Smile Dental Journal Volume 4 Issue 3

Dr.
Layla Abu-Naba'a
BDS, MFD, RCS, PhD Prosthodontics
Dr. Hazem Al-Ahmad
BDS, MSc, FDSRCS Maxillo-Facial Surgery
Dr. Zaid Al-Bitar
BDS, MSc, MOrth, RCS Orthodontics
Dr. Hatem Al-Rashdan
BDS, MSc, Jordanian Board of Maxillo-Facial Surgery
Dr. Majd Al-Saleh
BDS, DDS, MSc Pediatric Dentistry
Dr. Hisham Al-Shorman
BDS, PhD Periodontology
Dr. Ahmad Al-Tarawneh
DDS, M.Clin.Dent, Jordanian Board of Orthodontics
Dr. Hayder Al-Waeli
BDS, MSc, Jordanian Board of Periodontology
Dr. Moeen Al-Weshah
BDS, MSc, Jordanian Board of Endodontics
Dr. Muayad Assaf
BDS, MSc Endodontics
Dr. Bader Eddin Borgan
BDS,MDS, MOrth, RCSEd Orthodontics
Dr. Manal Azzeh
BDS,MSc, Jordanian Board of Periodontology
Dr. Iyas Darweesh
BDS
Dr. Moh'd Hammo
BDS, DESE Endodontics
Dr. William Khairallah
DrCD, CESE Restorative & Esthetic Desntistry
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BDS,MSc, Jordanian Board of Orthodontics
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BDS, MSc Pediatric Dentistry
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Pediatric Dentistry
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Dr. Nayef Younes
BDS, MSc, Jordanian Board of Endodontics
Dr. Muna Al-Ali
BDS, MFDS
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September 2009
Volume 4, Issue 3
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Dr. Mohammed Qasim Al Rifaiy
Pat ient s Sat isfact ion Wit h Removable Part ial Dent ures 50
Dubai, UAE / 06 07 November 2009
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Dent al Facial Cosmet ic Int ernat ional Conference
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Funct ion, Aest het ics and Biomimet ics in t he
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Dr. Evgeny Zhdanov, Dr. Alexey Khvat ov & Ilia Korogodin
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4 Smile Dental Journal Volume 4, Issue 3 - 2009
Edi t or i al
A vaccine against 2009 H1N1 f u is being produced. The FDA
announced on September 15
th
that it has approved four vaccines
against the 2009 H1N1 inf uenza virus. Based on preliminary data from
adults participating in multiple clinical studies, the 2009 H1N1
vaccines induce a robust immune response in healthy adults 8-10 days
after a single dose, as occurs with the seasonal inf uenza vaccine.
At this time, there are few cases and few deaths reported in people older
than 64 years old, which is unusual when compared with seasonal f u
as this age group is considered a high risk condition. However, pregnancy
and other previously recognized high risk medical conditions from
seasonal inf uenza appear to be associated with increased risk of
complications from this 2009 H1N1. These underlying conditions
include asthma, diabetes, suppressed immune systems, heart disease,
kidney disease, neuromuscular disorders and pregnancy.
People infected with seasonal and 2009 H1N1 f u may be able to infect
others from 1 day before the symptoms appear to 5-7 days after. This
can be longer in some people, especially children and people with
weakened immune systems.
CDC recommends the use of the antiviral drugs Oseltamivir or Zanamivir
this season. Antiviral drugs are medicines that f ght against the f u
by keeping f u viruses from reproducing in the body; they may also
prevent serious f u complications.
Inf uenza virus is destroyed by heat (75-100C). In addition, several
chemical germicides, including chlorine, hydrogen peroxide, detergents,
iodine-based antiseptics and alcohols are ef ective against human
inf uenza viruses if used in proper concentration for a suf cient length
of time.
Arthur A. Dugoni Pacif c School of Dentistry Infection Control Committee
released the following protocol for managing dental patients with
conf rmed or suspected respiratory infection in accordance with the
United States Centers for Disease Control and Preventions (CDC)
guidelines:
Patients who present with acute respiratory symptoms consistent with
infection (Fever, cough, fatigue, and sore throat) should be asked to
delay all routine dental treatment until their current illness is resolved
and the patient is symptom free. For patients who present with
conf rmed or suspected inf uenza A (H1N1) and require emergency
dental care, the following precautions should be followed:
* Limit treatment provided to the minimum necessary to reduce the
patients pain or oral infection.
* Instruct the patient to wear a surgical mask at all times when not
actively receiving treatment.
* Personnel treating the patient should wear a f tted surgical mask
during patient treatment to prevent contact with contaminated aerosol.
* Minimize the production of aerosols or cough-producing procedures
to the minimum.
While routine and accurate cleaning and disinfection strategies are
applied, and according to CDC, if a patient presents for routine treatment and
has acute respiratory symptoms with or without fever and the dentist
suspects the illness could be due to swine inf uenza (symptoms
include fever, body aches, runny nose, sore t hroat , nausea, or
vomit ing or diarrhea), elective dental treatment should be deferred
and the patient should be advised to contact their general health care
provider. The health care provider will determine whether inf uenza
testing or treatment is needed. If urgent dental care is required and
swine inf uenza A (H1N1) has either been conf rmed or is suspected,
the care should be provided in a facility (e.g., hospital with dental care
capabilities) that provides airborne infection isolation.
Staf experiencing inf uenza-like-illness (ILI) (fever with either cough
or sore throat, muscle aches) should not report to work. Staf who
have dif culty breathing or shortness of breath, or are believed to be
severely ill, should seek immediate medical attention.
Inf uenza A viruses are found in many dif erent animals, including
ducks, chickens, pigs, whales and horses. According to Thacker and
Janke pigs are unusual as they can be infected with inf uenza strains
that usually infect three dif erent species: pigs, birds and humans. This
makes pigs a host where inf uenza viruses might exchange genes,
producing new and dangerous strains. Because pigs are susceptible
to avian, human and swine inf uenza viruses, they potentially may be
infected with inf uenza viruses from dif erent species at the same time.
If this happens, it is possible for the genes of these viruses to mix and
create a new virus. This type of major change in the inf uenza A viruses
is known as antigenic shift. If this new virus causes illness in people
and can be transmitted easily from person to person, an inf uenza
pandemic can occur.
2009 H1N1 (referred to as swine f u early on) is a new inf uenza A virus
subtype causing illness in people. This virus is spreading from person
to person worldwide in much the same way that regular seasonal
inf uenza viruses spread. On June 11, 2009, the World Health Organization
(WHO) announced that the pandemic level of 2009 H1N1 f u had been
raised to its highest level. According to the World Health Organization
(WHO), a pandemic can start when three conditions have been met:
1-Emergence of a disease new to a population
2-Agents infect humans, causing serious illness
3-Agents spread easily and sustainably among humans
Spanish Flu which had spread to become a world-wide pandemic on
all continents in 1918, and eventually infected an estimated one third
of the worlds population, killing about 50 million people, was
identif ed as a subtype of H1N1 virus.
Spread of 2009 H1N1 virus is thought to occur in the same way that
seasonal f u spreads. Flu viruses are spread mainly from person to
person through coughing or sneezing. Sometimes people may
become infected by touching a surface or an object with f u viruses
on it and then touching their mouth or nose. Studies have shown that
inf uenza virus can survive on environmental surfaces and can infect
a person for 2 to 8 hours after being deposited on that surface. 2009
H1N1 viruses are not spread by food. You cannot get infected with
novel HIN1 virus from eating pork or pork products.
The symptoms of 2009 H1N1 f u include fever (Its important to note
that not everyone with f u will have fever), cough, sore throat, runny
nose, muscle aches, headache, chills and fatigue. A signif cant number
of people who have been infected with this virus also have reported
diarrhea and vomiting. While most people who have been sick have
recovered without needing medical treatment, hospitalization and
death from infection with this virus have occurred.
One thing that appears to be dif erent from seasonal inf uenza is that
adults older than 64 years do not appear to be at increased risk of
2009 H1N1 related complications. Centers for Disease Control and
Preventions (CDC) laboratory studies have shown that no children and
very few adults younger than 60 years old have existing antibody to
2009 H1N1 f u virus; however, about one-third of adults older than 60
may have antibodies against this virus.
Swine Flu:
What should
a Dentist Know
Dr. Issa Sal em Bader
Edi t or-In-Charge
Smi l e Dent al Jour nal
Visit www.smile-mag.com or Smile Dental J ournal page on facebook for updates
D
e
c
e
m
b
e
r
14 - 16
17
th
Scientific International
Conference of Syrian Dental
Association
Damascus, Syria
06 - 07
1
st
Dental Facial Cosmetic
International Conference
Dubai, UAE
www.cappmea.com
15 - 17
International 37
th
Expodental
Rome, Italy
www.expodental.it
10 - 12
1
st
Dubai International
Implant Summit
Dubai, UAE
www.diis.ae
28 Nov - 02 Dec
2009 Greater New York
Dental Meeting
New York, USA
www.gnydm.com
11 - 13
The E.D.A 14
th

International Dental
Congress
Cairo, Egypt
www.eda-egypt.org
27 - 29
5
th
Bahrain Dental Society
Conference 2009
Bahrain
www.bahrain-dental.com
O
c
t
o
b
e
r
N
o
v
e
m
b
e
r
03 - 06
1
st
Pan Arab &
2
nd
Jordanian
Endodontic
Conference
Amman, Jordan
www.jda.org.jo/endo
13 - 14
1
st
Qatar International Conference
Doha, Qatar
Cal endar of Event s
Evaluation Of Some Of The Clinical Variables Affecting
Patients Satisfaction With Removable Partial Dentures
Abstract
Purpose: The purpose of the study was to examine the clinical variables such as age, gender,
esthetic, comfort, speech and mastication on clinical acceptability and patient satisfaction
associated with wearing removable partial dentures.
Materials and Methods: Sixty-six patients with 52 maxillary and 34 mandibular removable
partial dentures (RPDs) were evaluated for satisfaction with their prostheses using visual
analogue scales (VAS). The dif erences between two independent categories such as genders
and dentures replacing mandibular or maxillary arches were tested for signif cance using Mann-
whitney U-tests. Tests for signif cance of dif erence in the Kennedy classif cation consisting of four
categories and opposing arch dentition with three categories were made by Krushkal Wallis
analysis of Variance tests. Spearman rank correlation coef cients between age of patients and
retention / stability of RPDs and the VAS scores were determined to test positive or negative
correlations.
Results: The dif erence between males and females for the mean scores for comfort was
signif cant (p < 0.05). Aesthetics had a signif cant negative association with patients age. There
were no signif cant dif erences between VAS scores and other clinical variables.
Conclusion: The dif erence between males and females for comfort was signif cantly dif erent
(p < 0.05). There was a signif cant negative association between aesthetic and age. The dif erence
among other VAS scores and other clinical variables were not signif cant.
Key words: Prosthdontics, Removable partial denture, Visual Analogue Scale.

Introduction
Removable partial dentures (RPDs) are one of the prosthetic treatment options for partially
edentulous patients. Success of RPD treatment is often judged dif erently by dentists and
patients. Dentists consider dentures to be successful when they meet certain technical standards
whereas the patients evaluate their prostheses from the view point of their personal
satisfaction.
1,2
Patients satisfaction with RPDs seems to have multicausal factors.
1
The risk of low
patients acceptance has been associated with patients demographic variables including age,
gender, previous denture experience and clinical variables such as pain, comfort, stability and
design of dentures.
2-7
According to Wakabayashi et al.
4
and Frank et al.
8-9
, dissatisfaction with RPDs
was higher in patients who had no prior experience with dentures. Other similar studies
4,10

demonstrated that patients younger than 60 years and in poor health showed lower acceptance
to RPDs. On the contrary, Knezovic et al.
5
found no signif cant dif erence in patients assessment
of the quality of their RPDs among age groups, previous denture experiences and type of
opposing dentition.
Frank et al.
8
reported that a majority of patients treated with RPDs, in private practices, were
satisf ed with their prostheses. However, even if the RPDs were constructed according to basic
principles and concepts recommended by the Academy of Prosthodontics
10
, 10% of patients
were dissatisf ed.
9
One study
11
reported that the proportion of patients dissatisf ed with their
RPDs ranged from 3% to 4%. Thus, conf icting views existed on the inf uence of various clinical
factors associated with the satisfaction or dissatisfaction with RPDs. Some of the clinical factors
that are indirectly related to feeling of dissatisfaction with RPDs include age, sex, health, prior
denture experience, esthetics and personality of patient. Dissatisfaction has also been reported
to be associated with biomechanical factors of RPDs including retention / Stability, type of
opposing dentition, pain, and ability to chew and speak. This study examined seven aspects of
Dr. Mohammed Qasim Al Rifaiy
BDS, Cert (Prosth), MSc
Chairman of Prosthetic
Dental Sciences Department
College of Dentistry
King Saud University
drrifaiy64@yahoo.com
Pr ost hodont i c s
clinical variables and evaluated them relative to the factors
associated with dissatisfaction with removable partial denture
treatment.
Materials and Methods
The subjects were selected from patients who were treated at
the Prosthodontic Department BLINDED. Maxillary and
mandibular clasp retained cast partial dentures were made by
the students under the supervision of one instructor. Patients
with previous denture experience, pain in the remaining teeth,
and who had recent extraction with incomplete healing and
history of temporomandibular joint disorders were not
included in the study.
Sixty-six subjects consisting of 38 males and 28 females with
a mean age of 64.1 years participated in this study. Fifty-two
maxillary and 34 mandibular RPDs were constructed by
students supervised by one instructor (Table 1). The RPDs
replacing partially edentulous arches were divided into four
groups according to Kennedy classif cation (Class 1 through
Class IV). Modif cation spaces and their numbers were not
considered. The RPDs were further classif ed according to arch
replacement as mandibular and maxillary RPDs. Opposing arch
dentition were classif ed into three categories as natural teeth
which included missing teeth replaced by f xed partial denture,
RPD or complete denture. Complaints of pain due to over
extension of denture base were relieved. The opposing
dentitions were recontoured to develop occlusal harmony by
recall appointments.
The patients were recalled after a period of one year for
evaluation. The stability and retention of the RPDs were
evaluated by one investigator using the index provided by
Kapur
12
modif ed by Wakabayashi et al.
4
(Table 2). Each single
prosthesis was evaluated by a sum score of retention and
stability from 0 to 5 points by one investigator.
Patients were instructed to complete a questionnaire regarding
name, age, gender and chronic diseases. In the other part of
the questionnaire, they were required to grade their RPDs
depending on the level of satisfaction with regards to
aesthetics, pain, comfort, speech ability, mastication ability and
general satisfaction using a visual analogue scale (VAS).
The VAS scale consisted of a 100 mm line with the ends
def ning the grade of feeling between the phases. The left end
of the line represented a satisfactory response and the right
end of the line represented an unsatisfactory response. The
patient registered his/her assessment with a pencil mark across
the line at a point that corresponded to his/her subjective
feelings. Satisfaction was then expressed as the distance in
millimeters from the left end limit to the distance of pencil
mark and represented as the VAS score. A low score
represented a satisfactory feeling and a high score represented
an unsatisfactory feeling.
13,14
The scores for each RPD (maxillary
and mandibular) were separately recorded by one investigator.
The VAS was used in this study because it is easily understood
and is sensitive.
15,16
The authors have noted that Several other
scales are available including behavior rating scale, verbal scale
and combination scale.
The inf uence of clinical variables on the VAS scores was tested
by the non-parametric Wilcoxon rank sum test. Kruskal-Wallis
one-way ANOVA was used to establish the dif erences among
the four Kennedy classif cation partial dentures and among the
three dif erent opposing arch dentitions. To establish positive
or negative correlations between some of the clinical variables
and the VAS scores, the Spearman rank correlation coef cient
test was applied. The tests were conducted at 0.05 level of
signif cance. The data were analyzed with statistical software
SPSS version 11.0 (SPSS Inc.).
Results
Table 3 presents the mean VAS scores for seven clinical
variables. The highest mean score value recorded was for
stability (46.0 mm) and lowest value was for pain (19.6 mm).
A signif cant dif erence (p < 0.05) was recorded between males
and females for comfort VAS scores (Table 3). There were no
signif cant dif erences between males and females with other
VAS scores. There was no signif cant dif erence in VAS rating for
maxillary and mandibular dentures and dentition of opposing
arches (Table 4). The dif erences for Kennedy classif cation were
not signif cant for other VASscores except for esthetics (Table 5).
Patients were dissatisf ed with Kennedy Class IV RPDs
compared with other types of dentures (p < 0.05). The
Spearmans rank correlation coef cient between age and
stability and VAS scores was presented in Table 6. With regards
to esthetics, younger patients recorded signif cant negative
correlation indicating that younger patients were less satisf ed
with Kennedy Class IV RPDs aesthetics compared with older
patients (p < 0.05). Similarly, no signif cant negative association
between stability of RPDs and VAS scores was observed.
Discussion
This study evaluated the relative dif erences in VAS scores for
some of the clinical variables. Patients treated with RPDs
usually complain of pain. However, in this study, the mean VAS
score for pain was the lowest compared to other clinical
variables. The reason for this could be that all the patients who
(Ta b le 1): Dist rib ut io n o f Ag e , Ge nd e r, Ma xilla ry a nd Ma nd ib ula r
RPDs o f Sub j e c t s in St ud y
52 / 34
Num b e r o f p a t ie nt s
22 / 16 30 / 18
64.1 - 8.2 61.2 - 8.3 64.4 - 7.6
40 - 66 46 -64 40 - 66
66 28 38
Ag e ra ng e (ye a rs)
Num b e r o f RPDs (Ma xilla /Ma nd ib le )
Me a n a g e ra ng e + /- SD
To t a l Fe m a le Ma le
(Ta b le 2): Sc o ring Ind ex fo r St a b ilit y a nd Re t e nt io n
0: No st a b ilit y, d e nt ure b a se d e m o nst ra t e s ext re m e ro c king o n
it s sup p o rt ing st ruc t ure s und e r p re ssure .
1: So m e st a b ilit y. De nt ure b a se d e m o nst ra t e s m o d e ra t e ro c king
o n it s sup p o rt ing st ruc t ure und e r p re ssure .
2: Suffic ie nt st a b ilit y d e nt ure b a se d e m o nst ra t e s slig ht o r no
ro c king o n it s sup p o rt ing st ruc t ure und e r p re ssure .
St a b ilit y
Re t e nt io n
0: No re t e nt io n. De nt ure d isp la c e s it se lf.
1: Minim um re t e nt io n. De nt ure o ffe rs slig ht re sist a nc e t o
ve rt ic a l p ull.
2: Mo d e ra t e re t e nt io n. De nt ure o ffe rs m o d e ra t e re sist a nc e t o
ve rt ic a l p ull.
3: Go o d re t e nt io n. De nt ure o ffe rs m a xim um re sist a nc e t o
ve rt ic a l p ull.
participated in this study were relieved of pain by adjusting
their dentures during recall appointments and the patients
were recalled for evaluation after a period of one year. The
f ndings of this study supported the results of Wakabayashi et
al.
4
who investigated the association of clinical variables ef ects
on satisfaction of patients to their prostheses.
In the literature, opinions vary among researchers as to which
scales are more sensitive to expose a change in pain and
discomfort. The dif erent scales include visual analogue scale
13,14
numerical scale, verbal scales and combined scale.
15,17

In this study, visual analogue scale was used because it has
been reported to be superior to the other four behavior rating
scales.
4,16

Comfort indicates absence of any pain and acceptable feeling
with the prosthesis. The VAS scores for comfort for females was
approximately twice than that of males. The gender dif erence
was statistically signif cant (p < 0.05). The f nding was in
accordance with the study of Wakabayashi et al.
4
who also
found that the females showed higher mean value of VAS score
than the males. The most commonly reported causes of
dissatisfaction with RPDs were the lack of stability, f t and
occlusion with opposing teeth. The VAS score for satisfaction
although was higher for females compared with males, the
dif erence was not statistically signif cant which compared
favorably with the results of Wakbayashi et al.
4
and Frank et al.
9
All
other clinical variables with the exception of comfort were not
signif cant.
This study showed that aesthetics had signif cant (p < 0.05)
negative association with younger patients wearing Kennedy
Class IV RPDs (Table 5) which is in agreement with the results of
Jepson et al.
2
and Wakabayashi et al.
4
On the other hand,
Kenozovic et al.
5
had results that seems to contradict. It is
reasonable to assume that younger patients with replacement
of anterior teeth by Kennedy Class IV RPDs would be more
concerned with the colour and arrangement of teeth. The
Kennedy classif cation I, II and III RPDs had no signif cant ef ect
on any other VAS scores of the patients. Furthermore, the
(Ta b le 3): Me a n & St a nd a rd De via t io n Va lue s fo r VAS Sc o re fo r Clinic a l Va ria b le s (m illim e t e r)
Ae st he t ic
Ge ne ra l
St a b ilit y Ma st ic a t io n Sp e e c h Co m fo rt Pa in
Sa t isfa c t io n
Me a n VAS
Sc o re (SD) (+ /- 4.0) (+ /- 4.1) (+ /- 3.4) (+ /- 3.9) (+ /- 3.0) (+ /- 2.7) (+ /-12.8)
41.7 41.6 28.4 46.0 35.6 19.6 35.4
(Ta b le 4): Me a n & St a nd a rd De via t io n Va lue s fo r VAS Sc o re s in Millim e t e rs fo r Ma xilla ry, Ma nd ib ula r RPDs a nd Ge nd e r
Ae st he t ic s
Ge ne ra l
Sa t isfa c t io n
Ma xilla (n= 52)
38.3 ( -5.0) 42.4 ( -5.2) 31.4 ( -4.5) 51.2 ( -4.9) 32.7 ( -5.0) 21.6 ( -5.7) 40.4 ( -4.8)
45.7 ( -6.1) 38.6 ( -5.1) 25.6 ( -4.7) 42.4 ( -6.1) 36.1 ( -4.9) 10.6 ( -4.1) 34.2 ( - 6.0)
D
e
n
t
u
r
e

A
r
c
h
Ma nd ib le (n= 34)
Ma le (n= 38)
45.3 ( -4.8) 41.8 ( -4.9) 29.4 ( -4.1) 47.1 ( -4.2) 40.1 ( -4.3) 19.5 ( -4.1)* 39.1 ( -3.8)
38.0 ( -6.1) 37.9 ( -5.8) 24.8 ( -5.9) 43.8( -6.6) 20.7 ( -5.9) 10.6 ( -2.8)* 32.4 ( -6.1)
G
e
n
d
e
r
Fe m a le (n= 28)
* De no t e s sig nific a nc e d iffe re nc e b e t we e n t he c linic a l va ria b le s. The st a nd a rd d e via t io n num b e rs a re in t he b ra c ke t s.
(Ta b le 5): Me a n & St a nd a rd De via t io n Va lue s fo r VAS Sc o re s in Millim e t e rs fo r Ke nne d y Cla ss I, II, III a nd IV RPDs & Op p o sing De nt a l Arc h De nt it io n
Ae st he t ic s
Ge ne ra l
Sa t isfa c t io n
Cla ss I (n= 44)
36.4( -7.1) 42.3( -8.1) 26.7( -5.1) 48.6( -6.9) 25.9( -4.6) 19.4( -4.3) 20.0 ( -3.2) *
46.9( -5.8) 54.6( -6.2) 32.4( -3.4) 57.6( -6.2) 34.8( -6.1) 20.9 ( -5.0) 44.6 ( /-4.9)*
Cla ss II (n= 21)
Cla ss III (n= 11)
68.7( -21.4) 51.3( -9.4) 37.0( -12.9) 56.8( -7.3) 63.6( -22.3) 29.6 ( -6.7) 78.5( -6.1) *
49.8( -7.4) 34.1( -6.7) 0.9( -0.4) 40.3( -8.2) 51.7 ( -21.9) 5.1( -3.9) 57.6 ( -21.0) *
Cla ss IV (n= 10)
K
e
n
n
e
d
y

C
l
a
s
s
i
f
i
c
a
t
i
o
n
Na t ura l (n= 25)
40.1( -8.) 38.6( -7.4) 22.6( -4.0) 51.3( -6.9) 35.8( -5.0) 10.9( -3.0) 35.1 ( -4.1)
52.3( -7.9) 36.8( -6.1) 38.6( -7.0) 46.6( -6.7) 40.6( -12.7) 26.6( -10.4) 37.8( -13.0)
Pa rt ia l (n= 51)
Co m p le t e (n= 10) 37.6( -10.1) 42.6( -6.8) 26.1( -8.0) 26.7( -8.0) 20.0( -9.4) 23.9( -12.9) 47.2 ( -12.9)
O
p
p
o
s
i
n
g

A
r
c
h

D
e
n
t
i
t
i
o
n
* De no t e s sig nific a nt d iffe re nc e b e t we e n t he d iffe re nt fa c t o rs a nd b ra c ke t s inc lud e st a nd a rd d e via t io n.
(Ta b le 6): Sp e a rm a ns Ra nk Co rre la t io n Co e ffic ie nt a m o ng so m e o f t he Va ria b le s a nd t he VAS Sc o re s
Ae st he t ic s St a b ilit y Ma st ic a t io n Sp e e c h Co m fo rt Pa in Sa t isfa c t io n
Ag e
Re t e nt io n & St a b ilit y
-0.297 -0.147 -0.079 -0.06 -0.162 -0.039 -0.304*
-0.173 -0.040 -0.106 -0.287 -0.101 -0.099 -0.234
* De no t e s sig nific a nt d iffe re nc e .
Pr ost hodont i c s
correlation coef cient between stability of RPDs recorded by
the investigator and the VAS score was not statistically
signif cant (Table 5). This study did not examine the correlations
between the number of replaced teeth, dif erent designs of
major connectors and previous denture experience with their
respective VAS scores. Further investigation of these clinical
variables is needed.
Conclusion
The dif erence in the mean visual analogue (VAS) rating for
comfort between males and females was statically signif cant.
Aesthetics with Kennedy Class IV partial denture showed a
negative association with the age of patients. There were no
signif cant dif erence between VAS scores and other clinical
variables examined.
References
1. Van der Waas MAJ, Meeuwissen JH, Meeuwissen R, et al. Relationship between
wearing a removable partial denture and satisfaction in the elderly. Community
Dent Oral Epidemiol. 1994; 22:315-8.
2. Jepson NJA, Thompson JM, Steele JG. Inf uence of denture design on patient
acceptance of partial dentures. Brit Dent J. 1995; 178:296-300.
3. Elias AC, Sheiham A. The relationship between satisfaction with mouth and number
and position of teeth. JOral Rehabil. 1998; 25:649-61.
4. Wakabayashi N, Yatabe M, Ai M, et al. The inf uence of some demographic and
clinical variables on psychosomatic traits of patients requesting replacement
removable partial dentures. JOral Rehabil. 1998; 25:507-12.
5. Knezovic ZD, Celebic A, Valentic-Peruzovic M, et al. A survey of treatment outcomes
with removable partial dentures. JOral Rehabil. 2003; 30:847-54.
6. Wostmann B, Budtz-Jorgensen E, Jepson N, et al. Indications for removable partial
dentures: A literature review. Int JProsthodont. 2005; 18:139-45.
7. Koyama S, Sasaki K, Kawata T, et al. Multivariate analysis of patient satisfaction factors
affecting the usage of removable partial dentures. Int JProsthodont. 2008; 21:499-500.
8. Frank RP, Milgrom P, Leroux BG, et al. Treatment outcomes with mandibular
removable partial dentures: A population-based study of patient satisfaction. J
Prosthet Dent. 1998; 80:36-45.
9. Frank RP, Brudvik JS, Leroux B, et al. Relationship between the standards of
removable partial denture construction, clinical acceptability and patient
satisfaction. JProsthet Dent. 2000; 83:521-7.
10. Academy of Prosthodontics. Principles, concepts and practice in Prosthodontics -
1994. JProsthet Dent.1995; 73:73-94.
11. Nyhlin J, Gunne J. Opinions of wearing habits among patients new to removable
partial dentures. An interview study. Swed Dent J. 1989;13:89-93.
12. Kapur KK. A clinical evaluation of denture adhesivesJProsthet Dent 1967;18,550-555.
13. Seymour RA, Simpson JM, Charlton JE, et al. An evaluation of length and
end-phrase of visual analogue scales in dental pain. Pain 1985;21:177-85.
14. Price DD, Harkins SW, Raf i A, Price C. A simultaneous comparison of fentanyls
analgesic ef ects on experimental and clinical pain. Pain1986;24:197-203.
15. Magnusson T, List T, Helkimo M. Self-assessment of pain and discomfort in patients
with temporomandibular disorders: A comparison of f ve dif erent scales with
respect to their precision and sensitivity as well as their capacity to register memory
of pain and discomfort. JOral Rehabil. 1995;22:549-56.
16. Lamb DJ, Ellis B. Comparisons of patient self-assessment of complete mandibular
denture security. Int JProsthodont. 1996;9:309-19.
17. Harms-Ringdahl K, Carlsson AM, Ekholm J, et al. Pain assessment with dif erent
intensity scales in response to loading of joint structures. Pain 1986;27:401-11.
Accuracy of the Raypex-4 and Propex
Apex Locators in Detecting Horizontal and
Vertical Root Fractures: An In Vitro Study
Abstract
Unforeseen root fractures during endodontic therapy are often dif cult to diagnose and treat.
Apex locators have been shown to be accurate in measuring the working lengths of root canals,
and it was postulated whether they could also be used to determine the position of root
fractures. This study was undertaken to assess the accuracy of two dif erent apex locators in
determining the position of fractures. Ninety six single rooted teeth were randomly divided into
two groups. One group had simulated horizontal fractures cut into them and the other group
had vertical fractures. All fractures were detected in both groups using both a Propex (third
generation) and a Raypex-4 (fourth generation) apex locators. The actual lengths of the
fractures were then measured under 2.5 times magnif cation, and the results subjected to
statistical analysis. Both locators produced similar results and were found to be very accurate,
with measurements that correlated closely to the actual lengths. Clinically, treatment options for
root fractures vary depending on their location. Thus apex locators may be a valuable aid in not
only determining the presence of a root fracture, but also its exact location, which will help the
clinician decide on the most appropriate management.
Key words: Endodontics, Apex locator, Root fracture, Raypex-4, Propex.
Introduction
Many studies using apex locators to determine the working lengths in root canals, showed them to be
very accurate and reliable.
1-5
In most of these reports Third generation apex locators such as the Root
ZX (Morit a Crop, Tokyo, Japan) apex locator were used. These instruments are also termed
comparative impedance apex locators as they are inf uenced by two alternating currents of dif ering
frequencies f owing through the tissue.
6
Recently, a new apex locator, Bingo 1020 (also known as
Raypex-4), (Forum Engineering Technologies, Rishon Lezion, Israel) has been introduced. The
manufacturers claim this to be a fourth generation apex locator, in that it also uses two separate
frequencies of 400 Hz and 8 KHz, but unlike the third generation locators, it uses only one frequency at
a time. The use of a single frequency signal eliminates the need for f lters that separate the
dif erent frequencies which helps prevent the noise inherent in such f lters, and increases the
measurement accuracy.
7
In addition; these newer apex locators work in the presence of electrolytes,
so there is no need to dry the canals before use.
8
In use, a f le is inserted onto the root canal and an
electrical contact is made with the shank of the instrument. The device has a second electrode, which
is placed in contact with the patients oral mucosa. A digital display or audible signal shows when the
tip of the instrument reaches the apical foramen.
8
A recent in vitro study compared the accuracy of a new fourth generation (Bingo 1020) locator with
a third generation (Root ZX) locator when measuring canal lengths, and then evaluated these results
against radiographic measurements. Both locators were equally accurate and reliable, and even
though the measurements obtained using the Bingo 1020 were closer to the actual lengths than those
obtained by the Root ZX, the dif erences were not statistically signif cant.
9
One of the more perplexing problems in endodontic therapy is unforeseen horizontal or vertical
fractures of the root canal wall, which are often dif cult to diagnose and to treat. It has been
postulated that apex locators could be used to determine the position of a fracture, if it communicates
with the periodontal membrane. However, until now only one study has been done to detect root
fractures using an apex locator.
10
The authors found that the locator could accurately determine
horizontal fractures, but was unreliable in detecting vertical fractures.
Objectives
The aim of this study was to measure the positions of simulated horizontal and vertical fractures
Dr. Hani Al Kadi
BDS, Dip ODONT (ENDO), MDS
(ENDO)
Private practice
haniqadi@yahoo.com
Prof. LM Sykes
HOD Department of
Prosthodontics, Univ. of Limpopo
lsykes@medunsa.ac.za
Dr. Z. Vally
Department of Operative
Dentistry, Univ. of Pretoria
zvally@medic.up.ac.za
Endodont i c s
using a third generation apex locator, Propex (J. Morit a Corp, Tokyo,
Japan) and a fourth generation apex locator, Raypex-4 (Forum
Engineering Technologies, Rishon Lezion, Israel), and to compare
these f gures with each other and with the actual measurements
of the fractures.
Materials and Methods
Ninety six recently extracted, single rooted permanent human
teeth were used in this study. Only teeth with sound roots and no
evidence of root resorption or fractures were used. All of the teeth
were placed in 10% formalin immediately after extraction. Access
cavities were prepared and the working lengths were determined
radiographically using a size 10 K-File (Dent sply, Tulsa, Okla). Teeth
were numbered and randomly divided into two groups of 48
each. One group had simulated vertical fractures prepared (group
V) and the other had horizontal fractures (group H), cut using a
0,2 mm thick diamond disc (Fig. 1). In group V, a cut was made
vertically through the entire length of the root until the root canal
was exposed, while in group H, the roots were incompletely cut
horizontally until the root canal was exposed.
A Propex and a Raypex-4 apex locator were used in this study.
A master plastic jaw in a phantom head model (Fig. 2) was used to
hold the tooth specimens during the testing.
11
The plastic
anterior teeth were removed from their sockets, and the sockets
were then enlarged with a bur until the human teeth could be
adapted and easily f tted into them. The teeth were placed in the
plastic jaw, and embedded with a layer of irreversible
hydrocolloid (Blue-print , De Trey, Surrey, UK). Additional alginate
was placed under the master model where the lip clip electrode of
the apex locator was to be inserted. Four teeth were tested at the
same time, and a new mix of alginate was used for every set.
All the fractures were detected in both groups using the Propex
and the Raypex-4 apex locators, and all measurements were
carried out by one operator to ensure standardization of the
experimental technique. Eight teeth from each group were
randomly re-tested to verify the accuracy and repeatability of the
testing.
In group H, after the lengths of the simulated fractures had been
recorded using both apex locators, the teeth were removed
from the model, and the fractures were completed with the disc.
The actual lengths were then measured using a size 10 K-File
under 2.5 times magnif cation, using a radiographic viewer
designed to eliminate extraneous light and magnify the image
(Fig. 3). In group V, the lengths were determined up to the coronal
end of the simulated fracture with the locators. They too were
removed and the lengths of the fractures determined using a size
10 K-f le under 2.5 times magnif cation.
Statistical Analysis
The Pearson correlation coef cient and regression analysis was
used to determine the dif erences between all the test samples.
Agreement between the two locators was measured by the Kappa
statistic. Horizontal and vertical fractures were analyzed and
compared to the actual values separately, and also with both sets
of results combined. Closeness of the Raypex-4 and Propex
measurements to the actual length was compared by the paired
t-test, based on their deviations from the actual lengths. All
statistical procedures were conducted on SASand p values 0,05
were considered signif cant.
Results
In both groups V and H, the mean values (mm), standard
deviations, and minimum and maximum values were calculated
for the Raypex-4 and Propex apex locators as well as for the actual
measurements. The dif erences between Raypex-4 and Actual,
Propex and Actual and Raypex-4 and Propex were then calculated
and used in the statistical analysis.
Results are shown in Tables 1 and 2 respectively. Table 3 shows
the results obtained when both the V and H measurements were
combined.
Discussion
Apex locators are capable of accurate measurement and can
determine the exact location of the apical foramen especially
in cases where the outline of the canal on the pre-operative f lm
is indistinct, or where the canal curves towards or away from the
radiographic beam.
8
They have also been used as an alternative
to working-length radiographs in cases where patients request to
have a minimum number of radiographs taken, however an initial
pre-operative f lm should still be used to obtain an estimated
f gure. Carrotte (2004)
8
cautioned that there is a learning curve
associated with the use of apex locators, thus the pre-operative
radiograph is an essential guide as to whether the measurements are
in accordance with the original radiographic estimated lengths.
In this study, when comparing the two dif erent apex locators,
(Fig ure 1)
Radiographic viewer
(Fig ure 2)
Phantom head used
to hold plastic jaws
(Fig ure 3)
Diamond discs (0,2
mm thick)
the operator found that both systems needed an initial practice
period before repeatable accurate results could be obtained,
however the Raypex was easier to use and detected the fracture
lines more readily.
Azabat et al. (2004)
10
found apex locators to be more accurate in
determining horizontal than vertical fractures, however, in this
study although both locators were slightly more accurate when
measuring horizontal fractures, the dif erences were not
signif cant statistically, and both locators were found to be very
accurate in determining the actual position of all the fractures.
In this study, for the group H, both locators correlated very closely
to the actual measurements with Raypex-4 being slightly more
accurate than Propex, but not signif cantly so (p = 1.00 and p =
0.739 respectively). The dif erence between the two locators was
also not statistically signif cant (p = 0.748). Group V showed similar
results, with the Raypex-4 being slightly more accurate than the
Propex (p = 0.369 and p = 0.339 respectively), but again, neither
these nor the dif erence between the two, were statistically
signif cant, and both were found to be extremely accurate. When
both the H and the V f gures were combined, similar results were
seen with the Raypex-4 being marginally more accurate than the
Propex (p = 0.438 and p = 0.405 respectively).
Clinically, it is more important to be able to diagnose the exact
location of a fracture rather than its mere presence, as this can
impact on the treatment options and eventual fate of the tooth.
Contrary to popular belief, not all teeth with fractured roots need
to be extracted. Rintaro et al. (2004)
12
reported that when a root
fracture is located very close to the gingiva, the chance of healing
with calcif ed tissue is the poorest. However, in these cases as an
alternative to extraction, the coronal fragments can be removed
followed by orthodontic or surgical extrusion of the remaining
root. This will allow for elevation of the fracture line above the
epithelial attachment, and will bring the margins to a visible level,
allowing for prosthetic restoration of the tooth. This is a more
conservative treatment choice in young children compared to the
prosthetic restorations that would be needed after an extraction.
13

Thus, where root fractures are detected within the upper third of
the root ( upper 4 mm), then forced eruption can be attempted
to allow for restoration with physiologic gingival conditions,
eliminating the need for surgical crown lengthening, marginal
osteotomies or tooth extraction.
14
Teeth diagnosed with fractures in the middle third of the root are
usually unsaveable, although some authors have suggested that
if these teeth are repositioned such that the displacement of the
segments does not exceed 1mm, and then splinted for 4 weeks,
(Ta b le 1): Va lue s fo r t he ho rizo nt a l fra c t ure s (g ro up H)
Va ria b le Minim um p Va lue Ma xim um St d De v Me a n (m m )
Ra yp ex-4
p < 0.0001 20.2 7.8 2.58 13.05 48
p < 0.0001 20 7.9 2.63 13.03
Pro p ex
Ac t ua l
p = 1.0 0.3 0.2 0.11 0 48
p < 0.0001 20 7.9 2.61 13.03 48
Diffe re nc e R: A
Diffe re nc e P: A
p = 0.748 1.7 2.7 0.58 -0.03 48
p = 0.739 2.8 1.6 0.56 0.03 48
Diffe re nc e R: P
N
48
(Ta b le 2): Va lue s fo r t he ve rt ic a l fra c t ure s (g ro up V)
Ra yp ex-4
p < 0.0001 13.2 4 2.04 8.61 48
p < 0.0001 13.1 4.2 2.04 8.73
Pro p ex
Ac t ua l
p = 0.369 0.4 -0.3 0.18 0.02 48
p < 0.0001 13 4.3 2.03 8.71 48
Diffe re nc e R: A
Diffe re nc e P: A
p = 0.235 2.5 -1.5 0.66 0.11 48
p = 0.339 1.3 -2.3 0.66 -0.09 48
Diffe re nc e R: P
N
48
(Ta b le 3): Va lue s fo r t he c o m b ine d ve rt ic a l a nd ho rizo nt a l fra c t ure s (g ro up s V a nd H)
Ra yp ex-4
p < 0.0001 20.2 4 3.21 10.83 96
p < 0.0001 20 4.2 3.18 10.88
Pro p ex
Ac t ua l
p = 0.438 0.4 -0.3 0.14 0.01 96
p < 0.0001 20 4.3 3.18 10.87 96
Diffe re nc e R: A
Diffe re nc e P: A
p = 0.493 2.5 -2.7 0.62 0.04 96
p = 0.405 2.8 -2.3 0.61 -0.03 96
Diffe re nc e R: P
N
96
Endodont i c s
they may be salvaged. The repair process involves interposition of
either hard tissue or periodontal ligament between the fragments,
while the pulp may heal or undergo necrosis, in which case
endodontic treatment would be required.
15
Many dif erent
endodontic techniques have been proposed to determine which
method will be the most successful in treatment of teeth with
fractures in the middle or apical thirds of the root. One study
found that root canal f lling with GP of the coronal fragment only,
with or without surgical removal of the apical fragment, can be
successful in selected cases. Treatment of the root canal with
calcium hydroxide followed by GP f lling was recommended for
root-fractured, non-vital teeth, and in those vital teeth where the
fracture had caused pulpal exposure, partial pulpotomy of the
exposed pulps showed similar results to those obtained following
pulpotomies in root-unfractured teeth where pulp exposures had
been similarly treated.
16
Fractures involving the apical third of the
root may also be saved by performing endodontics followed by an
apicoectomy to remove the fractured segment.
Vertical fractures are more dif cult to diagnose. Patients may
present with mild symptoms and it may appear as if the root canal
treatment has not been successful. The diagnosis can be
suspected when a radiograph shows bone loss extending all
around a root, or a tooth, where the vertical fracture has led to
bacterial contamination of the entire tooth surface.
17
There has
been no particular treatment established to preserve vertically
fractured teeth. A recent study evaluated the long-term prognosis
of intentional replantation of vertically fractured roots after they
had been reconstructed with 4-META/MMA-TBB dentin-bonded
resin. Results showed longevity of 88.5% at 12 months after
replantation, 69.2% at 36 months and 59.3% at 60 months. All of
the failures occurred in the premolars and molars, while those
teeth where the fracture extended more than 2/3 of the way
from the cervical towards the apical area had signif cantly shorter
survival times than roots where the fractures were shorter. The
authors concluded that replantation of vertically fractured roots
reconstructed with dentin-bonded resins may be considered for
incisors as an alternative to extraction, but cautioned that the
longterm success was not optimal.
18
Both of the apex locators tested in this study were not only able to
detect the presence of root fractures, but were also able to
determine their exact locations. They could prove to be of great
value clinically in determining the treatment options for fractured
teeth especially in cases where the fractures are impossible to
detect on routine radiographs. However, there are some other
factors to consider when using apex locators. Most of them
perform better when used in wet canals as they rely on the
presence of electrolytes to transmit the electrical signals. Errors
may occur if the canals are too dry (in dry canals the Raypex-4 was
more accurate than the Propex in this investigation), if there are
large coronal restorations or metallic crowns that can cause a short
circuit, if there is an open apex with a larger peri-radicular lesion,
or if there is a perforation of the apex. These are usually apparent
and then further measures will need to be taken.
8
Conclusion
Both the third generation and the fourth generation apex locators
were found to be equally accurate in determining the exact
position of horizontal and vertical root fractures. The fourth
generation locator however did have advantages in that it was
easier to use, performed better in wet and dry canals, and was
slightly more accurate, although not signif cantly so. Either
systems may be of value clinically in not only detecting the
presence of a root fracture, but in determining its exact location,
which can help the clinician decide on the best treatment option
for that particular tooth.
References
1. Kaufman AY, Fuss Z, Keila S, Waxenberg S. Reliability of Dif erent Electronic Apex
Locators to Detect Root Perforations In Vitro. Int Endod J. 1997 Nov;30(6):403-7.
2. Stef en H, Splieth CH, Behr K. Comparison of Measurements Obtained with Hand
Files or the Canal Leader Attached to Electronic Apex Locators: An In Vitro Study. Int
Endod J. 1999; 32:103-7.
3. Fouad AF, Rivera EM, Kerll KV. Accuracy of the Endex with variations in canal irrigants
and foramen size. JEndod. 1993 Feb;19(2):63-7.
4. Pratten DH, McDonald NJ. Comparison of Radiographic and Electronic Working
Length. JEndod. 1996; 22:173-6.
5. Ounsi HF, Haddad G. In Vitro Evaluation of the Reliability of the Endex Electronic Apex
Locator. JEndod. 1998; 24:120-2.
6. Ingle JI, Bakland LK. Endodontics. 5th ed. BCDecker Inc. 2002; 517-25.
7. Bingo 1020 Apex Locator User Manual (Revised). Forum Engineering Rishon Lezion,
Israel Technologies Ltd. 1999; 5-7M.
8. Carrotte P. Endodontics: Part 7. Preparing the root canal. Br Dent J. 2004 Nov
27;197(10):603-13.
9. Kaufman AY, Keila S, Yoshpe M. Accuracy of a New Apex Locator: An In Vitro Study. Int
Endod J. 2002 Feb;35(2):186-92.
10. Azabal M, Garcia-Otero D, De la Macorra JC. Accuracy of the Justy II Apex Locator
in Determining Working Length in Simulated Horizontal and Vertical Fractures. Int
Endod J. 2004 Mar;37(3):174-7.
11. Tinaz AC, Alaam T, Topuz . A simple model to demonstrate the electronic apex
locator. Int Endod J. 2002 Nov;35(11):940-5.
12. Rintaro T, Kiyotaka M, Minoru K. Conservative Treatment for Root Fracture Located
Very Close to Gingiva. Dent Traumatol. 2005 Apr;21(2):111-4.
13. Koyuturk AE, Malkoc S. Orthodontic Extrusion of Subgingivally Fractured
Incisor before Restoration. A Case Report: 3-Years Follow-Up. Dent Traumatol. 2005
Jun;21(3):174-8.
14. Wehr C, Roth A, Gustav M, Diedrich P. Forced Eruption for Preservation of a Deeply
Fractured Molar. JOrofac Orthop. 2004 Jul;65(4):343-54.
15. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 Intra-Alveolar Root
Fractures. 2. E ect of Treatment Factors such as Treatment Delay, Repositioning,
Splinting Type and Period and Antibiotics. Dent Traumatol. 2004 Aug;20(4):203-11.
16. Cvek M, Mejare I, Andreasen JO. Conservative Endodontic Treatment of Teeth Fractured
in the Middle or Apical Part of the Root. Dent Traumatol. 2004 Oct;20(5):261-9.
17. Carrotte P. Endodontic problems. Br Dent J. 2005 Feb 12;198(3):127-33; quiz 174.
18. Hayashi M, Kinomoto Y, Takeshige F, Ebisu S. Prognosis of Intentional Replantation
of Vertically Fractured Roots Reconstructed with dentin-bonded resin. JEndod. 2002
Feb;28(2):120-4.
Function, Aesthetics and Biomimetics in the
Interdisciplinary Treatment:
Concerning a Clinical Case
Abstract
The evolution of dentistry and dental specialties allowed for a clear improvement in the quality of
treatment results for the patients complete oral rehabilitation, considering both functional and
aesthetic aspects.
An adult patients aesthetic and functional rehabilitation present an even more dif cult challenge
for the dental professional, particularly in those situations where the treatment involves an
intimate collaboration between dif erent specialties, demanding a critical planning.
We will present a clinical case which involved an interdisciplinary approach, where the operative
sequence and the multidisciplinary approach exerted in this case illustrates the importance of
specialised knowledge and professional communication.
Key words: Aesthetics, Periodontics, Implantology, Orthodontics, Interdisciplinary approach.
Introduction
An adult patients aesthetic and functional rehabilitation presents a challenge for the dentistry
professional, particularly in those situations where the treatment involves an intimate collaboration
between several specialties, demanding a critical planning. It is therefore important to def ne in what
way aesthetic, periodontal, implantology and orthodontic specialists should connect in order to
properly achieve the proposed goals.
As an example of an interdisciplinary treatment, we present a complex clinical case in an adult patient
where periodontal, implantology, prthodontic and prosthodontic treatment were involved.
Case Description
A f fty-eight year old female patient consulted us to replace her missing teeth and to improve her
smiles appearance. This is a case of a patient with high expectations and a philosophical personality
according to Houses classif cation.
1
In medical terms, she was diagnosed as an ASA patient type 1,
2
not presenting any associated
pathology and not being under any kind of medication. She was non-smoker and had a moderately
stressful life style.
Extra-orally, we can observe in f gures 1 and 2 that the patient presents a facial type with normal
patterns and a straight prof le. It is also obvious in f gure 1 that the patient presents a low smile line.
Dr. Faria Almeida Ricardo
DDS, MSc Periodontology
- Associate Professor, Faculty
of Dentistry, Univ. of Oporto
rfaperio@gmail.com
Dr. Falco Costa Carlos
DDS, MSc Esthetic Dentistry
- Teacher at Fernando Pessoa Univ.
falcaoestetica@gmail.com
Dr. Pinho Monica
DDS, MSc Orthodontics
- Teacher at Fernando Pessoa Univ.
monicampinho@hotmail.com
Mr. Perez Lopez Javier
Ceramist, Lugo
tecnicadental@oraldesign.es
Dr. Afonso Pinho Ferreira
Orthodontics
- Full Professor, Faculty of
Dentistry, Univ. of Oporto
aferreira@fmd.up.pt

(Fig ure 2)
Initial lateral
profile
(Fig ure 1)
Initial anterior
profile
Mul t i di sc i pl i nar y
During intraoral examination we could observe the presence of
posterior bite collapse with decreased occlusal vertical dimension
resulting from the loss of posterior teeth number 14, 15, 24, 25,
26, 46 and 36, and from the mesioversion of teeth 47 and 37, as
well as the extrusion of tooth 16 (Figs. 3-5). It was also possible
to detect the presence of localized gingival recessions both in the
upper and lower arches.
The intraoral examination also showed an increased overjet due to
labial inclination of upper anterior segment with an increase of the
horizontal overbite, which resulted in the absence of the anterior
guide during protrusive movement. At the same time, we could
observe the presence of a parafunction (bruxing habit), since there
is a clear wear at the upper anterior teeths incisal edge (Fig. 6).
After examination of the upper anterior segment, gingival
asymmetry was observed, especially at teeth 11 and 21, as well as
presence of interincisal diastema that might have been caused
by the labial movement of these teeth (Fig. 3) and/or the loss
of teeth posteriorly. The upper anterior teeth present themselves
with an inadequate height width proportion and the incisors
show a somewhat triangular shape.
The periodontal examination showed moderate generalized
chronic periodontitis, with Plaque index values of 80% and
Bleeding of 48% (Dicotomic Index). One can verify, as mentioned
earlier, the presence of multiple areas of gingival recession. The
microbiological analysis allowed to observe the presence of
periodontal pathogens of endogenous character,
3
therefore not
presenting an increased risk in terms of response to the
periodontal treatment.
In the initial radiographic examination, it was possible to conf rm
the presence of periodontal pathology, with a moderate
radiographic horizontal bone loss except for tooth 27, which
presents a circumferential defect. The detected bone loss is
worsened due to the mal-positioning of some teeth (Fig. 7). We
could also observe the clear buccalization of the antero-superior
teeth in the lateral cephalometric projection (Fig. 8).
Diagnosis
The patient can be diagnosed with:
- Moderate Generalized Chronic Periodontitis.
- Bite Collapse Syndrome with buccal inclination of the
anterosuperior teeth and presence of inter-incisive diastema.
- Extrusion and mal-positioning of several teeth as well as
posterior edentulism.
- Bruxism.
- Asymmetry of the anterior gingival margins and incorrect
width-length ratio of anterior teeth.
Treatment Outcome
After the analysis of the presented case we can summarize our
treatment plan as follows:
1- Treatment of the periodontal pathology.
2- Alignment of the remaining molars and increase of the vertical
dimension.
3- Retrusion of upper incisors decreasing the horizontal overbite
and reestablishment of an adequate anterior guide.
(Fig ure 3)
Intra-oral 1
(Fig ure 4)
Intra-oral 2
(Fig ure 5)
Intra-oral 3
(Fig ure 6)
Wear of incisal edges
(Fig ure 7)
Panoramic view
(Fig ure 8)
Lateral cephalometric
view
(Fig ure 9)
Pre-operative, upper
right quadrant
4- Closure of the interincisal diastema and gingivoplasty.
5- Reconstruction of the lost dental structure of the upper anterior
segment.
6- Replacement of the lost teeth.
7- Treatment of the occlusal parafunction.
Treatment Plan
Hence our treatment plan consisted of the following, according to
the sequence we have described:
1- Initial or hygienic stage, with information and motivation for
the interdisciplinary treatment as well as implementation of a
basic periodontal treatment.
2- Placement of osseointegrated implants in the sites of 14, 15, 24
and 25.
3- Setting of provisional f xed partial prosthesis over implants on
14, 15, 24 and 25 for orthodontic anchorage.
4- Bimaxillary orthodontic treatment with f xed appliances.
5- Extrusion of tooth 47.
6- Placement of implant in the area of 46.
7- Placement of ceramic crown over implant in 46 and of
implant-supported metaloceramics f xed partial prosthesis in
the 14, 15 and 24, 25, 26.
8- Rehabilitation of the anterosuperior sector with ceramic veneer.
9- Placement of centric relation occlusal splint.
1- Initial or hygienic stage, with information and motivation
for the interdisciplinary treatment as well as implementation
of a basic periodontal treatment
The goal of the periodontal treatment was to eliminate the
opportunistic microorganisms that might impede, if not treated,
any kind of interdisciplinary therapeutic approach.
The initial or hygienic stage aims to eliminate the etiologic cause
of the periodontal disease; eliminating all the bacterial deposits, as
well as the plaque retaining factors. During this stage, we
proceeded with the patients motivation, instructing her on oral
hygiene techniques.
Therefore, in theory, with the basic periodontal treatment we
should get:
- A reduction of the Bleeding Index to values equal or inferior to 25%.
- A total elimination of gingival pockets with probing depth of
over 5 mm.
- Reduction of the furcation lesions.
- The elimination of pain since the only pain that the patient had
was
due to periodontal problems.
- Starting to achieve the patients functional and aesthetic
satisfaction.
At the same time, we must have the ability to ef ectively control
the risk factors associated with chronic periodontal disease, such
as bacterial plaque, tobacco and uncontrolled diabetes.
4
In this
particular case, the need to improve the used oral hygiene
techniques was to promote a better plaque control. From the
above mentioned risk factors, bacterial plaque was the only one
initially present. In terms of active treatment, we proceeded with
the root planing in the sites with probing depth of over 3 mm.
Forty-f ve days after the basic stages completion, we proceeded to
the re-evaluation of the performed treatment.
(Fig ure 10)
Implants placement in
positions 14 & 15 with
immediate sinus lifting
(Fig ure 11)
Post-operative photo of
implants in positions 14 &
15 after suturing
(Fig ure 12)
Incision for upper left
quadrant
(Fig ure 13)
Flap reflection
(Fig ure 14)
Sinus lifting
(Fig ure 15)
Bio-Oss application
(Fig ure 16)
Suturing
Re-evaluation aimed to assess the results of the established
treatment and to plan the need for additional periodontal
treatment (surgical, for example) or supporting periodontal
treatment. In the analyzed clinical case, and considering the good
results obtained (plaque index values and bleeding inferior to
20%) with the initial treatment it was possible to move the patient
to a supporting periodontal treatment program. The periodicity
of the appointments relative to the program is dependent on the
present risk factors, on the degree of initial bone loss presented
and on the treatments complexity to be executed in
interdisciplinary terms. For this patient periodontal supporting
appointments with a 2-month periodicity
5
were prescribed.
2- Placement of osseointegrated implants in positions 14, 15,
24 and 25
Considering the edentulous spaces and bearing in mind the
orthodontic movement to be performed it was decided to
proceed with the placement of osseointegrated implants in the
position of teeth 14, 15, 24 and 25 in the maxilla and tooth 46 in
the mandible. The decision was made in order to maintain teeth
27 and 47 as orthodontic anchorage and to re-evaluate their status
after orthodontic treatment ends.
For both sides in the maxilla, the need to perform sinus
elevation was verif ed, although on the right side such procedure
was performed at the same time of the implant placement,
6
as
there was over 6 mm of residual bone (Figs. 9-11),
7
but on the left
side, the necessity to perform a previous elevation of the
maxillary sinus f oor arose as we did not have suf cient alveolar
bone to achieve primary stability, and afterwards (6 months) we
proceeded with the placement of the implants (Figs. 12-16).
8
3- Setting of provisional f xed partial prosthesis over implants
14, 15, 24 and 25 for orthodontic anchorage
After the implants osseointegration period (6 months), we
proceeded with a casting and record registration for the
fabrication of a f xed partial prosthesis, screwed in metal-acrylic,
allowing, on one hand, the re-establishment of a suitable vertical
dimension and on the other hand, an additional anchorage during
the execution of the orthodontic treatment.
4- Bimaxillary orthodontic treatment with f xed appliances
The orthodontic treatment began with the alignment of
mandibular teeth (Fig. 17).

In a later stage, already with a steel rectangular arch, of a bigger
gauge, the verticalization of tooth 47 was initiated, resorting to an
open spring of nickel-titanium.

After tooth 47 verticalization, the alignment of maxillary teeth was
initiated (Fig. 18).
This arch being leveled and aligned, we proceeded with the recoil
of the anterosuperior sector, with steel contraction arches and
resorting to the anchorage provided by the implants previously
placed in teeth positions 14, 15, 24 and 25 (Fig. 19).

The canine neutroclusion was achieved and improved in an initial
stage through the use of triangular rubber bands placed bilaterally
(Fig. 20).

(Fig ure 17)
Alignment of
mandibular teeth
(Fig ure 18)
Initiation of maxillary
teeth alignment
(Fig ure 19)
Stainless steel
contraction arches
(Fig ure 22)
Implant placement in
the position of tooth 46
De p t h
GM
GM
De p t h
To o t h #
123 312 113 122 121 111 122 111 432
17 16 11 12 13 14 15 21 22 23 26 25 24 27
233 543 223 221 321 222 223 322 323
De p t h
GM
GM
De p t h
To o t h #
459
211 232 211 122 132 112 132 213
47 46 41 42 43 44 45 31 32 33 36 35 34 37
388 223 213 111 121 123 111 221 213
122 211 212
122 122 222
(Fig ure 21)
Periodontal
chart: tooth
# 47 had
mobility
grade II
(Fig ure 20)
Triangular rubber
bands placed
bilaterally
5- Extraction of tooth 47
As previously anticipated, tooth 47 extraction was decided due to
its periodontal bad condition (Fig. 21).
6- Placement of implant in the position of 46
Besides the implant at the site of tooth 46 and since tooth 47
extraction was performed, the possibility of also placing an
implant at the site of this last tooth was taken into consideration.
Nevertheless, the bone availability was limited and it would imply
the use of guided bone regeneration technique which was not
accepted by the patient at this stage of the treatment. The risk that
might exist from tooth 17 extrusion was not conf rmed due to the
centric relation splint foreseen for the end of the treatment (Fig. 22).
7- Placement of ceramic crown over implant in 46 and of
implant-supported metaloceramics f xed partial prosthesis in
the 14, 15 and 24, 25, 26
Right after the bimaxillary f xed orthodontic appliances removal
(that were used for 18 months), as well as after the
osseointegration period of the implants placed in the mandibular
arch, we proceeded with the def nitive impressions using an
elastomeric material, as well as to the collection of intermaxillary
registrations which allowed the elaboration of structures built in
metal-ceramics, which were cemented over prefabricated
intermediate abutments. As for the second quadrant, we decided
for an implant-supported structure design over implants in
positions 24 and 25 and a cantilevered pontic at the level of tooth
26 (Fig. 23).
8- Rehabilitation of the anterosuperior sector with ceramic
feldspar veneers
After the removal of the f xed appliances we also proceeded with
the anterosuperior segment rehabilitation. In order to do so, we
performed a previous waxing up, in order to be able to visualize
the intended f nal result. This wax up also made possible the
attainment of an in-mouth Mock-up , as well as it functioned
as a guide during all the dental preparation process, creation of
temporary restorations and the execution of ceramic feldspar
veneers (Fig. 24).
The dental preparation based on the previous wax up insured
a thickness of approximately 0,5 mm in buccal and 2 mm in the
incisal 1/3 in order to assure a suitable thickness for the feldspar
ceramic. The vestibular and palatal f nish line was a deep chamfer
to assure an easier positioning of the def nitive restorations and to
promote a higher marginal integrity after the def nitive
cementation (Figs. 25, 26).
In these areas in which the preparation included the exposure of
dentin, we recommend the use of an immediate dentinal sealing
technique by applying phosphoric acid and a dentinal adhesive
(of fourth or f fth generation) on areas of exposed dentin, where
after a f rst cycle of 20 seconds curing an oxygen inhibitor (glycerine
gel) was applied in order to perform a second cycle of curing,
assuring a total sealing of the exposed dentinal tubules. We also
intended, by doing this, to increase f nal adhesion values during
the cementation of the ceramic feldspar veneers.
After the dental preparation, we proceeded with the def nitive
casting as well as with the intermaxillary registrations,
determining the vertical dimension of the occlusion to be used.
(Fig ure 24)
Waxing up of the antero-
superior segment
(Fig ure 26)
Deep chamfer
vestibular & palatal finish
line
(Fig ure 25)
Preparation of the upper
anterior teeth
(Fig ure 29)
Centric relation occlusal
splint
(Fig ure 28)
Extra-oral view
(Fig ure 27)
Final cementation
of ceramic feldspar
veneers
(Fig ure 23)
Fabrication of fixed
partial dentures.
Tooth # 26 replaced
as a cantileverd
pontic
The cementation technique included the acid conditioning of
both enamel and dentin with phosphoric acid and of the interior
surface of the veneers with hydrof oric acid. We proceeded with
the silanization of the interior surface of the veneers, placed an
adhesive of fourth generation on the restorations and on teeth
without curing, used a photo-curable micro-hybrid resin
cement and performed the f nal cementation (Figs. 27, 28).
9- Placement of centric relation occlusal splint
Despite the thought that the incisal and canine guides
re-establishment will solve the parafunction problem, we decided
to produce an occlusal splint that will allow, on one hand, to
reduce the parafunctional habits ef ects and that will
simultaneously allow it to function as a retainer for the
orthodontic treatment performed at the maxilla (Figs. 29, 30).
Discussion
After the clinical case treatment, the main discussion topics are:
1- no placement of implant at the site of tooth 26, 2- the possible
extraction of tooth 27 and the extraction of tooth 47.
As to what concerns tooth 26, no implant was placed because the
initial planning foresaw the extraction of tooth 27, which would
make the implants location to be at 24, 25 and 27. However, and
since the tooth was maintained as a result of the periodontal
treatment, a cantilever was made supported on the 24 and 25
implants. Obviously, and once the case was f nished, we could
claim that it might have been preferable to place them at the sites
of the 24 and 26. Nevertheless, the performed treatment did not
present any kind of problem as far as the long term predictability
is concerned.
Relatively, tooth 47 had to be extracted due to periodontal causes.
The ideal would have been to also place an implant at that level.
However, as above mentioned, the bone availability was limited
and it would imply the use of guided bone regeneration
technique, not accepted by the patient at this stage of the
treatment. The risk that might derive from tooth 17 extrusion was
not conf rmed due to the centric relation splint foreseen for the
end of the treatment.
Conclusion
The evolution of dentistry and dental specialties allowed for a
clear improvement in the quality of treatment results for the
patients complete oral rehabilitation, considering both functional
and aesthetic aspects. Naturally, the excellence of the results
demands an interdisciplinary approach, consolidated in a close
collaboration between the dif erent protagonists where the
patients motivation and availability is pivotal. The therapeutic
planning, the operative sequence and the pluridisciplinarity
exerted in this case illustrate the importance of specialised
knowledge and professional communication.
(Fig ure 33)
Pos-operative
lateral cephalometry
(Fig ure 31)
Post-operative
anterior view
References
1. House MM. Full denture technique. In: Conley FJ, Dunn AL, Quesnell AJ, Rogers RM,
editors. Classic prosthodontic articles: a collectors item. Vol III. pp 2-24. Chicago:
American College of Prosthodontists, 1978.
2. Keats, AS. The ASA classif cation of physical status--a recapitulation. Anesthesiology.
1978 Oct;49(4):233-6.
3. van Winkelhof AJ, Rams TE, Slots J. Systemic antibiotic therapy in periodontics.
Periodontol 2000. 1996 Feb;10:45-78.
4. Kinane DF, Peterson M, Stathopoulou PG. Environmental and other modifying
factors of the periodontal diseases. Periodontol 2000. 2006;40:107-19.
5. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Chambers D. Periodontal implications of
orthodontic treatment in adults with reduced or normal periodontal tissues versus
those of adolescents. Am JOrthod Dentofacial Orthop. 1989 Sep;96(3):191-8
6. Summers RB. A new concept in maxillary implant surgery: the osteotome technique.
Compendium. 1994 Feb;15(2):152, 154-6, 158 passim; quiz 162.
7. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the Sinus Consensus
Conference of 1996. Int JOral Maxillofac Implants. 1998;13 Suppl:11-45.
8. Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986
Apr;30(2):207-29.
(Fig ure 32)
Post-operative
lateral view
(Fig ure 30)
Splinting of lower
anterior teeth
Mobile: +962796999310
e-mail: solange.sfeir@wamkey.com
Tooth Movement With Vacuum Formed
Retainer: A Case Report
Abstract
Nowadays, the adult patients demand for aesthetic alternatives other than casual orthodontic
treatment is increasing. The current case report introduces a technique of correcting a minor
crowding of maxillary incisors in an adult patient using a combination of thermoplastic retainer
and bonded composite buttons as force delivering appliance. Treatment plan, protocol, progress
and post retention pictures are presented throughout this article.
Key words: Aesthetic alternatives, Thermoplastic retainer, Bonded composite buttons.
Introduction
Adult patients are getting more interested in orthodontic treatment nowadays. This interest
increased the demand for aesthetic alternatives to conventional f xed stainless-steel appliances.
Lingual f xed appliances, ceramic brackets and removable appliances are the aesthetic alternative
of ered by the profession.
1
Although the removable appliances cannot of er the wide range of
movements such as the f xed appliances, in minor crowding cases such as post treatment relapse,
removable appliances can produce equally good results as the f xed appliance when tipping
movements are required. Removable appliances have the advantage of saving chair-side time.
2
In 1945 Kesling introduced the tooth positioner appliance as a f nishing device to achieve minor
tooth movements.
3
Major movements can be accomplished with a series of positioners, by
changing the teeth on the setup slightly as treatment progresses. Al i gn Technol ogy developed an
invisible method of orthodontic treatment (Invi sal i gn) that uses a series of computer-generated,
clear removable appliances.
4,5
Rai nt ree Essi x has developed a technique using aligners formed on
plaster models and can create tooth movement up to 2-3 mm.
According to Sheridan, the f rst law of biomechanics states that in order to get tooth movement
space, force and time are required. The space is created by Interproximal Reduction (IPR) with
stainless steel strips or slow- speed discs and burs, or by Air- Rotor Stripping using high-speed
burs. The force is applied by means of bumps formed at specif c sites in the aligners using either
Essix Divoter or the Hilliard Precision Thermoplier. In addition, windows should be cut with f ne
burs creating the space into which the teeth will move. The appliance should be worn full-time
except while eating. The expected tooth movement is approximately 1mm per month.
6-9
Aim of this Article
Through this case report, we are presenting an alternative for correcting minor crowding using
the concept of the aligners relying on a thermoplastic splint associated with composite buttons.
Case Presentation
A female patient (20 years old) presented to the Lebanese University complaining of crowding of
her maxillary left central and lateral incisors. Her extraoral examination showed proper
horizontal and vertical proportions but her upper lip is short, her prof le is straight and her smile
is not consonant with the lower lip (Fig. 1).
The intraoral examination shows weak Class I molar and canine on both sides. The overjet equals
3 mm and the overbite is 35%. The mandibular midline is on and the maxillary midline is deviated
by 0.5 mm to the right relative to facial midline (Fig. 2).
The cephalometric analysis shows the presense of a prognatic maxilla and a normodivergent
pattern, retroclined maxillary incisors and proclined mandibular incisors. The panoramic showed
normal anatomic structures, missing maxillary third molars and multiple restorations. The frontal
cephalogram showed symmetry and normal transverse relationship (Fig. 3).
Dr. Marc Rahme
DCD, DESSO, MSc
Private practice of Orthodontics
Beirut-Lebanon
rahmemarc@hotmail.com
Dr. Bilal Koleilat
DCD, MSc
Assistant Professor & Director of
Postgraduate Program in
Orthodontics, Faculty of
Dentistry Lebanese
University
bilako@cyberia.net.lb
Or t hodont i c s
(Fig ure 2)
Intra-oral photographs
(Fig ure 4)
Photographs showing arch
length deficiency
(Fig ure 3)
Frontal and lateral cephalograms with measurements and
panoramic radiograph
SN=77 (70mm)
SN/H=10 (8)
SNA=82 (82)
SNB=76 (80)
ANB=6 (2)
Retrognathic mandible

I/NA=10(22) -1 (4mm)
I/SN=95 (104)
I/PP=105 (110)
Retroclined maxillary incisors

i/NB=31 (25)
i/NB=6 (4mm)
i/Apo=25 (22)
i/Apo=2 (2mm)
i/MP=100 (90)
Proclined mandibular incisors
PP/MP=24 (27)
PP/H=0 (0)
MP/SN=33 (32)
MP/H=24 (25)
Normodivergent patten
(Fig ure 1)
Anterior and lateral
extra-oral views
Treatment options
Two treatment options were of ered for the patient:
1
st
option: Full maxillary and mandibular f xed appliances for
the purpose of aligning and leveling and uprighting the
mandibular right second molar.
2
nd
option: Correct the crowding on the maxillary incisors
using a removable thermoplastic splint with composite
buttons on the palatal side of the maxillary left central incisor
and on the buccal side of the maxillary left lateral incisor.
Treatment protocol
The patient opted for the second option. An alginate
impression was f rst taken and sent to the laboratory, one week
after we received the thermoplastic retainer. The next step was
to plan the movements in order to accurately bond the
composite buttons on the teeth and then create windows
through which the teeth will move. The windows were
exactly equal in size to the moving tooth; the thermoplastic
retainer was hard so no risk of breakage or bad retention was
presented. The clinical examination showed that the
maxillary left central incisor was rotated mesio-palataly and the
left lateral incisor was tipped bucally (Fig. 4). In order to correct
the misalignment of the incisors, space, force and time are
needed.
6
The space required was 1.5 mm. Enamel
stripping using abrasive strips were performed to acquire the
space needed. The enamel of the distal side of the central and
(Fig ure 5)
Composite button
bonded on the palatal
aspect of the central
incisor and on the
middle third of the
buccal aspect of the
lateral incisor
(Fig ure 6)
Two windows created in
the thermoplastic splint
using scissors
(Fig ure 7)
After 4 months
of treatment,
complete
alignment was
attained
(Fig ure 8)
Grinding of maxillary
incisors edges
(Fig ure 9)
Nine months
following treatment
The results were
stable and the
alignment was
perfect
Or t hodont i c s
both proximal sides of the lateral incisor has been stripped. The
stripping was done sequentially: about 0.5 mm in each
appointment. The force was planned in order to rotate the
central incisor mesio buccaly and push the lateral incisor
palatally. A composite button was bonded on the distal part
of the palatal aspect of the central incisor and on the middle
third of the buccal aspect of the lateral incisor. The composite
buttons were about 1mm thick (Fig. 5). To clear the way for the
teeth to be moved, two windows were created in the
thermoplastic splint using scissors. The f rst window was palatal
to the lateral incisor and the second was buccal to the central
incisor (Fig. 6). The patient was instructed to wear the splint 24
hours and only remove it during eating and brushing.
Treatment results
The patient was compliant wearing her appliance and was
warned that the seating will improve over time. Alignment
progressed gradually. At each appointment, stripping was
performed and composite buttons were added, in order to
create pressure at the location needed. After 4 months of
treatment, complete alignment was attained (Fig. 7).
Aesthetical grinding of the edges of the incisors was done
(Fig. 8). For retaining the results, a new thermoplastic splint was
delivered to the patient. The patient was instructed to wear it
24 hours per day.
Nine months following treatment the patient presented for
new records. The results were stable, the alignment was
perfect (Fig. 9).
Discussion
The option of treatment presented throughout this case report
of ered many advantages for the patient than the f xed
bimaxillary appliances. First the treatment was aesthetic and
less cumbersome, second the treatment time was less and
third the cost of treatment was much more less and in terms of
stability the post retention records showed a great stability 9
months following treatment.
Conclusion
The previous case report of ered a simple, aesthetic and
inexpensive alternative to f xed appliances. Fixed appliances
are often a frustrating option to adult patients complaining of
minor crowding.
References
1- Miller RJ, Derakhshan M. The Invisalign system: case report of a patient with deep
bite, upper incisor f aring, and severe curve of Spee. Semin Orthod. 2002;8(1):4350.
2- Grossman W, Moss JP. Removable appliance therapy. JPO JPract Orthod. 1968
Jan;2(1):28-36.
3- Kesling, H.D. The philosophy of the Tooth Positioning Appliance. Am. J. Orthod. 1945;
31:297-304.
4- Warunek SP, Sorensen SE, Cunat JJ, Green LJ. Physical and mechanical properties
of elastomers in orthodontic positioners. Am JOrthod Dentofacial Orthop. 1989
May;95(5):388-400.
5- Wong BH. Invisalign A to Z. Am JOrthod Dentofacial Orthop. 2002 May;121(5):540-1.
6- Sheridan JJ, LeDoux W, McMinn R. Essix appliances: minor tooth movement with
divots and windows. JClin Orthod. 1994;28:659-663.
7- Spranley T. Minor tooth movement. Woman dentist journal. 2005 Oct;3(9):39-42
8- Sheridan JJ, Hilliard K, Armbruster P. Essix Appliance Technology: Applications,
Fabrication and Rationale. GACInternational. 2003;19-55.
9- Rinchuse DJ, Rinchuse DJ. Active tooth movement with Essix-based appliances. JClin
Orthod. 1997 Feb;31(2):109-12.
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The Innovative Approach to the Treatment of Total
Edentulism and Advanced Alveolar Atrophy
Abstract
This article describes the surgical preparation and prosthodontic treatment of total edentulism
and advanced bone atrophy followed by alveolar reconstruction with tibial autografts and the
insertion of Ant hof t implant-supported removable prosthesis on telescopic crowns and a
zirconium framework (with the use of CAD/CAM technique and galvanoplasty).
Key words: Alveolar atrophy, Implantation, Tibia bone grafting, Galvanoplasty, Telescopic
prothesis, Zirconium dioxide.
Introduction
According to statistics, 20% of Russias population under age 60 suf er from total
edentulism.
1
The quality of life of totally edentulous patients is signif cantly decreased.
Edentulism inf icts a severe psychological injury on patients, and for many of them is associated
with the loss of self-esteem because of embarrassment and discomfort. Edentulism results in
pronounced esthetic disturbances: the height of the facial lower third decreases, occusal
relations are compromised, the labial muscle tone decreases, the lips become narrower, and the
face looks senile and unhappy. TMJ disorders and speech disturbances develop or exacerbate.
2
Traditionally, patients with total edentualism have been treated with removable prosthesis.
In 2003-2006 the percentage of cases treated with removable prosthesis, compared to other
treatment modalities, was as high as 50 to 70% in the Moscow region, according to the Moscow
regional dental clinic.
1
However, the performance of complete removable prosthesis has fallen
short of desired; for example, virtually every prosthesis required repair and adjustments after 1
year of service, and the average longevity was less than 3 years.
1
Removable prostheses further
promote jaw bone atrophy and worsen the anatomical conditions. Traditional mandibular
prostheses get often dislodged when buccal and hyoid-glossal muscles contract, therefore the
teeth tend to be placed not in anatomically favorable position, but in neutral zones to stabilize
the prosthesis. As bone atrophy advances, the height of the facial lower third decreases, and
traditional removable prostheses serve, to increasingly larger extent, to maintain facial contours,
thus they become bulkier and, as a consequence, less functional, less stable, and less retentive.
2

In recent decades, implant-supported prosthodontic restorations have proven to be a reliable,
predictable, and ef ective treatment modality.
2,3
Over the last 10 to 15 years, the survival rate for
implants and implant-supported restorations has reached as high as 96 to 98%.
2
Being inserted in
jaw bone, the implant prevents bone atrophy and serves as a reliable abutment for a prosthesis.
With the use of implant-supported prostheses, teeth can be set as required to fulf ll esthetic and
speech considerations. Implant-supported prostheses not only restore facial contours, but also
provide stability, reproducible centric relation, excellent retention and masticatory ef ciency.
Masticatory proprioception doubles, and bite force increases by 85%. Speech improves, and
clicking sounds typical for a traditional removable prosthesis user disappear.
2
Thus, implant-supported prostheses in patients with total edentualism have indisputable
advantages over traditional removable prostheses. However, edentulism is associated with advanced
bone atrophy, which counteract implant insertion without surgical preparation, which, in turn,
can be very extensive.
3
To perform alveolar reconstruction prior to implant insertion, many
grafting techniques have been suggested (for example, tibial grafts, calvarium grafts, iliac grafts).
3

A f xed prosthesis has clear advantages (in terms of psychology and convenience of use).
However, with advanced alveolar atrophy associated with total edentualism and the development of
false senile prognathism, f xed prosthesis has a number of disadvantages, such as lack of buccal
and labial soft tissue support, speech disturbances, implant care dif culties, the development of
frontal cantilever, poor load distribution, and long unaesthetic crowns.
2

Dr. Evgeny Zhdanov
DDS, PhD
Founder & Owner of Domodent
Dental Clinic
domodent@yandex.ru
Dr. Alexey Khvatov
DDS, prosthodontist
Private practice, Domodent
Dental Clinic
Ilia Korogodin
Dental Technician
Private practice
I mpl ant ol ogy
Implant-supported removable prosthesis possess a few
advantages, but in general patients like these prostheses less
than f xed ones. In many respects, this is associated with the
prosthesis mobility in the oral cavity.
This article presents an innovative approach to the fabrication
of esthetic, comfortable, hygienic and light removable
prostheses on telescopic crowns and zirconium frameworks
and galvanic caps. With good retention, simple care and
maintenance, and the precise f t of the components,
4
a patient
feels this prosthesis as f xed one.
Case Study
A 56 year-old male patient presented himself at our clinic on
the 31
st
of January, 2008. The patient was a non-smoker and
medically f t. In the maxilla, 3 remaining teeth exhibited
mobility (grade III) and were extracted. In the mandible, both
canines were preserved. In the maxilla, the alveolar process had
division C and D atrophy (according to 1985 Misch & Judy
classif cation). In the mandible, division B atrophy was observed.
Jaw relationship in the sagital plane was classif ed as pseudo-
class III malocclusion. The alveolar arch shape was f at (Figs. 1, 2).
After physical/lab examinations, preliminary wax-up and
computerized exam, the tooth roots were extracted and 8
Ant hof t implants were inserted in the mandible to seat a f xed
ceramic-to-metal prosthesis. During the implant insertion,
Kazanjian Vestibuloplasty was performed in the anterior
mandible. (The prosthesis was fabricated 4 months later (Fig. 17)).
To perform implant insertion in the maxilla, alveolar
reconstruction with tibial cortical grafts (in the form of bone
blocks and chips) and bilateral sinus-lifts with Bi o-Oss grains
were performed. The bone augmentation was performed only
in perspective insertion sites, which reduced the extent of the
surgery and the amount of grafted bone. For augmentation,
the vestibular approach with elements of tunnel technique was
used. The recipient and donor sites healed with primary
intention (Figs. 3-5).
In the maxilla, 6 implants were inserted to seat a dental
prosthesis on telescopic crowns. Due to the f at shape of the
alveolar arch, anterior implants were inserted in the positions
of missing canines. During implants insertion, the repaired
bone had good vascularization and no signs of resorption (Fig. 6).
Repaired bone morphology stained with hematoxylin-eosin
showed that grafted bone tissue was viable; it contained viable
osteoblasts and osteocytes. At the periphery of the grafted
bone young bone rods were being formed (Fig. 7). 4 mm
Ant hof t implants with internal octagonal connection were
inserted in positions 13, 15, 23, 25 and 5 mm in positions 17
and 27 f ve months after grafting (Fig. 8). On tibial X-rays 6
months later complete bone repair was noted (Figs. 9,10).
The implant exposure was performed 4 months later using free
palatal epithelial f ap split in the shape of mesh, consequently,
implant abutments were surrounded with dense attached
keratinized gingiva (Fig. 11). Four weeks after the uncovery
surgery, prosthodontic part of the treatment in the maxilla
began.
(Fig ure 1)
Pre-operative frontal
view
(Fig ure 2)
Pre-operative intra-oral
view
(Fig ure 3)
Tibial autogenous
graft
(Fig ure 4)
Collected bone from
the donor site
(Fig ure 5)
Bone graft fixation at
the recipient site
(Fig ure 6)
Good bone
vascularization and
no sign of resorbtion
(Fig ure 7)
Viable osteoblasts
& osteocytes and
young bone rods at
the periphery of the
grafted bone
For the provisional prosthesis, interim abutments (implant
carriers) with external hexagonal connections were used. The
fabricated removable prosthesis was adapted to the inserted
abutments. Due to provisional restoration, the patient received
f xed interim prosthesis soon after the uncovery (Fig. 12).
During the fabrication of f nal prosthesis, the patient was
rehabilitated prosthodontically.
For the f nal restoration, straight Ti n-pl us abutments with a
collar height of 1 mm were used. To select abutments,
orthopedic platform switch technique was used. The abutments
were machined in a surveyor. Zirconium frameworks for the
implant abutments were fabricated and machined with a
dental turbine in the surveyor with an angle of 2(Fig. 13).
In AGC Mi cro Wei l and machine, galvanic caps for zirconium
frameworks were fabricated (Fig. 14). A tertiary framework
(Fig ure 9)
Tibial X-ray immediately
after bone grafting
(Fig ure 13)
Implant abutments
(Fig ure 14)
Galvanic caps for
zirconium framework
(Fig ure 12)
Provisional prosthesis
(Fig ure 11)
Implants surrounded
by dense attached
keratinized gingiva
(Fig ure 10)
6 months after grafting:
complete bone repair
was observed
(Fig ure 15)
Tertiary framework
fixed to galvanic
caps
(Fig ure 16)
Final prosthesis
(Fig ure 17)
Occlusal view of
lower arch
(Fig ure 18)
Final extra-oral view
(Fig ure 19)
Post-operative
panoramic view
(Fig ure 8)
Implant insertion
5 months after grafting
I mpl ant ol ogy
made of chromium-cobalt-based alloy was fabricated to place
on the galvanic caps. The zirconium frameworks were
cemented on the implant abutments with Fuji + cement. The
tertiary framework was f xed to the galvanic caps with Ni met i c
Cem 3M Espe (Fig. 15). The centric relation was determined.
The restoration was checked in the oral cavity. Then, the f nal
prosthesis was f xed (Figs. 16-19).
Conclusions and Discussion
The treatment of total edentualism is a medical and social
problem that is expected to remain in the future due to the
increase in life expectancy. Prosthodontic treatment of the
elderly patient with traditional removable restorations doesnt
allow us to restore completely the functions of the stomatognatic
system and results in a signif cant compromise in patients
quality of life. The prosthodontic treatment of edentulous
patients is more ef ective, but is complicated by a number of
factors, where advanced bone atrophy and changes in oral
mucosa associated with edentulism are the most important.
For this reason, further development and ref nement of bone
reconstruction and soft tissue management are very topical.
Very promising, in our view, is the use of tibial cortical grafts
to perform alveolar reconstruction. The use of tibial grafts has
some advantages over other techniques in that it permits a
greater amount of grafted tissue, has lower morbidity, uses less
invasive surgical technique, is performed in an out-patient
setting, permits a bone repair of good quality and complete
and quick donor site restoration of bone tissue.
When fabricating implant-supported prostheses in general
and removable prostheses in particular, it is vital that the dense
gingival tissue be placed around the implants. The masticatory
mucosa (as the keratinized gingiva is sometimes referred to)
protects the osseointegration zone and prevents inf ammatory
complications. The dense keratinized gingiva is capable of
self-cleaning, which is very important to patients with limited
hygienic skills in older age groups.
In spite of psychological advantages and convenience of use,
an implant-supported f xed prosthesis to treat total edentulism
or/and advanced bone atrophy has a number of disadvantages.
The f rst disadvantage is the complicated hygiene. Both self
care and professional care are prerequisites for long term
function of an implant-supported prosthesis. Sometimes it is
extremely dif cult for patients, especially the elderly, to clean a
f xed prosthetic restoration on all sides. However, the
possibility to remove and clean the restoration and gain access
to implant abutments to clean them is the primary prevention
of mucositis and peri-implantitis and, consequently, implants
loss as a result of inf ammatory complications. The above
described prosthesis construction combines the advantages of
a f xed prosthesis; due to a very precise f t, the patient feels the
prosthesis as a bridge or his own teeth. At the same time, the
patient can take it out and provide hygienic care for the
prosthesis and implants. The second disadvantage of f xed
implant prosthesis, such as FP-3 (f xed prosthesis which replace
crown, part of the root & part of the gingiva) according to
Misch classif cation,
2
is speech disturbance. Too long tooth
crowns and loose contact between a framework and the
palate impede the pronunciation of sibilants and some vowels.
In contrast, a removable prosthesis on telescopic crowns closely
f ts to the palate and doesnt cause such problems. To fabricate
an implant-supported f xed prosthesis, 8 to 10 implants are
required. A prosthesis on telescopic crowns can function, at
least, on 4 implants in the presence of other favorable factors.
4

Fewer implants reduce treatment costs and the extent of bone
reconstruction.
Removable telescopic prostheses are as good as ceramic-to-
metal prosthesis. In addition, they are signif cantly lighter than
ceramic-to-metal prosthesis, whose framework often weighs
more than 40 g (in either arch) in such clinical situations.
They are also lighter than a screw-retained metal-plastic hybrid
prosthesis whose metal framework is by far bulkier and heavier
than a tertiary framework of a removable prosthesis on
telescopic crowns.
The important advantage of this prosthesis is the possibility
to repair as well as the possibility to splint teeth and implants
(taking into account prosthesis biomechanics), which permits
the preservation of proprioceptive sensibility of natural teeth,
which, in turn, protects the prosthesis from overloading.
4
In the
described clinical case, we managed to retain two opposing
natural teeth in the mandible. In addition, change in jaw position
in the sagital plane inevitably occurs in total edentualism, and
the so called senile prognathism precludes the fabrication of a
f xed prosthodontic restoration.
CAD-CAM technology to fabricate a primary prosthesis
framework and galvanic caps by means of galvanoplasty
provides the high precision of the component f t. Passive glue
f xation in the oral cavity sets of possible inaccuracies of the
tertiary prosthesis framework. A galvanic cap and zirconium
framework machined by a special cutter in a water-cooled
dental turbine ideally f t each other and provide smooth and
unimpeded movement of the cap on a primary framework
during insertion and removal of the prosthesis. Due to passive
f xation of the tertiary prosthesis bone tissue around the implants
doesnt experience strains that can occur after f xation of the
traditional metal-cast framework that splints several implants.
Thus, the innovative approach to surgical preparation and
prosthodontic treatment of patients with total edentulism
allows us to perform oral rehabilitation of patients with such
a condition in shorter terms and in out-patient setting and
fabricate implant-supported removable prosthesis on telescopic
crowns made with CAD/CAM technology and with reliable
prosthesis f xation, ease, high esthetic qualities and
convenience of use.
* Thi s ar t i cl e was pr esent ed i n France dur i ng t he 1
st
Int er nat i onal
Ant hogyr Leader s Meet i ng i n Sal l anches on 5,6 Febr uar y 2009.
References
1. The dental aid to the Moscow region population. Statistical data for 2007. Ministry for
health care of the Moscow Region. The Moscow regional board of stomatologists
and oral surgeons. Moscow 2008. pp:72-78.
2. Misch C. Dental Implant Prosthetics. St. Louis: Elsevier MOSBY, 2005.
3. Khoury F, Antoun H, Missika P. Bone Augmentation in Oral Implantology. UK:
Quintessence publ, 2007.
4. Weigl P, Trimpou G, Lee J-H, Krenz E, Arnold R. Inoovatives Behandlungsprotokol zur
Herstellung von Galvano-Konusprothesen. ANHANGStand: Juni 2005.
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Flexibility and reliability
It is essential that a modern implant system provides the
operator with an optimal combination of high f exibility, easy
handling, an ef cient technique and maximum safety and
reliability. Particularly in the case of surgical instruments, it is
essential that the operator can rely fully on the system during
the surgical procedure. The surgical components should be
suitable for use with any indication, even with dif cult cases,
and should be manufactured to a high quality. The design
of the tioLogic
implant system from Dentaurum Implants is

based on more than 18 years experience and on close
collaboration with experts.
www.anthogyr.com
The company ANTHOGYR, created more than 60 years ago, in 1947, benef ts from a very strong experience
and worldwide reputation, through its wide range of dental instruments and implants such as:
ANTHOGYR Bone Col l ect or ASPEO: The Aspeo bone collector is to be attached on the dentals chair
suction system and allows the harvesting of bone fragments during implant site preparation.
AXIOM: new implant system features a unique conical abutment connection for a signif cant and
intuitive connection. With its sub-crestal positioning, AXIOM provides a better aesthetic
management of restorations.
ANTHOFIT: with its internal octagon connection, this implant is easy to use in mouth, f exible
and adapts over time. Available in straight or tapered shape with a BCP body treatment, it is
recommended for juxta-crestal positions. The neck surface treatment helps to promote
attachment to bone at this level.
MONT BLANC CONTRA ANGLES: the new range delivers at last all the features you expected! The new technological
achievements allow easier access and better visibility in mouth. Full range for general dentistry, i.e 5:1, 1:5 and 1:1, and
implantology 1:20, with or without light.
IMPLANTEO: this brushless motor has been designed to complete any implant and surgical procedures.
TORQ CONTROL: the manual dynamometrical declutching wrench Torq Control allows very precise tight locking of the
prosthetic parts on implants. With its adjusting knob, it allows 7 tightening torque values from 10 to 35 N.cm. Once the desired
torque is reached, the tightening is automatically stopped.
Experience acquired in the cold disinfectant and steriliser f elds
for medical-surgical devices has allowed Zhermack to develop
a newly improved, widely ef ective range for dental clinics and
laboratories.
Zeta 1 ultra, Zeta 2 sporex, Zeta 2 enzyme, Zeta 3 ultra,
Zeta 3 soft, Zeta 3 foam, Zeta 3 wipes, Zeta 4 wash, Zeta 5
unit, Zeta 6 hydra, Zeta 7 solution & Zeta 7 spray.
The whole Zhermack products range is active on viruses
(including HIV, HBV, HCV), bacteria, fungus and tubercular
bacilli.
The whole Zhermack products range respect the most
restrictive European norms regarding disinfectants and
sterilisers. Their CE marking further ensures their conformity
with Directive 93/42/CEE on medical devices.
Thanks to careful research protocols, Zhermack products of er
an ideal ef ciency-time ratio by fully respecting the operator
and the environment.
ZETA HYGIENE
T e brand NEW Zhermack
Disinfectant range
www.zhermack.com
Fl ash New s
www.hu-friedy.com
EverEdge
Proprietary heat treatment and cryogenic processing ensure
that the superior edge retention and wear characteristics of
EverEdge Technology will last the entire life of the instrument.
Its not a superf cial coating EverEdge Technology scalers can
be sharpened again and again for your best instrument value.
Technology Scalers
EverEdge Technology is unlike anything youve experienced
before in a scaler. Weve applied state-of-the-art technology in
metallurgy, heat treatment and cryogenics to create a superior
stainless steel alloy for scalers and curettes that stay sharper
50% longer than any instrument youve used. That means less
frequent sharpening, less hand fatigue, and greater comfort
throughout the day.
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ISO 10
2 %
4 %
6 %
www. fkg. ch
TOOLS TO KEEP SMI LI N G
M echani cal Gli de Path
SM G handle
Indi cator of uses
For K/ H les and reamers
Fi nd the other ones. . .
4 Launches!
BioEDEN, an International, Britain based, Bio-Technology
company, launched its activity in Amman, Jordan on the 28
th
of
July 2009, in an elegant ceremony held at the British
ambassadors residency.
BioEDEN is the 1
st
company in the world to isolate
mesenchymal stem cells from deciduous teeth which
multiply rapidly and dif erentiate into many dif erent cell types;
these cells can then be introduced to damaged tissues to treat
debilitating conditions. Some scientists say that stem cells may
be used to cure conditions such as Alzheimers, Parkinsons,
diabetes and some cancers. There may also be cosmetic
benef ts as the cells isolated from teeth may be able to be used
to grow new teeth.
Through the partnership with BioInsure, their local agent in
Jordan, people can have the chance to of er their children what
might be their only hope in the future to treat major diseases.
When a childs primary tooth is shed, it is stored in fresh milk,
packed and then sent to BioEDENs laboratories.
Stem cells collected from primary teeth are a viable and ethical
alternative for embryonic stem cells and they grow faster and
have more potential to dif erentiate into other cell types than
adult stem cells.
BioEDEN
launched its activity in Amman
Recent Study Participants are WOWed by the sensitivity free whitening that comes with
Sapphire Professional Chairside Whitening!
Unbelievable brilliance and health
Sapphire Professional Whitening allows you to achieve dramatic results quickly. When used with the Sapphire Supreme Light1,
the system is proven to whiten smiles up to 7 shades in only 30 minutes. Sapphire Professional Whitening also gives you the
f exibility to whiten smiles without light activation. Beyond beautifying smiles you can also protect them from demineralization
and caries, thanks to the integrated f uoride.
With the Sapphire Supreme Light you can also say goodbye to complicated patient setup. Unlike other lights, it does not expose
your patients to harmful UV rays and thus does not require protective sunscreen or face masks.
Easy maintenance for lasting results
Not only can you create bright, white smiles with Sapphire Professional Whitening, but also included in the kit is everything you
need to maintain that radiance. Sapphire After Care is a complete maintenance kit with Sapphire Take Home Whitening.
Sapphire combines the speed of in of ce whitening with the longevity available with home whitening Zero sensitivity.
With Sapphire Professional Whitening, you can bid farewell to sensitivity - the most common patient complaint about whitening.
Not even a pre-treatment Aspirin is needed when you use this breakthrough chairside formula.
MILLENNIUM
Not Just Any Sterilizer
Millennium B+ is Mocoms revolutionary step forward in the f eld of type-B steam
sterilizers. It represents an ideal point of reference in terms of safety, performance
and f exibility.
Millennium B+ is a technologically advanced sterilizer which is also extremely easy
to use. Thanks to its high number of conf guration options and to the corresponding
patented devices, it can satisfy any sterilization requirement, and ensures the highest
performance in every situation.
It is equipped by microprocessor controlled electronics, an advanced sterilization process self-evaluation system (Process
Evaluation System, as def ned by EN 13060), an instant steam generation system, an integrated printer, a robot controlled locking
system, a widescreen liquid crystal display which allows the clear visualisation of all the necessary information in real time and a
wide range of programs specif cally developed for a suitable treatment of the various materials.
Millennium is today a complete line of autoclaves, including four models: Millennium B+, Millennium B, Millennium B2 and
Millennium Bmicro.
www.mocom.it
MM-GP Points
For a perfect match with the Revo-S root canal preparation system, MICRO-MEGA has
just launched the MM-GP Points 0.06 taper gutta percha points.
Advantages:
- Radio-opaque.
- Optimal biocompatibility.
- Easy to place.
- High plasticity and very f exible to mould perfectly to canal walls without bending.
- Colored top for quick and easy ISO number identif cation.
0.06 special taper gutta percha points
www.micro-mega.com
Fl ash New s
- 0.06 special taper ideal for use following continuously rotating canal preparations (ideally Revo-S).
- Cadmium-free fabrication using high quality raw materials.
- Shape that adapts to cold, hot and thermo mechanical condensation techniques.
- 29 mm in length, 60 points (n20-25-30-35-40-45).
Turnstrae 31 75228 Ispringen Germany Phone + 49 72 31 / 803-0 Fax + 49 72 31 / 803-295
www.dentaurum-implants.de E-M ail: info@ dentaurum-implants.de
perfect
aesthetics
easy
handling
maximum
safety
tioLogic
implantology course,
incl. 2 surgical live-operations
December 11-13, 2009 CDC, Ispringen, Germany
For further informationsplease contact: info@ dentaurum-implants.de

Area Manager Middle East:
Mahmoud Lutf
Tel: +962 6 5656404
Mobile: +962 7 95536867
Email: mlutf @go.com.jo

Area Manager Middle East:
Mahmoud Lutf
Tel: +962 6 5656404
Mobile: +962 7 95536867
Email: mlutf @go.com.jo

Aptica Plus B
the faster B class autoclave specially designed
for your handpieces sterilization.
Domina Plus B
designed for a safe, reliable and rapid
sterilization of all your instruments.
Dental X srl
via marzotto 11
36031 dueville vicenza
tel +39 0444 367400
fax +39 0444 367436
e mail dentalx@dentalx.it
internet www.dentalx.it
dx
Dental X a partner with great experience
Dental X ...the sterilization company
Class B sterilization

Area Manager Middle East: Mr. Mahmoud Lutfi
Tel: +962 6 5656404 Mobile: +962 7 95536867
Email: mlutfi@go.com.jo

CAPP Tel: +971 4 3616174; Fax: +971 4 3686883; Mob: +971 50 2793711; info@cappmea.com
www.cappmea.com/aesthetic www.cappmea.com/awards2009
Dr Julian Caplan, UK
British Academy of Cosmetic Dentistry
"Back tooth solutions Cerec is the answer"
"Anterior Cerecs discover their beauty"
Prof. Wolfgang Richter, Austria
President of ESCD
"Excellence in Esthetic Dentistry Using
Adhesive Direct Composite Restorations"
Dr. Luca Dalloca, Italy
"Veneers and Porcelain Crowns
how to make them look natural and real"

Dr. med. dent. Daniel Rothamel, Germany
"Guided bone and tissue regeneration:
success factors and treatment concepts"
Dr. Philippe Tardieu, France
"New Opportunities in Computer Guided
Aesthetic Reconstructions"
Dr. Nael Abouhassan, UAE
"Entice your patient with Clear Aligners"
Dr. M. Qureshi, Pakistan
"The New Frontier in the Reconstruction
of the Atrophic Maxillae"
Prof. Vintzen, Austria
Orofacial Esthetics Interdisciplinary
Aspects in Esthetic Dentistry
Dr. Donald J. Ferguson, Dr. Baltensperger,
Dr. Richard R. Lebeda, Switzerland
"Maximizing Dento-Facial Esthetics
Using Surgical-Orthodontic Techniques"
Dr. Joseph Muhammad, UAE
"Multidisciplinary Management of
Dentofacial Deformity: Achieving
Optimum Results Through a Team Approach"
Dr. Ninette Banday, UAE
Hollywood Smile
Dr. Kakino, France
The face harmony and some
post-orthodonties smiles
Dr.Reza Nokookar, Iran
Surgical procedures in partially
edentulous patients
Dr. Hani A. Salam, Canada
"An Overview of Minimally-Invasive
Facial Rejuvenation Techniques for the Lips"
Dr. Christian Makary, Lebanon
"Hard and soft tissue management:
The key for perfect esthetics"
Prof. Abbas Zaher, Egypt
Orthodontic nishing contributing
to ultimate esthetics
Organized by: Supported by:
Partners:
1
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Program:
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TOTAL HYGIENE SOLUTION
Tel. +39 - 0425 597611 - Fax +39 - 0425 597642
comm.expo@zhermack.com - www.zhermack.com
ZETA HYGIENE PROTECTS YOU AND YOUR PATIENTS!

Zeta Hygiene, the new disinfectant range with broad
spectrum and rapid action, is the most effective range
against infections.
The in-house production technology together with the
strong competence in the formulation of disinfectants
al l ows Zhermack to provi de steri l i zi ng systems,
disinfectants and detergents respecting the environment
and protecting your health.

Unique
Opportunities
not to be
Missed!
GCC Preventive Dentistry Conference
12
th
World Federation for Laser Dentistry Congress
1
st
AEEDC International Orthodontic Meeting
6 Highly Specialized Courses
2
nd
AEEDC Student Competition
UAE International Dental Conference &
Arab Dental Exhibition
www.aeedc.com
65
participating
countries
27,000
highly qualied
professionals &
oral healthcare
providers
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9 - 11 March, 2010
D u b a i In t e rn a t io n a l C o n ve n t io n & Exh ib it io n C e n t re

+ 971 50 4325515
On the 18th of April 1955, Mohammed Sherine Ibrahim El-Attar was born
in Alexandria, the Pearl of the Mediterranean, grew up there, and got his
f rst and second dental degrees from Alexandria University. In 1982 he
f ew to Pittsburgh, USA where he got his Master degree of Dental Science
in Prosthodontics. Back to Egypt, he got his Doctors Degree in Prostho-
dontics from the University of Alexandria in 1986.
We know Professor El-Attar for being a great instructor and lecturer since
1978.
We know him as a renowned speaker and chairman present in almost
every major congress or dental event in our region.
We know him as a leader implantologist since 1984 when he got his fellowship of the
International Congress of Oral Implantologists held in Munich, Germany, and as the chairman of Alexandria
Oral Implantology Association (AOIA) since 1996.
We know him for being such a beloved husband and caring father.
For Smile team, we know him as the spiritual father, strong supporter and intimate friend
Now We know him as the Dean of the Faculty of Dentistry, Pharos University
Your strong personality, professionalism, great experience and wonderful sense of humor are your armors
against the dif cult challenges and major responsibilities such an important position has.
Congratulations
Professor Sherine
Professor Mohammed Sherine El-Attar
Rec ogni t i on
S I M P L I F Y I N G D E N T A L M O T I O N
Via del Pescinale, 77
50041 Calenzano (Florence) - ITALY
m+39 055 8825741 - |+39 055 8825764
info@teknedental.com www.teknedental.com
UNI EN ISO 13485
THE NEW TURBINE WITH
SUPERIOR PERFORMANCE
AND LED ILLUMINATION
THE NEW COUPLING
WITH INTEGRATED LED
LIGHT SOURCE
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Now you can add the latest
LED technology to any dental air turbine
with Multiflex
LUX connection !
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P.O.Box:237
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Lebanon
Phone :+961 4 871 681
Fax:+961 4 871 680
Mobile :+961 70 100 232
Email :info@denterprise-middleast.com
Denterprise Syria
P.O.Box :5874
Damascus Central Post
Syria
Mobile :+963 945 989078
Email :info@denterprise-middleast.com

Allt
ts all bones and systems

Made in Switzerland
Angled Bendable Reverse Cone With Adapter
Middle East Head Ofce
www.denterprise-middleast.com
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KOS Four ways to success
R
KOS A implants are available as pre-angulated implants with a 15 or 25 degree angulation between
implant and abutment. This allows equipping the regions anterior to the maxillary sinus as well as
placement in the (edentulous) front area
KOS B implants provide a bendable neck. The neck is bent right after insertion. KOS B implants are
suitable for circular bridges and if multiple implants are placed and splinted
KOS EB: this reverse cone type features both the aesthetic neck (4.8mm width) and a reverse cone
which allows overcoming differences in the direction of insertion up to 20 degrees
All KOS & KOS A (and BCS) implants may be equipped with angulation adapters. Thos adapters are
cemented or glued onto the original implant head and help to overcome differences in the direction
of insertion of 15 or 25 degrees. Implant analogues for these adapters are available

The KOS concept allows the implantologist to treat virtually all cases without bone augmentations, a
tremendous advantage compared to tradition two-piece systems requiring more width of bone
KOS Implants 4 ways to create angulations in one-piece-implants
R

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