially corrected by complex antioxidant therapy. Moreover, 2 AOT courses were more effective than only 1 course. In all fluorideendemic regions of different countries it is necessary to carry out prophylactic actions, especially laying emphasis on small schools, pregnant women and feeding mothers. These prophylactic actions will decrease the risk of chronic intoxication by fluorides.
References
1. Alvarez JA, Rezende KM, Marocho SM, Alves FB, Celiberti P, Ciamponi AL. Dental fluorosis: exposure, prevention and management. Med Oral Patol Oral Cir Bucal, 2009; 14(2):E103-107. 2. Barnett RN. Photometric test, CPC method. J Clin Pathol, 1973; 59:836. 3. Bronckers AL, Lyaruu DM, DenBesten PK. The impact of fluoride on ameloblasts and the mechanisms of enamel fluorosis. J Dent Res, 2009; 88(10):877-893. 4. DenBesten PK. Mechanism and timing of fluoride effects on developing enamel. J Public Health Dent, 1999; 59(4):247-251. 5. Fluorides Environmental Health. Criteria 227. World Health Organization. Geneva, 2002. 6. Gavriliuc L, Stepco E, Godoroja P, Hornet V. Imbalance of certain components of saliva patients with fluorosis. J Oral Health Dental Management Black Sea Countries (Constanta, Romania), 2004; 3(4/10):15-19. 7. Gavriliuc LA, Stepco EA, Hornet VI, Mocan EI, Cheptanaru CF, Godoroja PD. Imbalance of the biochemical parameters in saliva of patients with fluorosis. Curierul Medical (Chisinau, Moldova), 2005; 2(284):10-13. 8. Gavriliuc LA, Stepco EA, Spinei IuG, Godoroja PD. Method of differential diagnostics of fluorosis. BOPI: MD 3163 G2, (Chisinau, Moldova), 2006; 10:32. 9. Gerasimov AM, Koroleva LA, Brusov OS, Olferev AM, Antonenkov VD, Pancenko LF. Enzymatic mechanisms of inhibition of peroxide oxidation in different regions of rat brain. Vopr Med Khim (Mosk), 1976; 22(1):89-94. 10. Habig WH, Jacoby WB. Assays for differentiation of glutathione S-transferase. Methods in Enzymology, 1981; 77:398-405. 11. Hofman LF. Human saliva as a diagnostic specimen. J Nutr, 2001; 131(5):1621-1625. 12. Huang Z, Li K, Hou G. Study on the correlation of the biochemical indexes in fluoride workers. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi, 2002; 20(3):192-194. 13. Miao Q, Xu M, Liu B. In vivo and in vitro study on the effect of excessive fluoride on type I collagen of rats. Wei Sheng Ian Jiu, 2002; 31(3):145-147. 14. Shivarajashankara JM. Oxidative stress in children with endemic skeletal fluorosis. Fluoride, 2001; 34:103-107.
Conclusions
On the basis of our results, we can confirm that in patients with dental fluorosis an imbalance between salivary parameters/indices takes place as a result of
Balk J Stom, Vol 16, 2012 15. Sedlak I, Lindsay RH. Estimation of total protein bound and nonprotein sulfhydryl groups in tissue with Ellmans reagents. Anal Biochem, 1968; 25(2):192-198. 16. Streckfus CF, Bigler LR. Saliva as a diagnostic fluid. Oral Dis, 2002; 8(2):69-76. 17. Susheela AK, Bhatnagar M. Reversal of fluoride induced cell injury through elimination of fluoride and consumption of diet rich in essential nutrients and antioxidants. Mol Cell Biochem, 2002; 234-235(1-2):335-340. 18. Vani ML, Reddy KP. Effect of fluoride accumulation on some enzymes of brain and gastrocnemius muscle of mice. Fluoride, 2000; 33:17-26. 19. Watanabe N, Kamei S, Ohkuto A. Urinary protein as measured with a pyrogallol red-molybdate complex: Manually and in a Hitachi 726 automated analyzer. Clin Chem, 1986; 32:1551-1554.
Complex Antioxidant Treatment of Dental Fluorosis 83 20. Wong MC, Glenny AM, Tsang BW, Lo EC, Worthington HV, Marinho VC. Topical fluoride as a cause of dental fluorosis in children. Cochrane Database Syst Rev, 2010; (1):CD007693.

Prof. Ludmila Gavriliuc State University of Medicine and Pharmacy Nicolae Testemitanu Department of Biochemistry and Clinical Biochemistry Bul. Stefan cel Mare 165, Chisinau MD 2004 Moldova e-mail: gavrlu@yahoo.com
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Release of Antimicrobial Agents from Glass Ionomer Cements

SUMMARY
The aim of this study was to determine the level of antimicrobial agents Benzalkonium Chloride and Cetylpyridinium Chloride released from ChemFlex, a conventional glass ionomer cement (GIC). The main null hypothesis tested was that there is no release of antimicrobial agents into the surrounding medium. 3 groups of the conventional ChemFlex GIC of 5 samples each, with Benzalconium Chloride and CPC incorporated, were prepared - each group with a different percentage of the agents (1%, 2%, and 3%). The determination of the quantity of the antimicrobial agents was done by an UV- Spectrophotometer. The measurements were performed at 11 successive time intervals. The results of the statistical analysis point out that it is possible to incorporate these antimicrobial agents in conventional GIC, especially when the added percentage of the antimicrobial agents is 3%.
Keywords: GIC; Antimicrobial Agents; UV-Spectrophotometry
Aleksandar Dimkov, Elizabeta Gjorgievska, Aleksandar Fildishevski Faculty of Dentistry, Clinic for Pediatric and Preventive Dentistry, Skopje, FYROM
ORIGINAL PAPERS (OP) Balk J Stom, 2012; 16:84-89
Introduction
Because of the relatively frequent occurrence of recurrent caries after a restorative treatment, and because of the huge number of cariogenic microorganisms existing in the oral cavity, which present a potential risk factor regarding the development of new carious lesions, attention has increasingly been directed toward therapeutic antimicrobial effects of restorative materials. The glass ionomer cements (GIC) distinguish themselves as most acceptable restorative materials possessing the positive characteristics of fluorine in the processes of remineralization and antimicrobial action1-4. Their usage is determined by their characteristic to release fluorine and to participate in the mechanism of inhibition of the secondary caries development5-7. At the same time they also act upon the surrounding bacteria by reducing the cariogenic microorganisms8. In addition to the release of fluoride ions, GIC can potentially be used as matrices for the release of other active antimicrobial components. In regard to the incorporation of antimicrobial agents, chlorhexidine has been described as a golden standard for antibacterial
application9. There are several studies dealing with the effect of incorporating chlorhexidine in different concentrations and its combinations in GIC to improve their antimicrobial properties10-14. There are only a few data in the literature referring to the incorporation and release of other antimicrobial components in GIC. Although a part of them have a confirmed effect in the reduction of cariogenic salivary flora when used in rinses or toothpastes, the results regarding their incorporation in GIC are still scarce15-18. Cetylpyridinium Chloride (CPC), as an active component of oral antiseptics, has a broad antimicrobial spectrum with a strong bactericidal effect on Gram positive pathogens and a fungicidal effect. Its effectiveness against gram negative pathogens and mycobacteria is questionable19,20. The official US pharmacopoeia accepts Benzalkonium Chloride as an auxiliary antimicrobial agent15. It is the major antimicrobial agent in numerous toothpastes and mouth rinses. The objective of this study was to determine the level of release of the antimicrobial agents Benzalkonium Chloride and Cetylpyridinium Chloride from the conventional GIK ChemFlex, previously incorporated
Antimicrobial Agents Release from GIC 85
with various concentrations of antimicrobial agents. The null hypothesis tested was that there is no release of antimicrobial agents into the surrounding medium, and that there are no differences due to the type of antimicrobial agents and their represented percentages.
Materials and Methods

The commercially available conventional GIC that was used in the analyses was a material being widely applied in restorative dentistry (ChemFlex, DENTSPLY DeTrey, Konstanz, Germany). The composition of this GIC is shown in table 1. The antimicrobial compounds used in the study were: Cetylpyridinium Chloride (C0732 by Sigma - Aldrich Co.) and Benzalkonium Chloride (12660 by Fluka Chemical Corporation Milwaukee, WI, USA).
Table 1. The material used in the research Material Classification Composition Strontium, aluminium, fluoride, silicate, tartaric acid, pigments, polyacrylic acid Manufacturer DENTSPLY DeTrey, Konstanz, Germany
Material
Conventional ChemFlex glass-ionomer cement
3 groups of the conventional GIC ChemFlex of 5 samples each, with Benzalkonium Chloride incorporated, were prepared - each group with a different percentage of the agent (i.e. 1%, 2% and 3%); and another 3 5 sample groups, but with Cetylpyridinium Chloride incorporated, were also prepared - each group having the corresponding percentage of the agent (1%, 2% and 3%). The antimicrobial compounds Benzalkonium Chloride (BCH) and Cetylpyridinium Chloride (CPC) were first incorporated into the GICs polyacrylic acid by mixing, and then the powder was added gradually, to the previously prepared acid and antimicrobial compound mixture, and they were mixed together until complete saturation. The antimicrobial agents were added in strict portions of 1, 2 and 3% of the weight of the cement. The determination of the concentration (weight) of BCH and CPC was done by measuring the given percentage of the antimicrobial agent with an analytical balance. Preceding analyses had determined the concentrations of 1, 2 and 3% of antimicrobial agents to be equivalent to 0.0022 g, 0.0044 g and 0.0066 g, of
the whole cement mass. The freshly mixed paste was placed into 6 mm high metal moulds having 4 mm in diameter. The moulds had been closed by metal plates on both sides, placed in special clamps and then placed in an incubator at 37oC for 1 hour (maturation time). After their removal from the incubator, the specimens were taken out from the clamps and moulds, and stored individually in separate marked plastic tubes with 5 ml de-ionized water at a temperature of 2224oC and at an air humidity of 4050% . The sample tubes had been chosen to allow minimal contact between the specimen and the tube and therefore allow diffusion of antimicrobial agents from all surfaces of the specimens into the surrounding aqueous medium. Determination of the Antimicrobial Agents (UV-Spectrophotometric Analysis) The determination of the quantity of the antimicrobial agents was done by a so UV- Spectrophotometer, and the results were expressed in Absorbance Units (AU). The spectrophotometer was calibrated using BCH and CPC solution with predetermined concentrations. The UV spectrophotometer was set to a detection wavelength of maximal absorption (214 nm) for BCH, and 259 nm for CPC. The measurements were performed at 11 successive time intervals as follows: 15, 30, 45 min, 1, 2, 3, 4, 24 hr, 7, 14 and 30 days. During the entire period, the de-ionized water where the samples were stored was not changed. The statistical analysis of the results was performed using the 1-way ANOVA, the Post-hoc-Tukey honest significant difference (HSD), and the Mann-Whitney U Test.
Results
The analysis of the variances (ANOVA) showed a statistically significant difference between the average values over the tested period in the group ChemFlex + BCH both for 1%, 2% and 3%, where p=0.000000 (Tab. 2). According to the post-hoc-Tukey honest significant difference test (HSD), the difference was statistically significant at 1% ChemFlex + BCH for p=0.000 between the average values at 24 hr, 7, 14 and 30 days and in respect to all other average values. In the case of 2% of the same compound, the difference was statistically significant for p=0.000 between the average values at 2, 3, 4 and 24 hr, 7, 14 and 30 days and in respect to all other average values, whereas in the case of 3% it was statistically significant for p=0.000 between the average values at 7, 14 and 30 days and in respect to all other average values.
Preparation of Samples
86 Aleksandar Dimkov et al.
Table 2. The average values of ChemFlex + Benzalkonium Chloride for the 3 tested concentrations over the test period (data obtained in AU) Time 15 min 30 min 45 min 1 hour 2 hours 3 hours 4 hours 24 hours 7 days 14 days 30 days p ChemFlex + Benzalkonium Chloride 1% MEAN (SD) 0.01 (0.00) 0.02 (0.00) 0.02 (0.00) 0.02 (0.00) 0.05 (0.01) 0.05 (0.01) 0.05 (0.01) 0.07 (0.02) 0.14 (0.02) 0.12 (0.04) 0.19 (0.03) 0.000000 ChemFlex + Benzalkonium Chloride 2% MEAN (SD) 0.01 (0.00) 0.01 (0.00) 0.01 (0.00) 0.01 (0.00) 0.04 (0.00) 0.04 (0.00) 0.08 (0.00) 0.06 (0.01) 0.16 (0.01) 0.20 (0.00) 0.25 (0.00) 0.00 ChemFlex + Benzalkonium Chloride 3% MEAN (SD) 0.03 (0.01) 0.03 (0.01) 0.03 (0.01) 0.04 (0.02) 0.05 (0.01) 0.05 (0.01) 0.05 (0.01) 0.07 (0.02) 0.15 (0.02) 0.17 (0.03) 0.23 (0.03) 0.000000
In the group ChemFlex + CPC the analysis of the variances shows a statistically significant difference between the average values over the tested period in the case of 1% CPC for p=0.000000, in the case of 2% CPC for p=0.000000 and the case of 3% CPC for p=0.000103 (Tab. 3). According to the post-hoc-Tukey honest significant difference test (HSD), when the differences in the average values were
tested individually, in the case of 1% CPC it was statistically significant for p=0.000 between the average values at 7, 14 and 30 days; in the case of 2% it was statistically significant for p=0.000 between the average values at 7, 14 and 30 days in respect to all other average values; in the case of 3% CPC, it was statistically significant for p=0.04 between the average values at 15, 30 min and 24 hr, and at 4 hr, 24 hr and 7 days.
Table 3. The average values of ChemFlex + Cetylpyridinium Chloride for the 3 tested concentrations over the test period (data obtained in AU) Time 15 min 30 min 45 min 1 hour 2 hours 3 hours 4 hours 24 hours 7 days 14 days 30 days p ChemFlex + Cetylpyridinium Chloride 1% MEAN (SD) 0.01 (0.00) 0.02 (0.00) 0.02 (0.00) 0.02 (0.00) 0.02 (0.00) 0.02 (0.00) 0.02 (0.00) 0.03 (0.00) 0.09 (0.01) 0.12 (0.02) 0.11 (0.06) 0.00000 ChemFlex + Cetylpyridinium Chloride 2% MEAN (SD) 0.03 (0.01) 0.02 (0.00) 0.03 (0.00) 0.02 (0.00) 0.03 (0.01) 0.03 (0.01) 0.03 (0.01) 0.04 (0.01) 0.08 (0.00) 0.07 (0.00) 0.11 (0.01) 0.00000 ChemFlex + Cetylpyridinium Chloride 3% MEAN (SD) 0.06 (0.01) 0.05 (0.01) 0.06 (0.01) 0.06 (0.01) 0.06 (0.01) 0.08 (0.01) 0.09 (0.01) 0.09 (0.01) 0.09 (0.00) 0.06 (0.01) 0.08 (0.01) 0.000103
Antimicrobial Agents Release from GIC 87
The difference in the average values obtained by treatment with ChemFlex + BCH 1% and ChemFlex + CPC 1% was statistically significant between the values at 2, 3, 4, 24 hours and 7 days for p<0.05; the other differences were statistically insignificant for p>0.05 (Tab. 4). The difference in the average values obtained by treatment with ChemFlex + BCH 2% and ChemFlex + CPC 2% was statistically significant between the values
at 15, 30, 45 min, 4 hr and 7,14 and 30 days for p<0.05; the other differences were statistically insignificant for p>0.05. The difference in the average values obtained by treatment with ChemFlex + BCH 3% and ChemFlex + CPC 3% was statistically significant between the values at 15, 30, 45 min, 1 and 4 hr and 7, 14 and 30 days for p<0.05; the other differences were statistically insignificant for p>0.05.
Table 4.
Mann-Whitney U Test for the average values between groups treated with ChemFlex + Benzalkonium Chloride and ChemFlex + Cetylpyridiniun Chloride ChemFlex + BCH 1% ChemFlex + CPC 1% p-level ChemFlex + BCH 2% ChemFlex + CPC 2% p-level 0.016294* 0.009024* 0.009024* 0.174526 0.174526 0.174526 0.009024* 0.075801 0.009024* 0.009024* 0.009024* ChemFlex + BCH 3% ChemFlex + CPC 3% p-level 0.047203* 0.047203* 0.047203* 0.047203* 0.117186 0.075801 0.028281* 0.117186 0.009024* 0.009024* 0.009024*
Time 15 min 30 min 45 min 1 hour 2 hours 3 hours 4 hours 24 hours 7 days 14 days 30 days
0.174526 0.676104 0.250593 0.117186 0.009024* 0.016294* 0.009024* 0.009024* 0.016294* 0.464703 0.016294
* - Statistical significant
Discussion
This study is a part of a comprehensive study dealing with the possibility to incorporate antimicrobial components from the group of quaternary ammonium compounds in conventional GIC. The results show a continual release of the antimicrobial compounds, starting at 15th minute, with a tendency of increase at all periods of measurement. The highest values were obtained at the end of the test time period, i.e. after one month, and for the highest tested concentration - 3%. The conclusion drawn from the statistical analysis stresses that the addition of BCH and CPC shows highly significant differences between the average values over the tested period and between the different percentages, and the incorporation of 3% antimicrobial components into GIC as being the most appropriate.
The finding that the specimens containing higher concentrations of antimicrobial agent (3% in this case) released proportionally its higher amounts is in agreement with the results of Ribeiro and Ericson21. In contrast to our study the GIC used were ChemFil and AquaCem. The concentrations of the antimicrobial agents used were also different (7.5% and 8.2% w/w) chlorhexidine digluconate, respectively, and 13.3% w/w of chlorhexidine diacetate. In contrast to our study, the specimens used by the authors of the aforementioned study had far lower dimensions (3 mm diameter and 1.5 mm thickness). Chlorhexidine digluconate was quickly released from AquaCem and after 5 days no measurable increase of concentration was seen. This tendency was also seen with diacetate /AquaCem. Similar to the previously mentioned results are those obtained by investigating the use of an experimental GIC as a carrier for the release of chlorhexidine acetate21. The concentrations range was from 0.5% to 13.0% of
88 Aleksandar Dimkov et al.
chlorhexidine acetate by weight. In contrast to our study, release into water was examined using high-performance liquid chromatography. The specimens had an internal diameter of 10 mm and a thickness of 1 mm. In this case the release of the antimicrobial compound had also occurred relatively soon, all measurable chlorhexidine was released within 22 hr; however, that was less than 10% of the total mass incorporated in the specimens. In both quoted papers, incorporation of the antimicrobial compound was made in the GIC powder. Contrary to this, in this study, incorporation of the 2 antimicrobial compounds was in the GIC liquid, because of the chemical structure of the antimicrobial compounds and the better distribution of the long chains of the quaternary compounds in a liquid medium. The data that an increased percentage of incorporated chlorhexidine acetate gave an increased release into the water is in correspondence with our results. The increasing amounts of incorporated antimicrobial agents (chlorhexidine diacetate) did not result in significant increases in eluted concentrations, which is in contrast to our study and also in contrast to the studies mentioned above14. Attempts have been made to incorporate antimicrobial compounds in other restorative materials by investigating the ability of incorporation of antimicrobial agent CPC in the resin matrix22. Among the antimicrobial properties of the resin, the releasing of CPC into water was investigated as well, using a UV-vis spectrophotometer during the different time periods. The results revealed that less than 0.11 AU of CPC was released into water for all specimens. In our case, the release of CPC in water in the amount of 0.11 AU+/0.2 AU was noted on the 14th and 30th day on an average in 1% ChemFlex + CPC; on the 30th day on the average for 2%, and on the 30th day in one specimen for 3% ChemFlex + CPC. As for this study, there is a question of the cumulative effect of the compounds in the medium (de-ionized water). The increase of the level of released compounds increase with time, which speaks of additional dilutions of the compounds in the medium. In order to see the anticariogenic effect of the compounds on the oral flora, i.e. in order to make a parallel with the effect that would have occurred inside the oral cavity, it would be necessary to perform certain microbiological analyses as well. Even though the majority of studies analyze the release of the compounds in a fresh medium before each measurement, the cumulative effect of the leached antimicrobial compounds is very important, above all in the cases of poor oral hygiene. An aspect of no less importance, yet, is the effect that such modified GIC could have towards the cavities in the course of application, i.e. the effect of the antimicrobial compounds being deposited at the junctures between the restoration and the dentine, and their protective effect. In situations of implementing a sound oral hygiene, the cumulative effect of antimicrobial compounds would not be of such
importance because of frequent rinsing of the oral cavity. Regarding such cases, an analysis should be made of the release of antimicrobial compounds in the medium by changing the latter in predefined time intervals.
Conclusions
1. The addition of BCH and CPC shows high significant differences between the average values over the tested period and between the different percentages. 2. The incorporation of 3% antimicrobial components (BCH and CPC) into GIC is the most appropriate. Acknowledgments: This article was submitted in partial fulfilment of a PhD degree at the School of Science, University of Greenwich, UK and the Faculty of Dentistry - Skopje, FYROM. I should like to thank to Professor John W. Nicholson for the award of a Visiting Fellowship which allowed complete experimental work reported in this paper to be carried out at the University of Greenwich, UK.
References
3. McLean JW, Nicholson JW, Wilson AD. Proposed nomenclature for glass-ionomer dental cements and related materials. Quintessence Int, 1994; 25:587-589. 4. Nicholson JW. Chemistry of glass-ionomer cements: a review. Biomaterials, 1998; 19:485-494. 5. Nicholson JW. Adhesive dental materials and their durability. Int J Adhesion Adhesives, 2000; 20:11-16. 6. Attar N, Onen A. Fluoride release and uptake characteristics of aesthetic restorative materials. J Oral Rehab, 2002; 29:791-798. 7. Berg JH. The continuum of restorative materials in pediatric dentistry - a review for the clinician. Pediatric Dentistry, 1998; 20:93-100. 8. Dionysopoulos P, Kotsanos N, Pataridou A. Fluoride release and uptake by four new fluoride releasing restorative materials. J Oral Rehab, 2003; 30:866-872. 9. Billington RW, Williams JA, Dorban A, Pearson GJ. Glass ionomer cement: evidence pointing to fluorine release in the form of monofluorophosphate in addition to fluoride ion. Biomaterials, 2004; 25:3399-3402. 10. Hengtrakool C, Pearson GJ, Wilson M. Interaction between GIC and S. sanguis biofilms: Antibacterial properties and changes of surface hardness. J Dentistry, 2006; 34:588-597. 11. Leunga D, Spratt DA, Pratten J, Gulabivala K, Mordan NJ, Young MN. Chlorhexidine-releasing methacrylate dental composite materials. Biomaterials, 2005; 26:7145-7153. 12. Jedrychowski JR, Caputo AA, Kerper S. Antibacterial and mechanical properties of restorative materials combined with chlorhexidine. J Oral Rehabil, 1983; 10:373-381.
Balk J Stom, Vol 16, 2012 13. Patel MP, Cruchley AT, Coleman DC, Swai H, Braden M, Williams DM. A polymeric system for the intra-oral delivery of an anti-fungal agent. Biomaterials, 2001; 22:2319-2324. 14. Sanders BJ, Gregory RL, Moore K, Avery DR. Antibacterial and physical properties of resin modified glass-ionomers combined with chlorhexidine. J Oral Rehab, 2002; 29:553-558. 15. Botelho MG. Inhibitory effects on selected oral bacteria of antibacterial agents incorporated in glass ionomer cements. Caries Research, 2003; 7:108-114. 16. Takahashi Y, Imazato S, Kaneshiro AV, Ebisu S, Frencken JE, Tay FR. Antibacterial effects and physical properties of glass-ionomer cements containing chlorhexidine for the ART approach. Dent Mater, 2006; 22:647-652. 17. Block, SS. Disinfection, Sterilization and Preservation. Fourth Edition. Philadelphia - London: Lea & Febiger, 1991; pp 225-242, 274-286. 18. Ciancio S. Expanded and future uses of mouth rinses. J Am Dent Assoc, 1994; 25(Suppl 2):29S-32S. 19. DePaola LG, Minah GE, Overholser CD, Meiller TF, Charles CH, Harper DS, McAlary M. Effect of an antiseptic mouth rinse on salivary microbiota. Am J Dent, 1996; 9: 93-95. 20. Charles CH, Sharma NC, Galustians HJ, Qaqish J, McGuire JA, Vincent JW. Comparative efficacy of an antiseptic mouth rinse and an antiplaque/antigingivitis dentifrice. A six-month clinical trial. J Am Dent Assoc, 2001; 32:670-675.
Antimicrobial Agents Release from GIC 89 21. Radford JR, Beighton D, Nugent Z, Jackson RJ. Effect of use of 0.05% Cetylpyridinium Chloride mouthwash on normal oral flora. J Dent, 1997; 25:35-40. 22. Pitten FA, Kramer A. Efficacy of Cetylpyridinium Chloride used as oropharingeal antiseptic. Arzneimittelforschung, 2001; 51:588-595. 23. Ribeiro J, Ericson D. In vitro antibacterial effect of chlorhexidine added to glass-ionomer cements. Scand J Dent Res, 1991; 99:533-540. 24. Palmer G, Jones FH, Billington RW, Pearson GJ. Chlorhexidine release from an experimental glass ionomer cement. Biomaterials, 2004; 25:5423-5431. 25. Namaba N, Yoshida Y, Nagaoka N, Takashima S, Yoshimoto KM, Maeda H, van Meerbeek B. Antibacterial effect of bactericide immobilized in resin matrix. Dental Mat, 2009; 25:424-430.

Aleksandar Dimkov Faculty of Dentistry, Clinic for Pediatric and Preventive Dentistry Skopje, FYR Macedonia E-mail: dimkovaleksandar@gmail.com
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Efficacy of Working Length Detection and Irrigation during Preparation of Curved Root Canals
SUMMARY
Ekaterina Boteva1, Dimitar Yovchev2 Faculty of Dental Medicine, Sofia, Bulgaria 1Department of Conservative Dentistry 2Department of Imaging and Oral Diagnostics
Curved root canals are challenge for instrumentation, preparation, irrigation and obturation. The aim of the present study was to find the working length (WL) and irrigation efficiency in root canals with curvatures 30-45 and in root canals with anatomical abnormalities 45-90. 68 human, matured, extracted molars with 201 root canals were included in the study. Molars were placed in 3 groups in relation to the angle between the root and the axis. The first group were teeth with straight canals (25-30, a control group; 14 teeth - 45 root canals), the second group were teeth with curved canals (30-45; 22 teeth 66 root canals) and third group were teeth with severely curved canals (45-90; 31 teeth with 96 root canals). Measurements: mesio-distal buccal size of the chamber in its largest part and both bucco-lingual sizes - mesial as L1 and distal as L2. Root canal preparation: removal of the root pulp with K endofiles number 6, 8 and 10, with Step-Down and Balance-force techniques. Canals length was measured radiographically by intra-oral radiographs, preparation continuous after X-ray analysis of the level of penetration of irrigants with contrast solution of diluted Urograffin 66%. Regime of active irrigation: same for all groups with 2% H2O2 and 1% NaOCl and paper points drying. To follow up the results a fourth radiograph was made and a second one with Urograffin. The applied criteria for WL and for penetration of the irrigant was as follows: 3 - the whole WL; 2 - 1 mm shorter than WL; 1 - 2 mm shorter than WL; and 0 - more than 2 mm shorter than WL. The active irrigation was more efficient in curved root canals, because in straight canals most of the irrigant was lost, back in the mouth or periapically. In straight root canals, only moisturizing (Miller pins) of the canal can be effective and less dangerous.
Keywords: Endodontics; Working Length; Root Canals, curved
Introduction
Curved root canals are well known challenge for instrumentation, preparation, irrigation and obturation. Root curvatures with abnormalities over 45 are not investigated from this point of view at all. Iatrogenic errors are often associated with these teeth. In the last 15 years, between 1995 and 2010, only 13 articles are related to this problem, excluding those with extreme methodology as the use of 6.25% NaOCl. All published articles are researches from in vitro studies and surprisingly the curvatures are from 20 up to 40. Teeth with curvatures between 25 and 45, as we
found in our previous studies, are from 16-19% of all teeth, and those with curvature of 45 are more than 1.3%. The number of experimental teeth in most of the studies varies between 30 and 135, while the average numbers are 59-621-14. In most studies, the preparation technique was reported to be Step-Down1,2,5-9,11,12. Different instrumentations with hand files6,13 and machine rotary files10,11,14 were used. Apical preparation size varied from 10-25 to 40-45, in relation to the degree of curvature. In these papers, the differences are not only in the irrigation regimes but in type of medication. NaOCl was used as 2.5-5%3,7,10 and in combination with EDTA5,6. In all
Working Length Detection of Curved Root Canals 91
H22 was used for irrigation. The followed up methods were x-ray3, SEM8, bioluminiscense7,9, intra-operative microscopy2, stereomicroscopy13 and light microscopy6. In most of the cases, the results were predictable and mostly a logical result from the design of the experiment. Summarizing the results, it can be concluded that the type of preparation is a major factor for the degree of removal of the smear layer and penetration of irrigants and medicines. The highest efficiency was 70% in one group in one article. In most articles, penetration of irrigants was not complete among curvatures between 30-40. The aim of the present study was to find the working length and irrigation efficacy in root canals with curvatures 30-45 and in those with anatomical abnormalities 45-90.
Irrigation measurements scale: The applied criteria for working length (WL) and for penetration of the irrigant were as follows: 3 - the whole WL, 2 - 1 mm shorter than WL, 1 - 2 mm shorter than WL, and 0 more than 2 mm shorter than WL. All measurements were performed by the same examiner, 3 times with at least 3 days intervals between.
Results
4 root canals from 207 were not found - 2%. 7 instruments were fractured, 4 in group 2, 3 in group 3, and none in the control group. In 7 canals, dentine debris formed intracanal blockage, from them 3 in group 1 (control group), 1 in group 2 and 3 in group 3. As is shown in table 1, most mistakes were made in the control group, nearly in one third of the cases. This fact can be explained in 3 different ways. The first explanation could be frequent ramifications, the second - difficulties related to the most accurate choice of the size of an instrument, and the third could be hyperinstrumentation, made more often in strait root canals. In all in vitro studies there is a lack of data on age and sex of the teeth and anthropometrical data. In the experimental groups, this percentage was 10% and 9%, or 3 times less. The same trend persisted when irrigants were tested. In the control group, in 50% of the cases the irrigant was not present in the canal system (table 2). Still high but lower were cases in the experimental groups - 33% in group 2 and 20% in group 3.

Teeth: 68 human matured extracted molars with 201 root canals are included in the study. All teeth are from the same geographical region. Groups: Molars are separated in 3 groups in relation to the angle between the root and the axis. Molars with straight roots (25-30) were a control group (14 teeth with 45 root canals), the second group were molars with curved roots (30-45; 22 teeth with 66 root canals), and the third group were teeth with severely curved roots (45-90; 31 teeth with 96 root canals). Measurements: Mesio-distal buccal size of the chamber in its largest part and both bucco-lingual sizes - mesial as L1 and distal like L2, and the average of last two as L. Root canal preparation: Started with opening the orifices with manual Orifice Openers and removal of the root pulp with K endofiles number 6, 8 and 10, using Step-Down and Balance force techniques. Root canal length was measured radiographically with K files, and preparation continued after X-ray analysis of the level of penetration of irrigants with contrast solution of diluted Urograffin 66%. Regime of active irrigation: It was the same for all groups - with 2% H2O2 and 1% NaOCl and paper points drying. The aim of root canal preparation was even in roots with 90 curvatures the apical stop to be number 20-25, and for the rest of the teeth 30-40. To follow up the results, a fourth radiograph was made and a second one with Urograffin. Instrument fractures and canal blockage were registered too. X-ray regimes: Dental X-ray unit was Phot-XII (Takara Belmont Corp, Japan) and intraoral digital sensor Eva (Dent-X Co.) was used. All radiographs were exposed under the same conditions (exposure settings 60 kv, 7mA and time 0.04s).
Table 1. Working length and number of samples of upper and lower molars GROUPS Controls (n=45) 30 to 45 (n=66) 45 to 90 (n=96) 3 (the 2 (1mm 1 (2mm 0 (>2mm whole WL) from WL) from WL) from WL) 26 42 42 7 7 36 4 7 2 1 1 1 5 3 6 1 2 -
Table 2. Penetration of the irrigant GROUPS Controls n=45 30 to 45n=66 45 to 90n=96 WL3 17 43 65 WL2 3 1 9 WL1 9 8 WL0 21 13 14
Figures 1-3 depict X-rays of the WL detection, as well as irrigant penetration in different groups.
92 Ekaterina Boteva, Dimitar Yovchev
a
(a) Correct and incorrect working length
b
(b) Correct and incorrect (non-sufficient) penetration of the irrigant Figure 1. Group 1 - Straight root canals
a
b
(b) Correct and incorrect (non-sufficient) penetration of the irrigant Figure 2. Group 2 - Curved root canals
a
b
(b) Correct and incorrect (non-sufficient) penetration of the irrigant Figure 3. Group 3 - Root canals with severe curvatures and abnormalities
Discussion
Under the conditions of this study, designed on the basis of realistic clinical approach to difficult teeth, it is difficult to favours the role of irrigants in the root canal preparation. In straight canals, especially in young patients, the extrusion of the irrigant periapically is more often. Clinically, this leads to toxic periodontitis and later to creation of chronic periapical lesions. In curved canals, penetration of irrigants is more difficult, which has its positive and negative aspects. Practically, more severe is the curvature more the instrumentation is related to moisturizing the internal root canal surface and the use of new flexible files with proper sizes. This finding is similar as in some other studies3,7,10.
Non-effective irrigation could happen even in curved canals only with 24-287 and 30-333. The separation of teeth in groups of lower and upper teeth in this study was found to be useless.
Conclusions
X-ray WL detection of molars with root canal curvatures is more accurate, compared to molars with straight roots. The active irrigation is more efficient in curved root canals, because in straight canals most of the irrigant is lost back in the mouth or periapically. In straight root canals only moisturizing (Miller pins) the canal can be effective and less dangerous.
Working Length Detection of Curved Root Canals 93 10. Schafer E, Vlosis M. Comparative investigation of two rotary NiTi instruments: ProTaper versus RaCe. Part 2. Cleaning effectiveness and shaping ability in severely curved root canals of extracted teeth. Int Endod J, 2004; 37:239-248. 11. Schafer E, Erler M, Dammaschke T. Comparative study on the shaping ability and cleaning efficiency of rotary Mtwo instruments. Int Endod J, 2006; 39:203-212. 12. Schnaider SW. A comparison of canal preparations in straight and curved canals. Oral Surg Oral Med Oral Pathol, 1971; 32:271-275. 13. Wu MK, Wesselink PR. Efficacy of three techniques in cleaning the apical portion of curved root canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endodont, 1995; 79:492496. 14. Yoshimine Y, Ono M, Akamine A. The shaping effects of three NiTi Rotary instruments in simulated S shaped canals. JOE, 2005; 31:333-340.
References
1. Baugh D, Wallace J. The role of apical instrumentation in root canal treatment: a review of the literature. JOE, 2005; 31:333-340. 2. Bing F, et al. Negotiation of C shaped canal system in mandibular second molars. JOE, 2009; 35:1003-1008. 3. Bronnec F, Bouillaguet S, Machtou P. Ex vivo assessment of irrigant penetration and renewal during the final irrigation regimen. Int Endod J, 2010; 43:663-672. 4. Ding-Ming H, et al. Study of the progressive changes in canal shape after using different instruments by hand in simulated S shaped canals. JOE, 2007; 33:986-989. 5. Liu SB, et al. Cleaning effectiveness and shaping ability of rotary ProTaper compared with rotary GT and manual K-Flexofile. Am J Dent, 2006; Dec.19:353-358. 6. Lumley PJ. Cleaning efficiency of two apical preparation regimes following shaping with hand files of greater taper. Int Endod J, 2000; 33:262-265. 7. Nguy D, Sedgley C. The influence of canal curvature on the mechanical efficiency of root canal irrigation in vitro using real-time imaging of bioluminescent bacteria. JOE, 2006; 32:1077-1080. 8. Rodig T, Hulsmann M, Kahlmeier G. Comparison of root canal preparation with two rotary NiTi instruments ProFile 04 and GT Rotary. Int Endod J, 2007; 40(7):553-562. 9. Sedgley CM, Applegate B, Nagel A, Hall D. Real time imaging and quantification of bioluminescent bacteria in root canals in vitro. JOE, 2004; 30:893-898.

Dr. Ekaterina Boteva Dept. of Conservative Dentistry Faculty of Dental Medicine 1 Georgy Sofiisky str. Sofia, Bulgaria E-mail: e_boteva@abv.bg
GI CA L SOCIETY
ISSN 1107 - 1141
LO TO STOMA
Salivary Thromboplastic Activity May Indicate Wound Healing after Tooth Extraction
SUMMARY
Oral mucosa is susceptible to tissue injury from many causes, including infection, autoimmune disorders, surgical and accidental trauma, and gingival and periodontal inflammation; however, little is known about the events that influence wound healing in the mouth. This study investigated the changes in salivary thromboplastic activity prior to and after primary tooth extraction. Cytological smears and biochemical tests were also used in this study. Salivary pH and salivary flow rate did not significantly change after primary tooth extraction. Salivary thromboplastic activity was not significantly higher after extraction than prior to extraction (p=0.068). Epithelial cells significantly decreased and leukocyte cells significantly increased in saliva after primary tooth extraction (p<0.001). In conclusion: oral cavity may aid the process of haemostasis and perhaps wound healing in the extraction area by increasing salivary leukocyte cells and thromboplastic activity. Thromboplastic activity may be a novel indicator of wound healing completion.
Keywords: Salivary Cells; Salivary Flow Rate; Salivary pH; Salivary Thromboplastic Activity; Tooth Extraction
T. Tunali Akbay1, M. Guvercin2, O. Gonul2, A. Yarat1, S. Akyuz3, R. Pisiriciler4, K. Gker2 Marmara University, Faculty of Dentistry 1Department of Biochemistry 2Department of Maxillofacial Surgery 3Department of Paediatric Dentistry 4Department of Histology and Embriology Istanbul, Turkey
Introduction
Wound healing is a dynamic, multi-faceted physiological process that involves a wide range of biological mediators1. Although primary tooth extraction is a simple intervention, some complications can occur. Oral mucosa is susceptible to tissue injury from many causes, including infection, autoimmune disorders, surgical and accidental trauma, and gingival and periodontal inflammation; however, little is known about the events that influence wound healing in the mouth15. Normally tooth extraction induces some changes in the oral cavity2. Saliva is important in maintaining oral health and much of this protective activity is mediated by the variety of different salivary proteins3. Damaged tissue release a lipoprotein known as thromboplastin (tissue factor, FIII), which activates the
extrinsic coagulation pathway. Activated monocytes and endothelial cells also express this thromboplastin in their surface and participate in coagulation4. Thromboplastin initiates the coagulation system and is a component of cell membrane, but not found active in the blood5,6. Like body fluids, saliva has also been known to have thromboplastic activity7-10. Thromboplastin in saliva is thought to supply haemostasis when injury takes place in the mouth and it facilitates the barrier function of buccal mucosa7,11. Thromboplastin is related to cells and cell fragments in saliva12,13. In the adult vertebrate body, physical integrity is continuously maintained by a tissue repair mechanism consisting of the vascular endothelium, tissue factor and circulating factors VII, IX and X that governs localized thrombin elevations. The cellular effects of these thrombin elevations explain all aspects of tissue repair and maintenance14.
Wound Healing and Thromboplastic Activity 95
It has been shown that oral cavity is also affected from the disturbances of the haemostatic system in which spontaneous bleeding of dental tissues, petechiae of oral soft tissues and ecchymoses are common in routine oral examination15. Post operative examinations show that minor oral surgery can also cause bleeding. Salivary thromboplastin may establish the hemostasis after oral traumas7,11. Thromboplastin also contributes to wound healing, inflammatory response, tumour growth, metastasis and angiogenesis16,17. The disturbance of hemostatic balance in the oral cavity is an indicator of an acquired or congenital defect of the coagulation system18. There is no study in the literature involving the relationship between the wound healing after primary tooth extraction and salivary thromboplastic activity. In this study; wound healing in oral cavity is followed by the salivary thromboplastic activity after primary tooth extraction. Salivary pH and salivary flow rate were also determined and saliva imprint samples were also evaluated cytologically.
plasma. All reagents were at the reaction temperature (37oC) before admixture. Since the clotting time is inversely proportional to the thromboplastic activity, the lengthening of the clotting time was counted as a manifestation of the decreased thromboplastic activity. For cytological examinations, saliva samples were smeared over a glass microscope slide and fixed with air. They were stained with Giemsa-stain20. All slides were examined microscopically (x100) for the presence of epithelium, erythrocyte, leukocyte and yeast cell. The results were evaluated using Student t-test, Wilcoxon test, Pearson correlation analysis and Spearman correlation analysis; the Unistat 5.0 statistical package programme was used.
Results
Mean age and body mass index of 25 children were 9.881.39 and 16.702.23, respectively. Salivary pH values and salivary flow rates did not significantly change after primary tooth extraction. Salivary thromboplastic activity was moderately higher after the extraction than prior to extraction (Tab. 1). No significant difference of yeast cells was found in the values prior to and after the extraction in saliva imprint samples (p>0.1). Erythrocytes were not found in saliva samples. Epithelial cells significantly decreased and leukocyte cells significantly increased in saliva imprint samples after primary tooth extraction (Tab. 2). Significant negative correlation was found between salivary flow rate and thromboplastic activity before primary tooth extraction (r= -0.413; p=0.04). No significant differences were found in any parameter were found in accordance with gender.
Table 1. Comparison of salivary flow rate, pH and thromboplastic activity prior to and after primary tooth extraction Pre-extraction (n=25) Salivary flow rate (ml/min) Salivary pH Salivary Thromboplastic Activity (sec) 0.21 0.11 7.22 0.45 72.64 27.59 Post-extraction (n=25) 0.21 0.08 7.34 0.40 60.08 26.23 p ( t-test) 0.782 0.136 0.068

This study was performed on 25 healthy children with the age range of 7-12 years. Healthy children were randomly selected from individuals who attended Marmara University Faculty of Dentistry. Oral dental examinations and restorative treatments were conducted by a paedodontist. Among the group, 80% of the children had experienced dental extractions before. Thereafter, they were sent to the Oral and Maxillofacial Surgery Department for tooth extraction as they had caries and pulpal pathology. Children had standard breakfast 1 hour before tooth extraction. 3 primary canines, 1 primary incisor, 21 primary molars were extracted from 25 children. Informed consent was obtained from each subjects family before saliva collection. All saliva samples were collected in the resting position in the surgery department. Firstly, subjects rinsed the mouth with distilled water 3 times. Unstimulated mixed saliva samples were collected by spitting into a funnel prior to and 1 hour after primary tooth extraction. Collection time was recorded and saliva volume was measured by pipetting the saliva into a new tube. Then the tubes were stored at -200C. Salivary flow rate was calculated by dividing the saliva volume to the collection time. Saliva samples were analyzed for pH by using pH-paper (Neutralit-pH 5.5-9.0; Merck-pH indicate paper). Thromboplastic activity of saliva samples was evaluated according to Quicks 1-stage method using normal plasma19. This was performed by mixing 0.1 ml of saliva with 0.1 ml of 0.02 M CaCl2, with the clotting reaction being started on addition of 0.1 ml of
Values are given as mean standard deviation. Since the clotting time is inversely proportional to the thromboplastic activity, the lengthening of the clotting time is a manifestation of decreased thromboplastic activity.
96 T. Tunali Akbay et al.
Table 2: Cytological examination of saliva samples Pre-extraction Post-extraction p Wilcoxon (n=25) (n=25) Epithelial cells (1) (2) (3) Leukocyte cells (0) (1) (2) (3) Yeast cells (0) (1) 16 % 28 % 56 % 56 % 32 % 4% 8% 68 % 32 % 64 % 36 % 0% 4% 16 % 56 % 24 % 68 % 32 %
0.001
0.001
1.000
Epithelial cells - 1: 0-15 cells (normal) 2: 16-30 cells (medium) 3: more than 30 cells (too much) Leukocyte cells - 0: nonexistent 1: 3-5 cells 2: 6-15 cells 3: more than 16 cells Yeast cells - 0: nonexistent 1: present
Discussion
Wound healing process seem to be strictly regulated by multiple growth factors and cytokines released at the wound site18. In this study, possible new marker - thromboplastin was monitored in saliva after tooth extraction, as alterations that disrupt controlled timely healing process would extend tissue damage and prolong repair18. Whole saliva is the most frequently used type of saliva for the diagnosis of systemic diseases, since it is readily collected and contains serum constituents. These constituents derive from the local vascular bed of salivary glands and reach the oral cavity via the flow of gingival fluid. Analysis of saliva may be useful for the diagnosis of hereditary disorders, autoimmune diseases, malignant and infectious diseases, and endocrine disorders, as well as in the assessment of therapeutic levels of drugs and the monitoring of illicit drug use21,22. Salivary thromboplastin may establish haemostasis following oral trauma and facilitates barrier functions of oral mucosa7,11. As thromboplastic activity has been measured by PT test, shortened clot formation time shows increased thromboplastic activity19. Salivary thromboplastic activity was moderately increased after a single tooth extraction. Our preliminary assays (data not shown) showed a significant increase in salivary thromboplastic activity after 2 teeth extraction. According to this finding, we consider that the size of an extraction area and the quality of the extraction may affect the thromboplastic activity.
Thromboplastin is related to the cells and cell fragments of saliva; consequently, high cell content of saliva (epithelial cells and leukocytes) increases thromboplastic activity7,10,11. Normally, leukocytes do not have thromboplastic activity, they can only secrete thromboplastin when they are exposed to vein media or collagene23-25. Clot formation and wound healing process following tooth extraction are initiated by saliva. In the present study, leukocyte cell count increased 1 hour after tooth extraction. There was no significant difference in STA between pre and post tooth-extraction time, possibly due to the decrease in epithelial cell count or inhibition of thromboplastic activity by specific inhibitor, like tissue factor pathway inhibitor. Saliva as well as blood coagulation system can play preventive role in oral cavity damages. Thromboplastin also plays an important role in wound healing, inflammatory response, tumour growth, metastasis and angiogenesis16,17. The relationship between salivary pH and salivary flow rate is well known12,13. Fluctuations in salivary pH may change the secretion of thromboplastin from the cells present in saliva. Salivary pH and thromboplastic activity can also be affected by the changes of salivary flow rate. In the present study, salivary pH and flow rate did not change after primary tooth extraction. Absence of significant difference in STA between groups may indicate undisturbed wound healing after tooth extraction. Negative correlation between salivary thromboplastic activity and salivary flow rate has been shown in healthy subjects10. In the present study, there was also negative correlation between thromboplastic activity and salivary flow rate before tooth extraction (r= -0.413; p=0.04); interestingly this correlation was not seen after tooth extraction. This finding may support the secretion of thromboplastin from the leukocytes 60 minutes following tooth extraction. Thromboplastic activity may be a novel indicator of wound healing completion.
References
1. McGrory K, Flaitz CM, Klein JR. Chemokine changes during oral wound healing. Biochem Biophys Res Commun, 2004; 324:317-320.Simon E, Matee M. Post-extraction complications seen at a referral dental clinic in Dar Es Salaam, Tanzania. Int Dent J, 2001; 51:273-276. 2. Kaufman E, Lamster IB. The Diagnostic Applications of Saliva - A Review. Crit Rev Oral Biol Med, 2002; 13:197-212. 3. Li J, Chen J, Kirsner R. Pathophysiology of acute wound healing. Clin Dermatol, 2007; 25:9-18. 4. Bachli E. History of tissue factor. Br J Haematol, 2000; 110:248-255. 5. Selighson U. Disseminated intravascular coagulation (DIC). In: Beutler E, Lichtman MA, Coller BS, Kipps TJ, Seligsohn URI (eds). Williams Hematology. USA: McGraw-Hill Companies Inc, 2001; pp 1677-1695.
Balk J Stom, Vol 16, 2012 6. Zacharski LR, Rosenstein R. Reduction of salivary tissue factor (thromboplastin) activity by warfarin therapy. Blood, 1979; 53:366-374. 7. Lwaleed BA, Francis JL, Chrisholm M. Urinary tissue factor levels in neoplastic disease. Ann Saudi Med, 2000; 20:197-201. 8. Tutuarima JA, Hische EAH, Trotsenburg L, Helm HJ. Thromboplastic activity of cerebrospinal fluid in neurological disease. Clin Chem, 1985; 31:99-100. 9. Yarat A, Tunali T, Pisiriciler R, Akyuz S, Ipbuker A, Emekli N. Salivary thromboplastic activity in diabetics and healthy controls. Clin Oral Invest, 2004; 8:36-39. 10. Belikov PP. Blood coagulation factors in saliva in injury of oral mucous membrane. Stomatologia (Moskva), 1971; 50:72-74. 11. Flink H, Tegelberg A, Lagerlof F. Influence of the time of measurement of unstimulated human whole saliva on the diagnosis of hyposalivation. Arch Oral Biol, 2005; 50:553-559. 12. Fenoll-Palomares C, Munoz Montagud JV, Sanchiz V, Herreros B, Hernandez V, Minguez M, Benages A. Unstimulated salivary flow rate, pH and buffer capacity of saliva in healthy volunteers. Rev Esp Enferm Dig, 2004; 96:773-783. 13. Coleman LS. A hypothesis: Factor VII governs clot formation, tissue repair and apoptosis. Med Hypoth, 2007, 69:903-907. 14. Whelton H. The anatomy and physiology of the salivary glands. In: Edgar WM, OMullane DM (eds). Saliva and Oral Health. Great Britain: Thanet Press Lim, 1996; pp 1-8. 15. Rickles FR, Shoji M, Abe K. The role of hemostatic system in tumor growth, metastasis and angiogenesis: tissue factor is a bifunctional molecule capable of inducing both fibrin deposition and angiogenesis and cancer. Int J Hematol, 2001; 73:145-150. 16. Rickles FR, Patierno S, Fernandez PM. Tissue factor, thrombin and cancer. Chest, 2003; 124:58-68. 17. Sindet-Pederson S. Haemostasis in oral surgery the possible pathogenetic implications of oral fibrinolysis on bleeding. Experimental and clinical studies of the haemostatic balance in the oral cavity, with particular reference to patients with acquired and congenital defects of the coagulation system. Dan Medl Bull, 1991; 38:427-443.
Wound Healing and Thromboplastic Activity 97 18. Ingram GI, Hills M. Reference method for the one-stage prothrombin-time test on human blood. Thromb Haemost, 1976; 36:237-238. 19. Atay Z, Topalidis T. Cytodiagnostik der Sersen Hhlen. Atlas und Lehrbuch. Hannover: Wolfgang Pabst Verlag, 1994; pp 356. 20. Humphrey SP, Williamson RT. A review of saliva: Normal composition, flow and function. J Prosth Dent, 2001; 85:162-169. 21. Jansen Van Rensburg BG. Saliva. In: Oral Biology. Berlin: Quinstessence Publishing Co Inc, 1995; pp 469-478. 22. Butenas S, Bouchard BA, Brummel-Ziedins KE, ParhamiSeren B, Mann KG. Tissue factor activity in whole blood. Blood, 2005; 105:2764-2770. 23. Day SM, Reeve JL, Pedersen B, Farris DM, Myers DD, Im M. Macrovascular thrombosis is driven by tissue factor derived primarily from the blood vessel wall. Blood, 2005; 105:192-198. 24. Roberts HR, Monroel DM, Hoffman M. Molecular biology and biochemistry of the coagulation factors and pathways of hemostasis. In: Beutler E, Lichtman MA, Coller BS, Kipps TJ, Seligsohn URI (eds). Williams Hematology. USA: McGraw-Hill Companies Inc, 2001; pp1409-1425.

Aysen Yarat Marmara University, Faculty of Dentistry Department of Biochemistry Guzelbahce, Buyukciftlik sok. No:6 34365 Nisantasi-Istanbul-Turkey e-mail : ayarat@marmara.edu.tr ttunali@marmara.edu.tr
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ISSN 1107 - 1141
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Biophysical Principles of the AcryLock Attachments Use in Contemporary Prosthetic Dentistry

SUMMARY
D. Veleski, B. Pejkovska, M. Antanasova University of St. Cyril and Methodius, Faculty of Stomatology, Clinic of Mobile Prosthetic Dentistry, Skopje, FYROM
Introduction. There are many choices and different protocols when determining treatment of partially edentulous patients. In this article we are reviewing the dental treatment throughout the use of partial dentures with AcryLock attachments in patients who previously have been treated with different types of fixed-mobile appliances. Material and Methods. We have accomplished fixed-mobile dental appliances with the use of AcryLock attachments in 7 patients who previously have worn appliances with Lecodent attachments. Comparative analysis has been carried out with the methods used in biophysics. The patients have been followed-up for a year. Results. After the fixed-mobile prosthetic rehabilitation has been accomplished with the use of attachments from the AcryLock system, exceptional functional and aesthetic results have been noticed. Conclusion. The AcryLock attachments serve the patient extremely well as a treatment modality option with removable partial dentures for several reasons. Primarily, they are designed very close to the abutment tooth centre, allowing the direction of the force vectors straight down along the long axis of the tooth. Attachments shown in this survey illustrate good functional and aesthetic aspects. Consequently, it is realistic to expect greater longevity in the use of these elements, in comparison to the previous methods in treatment of partially edentulous patients.
Keywords: Partial Dentures; Attachments; AcryLock
Introduction
There are many possibilities for the selection of different protocols to determine the treatment plan for partially edentulous patients. In this article, the dental treatment has been reviewed through the application of partial dentures with attachments in patients who were previously treated with other kinds of fixed-mobile allowances. Partial dentures throughout the application of attachments are categorized as a culmination of knowledge and art in dental removable prosthetics. Primarily, they seem very complex, but attachments bond the fixed and the mobile part of the allowance in a simple manner in an incredibly functional whole (Fig. 1).
Figure 1. The metal skeleton of a lower partial denture, with a green patrice on the left side of the patients fixed-mobile construction
The Use of AcryLock Attachments 99
A huge variety exists in partial dentures with attachments, not only in shape but also in the way of manufacturing, the material from which they are developed and, certainly, the indications. They belong to the group of complex partial dentures. Attachments represent polyvalent precision combining elements who serve to combine (attach) the fixed with the mobile part of complex fixed-mobile appliances. They have become from the need to hide the visible retention elements of removable partial dentures with which their aesthetic value has extremely increased. Attachments in most of the cases consist of 2 basic parts: -- Patrix, the primary or male part; -- Matrix, the secondary or female part. The parts of the attachments are constructed in a manner that, with their combining, a functional whole is accomplished of the attachment system and dental appliances. With the use of attachments in partial dentures, one part is incorporated in the fixed and the other in the mobile dental appliance. In this article attachments are being reviewed from the group of vertical slide attachments. They are represented by a system of double elements for retention, or cylinder assembly in a miniature shape. That system is consisted of: 1. Patrix, primary or inner part of the system, or positive; 2. Matrix, secondary or outer part of the system, or negative. From the industrially produces sliders, in this article the emphasis will be given on the AcryLock slide attachments. They belong to the group of extra-coronary attachments. They are made out of plastics, which burns out with no residual parts. The size of the non-residual burnout patrix is 0.04 mm to ensure a defined dimension for the plastic matrix after preparation and polishing. This slider consists of patrix and matrix. The system is specific because it consists of an extra-coronary part of the crown, which is consisted of a guide and a patrix. The guide is applied to the approximal side of the wax model of the application crown (special purpose crown) in the 0 position of the paralelometer. The role of the guide is for the patrix to be on an acceptable distance from the interdental papilla. On the guide then the patrix is applied and in accordance with the position and shape of the alveolar reef, it is positioned. A few millings are possible on the guide and the patrix with the purpose of improving the adaptation to the interdental papilla and the alveolar reef. The patrix with the wax is tied to the guide and together with the wax model on the fixed construction with specific laboratory procedures is replaced with precious or base alloys. The matrix of the Acrylock attachments is made out of hard plastics and with the responding instrument
is placed in the house of the metal skeleton of the partial denture. The matrices are available in 3 different sizes for setting different withdrawal forces: (1) green matrix normal friction; (2) yellow matrix - medium friction (Fig. 2); (3) red matrix - high friction.
Figure 2. Presentation of a fixed and mobile part of a prosthetic restoration with yellow matrices
The new matrix design with a single retention point allows the matrix to be easily exchanged without timeconsuming reduction and fitting of the friction insert. Only alloys with a 0.2 proof stress of over 500 N/mm2 should be used to ensure stability. The complexity with designing fixed-mobile dental appliances throughout the use of AcryLock attachments should be analyzed with the methods of biophysics. With the help of these useful methods, the forces of the chewing pressure (while using these attachments) are directed down the long axis of the tooth, minimizing the torque and the lateral forces, and therefore improving the chances for success of the restoration.
Material and Method

Complex fixed-mobile restorations have been accomplished with the application of Acrylock attachments in 7 patients who have previously been treated with different types of treatment modalities. In this article a review has been made by representing characteristic cases that have been treated with paying meticulous attention to details. The patients have been treated with these appliances and with the methods of biophysics in the clinic for removable dental prosthetics.
100 D. Veleski et al.
Before beginning with the prosthetic approach, the patients needed pre-prosthetic preparation due to the presence of mouth and periodontal diseases, and also at the clinic for oral surgery. With the team approach, the rest of the teeth were prepared for further development of application crowns, use of the AcryLock attachments and the development of the skeletal partial denture. The first patient was completely edentulous in the upper jaw and partially (subtotal) edentulous in the lower jaw. This patient has worn total acrylic denture in the upper jaw, and a bridge with Lecodent bars and a lower skeletal denture. Both dentures needed to be replaced with new prosthetic restorations. New total prosthesis was made in the upper jaw; in the lower jaw, 2 remaining canines were endodontically treated and the prosthetic preparation impression was taken for the production of a new dental bridge with the elements of the AcryLock attachments (Fig. 3). The patrix is incorporated in the
Presentation of cases
bridge construction while the matrix is applied in the lower skeletal prosthesis (Figs. 4 and 5). The second patient previously possessed a dental bridge construction with attachments of the type Lecodent, and a skeletal denture in the upper jaw. As local conditions enabled construction of fixed-mobile restorations with the system of AcryLock attachments (Fig. 6), it was performed as well (Figs. 7 and 8). The third patient came to the clinic for removable dental prosthetics, with worn out fixed-mobile dental appliances having Lecodent bars that needed to be replaced. The upper left premolar had to be extracted; furthermore, the supporting tissue complex had to be treated for the presence of periodontal pockets. The upper right canine was suitably treated endodontically and enhanced with metal posts and cores (Fig. 9). Our patients were followed in a period of time of one year in which many aspects were notified concerning the choice of these attachments in the complete prosthetic rehabilitation.
Figure 3. Metal ceramic bridge with the Patrice incorporated from the system of AcryLock attachments
Figure 4. A lower partial denture with the incorporated matrix from the system of Acrylock attachments
Figure 5. The completed fixed-mobile complex construction
Figure 6. The remaining 2 teeth were endodontically treated and prepared for crowns
The Use of AcryLock Attachments 101
Figure 7. Fixed-mobile construction before cementation of the bridge in the mouth - palatal view
Figure 8. The completed prosthetic restoration
Figure 9. Intraoral view of the teeth after the pre-prosthetic treatment and preparation of the teeth
Figure 10. The finished fixed-mobile construction - palatal view of the attachments of the AcryLock type
Results and Discussion

In patients who previously worn fixed-mobile dental appliances with bars of the Lecodent type, comparative analysis was carried out throughout the methods of the biophysics. This method emphasizes the meaning of the vectors that are gained when a force acts along the teeth, or, in these cases, along the teeth covered with dental crowns. That force is represented schematically with a vector that touches the tooth and divides in a vertical and in a horizontal component. The closer the direction of the vectors along the long axis of the tooth, the better they are from the aspect of minimizing the harmful lateral forces that would devastate the entire final restoration. The vertical forces physiologically burden the teeth optimally
Figure 11. The completed rehabilitation with complex denture - frontal dental bride and 2 applicable crowns
102 D. Veleski et al.
when acting along their long vertical axis. Horizontal forces, while they are in the physiological values, are neutralized with the compensatory mechanism. If they overcome the individual tolerance of the teeth, traumatic forces prevail and in the process of bone remodelling there is a predomination of degradation processes. Our experience is that teeth can react painfully when forces of 20 N act in horizontal direction, while in vertical forces may cause pain in the apical region with intensity of over 200 N. All of these facts should be considered while making a treatment plan and choosing attachments. In attachments from the type AcryLock there is a higher verticalisation in directing the forces of the chew pressure in comparison with sliders like Lecodent. After the successfully accomplished fixed-mobile prosthetic rehabilitation throughout the use of attachments of the system Acrylock, exceptional functional and aesthetic results were notified. Concerning the functional aspect, subjective approach should be taken into consideration (surveys taken from the patients at the regular controls); methods from the biophysics should be used as an objective method. Our patients in the period of time of a year responded positively and in comparison they accept the AcryLock devices rather than the old ones (Lecodent bars). The patients stated that they feel the new skeletal devices to be more stable than the old ones and they felt safer while talking and using them in the act of mastication. Patients also acceptet the new therapy plan from the aesthetic point of view. Throughout the measures of the biophysics, the functional value could be proved in addition to the axial transmission of the chew pressure, with minimizing lateral forces to the periodontium of the supportive teeth. With analysis of the vectors of the forces schematically shown as a comparative method by analyzing the Lecodent with the AcryLock attachments; using AcryLock attachments there was a higher vertical transmission of chewing forces, since they are referred as vertical sliders. In Lecodent bars, there is a minimal tendency of anterior-posterior moves on the removable dentures, especially if distal teeth are missing, and because they are horizontal sliders.
choice of materials, correct applications of procedures, as well as the construction with strict holding on to the biophysical principles. Attachments from the type of AcryLock shown in this article throughout the case of studies illustrate that they efficiently serve patients from aspect of function and aesthetics. Primarily, they are designed very close to the centre of the teeth carriers of the dental bridge construction, which enables the direction of the vector forces along the vertical long axis of the tooth. From the results which we have come to, it is realistic to expect longevity in the use of these elements, in comparison to the previous methods of treatment of partially edentulous patients.
References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Veleski D. Klinika i tehnika na parcijalnite protezi. Skopje: Stomatoloki fakultet, 2010. Veleski D. Klinika i tehnika na skeletiranite parcijalni protezi. Skopje: Stomatoloki fakultet, 2011. Veleski D. Evaluacija na vrednosta na dzvakopritisokot i reakcija na potpornite tkiva kaj subtotalni protezi. PhD Thesis, Skopje: Stomatoloki fakultet, 1988. Broadbent JM, Williams KB, Thomson WM, Williams SM. Dental restorations: a risk factor for periodontal attachment loss?J Clin Periodontol, 2006; 33:803-810. Bambara GE. Attachment dentistry. A rationale for reflection and treatment planning.N Y State Dent J, 2003; 69:28-30. Dawson PE.Evaluation, Diagnosis, andTreatment of Occlusal Problems.2nd ed. St. Louis: CV Mosby Co, 1989; pp 470-471. Donovan TE, Derbabian K, Kaneko L, Wright R. Esthetic considerations in removable prosthodontics.J Esthet Restor Dent, 2001; 13:241-253. Donovan TE, Cho GC. Esthetical considerations with removable partial dentures.J Calif Dent Assoc,2003; 31:551-557. Ku YC, Shen YF, Chan CP. Extracoronal resilient attachments in distal-extension removable partial dentures.Quintessence Int, 2000; 31:311-317. Porter JA, von Fraunhofer JA. Success or failure of dental implants? A literature review with treatment considerations.Gen Dent, 2005; 53:423-432. Stamenkovi D. Stomatoloka protetika, parcijalne proteze. Beograd: Interprint, 2006; pp 286-287.
Conclusion
The functional and the aesthetic demands that are expected from the dentists can be pleased with a suitable

D. Veleski, University of St. Cyril and Methodius Faculty of Stomatology, Clinic of Mobile Prosthetic Dentistry Skopje, FYROM
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ISSN 1107 - 1141
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Intraoral Ceramic Restoration Repair Techniques: Report of 3 Cases

SUMMARY
The authors intention was to present ceramic restoration repair as a reliable, low-cost and low-risk procedure, by demonstrating 3 cases in the aesthetic zone. Intraoral ceramic repair was chosen for the small porcelain fracture of the maxillary left central incisor and for the large porcelain surface detachment of the maxillary left lateral incisor, since patients did not want to replace the fixed denture. The third case presented an easy way to correct orthodontic treatment relapse when ceramic restoration have already been placed. Gaps formed between maxillary left lateral incisor and canine were closed using the same adhesion protocol. The sequence of treatment is demonstrated altering the basic repair protocol according to the needs of each case. The final outcome of the repair with composite resin was an aesthetic alternative and the patients were fully satisfied.
Keywords: Ceramic, repair; Adhesion; Silane; Sandblasting
Kosmas Tolidis1, Paris Gerasimou1, Christina Boutsiouki2 University of Thessaloniki, School of Dentistry, Dept of Operative Dentistry Thessaloniki, Greece 2Undergraduate Student, Aristotle University of Thessaloniki, School of Dentistry, Thessaloniki, Greece
1Aristotle
CASE REPORT (CR) Balk J Stom, 2012; 16:103-108
Introduction
Ceramic restorations have been part of dental prosthetics for many years as they are characterized by superior aesthetics, functionality and biocompatibility. Feldspathic porcelain with a metallic framework, ultra-low fusing porcelains and reinforced ceramics evolved over decades21. Metal-ceramic fixed restorations, probably the most frequently used, can survive up to 25 years3. But the inherent brittleness of porcelain and the kind of cements used for insertion might result in fracture and consequently failure. Fractures are caused by trauma, acute accidents, chronic habits (bruxism), flaws and contamination in the original porcelain fabrication, or inadequate tooth thickness during tooth preparation15. In these situations, ceramic restoration repair is a reliable, low-cost and lowrisk procedure. Moreover, the same protocol can be used for interdental gap closure between already placed ceramic restorations.
Case Reports
Description of the Technique
-- Treatment of ceramic and metal surface
Removing the glazed ceramic layer is suggested in order to allow the exposure of the underlying ceramic layer, which is more reactive and has greater contact surface area. This can be made mechanically (roughening with diamond burs), chemically (sandblasting, acid etching), or with the combination of both. Roughening with diamond burs should be performed at high-speed to avoid production of cracks and fissures in ceramic margins from the vibration of low-speed handpieces. Diamond bur roughening should be combined with other surface treatment methods in order to attain higher adhesion values18. Sandblasting is usually performed with a high-speed stream of purified aluminium oxide particles (30-250 m) delivered by air pressure (2-3 bars or 30-42 psi) for approximately 15 seconds. Treatment of metal surface, if showing, is done by sandblasting, in order to improve retention by eliminating oxides and greasy materials and by increasing surface area. Particles could also be 30 m silica coated (SiOx). This results in deposition of a molecular coating of alumina coated with silicic acid on the alloy surface, providing a reliable mechanical retention and physicochemical bond between the alloy and the composite (CoJet-Sand, CoJet System, 3M-ESPE). Allow drying for 5 minutes and do not use a water-syringe
104 Kosmas Tolidis et al.
because of possible water or oil contamination. Rubber dam isolation and high power suction systems prevent soft tissue injuries and control the emission and spread of the aluminium oxide particles over the operative area15,20,22,28. Acid etching yields a clean surface and produces micro-retentions that increase bond strength of the etched substrate, as in composite resin adhesion protocol. Metal is cleaned but not affected in another way. The following acid formulations can be used: a) 37% phosphoric acid - it does not produce any type of alterations on the ceramic morphology, but it can be used to clean the ceramic surface after mechanical roughening. It is also used where tooth structure is associated, as a part of the standard adhesion protocol25. b) hydrofluoric acid - it creates surface irregularities acting on the silicon dioxide (SiO2) of the porcelain vitreous phase. Concentration varies between 5-10% and etching time between 20 seconds-10 minutes, depending on ceramic type. Manufacturers instructions are followed. Hydrofluoric acid however is very aggressive to soft tissues and care should be taken. No consensus has yet been reached regarding its use, as similar results are obtained with other surface treatment methods too13,25,27. c) 1.23% acidulated phosphate fluoride - its effect on ceramics is similar to that of hydrofluoric acid, requiring more time but without the aggressiveness towards soft tissues, attacking glass probably due to selective release of sodium ions, interrupting the silica network. Etching time varies from 5-15 minutes. The etched porcelain does not have a frosted appearance after etching, as with hydrofluoric acid27. -- Metal surface treatment Besides sandblasting, metal primer must be applied on the showing metal surface in order to bond the resin onto the metal. If metal is high-noble or noble, bond strengths can be enhanced by tin plating the exposed metal. If the metal is determined to be base metal, tin plating is not necessary. The type of metal primer is specified by the type of alloy and its ingredients14. -- Silanization Ceramic primers containing silane are applied prior to the adhesive agent and used in order to improve the chemical bond between porcelain and composite resin. Silane consists of a carbon chain that presents a SiO2 group in a functional end. As a result, the functional end is joined with the porcelain, thus maintaining the carbon chain free for bonding to the resin. Silanization should be used in conjunction with other surface treatments (roughening with diamond burs, sandblasting, acid etching) and the resin adhesive system. There are no reports of disadvantages in the use of silane agents except for the short shelf life, being 12-18 months9,18,22,25. -- Application of unfilled resin If the patient has the fractured piece of porcelain, it can be re-bonded to the crown after using the etchant, silane and unfilled resin on the piece too22.
-- Application of opaquer Resin composites systems which offer opaque and translucent resins should preferably be used to re-establish aesthetics after ceramic repair15,18,22. Flowable resin in opaque shade seems to be very practical. Application of composite resin shades according to manufacturers recommendations, occlusal adjustment and polish. Case 1 (Incisal and Cervical Porcelain Fracture) A 47-year old male patient with a 4-unit metalceramic fixed partial denture presented with a fracture on the incisal edge and cervical margin of the maxillary left central incisor and on the joint between the maxillary left central incisor and maxillary right central incisor palatally (Fig.1). Intraoral ceramic restoration repair was selected as the treatment of choice. Cotton rolls were used for isolation and roughening of the ceramic surface was done with high speed bur. 10% hydrofluoric acid was applied for 2 min on the ceramic and metal surface, followed by thorough rinsing for 30s and drying (Fig. 2), application of metal primer for 1 min, silanization by silane application for 1 min, and application of unfilled resin and polymerization with a LED curing unit (Elipar S10, 3M-ESPE). Flowable opaquer was applied in 2 thin layers (Fig. 3) following by incremental placement of dentin and enamel A3 composite resin shades (Fig. 4). Occlusal adjustment was made and finishing and polishing were done with the appropriate tips (Fig. 5).
Figure 1. Initial aspect of the small fracture in the distal angle of the maxillary left central incisor
Figure 2. Etching with 10% hydrofluoric acid
Intraoral Ceramic Restoration Repair 105
(Fig. 8). Metal primer was applied for 1min, followed by silanization by silane application for 1 min and application of unfilled resin and polymerization with a LED curing unit (Elipar S10, 3M-ESPE). Opaquer was applied in 2 thin layers (Fig. 9) following by incremental placement of dentin and enamel A3 composite resin shades. Occlusal adjustment was made and finishing and polishing were done with the appropriate tips (Fig. 10).
Figure 3. Application of flowable opaquer
Figure 6. Initial aspect of the large porcelain surface detachment of the buccal surface of the maxillary left lateral incisor
Figure 4. Incremental placement of composite resin
Figure 5. Final aspect of the ceramic repair
Case Report 2: Large Porcelain Surface Detachment A 50-year old female patient with a 6-unit metalceramic fixed partial denture presented with total buccal surface detachment of maxillary left lateral incisor (Fig. 6). Intraoral ceramic restoration repair was selected as the treatment of choice. Light cured rubber dam and lip retractor were used for isolation. 10% hydrofluoric acid was applied for 2 min on the ceramic and metal surface (Fig. 7), followed by thorough rinsing for 30s and drying. Sandblasting with 30m silica oxide particles (CoJet Sand, 3M-ESPE) for 15s using a chairside air-abrasion device (CoJet System, 3M-ESPE) was done
Figure 8. Sandblasting with CoJet System (3M-ESPE)
Figure 9. Application of flowable opaquer
Figure 11. Initial aspect of the gap between the maxillary left lateral incisor and canine
Figure 12. Roughening ceramic surface with diamond bur
Case Report 3: Gap Closure between Porcelain Restorations A 42-year old male patient underwent orthodontic treatment and placed all-ceramic crowns in maxillary teeth. But orthodontic treatment relapsed and a small gap was formed between the maxillary left lateral incisor and canine (Fig. 11). Intraoral composite resin addition on ceramic was selected as the treatment of choice for the repair. Ceramic surface was roughened with high speed diamond bur (Fig. 12). Light cured rubber dam and lip retractor were used for isolation. 10% hydrofluoric acid was applied for 2 min on the ceramic surface (Fig. 13), followed by thorough rinsing for 30s and drying. Silanization was achieved through silane application for 1 min and application of unfilled resin followed, polymerized with a LED curing unit (Elipar S10, 3M-ESPE). A1 shade of composite resin was placed incrementally (Fig. 14) until the desired shape of incisor and canine was formed and polymerized with a LED curing unit (Elipar S10, 3M-ESPE). Occlusal adjustment was made and finishing and polishing were done with the appropriate tips (Fig. 15).
Figure 14. Incremental placement of composite resin
Intraoral Ceramic Restoration Repair 107
Discussion
Fracture can extend to ceramic only with or without metal showing, or include metal framework. The simplest repair is if the fracture is limited in the porcelain. If tooth structure is revealed, the process should be slightly altered, as clinical usage of hydrofluoric acid on dentine should be avoided25. Likewise, a stable and durable bond to ceramics that contain minimal or even no silica, such as aluminium or zirconium oxide ceramics, requires other surface pre-treatment techniques or modified luting cements7, although it seems that silane coating or silanization improve the longevity of repaired zirconia crowns1. With similar procedures, fractures in allceramic and in Cerec restorations can be fixed, but since there are no clinical trials of these restorations of more than 5 years3,29, it is questionable whether a repair or a replacement should be decided. Generally the basic protocol steps should be individualized to meet the needs of each special repair case, as demonstrated in the cases described. Within the limitation of the studies, it seems that acid etching and silanization create high bond strengths between feldspathic porcelain and resin composite cement11,24. Surface conditioning with hydrofluoric acid and silanization or silane coating with the use of CoJet and silanization, used as different options in the 2 cases described, exhibited no differences in shear bond strength12. On the contrary, Ozcan et al17 showed that the repair method based on silane coating and silanization was superior to other repair strategies without silane coating application. Combination of silane primer and unfilled resin, shows the greatest magnitude of bond strength in comparison with silane only, or unfilled resin only6. Others, however, state that use of adhesive resin does not improve resin adhesion to etched and silanized ceramic after long term thermocycling and water storage19. Research shows that sandblasting with aluminium oxide particles is a better method of preparing the surface than
roughening with diamond burs30, but some state that it is not superior to other kits without it10. Acid etching time and type of bonding agent influence bond strength, and self-etching bonding agents should be avoided5. Acid etching, sandblasting with aluminium oxide or silica coated particles, show no differences in fracture loads on repaired surfaces; however, addition of a layer of glass fibre-reinforced composite increased the load level16. CoJet system sandblasting offers the highest bond strength values for the metal substrate, in comparison to bonding agents4. However, it is also stated that micro-mechanical cohesion is not enough and that macro-mechanical retention should be prepared where possible10. Bond strengths between composite and porcelain resulting from silanization seem to increase over time, as an effect of water storage (Berry et al. 1999) and pre-polymerized resin structures obtain higher shear bond strength values, compared to in situ resin polymerization26. Intraoral ceramic repairs present a variety of difficulties and possible failures. The most important issue is to explain to the patient the cause of the initial restoration failure, to proceed in possible changes and include the challenge of anticipating longevity of the repair. The adhesive protocol needs to be abided by the practitioner and physical and mechanical behaviour of the very different materials used should be associated. Metameric effect between dental porcelain and resin composite8 and colour stability of repairing materials over time23, should also be considered but hybrid resin composites are best chosen for the repair procedure, as they are best suited due to their physical, mechanical and optical properties. Additionally, soft tissues should be protected by the use of high-speed burs and acid etchants in the operation field21. Moreover, function and thermal changes are detrimental to all bonded restorations22.
Conclusion
When attempting to repair a fractured ceramic restoration, it is important to determine the reason for failure and eliminate it, or else the repair will probably fair no better than the original restoration. The patient has to be informed for the possible risks and alternative solutions. Repairing ceramic restoration fractures with composite resins has some major advantages, as it preserves the main body of the restoration and avoids extra unnecessary cut of the tooth, making the treatment inexpensive and easy when no replacement or fabrication of an over-casting is possible. Dental practitioners should be familiar with the technique, as it can be used in aesthetic restorations as shown, but keeping in mind the fact that all clinical procedures have advantages and disadvantages.
Balk J Stom, Vol 16, 2012 17. Ozcan M, Valandro LF, Amaral R, Leite F, Bottino MA. Bond strength durability of a resin composite on a reinforced ceramic using various repair systems. Dent Mater, 2009; 25:1477-1483. 18. Pameijer CH, Louw NP, Fisher D. Repairing fractured porcelain: How surface preparation affects shear force resistance. J Am Dent Assoc, 1996; 127(2):203-209. 19. Passos SP, Valandro LF, Amaral R, Ozcan M, Bottino MA, Kimpara ET. Does adhesive resin application contribute to resin bond durability on etched and silanized feldspathic ceramic? J Adhes Dent, 2008; 10(6):455-460. 20. Reston EG, Closs LQ, Sato CT. Customized and low-cost aspirator device for intra-oral sandblasting. Oper Dent, 2004; 29(3):354-356. 21. Reston EG, Filho SC, Arossi G, Cogo RB, Rocha CS, Closs LQ. Repairing ceramic restorations: final solution or alternative procedure? Oper Dent, 2008; 33(4):461-466. 22. Robbins JW. Intraoral repair of the fractured porcelain restoration. Oper Dent, 1998; 23:203-207. 23. Saygili G, Sahmali S, Demirel F. Color stability of porcelain repair materials with accelerated ageing. J Oral Rehab, 2006; 33:387-392. 24. Sorensen JA, Kang SK, Avera SP. Porcelain-composite interface microleakage with various porcelain surface treatments. Dent Mater, 1991; 7:118-123. 25. Szep S, Gerhardt T, Gockel HW, Ruppel M, Metzeltin D, Heidemann D. In vitro dentinal surface reaction of 9.5% buffered hydrofluoric acid in repair of ceramic restorations: A scanning electron microscopy investigation. J Prosthet Dent, 2000; 83(6):668-674. 26. Tulunoglu IF, Beydemir B. Resin shear bond strength to porcelain and a base metal alloy using two polymerization schemes. J Prosthet Dent, 2000; 83(2):181-186. 27. Tylka DF, Stewart GP. Comparison of acidulated phosphate fluoride gel and hydrofluoric acid etchants for porcelaincomposite repair. J Prosthet Dent, 1994; 72(2):121-127. 28. Van der Veen JH, Jonglebloed WL, Dijk F. SEM study of six retention systems for resin-to-metal bonding. Dent Mater, 1988; 4:266-271. 29. Van der Vyver PJ, Marais JT, de Wet FA. Repair of Cerec porcelain with seven different systems. J Dent Assoc S Afr, 1996; 51(8):525-530 [abstract]. 30. Yesil ZD, Karaoglanoglu S, Akgul N, Ozdabak N, Ilday NO. Effect of different surfaces and surface applications on bonding strength of porcelain repair material. NYSDJ, 2007; 73(3):28-32. Correspondence and request foorr offprints to:
Kosmas Tolidis 51 Tsimiski Str. 54623, Thessaloniki Greece Email: ktolidis@dent.auth.gr
References
1. Attia A. Influence of surface treatment and cyclic loading on the durability of repaired all-ceramic crowns. J Appl Oral Sci, 2010; 18(2):194-200. 2. Berry T, Barghi N, Chung K. Effect of water storage on the silanization in porcelain repair strength. J Oral Rehab, 1999; 26:459-463. 3. Blatz MB. Long-term clinical success of all-ceramic posterior restorations. Quintessence Int, 2002; 33:415-426. 4. Gomes J, Fonseca R, Adabo G, Alberto C. Shear bond strength of metal-ceramic repair systems. J Prosthet Dent, 2006; 96:165-173. 5. Guler AU, Yilmaz F, Yenisey M, Guler E, Ural C. Effect of acid etching time and a self-etching adhesive on the shear bond strength of composite resin to porcelain. J Adhes Dent, 2006; 8:21-25. 6. Hisamatsu N, Atsuta M, Matsumura H. Effect of silane primers and unfilled resin bonding agents on repair bond strength of a prosthodontic microfilled composite. J Oral Rehab, 2002; 29:644-648. 7. Kern M, Wegner SM. Bonding to zirconia ceramic: Adhesion methods and their durability. Dent Mater, 1998; 14:64-71. 8. Kim SH, Lee YK, Lim BS, Rhee SH, Yang HC. Metameric effect between dental porcelain and porcelain repairing resin composite. Dent Mater, 2007; 23:374-379. 9. Kupiec KA, Wuertz KM, Barkmeier WW, Wilwerding TM. Evaluation of porcelain surface treatments and agents for composite-to-porcelain repair. J Prosth Dent, 1996; 76(2):119-124. 10. Leibrock A, Degenhart M, Behr M, Rosentritt M, Handel G. In vitro study of the effect of thermo- and load-cycling on the bond strength of porcelain repair systems. J Oral Rehab, 1999; 26:130-137. 11. Lu R, Hartcourt JK, Tyas MJ, Alexander B. An investigation of the composite resin/porcelain interface. Aust Dent J, 1992; 37:12-19. 12. Melo RM, Valandro LF, Bottino MA. Microtensile bond strength of a repair composite to leucite-reinforced feldspathic ceramic. Braz Dent J, 2007; 18(4):314-319. 13. Oh WS, Shen C. Effect of surface topography on the bond strength of a composite to three different types of ceramic. J Prosthet Dent, 2003; 90(3):241-246. 14. Okuya N, Minami H, Kurashige H, Murahara S, Suzuki S, Tanaka T. Effects of metal primers on bonding of adhesive resin cement to noble alloys for porcelain fusing. Dent Mater, 2010; 29(2):177-187. 15. Ozcan M, Niedermeier W. Clinical study on the reasons for and location of failures of metal-ceramic restorations and survival of repairs. Int J Prosth, 2002; 15(3):299-302. 16. Ozcan M, Van der Sleen JM, Kurunmaki H, Vallittu PK. Comparison of repair methods for ceramic-fused-to-metal crowns. J Prosthod, 2006; 15(5):283-288.
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A Multidiscipline Approach to Improve Aesthetics in a Patient with High Lip Line: A Clinical Report
SUMMARY
In the analysis of characteristics of a pleasant smile, a gummy smile has negative effects. A 25-year-old female patient was referred to the Marmara University, Faculty of Dentistry, Department of Prosthodontics. On the basis of radiographic, cephalometric and oral examinations, the patient was diagnosed with Class II skeletal malocclusion, high angle facial profile and partially edentulous. There was a severe aesthetic problem in the anterior maxillary segment because of high lip line and an excessive vertical growth of the maxillary anterior jaw. A surgical approach was performed and excessive bone in the maxillary anterior region was removed after extraction. 9 implants (SwissPlus, Zimmer Dental, Carlsbad, CA, USA) were inserted in maxilla and 8 implants in the mandible. The stability of the implants was evaluated by the resonance frequency analysis. After prosthodontic treatment, the patient was recalled up to 5 years. The implants were successful and patient satisfaction was high.
Keywords: Implants; High Lip Line
Burin Vanlolu1, Yaar zkan2, Yasemin Kulak-zkan1 University of Marmara, Faculty of Dentistry of Prosthetic Dentistry 2Department of Oral Surgery Istanbul, Turkey
1Department
Introduction
In the analysis of characteristics of a pleasant smile, a gummy smile has negative components, which most affects aesthetics of non-verbal communication. The nature of a high smile line can be: dento-gingival, connected to an abnormal dental eruption, which is revealed by a short clinic crown; muscular, caused by hyperactivity of the elevator muscle of the upper lip; dento-alveolar (skeletal), due to an excessive protuberance or vertical growth of the jawbone (maxillary); lastly, a mixed nature, in the presence of more than 1 of the above described factors1. Llocation of the lip during speaking, smiling, and at rest is of key importance in treatment planning for missing teeth in the aesthetic zone2. Orthognathic surgery, orthodontic therapy, maxillary and mandibular overlay removable partial dentures and fixed partial dentures could be treatment alternatives for patients with mixed dental and skeletal malocclusions3,4. In this study, surgical approach was performed in a female patient with gummy smile, and excessive bone in the maxillary anterior region was removed. The patient was treated with implant retained fixed partial dentures, and an aesthetic outcome was improved.
Case Report
25-year-old female patient was referred to our clinic for evaluation. Her chief complaints were aesthetic and functional deficiency. Cephalometric, panoramic and periapical radiographs were taken and Ricketts cephalometric analysis was completed. There was severe aesthetic problem in the anterior maxillary segment because of the high lip line. On the basis of radiographic, cephalometric and oral examinations, the patient was diagnosed with Angle Class II occlusion and high angle (Figs. 1 and 2). Intraoral examination revealed that several teeth were lost as a result of poor endodontic therapy and periodontal disease. There was an excessive protuberance and vertical growth of the maxillary anterior jawbone. The patients oral hygiene was poor. The temporomandibular joint was asymptomatic and associated muscles were not painful. The remaining dentition included 8 maxillary teeth (right lateral incisor, right canine, right first premolar, third molar, left canine, left first and second premolars, left third molar) and 4 mandibular teeth (left canine, left first premolar, left second and third molars). Several different restorative options were discussed with the patient, ranging from maintaining the existing
110 Burin Vanlolu et al.
dentition to extraction of the remaining maxillary and mandibular teeth. The patient expressed a desire to keep as many of the remaining teeth for as long as possible. In the maxillary and mandibular arches, the use of a fixed partial denture was contraindicated because of the extensive tooth loss. Therefore a decision was made to insert implants in the posterior edentulous parts.
Figure 1. Extraoral view before treatment at rest position
maxilla and mandible were prepared with a chamfer finish line and provisional restorations were performed and used for 2 weeks. The patient was unsatisfied with the aesthetic outcome in the maxillary anterior region, so it was decided to extract all the remaining maxillary teeth. A surgical approach was performed and excessive bone in the maxillary anterior region was removed after extraction. 4 implants were inserted in the maxillary anterior region in harmony with the lip line. The third molars in the maxilla and left mandible were extracted and the vertical dimension was decreased. Mandibular left canine and left first premolar were extracted because of periodontal tissue loss and 2 implants were placed. The patient was referred for prosthetic rehabilitation following 3 months to allow for osseointegration and full maturation of the soft tissue. Diagnostic casts and record bases were fabricated and then mounted in an articulator (Artex; Girrbach Dental GmbH, Pforzheim, Germany). Metal ceramic restorations (VMK-95 Metal Keramik; Vita Zahnfabrik, Bad Sackingen, Germany) were fabricated (Figs. 3 and 4) and cemented with glass ionomer cement. After prosthodontic treatment, the patient was recalled 3, 6, 12 and 24 months later. The implants were evaluated by clinical and radiographic parameters.
Figure 3. Extraoral view with provisional restorations at smile position Figure 2. Intraoral view before treatment
The operation was done under general and local anesthesia. 5 implants (SwissPlus, Zimmer Dental, Carlsbad, CA, USA) were placed in the maxilla and 6 implants were placed in the mandible. The stability of the implants was evaluated by the resonance frequency analysis (Osstell, Integration Diagnostics, Savedalen, Sweden) test during the osseointegration period of 8 weeks. The diagnostic models were examined in the articulator and it was decided to make temporary restorations in the ideal occlusion. All the teeth in
Figure 4. Location of implants at surgery
Improvement Aesthetics in a Patient with High Lip Line 111
Figure 5. Extraoral view after treatment
Figure 6. Intraoral view after treatment
The patients comfort with the decreased interocclusal dimension and the patient satisfaction was high at 24 month evaluation. The patient was very satisfied with the aesthetic outcome (Figs. 5 and 6). In this case there were no complications after implant placement. Evaluation of clinical parameters 5 years after final prosthodontic treatment demonstrated stable attached gingiva around the implants. Radiological evaluation demonstrated that periimplant bone loss was in the clinically acceptable levels.
References
1. Monaco A, Streni O, Marci MC, Marzo G, Gatto R, Giannoni M. Gummy smile: clinical parameters useful for diagnosis and therapeutical approach. J Clin Pediatr Dent, 2004; 29(1):19-25. 2. del Castillo R, Drago C. Indexing and provisional restoration of single implants. J Oral Maxillofac Surg, 2005; 63:11-21. 3. Fayz F, Eslami A. Determination of occlusal vertical dimension: a literature review. J Prosthet Dent, 1988; 59:321-323. 4. Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent, 1984; 52:467-474.
Discussion
The diagnosis of gummy smile must be precocious and based, with reference to specific parameters, upon a careful analysis of the etiopathogenetic factors and the degree of seriousness of the alteration. A correct treatment plan must contemplate the possibility of an orthodontic, orthopaedic and/or surgical therapeutic solution considering the seriousness and complexity of the gums exposures in connection with age of the subject1. In this case, at first, the remaining teeth were not extracted according to the wish and expectation of the patient, but the aesthetic outcome with the provisional restorations was not satisfactory; so, a surgical approach was preferred - to remove the excessive bone in the anterior maxilla.

Burin Vanlolu University of Marmara Department of Prosthodontics Bykiftlik Sokak, No: 6 Gzelbahe, 34365, Nianta Istanbul, Turkey E-mail: drburcinakoglu@hotmail.com
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The Use of Advanced Technology to Avoid Injury of the Inferior Alveolar Nerve during Implant Surgery
SUMMARY
Luan Mavriqi, Egresa Baca, Anila Vjeshta Brianza Dent, Tirana, Albania
Introduction. The aim was to present and evaluate strategy of avoidance the inferior alveolar nerve injury during implantation procedure using the advanced technology (3D x-ray and piezosurgery) in cases of the emphasized mandibular atrophy. Cases Report. 3 healthy females and 9 males, aged 47-60 years, were treated by implant supported dentures using the advanced technology. Patients were treated successfully and signs of nerve injury were not noted. They were advised to inform on the possible signs of prolonged paraesthesia or anaesthesia after the procedure. 3 months later, they were rehabilitated with implant supported bridges. Conclusions. The use of piezosurgery reduces the overall surgical time and allows better surgical control over the neurovascular bundle. The use of 3D x-ray device provides us a full map of the nerve path and reduces probability of nerve injury.
Keywords: Piezosurgery; Implantation; Nerve
Introduction
The aim was to present and evaluate strategy of avoidance the inferior alveolar nerve injury during implantation procedure using the advanced technology (3D x-ray and piezosurgery) in cases of the emphasized mandibular atrophy. Creating a small crestal bone window10 by piezosurgery, an oral surgeon may avoid overstretching the nerve or its injury inclining instruments adequately in apico-coronal direction. Clinical evaluation in a 36-month period found a return of normal sensation in all the patients after a brief period of sensibility disturbances. The quantity of bone available in the mandible posterior to the mental foramen is often reduced as a result of alveolar resorption following tooth loss (Fig. 1). This fact, as well as the high position of the inferior alveolar nerve (IAN) can impede placing implants of the appropriate length. Among the therapeutic approaches for treating severely atrophied mandible is IAN mobilization using the piezosurgery1-4 and creating a small bone window (Figs. 2 and 3) to expose the bundle and reduce overstretching
of the mental nerve and lower the risk of the IAN injury (Fig. 4). An ultrasound bone-surgery device specifically engineered for simplified bone surgery (piezosurgery) was developed to allow cutting of hard tissue without injuring the adjacent soft tissue. This article reports 12 cases where this technique was used.
Figure 1. Intraoral situation before the treatment
Avoidance of Inferior Alveolar Nerve Injury 113
Figure 2. Piezosurgery insertion allows removal of bone without damaging the nerve
Figure 5. Implant inserted to achieve bi-cortical fixation. The nerve bundle is lateralized from the implant
Figure 3. Osteotomy of cortical bone
Figure 6. Final intraoral view of the patient with implant-supported fixed prosthesis
Cases Report
3 females and 9 males, aged 47-60 years, were treated by implant supported dentures using the advanced technology. 2 of the male patients were under treatment for diabetes, and 3 other males were regularly taking medicaments for hypertension. The rest of the patients were healthy. 7 patients didnt have posterior teeth in the mandible and worn partial (skeletal) dentures, and 5 of them were edentulous in the mandible and worn total dentures. After the first panoramic x-ray (Fig. 7), an emphasized atrophy of the posterior region of the mandible, being less than 7 mm, was evidenced in all the patients, similar as already reported5-8. To gain more accurate information, all the patients were 3-dimensionally x-rayed (Fig. 8), so that the accurate
Figure 4. After the surgery the nerve is free of tension because ostectomy created more space for its accomodation
114 Luan Mavriqi et al.
values of the distance of the inferior alveolar nerve to the alveolar ridge were obtained. The values were from 4.5 mm (min) to 6 mm (max). These values excluded the probability of putting the implants classically, as in that case vertical dimension of the bone should be larger than 10 mm. The patients were informed about the probability of the IAN bypass, which was provided by 3D radiography measurements11 during the intervention (Figs. 9 and 10). The patients were informed about the option of receiving a surgical transposition of the IAN by ultrasound bone surgery device (piezosurgery). They were also informed about the probability of any sensibility disturbance.
Figure 10. Panoramic radiography after insertion of fixed prosthesis
Figure 7. Panoramic radiograph before the treatment
After application of articaine local anesthesia, a crestal incision extending from the retromolar to the premolar area was done, mucoperiosteal flap was raised and, at the implantation site cortical bone was penetrated by the millimetre pilot drill till the predefined depth. In the premolar zone, a mucoperiosteal flap was reflected exposing the mental foramen. After defining the correct direction, we continued with the pilot cutter going along the length of 10 mm. After the pilot cutter, we used the anatomic cutter and finally inserted the implant (Fig. 5). After the procedure, the 3D-radiogram was repeated (Fig. 9). Patients were prescribed antibiotics (amoxicillin) and analgesic for 5 days, and advised to keep in touch about the reaction after anesthesia. Only one out of 12 patients showed a slight paraesthesia of the lip, which improved after 2 weeks. The implant-supported bridges were done after 3 months in all the patients (Fig. 6).
Figure 8. 3-dimensional radiography before the treatment
Figure 9. 3-D radiography after surgery
Although IAN mobilization has been described in the literature, it has not been widely used because of concerns for injuring the IAN. The results of this case series suggest that surgical transposition of the IAN by means of ultrasound bone surgery is a safe option, since all the treated patients with this technique did not manifest signs of nerve injury; slight paraesthesia in 1 patient gone after a short period of 2 weeks. The IAN can be damaged during several phases of the procedure: (1) during osteotomy to expose the nerve; (2) during flap elevation; or (3) during insertion of the implant. Better results, in terms of sensory alterations, associated with IAN mobilization not involving the mental foramen can be explained by the reduced need to stretch the flap10. An osteotomy that is 20 mm long is required to achieve sufficient elasticity of the IAN bundle to avoid lengthening the bundle by more than 5% and damaging it. The piezosurgical method helps to avoid this problem.
Discussion
Avoidance of Inferior Alveolar Nerve Injury 115 7. Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers. A mixed longitudinal study covering 25 years. J Prosthet Dent, 1972; 27:120-132. 8. Karagaclioglu L, Ozkan P. Changes in mandibular ridge height in relation to aging the length of edentulism period. Int J Prosthodont, 1994; 7:368-371. 9. Peleg M, Mazor Z, Chaushu, G Garg AK. Lateralization of the inferior alveolar nerve with simultaneous implant placement: A modified technique. Int J Oral Maxillofac Implants, 2002; 17:101-106. 10. Vercelloti T, DePaoli S, Nevins M. The piezoelectric bony window osteotomy and sinus membrane elevation: introduction of a new technique for simplification of the sinus augmentation procedure. Int J Periodontics Restorative Dent, 2001; 21:561-567. 11. Nitsche T, Menzebach M, Wiltfang J. What are the indications for the three-dimensional x-ray diagnostic and image-based computerized navigation aids in dental implantology? Systematic review consensus statements and recommendations of the 1st DG Consensus Conference in September 2010, Aerzen, Germany. Volume 4, Issue 5. Correspondence and request for offprints to:
Luan Mavriqi Brianza Dent Rr: Bardhok Biba.P.Hodaj.Ap.A 9 Tirane, Albania luanmavriqi@yahoo.com
The described technique brings up several risks; primarily the temporary or permanent injury of the IAN, but the use of 3D radiograms provide us a full map of the nerves path and, during the intervention, enables a reduction of the damage probability.
References
1. Atwood DA. Bone loss of edentulous alveolar ridges. J Periodontol, 1979; 50:11-21. 2. Jensen O, Nock D. Inferior alveolar nerve repositioning in conjunction with placement of osseointegrated implants: a case report. Oral Surg Oral Med Oral Pathol, 1987; 63:263268. 3. Bovi M. Mobilization of the inferior alveolar nerve with simultaneous implant insertion: a new technique. Case report. Int J Periodontics Restorative Dent, 2005; 25:375383. 4. Misch CE, Judy KWM. Patient dental-medical, implant evaluation form. Int Cong Oral Implant, 1987. 5. Atwood DA. Postextraction changes in the mandible as illustrated by microradiographs of midsagittal sections and serial cephalometric roentgenograms. J Prosthet Dent, 1963; 13:810-824. 6. Atwood DA. Reduction of residual ridges: a major oral disease entity. J Prosthet Dent, 1971; 26:266-279.
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Bony Lid Approach in Dentoalveolar Surgery: Report of 2 Cases

SUMMARY
Conventional surgical approach for cyst enucleation is removal of buccal compact bone plate, which often results in remarkable bone loss and subsequent mucosal recession. This report presents one case of residual mandibular cyst enucleation and one case of apicoectomized mandibular molar, both treated with the bony lid approach. A window of buccal compact bone was precisely created using an electro-powered osteotome orientated beyond the limits of cyst, followed by removal of the bone segment. After the completion of the enucleation and apicoectomy, the bony lid was relocated on its original position. The main advantage of this method over conventional one is maintaining the buccal compact bone plate integrity and minimizing the dimensions of the remaining bone cavity.
Keywords: Bony Lid; Enucleation; Apicoectomy; Mandibular Molar
Stelios Karamanis1, Dimitrios Tsoukalas2, A. Traskas3, Nikolaos Parissis4 Aristotle University of Thessaloniki, School of Dentistry, Dpt. of Dentoalveolar and Implant Surgery and Radiology Thessaloniki, Greece
Introduction
In most cases, conventional osteotomies in the maxilla and the mandible are invasive surgical procedures and result in remarkable bone loss. The created defects very often can not be completely regenerated. They persist for years causing problems for feature treatment and impairing aesthetics13. Guided bone regeneration with or without graft materials may offer solutions, but this procedure requires more time and involves risk of wound dehiscence and subsequent contamination3,4,16. Jaw cysts remaining after tooth extraction, also called residual cysts, and periapical cysts are frequent findings in dentoalveolar surgery. The classic method for their removal is conventional enucleation. According to this procedure, the buccal bone plate is removed, the cystic membrane is separated from the surrounding bone and the enucleation follows as usual. In cases of periapical cysts the whole procedure is combined with root apex resection. The disadvantage of the classical method is the bone defect that is often left after healing, which usually results in mucosal recession that is likely to have an impact on the adequate control of a conventional or implant prosthesis, or even on the aesthetics of the area. The use of autogenous bone graft, bone substitutes or connective tissue graft, may give satisfactory solutions
to these problems16. However, besides the possible risks mentioned above, some patients do not desire either to undergo a second surgery, or to afford the financial cost of such procedures. For these reasons, it is preferable to avoid, where possible, creation of such defects from the beginning, by utilizing more conservative surgical techniques. The bony lid technique has been described as a bone-saving method and was originally applied in cases of maxillary sinus surgery6,8,9,21. Subsequently, it was expanded in cases of apicoectomy of mandibular molars15,17,19,24 and enucleation of residual cysts5. Based on previous experience, this paper describes 2 cases where the bony lid approach was advocated, and explores problems and concerns related to this treatment concept.
Case Reports
A female and a male patient of 63 and 25 years old respectively presented to the clinic. The first patient desired to wear a partial denture and was referred by the department of prosthodontics. The second one mentioned history of swelling in the region of second right lower molar.
Bony Lid Approach in Dentoalveolar Surgery 117
Figure 1. Pre-operative panoramic radiography
Figure 4. The bony lid
Figure 5. The cyst before removal
Figure 2. Pre-operative cross-sectional reconstruction of CT scan images
Figure 6. The detached bony lid
Figure 3. Creation of the bony lid
Figure 7. The bone cavity after cyst removal
118 Stelios Karamanis et al.
Figure 8. Relocation of the bony lid
Figure 11. Pre-operative panoramic reconstruction of CT scan images
Figure 12. Pre-operative cross-sectional reconstruction of CT scan images
Figure 9. Wound suturing
Figure 13. The bony lid
Figure 10. 3-months follow up CT scan image
Figure 14. The resected apexes
Bony Lid Approach in Dentoalveolar Surgery 119
Figure 15. Relocation of the bony lid
Figure 16. Wound suturing
Prior to surgery, both cases were evaluated radiographically by conventional panoramic and CT scan examination (Figs. 1, 2, 11 and 12). The first case presented radiolucency in the region of lower right molars, whilst the second one presented radiolucency around the apices of the second right molar. Both radiolucencies were well defined. The diagnoses were residual and periapical cysts and the treatment plan comprised enucleation and enucleation/apicoectomy respectively using the technique of bony lid. In both cases, after a full thickness mucoperiosteal flap elevation, a parallelogram window of buccal compact bone to the trabecular bone was precisely created using an electro-powered MicroSaw (Dentsply Friadent, Mannheim, Germany). The latter was first developed in 1984 and consists of a thin diamond disk with a diameter of 8mm. The disk is mounted on the hand piece with a disk protector to prevent any injuries of the soft tissues16. The sequence of osteotomies performed with the diamond disk was, 2 proximal, 1 baso-horizontal and 1 on the occlusal crestal site. The window was orientated beyond the limits of the cyst (Figs. 3, 4 and 13). Subsequently, the removal of the bone lid took place using a chisel. The detached bony lid (Fig. 6) was being kept in physiological saline solution during the operation. The enucleation of the cyst in the first case was performed in the usual manner (Fig. 7). In the second case, the root apex was removed by 2mm at least in order to eliminate the apical canal delta. The apicoectomy was not followed by retrograde filling due to the difficulty of access to the surgical area (Fig. 14). Emphasis was given however to the quality of root filling. The resection angle was approximately equal to 100. The procedures were completed with the relocation of the bony lid on its original position (Figs. 8 and 15). In both cases, the native bone graft was stabilized without sutures since the bony lid was slightly bevelled, so that the later be able to apply as an inlay autogenous bone graft. After the operation was completed, the mucoperiosteal flap was sutured with 4.0 mattress sutures (Figs. 9 and 16). The patients were subscribed the routine postoperative medication. 3 months later, in both cases no clinical symptoms or signs were found and the follow-up CT scan images revealed completely integration of the bony lids (Figs. 10 and 17).
Discussion
The main advantage of the osteoplastic method over the conventional approach is the maintenance of the buccal compact bone plate integrity12. Replacement of the buccal compact bone minimizes dimensions of the remaining bone cavity. Filling of the cavity with any bone graft material is not always necessary, and it depends on
Figure 17. 3-months follow up CT scan image
120 Stelios Karamanis et al.
the size of the remained defect. In general, if the defect size is estimated to be small, the latter may be left to heal spontaneously, either a conventional prosthesis is to be placed or an implant supported one. On the contrary, if dimension of the remained defect is not negligible, the use of autologous bone and bone substitute is proposed. This is particularly important when the bone segment has a small thickness14. Additional advantages are good vision and access in the lower molar region, and creation of a bone boundary which may be helpful in containing any haematoma and allowing primary bone healing15. There are some conditions that should be always taken into consideration. The incision must be generous and made from the canine tooth to the wisdom tooth area. It also has to be fine and made through the compact bone to the trabecular bone. Caution must be taken regarding the possible buccal location of the mandibular canal. The CT scan examination in such cases may be helpful. The initial stability of the bony lid must be sufficient. Since the bony lid must be chiseled, some patients under regional anaesthesia may find it quite disagreeable15. In the case of apicoectomy, the integrity of bony window depends, apart from the aforementioned factors, also on the quality of root filling and the absence of unfilled canals or isthmuses. In this respect, the root apex is supported to be removed by 2mm7. The necessity of retrograde filling remains controversial. Some authors prefer root canal filling and resection alone, without even smoothing the exposed gutta-percha1,11. Some others find that retrograde root filling improves apical sealing18,23. In general, if the access for retrograde filling is limited but root canal is completely filled, this may result in long term clinical success. In case of retrograde filling the cavity must be at least 3mm deep and the filling material as bacteria-proof as possible10. The angle of resection is supported to be 100approximately25. Finally, it is supported that avoiding bacterial re-infection from the root canal is far more important than complete curettage, since remaining inflammatory tissue is intergraded in the granulation tissue of the healing process. So, complete curettage can be omitted if anatomical structures are at risk20. Bony lid approach is likely to present some complications. The clinicians should be aware of possible injury to adjacent anatomical elements (nerves, tooth roots) due to poor preoperative planning. Furthermore, fracture of the bone segment during reposition or accidental drop into the bone cavity during the healing period may occur. Infection and necrosis of the avascular replanted bony lid is also a possible risk14,15. Considering limitations of classic bony lid approach exposed above, access to lower molar region was proposed via trephining. If the distance between the roots is small, a burr of 10-12mm in diameter should be used. If the distance between the apexes is greater, trephination must be performed twice, once mesial and once distal to
the apexes using burr diameter of 4-6mm. The advantages of this modified technique are easier surgical procedure compared to the traditional one, significant reduction of post-operative pain due to the shorter and easier operation and significantly quicker consolidation of graft material in the bone defect. However, the risk of nerve damage remains, and there is also the disadvantage of poorer view of the surgical field compared to the traditional bony lid method2. Many studies have shown that the use of bony lid method resulted in faster bone regeneration without connective tissue ingrowth compared with the conventional approach15,17,22. It is worth mentioning that in less than 2% of patients wound dehiscence occurred with contamination of the inlay bone graft and subsequent wound revision15. In both the presented cases, it was estimated that the use of an electro-powered MicroSaw instead of continuous drilling of the bone with burs offers advantages as regards the accuracy of replacement and stabilization of the bony lid. However, further investigation is required to support the results of this report despite the promising clinical outcome.
References
1. Bramwell JD, Hicks ML. Sealing ability of four retrofilling techniques. J Endond, 1986; 12:95-100. 2. Buchter A, Kleinheiz J, Joos U. Wurzelspitzenresektion unterer molaren ber eine trepanbohrung. Quintessenz, 2002; 53:695-700. 3. Buser D, Dula K, Belser UC, Hirt H-P, Berthold H. Localized ridge augmentation using guided bone regeneration. I. Surgical procedure in the maxilla. Int Periodontics Restorative Dent, 1993; 13:29-45. 4. Buser D, Dula K, Belser UC, Hirt H-P, Berthold H. Localized ridge augmentation using guided bone regeneration. II. Surgical procedure in the mandible. Int Periodontics Restorative Dent, 1995; 15:11-29. 5. Drke B. Osteoplastic procedure for cystic processes in posterior mandibular region. ZWR, 1990; 99(12):957, 959960. 6. Gonzalez Ortin M, Argudo Marco F. Radiographic advantages of the use of an osteoplastic technique in classical surgery of the maxillary sinus. An Otorrinolaringol Ibero Am, 1983; 10(2):107-113 (in Span) 7. Gutmann JL, Harrison JW. Posterior endondontic surgery: anatomical considerations and clinical techniques. Int Endod J, 1985; 18(1):8-34. 8. Feldmann H. Osteoplastic operation of maxillary sinus. Laryngol Rhinol Otol (Stuttg), 1978; 57(5):373-378. (in German) 9. Hardy JM, Montgomery WW. Osteoplastic frontal sinusotomy: an analysis of 250 operations. Ann Otol Rhinol Laryngol, 1976; 85(4 Pt 1):523-532.
Balk J Stom, Vol 16, 2012 10. Johnson BR. Considerations in the selection of a root-end filling material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1999; 87:398-404. 11. Kaplan SD, Tanzilli JP, Raphael D, Moodnik RM. A comparison of the marginal leakage of retrograde techniques. Oral Surg Oral Med Oral Pathol, 1982; 54:583585. 12. Khoury F. A new technique for periapical curettage of lower molars. Acta Odontol Stomatol, 1986; 154:181-186 (in French) 13. Khoury F, Happe A. Soft tissue management in oral implantology: a review of surgical techniques for shaping an esthetic and functional peri-implant soft tissue structure. Quintessence Int, 2000; 31:483-499. 14. Khoury F, Hemprich A, Sass T. Use of free bone graft in various surgical procedures for the mandible. Dtch Z MundKiefer-Gesichtschir, 1985; 9:298-304 (in German) . 15. Khoury F, Hensher R. The bony lid approach for the apical root resection of lower molars. Int J Oral Maxilofac Surg, 1987; 16:166-170. 16. Khoury F, Antoun H, Missika P. Bone Augmentation in Oral Implantology. New Malden, UK: Quintessence Pub Co Ltd, 2007; pp 75-212, 299-320, 341-372. 17. Khoury F, Sass T. Methods and results of a replantable bone lid in the apicectomy of lower molars. Dtch Z Mund-KieferGesichtschir, 1986; 10:124-129 (in German) 18. King KT, Anderson RW, Pashley DH, Pantera EA Jr. Longitudinal evaluation of the seal of endodontic retrofillings. J Endod, 1990; 16:307-310.
Bony Lid Approach in Dentoalveolar Surgery 121 19. Lasaridis N, Zouloumis L, Antoniadis K. Bony lid approach for apicoectomy of mandibular molars. Aust Dent J, 1991; 36(5):366-368. 20. Lin LM, Gaengler P, Langeland K. Periradicular curettage. Int Endod J, 1996; 29:220-227. 21. Lindorff HH. Surgery of the endogenic-deseased maxillary sinus: Technique and experiences with the bone cover method. HNO, 1985; 33(9):416-421 (in German) 22. Schmidt J. Erfahrung mit der Knochendeckelmethode nach Khoury zur Wurzelpitzenresextion unterer molaren in der oralchirurghichen praxis. Quintessenz, 1990; 41:1263-1270. 23. Truggle ST, Anderson RW, Pantera EA Jr, Neaverth EJ. A dye penetration study of retrofilling materials. J Endod, 1989; 15:122-124. 24. von Arx T. The tooth apex resection of molars. Schweiz Monatsschr Zahnmed, 1999; 109(9):916-929. 25. Zuolo ML, Ferreira MOF, Gutmann JL. Prognosis in periradicular surgery: a clinical prospective study. Int Endod J, 1991; 33(2):91-98.
Correspondence and request foorr offprints to:

Stelios Karamanis G.Papazoli 3 546 30 Thessaloniki Greece E-mail: karamaniss@yahoo.gr
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Technique of Frenectomy of Labial Fraenum with Combined Osteotomy at Intermaxillary Suture

SUMMARY
S. Dalampiras, C. Boutsiouki School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece
Introduction: Maxillary midline diastema is often associated with an abnormal labial fraenum. Labial frenectomy is a common surgical procedure and is usually combined with orthodontic therapy for paediatric patients. Methods and Results: This case report describes the clinical condition of a 14 year old patient with hypertrophied labial fraenum and maxillary midline diastema. The treatment included frenectomy with osteotomy combined with orthodontic therapy. Conclusions: When an abnormal labial fraenum consists of fibrous attachment inserting into the intermaxillary suture, frenectomy accompanied by osteotomy seems to be the treatment of choice to prevent post-treatment relapse.
Keywords: Frenectomy; Osteotomy; Intermaxillary suture; Maxillary midline diastema
Introduction
Maxillary labial fraenum is a normal, triangular, anatomic structure in oral cavity, extending from maxillary midline gingival area into the vestibule and mid-portion of the upper lip1. Sometimes it is present as a thick, broad, fibrous attachment (called abnormal fraenum). Depending on the level of gingival insertion2 and the extent of trans-septal fibres chain disruption3, this situation may lead to maxillary midline diastema preservation at a space-prone dentition3. The diastema is termed developmental as it can often fully or partially close after eruption of permanent lateral incisors and canines4 in absence of pathological aetiology. But a wider intermaxillary suture accompanying the abnormal fraenum sometimes implicates aetiology of diastema preservation1. If intermaxillary suture persists due to insufficient compressive force during canine eruption, or due to trans-septal fibres insertion5, or if fraenum consists of dense collagen fibres3,6, diastema closure will relapse. Initial diastema size, familial history and spacing in dentition are mentioned as significant pretreatment factors for possible relapse7. In order to avoid post-treatment complications7, frenectomy combined with osteotomy is advised5.
Case Report
A 14-year-old patient was referred by the orthodontist for management of labial fraenum (Fig. 1, left). Clinical examination revealed the presence of an abnormal, hypertrophied labial fraenum and midline diastema of about 2 mm (Fig. 1, left). Blanch test was positive3. Radiographic examination exhibited a V-shaped radiolucency in crestal bone between central incisors7. The need for treatment was clearly guided by orthodontists instructions for combination of frenectomy with osteotomy. Surgical procedure was performed under local anaesthesia (lidocaine with 1:200.000 epinephrine). Technique included gaining access to intermaxillary suture by labial rhomboidal incision with a scalpel, which combined removal of labial fraenum by dissection of fibrous tissue attached to the upper lip (Fig. 1, right). Interdental papilla was not included in the incision in terms of better aesthetic results. Osteotomy was performed at low speed with a cylindrical bur, under continuous irrigation with sterile water. Labial and palatal maxillary bone cortex was included, leaving palatal periosteum intact. The surgical procedure resulted in local separation of right and left maxilla at width of bur (1.6 mm - 2 mm) and at 5 mm height, starting from crestal
Frenectomy with Combined Osteotomy 123
bone ridge and ending at cervical third of maxillary bone (Fig. 1, right). Therefore, trans-septal fibre attachment was destroyed. Sutures with 3-0 silk were made at upper lip area, while gingival area was covered with gingival
dressing (Septo-pack, Septodont). Analgesics and 0.2% chlorhexidine mouthwash were prescribed for 5 days. After 10 days healing was uneventful, orthodontic treatment started and is still ongoing.
Figure 1. Left: Clinical and radiographic examination. Clinical examination reveals abnormal fraenum and midline diastema preservation after lateral incisors and canines eruption. Radiographic image before intervention, indicating width of intermaxillary suture and V-shaped radiolucency between maxillary central incisors, possibly due to fraenum fibre insertion. The gap is broader at the cervical third of the suture Right: Immediate inter-surgical view. Excision of the fraenum creates rhomboidal wound. Radiographic image shows the extent of bone removal, which is clearly guided by the need to eliminate fibrous attachment into the intermaxillary suture
Discussion
Management of maxillary midline diastema can be treated with orthodontics, restorative dentistry, surgery and with combinations of the above. The ideal treatment should emphasize on the aetiology and on long-term preservation of the therapeutic results, as it is noted that relapses were twice as great in patients with abnormal fraenum1.
Diastema treatment with frenectomy, fixed orthodontic appliance and retainer, produces more stable results, compared to treatment without frenectomy6,8. Combination of frenectomy with osteotomy results in stability in orthodontic closure of midline diastema5 as resistance against closure from alveolar bone is eliminated9. Osteotomy results in de-cortication of intermaxillary suture and elimination of possible transseptal fibres penetration5. However, trans-septal fibres can
124 S. Dalampiras, C. Boutsiouki
Balk J Stom, Vol 16, 2012 4. Weyman J. The incidence of median diastemata during the eruption of the permanent teeth. Dent Pract, 1967; 17:276-278. 5. Kraut RA, Payne J. Osteotomy of intermaxillary suture for closure of median diastema. J Am Dent Assoc, 1983; 107:760-761. 6. Ziemba Z. Histomorphologic evaluation of upper lip frenum in relation to the method of treating diastema. Ann Acad Med Stetin, 2003; 49:353-365. 7. Shashua D, Artun J. Relapse after orthodontic correction of maxillary median diastema: A follow-up evaluation of consecutive cases. Angle Orthod, 1999; 69(3):257-263. 8. Antoni R, De Angelis D, Gravina GM, Accivile E. The superior median frenulum. Surgical-orthodontic treatment of a recurrence. Clin Ther, 1989; 130(2):95-100. 9. Bell WH. Surgical-orthodontic treatment of interincisal diastemas. Am J Orthod, 1970; 57:158-163. 10. Stubley R. The influence of transseptal fibers on incisor position and diastema formation. Am J Orthod, 1976; 70(6):645-652.
be reformed and create an elastic chain which preserves tooth position and eliminates chance of displacement1,10. Concerning gingival tissue aesthetics, in this case interdental papilla was not violated and satisfying aesthetic results are expected.
Conclusions
In cases of midline diastema combined with abnormal labial fraenum and a radiographically diagnosed persistent intermaxillary suture, frenectomy with osteotomy seems to be the treatment of choice.
References
1. Edwards JG. The diastema, the frenum, the frenectomy. A clinical study. Am J Orthod, 1977; 71:489-508. 2. Diaz-Pizan ME, Lagravere MO, Villena R. Midline diastema and frenum morphology in the primary dentition. J Dent Child (Chic), 2006; 73(1):11-14. 3. Ferguson MWJ. Pathogenesis of abnormal midlines spacing of human central incisors. Br Dent J, 1983; 154:212-218.

Boutsiouki Christina Kallidopoulou 12, Faliro 54642, Thessaloniki, GREECE E mail: bou_chri@yahoo.gr
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Fracture of the Maxillary Tuberosity: A Case Report

SUMMARY
Biljana Evrosimovska, Boris Velickovski, Zaklina Menceva St Cyril and Methody University PHO University Dental Clinical Centre St. Pantelejmon, Faculty of Dentistry Clinic for Oral Surgery Skopje, FYROM
In everyday dental practice, during typical tooth extraction or oral surgery, sometimes unexpected complications happen. Concerning extraction of maxillary molars, fracture of the maxillary tuberosity is among the most delicate. This fracture is a serious complication; depending on its dimensions, it can present surgical, as well as prosthetic problem. From the prosthetic point of view, anatomic area of maxillary tuberosity is especially important for providing desired retention and stability of upper denture. The aim of this paper is to show the surgical therapeutic approach to the treatment of the maxillary tuberosity fracture occurred during extraction of the maxillary second molar. In particular case, after complete intraoral examination and X-ray analysis, possible fracture of tuber maxillae could be predicted. Dentist should mention this to the patient before starting the procedure and try to avoid it with cautious and professional work. Otherwise, this can be a matter of criminal act, with possible legal consequence.
Keywords: Maxillary Tuberosity, fracture; Maxillary Molars, extraction
Introduction
In everyday dental practice, during typical tooth extraction or oral surgery, sometimes unexpected complications happen. Peri-operative complications can happen due to multiple causes, but unfortunately, the main cause is still the iatrogenic factor. Some of these complications happen relatively often, and some extremely rarely. During extraction of maxillary molars many complications can happen, and fracture of the maxillary tuberosity is among the most delicate. This fracture is a serious complication; depending on its dimensions, it can present surgical, as well as prosthetic problem. From the prosthetic point of view, anatomic area of maxillary tuberosity is especially important for providing desired retention and stability of upper denture. There are numerous circumstances that could increase the risk of appearance of this peri-operative complication1,8,11: weakness of the tuber maxillae as a result of the strong maxillary sinus pneumatisation, low resistance of bone in this area as a result of impacted or
semi-impacted maxillary third molar, solitary maxillary molar, maxillary molar with extremely divergent or hypercementotic roots or anomaly of the number of roots, and tooth germination - fusion of second and third maxillary molar. As a result of smaller elasticity of bone tissue, the risk of maxillary tuberosity fracture in older patients increases. In addition, the risk of this complication increases during ankylosis of maxillary molars, which gives resistance to tooth luxation movements during extraction2. In some particular cases, genesis of this complication can indicate a therapeutic mistake (vitium artis). Namely, as a result of the uncontrolled force, as well as the use of inappropriate instrument during extraction or inappropriate use of elevator, overly deep or careless application of the forceps are possible factors of additional risk for emergence of this complication4. Diagnosis of the maxillary tuberosity fracture assumes inspection, palpation and analysis of the panoramic X-ray (orthopantomogram). Existence of deformity is appointed with inspection during intraoral examination. Orthopantomogram confirms the diagnosis
126 Biljana Evrosimovska et al.
by finding of fracture line, which can be palpated from the buccal or palatal side. Fracture of the maxillary tuberosity can be confirmed since the time of performing the extraction, because together with the forceps and tooth, the whole tuber maxillae displaces. Oroantral communication usually accompanies this complication6. The aim of this paper is to show the surgical therapeutic approach to the treatment of the maxillary tuberosity fracture occurred during extraction of the maxillary second molar.
As the fractured tuberosity could not be repositioned, surgical removal of the fractured tuberosity together with both teeth was performed (Fig. 2). During surgery, the oroantral communication was confirmed due to the fracture of the maxillary sinus walls (Fig. 3). Due to soft tissue injury, the buccal adipose corpus could be seen (Fig 4). In the same act, after levelling bone edges and irrigation of the wound, it was completely sutured.
Case Report
A 45-year old female patient reported pain in the area of second and third maxillary molar to her private dentist. Beyond the clinical examination, without taking an X-ray, extraction of the third maxillary molar was performed by the dentist. However, after unsuccessful attempt of tooth removal, the patient was sent to the Clinic of oral surgery at the University dental clinical centre Sts. Pantelejmon in Skopje. Patient had not been informed about the previous nascent complication. Furthermore, the dentist did not point out nor specify kind of complication. Patient was accepted the same day at the Clinic for oral surgery. From the dental history, we couldnt find out that fracture of the maxillary tuberosity happened as the patient was not informed about that. However, during intraoral examination mobility of the bone and soft tissue in the area of the maxillary tuberosity could be noted. Based on affirmative intraoral clinical finding, the panoramic X-ray was made, which disclosed the existence of a fracture line at the area of right maxillary tuberosity, expanding to the space between second and third maxillary molar (Fig. 1).
Figure 2. The removed fragment of the maxillary tuberosity, together with teeth
Figure 3. The created oroantral communication after the removal of maxillary tuberosity
Figure 1. Orthopantomogram X-ray of the patient showing the fracture line in the area of maxillary tuberosity, performed during the extraction of third molar
Figure 4. Intraoral view of the exposed buccal adipose corpus
Fracture of the Maxillary Tuberosity 127
After surgery, the usual postoperative instructions were suggested, as well as the food regime. In addition, antibiotic therapy (Neloren 600mg, twice a day for 5 days) and corticosteroids (Dexamethason 4mg, once daily for 3 days) were ordered to the patient. Postoperative period was characterised by intraoral haematoma (Fig. 5) and extraoral presence of oedema (Fig. 6), as a result of the tuberosity fracture and long lasting of surgery.
Figure 5. Postoperative intraoral haematoma
Figure 6. Postoperative extraoral oedema
alveolar process, the fracture line, the presence of the antagonistic tooth, etc1,11. In certain circumstances, after the detailed intraoral examination and analysis of X-ray, the possibility for the fracture of the maxillary tuberosity during tooth extraction can be foreseen, and duty of the dentist is to inform the patient in advance, but caution and professionalism during the procedure must be maintained10. If the maxillary tuberosity fracture nevertheless happens, the dentist must diagnose the complication and inform the patient about it. Otherwise, this managing could be considered as a criminal act of the neglectful dentist, with low consequences9. There are several possibilities for treatment of the maxillary tuberosity fracture. If the soft tissue is not harmed, and the fractured tuberosity is still attached to the periosteum, tooth could be carefully detached from the bone and removed, and the bone fragment immobilized. If the tooth was without any pathological changes (extraction from orthodontic reasons), it can be maintained, and the fractured tuberosity repositioned and immobilized. At the same time, extraction should be postponed for 6-8 weeks, and afterward extraction of the tooth should be performed surgically circumstances7. If the fractured bone fragment is detached from the soft tissue, it should be separated and removed, the sharp edges smoothed, and soft tissue sutured. Once oroantral communication is present, surgical closure is obliged7. Regardless the procedure, antibiotic cover is mandatory in order to prevent secondary infection. Best therapeutic option is, certainly, prevention of provoking such a complication, applying a detail clinical examination, proper X-ray analysis, and the use of adequate tooth extraction technique. If during the tooth extraction certain degree of mobility of the maxillary tuberosity is established visually and tactually, it is especially important to stop with further extraction and try to separate the roots, which should reduce the possibility of this complication occurrence. Fracture of the maxillary tuberosity is a serious complication that creates difficulties for the subsequent prosthetic rehabilitation. Moreover, it may provoke serious secondary complications (bleeding, maxillary sinus infection, etc). Dentist must estimate and predict its possible creation and refer the patient for oral-surgery intervention.
Discussion
The fracture of the maxillary tuberosity is one of the worst peri-operative complications that may happen during tooth extraction in the maxillary molar region5. Several therapeutic procedures can be implemented depending on different factors, such as patient general health and age, the reason for tooth extraction, the existence of oroantral communication, condition of the
References
1. Altu HA, Sahin S, Sencimen M, Dogan N. Extraction of upper first molar resulting in fracture of maxillary tuberosity. Dent Traumatol, 2009; 25(1):1-2. 2. Chrcanovic BR, Freire-Maia B. Considerations of maxillary tuberosity fractures during extraction of upper molars: a literature review. Dental Traumatology, 2011; 27(5):393-398.
128 Biljana Evrosimovska et al. 3. Fragiskos D. Oral Surgery. Berlin, Heidelberg, New York: Springer, 2007; pp 183-184. 4. Joji B, Perovi J. Oralna hirurgija. Beograd: Nauna knjiga, 1994; pp 169-170. (in Serb) 5. Lillich JD. Complications of dental surgery. Vet Clin North Am Equine Pract, 1998; 14(2):399-410. 6. Miloro M. Petersons principles of oral and maxillofacial surgery. 2nded. London: BC Decker Inc, 2004; pp 435-443. 7. Ngeow WC. Management of the fractured maxillary tuberosity: an alternative method. Quintessence Int, 1998; 29(3):189-190. 8. Pievi A, Gavri M, Sjerobabin I. Maksilofacijalna hirurgija. Beograd: Dragani, 1995, pp 18-44. (in Serb 9. Puzovi D, oli S. Sudskomedicinsko tumaenje preloma tubera gornje vilice nastalog prilikom vaenja zuba. Vojnosanit Pregl, 2010; 67(9):777-780. (in Serb)
Balk J Stom, Vol 16, 2012 10. Shan N, Bridgman JB. An extraction complicated by lateral and medial pterygoid tethering of a fractured maxillary tuberosity. Br Dent J, 2005; 198(9):543-544. 11. Todorvi Lj, Petrovi V, Jurii M, Kafediska-Vraar V. Oralna hirurgija. Beograd: Nauka, 2002. (in Serb)

Ass. d-r Biljana Evrosimovska mr. sci. Faculty of dentistry, Department of oral surgery Str. Vodjanska 17 1000 Skopje, FYR Macedonia E-mail: tatijana_78@yahoo.com

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BALKAN JOURNAL OF STOMATOLOGY

Official publication of the BALKAN STOMATOLOGICAL SOCIETY Volume 16 No 2 July 2012

ISSN 1107 - 1141

BALKAN JOURNAL OF STOMATOLOGY

ISSN 1107 - 1141

Address: Faculty of Dentistry Dr Subotia 8 11000 Beograd, Serbia

International Editorial (Advisory) Board

BALKAN STOMATOLOGICAL SOCIETY

BALKAN JOURNAL OF STOMATOLOGY

ISSN 1107 - 1141

BALKAN JOURNAL OF STOMATOLOGY

ISSN 1107 - 1141

Release of Antimicrobial Agents from 84 Glass Ionomer Cements

Biophysical Principles of the AcryLock Attachments Use in 98 Contemporary Prosthetic Dentistry

Intraoral Ceramic Restoration Repair Techniques: Report of 3 Cases 103

Balk J Stom, Vol 16, 2012

Bony Lid Approach in Dentoalveolar Surgery: Report of 2 Cases 116

BALKAN JOURNAL OF STOMATOLOGY

ISSN 1107 - 1141

Langerhans Cell Histiocytosis: Its Oral and Maxillofacial Dimension

LITERATURE REVIEW (LR) Balk J Stom, 2012; 16:69-73

Role of Langerhans Cells in Oral Pathology

Balk J Stom, Vol 16, 2012

Incidence and Dental Predominant Sites

Balk J Stom, Vol 16, 2012

Langerhans Cell Histiocytosis 71

Diagnosis - Radiographic Image

Balk J Stom, Vol 16, 2012

Balk J Stom, Vol 16, 2012

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ORIGINAL PAPER (OP) Balk J Stom, 2012, 16:74-78

Material and Methods

Balk J Stom, Vol 16, 2012

0.55 0.11 0.72 0.09

0.11 12.17 <0.001 0.09 10.30 <0.001

0.11 16.10 <0.001 0.09 16.15 <0.001

76 Maja Pandilova et al.

Balk J Stom, Vol 16, 2012

Balk J Stom, Vol 16, 2012

Application of Ascorbic Acid and Glutathione by Iontophoresis 77

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Material and Methods

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Complex Antioxidant Treatment of Dental Fluorosis 81

82 Ludmila Gavriliuc et al.

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Release of Antimicrobial Agents from Glass Ionomer Cements

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Antimicrobial Agents Release from GIC 85

Materials and Methods

Conventional ChemFlex glass-ionomer cement

86 Aleksandar Dimkov et al.

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