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Smile Dental Journal Volume 4, Issue 1 - 2009
5

Pediatric Dentistry
The Clinical Applications of Tooth Mousse TM and
other CPP-ACP Products in Caries Prevention:
Evidence-Based Recommendations
Dr. Ola B. Al-Batayneh
BDS, MDSc, JDB (Paed),
FRACDS (Paed)
. Assistant Prof. Department
of Preventive Dentistry,
Faculty of Dentistry,
Jordan Univesity of Science
& Technology (JUST)
. Specialist Pediatric Dentistry,
King Abdullah University
Teaching Hospital, Jordan
olabt@hotmail.com
8 Smile Dental Journal Volume 4, Issue 1 - 2009
Abstract
Casein phosphor-peptides-amorphous calcium phosphate (CPP-ACP) products have been
widely used in the field of preventive dentistry. CPP exerts its main effect through binding
and stabilizing calcium and phosphate ions (ACP) in an amorphous, non-crystalline state
where they can enter enamel and enhance remineralization. The following article presents a
background on these products, in addition to the scientific rationale behind their anti-cariogenic
mechanisms and a great deal of useful evidence-based clinical applications.
Key words: CPP-ACP, Tooth Mousse, Recaldent, remineralization, casein, milk.
Since its introduction in late 2002, GC Tooth Mousse has quickly become a useful topical coating
for teeth with a myriad of uses. More and more applications are being suggested for Tooth
Mousse and so the intent of this article was to compile the most common applications. If you
already use Tooth Mousse, it’s hoped that you may find some additional applications by reading
through the growing body of evidence supporting its clinical effectiveness. If you haven’t
tried this amazing product, you will find lots of encouragement to sample the product.
Casein Phosphopeptides (CPP)
Casein, a bovine milk phosphor-protein is known to interact with calcium and phosphate and
is a natural food component. 1 Its technical name is casein phosphor-peptides-amorphous
calcium phosphate, or CPP-ACP. It was discovered by Prof. Eric Reynolds at the school of
Dental Science at the University of Melbourne in Australia. Casein phosphor-peptides (CPP)
are responsible for the high bioavailability of calcium from milk and other dairy products.
CPP have the ability to bind and stabilize calcium and phosphate in solution, as well as to
bind to dental plaque and tooth enamel. Calcium phosphate is normally insoluble, i.e. forms
a crystalline structure at neutral pH. However, the CPP keeps the calcium and phosphate in
an amorphous, non-crystalline state. In this amorphous state, calcium and phosphate ions can
enter the tooth enamel. The high concentration of calcium and phosphate ions in dental plaque
have been extensively researched and proven to reduce the risk of enamel demineralization and
promote remineralization of tooth enamel. 2
Casein phosphor-peptides (CPP) containing the cluster sequence [-Ser(P)-Ser(P)-Ser(P)-Glu-Glu]
have a remarkable ability to stabilize calcium phosphate in solution and substantially increase
the level of calcium phosphate in dental plaque. 3
Reynolds and coworkers, in a series of publications (reviewed in 1999), demonstrated the
role of casein in the anti-cariogenic and the enamel-protective effects of milk. 4 Calcium and
phosphate bound to the protein became available under the acid conditions of the plaque
and reduced demineralization. The investigators isolated casein phospho-peptides from milk
that react with high concentrations of calcium and phosphate to form colloidal amorphous
calcium phosphate complexes (CPP-ACP). 4
The CPP-ACP products contain no lactose which is the carbohydrate in milk that can cause
gastrointestinal upset sometimes seen with dairy-based products. Therefore, despite its dairy
origin, gastrointestinal symptoms are not seen with CPP-ACP. However, patients with a known
allergy to milk protein should avoid products containing CPP-ACP because they will be allergic
to the casein protein from which CPP-ACP is derived. 2
Background
Dairy products (milk, milk concentrates, and cheeses) have been shown to be anti-cariogenic
in animal and human in situ caries models. This effect could not be attributed to a change in
level of infection of Streptococcus sobrinus and so was attributed to a direct chemical effect

y cheese components. It has been concluded from many
studies that the protective effect was best attributed to the
phospho-protein casein and calcium phosphate contents of
the cheese. 5,6
Milk is known to be harmful in baby bottle tooth decay.
A condition also termed early childhood caries in which
infants develop rampant tooth decay when they are left to
fall asleep with a bottle of milk, juice or any drink containing
fermentable carbohydrates. Milk pools in the infant’s mouth
over a prolonged time and plaque microorganisms cotinually
ferment the milk lactose. The result is an almost continuous
exposure to acids where plaque accumulates on the teeth
and a progressive dissolution of the tooth enamel under the
plaque occurs. 7
Milk has been shown to be essentially “tooth friendly”
(i.e. its consumption does not increase plaque acidity or
conversely, lower pH) in human trials. Kashket and Yaskell in
1997, using an intraoral caries test system in human
volunteers, demonstrated that enamel demineralization
was reduced by approximately 50% when 3% calcium
lactate was added in the preparation of cookies made with
flour, shortening, and water. 7
Investigators have concluded that milk by itself was not
cariogenic. 8 Some anticariogenic characteristics of milk may
be summarized in the following points:
1. Milk produced only a minimal drop in plaque pH in
subjects who rinsed with milk for 30 seconds after refraining
from tooth brushing for three days, the extent and duration
of which was recognized as non-cariogenic. 9
2. Milk greatly reduced the dissolution of enamel when
extracted teeth were incubated for 24 hours in either
acidified buffers or in saliva. 9
3. Calcium and phosphates in the milk were in large part
responsible for the observed enamel-protective effects. 10
4. The casein products of milk were rapidly absorbed onto
the enamel surfaces and provided resistance to the acid.
Milk itself brought about little enamel demineralization. 11
Supplementation of a normal diet with milk substantially
reduced caries in rats. 8
5. The k-casein fractions in milk can modulate adherence
of a strain of the cariogenic microorganism, Streptococcus
mutans, to hydroxy-apatite. Adherence of Streptococci to
enamel is an important element in the formation of dental
plaque. 12
6. Micellar casein, a dietary component in milk, selectively
modifies the microbial composition of dental plaque,
reducing its cariogenic potential. The Guggenheim et al.
study in 1999 was the first study that demonstrated the
dietary component- micellar casein- that selectively
modifies the microbial composition of dental plaque,
reducing its cariogenic potential. 13
Enamel protective effects of cheese have been studied
and measurements of plaque pH in humans have shown
that cheese consumption does not lead to decreased pH.
Instead, Rugg-Gunn et al., in 1975 found that chewing
cheddar cheese after consumption of sugary food, rapidly
returned the plaque pH towards neutrality. 14 A number of
investigators have proposed various mechanisms to explain
the observed anti-cariogenic effects of cheeses (Table 1). 7

Pediatric Dentistry
Table 1. Anti-cariogenic effects of cheese.
Evidence-Based Anticariogenic Mechanism of CPP-ACP
The anti-cariogenic mechanism of CPP-ACP is achieved by
the incorporation of the nano-complexes of the amorphous
calcium phosphate (ACP) into plaque and onto the tooth
surface. The casein phosphor-peptides (CPP) have an
important role as an ACP carrier localizing the highly solble
calcium phosphate phase at the tooth surface. This localization
maintains high concentration gradients of calcium and
phosphate ions in the subsurface enamel, thereby facilitating
remineralization. 4
Casein phosphopeptide calcium-phosphate complexes
(CPP-CP) have been found to increase the levels of calcium
and phosphate in plaque up to five folds in humans in in
situ caries models and short-term mouthwash studies. 15 The
proposed mechanism of their anticariogenicity is that they
act as a calcium-phosphate reservoir, buffering the activities
of free calcium and phosphate ions in the plaque fluid helping
to maintain a state of supersaturation with respect to enamel
minerals, thereby depressing enamel demineralization and
enhancing remineralization. 16 The binding of ACP to CPP is
pH dependent; with binding decreasing as the pH falls.
Casein phosphopeptide-amorphous calcium phosphate
compounds (CPP-ACP) have been demonstrated to have
anticariogenic potential in laboratory, animal, and human in
situ experiments. 3-5,17-18
Rose (2000a) study investigated these effects by measuring
the affinity and capacity of Streptococcus mutans for CPP-ACP.
The study demonstrated that CPP-ACP binds with about
twice the affinity of the bacterial cells for calcium. Application
of CPP-ACP to plaque may cause a transient rise in plaque
fluid free calcium which may assist remineralization.
Subsequently, CPP-ACP will form a source of readily available
calcium to inhibit demineralization. 18
Rose (2000b) investigated the effects of casein phospho-peptides
(CPP) in reducing demineralization and enhancing reineralization
in tooth enamel by measuring the effect of CPP-ACP on
calcium diffusion in plaque. 19 Calcium diffusion was measured
in streptococcal model plaques. This demonstrated that by
providing a large number of possible binding sites for calcium,
0.1% CPP-ACP reduces the calcium diffusion coefficient by
about 65% at pH 7 and 35% at pH 5. Hence, CPP-ACP binds
well to plaque, providing a large calcium reservoir within
the plaque and slowing diffusion of free calcium. This is
likely to restrict mineral loss during a cariogenic episode
and provide a potential source of calcium for subsequent
remineralization. 19
CPP-ACP has been shown in animal studies to enhance the
10 Smile Dental Journal Volume 4, Issue 1 - 2009
effects of fluoride. Animals receiving 0.5% CPP-ACP and 500
ppm fluoride had significantly lower caries activity than
those animals receiving either CPP-ACP or fluoride alone.
This is actually not surprising, since fluoride requires a good
source of calcium and phosphate for remineralization of
tooth enamel with the more acid-resistant fluorapatite, and
CPP-ACP provides this in an amorphous, soluble form. 2,17
In a human in situ enamel demineralization study, a 1.0%
w/v CPP-ACP solution used twice daily, produced a 51±19%
reduction in enamel mineral loss caused by frequent sugar
solution exposure. 3 The twice daily use of the 1.0% CPP-ACP
solution resulted in a 144% increase in calcium level and a
160% increase in inorganic phosphate level. 3 These results
suggested that an anticariogenic mechanism for the CPP-ACP
exists, where the CPP stabilizes and localizes ACP at the
tooth surface, thereby buffering plaque pH, depressing
enamel demineralization and enhancing remineralization. 3
These results were extended by the incorporation of
CPP-ACP into sugar-free chewing gum and in situ clinical
studies demonstrated that the addition of 1.0% CPP-ACP to
either sorbitol or xylitol-based gym resulted in an increase
in enamel remineralization of 100% relative to the control
gum. 20 Shen and Reynolds in 2001, in an in situ human
study showed that CPP-ACP in a sugar-free chewing gum
enhanced remineralization of enamel subsurface lesions in
situ by 100-150%, when compared with the control sugar-free
gum not containing CPP-ACP. 21 The results revealed a doserelated
increase in enamel remineralization independent of
chewing gum weight and type.
Reynolds in 2003 performed a clinical study that compared
the ability of CPP-ACP with that of other forms of calcium,
to be retained in supragingival plaque and remineraize
enamel subsurface lesions in situ when delivered in a
mouthrinse or sugar-free gum. 22 CPP inhibited the tranformation
of amorphous calcium phosphate (ACP) into the crystalline
phases, such that they did not directly promote calculus
formation like other plaque mineralizing solutions. The
study indicated that the CPP-ACP was superior to that
achieved with other forms of calcium in remineralizing
enamel susurface lesions. 22
A recent study by Kumar in 2008 has proved great efficiency
of CPP-ACP in remineralization of initial enamel lesions and
showed a higher remineralizing potential when applied as
a topical coating after the use of a topical toothpaste (1100
ppm), than when used alone. 23 Since additive effects were
obtained when CPP-ACP is used in conjunction with fluoride,

it can be recommended that CPP-ACP should be used as
a self-applied topical coating after the teeth have been
brushed with a fluoridated toothpaste by children who
have a high caries risk. 23
Interaction of CPP-ACP with Fluoride
The CPP-ACP and fluoride have been shown to have additive
effects in reducing caries experience. The additive anticariogenic
effect of the 1.0% CPP-ACP and 500ppm fluoride in the rat
caries experiments led to the investigation of the potential
interaction between the CPP-ACP and fluoride. 17 The fluoride
ion had incorporated into the ACP phase that was stabilized
by the CPP to produce a novel amorphous calcium fluoride
phosphate phase (ACFP) at the tooth surface. The identification
of this novel amorphous calcium fluoride phosphate (ACFP)
phase led to the proposition that the formation of this phase
is responsible for the observed additive anticariogenic effect
of CPP-ACP and fluoride. 17
The formation of fluoroapatite, calcium and phosphate
ions must be co-localized in plaque at the tooth surface
with the fluoride ion for promoting enamel remineralization.
Therefore the additive anti-cariogenic effect of CPP-ACP and
fluoride may be attributable to the localization of ACFP at the
tooth surface by the CPP, which would co-localize calcium,
phosphate and fluoride. CPP may be an excellent delivery
vehicle for the co-localization of calcium, phosphate, and
fluoride at the tooth surface in a slow release amorphous
form with superior clinical efficacy. 3
Mazzaoui et al. in 2003 evaluated the effect of incorporating
CPP-ACP into a self-cured glass ionomer cement (GIC) in order
to enhance its anticariogenic potential. 24 Incorporation of
1.56% w/w CPP-ACP into the GIC significantly increased
microtensile bond strength to dentin by 33%, increased its
compressive strength by 23% and significantly enhanced
the release of calcium, phosphate, and fluoride ions at neutral
and acidic pH. The release of CPP-ACP and fluoride from
the CCP-ACP-containing GIC as the acid erodes the cement
was associated with enhanced protection of the adjacent
dentin during acid challenge in vitro. It was concluded that
the 1.56%-CPP-ACP-containing GIC might be a superior
restorative/base with an improved anticariogenic potential. 24
Furthermore, CPP has been shown to keep calcium, phosphate
and fluoride as ions in solution, thereby enhancing the efficacy
of the fluoride as a remineralizing agent. 2
CPP-ACP has been incorporated into commercial products
by (GC corporation, Tokyo, Japan) such as:
1. GC Tooth Mousse (water based, sugar free crème with
various flavors available).
2. GC MI Paste Plus (with the incorporation of 900 ppm fluoride).
3. Recaldent Chewing Gum (xylitol and CPP-ACP).
4. Recaldent Lozenges.
Clinical Applications of CPP-ACP
The applications of CPP-ACP include 25 ;
- Used for both primary and permanent teeth. Fluoride-free
regular Tooth Mousse is a safe product to use in babies’
teeth especially young children under 2 years of age with early
childhood caries.
- Used for patients with special needs such as those with
intellectual impairment, developmental and physical disabilities,
cerebral palsy, Down syndrome and those with any medical

Pediatric Dentistry
problems such as those undergoing radiation therapy.
- Used for high caries-risk patients in an attempt to remineralize
early enamel lesions, early childhood caries, stabilize carious
lesions awaiting treatment and root surface caries.
- Used in cases of molar incisor hypomineralization (MIH).
This is done for remineralizing hypoplastic molars and
remineralization of white spot lesions (enamel opacities and
some cases of mild fluorosis).
- Used in cases of erosion whereby it neutralizes acid challenges
from internal and external acid sources. 26
- Used in the prevention of tooth wear.
- Used in patients with orthodontic appliances for the purpose
of caries prevention and prevention/remineralization of
white spot lesions.
- Used to reduce dentinal sensitivity by occluding patent tubules.
- Used as a substitute for toothpaste in those allergic to
commercial toothpastes.
Instructions for Clinicians on the Use of Tooth Mousse (TM)
1. Explain the following product characteristics to the patients/
child’s parent:
- Tooth mousse is commercially available through dentists only.
- The active ingredient is derived from cow’s milk, and
therefore cannot be used for patients with allergies to
cow’s milk (milk protein allergy), but can however be used
for patients complaining of lactose intolerance since no
lactose is present in Tooth Mousse. Besides, patients who
have an allergy to benzoates or some other components
shouldn’t use the product.
- The product has been extensively tested; very safe with
minimal side effects, if any. It has been classified by the
United States Food and Drug Administration as GRAS (generally
recognized as safe). Any material that is swallowed is safe
as it will contribute to dietary calcium. It can be used with
patients of any age.
- The product is highly effective for re-mineralization of
enamel and works well with fluoride.
- The product has a pleasant taste and comes with different flavors.
2. Explain benefits of TM for enamel hypoplasia, cases of
erosion, caries prevention...etc.
3. Explain the proper way of using TM;
- It should be rubbed on tooth surfaces after brushing
and no rinsing should be done after that.
- It should be used twice daily; after morning toothbrushing
and before going to bed, avoiding eating or drinking for
30 minutes afterwards.
4. Obtain parents’ consent before using the product in children;
- Explain the need to evaluate the product to determine
the effects on your patient for long term use.
- Explain the need to contact the dentist if any problem arises.
5. Evaluate product use; review the patient at 1, 3, 6 and 12
months. File in case notes in patient’s chart.
Conclusions
Based on the previous literature and the proven efficacy of
CPP-ACP products through clinical and laboratory studies,
it seems that we should shift our ways of caries prevention
to include products such as CPP-ACP in our prevention
schemes for patients through remineralization of enamel
and application of minimal invasive approaches in dentistry.
Recent studies support the use of fluoride in toothpastes
and gels with CPP-ACP. CPP-ACP products are recommended
12 Smile Dental Journal Volume 4, Issue 1 - 2009
to be used twice daily and are safe to be used in young
children. Their use seems to be rewarding in the field of
preventive dentistry.
References
1. Reeves R, Latour N. Calcium phosphate sequestering phosphopeptide
form casein. Science 1958 Aug;128: 472.
2. Walsh LJ. Preventive Dentistry for the general dental practitioner. Aust
Dent J. 2000 Jun;45(2):76-82.
3. Reynolds EC. Anticariogenic complexes of amorphous calcium
phosphate stabilized by casein phosphopeptides: a review. Spec Care
Dentist. 1998 Jan-Feb;18(1):8-16.
4. Reynolds EC. The role of phosphopeptides in caries prevention. Dental
Perspectives 1999;3:6-7.
5. Reynolds EC. Remineralization of enamel subsurface lesions by casein
phosphopeptide-stabilized calcium phosphate solutions. J Dent Res.
1997 Sep;76(9):1587-95.
6. Scholz-Ahrens KE, Schrezenmeir J. Effects of bioactive substances in
milk on mineral and trace element metabolism with special reference to
casein phosphopeptides. Br J Nutr. 2000 Nov;84 Suppl 1,S147-53.
7. Kashket S, Yaskell T. Effectiveness of calcium lactate added to food in reducing
intraoral demineralization of enamel. Caries Res. 1997;31(6):429-33.
8. Reynolds Ec, Johnson IH. Effect of milk on caries incidence and bacterial
composition of dental plaque in the rat. Arch Oral Biol. 1981;26(5):445-51.
9. Jenkins GN, Ferguson DB. Milk and dental caries. Br Dent J. 1966 May
17;120(10):472-7.
10. Weiss ME, Bibby BG. Effects of milk on enamel solubility. Arch Oral Biol.
1966 Jan;11(1):49-57.
11. Bibby BG, Huang CT, Zero D, Mundorff SA, Little MF. Protective effect of
milk against in vitro caries. J Dent Res. 1980 Oct;59(10):1565-70.
12. Vacca-Smith AM, Van Wuyckhuyse BC, Tabak LA, Bowen WH. The effect
of milk and casein proteins on the adherence of Streptococcus mutans
to saliva-coated hydroxyapatite. Arch Oral Biol. 1994 Dec;39(12):1063-9.
13. Guggenheim B, Schmid R, Aeschlimann JM, Berrocal R, Neeser JR. Powdered
milk micellar casein prevents oral colonization by Streptococcus sobrinus
and dental caries in rats: A basis for the caries protective effect of dairy
products. Caries Res. 1999 Nov-Dec;33(6):446-54.
14. Rugg-Gunn AJ, Edgar WM, Geddes DA, Jenkins GN. The effect of different
meal patterns upon plaque pH in human subjects. Br Dent J. 1975 Nov
4;139(9):351-6.
15. Reynolds EC. The prevention of sub-surface demineralization of bovine
enamel and change in plaque composition by casein in an intra-oral
model. J Dent Res. 1987 Jun;66(6):1120-7.
16. Reynolds EC. Remineralization of enamel subsurface lesions by casein
phosphopeptide-stabilized calcium phosphate solutions. J Dent Res.
1997 Sep;76(9):1587-95.
17. Reynolds EC, Cain CJ, Webber FL, Black CL, Riley PF, Johnson IH, et al.
Anticariogenicity of calcium phosphate complexes of tryptic casein
phosphopeptides in the rat. J Dent Res. 1995 Jun;74(6):1272-9.
18. Rose RK. Effects of an anticariogenic casein phosphopeptide on
calcium diffusion in streptococcal model dental plaques. Arch Oral Biol.
2000 Jul;45(7):569-75.
19. Rose RK. Binding characteristics of streptococcus mutans for calcium
and casein phosphopeptide. Caries Res. 2000 Sep-Oct;34(5):427-31.
20. Reynolds EC, Black CL, Cai F, Cross KJ, Eakins D, Huq NL, et al. Advances
in enamel remineralization: casein phosphopeptide amorphous calcium
phosphate. J Clin Dent. 1999;10:86-88.
21. Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC. Remineralization of
enamel subsurface lesions by sugar-free chewing gum containing casein
phosphopeptide-amorphous calcium phosphate. J Dent Res. 2001
Dec;80(12):2066-70.
22. Reynolds EC, Cai F, Shen P, Walker GD. Retention in plaque and remineralization
of enamel lesions by various forms of calcium in a mouthrinse or sugar-free
chewing gum. J Dent Res. 2003 Mar;82(3):206-11.
23. Kumar VL, Itthagarun A, King NM. The effect of casein phosphopeptideamorphous
calcium phosphate on remineralization of artificial caries-like
lesions: an in vitro study. Aust Dent J. 2008 Mar;53(1):34-40.
24. Mazzaoui SA, Burrow MF, Tyas MJ, Dashper SG, Eakins D, Reynolds EC.
Incorporation of casein phosphopeptide-amorphous calcium phosphate
into a glass-ionomer cement. J Dent Res. 2003 Nov;82(11):914-8.
25. Walsh L. MI paste, MI paste plus. Anthology of applications. Available
at: URL:http://www.gcamerica.com/products/hp/MIPaste/mipaste_
cookbook.pdf. Accessed 10th Feb 2009.
26. Piekarz C, Ranjitkar S, Hunt D, McIntyre J. An in vitro assessment of the
role of Tooth Mousse in preventing wine erosion. Aust Dent J. 2008
Mar;53(1):22-5.

Endodontics
Proven Strategies to Improve Endodontic Success
and Promote Natural Tooth Retention
Dr. Richard E. Mounce
DDS
. International lecturer in
endodontics
. Private practice Vancouver,
WA, USA
Lineker@comcast.net
16 Smile Dental Journal Volume 4, Issue 1 - 2009
Abstract
A series of clinically relevant steps to enhance the clinical success of endodontic therapy is
presented. Emphasis has been placed on use of the surgical operating microscope, straight
line access, patency, copious irrigation, frequent recapitulation, passive rotary nickel titanium
file use, bonded obturation and placement of an early coronal seal.
Key words: Root canal, treatment planning, patency, straight-line access, recapitulation,
bonded obturation.
While materials and methods to clean shape and fill the root canal space might differ, the
principles required do not. The goal of endodontic therapy is the three dimensional cleaning,
shaping and obturation of the canal space from the orifice to the minor constriction (MC) of
the apical foramen. Coincident and vitally important to the long-term success of endodontic
treatment is the placement of a coronal seal and a final restoration to provide function and
esthetics. 1-4
To achieve this goal, all mechanical shaping procedures must follow the same principle driven
criterion. These criterion include:
• Keeping the MC at its original position and at its original size.
• Keeping the canal in its original orientation and position within the root.
• Making the final prepared shape to resemble a tapering funnel, with a taper that is continuous
along all levels of the root.
• Preparing the canal to a biologically relevant master apical file (MAF) size. This implies that
the clinician will remove dentin circumferentially at the MC.
• Preparing the canal to a biologically relevant master apical taper.
• Both that the MAF and master apical taper (MAT) are a size that facilitates the optimal flow
of irrigants. At the same time, this size should not predispose the roots to either canal transportation
or vertical root fracture.
In the most general sense, files shape the canals but they do not clean canals. While irrigation
as we know it today does not render a canal bacteria free, especially of biofilms, the goal of
irrigation, during and after the shaping of the root canal system, is to kill bacteria, flush debris,
lubricate, clear the smear layer and dissolve pulp tissue in all the areas of the canal that shaping
instruments do not reach to. In concept, this combination of shaping goals and irrigation acts
to clear the pulp space in such a manner as to facilitate apical healing through diminishing
the bacterial load present within the root canal system once the coronal seal is placed.
Several key concepts guide the steps in endodontic therapy. Adherence to these principles
can enhance the long-term prognosis and improve healing and success rates. These concepts
are, to a large degree, independent of the materials used and include:
The Surgical Operating Microscope
Use of the surgical operating microscope (SOM) increases the visual acuity of all stages of the
endodontic treatment process, for example the use of Global Surgical microscope (Global
Surgical, St. Louis MO, USA). The benefits of the SOM cannot be overstated. Most SOMs have
between 3-6 magnification steps that range from approximately 2x-19x magnification power,
some even more. This allows the clinician to move between powers as the case might require.
In essence, in occlusal access, less magnification is needed and lower powers are used. Once
access is made, the actual location of the canal can be easily found at higher powers and
direct the removal of dentin and allow easier negotiation of the canal space throughout the
initial stages of treatment. In clinical terms, this means that; 2 nd mesial-buccal canals can
virtually always be located with the SOM and improve the chances of their negotiation, that
separated (fractured) rotary nickel titanium (RNT) files can usually be removed, that vertical

Endodontics
(Figure 1)
The surgical operating microscope
(Global Surgical, St. Louis, MO, USA).
(Figure 2 a)
Lack of Straight-line access and
improper orifice management. (Image
courtesy of Dr. Arnaldo Castellucci).
(Figure 2 b)
Straight-line access and proper orifice
management. (Image courtesy of Dr.
Arnaldo Castellucci).
(Figure 3)
EndoBender pliers (SybronEndo,
Orange, CA, USA) used to pre curve
hand K files for negotiation.
and furcal floor fractures can be observed easily, amongst
a host of other important clinical information. Besides, tactile
control at all levels of the process is improved. The use of the
SOM is not limited to endodontics, but rather the instrument
has application in a wide variety of clinical situations that
include all phases of general dentistry. Many teeth that
would have had apical surgery in the past can now be
retreated with great precision as the previous technical
18 Smile Dental Journal Volume 4, Issue 1 - 2009
deficiency can often be addressed, in part, because it can
both be observed and addressed (Fig. 1).
The Straight-line Access
Straight-line access is essential. Compromises in access can
and will lead to deficiencies in apical third cleaning and
shaping. A lack of straight-line access leads to a loss of both
hand and rotary nickel titanium tactile control. Iatrogenic
events are far more likely to occur without straight-line
access as shaping instruments deflect off of the canal walls
they should not touch. Irrigation becomes less effective
as both the access to and the visualization of the orifices is
diminished. Removal of the cervical dentinal triangle (CDT)
is also critical to provide straight-line access. Straight-line
access under the SOM provides the best possible platform to
manage the shaping of the orifice as well as canal enlargement.
Removal of all coronal restorations, including crowns, is
most ideal. Often caries, coronal fractures, unset restoratives
amongst other sources of coronal leakage are hidden under
restorations. It is possible and occurs frequently enough,
that some teeth, which may appear restorable, once all
coronal restorations are removed, are found to be non
restorable, knowledge of which has obvious clinical benefit (Fig. 2).
Patency of the Canals
Patency is highly valued and ideally obtained and maintained
throughout the process of enlargement. The vast majority
of the iatrogenic events that bedevil clinical procedures can
be avoided through the intelligent, copious and proper use
of hand K files. Once an orifice is uncovered, the cervical
dentinal triangle removed and the orifice enlarged, it is
advisable to use small hand K files to assure the clinician
that the canal is open, patent and negotiable. Some canals
will be open and negotiable easily to the minor constriction
(MC) and others will need to be opened with hand K files to
the MC. Before the use of rotary nickel titanium instruments,
all canals should be enlarged to a minimum #15 hand K file
size ideally to the MC. These hand K files should be precurved
to make them match the expected canal curvature. In addition,
hand K files can be trimmed to match the optimal point of
use. For example, if the clinician is having a challenge getting
past 18 mm in a 22 mm root, using a 25 mm hand K file will
not be efficient as a negotiation instrument. The hand K file
in this example will buckle easily and lack function. Little
intentional pressure will be possible in attempting to bypass
a ledge or blockage. The hand K file can be trimmed to a
length that is slightly longer than the ledge or blockage. In
this example, if the clinician were to cut the hand K file to
19 mm, and precurve it as well, many ledges, calcification,
acute curvatures can be bypassed and allow the creation of
patency (Fig. 3).
Once patency is achieved, and the hand K files reach the
position of the MC, the use of a reciprocating handpiece is
highly valuable in efficiently shaping a glide path to make
way for the use of rotary nickel titanium instruments. The
M4 Safety Handpiece (SybronEndo, Orange, CA, USA) can
be used for this function. The M4 is a reciprocating handpiece
with an attachment that fits onto an electric motor with
an E type coupling, such as the TCM III motor (SybronEndo,
Orange, CA, USA). Hand K files are reciprocated at 900 rpm
at the 18:1 setting. Reciprocation provides the movement of

a hand K file 30 degrees clockwise (CW), 30 degrees counter
clockwise (CCW) and/or it may have some other vertical
competent or degree of CW/CCW movement depending on
the brand used. Clinically, once the hand K file can reach
the MC, the file is left in the canal and the clinician’s hands
are taken away. The M4 is attached to the file and the foot
pedal engaged to power the file. The file is moved with a
vertical amplitude (up and down motion) of 1-3 mm and in
15-30 seconds the canal that may have, for example, barely
allowed a #6 hand K file to be inserted, will enlarge the canal to
the size of a #8 hand K file. The #8 hand K file when reciprocated
next will create the size of a #10 hand K file...etc. This early
enlargement of canals with reciprocation is much faster and
predictable than the manual use of hand K files. Once a #15
hand K file can spin freely at the MC, the canal is ready for
rotary nickel titanium files use. The clinician should irrigate
and recapitulate the canal after every use of the M4 as well
after every use of rotary nickel titanium files. Recapitulation
refers to the placement of a hand K file into the canal after
every RNT insertion to verify that the canal is still open and
negotiable. Recapitulation is usually done with either #6 or
a #8 hand file.
It is not advised to take a hand K file, place it in the M4
handpiece and attempt to drive it to the MC in a calcified
canal as ledging will result. In addition, some canal enlargement
systems recommend reciprocation for the entire preparation.
While these systems have their champions; the possibilities
for canal transportation above a #15 hand file in delicate
apical anatomy are substantial.
Irrigation
Irrigation should be copious and continuous throughout
the instrumentation phase of treatment. The use of EDTA
gel for emulsification is advised in the elimination of vital
and necrotic pulp tissue from the chamber during access
procedures, for example File Eze (Ultradent, South Jordan, UT,
USA). Once the chamber is cleared, and orifices are ready to
be entered, the clinician can change to their liquid bactericidal
irrigant. For vital cases, 5.25% sodium hypochlorite (SH) is
the ideal irrigation solution. The use of 2% Chlorhexidine
(CHX) is however ideal for non-vital and retreatment cases.
The difference is related to the tissue dissolving capability
of SH, a quality that is more essential in vital cases. SH which
carries with it potentially severe toxicity if extruded into the
apical tissues. Its use is much less desirable if a perforation
or open apex is present. CHX is relatively non-toxic and in
the endodontic literature relatively equal in efficacy to SH
without the toxicity. CHX also possesses antimicrobial qualities
after it has been removed from the canal. Its drawback,
while being a relative one, is that CHX does not dissolve tissue.
CHX is effective against E. Faecalis, the primary bacteria
found in cases of endodontic failure.
A final irrigation rinse is used; such as SmearClear (SybronEndo,
Orange, CA, USA), a liquid EDTA solution that is used to
clear the smear layer. In every case, irrigants are heated and
ultrasonically activated. This activation takes place with an
ultrasonic file blank (EMS, Dallas Texas, USA), placed into
an Ultrasonic File Holder (SybronEndo, Orange, CA, USA).
The blank and holder are used with a relatively low power
on an ultrasonic unit with the file blank passively moving
vertically for 15-30 seconds per canal without attempting
to touch the walls. After each activation, the solution is
refreshed. Each canal is activated 2-3 times with both the
bactericidal irrigant and the liquid EDTA solution. A final
rinse of distilled water is carried out. After this rinse, the
smear layer has been cleared and the canal is ready for a
bonded obturation. 5-17
Rotary Nickel Titanium Files
Aside from the strategies above, safe and efficient use
of rotary nickel titanium (RNT) files are a prerequisite for
enlarging canals. RNT instruments must be inserted gently
and passively. Irrespective of the brand or canal third being
shaped, RNT files that are inserted with continuing force,
when the canal resists their advancement, loads the files
with excessive torsion and increases exponentially the
possibilities that the instrument may fracture or that it may
transport the canal. Each RNT file insertion should be followed
by irrigation and recapitulation.
Before RNT file preparation, the clinician should evaluate
the root form to determine the ideal master apical taper
(MAT) and have some concept of the optimal master apical
file (MAF). While a modification of the expected MAF and
MAT will be possible, it is vital that the canal be prepared
to an MAF and MAT of an adequate size. Adequate size in
this context implies a size that gives optimal irrigation and
in which SystemB heat pluggers can achieve their desired
length of insertion apically.
RNT that are manufactured by grinding, are usually prepared
to a taper of .06. This limited taper size is a result of the limitations
of ground file technology. The Twisted File (SybronEndo,
Orange, CA, USA) allows the preparation of canals to larger
tapers and does so, safely and efficiently. For large canals
(the palatal canal of an upper molar), a .10 taper Twisted File
(TF) is often appropriate. For more intermediate canals (the
mesial root of a lower molar), a .08 TF is often appropriate. For
small, complex and calcified canals, (lower anterior teeth) a
.06 TF is often appropriate.
TF can often be used in a single file technique and done
so with as few as 2-3 insertions. As a single file technique,
if the given TF will allow passive insertion to the true working
length, it can be taken apically to the MC. With practice,
fewer TF files and insertions are needed to accomplish the
same preparation as the clinician becomes more experienced
with the instruments. TF eliminates the need for
Gates Glidden drills and other orifice openers. It is rotated
in hands at between 500-900 rpm with the torque control
off. Regardless of the RNT system used, there is no value in
pumping the RNT file into the root repeatedly, one insertion is
made to resistance, the file withdrawn, irrigation and
recapitulation ensues and the desired TF is inserted next (Fig. 4).
Warm Obturation
Obturation should ideally be performed warm in order to
move a heat-softened mass of material into all of the
ramifications of the cleared root canal space. While a
number of warmed techniques have been suggested and
proven in the literature, what is more important than the
given technique per sey, is that the canal is three dimensionally
filled with obturating material from the orifice to the MC.
Coincident to this goal is the desire to have a minimum film
thickness of sealer. While a comprehensive discussion of
Smile Dental Journal Volume 4, Issue 1 - 2009
19

Endodontics
(Figure 4)
The Twisted File
(SybronEndo, Orange, CA,
USA).
(Figure 5)
RealSeal Bonded
Obturation. SEM courtesy
of Dr. Martin Trope.
(Figure 6)
RealSeal One Bonded
Obturators (SybronEndo,
Orange, CA, USA).
(Figure 7)
Maxcem Elite (Kerr,
Orange, CA, USA).
(Figure 8-10)
Clinical cases using the materials and concepts discussed.
20 Smile Dental Journal Volume 4, Issue 1 - 2009
obturation techniques is beyond the scope of this paper, suffice
it to write that a greater degree of resistance to coronal
leakage can be obtained with bonded obturation than
gutta percha. Gutta percha does not bond to dentin. Gutta
percha does not bond to sealer. Gutta percha requires a
coronal seal to make it function, in that otherwise, if allowed
to challenge gutta percha, in a time dependent fashion,
bacteria will leak along the length of the canal in either the
gap between the gutta percha and the sealer or the sealer
and the canal wall (depending on whether the smear layer
was cleared and a resin based sealer used). 18-25
Due to the limitations of gutta percha, bonded obturation
in the form of RealSeal (SybronEndo, Orange, CA, USA) is
preferred. RealSeal comes in a master cone based and obturator
(carrier) based variety of the product, RealSeal One Bonded
Obturators (SybronEndo, Orange, CA, USA). While the resistance
to leakage is not absolute, bonded obturation in the form of
RealSeal has been shown, in a number of different studies, to be
superior to gutta percha in resistance of coronal microleakage
in both in vivo and in vitro models (Figs. 5 and 6). 26-29
Coronal Seal
After obturation, the placement of a coronal seal is absolutely
correlated with clinical success in the endodontic literature.
Such a seal could be achieved by using Maxcem (Kerr,
Orange, CA, USA); a self adhesive and self-etching composite
for build up procedures and/or coronal seal. Placement of
the coronal seal should be accomplished without delay
while the rubber dam is still on and before the patient is
released from the treatment visit. Doing so will reduce the
possibilities of vertical root fracture due to the lack of a
coronal build up in addition to concerns of microleakage
(Figs. 7-10).
Conclusion
A series of clinically relevant steps to enhance the clinical
success of endodontic therapy has been presented with the
goal of optimizing endodontic therapy as an alternative to
extraction and the placement of implants. Emphasis has
been placed on use of the surgical operating microscope,
straight line access, patency, copious irrigation, frequent
recapitulation, passive rotary nickel titanium file use,
bonded obturation and placement of an early coronal seal.
Acknowledgements
The author does not have a financial interest in any of the
products discussed in this article.

References
1. Naito T. Better success rate for root canal therapy when treatment
includes obturation short of the apex. Evid Based Dent. 2005;6(2):45.
2. Siqueira JF Jr, Rôças IN, Alves FR, Campos LC. Periradicular status related
to the quality of coronal restorations and root canal fillings in a Brazilian
population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005
Sep;100(3):369-74.
3. Nair PN. Pathogenesis of apical periodontitis and the causes of endodontic
failures. Crit Rev Oral Biol Med. 2004 Nov 1;15(6):348-81.
4. Ørstavik D, Qvist V, Stoltze K. A multivariate analysis of the outcome of
endodontic treatment. Eur J Oral Sci. 2004 Jun;112(3):224-30.
5. Vianna ME, Horz HP, Gomes BP, Conrads G. In vivo evaluation of microbial
reduction after chemo-mechanical preparation of human root canals
containing necrotic pulp tissue. Int Endod J. 2006 Jun;39(6):484-92.
6. Van der Sluis LW, Gambarini G, Wu MK, Wesselink PR. The influence of
volume, type of irrigant and flushing method on removing artificially
placed dentine debris from the apical root canal during passive ultrasonic
irrigation. Int Endod J. 2006 Jun;39(6):472-6.
7. De la Casa ML, Raiden G. A scanning electron microscopy evaluation
of different root canal irrigating solutions. Acta Odontol Latinoam.
2005;18(2):57-61.
8. Ari H, Erdemir A. Effects of endodontic irrigation solutions on mineral
content of root canal dentin using ICP-AES technique. J Endod. 2005
Mar;31(3):187-9.
9. Ari H, Erdemir A, Belli S. Evaluation of the effect of endodontic irrigation
solutions on the microhardness and the roughness of root canal dentin.
J Endod. 2004 Nov;30(11):792-5.
10. Law A, Messer H. An evidence-based analysis of the antibacterial effec
tiveness of intracanal medicaments. J Endod. 2004 Oct;30(10):689-94.
11. Lin YH, Mickel AK, Chogle S. Effectiveness of selected materials
against Enterococcus faecalis: part 3. The antibacterial effect of calcium
hydroxide and chlorhexidine on Enterococcus faecalis. J Endod. 2003
Sep;29(9):565-6.
12. Gomes BP, Souza SF, Ferraz CC, Teixeira FB, Zaia AA, Valdrighi L, Souza-Filho
FJ. Effectiveness of 2% chlorhexidine gel and calcium hydroxide against
Enterococcus faecalis in bovine root dentine in vitro. Int Endod J. 2003
Apr;36(4):267-75.
13. Vivacqua-Gomes N, Ferraz CC, Gomes BP, Zaia AA, Teixeira FB, Souza-Filho
FJ. Influence of irrigants on the coronal microleakage of laterally
condensed gutta-percha root fillings. Int Endod J. 2002 Sep;35(9):791-5.
14. Tanomaru Filho M, Leonardo MR, da Silva LA. Effect of irrigating solution
and calcium hydroxide root canal dressing on the repair of apical and
periapical tissues of teeth with periapical lesion. J Endod. 2002
Apr;28(4):295-9.
15. Averbach RE, Kleier DJ. Clinical update on root canal disinfection. Compend
Contin Educ Dent. 2006 May;27(5):284, 286-9.
16. De la Casa ML, Raiden G. A scanning electron microscopy evaluation
of different root canal irrigating solutions. Acta Odontol Latinoam.
2005;18(2):57-61.
17. Zehnder M. Root canal irrigants. J Endod. 2006 May;32(5):389-98.
18. Jenkins S, Kulild J, Williams K, Lyons W, Lee C. Sealing ability of three
materials in the orifice of root canal systems obturated with gutta-percha. J
Endod. 2006 Mar;32(3):225-7.
19. Trope M, Chow E, Nissan R. In vitro endotoxin penetration of coronally
unsealed endodontically treated teeth. Endod Dent Traumatol. 1995
Apr;11(2):90-4.
20. Ray HA, Trope M. Periapical status of endodontically treated teeth in
relation to the technical quality of the root filling and the coronal restoration.
Int Endod J. 1995 Jan;28(1):12-8.
21. Barrieshi KM, Walton RE, Johnson WT, Drake DR. Coronal leakage of
mixed anaerobic bacteria after obturation and post space preparation.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997 Sep;84(3):310-4.
22. Torabinejad M, Ung B, Kettering JD. In vitro bacterial penetration
of coronally unsealed Endodontically treated teeth. J Endod. 1990
Dec;16(12):566-9.
23. Saunders WP, Saunders EM. Assessment of leakage in the restored pulp
chamber of Endodontically treated multirooted teeth. Int Endod J. 1990
Jan;23(1):28-33.
24. Chailertvanitkul P, Saunders WP, Saunders EM, MacKenzie D. An evaluation
of microbial coronal leakage in the restored pulp chamber of root canal
treated multirooted teeth. Int Endod J. 1997 Sep;30(5):318-22.
25. Swartz DB, Skidmore AE, Griffin JA. Twenty years of Endodontic success
and failure. J Endod. 1983 May;9(5):198-202.
26. Leonardo MR, Barnett F, Debelian GJ, de Pontes Lima RK, Bezerra
da Silva LA. Root canal adhesive filling in dogs’ teeth with or without
coronal restoration: a histopathological evaluation. J Endod. 2007
Nov;33(11):1299-303. Epub 2007 Sep 17.
27. Stratton RK, Apicella MJ, Mines P. A fluid filtration comparison of gutta-percha
versus Resilon, a new soft resin endodontic obturation system. J Endod.
2006 Jul;32(7):642-5.
28. Shipper G, Teixeira FB, Arnold RR, Trope M. Periapical inflammation
after coronal microbial inoculation of dog roots filled with gutta-percha
or resilon. J Endod. 2005 Feb;31(2):91-6.
29. Shipper G, Ørstavik D, Teixeira FB, Trope M. An evaluation of microbial
leakage in roots filled with a thermoplastic synthetic polymer-based
root canal filling material (Resilon). J Endod. 2004 May;30(5):342-7.

Forensic Dentistry
Dr. Suhail Hani Al-Amad
BDS, DCD, GradDip ForOdont,
MRACDS (Oral Med), JMC
cert. (Oral Med)
. Assistant Professor of Oral
Medicine,College of Dentistry,
University of Sharjah
suhail_amad@hotmail.com
22 Smile Dental Journal Volume 4, Issue 1 - 2009
Forensic Odontology
Abstract
Forensic Odontology is a relatively new science that utilizes the dentist’s knowledge to serve
the judicial system. Worldwide, dentists qualified in forensic science are giving expert opinion
in cases related to human identification, bitemark analysis, craniofacial trauma and malpractice.
Human identification relies heavily on the quality of dental records; however Forensic Odontologists
can still contribute to the identity investigation in the absence of dental records through
profiling the deceased person using features related to teeth.
Along with other healthcare providers, dentists encounter cases of injuries which could be
non-accidental. Detection, interpretation and management are important from a legal and
humanitarian point of view. Dentists should be aware of the legal impact those cases have,
and should refer them to the appropriate authorities for suitable action.
This article gives an insight to Forensic Odontology and outlines some of its medico-legal applications.
Key words: Forensic Odontology, identification, violence, abuse.
The roles of any forensic scientist are to collect, preserve and interpret trace evidence, then to
relay the results to the judicial authority in a form of a report. Those functions require sound
knowledge in dealing with crime scenes and sufficient acquaintance in law. Forensic Odontology
is the forensic science that is concerned with dental evidence.
The use of teeth as evidence is not recent. There are historical reports of identification by
recognizing specific dental features as early as 49 A.C. However, Forensic Odontology, as a
science, did not appear before 1897 when Dr. Oscar Amoedo wrote his doctoral thesis entitled
“L’Art Dentaire en Medecine Legale” describing the utility of dentistry in forensic medicine
with particular emphasis on identification. 1
Traditionally, Forensic Odontology covered various topics that can be broadly classified into
human identification and injury analysis. However, tasks of Forensic Odontologists have
broadened in recent years to cover issues related to child abuse and domestic violence, human
rights protection and professional ethics.
This article gives a brief overview of some of the roles undertaken by Forensic Odontologists.
Human Identification
Identification is based on comparison between known characteristics of a missing individual
(termed ante-mortem data) with recovered characteristics from an unknown body (termed
post-mortem data).
Identification of the deceased is most commonly achieved visually by a relative or a friend
who knew the person during life. This is performed by looking at characteristics of the face,
various body features and/or personal belongings. However, this method becomes undesirable
and unreliable when the body features are lost due to post- and peri-mortem changes (such
as decomposition or incineration). Visual identification in those circumstances is subject to error.
Methods of human identification that are acknowledged as scientific are fingerprint, DNA,
dental and medical characteristics. 2 Those methods vary in complexity, but share similar level
of certainty. The dental characteristics method is unique in being the easiest and quickest
method of identification.
The diversity of dental characteristics is wide, making each dentition unique. 3 The dental
enamel is the hardest tissue in the body, and would thus withstand peri- and post-mortem
damages, and so would dental materials adjoined to teeth. Being diverse and resistant to
environmental challenges, teeth are considered excellent post-mortem material for identification

with enough concordant points to make a meaningful comparison.
For dental identification to be successful, ante-mortem data
need to be available. This relies heavily on dental professionals
recording and keeping dental notes, radiographs, study
models, clinical photographs…etc. The availability of dental
records will allow comparing the dental characteristics of the
person during life with those retrieved from the person
after death (Fig. 1).
In cases where dental records are not available, Forensic
Odontology can still contribute to establishing the identity
by creating a profile of how the deceased person was during
life. This includes any unusual oral habits, type of diet,
socio-economic status, but most importantly the age of the
person at time of death.
Dental aging is based on the chronology of formation and
eruption of teeth. This helps in determining the age for persons
up to 15 years-old in a fairly accurate manner. After 15 years
of age, dental aging relies on modifications that take place
during life, such as attrition, cementum formation and root
transparency. 4 Despite being extensively studied, results of
aging of this latter group remain less than optimal because
those age-related modifications can be influenced by various
factors, such as diet and dental pathosis. 4
Dentists’ Role in Mass Fatality Incidences
Routine identification tasks are a simple one-to-one matching
process. This is not the case in disasters. Mass fatality
incidences represent a big challenge to local authorities.
Another challenge is the damage inflicted on infra-structure
that includes hospitals, transportation, communications…
etc. which impede recovery.
The identification of deceased victims in those circumstances
necessitates putting a hierarchy system consisting of an
ante-mortem, post-mortem and reconciliation teams. Those
teams are headed by team leaders, with liaison officers to
coordinate the work. The results are reported to an identification
board which is headed by a commander, who in most cases
is a senior police officer.
Forensic Odontologists have contributed to the resolution
of many mass disasters. The 2004 Indian ocean tsunami
is probably the most eminent example on the success
of Forensic Odontologists in identifying large number of
victims in short time. Nearly half of the victims in Thailand
were identified by dental characteristics method alone, and
Forensic Odontologists contributed to the identification
of the remaining half by assisting the fingerprint, DNA and
physical characteristics teams.
Weak, and even absence of dental records did not stop
Forensic Odontologists from contributing to the identification
of tsunami victims in Thailand. Victims with no dental
records were either identified by photographic superimposition,
if a photograph showing upper anterior teeth was provided5 (Fig. 2), or by narrowing down possible matches for the
DNA and fingerprint teams through dental aging.
Bitemark Analysis
Injuries induced by teeth and left on objects, such as skin,
have a distinctive pattern. Those patterned injuries (bitemarks)
are useful to judicial authorities because they help in reconstructing
(Figure 1)
Ante-mortem radiograph
taken by the treating
dentist and post-mortem
radiograph taken by the
Forensic Odontologist
of the unknown
deceased. There are
many concordant points
to establish a positive
identification.
(Figure 2)
Identification by photo-skull
superimposition. The
skull of an unknown
child was superimposed
onto the portrait of a
missing person. The
outline of teeth and
the facial anatomical
similarities suggested
that the skull belongs to
the child in the portrait.
The right central incisor
in the skull was lost after
death.
past events that surrounded the biting process. For example,
bitemarks indicate a violent interaction between the
perpetrator and the victim, and they might tell us something
about the criminal intentions of the perpetrator, whether sexual,
child abuse, or other forms of assaults. Moreover, bitemarks
are the only patterned injuries that can indicate (with different
levels of certainty) who the biter was. By comparing the
locations and measurements of teeth marks in a bitemark
with those of the suspect(s), Forensic Odontologists can
exclude or include persons suspected of causing the bitemarks.
However, several erroneous bitemark analysis, mainly from
the United States courts, rendered this type of evidence
Smile Dental Journal Volume 4, Issue 1 - 2009
23

Forensic Dentistry
questionable. 6 The validity of bitemark analysis has undergone
decent review in the last ten years aiming at boosting the
scientific weight and improving the technique in a manner that
can be reproducible. New research is underway to allow
digital comparison of teeth and bitemarks at a 3-dimensional level. 7
This novel technique is aimed to overcome perspective
distortion, a significant morbid factor in bitemark analysis that
results from reducing 3-dimensional objects to 2-dimensional
images.
Domestic Violence and Child Abuse
The World Health Organization (WHO) has declared that violence
is a major and growing public health problem across the
world. 8 This landmark declaration meant that healthcare
providers are involved in detecting and managing cases
of violence, including abuse to vulnerable populations, i.e.
children, elderly and women.
The WHO further distinguishes four types of violence; physical,
sexual, psychological and neglect. All forms of violence can
manifest in the oro-facial region, and are hence should be
of concern to dentists. Prevalence of physical violence, as a
cause of maxillofacial injuries, ranges from 3.3% to 41% in
various countries. 9 This wide range is probably due to different
reporting thresholds in different communities. The true
prevalence of violence is thus difficult to establish because
of not or under-reporting this problem.
Injuries due to abuse can manifest in the oro-facial region in
various forms, including fractured anterior teeth, fractured
alveolar bone, lacerations of the labial and buccal mucosae,
lacerations to the frenum and bruises to the lips, face and
neck (Fig. 3). Non-accidental injuries have certain characteristics
which help in their recognition (Table 1). 10
The most common site to be non-accidentally traumatized
is the head. 11 Therefore, injuries to the oro-facial region
should raise reasonable suspicion to the treating dentist.
Suspicion should lead to investigation and reporting, but
the reporting must be well-thought of. On one hand, there
is a necessity to report those cases to authorities. But on the
other hand, reporting false cases is stigmatizing and is an
unacceptable interference in the victim’s personal affairs.
In various countries there are laws that govern reporting of
violence. Some laws penalize healthcare workers by
imprisonment, and/or fines, for not reporting violence manifested
on their patients. 12,13 However, due to the sensitivity of this
matter, reporting has to follow a sound mechanism, and be
addressed to a proper authority with specifically-trained
personnel. Readers are advised to search for the proper
reporting authority in their respective countries.
Conclusion
Dental practitioners should be aware of the forensic application
of dentistry. Dental records that are used to provide patients
with optimal dental service could also be very beneficial to
legal authorities during an identification process. Therefore,
all forms of dental treatments should be recorded and kept
properly. Dental clinicians, as other healthcare workers, are
at the forefront in detecting signs of violence appearing
on their patients. They should be aware of the criteria of
abusive injuries, and the reporting mechanisms to ensure a
correct response by the concerned authorities.
24 Smile Dental Journal Volume 4, Issue 1 - 2009
(Figure 3)
Lacerated injury on the
upper lip of a child after
a smothering attempt
(Courtesy of Dr. Mumen S.
Haddidi).
References
1. Bernstein M. Forensic odontology. In: Eckert WG. editor. Introduction to
Forensic Sciences. 2 nd ed. Boca Raton, FL: CRS Press; 1997, p. 304-51.
2. Interpol. Disaster victim identification. Available at: URL:http://www.
interpol.int/Public/DisasterVictim/default.asp. Accessed 5 th Feb 2009.
3. Adams BJ. Establishing personal identification based on specific
patterns of missing, filled, and unrestored teeth. J Forensic Sci. 2003
May;48(3):487-96.
4. Meinl A, Huber CD, Tangl S, Gruber GM, Teschler-Nicola M, Watzek G.
Comparison of the validity of three dental methods for the estimation of
age at death. Forensic Sci Int. 2008 Jul 4;178(2-3):96-105. Epub 2008 Apr 8.
5. Al-Amad S, McCullough M, Graham J, Clement J, Hill A. Craniofacial
identification by computer-mediated superimposition. J Forensic
Odontostomatol. 2006 Dec;24(2):47-52.
6. Bowers CM. Problem-based analysis of bitemark misidentifications: the
role of DNA. Forensic Sci Int. 2006 May 15;159 Suppl 1:S104-9. Epub
2006 Apr 4.
7. Blackwell SA, Taylor RV, Gordon I, Ogleby CL, Tanijiri T, Yoshino M, et al.,
3-D imaging and quantitative comparison of human dentitions and
simulated bite marks. Int J Legal Med. 2007 Jan;121(1):9-17. Epub 2006 Jan 4.
8. World Health Organization. Prevention of violence: a public health problem.
49 th World Health Assembly Resolution WHA49.25: Geneva: WHO, 1996.
9. Eggensperger N, Smolka K, Scheidegger B, Zimmermann H, Iizuka T. A.
3-year survey of assault-related maxillofacial fractures in central Switzerland. J
Craniomaxillofac Surg. 2007 Apr;35(3):161-7. Epub 2007 Jun 20.
10. Mok JY. Non-accidental injury in children--an update. Injury. 2008
Sep;39(9):978-85. Epub 2008 Jul 25.
11. Maguire S. Bruising as an indicator of child abuse: when should I be
concerned? Paediatrics and Child Health. 2008 Dec;18(12):545-9.
12. Government of Dubai. Article 273 Federal Penalties Law of the UAE
Number 3. 1987. Available at:URL:http://www.dc.gov.ae. Accessed 5 th
Feb 2009.
13. Jordanian Legislations. Article 207 Penalties Law of Hashemite Kingdom of
Jordan. 1960. Available at:URL:http://www.lob.gov.jo. Accessed 5 th Feb 2009.

Implantology
Dr. Philippe Tardieu
DDS, PG in Implantology
. Adjunct Associate Professor
New York University
. Founder and owner of
Accuracy Current
Technologies (ACT)
. Founder and President
of One-million Smiles, a
French NGO.
. Private Practice Dubai, UAE
pt@frenchdentistdubai.com
Immediate Smile® Procedure
A Clinical Case Report
26 Smile Dental Journal Volume 4, Issue 1 - 2009
Abstract
Improvement of implantology driven by computers deeply changed our point of view to treat
patients. Using a CT-scan based planning system; the surgeon is able to select the optimal
location for implant placement. Precise osteotomy control is performed using stereo-lithographic
surgical guides. The SAFE System® is a serial instrumentation allowing transfer of planned
implant positions to the mouth. Accuracy in implant placement is such that it allows not
flapless implant placement with a submillimetric precision. Pain and swelling are minimized
using trans-mucosal approach. Since 2002, vertical control of implant placement by the SAFE
System® opened the way to the Immediate Smile® protocol. The prosthesis is made before the
surgery without taking an impression and placed in the mouth during the same appointment
as the surgery. The unique part of this procedure comes from the fact that the temporary
bridge is screw retained on the implants without being relined and without using fancy and
expensive components. The Immediate Smile® technique and components are introduced in
this article and a clinical case illustrates the process.
Key words: Computer-guided implantology, surgical guide, immediate smile, immediate loading.
Since the 1990’s, several medical teams approached the problem of implant cases planning
with the assistance of computer applications. 1-3 More recently other teams were in search of
methods to transfer the data from the computer right to the mouth of the patients. 4,5
Several systems have been designed to allow for an accurate transfer of planned data from
the computer to the mouth of the patients at the time of implant placement. 6-9 Within the
framework of the European Personalized Implants & Surgical Aids (PISA) project, several
industrial companies and universities (Materialise, Philips Medical, Ceka, OBL, DuPuy International,
Katholieke Universiteit Leuven, University of Leeds) have pooled their knowledge between
1997 and the beginning of 2001. This led to the evolution of computer programs for the
planning of implants and the design of custom made stereo-lithographic drill guides: the
ScannoGuides® which is fabricated at the dental lab. This is what is called Computer Guided
Implantology. This format was first validated on cadavers and in 1999 human clinical applications
started. As part of this, we have tested different kinds of situations; partial or total cases, maxillary
or mandibular restorations, implants with vertical or lateral insertion, implants in extended
bone grafts, classical (in 1 or 2 surgical times) and immediate loading protocols, placement of
implants throughout the bone or mucosa and at last, placement of zygomatic, pterygoid and
sphenoid implants. 10,11
We rapidly became aware that the tools of “classical” implantology were not adapted to this
new approach and again accuracy, security and easiness were required during the novel
implant placement approach. This reflection has become a major step towards the finalization
of the SAFE System. 12,13
The SAFE System was so accurate that it lead us to ovoid elevating flaps during implant placement
and thus keeping intact the supracrestal vasculature and allowing real micro access surgery to
be performed in oral implantology. 14 Choosing the proper dense bone available also allowed
us to better stabilize implants and immediately load them. The missing link at that time was
the way to fabricate a screw-retained bridge prior to implants placement. We did not want to
reline the bridge (unless necessary) and we wanted the bridge to be immediately placed into
the patient’s mouth during the same appointment at implant placement.
Since 2002 and to achieve this goal we developed with Materialise Dental collaboration
(Materialise Dental, Leuven, Belgium) the Immediate Smile procedure and components.The
procedure is in this article explained and illustrated by a clinical case.

Case Report
An elderly patient was unhappy with his lower denture after
the recent extraction of his last lower anterior hopeless
teeth (Figs. 1 and 2). He wished to recover a good function.
An Immediate Smile procedure was proposed to him to get
a functional result with minimum intervention and time.
ScannoGuide®
The scannographic template not only allows the transfer of
the predetermined prosthetic set up to the actual implant
planning but also gives us an image of the underlying soft
tissue. Incorporation of the scanning template in the CT
scanning data allows the surgeon to base his implant planning
on the desired prosthetic outcome. The treatment plan is a
synthesis of existing information between bone and teeth
to be replaced. The scannographic template is built out of a
duplicate of the denture of the patient (Fig. 3). For a full arch
reconstruction we use a 30% barium sulfate and resin mix in
weight for teeth and a 10% mix for the base. On the
scannographic template, the main axis of the tooth is
marked by drilling a cylindrical shaft in the tooth, centered
on its occlusal side and emerging at the center of the cervical
surface (Fig. 4). On the scanning images, this cylindrical
shaft is easily visualized.
CT Scanning and Data Conversion
The patient was sent to the radiologist together with the
scannographic template. The CT scan quality is of major
importance. Not only implant placement planning and transfer
will be based on these data, but the Immediate Smile
prosthesis will be also fabricated depending on these data.
After the scan was completed, the radiologist sent the data
to a “data processing center”. A computer engineer edits the
images by removing scattered images and useless parasite
images such as the spinal column, antagonist teeth and ramus
of the mandible when working on a maxillary analysis. The
scanning template can be easily identified in axial sections.
Different anatomic structures such as the maxilla and
mandible and the scannographic template are separated in
different masks. Each of these masks can be toggled on or
off to allow separate visualization and interpretation.
Implant Position Planning
The SimPlant software provides four planes in which it is
possible to modify the outline and display resolution at
one’s convenience (Fig. 5). Each of these planes displays
either the sections at the gray level, or the 3D color
reconstructions. The 3D reconstructions allow seeing the
lingual emergence of the implants, the inferior alveolar
nerve path and the plan of the three retention screws we
(Figure 1)
The clinical case before
extraction of the lower
hopeless anterior teeth.
(Figure 2)
The fabricated lower
denture was used to
change the anterior
guidance during a healing
period of 8 weeks.
(Figure 3)
Denture duplicate used as
a scannographic template.
(Figure 4)
Cylindrical shafts at the
main axis of the teeth.
(Figure 5)
SimPlant software showing
four planes of the scanned
images.
(Figure 6-7)
3D reconstructions showing masks of the inferior
alveolar nerves, masks of the base plate of the
denture and of the teeth of the denture. Note that
not only implants have been planned but also
retention screws to stabilize the surgical guide during
implant placement.
Smile Dental Journal Volume 4, Issue 1 - 2009
27

Implantology
(Figure 8)
Implants’ planned
positions and retention
screws’ positions can
be fine tuned on the 3D
display before sending an
order for a surgical guide.
(Figure 9)
Immediate smile
components including IS
cylinder, centering screw,
retention screw, implant
analogue with flat surface
and internal retention and
a sample of an implant.
(Figure 10)
SAFE System implant
holder and Implant
analogue.
(Figure 11)
3D image of the planned
mucosa-supported
surgical guide SAFE
System.
(Figure 12)
Surgical guide placed
over the lower jaw
stereolithographic model.
This is done to position
the implant analogues and
fabricate the Immediate
Smile screw retained
temporary bridge.
(Figure 13)
The Surgical guide
is perfectly adapted
to the surface of the
stereolithographic jaw
model which includes the
soft tissue.
28 Smile Dental Journal Volume 4, Issue 1 - 2009
planned to use to stabilize the surgical guide (Figs. 6 and 7).
The surgeon is able to view the implant project 3D color
reconstructions and play with 3D images which are called
“masks”. The position of the implant can then be fine-tuned
by shifting, tilting or by adaptation of its dimensions in a
panoramic reconstruction plane (Fig. 8).
The software has some semi-automatic functions to help
the surgeon in placing a newly planned implant between
two other previously placed implants. Another function
helps the surgeon in translating an implant over a certain
amount of space along a predefined curve. The remarkable
versatility of the software in manipulation of the implants
thus helps the surgeon to choose optimal locations for the
implants according to a complex set of prerequisites,
correspondence with the initial prosthetic plan, visual check
that the implant is in all directions encased in bone, optimal
position so that the implant is in a zone with the highest
possible Hounsfield unit value which is correlated to the
biomedical characteristics of the bone namely its hardness.
Pre-Surgical Fabrication of the Immediate Smile Bridge
For the lab procedure, the following components are used
(Figs. 9 and 10)
• An immediate smile (IS) cylinder to fabricate the screw
retained temporary bridge.
• A centering screw allowing correct placement of the IS
cylinder on the implant analogues in the laboratory.
• An IS implant analogue. In certain cases we have been using
fake IS implants and the comparison of these different protocols
will be published in a fore coming article.
• An IS screw, specially designed to allow a horizontal
displacement of plus or minus 0.5 mm around the ideal
implant position.
• An IS implant presenting an internal hex and a flat surface
allowing a horizontal adaptation with the IS cylinder.
• SAFE System implant holders of the pre determined length.
The final bridge is fabricated using standard components.
It is fabricated on a stereo-lithographic model of the jaw
provided by Materialise. This model includes the soft tissue
on implant emergence area. The surface of the soft tissue
is found using the underlying surface of the ScannoGuide.
Holes are pre-prepared to allow placement of implant
analogues (Fig. 11). A surgical guide is pre planned with implants
and retention screws positions (Fig. 12). The surgical guide
is snapped on the stereolithographic jaw model. The Surgical
guide is also used to position implant analogues in the jaw
model. We can notice the perfect adaptation of the SurgiGuide
on the stereo-lithographic model (Fig. 13).
Implants’ analogues are placed using the SAFE System implants’
mounts through the SurgiGuide which has been stabilized
using osteosynthesis screws (Fig. 14). The analogues are
glued from the bottom of the holes to be stabilized inside
the stereo-lithographic model (Fig. 15).
The jaw is mounted in occlusion using the Scannoguide.
The Immmediate Smile (IS) cylinders are placed on the
analogues using the centering screws to fabricate the temporary
bridge (Fig. 16). The SurgiGuide is controlled in the mouth using a
resin template to check the final occlusion, then the bridge is
fabricated and retained with the IS screws (Figs. 17 and 18).
We found out that the accuracy of the SAFE System is such

that the vertical precision is good enough not to use special
components for that. The Immediate Smile components will
correct a horizontal error of plus or minus 0.5 mm all around
the ideal implant position. The design of the Immediate
Smile screws and cylinders allows this horizontal adaptation.
We can notice that the simplicity of these components is
evident and particularly adapted to screw retrained bridges.
This is only possible once the whole chain of accuracy of
Computer Guided Implantology has been respected. We
talk about a submillimetric accuracy that is actually impossible
to appreciate visually. The surgeons need to go through a
learning curve using these systems prior to performing an
Immediate Smile procedure. The more implants support the
bridge the more difficult the case will be.
Implants and Bridge Placement
The finalized treatment plan is used for the fabrication of
a surgical drill guide, with bone, mucosal or teeth support.
The drill guide is produced by stereolithography (USP Class
VI approved resin which is a US norm used for surgical components)
containing medical grade stainless steel tubes. The position
and direction of the cylinders correspond exactly to the
position and direction of the planned implants.
The SAFE System is incorporated in the SurgiGuide. This
system allows the use of drills as well as implant placement
guidance through one and only SurgiGuide. SAFE is the
acronym of Secure, Accurate, Flexible and Ergonomic. It
contains a set of new cylinders to guide not only drilling,
but also to drive the implants in position after drilling. It
also includes new drills, limited to a pilot drill and a final
drill with a flange to introduce depth control. It includes
new implant holders to allow perfect positioning, angulations
and depth of the implants. Some other instruments such as
trephines to remove soft tissue or different kind of taps can
be used too.
One of the major advantages of using SAFE-SurgiGuides
is the exact transfer of implant positions to the mouth. We
have been using a variety of systems to do that. Accuracy
of transfer has been studied by the author and will be soon
published in a book under the title “The Art of Computer-guided
Implantology” by P. Tardieu and A. Rosenfled by Quintessence
publishing, 2009.
The mucosal SAFE-SurgiGuide is in this case directly stabilized
using an occlusal template and secured by several
osteosynthesis screws to prevent it from moving during surgery.
Stabilization of the SAFE-SurgiGuide is mandatory to ensure
accuracy of implant placement and accuracy of the inter-arch
position. With the SAFE System, implants are accurately
placed in position, angulations as well as in depth. Depth
control is done by using a flange
on drills and implants’ mounts
allowing exact implant placement.
A detailed plan was received
setting the SAFE System drill
and implants’ mounts choice
(Fig. 19). Intra-orally, it can be
readily seen that the mandibular
crest is highly resorbed and
(Figure 14)
SAFE system implant
holders are used to
position the implant
analogues inside the jaw
model.
(Figure 15)
Implant analogues are
glued in the jaw model.
(Figure 16)
Centering screws are used
to center the IS cylinders
on top of the implant
analogues.
(Figure 17)
The jam model is mounted
on an articulator using
the ScannoGuide first and
then the temporary bridge
is fabricated.
(Figure 18)
Top view of the 10 teeth
temporary screw retained
bridge showing the space
around the top of the
retention screws. This is
done to allow a horizontal
deviation of 0.5 mm if
needed.
(Figure 19)
This guiding sheet drives
the surgeon to select
the right SAFE drills and
SAFE implant holders to
place the implant in a
very accurate position (30
microns).
Smile Dental Journal Volume 4, Issue 1 - 2009
29

Implantology
(Figure 20)
This figure explains the
way height of drills and
implant holders are
selected based on the
Regulator distance which
is the distance between
the top of the implant to
the bottom of the guiding
cylinder.
(Figure 21)
View of the lower jaw
before starting the surgery.
Note the highly resorbed
bone.
(Figure 22)
SAFE System guide is
placed and secured on the
mucosa using retention
screws. A trephine is used
to remove the soft tissue
before using drills.
(Figure 23)
Accurate implants
placement through the
SurgiGuide isunh SAFE
System implant holders.
(Figure 24)
After implant placement,
the surgical guide is
removed showing the top
of implants. No sutures are
needed at that step.
(Figure 25)
Immediate Insertion of the
presurgically fabricated
bridge.
30 Smile Dental Journal Volume 4, Issue 1 - 2009
the floor of the mouth is close to the level of the crest (Fig.
21). The SurgiGuide SAFE System is placed on the mucosa
and the position with the opposite arch is checked with the
resin template. A 4.0 mm trephine is engaged inside the
titanium guiding cylinders to remove tissues from on top
the osteotomy sites to avoid any soft tissue contamination
during the procedure. We can notice that the guide is securely
stabilized using three retention screws (Fig. 22). Drilling
for implants’ placement is then proceeded and precisely
controlled by SurgiGuide SAFE System. The procedure is not
finished after implant placement (Fig. 23). The prefabricated
bridge should be now seated into the patient’s mouth.
The SurgiGuide is unscrewed, removed and the implants
can be readily seen (Fig. 24). The pre-fabricated bridge is
first placed on one screw without screwing it in depth. Once
all screws are in position, all of them can then be screwed to
the full depth. Very limited occlusal adjustments are usually
requested (Fig. 25) and a panoramic x-ray is taken to check
the adaptation of the bridge on the implants (Fig. 26). We
can appreciate on figure 27 the difference of position of
screws from one cylinder to another one. If a lack of adaptation
appears on one or several implants, it is always simple to
unglue a cylinder, to screw it back on the implant and to
glue it again into the resin bridge in a limited time.
This procedure gives patients an unparallel service that is
highly appreciated due to the limitation of time and of post
operative complications and pain. Within 8 weeks, after implant
validation a 12-teeth-bridge with a metal framework is
performed (Fig. 28).
Discussion
Since a long time, several different teams proposed a short
time delivery of a prosthesis, by relining or adapting a
previously made bridge or by very fast fabrication of the
prosthesis. Immediate Smile procedure is an immediate
screw-retained prosthesis with as limited oral interventions
as possible, no implant impressions, no transfer of occlusion
from the mouth and no relining. To reach this goal we need
to have good control over certain number of points.
1. One needs to have good control over immediate loading
procedures. The surgeon and his team, including the lab
technician, need certain clinical experience to be comfortable
with these procedures.
2. One should be able to transfer implant position and
angulation from a computerized plan to the mouth with
submillimetric accuracy. In the case of computer guided
implantology, this can be achieved by respecting the
whole chain of accuracy using ScannoGuide, SimpPlant
software and SurgiGuide SAFE System.
3. One should be able to control the depth of implants

Implantology
(Figure 26)
Excellent adaptation of the
IS cylinders to the implants
as demonstrated by a
panoramic x-ray.
(Figure 27)
Lingual view of the
Immediate Smile bridge,
screw retained on top of
the flat implants. Note the
lateral deviation of screws
allowed by the design of
the IS retention screws and
cylinders.
(Figure 28
The bridge after two years
of insertion.
independent of the kind of surgical guide used; bone,
mucosa or tooth supported. This is done with measures
that the surgeons receive from Materialise on the guiding
sheet showing the drill lengths and implants’ mounts
lengths that should be used for every single implant.
4. One should be able to fabricate a prosthesis at the lab
prior to the surgery using a lab model including the
transfer of implants’ analogues. Materialise can provide a
stereo-lithographic model with reservations for implantanalogue
placement. This model can be mounted on the
articulator using the scannographic guide (ScannoGuide),
to transfer the occlusion. Accordingly, all the required elements
to be able to fabricate the immediate temporary prosthesis
are present.
5. It should be possible to overcome some minor differences
between implant positioning plan and real implant position
in the mouth. Certain Immediate Smile components have
been developed for this purpose. These components
allow a difference of circa half a millimeter. We should
notice that the difference between implant positions is
often very small as long as implants are driven in position
by the guiding cylinders of the SAFE System.
Since our first trials in 2002, we have been doing a wide variety
of cases; full upper and lower cases, partial upper and lower
cases. In our learning curve, not all cases went out perfectly
at once, but we improved very fast with the help of different
tools available at Materialise. The more implants we have
the more difficult it is to adapt all of them without any modification.
Immediate Smile is the knife hedge knowledge in this
field and brings several benefits to our patients and to the
32 Smile Dental Journal Volume 4, Issue 1 - 2009
surgical team. Immediate Smile allows us to work securely
because we can get submillimetric accuracy in implant
placement. This procedure is very efficient because in one
appointment not only the surgery is performed but also the
bridgework is delivered. Pain is limited to nearly nothing.
Working through the mucosa avoids flap elevation, sutures
and keeps the supra-crestal vasculature intact to keep the
underlying bone intact.
Conclusion
Progress in medical imaging and data processing are creating
profound changes in the way professional practice is perceived.
Treatments are becoming more precise, faster and safer for
the patients. Surgeons are also able to better control
and carry them out. The precision of implant positioning
also helps in reducing the cost of prosthetic restorations
avoiding the use of additional abutments to realign implants.
The overall result is very gratifying for the patient and the
implant team as a whole. Ongoing studies and new protocols
are constantly emerging in computer guided implantology.
References
1. Schwarz MS, Rothman SL, Rhodes ML, Chafetz N. Computed tomography:
Part I. Preoperative assessment of the mandible for endosseous implant
surgery. Int J Oral Maxillofac Implants. 1987 Summer;2(3):137-41.
2. Schwarz MS, Rothman SL, Rhodes ML, Chafetz N. Computed tomography:
Part II. Preoperative assessment of the maxilla for endosseous implant
surgery. Int J Oral Maxillofac Implants. 1987 Summer;2(3):143-8.
3. Rothman SL, Chaftez N, Rhodes ML, Schwarz MS. CT in the
preoperative assessment of the mandible and maxilla for endosseous
implant surgery. Work in progress. Radiology. 1988 Jul;168(1):171-5.
4. Mole C, Gerard H, Bouchet P, Della Malva R, Corbel S, Miller N, penaud
J. Imagerie médicale exploitations et perspectives modélisation 3-D et
reconstruction plastique stéréolithographique. Actualités odontostomatologiques.
L’encyclopédie du praticien. 1993, no 181 (34 ref.), pp. 127-141.
5. Klein M, Abrams M. Computer-guided surgery utilizing a computer-milled
surgical template. Pract Proced Aesthet Dent. 2001 Mar;13(2):165-9; quiz 170.
6. Molé C, Gérard H, Mallet JL, Chassagne JF, Miller N.A new threedimensional
treatment algorithm for complex surfaces: applications in
surgery. J Oral Maxillofac Surg. 1995 Feb;53(2):158-62.
7. Philippe B, Tardieu P. Edentement complet maxillaire avec atrophie
osseuse terminale : Prise en charge thérapeutique. A propose d’un cas
Partie 1 Phase chirurgicale: principes thérapeutiques et indications.
Implant. 2001;7:99-111.
8. Tardieu P, Philippe B. Edentement complet maxillaire avec atrophie
osseuse terminale : Prise en charge thérapeutique. A propose d’un cas
Partie 2 Réalisation implantaire et prothétique: l’implantologie assistée
par ordinateur. Implant. 2001;7:199-210.
9. Vrielinck L, Wouters K, Wivell C, Dhoore E. Further development of drilling
templates for the placement of regular dental implants and zygomatic
fixtures, based on preoperative planning on CT images. In: Lemke HU,
Vannier MW, Inamura K, Farman A, editors. Computer assisted
radiology and surgery. Berlin, Germany: Elsevier Science; 2000, p. 945-49.
10. Vrielinck L, Politis C, Schepers S, Pauwels M, Naert I. Image-based
planning and clinical validation of zygoma and pterygoid implant
placement in patients with severe bone atrophy using customized drill
guides. Preliminary results from a prospective clinical follow-up study.
Int J Oral Maxillofac Surg. 2003 Feb;32(1):7-14.
11. Tardieu P, Vrielinck L. Implantologie Assistée par ordinateur.Cas
clinique: Mise en charge immédiate d’un bridge maxillaire avec des
implants à appuis zygomatiques et ptérygoïdiens. Implantodontie 2002
Août;46:41-8.
12. Tardieu P, Vrielinck L. Implantologie assistée par ordinateur: le
programme SimPlant/SurgiCase et le SAFE System. Mise en charge
immédiate d’un bridge mandibulaire avec des implants transmuqueux.
Implant. 2003;9(1):15-28.
13. Tardieu PB, Vrielinck L, Escolano E. Computer-assisted implant placement.
A case report: treatment of the mandible. Int J Oral Maxillofac Implants.
2003 Jul-Aug;18(4):599-604.
14. Sarment DP, Sukovic P, Clinthorne N. Accuracy of implant placement
with a stereolithographic surgical guide.Int J Oral Maxillofac Implants.
2003 Jul-Aug;18(4):571-7.

Implantology
Comparison of Basal and Crestal Implants
and eir Modus of Application
Dr. Stefan Ihde
Dr.med.dent.
. International lecturer in
implant dentistry
. Editor of “Principles of BOI”
book
. Private practice, Switzerland
dr.ihde@implant.com
36 Smile Dental Journal Volume 4, Issue 1 - 2009
Abstract
According to the well-known implantological rules for dental restorations, crestal implants
are indicated in situations when an adequate vertical bone supply is given. Crestal implants
function well in patients who provide enough bone when treatment starts, but results are
not predictable as soon as augmentations become part of the treatment plan. Augmentation
procedures are possible today, but they increase the risks and costs of dental implant treatment as
well as the number of necessary operations. Patients providing severely atrophied jaw bones
(i.e. those patients who need the implantologists’ attention most), paradoxically receive little
or no treatment, as long as crestal implants are considered the device of first choice. This article
discusses the value of using basal implants and the differences that exist between basal
implants and crestal implants in perioperative status, infection around integrated implants,
load transmissions and replacement of failing implants.
Keywords: Basal implants, orthopaedic implants, crestal implants, overload osteolysis.
Crestal and basal implants are endosseous aids to create osseointegrated points of retention
for fixed or removable dentures. These two types of implants are not only differentiated by
the way they are inserted and by the way forces are transmitted. Rather, the more substantial
differences lie in the planning and execution of prosthodontic care and, most of all, in the
post-insertion treatment regime. For this reason, the literature on basal implants has introduced
the terms “orthopaedic technique” and “orthopaedic implant” 1 to mark a clear distinction
between them and the well-known term “dental implant”.
Crestal implants (i.e. implants inserted from the top of the alveolar crest into the bone such
as cylinders and blade implants) are indicated in situations where an adequate vertical bone
supply present. Although, crestal implants enjoy a high degree of success, their success is
reduced in cases where bone augmentation procedures become part of the treatment. In
addition, augmentation procedures increase the overall costs of dental implant treatment as
well as the number of necessary operations. Patients providing severely atrophied jaw bones
(i.e. those patients who need the implantologists’ attention most) paradoxically receive little
or no treatment, as long as crestal implants are considered the device of first choice.
Basal implants, i.e. BOI®, Diskos® by contrast, were developed additionally and primarily for
immediate use as well as for use in the atrophied jawbone. They can also be applied where
very little vertical bone is present, while the supply of horizontal bone is still sufficient, even if
these quantities are not contiguous such as in the sinus region. There are no difficult or
impossible cases for implantologists familiar with basal implants, and their use leads in all
cases straight forward to the desired treatment result. The typical objective of treatments
including basal implants is a fixed restoration with 12 teeth per jaw. Optionally, removable
dentures may be inserted as well, as long as enough basal implants are splinted by rigid
connectors (i.e. bars). Single crowns are primarily realized on internal or single-unit BOI
implants. They may be loaded immediately only in favourable situations. As the use of BOI
implants can help avoid risky and expensive bone augmentation procedures, these implants
are the therapy of first choice in moderately or severely atrophied jaws as well as in those
cases, where immediate loading or cheaper treatments are desired by the patients.
Whereas crestal (i.e. axial) implants are inserted vertically from the crest of the alveolar ridge,
basal implants are inserted laterally. These basal implants are synonymously called lateral
implants or disk implants. 2 With basal implants, the regions of load transmission and the
place of bacterial attack do not coincide; no masticatory forces need to be transmitted to the
bone via vertical aspects of the implant; the positive retention in the bone is created in the cortical
bone region.

Differences in Perioperative Status
An implant bed that is congruent with the implant shape is
created using burs for crestal (axial) implants. Most common
crestal implants in use today feature a self-tapping thread,
many types feature compression of bone. Once the crestal
implant is inserted, the insertion site is obturated by the
implant itself. Any infection carried into the implanted bone
intraoperatively or any infection that had already been
present preoperatively (such as residual ostitis) can endanger
the therapeutic result considerably by leading to an early
loss, “idiopathic loss” of implants. The mechanism resulting in
early loss can be described as follows; to combat any such
infection, the flow of blood from and to the bone must be
increased. However, this is inherently inconsistent with the
existence of bone tissue. 3 The resulting increased oxygen
pressure in the bone results in local bone loss, which does
not necessarily involve bacteria or purulence. The implant
loses its stability and will be lost subsequently. The bone
loss associated with this scenario is usually low, since it
barely affects any areas beyond the implant bed itself,
especially if the implant is also rapidly exfoliated. If, however,
exfoliation does not occur as in cases were implants are
kept in place within the bone by the prosthodontic
superstructure, an infection may develop in the spongeous
region that spreads and causes a significant dissolution of
the spongeous and cortical bone substance. In this case, the
cortical bone will be replaced by rapidly formed plexiform
bone, while the bone marrow spaces remain filled with
Migliore Tenuta
Easier Handgrip
Migliore Pulizia
Improved Cleaning
Migliore Comfort
Better Comfort
(Figure 1)
Histological section from a
dog’s mandible, four months
postoperatively. The implant was
inserted in a non-sterile manner and
protected from exfoliation by the
superstructure. The cortical bone
in its entirety was re-formed as
plexiform bone. The implant is not
osseointegrated anywhere.
granulation tissue. The histological findings in such conditions
are typical for an osteomyelitis (Fig. 1).
The situation with basal implants is completely different. For
basal implants, a T-shaped slot is cut into the bone, which
is practically left unobturated by the implant immediately
after insertion. Neither intraoperative nor preoperative
infection will normally threaten the treatment result, since
suppuration from the osteotomy slot is usually uninhibited
at all times. In animal studies, no failure of BOI® implants
(infection of the implant site, primary implant loss, absence
of osseointegration) could be provoked by contamination or
infection present preoperatively or introduced intra-operatively.
The degradation products of infection are resorbed via the
periosteal tissues or removed to the oral cavity through the

Implantology
mucosal access. The necessary pressure is built from inside
the bone. This pressure must never be blocked, and the
direction of flow must never be inverted by the dentist. Early
idiopathic loss thus hardly ever occurs with basal implants.
Infection around Integrated Implants
Crestal (Axial) Implants
Crestal implants are supposed to osseointegrate along the
vertical axis of the implant. The term “osseointegration”
describes a state in which there is no more than an ultra-thin
layer of connective tissue between the implant surface and
the mineralized bone matrix and where this layer contains
neither blood vessels or directional fibres or other components
characteristic of the periodontal system. This is why
osseointegrated crestal implants do not contribute- as
opposed to natural teeth or freshly inserted basal implantsto
draining the bony implant site.
If peri-implantitis develops around crestal implants, the
adducing vessels of the peri-implant mucosa are widened
in a pathological way. In addition, the blood is removed
by the same route it came, requiring space. The resulting
increase in the oxygen pressure in itself causes bone loss.
Whether or not the counteracting tendency towards
retention of the mineralization or towards remineralization
is preserved, will depend on functional stimuli. This is why
crestal implants, if initially osseointegrated, are often lastingly
and stably osseointegrated at their apical even though their
upper enossal portion may be subject to funnel or crater-shaped
areas of bone collapse (Fig. 2). Once the crestal bone is lost,
macrotrajectorial load transmission is shifted to the basal
aspect of the bone, or at least the middle implant region, in
almost all areas of the jaw. Although the total bone mass is
reduced due to the bone collapse, yet the task of transmitting
loads is not made easier as masticatory function persists
and thus the remaining basal bone areas have to be more
strongly mineralized. This will afford them better protection
from further resorption. Nowadays, the surface of crestal
implants is usually enlarged in their enossal part, as they do
not have the retentive baseplates that basal implants have.
The state of the art is that typical surface enlargements are
often created by the manufacturer by adding a TPS layer, by
sandblasting, by etching or by a combination of these latter
procedures. The surface enlargements are to improve the
adhesive properties of the blood and the bone cells,
presumably creating a “cell-friendly” environment. Unfortunately,
bacteria are also cells and a bone-friendly surface is always
at the same time a bacteria-friendly surface. This is why
peri-implantitis around crestal implants is difficult to
control; as soon as surface enlarged portions of the implant
surface are exposed to the oral cavity, these bacteria may
travel more deeply and below the bone level due to the
“candle wick” phenomenon, again increasing blood
circulation and promoting bone loss. As we have seen, only
more highly mineralized bone have better protection
against resorption as a result of the predominant trajectorial
load. This is why some crestal implants have a hybrid
design, where the 1-2 mm of the enossal aspect of the
implants located most closely to the mucosa are not surface
enlarged. However, these implants tend to require more
vertical bone to achieve sufficient retention. More recently,
microsphere-coated surfaces have been introduced in dental
38 Smile Dental Journal Volume 4, Issue 1 - 2009
implantology, something that has been a familiar concept in
endoprosthetics for quite some time now.
Sintered titanium microspheres, 100–150 µm in diameter
are completely smooth, offering no microretention for bacteria,
even though the surface looks very rough to the naked eye.
Studies have shown that the type and roughness of implant
surfaces determines the behaviour of the osteoblasts.
Osteogenic cells will settle or be created on smooth,
microstructured surfaces more quickly than on SLA surfaces.
The latter show more fibroblastic than osteoblastic cells,
something that ultimately has considerable influence on
implant integration. 4
Basal Implants
With basal implants, load transmission is supposed to
occur primarily, and initially exclusively, within the basal
aspect of the implant, far away from the site of bacterial
infection from the oral cavity. All aspects of the implant
are smoothly polished. Several basal implant systems with
different platforms are available today; internal systems that
can be secured against rotation and that have an internal
screw connection (Fig. 3) and external systems that do not
have a rotation-protected external thread (Fig. 4). With
basal implants, the terms internal and external thus refer
to the thread and not as with crestal implants to the type
and position of the surfaces that protect against rotation.
By design, the mucosal penetration areas are considerably
smaller with external systems than with internal systems.
Whether or not this results in different degrees of resistance
to infection (countable as losses / time unit) has not been
(Figure 2)
Funnel or crater-shaped
crestal bone topography
may occur around
osseointegrated crestal
implants. The extent of
vertical bone loss can
be determined by depth
probing.
(Figure 3)
Internal BOI implants can have
different platforms. Left: An
ITI-compatible Diskos® implant
with octagon. Right: A French
“Diskimplant” with an external
hex. These implants feature all
advantages and disadvantages
of screw implants with internal
connection.
(Figure 4)
One piece external basal
implants for cortical
engagement in vertical
or horizontal bone
morphology.

Implantology
examined. Examining the status of the peri-implant bone
with a probe is considered malpractice with basal implants,
as no osseointegration is required on the vertical aspect of
the implant anyway for permanent function of the implant.
The path of insertion of the vertical aspect of the implants
can no longer be determined postoperatively, and the positions
of the horizontal disk suspensions are unknown. For those
two reasons probing may yield false results. On the other
hand, probing may carry pathogens into the depth of the
interfacial region that is filled with non-irritant connective
tissue at a time when there is little chance of suppuration
left. Callus formation and the maturation of the callus in
the slot areas are endangered through probing. Facultative
pathogens can be transported to an environment that is
normally inaccessible to them and cause great damage. In
particular, the maxillary sinus area may be contaminated
by germs of oral origin by simple probing, if bone height is
reduced or if a trans-sinus implant insertion was performed.
Probing around basal implants is therefore contraindicated
and potentially dangerous. 5 The same considerations show
that rinses and any medication down along the threaded
pins and under pressure are contraindicated. This is because
ahead of the medication, liquid contaminated with pathogens
is pressed into the deep without any control. The direction
of flow is deleteriously inverted, resulting in infectious
osteolysis which is otherwise a rare occurrence. The pressure
of forced medication down along the threaded pins applied
by the treatment provider and his syringe is greater by a
factor than the internal pressure of the bone or soft tissues,
so that this procedure will almost invariably result in massive
adduction of germs and the spread of infection, which may
become chronic. A similar effect is observed if dental restorations
are seated loosely on individual implants for a protracted
time period (months or years) and the continuous relative
movement of the abutment and crown creates a chronic
submucosal inoculation with debris and pathogens. Here
too, inoculation pressure is higher than internal tissue pressure,
resulting in repeated inversion of the direction of flow and
increasing osteolysis due to the measures taken by the
body to fight infections.
With basal implants, there are normally no funnel or cratershaped
areas of bone collapse anyway, as the cortical bone
closes as part of the healing process and no infection
can be transported into the depth of the bone along the
smooth threaded pins. Exceptions may occur if there is
functionally related massive vertical bone growth along
the threaded pin. 6 Surprisingly, bone growth is in some
cases unfavourable, but this is explained by the fact that
bone growth will cause colonized intraoral areas of the implant
to be relocated to submucosal or enossal regions. The
proper therapy in these cases consists invariably in creating
local drainage around the vertical implant part.
With integrated basal implants, infection originating in
the oral cavity would not normally be expected to spread
enossally, for as long as the implants are not mobile to the
extent that they can be intruded. Infections can be caused
by food retention or impaction or as a consequence of vertical
bone growth. However, unlike with crestal implants, they
do not spread intraosseously but submucosally (Fig. 5). The
latter may result in infected vertical parts if the implants are
40 Smile Dental Journal Volume 4, Issue 1 - 2009
(Figure 5)
With integrated basal implants,
infections unlike crestal implants
do not spread intraosseously but
submucosally.
submerged below the mucosal level over time, eliminating the
necessary gateway for suppuration as the area of penetration
is closed with scar tissue. Any inflammation of this type will
spread just like a submucosal abscess and is treated in the
same way. It is recommended to make generous incisions
to open the abscess. The mucosal area immediately adjacent
to the threaded pin can be excised by electrosurgery. In
rare cases, reduction osteotomies or the replacement of
implants will be required if vertical bone growth becomes
excessive.
Bicortical screws (BCS®) are also considered basal implants,
because they transmit masticatory loads deep into the
bone, usually into the opposite cortical bone, while full
osseointegration along the axis of the implant is not a
prerequisite. BCS provide at least initially some elasticity
and they are not prone to peri-implantitis due to their polished
surface and their thin mucosal penetration diameter.
Peculiarities of Basal Implants
Overload Osteolysis and Basal Implants
It is normally impossible to perform successful recovery
treatment for mobile crestal implants, as the mucosal
penetration area is too large and infections will recur and
descend continuously along the rough interface area.
The situation is different around basal implants; one possible
complication of basal implants, although initially reversible,
is functional overload osteolysis. Successful therapeutic
measures are possible. The physiological background for
overload osteolysis should be however explained briefly;
On one hand, the load-transmitting interface areas are
located in the cortical bone, which has to perform structural
tasks and therefore has a more pronounced self-preservation
tendency, and a more favourable prognosis, than spongious
bone, which is of minor importance both structurally and
with regard to macrotrajectorial tasks and therefore
dispensable. It should be noted, however, that large-lumened
crestal fixtures (just as teeth) are on the way of the jaws
macro-trajectories anyway, so that these bone lines must
seek different paths.
On the other hand, masticatory forces transmitted via the
basal implants to an enossal location create local microcracks
in the cortical bone. 7 Microcracks are repaired by the formation of
secondary osteons, a process called remodelling. This,
however, will temporarily increase the porosity of the
affected bone region and temporarily reduce the degree
of mineralization additionally. If microcracks accumulate

Implantology
at the bone/implant interface, the reduction in mineralization
can also be detected on radiographs (Fig. 6a) where the
osteolytic area initially exhibits only diffuse radiological borders.
As long as the bone substance is not torn away from the
implant (Fig. 6 b) and the area is not superinfected, the loss
of mineralization remains diffuse but usually reversible 8 , and
it should be remembered, that the term “osseointegration”
describes the close contact between bone and the implant,
but it does not describe a high degree of mineralization.
Osseointegration at a lowered degree of mineralization is
not the same as “fibrointegration”. Orthopaedic surgeons
describe the equivalent status of orthopaedic implants as
“sterile loosening”, but they usually have no means of treating
this status. Basal implants in this status have a good chance
of getting reintegrated at a high degree of mineralization,
if loads are reduced to an adequate amount. The measures
necessary are discussed below and they are part of the
education of a basal implantologist.
Radiological findings should be secured both in the form
of overview radiographs (tomographs) and in the form of
summary radiographs (small-format radiographs). The
implant will now be slightly mobile, which is easily discernible
clinically. If areas with mineralization deficiencies are
superinfected, granulation tissue is created in the interfacial
region that will hardly be replaced by new bone without
an added osteotomy stimulus, especially since granulation
tissue requires or results in an increase in blood circulation
that is maintained from a periosteal direction or enossally
and which per se inhibits new bone formation. Nevertheless,
even these implants could be re-integrated in isolated
cases, if the implant site per se exhibits pronounced
remineralization tendencies, for functional reasons. Typical
examples of such areas with pronounced remineralization
are the region of the mandibular second molars, and the
maxillary and mandibular canines (the so-called strategic
positions) and of course the basal regions of the jawbones
as such. These areas must therefore be preferred as implant
sites and other sites outside the strategic regions may even
be dispensed within the case of complete rehabilitation of
an entire jaw, if the concept of strategic implant positioning
is consistently followed. Additional implants may be placed
if the preferred regions offer insufficient anchorage.
An equilibrated masticatory pattern is of particular importance
for maintaining mineralization in the interfacial region,
especially in the first months after implant placement.
Unilateral or anterior (as in Class II division 2 malocclusions)
masticatory patterns result in unilateral or anterior overload,
which would seem to be immediately apparent, and also in
increased porosity of the crestal aspect of the jawbone on
the balancing or distal part of the jaw and thus in atypical
patterns of mineralization. 9,10 This porosity is a consequence
of the increased bone morphological unit (BMU) activity in
this region due to a predominance of tensile forces in this
region. For this reason, mobilization of basal implants can
be expected also on the non-working side on which the
implants are subject to high extrusion forces within the
framework of asymmetrical mastication. In case of mobility, it is
therefore necessary to make adjustments on the side opposite
the mobile side; something that crestal implantologists with
their typical mechanist mindset almost invariably get
42 Smile Dental Journal Volume 4, Issue 1 - 2009
(Figure 6-a)
Diagram showing a diffuse zone of
low mineralization around the base
plate of a functionally overloaded basal
implant.
(Figure 6-b)
A clearly delimited light zone
on the radiograph is indicative
of an irreversible loosening and
detachment of the bone in the
interfacial region.
wrong. Alternatively, occlusal areas on the underload side
should receive an additive occlusal adjustment, leading to
an equal loading of both sides of the jaw.
Therapeutic Considerations for Overload Osteolysis
First and foremost, the prognosis of the implant must be
determined according to the consensus on basal implants.
As long as implant removal is not indicated11 , there are several
therapeutic strategies that can be followed:
- First of all, it must be determined whether or not the
masticatory pattern is evenly balanced and symmetrical.
If this is not or no longer the case, the first therapeutic
step must be aimed at achieving a bilaterally balanced
situation with regard to bone mineralization tendencies.
- In some cases, extensive occlusal adjustment will therefore
be required. Deficiencies in vertical dimension must be
treated prosthodontically. For example, by building on
the superstructure with composite or by fabricating a
new superstructure with changes in vertical dimension.
The development of anterior masticatory patterns must
be prevented with all means and immediately. Existing
anterior masticatory patterns can usually be corrected by
increasing the vertical dimension; however, the optimum
bite plane must be retained or created and this determines,
in which jaw the addition has to be made.
- Furthermore, the question must be evaluated whether or
not remineralization by way of self-healing or supported
by a suitable therapy can be expected at the existing mobile
implants. 12 Possible therapeutic steps are temporary
isolation of individual implants from the superstructure
and thus facilitating remineralization of the bone
surrounding these implants. The lower bone density
caused by excessive function does not lead to reintegration;
on the contrary, the result will be implant mobility.

Implantology
- If excessive parafunctional habits or nocturnal positional
deviations of the mandible are suspected, the fixed denture
can be replaced, permanently, temporarily or prophylactically,
by a bar-supported denture. 12 This type of denture is
supposed to be removed by patients at night. This will
help avoid peak nocturnal pressure on the bone/implant
interface and result in a very stable direct fixation of the
implants relative to each other. Masticatory shear forces
will also be more favourably distributed between the bar
and the denture.
- It is also possible to add basal implants without removing
mobile basal implants (Fig. 7 a,b). Both implants can
subsequently be integrated with a high degree of
mineralization. The rationale of this procedure is found in
the distribution of the 0 and 1 areas within the bone itself.
Mobile implants create 0-areas at the implant/bone interface,
that is, areas that cannot perform any macrotrajectorial
load transmission tasks. These tasks must then be performed
mostly by bone areas in the vicinity, which will mature to
form highly mineralized 1-areas. However, implantation
into these 1-areas will interrupt the macrotrajectorial load
transmission at the new implant site and promote the
bone’s tendency to once again increase mineralization
around the mobile basal implant. Since the masticatory
forces will subsequently be distributed to two implants,
both implants can stabilize at an even pace. If the dentist
intervenes in time, implant removal can be avoided in this
manner. Additional implants may be required for the only
reason that the masticatory forces can be greatly increased
once the removable denture is replaced by fixed bridges.
This increase in masticatory forces, however, will be
accompanied with an absolute increase in bone mass and
an improvement in bone quality (i.e.degree of mineralization),
something that may have made the insertion of additional
basal implants possible in the first place. Often the placement
of additional Bicortical screws (BCS) implants is easier
than placing more BOI, as BCS implants may be inserted
without a flap procedure.
- If the fixed denture must or should remain in place, the
masticatory forces can be temporarily reduced by injecting
botulinum toxin 13,14 (such as Dysport®) into the masseter
and temporal muscles. This measure also prevents
parafunctional loads and has been clinically proven to be
extremely effective. Botulinum toxin can be administered
prophylactically in cases with a scant bone supply, especially
in the maxilla and especially if bar-retained removable
superstructures are to be avoided right from the start.
Therapeutically, the administration of botulinum toxin is
indicated when BOI implant-supported superstructures
(bone/implant/restoration systems) have become mobile
due to parafunction or due to changes in the bite plane
or masticatory pattern that have remained uncontrolled
for too long. Note that the cause of overloading or missloading
must be treated while the medication is acting.
Otherwise, after the effect of botulinum toxin ceases, the
mobility of the implants will of course return.
- It will frequently be necessary to perform several of the
above measures in combination. At any rate, the correct
44 Smile Dental Journal Volume 4, Issue 1 - 2009
(Figure 7a-b)
Treating overload-related
osteolysis by adding
a second lateral
implant. Because of the
elastic properties of
these implants, screw
implants must not be
included in wide-span
bridges.
therapeutic decisions must be made well in time and
implemented determinedly, as “self-healing” per se, with
all adverse influences remaining present, can be expected
only in very isolated cases.
The question as to when or for how long the measures
described above may be expected to result in healing or
restabilization at all, cannot be answered summarily. A great
deal of clinical experience with basal implants is required to be
able to make halfway reliable recommendations in borderline
cases. In particular, care must be taken to re-examine the primary
healing process after implant insertion and to check what
types of basal implants were used. In particular the thickness
of the disks, the surface structure of the enossal aspects and the
material properties (i.e. titanium graduation) of the implant in
question, are important factors of treatment planning. Usually,
an untrained secondary treatment provider will not have the
required familiarity with the aspect of masticatory
function and its relation to bone physiology. This alone is
reason enough for complications always to be treated by the
primary treatment provider. If that is not possible when
complications occur, close consultation is required between the
primary and the secondary treatment provider.
BOI implants inserted trans-sinusally without prior augmentation
or lifting of the Schneiderian membrane may cause or
promote sinusitis if there is vertical mobility, usually caused
by overloading. Trans-sinus implant placement with
augmentation (e.g. with Nanos®), by contrast, show a rather
favourable stabilization potential over the medium term.
Primary stabilisation must always be gained in native bone.
Placement of a tubero-pterygoid screw distally of the basal
implant in area six of the upper jaw reduces the chances of
overloading implants in the sinus area dramatically. For this
reason, this type of basal implant should be placed always
in combination with BOIs.
Replacing Basal and Crestal Implants
If an indication for replacing a basal implant really exists,

this measure should be taken right away, since mobile implants
will invariably cause bone damage. By contrast with screw-type
implants, BOI implants will never exfoliate spontaneously.
For this reason and because overload trauma may be
transferred from one side of the jaw to the other via the
denture or via an involuntary change in the preferred working
side, there is no point in waiting. The objective of any
replacement will be to restore the full function of the fixed
restoration and thereby the full range of masticatory
movements. This is why the insertion of the new implant
must be planned along with the removal of the old implant.
In most cases, immediate reimplantation will be possible
and indicated.
When replacing defective implants, the osteotomy for the
new implant must always be created first, that is, before the
existing implant is removed, unless the new implant is to
be inserted in the same position as the old one. It has been
shown that this procedure (i.e. preparing the new osteotomy
before removal of the old implantis), is much easier on the
bone than the inverse procedure; often only very little bone
substance must be removed to remove the old implant.
Leaving isolated integrated implant parts that have no contact
with the oral cavity, in situ, instead of sacrificing a lot of
bone substance to remove them does not usually cause any
problems and can be considered lege artis.
While after the removal of formerly integrated crestal implants,
only rarely new crestal implants can be placed (immediately
or at all), the immediate replacement of (crestal and basal)
implants by basal implants and their immediate loading is
a simple and successful procedure, which is virtually always
possible.
Post-Insertion Treatment of BOI Implants Seen From the
Vantage Point of Crestal Implantology
When complications occur, crestal implantologists unfamiliar
with BOI implants may occasionally argue that there is not
enough bone left for further implant treatment once an
implant is lost. This is incorrect, since there is always enough
available bone in the cranial regions of the facial skull and
the basal region of the mandible.
In practical crestal implantology, saving a case over time
(and beyond the warranty period) is an important aspect. In
the cases of ailing crestal implants that are well
osseointegrated basally but show unavoidable systemrelated
continuous bone loss near the alveolar ridge (Fig.
2), it is possible to sell the patient many years of delaying
peri-implantitis therapy until the situation deteriorates to
the point that leaving the implant in place becomes inconsistent
with any definition of an acceptable oral situation. This kind
of approach is clearly wrong in the case of basal implants.
Problems must be addressed immediately and professionally,
not least in order to prevent the spread of overload-related
damage to other implants, which carries a risk of subsequent
fracture or overload osteolysis and thus to prevent bone

Implantology
loss. It is also not necessary to wait with the corrective
intervention, because every patient has enough bone
for treatment with basal implants. The waiting-strategy of
crestal implantologists is caused with the fear, that after the
removal of the ailing crestal implant no further treatment
with crestal implants is possible. This point of view is
short sighted.
In crestal implantology, specific aspects of masticatory function
play a minor role with regard to bone preservation and
the preservation of the masticatory function per se. Certain
implantological schools traditionally advocate narrow occlusal
surfaces, restricting patients to a primitive chopping
masticatory function. Allegedly, this is done to avoid shear
forces and fractures in ceramics and implant-parts (implant
bodies, screws, abutments); in reality however, the desirable
increased functional stimulation of the jawbone will not
occur. That masticatory function can actually be controlled
to positively influence and modulate the bone/implant
interface. This positive control is usually something that is
beyond the experience of the typical crestal implantologist.
Particularly, serious damage can be observed when and because
a crestal implantologist or a non-implantologist does not
have the possibility (material, knowledge, experience) to insert
additional basal implants, while crestal implants cannot or
must not be inserted due to a lack of vertical bone or due to
their different biomechanical function. A good example is
the extraction of teeth in the opposing jaw or on the contralateral
side, which of course would require the insertion of a fixed
implant-supported replacement restoration in order to
maintain a symmetrical masticatory function. If the patient
is not informed of this or if the treatment is not performed,
the consequence will be overload-related damage on the
working side, either to natural teeth or to implants.
Orthopaedic deformation of the jawbone and the supporting
ligaments and locomotor systems of the cranium as a
result of changes in loads and function, will in turn result
in changes in the relative position of the restorations in the
maxilla and mandible. This will almost always make massive
occlusal adjustments of the restorations necessary over time.
These adjustments must usually be much more pronounced
than the usual experience tells dentists working with crestal
(axial) implants or on natural teeth; orthopaedic deformations
of bones being on the order of millimetres rather than of
microns.
Special consideration when working with basal implants
should always be given to the preservation of a chopping or
a lateral masticatory function: anterior masticatory patterns
must be corrected, which often requires an elevation of the
restoration in the posterior region.
Conclusion
Therapeutic options for peri-implantitis around crestal
implants are limited; usually the disease stops as soon as it
reaches basal (i.e. resorption resistant) bone areas.
Peri-implantitis is not found with basal implants.
For sterile loosening of basal implants, numerous therapeutic
46 Smile Dental Journal Volume 4, Issue 1 - 2009
options exist; functional adjustments or combined surgical/
functional treatment of bone/implant/restoration systems
are required and in some cases the reduction of muscle
forces is part of the therapy plan. Such options are not
given for crestal implants. Even the replacement or addition
of basal implants is easily possible, since there is usually
sufficient cortical bone available for additive therapy.
Corrective actions must be taken in a timely manner. The
correct diagnosis and treatment of problems related to
basal implants requires specific clinical experience, specific
tools and of course basal implants. This is why the work
with and on basal implants is and has been restricted by the
manufacturer to authorized practioners.
Also with respect to the accepted principle “primum nihil
nocere”, i.e. limiting treatment, basal implants are the
devices of first choice, whenever (unpredictable) augmentations
are part of an alternative treatment plan.
The technique of basal implantology solves all problems
connected with conventional (crestal) implantology. It is a
customer oriented therapy, which meets the demands of
the patients ideally.
References
1 Donsimoni JM, Dohan A, Gabrieleff D, Dohan D. Les implants maxillofaciaux
à plateaux d’assise : troisième partie : reconstructions maxillo-faciales;
Les implants maxillo-faciaux à plateaux d’assise : concepts et technologies
orthopédiques, réhabilitations maxillo-mandibulaires, reconstructions
maxillo-faciales, réhabilitations dentaires partielles, techniques de
réintervention, méta-analyse. Implantodontie 2004 Avril Juin;13(2),71-86.
2 Geman & European Standard: DIN EN 31902-1.
3 Kiaer T. Bone perfusion and oxygenation. Animal experiments and clinical
observations. Acta Orthop Scand Suppl. 1994 Apr;257:1-41.
4 Fillies T, Wiesmann H, Sommer D, Joos U, Meyer U. Primäre
Osteoblastenreaktionen auf SLA-und mikrostrukturierten
Implantatoberflächen. Mund Kiefer GesichtsChir. 2005 Jan;9(1):24-8.
5 Internationnal Implant Foundation. Konsensus zu Sondierungen an
basalen Implantaten. Available at: http://www.implantfoundation.org/
index.php/.Accessed Feb 21, 2009.
6 Ihde S. Adaptations fonctionelles de la hauteur de l’os peri-implantaire
après implantation de BOI dans la mandibule. Implantodontie 2003
Dec;12:23-33.
7 Martin RB, Burr DB, Sharkey NA. Skelettal Tissue Mechanics. New York:
Springer; 1998.
8 Ihde S. Principles of BOI., Berlin-Heidelberg: Springer; 2005.
9 Korioth TWP, Hannam AG. Deformation of the human mandible during
simulated tooth clenching. J Dent Res. 1994 Jan;73(1):56-66.
10 Rubin CT, Lanyon LE. Regulation of bone formation by applied dynamic
loads. J Bone Joint Surg AM. 1984 Mar;66(3):397-402.
11 Besch KJ. A consensus on basal osseointegrated implants (BOI).
The Implantoral- Club Germany (ICD). Schweiz Monatsschr Zahnm
1999;109:971-2.
12 Rüedi TP, Murphy WM. AO Principles of bone management. AO Publishing,
Thieme; 2001.
13 Ihde S.Utilisation thérapeutique de la toxine botulique dans le traitement
d’entretien en implantologie dentaire. Implantodontie 2005 Apr-
Jun;14(2):56 -61.
14 Ihde S. Utilisation prophylactique de la toxine botulique en implantologie
dentaire Implantodontie 2005 Apr-Jun;14(2):51-5.

Events
Summary of the Activities of the Arab Society of Oral
Implantology Annual Conference 2009
Cairo, Egypt / 08 - 10 January 2009
The Arab Society of Oral Implantology (ASOI) held this year
a magnificent meeting in Cairo, Egypt, on the 8 th -10 th of January,
2009. The meeting gathered over 670 participants from
Egypt and from all over the Middle East. In this meeting
strong evidence based scientific program and more than
seven different workshops in the various aspects of dental
implantology were presented. Speakers from USA, Austria,
Mexico, Lebanon, England, and Italy gathered for this event.
Parallel sessions for laboratory technicians were also held to
motivate those important element in the dental profession.
The meeting had a final 90-minute-dedicated-panel discussion
between all the speakers and the participants in all the
topics raised during the meeting. A junior podium
competition was also held to elicit the best future dentist
speakers in the field of oral implantology. The competition
was held originally to encourage young dentists to be
on the podium to project their work, ideas, and gain self
confidence. The program had over 21 speakers in the junior
podium this year. Financial and prestigious awards were
given to the top three winners.
“It is the mission of the Arab society of oral implantology
to offer science, modern technology in an affordable and
easy way to all the members of the society” Dr Abdelsalam
Elaskary said.
An up-to date exhibition that gathered over 24 implant
related manufacturers, from all over the world, was held
alongside the conference.
All the scientific events of the Arab Society of Oral
Implantology are fully accredited by the International Congress
of Oral Implantologists (ICOI) and the University of Temple., All
ICOI fellow awardees were awarded in this meeting.
For more information on this meeting, to view a full video
48 Smile Dental Journal Volume 4, Issue 1 - 2009
Dr. Abdelsalam Elaskary; President of ASOI
Dr. Marco Esposito speaking on evidence based implant dentistry
shooting for this meeting highlights, to check the society latest
educational modules offered, and clinical training courses for
dentists, please log on to www.askaryimplants.com

Flash News
HiGeen® Tooth Gel
HiGeen Tooth Gel for fragile gums delivers all
the fluoride protection of regular toothpaste.
Plus, the patent ingredients of Dead Sea salts,
allantoin and chamomile extracts fight
gingivitis and reduce swelling, redness and
bleeding of the gums.
Stimulating the repair process of damaged
cells in the gums and improving and regulating
minerals and nutrients through cell membrane, Dead Sea salts
protect the gums and speed up the healing of the diseased gums.
HiGeen Toothgel has better distribution and infiltration to the gums and is more controllable. It can be applied
by toothbrush or direct application by finger. It is recommended in to use HiGeen fragile gums 2-3 times per day.
Zirc
Zirc introduces the Crystal HD Mirror
40% brighter than Rhodium mirrors,
designed to reduce eye strain and fatigue.
It is autoclavable and available in 16 colors.
www.pirotrading.com
15 years WHITEsmile with
new BLEACHING LAMP
The German tooth whitening manufacturer WHITEsmile
celebrates its 15 th anniversary in 2009. In the relatively new
field of tooth whitening (starting 1989) WHITEsmile is one
of the eldest companies specialized in beautiful white teeth.
In their 15 th anniversary WHITEsmile completes the product
range with a new bleaching lamp. The WHITEsmile
BLEACHING LAMP combines excellent bleaching results
with maximum comfort for the clinic: no harmful UV light
– covering of the patient’s skin is not necessary. No activation
key for the lamp is needed. Material costs are the same as
for bleaching with or without light. WHITEsmile offers a
choice of 32% or 38% hydrogen peroxide Power Bleaching
gels. Now WHITEsmile offers all choices for the clinic: Home
Bleaching with customized trays, Power Bleaching with no
light, Power Bleaching with Bleaching lamp and all necessary
accessories. See us at the AAEDC in Dubai (Booth #239 -Piro
Trading International).
56 Smile Dental Journal Volume 4, Issue 1 - 2009
Hoya ConBio
VersaWave® Specialty By HOYA ConBio -
Leader in Laser Dentistry- not just precise, it
is precisely the laser you need whether you’re
a general dentist who wants to retain more
challenging procedures or a specialty dentist
who wants to offer superior, gentle results
every referring doctor expects.
The VersaWave® Specialty all-tissue laser is a
versatile and surprisingly affordable addition
to the HOYA ConBio family of dental lasers.
Combining extremely functional VersaWave
technology and user defined features, the
VersaWave Specialty is the laser you want for
the procedures you’ll do.
New
www.whitesmile.de
www.pirotrading.com

Accutron Inc.
Aurident, Inc.
Vaniman
Micro-Abrasive Blasters For Dental laboratory and Dental oce oce
SandStorm Expert:
A high quality and economical blasting system for moderate to heavy production. Low
maintenance media flow system virtually eliminates wasteful down-time and lowers
maintenance costs.
Two 50-100 Micron, 1000 ml tanks
• Extra large tanks - Labor saving Easy Fill sand tanks hold up to 4 pounds of media
• Exclusive non-clogging flow design - internal automatic air/media purging system
• Contact-Lens magnified viewing window - reduces eye strain and improves overall viewing area
• Blast proof resin cabinet is maintenance free
• Includes 1 precision Tungsten Carbide Tip plus 1 Crystal Embedded Tip
• Foot pedal control
• Adjustable Air Pressure
• Two hand pieces
SandVac
Dust collection system specifically designed for use with micro-abrasive blasters
• Powerful suction
• Quiet operation (55dbA)
• Compact, space saving design
• Dual function remote control included
• Accumulator pre-filter captures 95% of all dust and 99% of all abrasive media
• Plug in your micro-abrasive blaster and control both with one easy step
• 2 Year Warranty
www.pirotrading.com
Piro Trading introduces Accutron Inc., a
leading manufacturer of
technologically-advanced analgesia
conscious sedation equipment and
accessories. Serving the dental industry
for more than 35 years, the Ultra PC %
Flowmeter is designed for the practitioner
who demands precision control, consistent
performance and state-of-the-art innovation.
The unit combines efficient operation with
optimal safety, and its appearance
complements modern operatory esthetics.
Digital unit is also available!
GO DIGITAL WITH ACCUTRON INC.
New
www.pirotrading.com
Dental Alloys
New Products from
Whipmix
Introducing the new Xcavator. the first ever
automated divesting unit for divesting pressable
ceramics. CUT AN HOUR OR MORE FROM YOUR
DIVESTING TIME!
New
www.pirotrading.com
Aurident provides the Highest quality casting and ceramic alloys to meet all the needs of
the dental technician. For nearly 30 years, Aurident has earned a reputation for
excellence as a manufacturer of a complete line of quality dental alloys for dental
laboratories and dentists worldwide.
Our Identalloy® Council membership assures Aurident customers identifiable, consistent
composition for every package of Aurident alloy.
www.pirotrading.com
Smile Dental Journal Volume 4, Issue 1 - 2009
57

Flash News
APEX POINTER +
New apex locator
Electronic apex locator applying the latest 21 st century high frequency and constant current amplitude
technologies, Apex Pointer+ TM provides accurate, precise and repeatable root canal length
measurements in dry and humid canals.
Advantages
• Easy to operate.
• Rapid: Apex Pointer+ requires no calibration and is ready to use
immediately after self test has elapsed.
• Accurate, reliable and instant measurement whatever the
canal anatomy.
• The measurement is independent of canal conditions – dry,
humid, with blood, saline, hypochlorite, or other liquids.
• Large intuitive liquid crystal display (LCD) indicating gradual
progress of the file, increasing accuracy and resolution when
approaching the apical constriction.
• Stable canal length readings.
• The displayed values are directly related to the file tip location
in the canal and to its distance from the apical constriction
and the apex (foramen).
Vision USA & Piro Trading
New
Characteristics
• Compact, light weight and wireless.
• Changing beep frequencies to indicate the distance from
apex between the apical constriction and apex.
• Autoclavable electrodes.
• Electronic current limiter guarantees patient’s safety.
• Low power consumption and automatic power off ensures
prolonged battery life.
• Auto test feature.
www.micro-mega.com
Vision USA-a Dentrex Company is pleased to announce that they have appointed Lazar
Piro of Piro Trading International to be their sales and marketing person for the Middle
East and Africa region. Vision USA is extremely excited to offer their products for dentists and
dental laboratories including; Solera High Fusing Porcelain - Shade Perfect Restorations - the
«Injection Precision Cut» grain structure makes Solera the fastest building porcelain available.
Perfect for use with silver containing alloys. It’s non greening with CTE 13.8 - 15.2. Economically
priced, Vision USA Optical - Loupes, Magnification, Safety and Lighting Products to fit all
needs. Vision Lab Supplies - Unique products to enhance production in the dental laboratory
including Purge ZR (Zirconia Decontaminator for your porcelain furnace), Enzo Universal Plaster
less Articulator with disposable bases that can be glued to any model.
Chu’s Aesthetic Gauges
designed by Dr. Stephen J.
Chu, New York University, these
Gauges are designed to help
the dentist diagnose tooth size
discrepancies, measure them
accurately and correct them
appropriately.
The Gauges are color-coded
instruments having a
predetermined ratio of about
78%, it is the easiest, fastest, and most precise instruments
for diagnosing tooth size and proportion discrepancies.
They are used to achieve the proper mid-facial clinical
crown and biologic crown length during crown lengthening
procedure and stablish the correct aesthetic position of the
interdental papilla from the incisal edge before the flap
is closed and sutured. Finally, they help to provide quick and
simple analysis of the osseous crest location both mid-facially
and inter-dentally. They are used in aesthetic and surgical
crown lengthening procedure to determine the bone level
before reflecting the flap.
58 Smile Dental Journal Volume 4, Issue 1 - 2009
www.pirotrading.com
CHOICE 2 Veneers Cement
CHOICE 2 is a high compressive strength, light-cured luting
cement designed for cementation of porcelain and indirect
composite veneers. CHOICE 2 exhibits superior color stability
which is a critical factor in aesthetic veneer cementation
hence eliminating shade shifting, providing exceptional
aesthetics. The material is highly filled and enhances the
overall strength and wear resistance . The film thickness is
ideal to ensure that veneers are successfully placed. Choice 2
is available in a multitude of shades that blend in with the
natural dentition.
www.hu-friedy.com www.bisco.com

EZ-Fill®
Obturation with control. Fill laterally not
beyond the apex!
EZ-Fill’s patented Bi-Directional Spiral and
Epoxy root canal cement combined with a single
point technique has been shown to create a
seal equivalent to lateral condensation and
thermoplastic gutta percha.
• Thoroughly coats the walls of the root canal
and lateral canals without significant cement
being forced apically.
• The reverse spirals on the apical end rotate
in an unwinding direction out of the canal,
and thus never bind.
• Unlike thermoplastic techniques there is no shrinkage
upon cooling.
www.edsdental.com
Angled Bendable Reverse Cone With Adapter
KOS® Implants
4 ways to create angulations in one-piece implants
In the past one-piece implants were used mainly in the posterior
region, because the aesthetic zone often required an angulation
between implant and abutment.
Dr. Ihde Dental offers 4 different ways to overcome this problem easily:
- 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
bridge 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”. These 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 traditional two-piece systems requiring more
width of bone.
KOS implants provide the possibility to work in an immediate
loading protocol.
therese.debs@denterprise-middleast.com

Visit us at
IDS 2009
Hall No. 11.2 P
Stand No. 060

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