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Smile Dental Journal - June 2011 - Volume 6, Issue 2 - www.smiledentaljournal.com - Distributed free of charge
Ankyloglossia
in a Pseudo-Class III
Malocclusion
In-House
Maxillofacial 3D
Rapid Prototyping
3D Innovations of
Cranioplasty Plate
Construction
Celebrating
5 th Anniversary
“1 st Smile Symposium”
Confusing
Endodontic
Cases
Functional
and Aesthetic
Management of
Worn Dentition
with Direct
Composite
Restorations
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Smile Dental Journal
June 2011
Volume 6, Issue 2
Quarterly Issued
Distributed Free of Charge
+962 7 96367954
Amman, Jordan
info@smile-mag.com
sola@smiledentaljournal.com
www.smiledentaljournal.com
Director
Dr. Ma’moon A. Salhab
Director in Charge &
Chief Editor
Dr. Issa S. Bader
Editorial Director
Dr. Hassan A. Maghaireh
Marketing Director
Solange R. Sfeir
Photography
Solange R. Sfeir
Art & Design
Yazid M. Masa
Published by MENA Co. for
Dental Services
Jordanian National Library
Registration # 3954/2008/P
ISSN 2072-473X
Printed By:
Ad-Dustour Commercial Printing Press
Amman, Jordan
Mission Statement
Bridging the gap between advanced uptodate
peer-reviewed dental literature and
the dental practitioners enabling them to
do their jobs better- is our ultimate target.
Besides, Smile provides readers with
information regarding the available dental
products, armamentarium, news
and proceedings of dental symposia,
workshops and conferences.
Disclaimer
Smile Dental Journal makes every
effort toreport clinical information and
manufacturers’ product news accurately, but
cannot assume responsibility for the validity
of product claims or typographical errors.
Opinions or interpretations expressed by the
authors are their own and do not necessarily
reflect nor hold Smile team responsible for
the validity of the content.
Editorial Review Board
• Prof. Louis Hardan / Lebanon
DDS, DEA, PhD, Restorative & Esthetic Dentistry
• Dr. Maher Abdeljawad / Jordan
BDS, MDentSci, Restorative Dentistry
• Dr. Hani Abudiak / UK
BDS, MFDS RCSFRCD, PhD Paediatric Dentistry
• Dr. Eyas Abu-Hijleh / UAE
DDS, PhD, Orthodontics & Dentofacial Orthopedics
• Dr. Layla Abu-Naba’a / Jordan
BDS, MFD, RCS, PhD, Prosthodontics
• Dr. Ali Abu Nemeh / Jordan
BDS, NDB, MSc, Endodontics
• Dr. Hazem Al-Ahmad / Jordan
BDS, MSc, FDSRCS, Maxillo-Facial Surgery
• Dr. Muna Al-Ali / Australia
BDS, MFDS
• Dr. Suhail H. Al-Amad / UAE
D.Clin.Dent (Melb), FRACDS-Oral Med, GradDip
ForOdont (Melb), JMC-Oral Med
• Dr. Zaid Al-Bitar / Jordan
BDS, MSc, MOrth, RCS, Orthodontics
• Dr. Wesam Aleid / UK
BDS, MBBS, MRCSEd, FFDRCSI(OSOM), FRCS(OMFS)
Oral, facial, and Head & Neck Surgeon
• Dr. Raed Al-Jallad / Palestine
BDS, MSc, FFDRCS, FDSRCS, Oral & Maxillofacial
Surgery
• Dr. Hani Al Kadi / KSA
BDS, Dip ODONT, MDS, Endodontics
• Dr. Mohammad Al-Rabab’ah / Jordan
BDS, MFD RCSIre, MRD(Pros), RCSEd, JB(Cons) PhD
• Dr. Hatem Al-Rashdan/ Jordan
BDS, MSc, Jordanian Board of Maxillofacial Surgery
• Dr. Majd Al-Saleh / Jordan
BDS, DDS, MSc, Pediatric Dentistry
• Dr. Ahmad Al-Tarawneh / Jordan
DDS, M.Clin.Dent, Jordanian Board of Orthodontics
• Dr. Hayder Al-Waeli / Jordan
BDS, MSc, Jordanian Board of Periodontology
• Dr. Muayad Assaf / Jordan
BDS, MSc Endodontics
• Dr. Manal Azzeh / Jordan
BDS, MSc, Jordanian Board of Periodontology
• Dr. Menah Barmawi / Jordan
BDS, Jordanian Board of Maxillofacial Surgery
• Dr. Bader Eddin Borgan / Jordan
BDS, MDS, MOrth, RCSEd, Orthodontics
• Dr. Edgard El Chaar / USA
DDS, MS. Periodontology & Implantology
• Dr. Lama Jarrah / Jordan
BDS, MSc, Jordanian Board of Orthodontics
• Dr. Ghada Karien / Jordan
BDS, JDB, Pediatric Dentistry
• Dr. Ahmad Kutkut / USA
DDS, MS, Prosthodontics, USA
• Dr. Yousef Sadik Marafie / Kuwait
BDS, MSD, Prosthodontics
• Dr. Hakam Mousa / Jordan
BDS, MSD, Operative Dentistry
• Dr. Jumana Sabbarini / Jordan
BDS, MSc, Jordanian Board of Pediatric Dentistry
• Dr. Samer Sunna / Jordan
BDS, MSc, M.Orth, RCS, Orthodontics
• Dr. Thamer Theeb / Jordan
BDS, MSc, Prosthodontics
• Dr. Leema Yaghmour / Jordan
BDS, DUA, DUB, Pediatric & Community Dentistry
International Advisory Board
• Prof. Abdullah Al-Shammery / KSA
BDS, MS Restorative Dentistry / Rector, Riyadh Colleges of
Dentistry & Pharmacy
• Prof. Magid Amin Ahmed / Egypt
Oral & Maxillo-Facial Surgery / Vice President MSA University
Dean, Faculty of Dentistry MSA University
• Prof. Jamal Aqrabawi / Jordan
DDS, DSc, DMD Endodontics / Dental Faculty, University of Jordan
• Prof. Nabil Barakat / Lebanon
DDS, MSc, FICD Maxillo-Facial Surgery / President of LAO & EMAO
• Prof. Stephen Cohen / USA
MA, DDS, FICD, FACD, Diplomate, American Board of Endodontics
• Prof. Azmi Darwazeh / Jordan
BDS, MSc, PhD Oral Pathology Oral Medicine / Former Dean,
Faculty of Dentistry JUST / Examiner, Faculty of Dentistry RCS
Ireland
• Prof. Mohamed Sherine Elattar / Egypt
BDS, MSc, PhD Prosthodontics / Dean, Faculty of Dentistry, Pharos
University / President of AOIA
• Prof. Dr. Marco Esposito / Italy
DDS PHD, Editor of the Cochrane Oral Health Group
Editor in Chief of the European Journal of Oral Implantology
• Prof. Fouad Kadim / Jordan
BDS, MSc, PhD Conservative Dentistry / Vice Dean, Faculty of
Dentistry, University of Jordan
• Prof. Howard Lieb / USA
DMD General Dentistry & Management Sciences / College of
Dentistry, New York University
• Prof. Edward Lynch / UK
PhD (Lon), MA, BDentSc, TCD, FDSRCS (Ed), FADFE, FDSRCS (Lon)
Head of Dental Education and Research Warwick University
• Prof. Lamis D. Rajab / Jordan
DDS, PhD, Pediatric Dentistry / Former Dean, Faculty of Dentistry,
University of Jordan
• Prof. Issam Shaaban / Syria
BDS, PhD, Maxillo-Facial Surgery / Former Dean, Faculty of
Dentistry Damascus University / President of Syrian OMFS Society
• Prof. Yousef Talic / KSA
BDS, MSc, DASO, FICOI, FICD, Editor-in-Chief, Saudi Dental
Journal / Consultant in Prosthodontics & Implantology, College of
Dentistry, King Saud University
• Prof. Abbas Zaher / Egypt
BDS, MS, PhD Orthodontics, Professor of Orthodontics / Vice-
Dean, Alexandria University / Vice-President, World Federation of
Orthodontists
• Prof. Carina Mehanna Zogheib / Lebanon
DDS, PhD Restorative and Esthetic Dentistry, FICD
Head of Restorative and Esthetic Dentistry Department, Saint-
Joseph University
• Dr. Nadim Abou-Jaoude / Lebanon
CES, DU, FICD Prosthodontics, Lecturer, Lebanese University /
Clinical Associate, American University of Beirut
• Dr. Hasanen H. Al-Khafagy / UAE
BDS, MSc, PhD Conservative Dentistry, Ajman University of Science
& Technology
• Dr. Jaser Al-Ma’itah / Jordan
BDS, MSc Oral Surgery, Head of Dental Department, Jordanian
Royal Medical Services
• Dr. Maher Almasri / UK
DDS, MSc, PhD, FADFE, Director of Oral Surgery Courses, Bone
Graft Modules Leader, Warwick University / President of the Syrian
Section of IADR
• Dr. Abdelsalam Elaskary / Egypt
BDS, FICOI, President of ASOI
• Dr. Yasin El-Husban / Jordan
DDS, MSc Prosthodontics, Former Minister of Health
Former Head of Dental Department & King Hussein Hospital
• Dr. Zbys Fedorowicz
Director, The Bahrain Branch of the UK Cochrane Centre
• Dr. Wolfgang Richter / UK
DDS, PhD, Restorative Dentistry, President of ESCD
• Dr. Mohammad Sartawi / Jordan
BSc, BDS, MSc, FFDRCSI (OSOM)
Senior Consultant Maxillo-Facial Surgery

12
Orthodontics
Ankyloglossia in a Pseudo-Class III Malocclusion: A
Case Report
By Salwa Jeragh Alhaddad, Mohammed Alnoori, Manar Alnoori
Maxillofacial
18 In-House Maxillofacial 3D Rapid Prototyping
By Wesam Aleid
Dental Laboratory
22 3D Innovations of Cranioplasty Plate Construction: a Case Report
By Muhanad M. Hatamleh, Jason Watson
Endodontics
26
Confusing Endodontic Cases: Case Series Report
By Masahiro Yoneda, Nao Suzuki, Sonia M. Macedo, Hisashi Anan, Takao Hirofuji
Restorative
Functional and Aesthetic Management of Worn Dentition with
Direct Composite Restorations: A Clinical Report
32
By Shihab A. Romeed, R. Malik, S.M. Dunne
Debate in Focus
08
36
42
Research
Summaries in
Focus
Maxillary Sinus
Augmentation as a Risk
Factor for Implant Failure
The McGill and York
Consensus Statements on
Two- Implant Overdentures
Interventions for Replacing
Missing Teeth: Dental
Implants in Fresh Extraction
Sockets (Immediate,
Immediate-Delayed and
Delayed Implants)
46
54
66
Ask the Experts
Flash News
Event Reviews
2 Minutes With
Affiliation & Distributors
• Bahrain
Bahrain Dental Society
+973 17723767, bahds@batelco.com.bh
• Egypt
Alexandria Oral Implantology Association
+203 5451277, www.aoiaegypt.com
• Iran
Shayan Simin Teb Co.
+98 21 66380364/5, info@shayansiminteb.com
Iranian General Dental Association
+98 2188287794/5, info@igda.ir
• Iraq
Iraqi Dental Association
+964 015379267, Info@iraqidental.org
Kurdistan Dental Association
+964 7504510315, dara_saeed@yahoo.com
• Jordan
Basamat Medical (Pharmadent)
+962 6 5605395, www.basamat.com
• Kuwait
Kuwait Dental Association
+965 5325094, www.kda.org.kw
• Lebanon
Lebanese Dental Association
+961 1 611555, www.lda.org.lb
Lebanese Dental Laboratory
Association
+961 5955 151, www.opdlb.com
Richa Dental Store
+961 5 452555, www.richadental.com
• Oman
Oman Dental Society
+968 95769039, omandent@omantel.net.om
• Qatar
Qatar Dental Society
+974 4393144, www.qatardentalsociety.org
Ali Bin Ali Medical The i-partner
+974 4867871 ext. 247, www.alibinali.com
• Saudi Arabia
Saudi Dental Society
+966 1 4677743, www.sds.org.sa
• Sudan
Sudanese Dental Association
+249 83 779769, sdaassnan@hotmail.com
• Syria
Najjar Trading Est.
+963 (11) 2244140, najjest@scs-net.org
• United Arab Emirates
Noble Medical Equipment
+971 4 8854544, imad.kafity@noblemedical.ae
Dubai Medical Equipment L.L.C.
+971 6 554 0206, www.mamut-dental.com
Editorial Policy
• Our objective is to publish a dental journal of consistent high quality and help to increase the exposure of literature written by dental professionals from our region at a global
level.
• Literature review, original research, clinical case reports, case series, short communication, randomized clinical trials, and book reviews are among our scope of published
material, where the clinical aspect of dentistry is presented in a scientific way, starting each article with an abstract, backed up by references in accordance with the
Vancouver citation style.
• The journal encourages the submission of papers with a clinical approach, practical or management oriented, besides papers that bridge the gap between dental research
and clinical application.
• Received manuscripts are first revised by the editor to check if it is appropriate for publishing in Smile and that it complies with the author›s guidelines. The manuscript is then
forwarded to two or more professional reviewers. Anonymity of both the author and reviewer is preserved (double blinded peer-review process).
• Our editorial policy which controls the quality of articles and assures their accuracy, clarity, and smooth readability through high level enthusiast regional and
international team of experts is our golden key for success.
• Finally, we believe that a controlled content of advertisements could be informative and beneficial especially in dentistry, where the armamentarium and pharmaceuticals
are a major and integral part of the dental science.

Happy 5 th Birthday to
Smile Dental Journal
This month, we are celebrating the 5th Birthday of Smile Dental Journal and it’s
time to look back on the last five years of our journal. The plan for the last years was
to bridge the gap between advanced up-to-date peer-reviewed dental literature and
the dental practitioners enabling them to do their jobs better. I believe that we have
achieved this goal; Smile Dental Journal already has more than 30.000 readers in more than 28 countries and has
become the official publication of many Dental Societies and Congresses in the Middle East and North Africa
region.
As a new Editorial Director I am very pleased with this achievement and would like to congratulate and thank my
predecessors, my colleagues in the International Advisory Board, the Editorial Review Board and Smile Directors
for their efforts and achievements in promoting Smile Dental Journal in the last five years. I look forward to
continuing this momentum.
The next question is whether we are satisfied, and of course the answer is no. There is a bias in the publications,
in the sense that the same group of authors have contributed to many articles in addition to the fact that some of
the submitted manuscripts were of poor quality. The challenge now is to deliver a premium clinical & evidence
based journal to bridge the gap in a very competitive field, providing sound science on which to base decisions for
everyday clinical practice, and I would like to invite you to submit your manuscripts for the upcoming issues of
Smile Dental Journal. You can contribute in a variety of ways: write a clinical case report with an evidence based
review, retrospective, prospective or any other clinical study conducted at your University, Hospital or Private
office. You could also share your practice, clinical and or management tips and tell your colleagues what has (or
hasn’t) worked for you in your practice by contributing to one of the newly introduced sections: Debate in Focus,
Ask Smile Experts and Research Summaries in Focus in addition to the other new section you will find in this
issue: Two minutes with a Smile guest.
We wish to be open-minded and objective and to present reliable and balanced information. We shall aim for quality
and not for numbers of published articles in order to publish articles with good, sound and up to date evidence in
order to join the MEDLINE and other high quality databases as quickly as possible.
Finally, we would like to welcome the new esteemed Editorial Team, Reviewers as well as Advisory, whom with
their help, we plan to change things for the better.
I wish you all a pleasant reading. In the mean time, should you have any comments or suggestions, please do not
hesitate to email me at maghaireh@smiledentaljournal.com
Dr. Hassan Maghaireh
BDS, MFDS, MSc Implants (Manchester)
Editorial Director
Smile Dental Journal
| 4 | Smile Dental Journal | Volume 6, Issue 12 - 2011

Calendar of Events
September 14 - 17
FDI Annual World
Congress
Mexico City, Mexico
www.fdiworldental.org
September 21 - 24
21 st BIDM & 7 th Arab
German Implantology
Meeting of DGZI
Dbayeh, Lebanon
www.lda.org.lb
October 6 - 8
International
Expodental
Rome, Italy
www.exp odental.it
October 12 - 15
20 th EAO Annual
Scientific Congress
Athens, Greece
www.eao-congress.com
October 22 - 23
Dental Istanbul 2011
Istanbul, Turkey
www.dentalistanbul.com
October 25 - 28
Egyptian Dental
Association (EDA)
Congress
Cairo, Egypt
www.eda-egypt.org
October 27 - 28
3 rd Dental-Facial
Cosmetic International
Conference
Dubai, UAE
www.cappmea.com/aest
hetic2011
November 17 - 18
1 st Smile Symposium
Amman, Jordan
www.smiledentaljournal.com
November 22 - 24
7 th International Sudanese Dental
Association Conference
Khartoum, Sudan
www.sdasudan.org
November 27 - 30
Greater New York
Dental Meeting 2011
New York, USA
www.gnydm.com
December 7 - 9
3 rd Sharjah Dental College & 16 th
EMA International Dental
Conference
Sharjah, UAE
www.sharjah.ac.ae
For more events visit www.smiledentaljournal.com or our page on Facebook.
Smile Dental Journal | Volume 6, Issue 2 - 2011| 5 |

Smile Message
If You Want Something Done, Ask a Busy Person to Do It
It is with great delight we welcome our new Editorial Director; Dr. Hassan Maghaireh
whom I have known personally since he was an undergraduate student in the mid
nineties. Dr. Maghaireh graduated from the University of Cairo in June 2000 after
which he undertook a five year maxillofacial training in the United Kingdom Hospitals,
he obtained his MFDS from the Royal College of Surgeons in Edinburgh in May
2004 and was awarded his Clinical Masters Degree in Dental Implantology from
the University of Manchester in July 2008, when he started working with Professor
Marco Esposito at the Oral health group in Cochrane Collaboration, as well as a Clinical Mentor at the Association of Dental
Implantology in England. Hassan acts as a co-author for implant related systematic reviews as part of Prof. Marco Esposito’s
research team and he is on the Editorial Board of the European Journal of Oral Implantology.
Dr. Maghaireh is now a part time clinical teacher at the Department of Implant Dentistry at the Univeristy of Manchester, he also
maintains a private implant referral practice in Leeds- England.
Indexing of Smile Dental Journal
As you might all be aware, it is not an easy task to attract high quality articles and we are well aware that many authors are
concerned that the journal is not yet indexed in PubMed and has no impact factor. However, we are proud to say that Smile
Dental Journal has moved from a magazine aimed to bridging the gap between advanced up-to-date peer-reviewed dental
literature and the readers, to a well recognized peer-reviewed and indexed scientific journal. Smile Dental Journal has been
selected to be one of the sources of input of the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR), Ulrich’s,
DOAJ, Open J-Gate, Index Copernicus, Portal LivRe and The Electronic Journals Library.
Any scientific journal aims to be indexed by PubMed and this request can only be made after several issues with strong, evidence
based and well conducted studies have been published at this journal. Therefore, our priority in the next two years is to improve
the quality of our published articles in order to have Smile Dental Journal indexed in PubMed and Scopus as soon as possible. In
the mean- time, we wish to grow and become the leading provider of evidence-based information for dentists in the Middle East
and North Africa region.
Publishing at Smile Dental Journal
Our new editorial team has taken a clear decision to only accept well conducted clinical studies, clinical audits and rare case
reports providing an up-to date, evidence based mini review is enclosed as part of that article. Priority in publishing will
always be given to higher quality clinical studies rather than to the date of acceptance. We would like to invite all our readers;
academics and clinicians to submit to Smile Dental Journal and in return we promise a quick and efficient reviewing process and
publishing good quality articles in no time in addition to exposing your clinical work and yourself to more than 30.000 readers
in more than 28 countries.
1 st Smile Dental Symposium: “Implant Dentistry: Is Quicker Always Better?”
Our mission at Smile Dental Journal has always been to bridge the gap between evidence based dentistry and clinical practice.
For the last five years our focus was mainly on the hard and electronic copies of our journal as main tools to implement our
mission and spread the message, but today, recognizing the importance of continual education as one of the tools in bridging
the gap between the up to date evidence based literature and day to day clinical practice, we at Smile Dental Journal are
delighted to invite you all to our 1 st Smile Dental Symposium which will be on Implant Dentistry. This clinical symposium which
will be at the continual education centre in the University of Jordan in Amman, on 17 th November 2011, will be run by Professor
Dr. Marco Esposito and our editorial director; Dr. Hassan Maghaireh and will be on the importance of timing of dental implants
placement and loading. The up to date evidence on immediate implants, clinical scenarios and tips & hints will be presented and
discussed at this one day symposium.
Dr. Mamoon Salhab Tamimi
Director
Smile Dental Journal
| 6 | Smile Dental Journal | Volume 6, Issue 12 - 2011

1 st Smile Dental
Symposium
First Announcement
17 – 18 November 2011
Amman – Jordan
“Dental Implants
Is Quicker Always Better?”
Prof. Dr. MARCO ESPOSITO
Editor of the Cochrane Oral Health
Group, The University of Manchester, UK
Assoc. Prof. in Biomaterials, Göteborg
University, Sweden
Editor-in-Chief of the European Journal of
Oral Implantology (EJOI)
Editor of the Rivista Italiana di Stomatologia,
Italy
Specialist Periodontists, UK
Dr. HASSAN MAGHAIREH
Clinical Teacher in Implant Dentistry,
The University of Manchester, UK
Editorial Director of Smile Dental
Journal
Editorial Board, European Journal of
Oral Implantology
Senior Clinical Mentor, Association of
Implant Dentistry (ADI), UK
Implant Private Practice, Leeds, UK
Post Symposium Clinical Course
Soft Tissue Management Around Dental Implants
This course includes tutorials on basic and advanced
soft tissue management and designed to provide
clinicians with the knowledge, skill sets and confidence
in raising and managing flaps for implant surgery.
More info:
www.smiledentaljournal.com
symposium@smile-mag.com
+962 795556333

Zirconia All-Ceramic Restorations:
Do They Perform Well?
Ahmad Jum’ah
BDS(Hons), MSc/PhD (Clin) Student-First year
Restorative Dentistry Department, Leeds Dental Institute, University of Leeds, UK
dnaahj@leeds.ac.uk
The extensive use of ceramics in industrial, medical and
dental fields makes this period of time a good candidate
to be named as the “Ceramic age” (Vagkopoulou et
al. 2009). In dentistry, PFM (Porcelain Fused to Metal)
restorations are among the most commonly prescribed and
serviceable restorations with the longest and most traceable
record of predictable performance. However, driven by
the extraordinary increase of aesthetic demands, concerns
about allergies and systemic effects of metal alloys, and
adverse effects of destructive tooth preparation for PFM
restorations, light has been shed on all-ceramic restorations
and rigorous research and development in this field has
been performed. The ambition of complete replacement
of PFM restorations with all-ceramic counterparts was
curbed by the brittleness and limited flexural strength of the
latter especially in areas subjected to high occlusal forces.
Development of high strength zirconia and alumina cores
seems to be potentially effective to overcome this problem.
Partially stabilized zirconia based ceramics have distinct
mechanical and optical properties and exhibit a very
high biological compatibility with the oral environment:
consequently, huge amount of research has been
directed toward this material. Thus, clinicians should
be aware of the current evidence and literature about
zirconia all-ceramic restorations and their clinical
serviceability in order to communicate with patients on
solid scientific bases, clearly describe pros and cons
of such restorations, and deal with the material in the
proper way to guarantee better longevity.
As is the case with all new dental materials, clinicians
should bear in mind that the evidence available about
zirconia is largely based on in vitro studies that might be
inapplicable to some clinical situations and the long term
clinical trials are scarce. In general, clinical data about
this material is of a short term and unfortunately, many
contradictory findings are present. This article briefly
envisages these findings, and attempts to establish a
well-structured argument that will help the reader to
get a broader image about the performance of these
restorations in terms of their functional, aesthetic, and
biological characteristics.
Recently, zirconia or “Ceramic steel” has been used
extensively in fabrication of extra-coronal restorations
especially, crowns and FPDs (Fixed Partial Dentures).
This is largely attributed to the excellent mechanical
properties the material exhibits and increasing
popularity of CAD/CAM technology. The evidence
from experimental work by Guazzato et al. 2004
indicates that the core of the all-ceramic crown dictates
the fracture strength of the restoration. Thus, utilizing
zirconia as substructure guarantees high success rate for
such restorations. Clinical trials studying the performance
of zirconia single crowns are few; most clinical trials
examined the performance of multiunit restorations. In
their 3-year clinical study, Beuer et al. 2010 reported
that none of fifty single crowns failed at the end of the
observation period. However, fractured lingual cusps of
all-ceramic crowns used to restore mandibular molars is
a frequent technical complication that has been reported
by Raigrodski et al. 2006. Area-specific modification of
the core design and thickness was suggested to increase
support for the veneering porcelain. Silva et al. 2010
found increased reliability of modified Y-TZP (Lava)
crowns while such an improvement wasn’t demonstrated
by Lorenzonis’ et al. study in the same year.
In contrary to his findings regarding single crowns,
Guazzato et al. 2004 stated that the strengthening
action of the Y-TZP is outweighed by the weaker
veneering porcelain in case of FPDs. This experimental
finding has been substantiated by number of clinical
studies that reported high incidence of chipping or
complete delamination of veneering porcelain. Poor
mechanical properties of the veneering porcelain and
“a weak interface” between zirconia core and veneer
are blamed for such complications. The former is a
well-accepted justification for minor chipping especially
when low fusing ceramics are used while some authors
cast doubt that the weak interface even exists. Bond
strength between zirconia core and veneering porcelain
was found to be similar to the bond in metal ceramic
samples used as controls (Al-Dohan et al. 2004). This
in vitro finding was substantiated by Raigrodski et al.’s
2006 clinical study who reported absence of adhesive
failures at the interface after 3 years follow-up period.
However, the amount of evidence demonstrating the
role of -“a weak interface”- in zirconia FPDs seems to be
convincing (Aboushelib et al. 2007).
| 8 | Smile Dental Journal | Volume 6, Issue 2 - 2011

Clinical studies reported 73.9-100% survival rate of
zirconia all-ceramic FPDs over 2-5 years observation
periods. The most common complication (15% in 3
studies) was veneer layer chipping or delamination
(Sailer et al. 2007, Raigroski et al. 2006, and Vult von
Steyern et al. 2005). Framework fracture was a far rarer
complication and found to be as low as 0-2.2% in some
studies (Sailer et al. 2006, 2007). The high complication
rate in some studies may be worrying especially when
compared to survival rate of PFM FPDs which is 94.4%
for 5 years as estimated in the systematic review by Sailer
et al. 2007. However, Denry and Kelly 2008 remarked
that replacement of any restoration due to veneer layer
crazing or chipping was not needed. The oscillation of
complication and survival rates between different studies
necessitates careful interpretation and paying attention
to what is deemed to be failure. From a clinical point
of view, the restoration is successful if it does not need
further intervention or remaking, and it maintains health,
function and aesthetics (Ahmad 2006).
The amount of research tackling mechanical properties
of zirconia dental ceramics far exceeds that investigating
wear properties of this material. This is largely attributed
to the fact that wear properties of veneered zirconia
restorations are primarily dictated by those of the
veneering porcelain and the clinical applications of
unveneered zirconia are not so popular and limited to
cases of lack of interocclusal clearance, compromised
abutments and resin-bonded and inlay-retained zirconia
FPDs. In 2010, two papers published on the wear of
unveneered zirconia, one investigated the antagonistic
tooth wear (wear of the tooth structure opposing to
restoration) and found that unveneered zirconia is
associated with a lower antagonistic tooth wear when
compared to polished feldspathic porcelain (Jung et
al.2010). The other study was by Albashaireh et al. who
found that wear resistance of the zirconia ceramics is the
highest when compared to others. These studies indicate
that zirconia ceramics are compatible to opposing
dentition and at the same time structurally stable. These
results may be promising and encourage the use of
unveneered zirconia especially in the era of improved
shading techniques of zirconia frameworks; however
the phenomenon of low temperature degradation –
alternatively called aging- that causes slow material
deterioration when exposed to wet environment is still
troublesome and concerning.
Bonding to zirconia poses a big challenge in some
clinical situations as surface treatments used with glass or
silica containing ceramics, e.g., hydrofluoric acid etching
and silanization, have been found to be ineffective
(Blatz et al. 2007). Use of adhesive cementation was
found to have no effect on the performance of zirconia
restorations, however it is still necessary when dealing
with cases of compromised retention as in the case of
short abutments or when using resin bonded zirconia
FPDs (Komine et al. 2010). Lack of bonding also
compromises the outcome of repairing delaminated
veneering porcelain layer. in vitro studies investigated
different surface treatments in attempts to overcome such
problems, tribochemical silica coating (e.g. Rocatec ® and
CoJet ® ), plasma spraying, pre-treatment with phosphate
containing primers, airborne particles and etching with
CO 2 laser were among those found to be effective.
However, a recent report by Behr et al. 2011 found that
silica coating and application of phosphate containing
primers in addition to silanization was insufficient to
attain a clinically acceptable bond strength which was
predetermined as 10 MPa.
Owing to their excellent optical properties, zirconia allceramic
restorations are aesthetically appealing.
Absence of the black line at the gingival margins is an
important advantage of using white zirconia frameworks
over PFM restorations. Translucency and opacity of
zirconia frameworks vary between different systems.
For example, a 0.5mm thick core made of In-Ceram
Zirconia or Cercon is completely opaque, it is thus
recommended to be used in cases when masking
discoloured cores is necessary. On the other hand, Lava
frameworks are considered to be semi-translucent and
they are advantageous as they enhance the accurate
reproduction and depth of the natural tooth shade.
The introduction of coloured zirconia frameworks
hypothetically enhances the overall colour matching,
disputes the concerns about “too white frameworks”,
negates the need for liner application -which was
found to weaken core-veneer interface- and reduces
the thickness of veneering layer. Aboushelib et al.
2008 found that air-borne particle abrasion increased
bond strength of the core-veneer interface when used
with white zirconia framework in contrast to coloured
ones. Furthermore, they stated that application of liner
was found to enhance the bond in case of coloured
frameworks yet, a high incidence of de-lamination
was reported. Colored Cercon frameworks showed
higher core-veneer bond strength than Lava despite the
fact that their chemical composition was similar. They
attributed this to the structural changes occurring as a
result of different staining procedures. The significance
of using coloured zirconia frameworks was assessed
two years later by the same authors who concluded that
this technique did not offer any direct advantage over
the white zirconia frameworks layered with veneering
porcelain. Finally, Jung et al. 2007 investigated soft
tissue colour changes associated with veneered and
unveneered zirconia. It was found that zirconia did not
induce visible colour changes when thickness of mucosa
was 2 and 3mm. Also, the colour change that occurred
with 1.5mm thick mucosa was the least in case of
zirconia when compared to titanium. This may indicate
that gingival aesthetics are not affected when margins of
zirconia restorations placed in a sub-gingival location.
Results of in vitro and in vivo studies that proved high
Smile Dental Journal | Volume 6, Issue 2 - 2011| 9 |

iocompatibility of zirconia coupled with reduced
bacterial and plaque colonization when compared to
titanium encouraged the use of zirconia in implant and
restorative dentistry as a material with periointegrative
properties. Readers are referred to the excellent review
by Hisbergues et al. 2008 for more information about
the biocompatibility of zirconia and its applications in
implant dentistry.
Finally, there remain debatable questions to be asked
when all-ceramic zirconia restorations are concerned.
Firstly, if the tooth preparation guidelines are basically
similar to PFM restorations and zirconia has no
advantage over other types of all-ceramic restorations in
cases of limited inter-occlusal space and para-functional
habits, do we really get a benefit from substituting PFM
restorations with zirconia in terms of conservation of
tooth structure and dealing with difficult cases? Secondly,
does the gain from excellent aesthetic, mechanical and
biological properties outweigh the risk of restoration
failure -mainly delamination- which was found to be very
high in some studies? Thirdly, is there any guarantee
that zirconia restorations will not massively fail in a
manner analogous to zirconia heads used in total hip
arthroplasty due to low temperature degradation?
Answering these questions should be done through
conducting long term clinical trials exploiting the results
of in vitro research in hot topics like improving coreveneer
interface utilizing different surface treatments and
testing aging-free zirconia ceramics namely, zirconia
toughened alumina and ceria-doped zirconia.
Acknowledgment
I would like to acknowledge with gratitude Dr. Brian
Nattress for the clinical photographs, Professor David
Wood for editing the paper and continuous support and
Dr. Hassan Maghireh for his kindness and motivation.
A clinical case of three-unit all-ceramic zirconia FPD over implants with an excellent aesthetic outcome. Zirconia abutments were used.
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| 10 | Smile Dental Journal | Volume 6, Issue 2 - 2011
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Ankyloglossia in a Pseudo-Class III
Malocclusion: A Case Report
Abstract
This case report describes a 14 year old female patient, with pseudo-Class III incisor
relationship on a mild Class III skeletal base with ankyloglossia. It highlights the
relationship of an unfavorable soft tissue environment exerted by “tongue tie” and
genetic factors proposed by the presence of family history in the development of a
Class III malocclusion. Orthodontic treatment was provided on, a non-extraction basis
to correct the Class III relationship. The patient was then referred for labial and lingual
frenectomy using laser surgery to stabilize the achieved correction and facilitate the
wear of orthodontic retainers by the patient. The first annual review carried out at the
age of 17 years has revealed stable results.
Keywords: Ankyloglossia, Pseudo Class III, Frenectomy.
Salwa Jeragh Alhaddad
BChD, MFDS RCSI, MSc
Orthodontics, M’Orth
RCSEng.
Specialist Orthodontist at Ameri
Hospital and Kuwait University
Kuwait
drjeragh@hotmail.com
Mohammed Alnoori
BDS, MS
Senior Specialist Periodontist at
Ameri Hospital
Kuwait
Manar Alnoori
BDS, MFDS, MGD
Ameri Dental Center
Kuwait
Introduction
The etiology of malocclusions has been the subject of a long standing debate in the
orthodontic literature. 1 The role of both genetic and soft tissue factors has been well
established. Monozygotic twin studies suggested a complex interplay between the two
factors. 2,3 Successful management of orthodontic patients is dependent on accurate
identification of all etiological factors involved in the development of the malocclusion.
With an estimated incidence of 4.8% 4 ankyloglossia is a congenital anomaly in which
the mucous membrane under the tongue is too short, limiting the mobility of the
tongue. The condition varies in the degree of its severity from mild mucous membrane
bands to complete tethering of the tongue to the floor of the mouth. Patients with
ankyloglossia frequently suffer from feeding, cleaning and swallowing difficulties, 5
with the later being associated with anterior open bite due to a constant forced tongue
thrust. 6
Despite the lack of strong evidence, the constant forward tongue position has also been
implicated, as a factor contributing to the establishment of a Class III malocclusion. 7
Diagnosis and Aetiology
A 14 year old female patient, with no relevant medical history, presented to our clinic
with a chief complaint of upper midline diastema and inability to bite. Extraorally, the
patient presented with a mild Class III skeletal pattern, slight maxillary hypoplasia,
flattening of the malar base and increased lower anterior facial height.
The family history revealed a genetic component towards Class III jaw relationship,
with similar presenting features of the malocclusion evident in the patient’s father.
The condition, however, was further complicated by the presence of ankyloglossia.
Intraorally, she had a generally well aligned dentition with a 2mm maxillary midline
diastema associated with a prominent labial frenum.
In occlusion, the patient had a Class III incisal relation, with reverse overjet of 3mm
following a displacement from an initial edge to edge incisal relation (centric relation to
centric occlusion). The overbite was adequate with a 50% vertical overlap of the lower
incisor. Canines and Molars were also in Class III relation. Ankyloglossia was evident,
and the lower centre-line was displaced 2mm to the right of the patient’s mid-facial line
due to mandibular shift on maximum intercuspal position.
| 12 | Smile Dental Journal | Volume 6, Issue 2 - 2011

Pre Orthodontic intra-oral Views Pre Orthodontic Extra-oral Views
A
B C D
E
F
G
H I J
(Picture 1) A: Initial facial view, B: Initial facial view with a smile, C: Initial 3-4 view, D: Initial lateral profile view, E: Initial
incisal relation in centric relation, F: Initial incisal relation in centric occlusion, G: Initial right buccal segment in occlusion,
H: Initial left buccal segment in occlusion, I: Initial occlusal view of the lower arch, J: Initial occlusal view of the upper arch.
Cephalometric analysis confirmed a mild skeletal III
pattern (ANB= -3 degrees), mild maxillary hypoplasia
(Angle SNA=76 degrees), normal mandibular length,
and dental compensation through retroclination of the
lower labial segment (Angle LIMP=84 degrees) (Figure 1
& Table 1).
(Table 1)
Measurement Value Norm Standard deviation
SNA 77˚ 81˚ +/-2˚
SNB 79˚ 79˚ +/-2˚
ANB -2˚ 3˚ +/-1˚
UIMP 109˚ 113˚ +/-6˚
LIMP 84˚ 92˚ +/-6˚
IIA 139˚ 135˚ +/-11˚
MMPA 30˚ 24˚ +/-2˚
SnMax 10˚ 8˚ +/-3˚
LAFH 57% 55% +/-2%
(Fig. 1) Patient’s lateral cephalogram tracing prior to
orthodontic treatment.
Rationale for Treatment
Elimination of the forward mandibular posture was
considered; to eliminate the risks of incisal attrition, root
Smile Dental Journal | Volume 6, Issue 2 - 2011| 13 |

esorption due to occlusal trauma, and reduce the stress
on the tempomandibular joint as a result of repeated
forward mandibular displacement.
Correction of the lower centerline by eliminating
the lateral mandibular displacement to the right on
maximum intercuspal position, to enhance dental and
facial aesthetics.
Space closure within the maxillary arch was considered
to give favorable aesthetics despite the added difficulty in
Class III correction.
Both patient and parents were informed, that patient’s
co-operation in wearing Class III elastics played a key
role in treatment success. Whilst the adverse effects of
further forward mandibular growth were fully explained.
Labial and lingual frenectomies using laser surgery were
recommended to eliminate any potential role of these
soft tissues in the etiology of the patient’s malocclusion,
to help stabilize the orthodontic treatment outcome and
to facilitate the wearing of retainers.
Treatment
The patient was treated on a non-extraction basis,
keeping orthognathic surgery as a valid treatment option
should future growth dictate it. Treatment objectives
were, to close the spaces within the maxillary arch, and
eliminate forward mandibular displacement.
Upper and lower fixed appliances of MBT prescription,
with a 0.022 inch bracket slot were bonded with the four
first molars banded using Andrew’s prescription due to
their characteristic lingual torque to maintain the molar
relation.
Treatment Results
The patient completed the orthodontic treatment in 23
months at the age of 16 years. Complete space closure
with correction of the incisal relation were achieved
enhancing the existing dentoalveolar compensation.
The mandibular shift was eliminated successfully and
the patient and parents were happy with the treatment
outcome.
Following debond, the patient was referred to undertake
Post Orthodontic intra-oral Views Post Orthodontic Extra-oral Views
A
E
H
B C D
F
I
G
(Picture 2) A: Facial view, B: Facial
smile, C: 3-4 view, D: Lateral profile
view, E: Anterior view of the dentition in
occlusion, F: Right view of the dentition
in occlusion, G: Left view of the dentition
in occlusion, H: Lower occlusal view, I:
Upper occlusal view.
| 14 | Smile Dental Journal | Volume 6, Issue 2 - 2011

laser frenectomy for the labial and lingual frenal
attachments. Signs of healing were evident on the next
day review and salt water mouth rinses in conjunction
with routine tooth cleaning were advised.
Upper and lower Begg style, wrap around retainers were
A
B
(Picture 3) A: Anterior view one day post laser labial
frenectomy, B: Lower occlusal view one day post laser
lingual frenectomy.
augmented with local anaesthesia for more severe
cases as required. Laser surgery eliminates the need for
general anaesthesia but it is essential that the patient
is cooperative and remains motionless throughout the
procedure. The procedure offers virtually no bleeding,
with reduced reported pain and risk of infection.
The “pseudo” nature of the Class III relationship in this
case, may suggest a stronger influence of the soft tissue
over the inherited genetics.
However, it is very difficult to draw conclusions based
on the presenting findings in isolation, regular reviews
of future growth, as well as the stability of the achieved
correction, are the only ways to determine the roles
played by soft tissues and growth in the etiology of the
malocclusion seen in this case.
Cephalometric analysis at the first annual review at the
age of 17 years, revealed a stable enhancement of the
dental compensation presented initially at 14 years of
age, with a 3 degrees increase in the upper incisor to
maxillary plane angle (109 to 112 degrees, 8 degrees
of retroclination of the lower labial segment with regard
to the mandibular plane (84 to 76 degrees) and stable
skeletal features and vertical proportions. (Figure 2 &
Table 2).
The stability observed in this case may suggest a
potential relation between the unfavorable soft tissue
“tongue tie” and the Class III malocclusion seen in this
case.
given to the patient emphasizing the importance of full
time wear and the need for regular reviews until growth
ceases. At the age of 17, the patient attended her first
annual post-orthodontic treatment review with a stable
treatment outcome.
Discussion
This case report highlights the role of both genetic
influence proposed by the patient’s family history, as well
as the role of unfavorable soft tissue environment exerted
by ankyloglossia, in the development of a pseudo-Class
III skeletal pattern in a 14 year old female patient.
While accepting milder cases of ankyloglossia
remains a common option, particularly if there was
a lack of patient’s concern, surgical intervention
may be considered in more severe cases. Different
types of surgical procedures have been described
in the literature. However, case selection remains
the key to successful management. Surgical partial
frenectomy, complete frenectomy, revision frenoplasty
or electrocautery procedures have all been described. 8
More recently, however, laser surgery has been used
to relieve ankyloglossia. 9,10 Topical gel analgesia has
been recommended for this procedure which may be
(Fig. 2) Patient’s lateral cephalogram tracing after
orthodontic treatment.
Smile Dental Journal | Volume 6, Issue 2 - 2011| 15 |

(Table 2)
Measurement Value Norm Standard deviation
SNA 76˚ 81˚ -1˚
SNB 79˚ 79˚ 0˚
ANB -3˚ 2-4˚ -1˚
UIMP 112˚ 113˚ +3˚
LIMP 76˚ 92˚ -8˚
IIA 142˚ 135˚ +3˚
MMPA 30˚ 24˚ 0˚
SnMax 10˚ 5-11˚ 0˚
LAFH 57% 55% 0%
Conclusion
The coexistence of both genetic “family history”
and soft tissue “tongue tie’’ factors and their
association with the development of Pseudo Class
III malocclusion has been highlighted in this case
report. Special emphasis is placed on the need
for accurate diagnosis, elimination of unfavorable
features and regular reviews of future growth,
as these are regarded as keys to successful
management.
References
1. Subtelny JD. Malocclusions, orthodontic corrections
and orofacial muscle adaptation. Angle Orthod.
1970;40(3):170-201.
2. Kawala B, Antoszewka J, Necka A. Genetic or environment?
A twin-method study of malocclusions. World J Orthod.
2007;8(4):405-10.
3. Jena AK, Duggal R, Mathur VP, Parkash H. Class III
malocclusion: Genetic or environment? A twin study. J Indian
Soc Pedod Prev Dent. 2005;23(1):27-30.
4. Messner AH, Anna H, Lalakea M, et al., Ankyloglossia:
Incidence and associated feeding difficulties.
Otolaryngology–Head and Neck Surgery. 2000;126:36-9.
5. Messner AH and Lalakea ML, The effects of ankyloglossia on
speech in children. Otolaryngology-Head and Neck Surgery.
2002;127(6):539-45.
6. Horton CE, Crawford HH, Adamson JE, et al. 1969,
‘’Tongue-tie’’. The Cleft palate journal;6:8-23.
7. ang SJ, Cha BK, Ngan P, Choi DS, Lee SK, Jang I.
Relationship between the lingual frenulum and craniofacial
morphology in adults. Am J Orthod Dentofacial Orthop.
2011;139(4 Suppl):e361-7.
8. Naimer S, Biton A, Vardy D et al., Office treatment
of congenital ankyloglossia. Med Sci Monit.
2003;9(10):CR432-5.
9. Kotlow LA. Using the Erbium: Yag Laser to correct an
abnormal lingual frenum attachment in newborns. The
journal of the Academy of Laser Dentistry. 2004;12(3):22-3.
10. Suter VG and Bornstein MM. Ankyloglossia: facts and myths
in diagnosis and treatment. Journal of periodontology. 2009;
80(8):1204-19.
| 16 | Smile Dental Journal | Volume 6, Issue 2 - 2011

TM
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one minute and continued relief with subsequent
twice-daily brushing 3
In Vitro SEM photograph of untreated
dentin surface.
The tubules that lead to
sensitivity are open
In Vitro SEM photograph of dentin
surface after application.
The tubules are plugged
for instant, lasting relief
With Pro-Argin Technology, you can finally provide instant*
and lasting relief from dentin hypersensitivity using the
Colgate® Sensitive Pro-Relief Treatment Program:
• In-office desensitizing paste
• At-home everyday toothpaste
Air blast sensitivity score
3
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1
0
Baseline
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Immediate
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improvement
3-day
Sensitivity relief
When applied directly
to the sensitive tooth
with a fingertip and
gently massaged for
1 minute, Colgate ®
Sensitive Pro-Relief
Toothpaste provides
instant sensitivity
relief compared to the
positive and negative
controls. The relief was
maintained after 3 days
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Pro-Argin Technology works through a natural process of
dentin tubule occlusion that attracts arginine and calcium
carbonate to the dentin surface to form a protective seal
that provides instant relief. 2
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Scientific works cited: 1. Petrou I et al. J Clin Dent. 2009;20(Spec Iss):23-31. 2. Cummins D et al. J Clin Dent. 2009;20(Spec Iss):1-9.
3. Nathoo S et al. J Clin Dent. 2009;20(Spec Iss):123-130.
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In-House Maxillofacial 3D Rapid
Prototyping
Abstract
Three-Dimensional Imaging (3D) and rapid prototyped (RP) planning models have
been reported many times in the past two decades. It has always been described as
an excellent diagnostic tool. 1 The major limitations are the increased time needed 2
especially in management of emergency cases 3,4 and increased costs. 4,5 Some of
the technical and organisational issues encountered in the implementation of this
technology in a modelling service have been addressed elsewhere. 6
In this note I will describe the office based system, advantages, technique, and current
applications.
Wesam Aleid
BDS, MBBS, MRCSEd
(Surgery-in-General),
FFDRCSI (OSOM), FRCSEd
(OMFS)
Oral, Maxillofacial, and Head
& Neck Surgeon
eidwisam@yahoo.com
Keywords: Three-Dimensional Imaging, Prototyping, Trauma, Oncology, Facial
Prosthesis.
Satellite RP Bureaus are expensive to set up (high cost machinery and overheads).
Making profit relies on wide service provision and high numbers. Office based
systems are far less expensive, require smaller premises and use simpler technology.
Technology choices are limited to 3D printers (Gypsum/Starch based) (Figure 1), Fusion
deposition modelling (FDM - ABS plastic based) (Figure 2) or Thermojet- Wax based
systems.
The ZCorp 310 Plus is a 3D Gypsum based printer. It is relatively cheap, fast (4 hours
for a full skull), easy to maintain, accurate (+- 0.1mm in Z plane, +-0.2mm in the X,
Y planes), cost effective (£1cm3) with low waste, has small proportions and its output
models can be made with different properties (hard, soft, flexible).
Utilizing MIMICS Z software, the system can be used to identify different types of body
tissues, by selecting predefined threshold setting (Figure 3). Being an office based
systems the clinician have the control of the interface with the use of Computer Aided
Design (CAD) for image manipulation.
(Fig. 1) 3-D Printer (Gypsum based).
(Fig. 2) FDM (ABS plastic based).
| 18 | Smile Dental Journal | Volume 6, Issue 2 - 2011

Technique
Data can be acquired using a laser surface scanner
(Figure 4), a photographic surface scanner or a CT scan.
CT is the preferred medium. The CT data (Dicom) then
can be transferred on a CD, into an ordinary windowsoperated
computer. The Dicom is then converted using
MIMICS Z software (Materialize, Belgium) which allows a
some image manipulation (Figure 3). Following selection
of the required threshold setting image noise and
artefacts can be reduced to define any required structure
(Figure 5).
(Fig. 5) Image noise and artefact reduction.
The image is then exported to the ZCorp proprietary
software (ZPrint V 7.6) and placed into the virtual build
area of the printer. Multiple images can be placed into
the build area to maximise its use. The print head expels
a binding solution onto a powder surface. This moves
down a layer and a new powder is distributed. This next
layer is then built on the first, building a solid 3D model.
The powder that is not used supports the built structure.
The unused powder is vacuumed from around the model
exposing its surface (Figure 6). The model is very porous
and can be infiltrated with different solutions to create
different properties.
(Fig. 3) Software (tissue identification).
(Fig. 6) 3-D Model Building.
This technology can successfully be used for planning
of trauma (Figure 7) and oncology cases, osteotomies,
radiotherapy, burns (Figure 8), facial prosthetics, and
deep buried implant design and manufacture (Figure 9). 7
(Fig. 4) Laser surface scanner.
In summary, rapid prototyping is not new but the use
of in-house RP, has wide applications in maxillofacial
surgery, and huge potential for service development.
Smile Dental Journal | Volume 6, Issue 2 - 2011| 19 |

(Fig. 7) Complex Maxillofacial
Trauma.
(Fig. 8) Mask prepared
using 3-d Prototyping
for Burn Patient.
(Fig. 9) Software interface in preperation of deeply burried
skull implant.
Acknowledgement
Special thanks to Mr. J Watson for the provision of the
excellent photographs and the superb technical work to
produce these models.
References
1. Aleid W, Watson J, Sidebottom A, Hollows P. Development of
in-house rapid manufacturing ofthree-dimensional models in
maxillofacial surgery. Br J Oral Maxillofac Surg. 2010;48:479-81.
2. Kernan T., Wimsatt A. Use of a Stereolithography Model for
Accurate, Preoperative Adaptation of a Reconstruction Plate. J Oral
Maxillofac Surg. 2000;58:349-51.
3. Arvier JF, Barker TM, Yau YY, D’Urso PS, Atkinson RL, McDermant
GR. Maxillofacial biomodelling. Br J Oral Maxillofac Surg.
1994;32:276-83.
4. Al-Sukhun J, Helenius M, Lindqvist C, Ashammakhi N, Törnwall
J, Penttila H. Stereolithography and the use of pre-adapted or
fabricated plates for accurate repair of maxillofacial defects.
Corrected Proof, 30 November 2006 Br J Oral Maxillofac Surg
DOI: 10.1016/j.bjoms.2006.10.016
5. Cunningham L, Madsen M, Peterson G. Stereolithographic
Modeling Technology Applied to Tumor Resection. J Oral
Maxillofac Surg. 2005;63:873-8.
6. Sugar A, Bibb R, Morris C, Parkhouse J. The development of a
collaborative medical modelling service: organisational and technical
considerations. Br J Oral Maxillofac Surg. 2004;42:323-30.
7. Chandra A, Watson J, Rowson J.E, Holland J, Harris R A, Williams
D J. (2005) Application of rapid manufacturing techniques in
support of maxillofacial treatment; evidence of the requirements of
clinical applications. Journal of Engineering and Manufacturing;
ImechE Vol 219 Part B.
| 20 | Smile Dental Journal | Volume 6, Issue 2 - 2011

3D Innovations of Cranioplasty Plate
Construction: a Case Report
Abstract
Titanium cranioplasty is one of the well-established and widely used techniques
in restoring skull defects for optimal protection to skull internal structures and reestablishing
skull conformity. Nowadays, most centres utilise computer-assisted
reconstruction for manufacture of titanium plates. In this paper we presented a method
for making titanium cranioplasty plates using the 3D innovation through making a 3D
model.
It can be stated that computer assisted production titanium plate for repairing skull defects
is hassle free to patient and prosthetists, efficient and reliable, accurate and reproducible
method. Furthermore, the resultant prosthesis constructed is accurately fitting.
Muhanad M. Hatamleh
BSc, MPhil, MSc (Health
Mgmt), MaxFac Dip, PhD
Tutor, School of Dentistry,
University of Manchester.
Trainee, Maxillofacial
Prosthetics and Technologies,
Queen Medical Centre,
Nottingham University Hospital
Trust, Nottingham, UK
muhanad.hatamleh@
manchester.ac.uk
Jason Watson
BMed Sc, MIMPT
Consultant, Maxillofacial
Prosthetists and Healthcare
Scientist, Maxillofacial Dep.,
Queens Medical Centre
Campus, Nottingham
University Hospital Trust, UK
jason.watson@nuh.nhs.uk
Keywords: Titanium, Cranioplasty, Skull defects, Three-Dimensional Model.
Introduction
Maxillofacial prosthetics are defined as “ the art and science of anatomical, functional or
cosmetic reconstruction by means of artificial substitutes of those regions in the maxilla,
mandible, and face that are missing or defective because of surgical intervention,
trauma, pathology, or developmental or congenital malformation”. 1 Facial defects often
result in devastating cosmetic, functional and psychological consequences and continue
to require difficult and challenging management procedures from maxillofacial surgeons
and prosthodontics alike.
Complete rehabilitation of patients with disfigurements (i.e. facial, skull) is achieved using
a multidisciplinary team approach, involving both surgical and prosthetic personnel.
The role of technology in facial prosthetics is vital in transforming the fabrication process
of facial prosthetics. It spans wide uses including computerized shade selection, threedimensional
digital photography, virtual surgical planning, surface scanning, and threedimensional
imaging to obtain the wax pattern. 1
Three-dimensional photography and surface scanning have been achieved using
Phase measuring profilometry (PMP), CAD/CAM technology and laser scanning. 1-4 A
cranioplasty is the term that relates to the procedure of repairing skull bone defect, 5
to provide neural protection to the internal skull structures (including the brain) in an
aesthetically desirable and functional way. Ideally, bone flap is removed during the
operation and is stored for later insertion. However, in most cases a bone flap may not
be available to repair, especially trauma defects caused by congenital abnormalities,
comminuted or compound fractures, skull tumours, osteomyelitis or bone flap
resorption. 6,7 Thus, many substitute materials proven to have high biocompatibility and
clinical reliability, such as Poly Methyl Metha crylate (PMMA), titanium, and ceramics 6
and it is still unclear of the optimum material. However, titanium plates offer an excellent
choice for cranioplasty based on their strength, low infection rate, biocompatibility,
handling characteristics and being suitable for postoperative imaging techniques. 6 There
have been different methods documented in the literature to manufacture titanium plates
including conventional impression techniques or computer assisted technique. 8-10
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Techniques of plate fabrication have often been
difficult and inexact. Additionally, producing a cosmetic
deformity, poorly shaped prostheses may be problematic
to insert which subsequently cause scalp necrosis,
perforation and infection. 7 Modern computer technology
enables three-dimensional (3D) reconstruction of
computer tomography (CT) images. Usually these 3D
reconstructions are viewed as two dimensional (2D)
images. Models produced by these CT scans are of
high accuracy, details and reproducible. Furthermore,
these models enable the operator for better visualisation
of the defect in 3D orientation and thus better results
are achieved when compared to conventional casts
produced by traditional impression techniques. This
paper aims to present a method of making titanium
cranioplasty plate utilizing 3D innovations.
Case History and Presentation
Diagnosis: A 26 year old female teacher was originally
admitted to Kings Mill Mansfield A&E department
(Nottingham, UK) following a sudden onset occipital
headache. A CT scan showed subarachnoid blood and
was transferred to the neurosurgical unit at Queens
Medical Centre (QMC, Nottingham, UK). She was found
to have a large left deep cerebral Venous Malformation
(VM) on CT angiogram. She underwent a partial
embolisation of this VM complicated by intra-vetricular
re-bleed. Her GCS (Glasgow Coma Score) were initially
well being at 14-15 however, 7 days post procedure she
developed dense right hemiparesis and became aphasic
secondary to vasospasm. Her GCS dropped to 4. A CT
showed large left-sided maturing infarct with global left
hemispheric swelling and mild sub-falcine herniation.
The same day she underwent a left decompressive
cranioectomy. Later, she underwent tracheostomy and
her GCS improved to 11.
Her management plan included physiotherapy, speech
and language therapy and occupational therapy prior
to transfer to a rehabilitation unit. Follow up showed
that she improved. On examination her face is moving
symmetrically and she still has good sensation in her right
arm and leg. Her left craniotomy wound has healed nicely.
2. MCS extension files were converted to files with PR
extension that makes them compatible (readable) with
the Z print software (Z Corp 310 plus print system,
Burlington, MA, USA). A 3D virtual model was produced
giving us the potential for rotating and slicing. The CT
scan files enabled us to customize the area of interest for
printing as only the defect was sent for printing rather
than printing the entire skull (Figure 1).
3. The printer formed the 3D model by binding gypsum
powder (ZB 140, Z Corp, USA) particles using clear
binder solution (ZB 60, Z Corp, USA) and water in
layering technique. Then the mould was sealed and
made ready for waxing up.
(Fig. 1) 3D CT scan Imported into MIMICS (A), modelling
(B) and slicingpossibilities (C) and production of the working
template (D) in Z PRINT Software.
2. Titanium plate production: Steps are illustrated
in figure 2. The defect was restored by waxing up
to normal conformity, and then it was duplicated in
crystal cal (Stone Type IV, British Gypsum, UK). An
impression of the wax and surrounding area is taken
using alginate (Hydrogum, Coltene, UK) which is backed
with plaster (Sugical plaster, British Gypsum, UK). Then
the impression was cast with vacuum mixed crystal cal
gypsum. Using an indelible pencil a line outlining the
defect margin was drawn, and another line was drawn
Next steps of treatment are titanium cranioplasty
manufacture and fitting and further treatment of her
residual deep VM.
Cranioplasty Manufacture
1. Production of 3D model: A three dimensional (3D)
CT of the defect has been conducted in order to produce
a 3D model of the defect following these steps:
1. CT scans are produced as DICOM digital format.
These are then converted using MIMICS (Materialize,
Belgium) into MCS extension files. These files were
converted to STL (Standard Triangulation Language). This
is an open format that is possible to be opened by most
3D manufacture machines world wide.
(Fig. 2) Steps followed in constructing the titanium plate.
The 3D model produced (A&B), defect wax up (C), stone
duplication (D), titanium plate swaging (E) and final
titanium plate prior to sterilization (F).
Smile Dental Journal | Volume 6, Issue 2 - 2011| 23 |

5mm outside the defect line. These lines determine the
periphery of the final titanium implant.
The model is then invested in a large flask to produce
the die, which was then separated with mould seal
(Vertex, Bracon, UK) and topped with another crystal cal
mix to produce the counter-die. Then a piece of titanium
plate (0.5 mm, Titanium International, UK) is cut, larger
than the defect and placed between the two halves of
the flask, and the flask was closed slowly using hydro
press to swage the plate to the desired shape. Then the
flask was opened after couple of hours and the excess
was cut. It was closed, and tightened and placed under
bench press, and the opening/closing process was
repeated couple of times (over 5 days period) till the
implant has been swaged to the desired contour. The
periphery rounded using rubber wheels, and holes (for
screws fixing) were drilled. The implant was cleaned and
sterilized (10w Steam at 132°C) prior to sending it to
theatre.
Discussion
The need for precision-fitting titanium plates has
prompted the development of several computeraided
methods of cranioplasty plate manufacture.
Defects have been modelled from CT scan data using
SLA (Stereolithography), LOM (Laminated Object
Manufacture), Thermojet Wax Printer, SLM (Selective
Laser Melting), and FDM (Fused Deposition Modelling).
On one hand, titanium cranioplasty plates manufactured
using most of these methods have been reported to fit
even the most complex defects, are easy to insert, and
produce excellent cosmetic results. 7 Furthermore, 3D
modelling and scanning technique have been related to
storage saving in addition to reproducibility (meaning
ability to cast as much models as needed without the
need to take another impression) and being patient
friendly.
On the other hand, the main disadvantage of these
computer-assisted techniques is capital. It is necessary
to have access to a computer work station with a large
memory capacity and running appropriate software that
will render the CT data. The final cost of the titanium
plate would be about £695 which is the sum of the
cost of running the work station, royalties for using the
software, maintenance contract annual, production
of the model by a computer modelling technique and
fabrication of the titanium prosthesis. For difficult and
complex cases, the improvement in cosmetic results and
the probable reduction in complication rates would justify
the cost. However, it needs to be said that the expense
and time involved in producing a plate may currently
preclude the routine use of the computer techniques,
but as equipment costs and production time diminish,
this may become the standard allograft cranioplasty
technique.
A side form the technological aspect, titanium sheet is
a commonly used material for cranioplasty. While it is
a safe and highly biocompatible material, it can modify
the presentation of post-operative complications, 11
thus we are currently in the process of investigating the
possible use of net shaped glass fibres that have been
used in crown and bridge restoration in what is known
as all-polymer fixed prostheses. They have shown similar
or increased mechanical properties in comparison to
conventional metal ceramic prostheses, indicating fibres
as suitable substitutes for metal FPDs. 12 They are highly
aesthetic and easy to manipulate and work with. We
expect that this new technique in comparison to the
conventional titanium-plate technique will save time,
effort, materials and subsequently cost.
Recommendations for future use of CT scans and
measurements are to create an analogue without the
cost and time required for an SLA model.
Summary
Computer assisted production of titanium plate for
repairing skull defects is hassle free to patient and
prosthetists, efficient and reliable, accurate and
reproducible method. Furthermore, the resultant
prosthesis constructed is accurately fitting.
References
1. Davis, B.K., The role of technology in facial prosthetics. Curr Opin
Otolaryngol Head Neck Surg. 2010;18(4):332-40.
2. Wu, G., et al., Computer-aided design and rapid manufacture of
an orbital prosthesis. Int J Prosthodont. 2009;22(3):293-5.
3. Ciocca, L. and R. Scotti, CAD-CAM generated ear cast by means
of a laser scanner and rapid prototyping machine. J Prosthet Dent.
2004;92(6):591-5.
4. Feng, Z., et al., Computer-assisted technique for the design and
manufacture of realistic facial prostheses. Br J Oral Maxillofac
Surg. 48(2):105-9.
5. Department of Neurosurgery, B., Havering and Redbridge
Hospitals NHS Trust, Your Operation: Cranioplasty. http://www.
bhrhospitals.nhs.uk/neuro/pdfs/neuropicranioplasty.pdf [Accessed
December 2010], 2010.
6. Cabraja, M., M. Klein, and T.N. Lehmann, Long-term results
following titanium cranioplasty of large skull defects. Neurosurg
Focus. 2009;26(6):E10.
7. Stoodley, M., J. Abbott, and D. Simpson, Titanium cranioplasty
using 3-D computer modelling of skull defects. Journal of Clinical
Neuroscience. 1996;3(2):149-55.
8. Bhargava, D., et al., Construction of titanium cranioplasty plate
using craniectomy bone flap as template. Acta Neurochir (Wien).
152(1):173-6.
9. Bartlett, P., L.M. Carter, and J.L. Russell, The Leeds method for
titanium cranioplasty construction. Br J Oral Maxillofac Surg.
2009;47(3):238-40.
10. Joffe, J.M., S.R. Nicoll, R. Richards, A.D. Linney, and M. Harris,
Validation of computer-assisted manufacture of titanium plates for
cranioplasty. Int J Oral Maxillofac Surg. 1999;28(4):309-13.
11. Martin, M.P. and S. Olson, Post-operative complications with
titanium mesh. J Clin Neurosci. 2009;16(8):1080-1.
12. Unlu, N. and S. Belli, Three-year clinical evaluation of fiberreinforced
composite fixed partial dentures using prefabricated
pontics. Journal of Adhesive Dentistry. 2006;8(3):183-8.
| 24 | Smile Dental Journal | Volume 6, Issue 2 - 2011

Confusing Endodontic Cases
Case Series Report
Abstract
Here, we introduce some confusing endodontic cases, which we had experienced in
our clinic. The first case had been misdiagnosed as a skin lesion and received extended
skin treatment. The second case had been misdiagnosed as a periodontal lesion and
received periodontal treatment by two former dentists. The third case exhibited oral
malodor and the patient worried about his breath odor for a long period. These three
cases have received endodontic treatment in our clinic, and the patients were free from
their long-lasting problems. We also discuss other confusing cases with literature minireview.
Keywords: Diagnosis, Endodontics, Skin Lesion, Periodontics.
Masahiro Yoneda
Section of General Dentistry,
Department of General
Dentistry, Fukuoka Dental
College, Fukuoka, Japan
Yoneda@college.fdcnet.ac.jp
Nao Suzuki
Section of General Dentistry,
Department of General
Dentistry, Fukuoka Dental
College, Fukuoka, Japan
Sonia M. Macedo
Faculdade de Odontologia da
Universidade de São Paulo
São Paulo, Brazil
Hisashi Anan
Section of Operative
Dentistry and Endodontology,
Department of Odontology,
Fukuoka Dental College
Fukuoka, Japan
Takao Hirofuji
Section of General Dentistry,
Department of General
Dentistry, Fukuoka Dental
College, Fukuoka, Japan
Introduction
Making a diagnosis is one of the most important stages in dental treatment. We
sometimes encounter endodontic cases in which making a straight forward diagnosis
can be a real challenge. Furthermore, endodontic lesions sometimes manifest
symptoms that are similar to those of other diseases. However, one of the difficult
points in endodontic treatment is that the lesion cannot be seen from the outside, and
unless we take a 3D radiograph, we need to speculate about what is happening in
the bone. It is also dangerous for dentists to make a diagnosis with preconceptions.
Here, we report endodontic cases that had been misdiagnosed as skin or periodontal
diseases. Conversely, certain diseases, including malignant diseases, are sometimes
misdiagnosed as endodontic lesions. We also present a literature review of these
diseases that show similar manifestations to endodontic disease.
Case Reports on Endodontic Lesion-derived Symptoms that had been
Misdiagnosed
Skin problem caused by an endodontic lesion
A 22-year-old male patient visited the Fukuoka Dental College Hospital complaining
of a prolonged fistula in the right lower cheek skin. 1 His former doctor treated the
patient for 6 months. Repeated skin incisions and long-term antibiotic therapy were
not effective and the doctor referred the patient to us. An external dental fistula with a
diameter of about 10mm and continuous pus discharge was observed (Figure 1A). By
X-ray findings and electric pulp examination, we diagnosed an external dental fistula
caused by chronic purulent apical periodontitis of tooth 46 (Figure 1B). We performed
an infected root canal treatment including anaerobic culture examination. The response
to the root canal treatment was good. The size of the external dental fistula dramatically
decreased and the skin lesion became dry at the third visit (Figure 2A). After confirming
that intra-root canal bacteria were negative, the root canals were filled (Figure 2B).The
external dental fistula completely closed after 2 months. Two and half years after the
root canal filling, the patient came for tooth maintenance. The external dental fistula
had not recurred (Figure 3A) and radiolucency in the periapical and furcation area had
disappeared (Figure 3B).
| 26 | Smile Dental Journal | Volume 6, Issue 2 - 2011

(Fig. 1A) Right facial view at the first visit. An external dental
fistula with pus discharge is observed at the right cheek area.
(Fig. 1B) Dental X-ray photograph at the first visit.
Radiolucency at the apex and furcation area of tooth 46 is
observed.
(Fig. 2A) External dental fistula after the initiation of
endodontic treatment. The pus discharge has stopped and
the external dental fistula is dry.
(Fig. 2B) Dental X-ray photograph at the root canal filling.
(Fig. 3A) Right facial view at 2.5 years after the root canal
filling. The external dental fistula has not recurred.
(Fig. 3B) Dental X-ray photograph at 2.5 years after
the root canal filling. The radiolucency at the apex and
furcation area of tooth 46 has disappeared.
Smile Dental Journal | Volume 6, Issue 2 - 2011| 27 |

Gingival swelling and furcation bone loss caused by
an endodontic lesion
A 59-year-old female attended our hospital with a
chief complaint of mobility of tooth 46 and recurrent
gingival swelling around the tooth (Figure 4A). She had
previously received dental treatment from two dentists
who performed gingival incisions, scaling and root
planning, but her gingival condition did not improve. 2
Her tooth 46 manifested the symptoms of typical
periodontitis, such as gingival swelling, tooth mobility,
pus discharge from the periodontal pocket and furcation
bone loss (Figure 4B). The tooth responded to electric
pulp examination but a gutta-percha point inserted from
the fistula reached the mesial root apex. Consequently,
we diagnosed a type I endoperiodontal lesion of
tooth 46. Soon after root canal treatment, the gingival
condition at tooth 46 improved without periodontal
treatment (Figure 5A). After confirming the absence of
bacteria, the root canals were filled (Figure 5B). After
3 months, the furcation bone loss was on the way to
recovery (data not shown). At 5 years after the root canal
filling, the patient came for treatment of other caries. The
gingival condition was good and the furcation bone loss
had not recurred (Figure 6A, B).
(Fig. 4A) Lateral view of the right teeth and gingiva at the first
visit. Gingival swelling is observed around the margin of tooth
46.
(Fig. 4B) X-ray photograph of tooth 46 at the first visit.
Bone resorption is observed at the furcation area, and the
periodontium around the mesial root of tooth 46 is enlarged.
(Fig. 5A) Lateral view of the right teeth and gingiva after
initiation of endodontic treatment. Soon after initiation of
the infected root canal treatment, the gingival swelling has
disappeared.
(Fig. 5B) X-ray photograph of tooth 46 after the root canal
filling. Furcation bone loss remains at the root canal filling.
(Fig. 6A) Lateral view of the right teeth and gingiva at 5
years after the root canal filling. Gingival condition is good.
(Fig. 6B) X-ray photograph of tooth 46 at 5 years after the
root canal filling. There is no furcation bone loss.
| 28 | Smile Dental Journal | Volume 6, Issue 2 - 2011

Oral malodor caused by an endodontic lesion
A 72-year-old male patient visited our breath clinic
complaining of strong breath odor. Former dentists had
performed periodontal treatments including scaling and
root planing, but his oral malodor did not decrease.
third visit and restored with metal bridge (Figures 8A, B).
We measured the breath odor and compared it with that
at the initial visit. All of the malodor scores were found to
have decreased (Figure 9) and the patient was satisfied
with our treatment.
(Fig. 7A) Occlusal view of upper jaw at the first visit. Severe
inflammation was not observed, but there is an unfitted metal
crown on tooth 16.
(Fig. 7B) X-ray photograph of tooth 16 at the first visit. No
periapical lesion is observed, but the root canals appear to
be poorly treated.
(Fig. 8A) Occlusal view of upper jaw at the time of bridge set.
A bad odor was confirmed by halitosis measurements
including an organoleptic test, a portable sulfide
monitor and gas chromatography. 3 We performed an
oral examination, but no remarkable problems such as
gingival swelling, deep periodontal pockets, big caries or
dry mouth, which may cause oral malodor production,
were detected (Figure 7A). The patient also complained
of an uneasy feeling in tooth 16. There was an
improperly fitted restoration in tooth 16 and we sensed
some malodor when compressed air was applied. An
X-ray of the tooth did not reveal a periapical lesion, but
the root canals appeared to be poorly treated (Figure
7B). Immediately after removing the metal crown and
core, a large amount of pus accompanied by malodor
coming from the root canals. We diagnosed that part
of the oral malodor was caused by a periapical lesion
of tooth 16, and performed an infected root canal
treatment. The condition of the root canals had improved
at the second visit, and the root canals were filled at the
(Fig. 8B) X-ray photograph of tooth 16 after the root canal filling.
(Fig. 9) Comparison of the breath odor measurements
before and after treatment. The results of organoleptic tests
and the concentrations of three volatile sulfide gases are
shown.
Smile Dental Journal | Volume 6, Issue 2 - 2011| 29 |

Summary and Discussion
Endodontic lesions usually manifest typical symptoms
such as percussion pain, gingival swelling or a dental
fistula around the root apex. X-ray photographs also
indicate the causative teeth by radiolucency around the
root apex. Consequently, dentists can usually identify
endodontic lesions. However, the lesions sometimes
spread to the skin in distant areas and are misdiagnosed
as skin lesions. Patients with an external fistula
sometimes visit a dermatologist. If they are properly
diagnosed, they will be referred to a dentist and the
lesion will soon be resolved. 4,5 However, diagnostic
errors can result in multiple excisions, biopsies and
ineffective long-term antibiotic therapy. 6,7 A case of
odontogenic sinus simulating a basal cell carcinoma has
been reported. 8 On the other hand, a case of extraoral
sinus that was not caused by an endodontic lesion has
also been reported. 9 Therefore, careful examination and
close contact between dentists and dermatologists are
strongly recommended. 10,11
Endoperiodontal lesions are sometimes difficult to
diagnose. Endoperiodontal lesions are sometimes
misdiagnosed, and the importance of a differential
diagnosis is noted. 12 There is a possibility that oral
malodor can be caused by an endodontic lesion. These
cases may be rare, but dentists need to consider such
cases in the diagnosis of oral manifestations. We have
also reported a case of oral malodor associated with
internal root resorption. 13 The main causes of oral
pathologic halitosis are periodontal disease and tongue
coating, 14,15 and oral malodor caused by an endodontic
lesion is rarely reported. However, careful examination
is necessary if no apparent causes are found in the oral
cavity of a patient with oral malodor.
The main theme of this case series report is to introduce
several symptoms caused by endodontic lesions.
However, the opposite cases are sometimes reported,
in which the manifestations of other diseases are
very similar to those of endodontic lesions. Periapical
cemental dysplasia is known to be similar to periapical
granuloma. 16,17 To prevent misdiagnosis, application of
electric pulp examination and confirmation of the dental
history are recommended. Giant cementoblastoma
can also be misdiagnosed as an endodontic lesion. 18
Paradental cysts mimicking a radicular cyst 19 and a
simple bone cyst 20 have been reported. Since there is
a possibility that these cases can be misdiagnosed as
endodontal lesions, detailed clinical and radiographic
examinations are necessary. Other osseous diseases,
such as ossifying fibroma, 21 focal cemento-osseous
dysplasia 22 and Stafne’s bone cavity, 23 have also been
reported. We need to be careful in the diagnosis of
these diseases, because they sometimes manifest similar
symptoms to those of a periapical lesion.
There is also a possibility to misdiagnose malignant
diseases as an endodontic lesion. In fact, a gingival
squamous cell carcinoma mimicking a dentoalveolar
abscess has been reported. 24 Some metastatic
carcinomas manifesting as periapical lesions have
also been reported as well as an oral-derived
carcinoma. 25,26 An osteosarcoma 27 and a mesenchymal
chondrosarcoma 28 resembling dental periapical lesions
have also been reported. Some lymphomas were
misdiagnosed as endodontic lesions and the proper
treatments were delayed. 29 Although some cases may be
difficult to diagnose, 30 we always need to consider the
possibility of malignant diseases.
In this way, making diagnosis is important in the
treatment of endodontic cases and cases, which manifest
endodontic-like symptoms.
Acknowledgment
This work was partly supported by a Grant-in-Aid for
Scientific Research (No. 20592249) from the Japanese
Ministry of Education, Science, Sports and Culture.
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| 30 | Smile Dental Journal | Volume 6, Issue 2 - 2011

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apical periodontitis. J Endod. 2008;34(11):1415-9.
29. Graham RM, Thomson EF, Cousin GC, Kumar SN, Awasthi
A. A case of faciel lymphoma mimicking dental infection.
Dntal Update. 2009;36(4):244-6.
30. Saund D, Kotecha S, Rout J, Dietrich T. Non-resolving
periapical inflammation: a malignant deception. Int Endod J.
2010;43(1):84-90.
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Smile Dental Journal | Volume 6, Issue 2 - 2011| 31 |

Functional and Aesthetic Management
of Worn Dentition with Direct Composite
Restorations: A Clinical Report
Abstract
The management of tooth surface loss (TSL) could be challenging in primary dental care
settings. However the introduction of resin-based composite restorative materials have
significantly changed our traditional mechanistic approach in favour of more toothtissues
conservative treatments whilst improving both functional and aesthetic demands
by patients. Direct bonding to remaining tooth tissues is more predictable than any time
before, it has been clinically proven that the applications of direct composite restorations
could be extended beyond building up a single tooth and become a viable option for full
mouth rehabilitation. Economic factors are crucial elements in the success of our day to
day dental treatments as there is more emphasis on implementing time and cost-effective
and reversible treatments at low biological risks.
Shihab A. Romeed
PhD, MSc, MFDS, DDS
Lecture and Honorary
Specialist Registrar in
Restorative Dentistry
Kings College London Dental
Institute, Denmark Hill, UK
shihab.romeed@kcl.ac.uk
R. Malik
BDS
Graduate Dentist
S.M. Dunne
PhD, FDS, BDS
Professor and Honorary
Consultant in Restorative
Dentistry
Keywords: Tooth surface loss, Dahl concept.
Introduction
Tooth surface loss (TSL) can be defined as the loss of tooth substance in the absence
of caries or trauma. TSL is becoming an increasingly common problem and presents
increasing restorative management challenges. The adult dental health survey in 1998
stated that 65% of adults in the UK had some form of toothwear. 1,2 TSL can arise due to
erosion, attrition, abrasion and abfraction and often these occur in combination with each
other, though one usually predominates. These terms are usually applied based on the
presentation of the tooth wear and there are a number of aetiological factors that can lead
to these types of tooth surface loss. 3
Case description
A 49 year-old male patient was referred by his general dental practitioner to King’s
College London Dental Hospital in late 2009. The patient’s chief complaints were
unsightly smile, tooth sensitivity and loss of efficient masticatory function. However,
appearance was his main concern as it led to a lack of self esteem.
The patient’s medical history was unremarkable. Social and diet history revealed daily
consumption of two large glasses (250ml) of red and white wine along with significant
amount of soft drinks and orange juice. He smokes 10 cigarettes a day. The impact of
his excessive consumption of alcohol and acidic drinks was evident on all teeth in a form
of cupped out surfaces which clearly represents severe erosion (Figure1). Bruxism was
also identified as one of the main aetiological factors for the TSL in this case. The patient
first noticed some changes in the size of his teeth approximately five years ago. However,
his problems rapidly deteriorated which resulted in a progressive TSL especially on the
anterior teeth. He had lost some of his posterior teeth namely 12, 13, 18, 19.
Clinical Examination showed scalloping of the tongue borders, hyperkeratosis lines on
the buccal mucosa, bilateral masseter hypertrophy, tooth attrition and antegonial notches
which are all indicative signs of bruxism as another contributing factor for his generalised
tooth surface loss. The patient had no symptoms of temporomandibular joint disorders
(TMDs). Periodontal examination indicated generalised moderate chronic periodontitis
and his dentition was moderately restored (Figure 2). Significant loss of occlusal vertical
dimension (OVD) was very obvious in centric occlusion. Upper left lateral incisor was
fractured at the gingival level and root treated long time ago. The history and clinical
presentation indicated that tooth surface loss was a combination of erosion and attrition
along with some element of abrasion (Figure 3).
| 32 | Smile Dental Journal | Volume 6, Issue 2 - 2011

provided will ultimately fail therefore it is a crucial step in
the management of wear.
(Fig. 1) Generalised tooth surface loss in a form of cupped
out surfaces on the buccal surfaces and attrition on the
incisal edges.
(Fig. 2) Generalised erosion and attrition on the lower
teeth, corroded and ditched amalgam restorations on
posterior teeth.
(Fig. 3) Tooth no 7 was vital and underwent sever TSL. Tooth
no 9 lost its post crown and root treated.
Plaque control advice, smoking cessation and diet
counselling, supra and sub-gingival debridement and
root planning were performed as part of the treatment
plan. Initially it was important to stabilise the patient’s
periodontal condition as there is an increase risk of
failure of restorative treatment in a mouth with active
periodontal disease. An early analysis has revealed a
significant reduction in plaque and bleeding scores. A
programme to prevent further tooth surface loss was
also simultaneously implemented which consisted of
diet counselling and wearing a lower soft occlusal splint.
The splint was provided to reduce forces generated
during bruxism and prevent further loss of tooth
substance caused by citrus fruits and soft drinks whilst
the periodontal health was being stabilised. 4 Without
prevention surface loss will continue and treatment
The tooth surface loss was deemed to be pathological
as the degree of wear exceeded the TSL level excepted
at the patient’s age and subsequently function
and appearance were compromised. 5 A decision
was therefore made to restore the worn dentition
conservatively with direct composite restorations with the
goal of preserving and protecting the remaining tooth
tissues and providing durable aesthetic restorations.
Other advantages of using composite include; reduction
of costs and treatment time, ease of repair as well as
giving the clinician control over the aesthetics. 6,7
It is well documented in the literature that indirect
restorations confer higher strengths than direct
restorations. Improvements in composite mechanical
properties and bonding chemistry over the years,
however, have made it possible to restore surfaces
of worn teeth directly without recourse to indirect
restorations, though this option remains viable if the
need arises in the future. Hemmings et al., conducted
a 30 month prospective clinical trial using direct
composite restorations for the treatment of localised
anterior toothwear. The group reviewed the progress
of 225 restorations placed over a period of 5 months
to six years in thirty-one patients. They found relatively
low failure rates of the composites; failure was mainly
due to generalised marginal failure and discolouration.
They also confirmed that the median survival rate of the
composites used to treat TSL was five years. 8,9
Discussion
Generally there are two types of techniques that can
be employed in the direct build up of worn teeth; free
hand technique and matrix-guided technique. These
techniques can be used regardless of whether dentalalveolar
compensation has occurred or not. However it is
important to determine whether there is a freeway space
loss because that will have implications on the available
space for the amount of composite build-ups and on the
anatomical form of the restorations i.e. the height/width
proportion of the finished restorations 10 and whether the
Dahl concept needs to be applied or not. 11
1. Free-hand technique
In this technique the worn teeth are built individually one
by one. A silicone putty matrix is taken of the palatal/
lingual surface of the articulated diagnostic wax up. This
provides an intra-oral template which is used to determine
the height of the restoration. The next step is to start
building up composite on the palatal/lingual surface
of the tooth against this template. Once the first initial
opaque layer of composite is placed, the template can be
removed and the next layer built. It is important to have
good isolation and this can be achieved by rubber dam if
there is enough tooth tissues left or cotton wool rolls and a
saliva ejector. Mylar strips are used to obtain good contact
points both mesially and distally. We found the use of PTFE
tape (polytertafluoroethylene tape) which is usually used
Smile Dental Journal | Volume 6, Issue 2 - 2011| 33 |

in plumbing effective to prevent adhesion of composite
to adjacent teeth. It is simply wrapped around adjacent
teeth to provide effective isolation. Dentine followed by
the enamel shade should be applied incrementally. Finally
the restoration is finished to the required dimensions by
the use of fine diamond and carbide burs, polishing discs
and interproximal polishing strips (Sof-Lex, 3M ESPE, MN,
USA). Occlusion should be checked with the aid of an
articulating paper (8-12 microns thick) in protrusive and
lateral excursive movements ensuring even contacts on
anterior guidance and mutually-protected occlusion on
either side, if possible, with no non-working side occlusal
interferences.
2. Matrix technique
Vacuum-formed matrix is produced using a duplicate of
the diagnostic wax-up articulated model in the retruded
position or centric relation (CR) (Figure 4). Initially the
matrix should be checked intra-orally for accuracy of fit.
The teeth should be etched and bonded, matrix is then
filled with composite; usually a layer1.5-2mm thick of
composite is applied. 12 The matrix is then placed on the
corresponding teeth and the composite is light-cured
through its holding matrix. The procedure is repeated
till the whole tooth is fully built up and the remaining
restoration is then finished as described above for the
free hand procedure.
The technique chosen largely depends on the preference
of the operator. Both confer certain advantages and
disadvantages. The major advantage of the matrix
technique is the formation of good anatomical form
providing the anatomy of the diagnostic wax up is
acceptable to the patient and clinician. However a
commonly found problem is that adjacent teeth can
become bonded together through this technique. The
free hand technique prevents this, providing mylar strips
have been used. However in the hands of inexperienced
operators it can be difficult to obtain correct dimensions
and anatomy of the tooth being restored. Though
experienced clinicians may prefer having control of the
dimensions and opt to use free-hand technique for that
reason. It also provides the operator with ease in restoring
the teeth using different shades but can be time consuming.
(Fig. 4) Waxed-up study model at centric relation (retruded
contact position).
In our presented case both techniques were adopted in the
posterior segments a suck-down matrix was used to restore
the posterior teeth as most of the surface loss was located
buccally and occlussally to a lesser extent. Anteriorly
free-hand technique was adopted to have some control
over shade and shape forming. Two-step etch-and-rinse
bonding adhesive was employed using OptiBond Solo Plus
(5 th generation) (Kerr, Orange, CA, USA). Dentine shade
D3 and enamel shade E3 were layered using Dentsply
Ceram.X Duo composite. Anterior teeth were built up
first followed by posteriors. Upper left lateral incisor was
restored with fibre post and direct full composite crown as
illustrated in post-operative views Figures 5-8.
Occlusion was reorganised rather than depending on
a conformative approach as OVD was lost and several
of the occluding surfaces were re-built. 13 Furthermore,
stable contacts were lost due to the tooth surface loss
and an attempt to produce restorations in centric
occlusion would have increased the risk of interferences
in lateral and protrusive movements, ultimately leading
to failure of treatment. A face bow record was taken in
order to allow correct mounting of the maxillary cast on
the articulator so that all aspects of the occlusion could
be analysed outside of the patient’s mouth and allow
an articulated diagnostic wax up of both upper and
lower arches to be produced accordingly. In addition the
waxed-up models allow more accurate assessment of the
restoration height and subsequently the increase in OVD,
help identify any potential difficulties that may arise
during treatment and to allow the patient to visualise the
treatment outcome (Figure 4). 6
As a result of tooth wear the patient’s OVD was reduced
and the FWS increased. We benefited from the fact that
there was no dental-alveolar compensation i.e. over
eruption of teeth and no loss of the freeway space, hence
the freeway space provided the space necessary for the
placement of the anterior composite restorations. 14
Further, some space was obtained from re-organising
the occlusion into CR. If there was compensation present
then space should have been created by following the
principles of Dahl, 11 Dhal expalined that for worn anterior
teeth space could be created where it had been lost by the
use of a cobalt chrome appliance consisting of an anterior
bite plane. The appliance would result in the separation
of the posterior teeth which over a period of few weeks
and maximum two months would allow overeruption of
the posterior teeth back into occlusion and intrusion of the
anterior teeth. Subsequently, the space created anteriorly
could be used for placement of definitive restorations. It
was then realised with time that the Dahl concept could
be utilized without the provision of an active appliance
by placing anterior restorations at an increased occlusal
vertical dimension thus reducing the need for compliance
with an appliance, simplifying treatment and shortening
the time required for treatment. 6
In our case The OVD was increased by 5mm. The patient
adapted well to the increase with no associated signs or
symptoms to suggest otherwise. It is desirable to have
adequate anterior guidance including the upper canines,
as posterior interferences between opposing teeth could
result in production of potentially damaging lateral
forces on these teeth during bruxism, leading to fracture
| 34 | Smile Dental Journal | Volume 6, Issue 2 - 2011

(Fig. 5) Direct composite build-ups and recontouring of the
upper anterior teeth.
(Fig. 7) Direct composite build-ups and recontouring of the
right upper and lower posterior teeth.
(Fig. 8) Completed direct composite build-ups for the
anterior and posterior teeth.
(Fig. 6) Direct composite build-ups and recontouring of the
lower anterior teeth.
of restorations. 15 Occlusion was therefore assessed
continually throughout treatment to ensure that there was
even contact in the retruded contact position (CR) and
that there were no posterior interferences and no nonworking
side interferences. Most importantly no occlusal
contact on upper lateral incisors during protrusive
movement was planned to limit shear stresses on these
fully built composite crowns especially the upper left
lateral incisor whose ferrule was almost 1mm.
Conclusions
Tooth wear is a multifactorial dental problem which
is classified as pathological if it exceeds the expected
level at different age points. Planning treatment is
extremely important. Factors such as occlusion should
be thoroughly planned to ensure occlusal harmony and
stability, which is paramount for the long term success
and survival of the direct composite restorations. 11
Treatment of worn teeth should be attempted using direct
composite restorations first. This has the advantage
of retaining and protecting remaining tooth structure.
Reversibility of the procedure, ease of repair and
reduced costs are added benefits. Advances in composite
technology and the availability of data showing that
these restorations have the ability to withstand functional
and parafunctional forces which makes them ideal in
treatment of tooth wear cases without recourse to the use
of expensive, non-conservative indirect restorations.
Acknowledgment
This case report was part of a final-year undergraduate
project for Mr. Raheel Malik at Kings College London
Dental Institute. We would like to thank Dentsply, UK for
donating all composite materials (Ceram.X Duo composite)
which were exclusively used in managing this case.
References
1. Kidd EAM, Smith BGN, Watson TF. Pickard’s manual of operative
dentistry. 8 th ed. Oxford Press. 2003;20-27.
2. Kelly M, Steele JG, Nuttall N. Adult Dental Health Survey. Oral
Health in the United Kingdom, London: ONS. 1998.
3. Kelleher M, Bishop K. Tooth Surface Loss. BDJ Publications.
2000;3-8.
4. Solberg WK, Clark GT, Rugh JD. Nocturnal electromyographic
evaluation of bruxism patients undergoing short-term splint
therapy. J Oral Rehab. 1995;12:215-23.
5. Capp NJ. Tooth Surface Loss. BDJ Publications. 2000;15-20.
6. Robinson S, Nixon PJ, Matthew JG, Martin FWC. Techniques for
restoring worn anterior teeth with direct composite resin. Dent
Update. 2008;35:551-8.
7. Allen PF. Use of tooth-coloured restorations in the management of
toothwear. Dent Update. 2003;30:550-6.
8. Hemmings KW, Darbar UR, Vaughan S. Toothwear treated with
direct composite restorations at an increased vertical dimension:
results at 30 months. J Prosthet Dent. 2000;83:287-93.
9. Redman CD, Hemmings KW, Good JA. The survival and clinical
performance of resin-based composite restorations used to treat
localised anterior tooth wear. Br Dent J. 2003;194:566-72.
10. Mizrahi B. A technique for simple and aesthetic treatment of
anterior Toothwear. Dent Update. 2004;31:109-14.
11. Dahl BL, Krogstad O, Karlsen K. An alternative treatment in cases
with advanced localized attrition. J Oral Rehabil. 1975;2:209-14.
12. Daoudi MF, Radford JR. Use of a matrix to form directly applied
resin composite to restore worn anterior teeth. Dent Update.
2001;28:512-4.
13. Davies SJ, Gray RJM, Whitehead SA. A Clinical Guide To occlusion.
BDJ Publications. 2002;37-46.
14. Faigenblum M. Tooth Surface Loss. BDJ Publications. 2000;21-24.
15. Davies S.J, Gray RJM. A Clinical Guide To occlusion. BDJ
Publications. 2002;3-11.
Smile Dental Journal | Volume 6, Issue 2 - 2011| 35 |

June’s Panel
Mohammad Sartawi
BSc, BDS, MSc (OMFS)
London, FFDRCSI (OSOM)
Dublin
• Senior Consultant, Maxillo
• Director, Jordan British
Specialty Center for Oral
& Maxillofacial Surgery
& Implantology, Amman,
Jordan
• EX-Chairman/Scientific
Committee of the JDA 02-04.
• Member of International
Advisory Board, Smile Dental
Journal
• Visiting Clinical Professor
and External Examiner in
Oral & Maxillofacial Surgery,
Jerusalem University
Hakam Mousa
D.D.S., M.S.D., F.A.G. D.
• Musa Dental Clinics,
Amman, Jordan
• Bachelors of Dental Surgery
(B.D.S.), University of Jordan
• Postgraduate Certificate in
Operative Dentistry, Major
in Operative Dentistry, Minor
in Dental Materials, Indiana
University, USA
• Masters of Science in
Dentistry (M.S.D.), Indiana
University, USA
Ashraf E Abu Karaky
BDS MSc MFDSRCSEd
FFDRCSI
• Assistant Professor, Faculty
of Dentistry the University of
Jordan, Amman, Jordan
• Consultant Oral and
Maxillofacial Surgeon,
Jordan University Hospital
Yousef Sadik Marafie
BDS, MSD, Prosthodontist
• Advanced Education in
General Dentistry Certificate,
Baltimore College of Dental
Surgery, Maryland, USA
• Certificate in Prosthodontics,
Medical College of Georgia,
USA
• Master of Science in
Prosthodontics, Boston
University, USA
• Clinical Instructor, Faculty of
Dentistry, Kuwait University
• Full Time Prosthodontist at
Bayan Dental Center, Egaila,
Kuwait
A patient reported to my clinic
with an ulcer on the side of his
tongue. The ulcer is non-healing,
expanding, with raised borders,
firm and indurated. However,
although it has been there for
more than three weeks, it is
painless and the base of the
ulcer looks smooth. I have three
questions please:
1. What is the most likely
diagnosis?
2. What is the most common
technique to confirm the
diagnosis?
3. What are the current therapeutic
approaches for treatment?
Dr. Soud Ammeri, Jeddah, Saudi
Arabia
Answer: Dr. Mohammad Sartawi
1. The diagnosis is most likely to be
Squamous cell carcinoma.
2. Biopsy remains the most common
and definitive technique for the
diagnosis of a suspected oral
cancer. Biopsy should be incisional
rather than excisional so as not to
obscure the extent of the tumor.
3. Early detection and treatment
really have a positive impact on
outcome and prognosis. Tumor
staging which provides a uniform
system to describe the lesion and
its projected clinical behavior. The
staging of oral cancer involves
three parameters: the size and
extent of the tumor, the presence
and extent of lymph node
involvement, and the presence or
absence of metastases. The system
that was developed in 1942 is thus
called the TNM system for tumor,
nodes and metastases.
The current therapeutic approaches
for treatment of Squamous cell
carcinoma are:
• Definitive surgery with wide safety
margins
• Definitive radiation therapy
• Surgery with planned postoperative
radiation therapy
• Definitive radiation with surgery
only for salvage or recurrence
• Palliation with chemotherapy or
radiation therapy
• Radiation therapy with concomitant
chemotherapy
Therefore, a thorough and
aggressive routine clinical
examination of the mouth by health
care provider’s especially dental,
oral and maxillofacial surgeons
is crucial for early diagnosis and
radical treatment of Squamous
cell carcinoma aiming for better
prognosis and cure.
Some clinicians advocate the use
of fibber based posts rather than
the cast post and core group, is
there any evidence supporting the
use of the fibber based posts over
the classical metal based posts?
Dr. Rana Omar, Jeddah - Saudi Arabia
Answer: Dr. Hakam Mousa
The use of fiber post systems
in recent years has increased
in an attempt to replace metal
prefabricated and/or cast post and
core systems.
First, what is a fiber post?
It is made of specially - oriented
reinforcement of continuous
elongated fibers, a matrix of a
| 36 | Smile Dental Journal | Volume 6, Issue 2 - 2011

proprietary epoxy resin and an
interface: a bonding system between
the matrix and the fiber.
Some of The advantages of using
fiber posts is in the aesthetic zone.
Its white or translucent color, will
help dentists to use more options for
direct or indirect restorations since
no metal shadowing could be seen.
one other advantage is more
favorable stress distribution along
the long access of the root area,
causing less risk of root fracture,
this is due in part to elastic modulus
(relative rigidity) that is close to
dentin(e).
Retrievability is another advantage of
fiber post systems.
The use of fiber posts, prefabricated
metal posts, or cast post and core
systems should be the dentist
decision according to his or her
experience and clinical case
management.
UL1 Root, prepared for a post crown
Fiber post UL1
Post and Core UL1
UL1 post crown
Hopefully some of these articles
comparing fiber post and metal
post systems will aid in making
an informed decision relying on
evidence based practices in selecting
the type of post system(s) you wish to
adopt in your practice.
Ref: Naumann M, Sterzenbac GJ, Alexandra F,
Dietrich T. Randomized controlled clinical pilot
trial of titanium vs. glass fiber prefabricated
posts: preliminary results after up to 3 years.
Int J Prosthodont. 2007;20(5):499-503.
- Goodacre CJ. Carbon fiber posts may have
fewer failures than metal posts. Evid Based
Dent Pract. 2010;10(1):32-4.
- G. Bateman,1 D. N. J. Ricketts2 and P.
Saunders3. Fibre-based post systems: a
review British Dental Journal, Volume 195
July122003W.
I started placing and restoring
dental implants in my private
practice and i would like to know
whether there is a strong evidence
recommending antibiotics
prophylaxis before and after
implant surgery, and if so, what is
the recommended regimen?
Dr. Fadi Sukaria, Leeds - UK
Answer: Dr. Ashraf Abu Karaky
Despite the daily practice of dental
implantology worldwide, and despite
the importance of careful selection
and prescribing of antibiotics, till
present there is no consensus on
the antibiotic protocols in dental
implantology. Whereas some studies
found no significant benefits from
antibiotics prescribing in ordinary
dental implants insertion, others
recommend otherwise and prescribe
antibiotics. Recently several systemic
reviews has recommended the oral
administration of 2gms amoxicillin
one hour prior to implant insertion,
this is thought to reduce the number
of patient experiencing implant
failure. Little is known about the
efficacy of post-operative antibiotics
and about its appropriate type, dose
and duration. At Jordan University
Hospital we conducted a study to
compared three different antibiotic
regimens for dental insertion
(preoperative, postoperative, pre
and post-operative), and we found
no significant difference on implant
survival rate between the three
group. (Antibiotic prophylaxis and
early dental implant failure: a quasirandom
controlled clinical trial, EJOI
2011). Based on the evidence found
in the dental literature and based
on the results we had from our study,
I recommend a single preoperative
oral dose of 2gms amoxicillin one
hour before implant insertion with
no postoperative antibiotics. And
for patients allergic to penicillin, I
recommend a single preoperative
oral dose of 600mgs clindamycin
one hour before implant insertion.
Ref: Antibiotic prophylaxis and early dental
implant failure: a quasi-random controlled
clinical trial. Karaky AE, Sawair FA, Al-
Karadsheh OA, Eimar HA, Algarugly SA,
Baqain ZH.Eur J Oral Implantol. 2011
Spring;4(1):31-8.
Is it safe to adjust and prepare
the implant abutment intra-orally,
and if not, do you recommend
any way to facilitate extra-oral
abutment preparation?
Dr. Ahmad Abdelazeez, Cairo - Egypt
Answer: Dr. Yousef Marafie
After osseointegration of dental
implant(s), definitive abutment(s)
and a final prosthetic superstructure
must be fabricated. Some
abutments could be custom made
and prepared by the laboratory
technician, alternatively the dentist
might choose to use a ready made
abutment and adjust it chair side to
reduce cost and time of the implant
treatment. In these case,the restoring
dentist has the option of using a
direct or indirect technique for the
preparation of implant abutments.
With the direct technique,
excessive heat generation at the
implant-bone interface may cause
irreversible bone damage and loss
of osseointegration as reposted
by Gross et al. in the int J Oral
Maxillofac Implants (1995).
Therefore, extra oral abutment
preparation is recommended to
avoid peri-implant marginal bone
loss and/or dental implant failure.
Other advantages of extra oral
Smile Dental Journal | Volume 6, Issue 2 - 2011| 37 |

QUICK, EFFECTIVE and SAFE
preparation are:
1. Ease of preparing better margins
and emergence profile
2. Improved quality of dies to
fabricate the prosthesis
3. Subgingival margin preparation is
made possible without risk of soft
tissue trauma or postimpression
shrinkage.
However, extra oral abutment is
often a challengeable task due to
difficulty in holding and controlling
the abutment while preparation.
Londono and Marafie et al from
Medical College of Georgia (USA)
described in their case report in
the J Prosthet Dent. 2009;102:54-
5, an easy, quick, accessible, and
economical way of fabricating
an implant abutment holder for
extraoral abutment preparation.
Only 3 instruments for most cases
R1 15/.06 R2 25/.04 R3 30/.04
It can be used with any implant
abutment using a corresponding
implant replica that can be fit in to
the active part of the tissue punch
using a small amount of acrylic resin
followed by preparing the abutment
using high-speed handpiece and
suitable burs.
Implants replicas fitted into the
tissue punch
Endo treatment of teeth 47
with the iRaCe R1, R2, R3.
Curvatures have been fully respected.
Abutments connected to the
implant replicas
Courtesy of Dr. Bertrand Khayat (France)
Extra oral abutment preparation
www.iRaCe.ch
| 38 | Smile Dental Journal | Volume 6, Issue 2 - 2011

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Summarized & Presented by:
Hassan Maghaireh
BDS, MFDS, MSc Implants (Manchester)
Clinical Teacher, Dept. of Dental Implants, University of Manchester
bjdi.group@hotmail.com
Maxillary Sinus Augmentation as a Risk Factor
for Implant Failure
McDermott N., Chuang S-K., Woo V., Dodson T.
Int. Journal of Oral and Maxillofacial Implants, Vol. 21 No. 3, June 2006
Maxillary sinus augmentation is commonly undertaken to enhance otherwise inadequate bone support for placement of dental
implants in the posterior maxilla. Generally speaking it has been shown that bone grafting is not correlated with an increase
in implant failure, however little specific data exists for sinus grafts alone. This study therefore set out to undertake a rigorous
multivariate analysis of a retrospective cohort, adjusted for clustered, correlated observations, to determine if sinus grafts (SG)
are an independent risk factor for implant failure.
Materials and Methods
All patients treated in one center over an 8-year period for the replacement of missing maxillary molars and premolars were
included in the analysis. Patients were grouped according to whether they required pre-implant sinus grafting (SG group) or not
(non-SG group). Patients who showed 4mm or less of alveolar bone below the floor of maxillary sinus, underwent sinus grafting
which was carried out either via a modified Summer’s technique simultaneous with implant placement or via a Caldwell Luc
approach with a lateral window and staged implant placement 4 to 8 months later. Grafts included both autogenous and nonautogenous
materials.
Implant failure was defined as implant removal as a result of perceptible mobility. Survival times were calculated from time
of placement to time of implant removal or most recent follow-up. In addition to failure, information was collated on patient
demographics, patient health status, anatomy, bone density, implant location, implant dimension, abutment dimension, angled
versus non-angled abutments, fixed versus removable prosthesis, and use of antibiotics. These data were also analyzed with respect
to risk for implant failure.
Results
Seven hundred and two patients were included in this retrospective cohort of which 677 had adequate records for analysis. Of
these 318 patients received 762 implants in the posterior maxilla, with a mean follow-up of 22.5 months. The vast majority of
patients were systemically healthy and there was a relatively equal number of males and females in the SG and non-SG groups.
The mean age for both groups was circa 56years. Nine percent of patients in the SG group were smokers compared to 11.9% in
the non-SG group. A greater number of molars were treated in the SG group, p < 0.001 where the bone density was described
as less dense, p < 0.001. Implant dimensions were comparable in the two groups. There was no significant difference between
the groups with a one year survival rate of 96.2% for the SG group and 92.6% for the non-SG group. The 5-year survival rates
were 87.9% and 88.0% respectively.
Discussion and Conclusions
In the current study there was no significant difference in the implant survival rates at 5 years between implants in sinus grafts
and those in native alveolar bone. The sinus graft was not identified as a risk factor for implant failure. However, considering
potentially confounding variables, it was possible to identify implants in smokers, molar implants and implants placed in a
simultaneous procedure with grafting as having a greater risk of failure.
| 42 | Smile Dental Journal | Volume 6, Issue 2 - 2011

The McGill and York Consensus Statements on Two- Implant
Overdentures
J.M. Thomason, S.A.M. Kelly, A Bendkowski , J.S. Ellis
Introduction
The default position for treatment for the edentulous patient is complete conventional dentures (complete removable maxillary
and mandibular dentures). However, such prostheses especially the mandibular denture, have well-documented problems such
as lack of stability and retention which can cause them to move around in the mouth (Doundoulakis 2003). This can be affected
by the height and shape of the mandibular ridge and in edentulous patients continued loss of alveolar bone and resorption of
the mandibular ridge can occur over time, and cause previously stable dentures to become ill-fitting. It has been reported that
more than 50% of those with mandibular complete dentures may have problems with stability and retention (Redford 1996).
These factors cause a range of problems for patients ranging from minor discomfort and inconvenience to more significant
impacts. Many patients experience pain when eating and chewing. Patients are often concerned about the denture moving
when eating, speaking or laughing and report fears about the negative effect of dentures on social situations (Hyland 2009).
Movement of the denture can lead to concerns about aesthetics and patients also report that because of difficulty eating foods
that are difficult to bite or chew they have to adapt their food choices, especially when eating out and in social situations. In
some cases, people avoid social situations completely.
Implant-supported overdentures (ISOD’s) offer better stability and retention of the mandibular denture and better chewing
function. Patients also report greater satisfaction with aesthetics because the denture is not visibly moving. Additionally, implants
can help to prevent further resorption of the mandible. It has been reported that the long-term success rate of implants in the
lower mandible is at least 95% (Doundoulakis 2003) and there are few serious complications.
The McGill and York consensus statements on overdentures
The McGill consensus statement on overdentures (The McGill consensus statement on overdentures. European Journal of
Prosthodontics and Restorative Dentistry 2002) was published following a symposium held at McGill University in Montreal, Canada
in 2002. A panel of relevant experts in the field stated that: The evidence currently available suggests that the restoration of the
edentulous mandible with a conventional denture is no longer the most appropriate first choice prosthodontic treatment. There
is now overwhelming evidence that a two-implant overdenture should become the first choice of treatment for the edentulous
mandible.
In 2009, a further consensus statement was released as a support and follow-up to the McGill consensus statement. This report was
jointly created by members of the BSSPD (British Society for the Study of Prosthetic Dentistry) Council and the panel of presenters at
the BSSPD conference in York, UK in April 2009 (Thomason JM, Feine J, Exley C, Moynihan P, Muller F, Naert I, et al. Mandibular
two implant-supported overdentures as the first choice standard of care for edentulous patients-the York Consensus Statement. British
Dental Journal 2009). This report also highlighted that since the McGill statement in 2002, uptake by dentists of implant technology
for complete denture wearers has been slow.
The York statement concluded that “a substantial body of evidence is now available demonstrating that patients” satisfaction and
quality of life with implant-supported mandibular overdentures is significantly greater than for conventional dentures. Much of this
data comes from randomised controlled trials.
While it is accepted that the two-implant overdenture is not the gold standard of implant therapy it is the minimum standard that
should be sufficient for most people, taking into account performance, patient satisfaction, cost and clinical time.
This paper aims to present the current evidence and rationale to support the McGill and York consensus statements.
Conclusions
There is now overwhelming evidence to support the proposal that a two-implant overdenture should become the first choice
of treatment for the edentulous mandible. The next task is to identify and overcome barriers for the delivery of this care for the
benefit of edentulous patients.
Smile Dental Journal | Volume 6, Issue 2 - 2011| 43 |

Interventions for Replacing Missing Teeth: Dental Implants in
Fresh Extraction Sockets (Immediate, Immediate-Delayed and
Delayed Implants)
Marco Esposito, Maria Gabriella Grusovin, Ilias P Polyzos, Pietro Felice, Helen V Worthington
The Cochrane Library June 2010, issue 10, 2010
Background
“Immediate” implants are placed in dental sockets just after tooth extraction. “Immediate-delayed” implants are those implants
inserted after weeks up to about a couple of months to allow for soft tissue healing. “Delayed” implants are those placed
thereafter in partially or completely healed bone. The potential advantages of immediate implants are that treatment time can
be shortened and that bone volumes might be partially maintained thus possibly providing good aesthetic results. The potential
disadvantages are an increased risk of infection and failures. After implant placement in post-extractive sites, gaps can be
present between the implant and the bony walls. It is possible to fill these gaps and to augment bone simultaneously to implant
placement. There are many techniques to achieve this but it is unclear when augmentation is needed and which could be the
best augmentation technique.
Objectives
To evaluate success, complications, aesthetics and patient satisfaction between “immediate”, “immediate-delayed” and
“delayed” implants. Also, to evaluate whether and when augmentation procedures are necessary and which is the most effective
technique.
Selection Criteria
Randomised controlled trials (RCTs) comparing immediate, immediate-delayed, and delayed implants, or comparing various bone
augmentation procedures around the inserted implants, reporting the outcome of the interventions to at least 1 year after functional
loading.
The authors used the following definitions:
• Immediate implants: any implant placed in a fresh extraction socket just after tooth extraction.
• Immediate-delayed implants: any implant placed in a extraction socket within 8 weeks after tooth extraction.
• Delayed implants: any implants placed at least 2 months after tooth extraction.
Fourteen eligible RCTs were identified but only seven trials could be included. Four RCTs evaluated implant placement timing. Two
RCTs compared immediate versus delayed implants in 126 patients and found no statistically significant differences. One RCT
compared immediate-delayed versus delayed implants in 46 patients.
Main Results
The following interventions were tested in this systematic review:
1. Immediate versus delayed implants (2 trials):
• One study (Lindeboom 2006) of parallel group design compared immediate versus delayed implants in periapical infected
sites. Twenty-five patients were enrolled in each group and none dropped out. All patients were bone grafted at implant
placement and subjected to a regenerative therapy with resorbable membranes. One year after placement, there were no
statistically significant differences for prosthesis and implant failures, aesthetics assessed by a dentist: papilla height and the
level of the perimplant marginal mucosa in relation to that of the adjacent teeth, and perimplant marginal bone level changes.
• Another study (Block 2009) of parallel group design compared immediate versus delayed implants. Seventy-six patients were
enrolled and 16 dropped. Two years after loading, four implants failed in the immediate group versus one in the delayed
group and this was not statistically significant.
2. Immediate-delayed versus delayed implant placement (1 trial):
• (Schropp 2003) in their parallel group RCT compared immediate-delayed versus delayed implant placement up to 5 years
after loading. Twenty-three patients were enrolled in each group. Three early implant failures occurred, two in the immediatedelayed
group and one in the delayed group. Four postoperative minor complications occurred all in the immediate-delayed
group: one fistula in relation to remnants of cement at the implant-abutment joint (after meticulous scaling the fistula
disappeared but the patient suffered from a bad taste originating from the perimplant mucosa), two cases of temporarily
sensibility disturbances which recovered within 1 month, and one minor postoperative bleeding. After 2 years there were
no statistically significant differences for prosthesis and implant failures, complications, aesthetics assessed by the patient,
the papilla height assessed by the dentist, and marginal bone level changes. However, there was statistically significantly
higher patient satisfaction in the immediate-delayed group and an independent blinded assessor also judged the level of the
perimplant marginal mucosa in relation to that of the adjacent teeth as more appropriate in the immediate-delayed group.
3. Immediate versus immediate-delayed implant placement (1 trial):
• One trial of parallel group design compared eight patients receiving nine single immediate postextractive implants with eight
patients receiving nine immediate-delayed implants 8 weeks after extraction at maxillary anterior and premolar teeth (Palattella
| 44 | Smile Dental Journal | Volume 6, Issue 2 - 2011

2008). Implants were restored within 48 hours with provisional acrylic crowns not in occlusal contact. Two years after implant
placement there were no implant failures, complications, drop-outs, nor statistically significant differences for the level of the
perimplant marginal mucosa in relation to the implant collar, and perimplant marginal bone level changes.
4. Are augmentation procedures necessary? (1 trial)
• One trial of parallel group design compared 14 patients receiving particulate autogenous bone harvested from the implant
osteotomy site versus 12 patients who were not subjected to any augmentation procedure at immediate single implants placed
in fresh extraction sockets at maxillary anterior and premolar sites (Chen 2005) up to 2 years post-loading. Two complications
occurred in the group treated with autogenous bone: one abscess that determined the early failure of the implant and one
wound dehiscence. In total two implants were lost in the autogenous bone group, whereas no complications or failures
occurred in the non-augmented control group. Both treatments resulted in statistically significant bone gain, however no
statistically significant differences were found among the two procedures. With respect to cost and treatment time, the
difference between groups may not be clinically significant.
5. Which is the most effective augmentation technique? (2 trials)
• One trial of parallel group design (Chen 2005) compared 12 patients receiving non-resorbable barriers versus 11 patients
receiving resorbable barriers versus 13 patients receiving resorbable barriers and particulate autogenous bone harvested from
the implant osteotomy site at immediate single implants placed in fresh extraction sockets at maxillary anterior or premolar
sites up to 2 years post-loading. No patients dropped out. Four complications occurred, two dehiscences occurred in the
resorbable group whereas one abscess (successfully treated with systemic antibiotics) and one dehiscence occurred in the group
treated with resorbable barriers and autogenous bone All treatments resulted in statistically significant bone gain, however no
statistically significant differences were found between the three procedures.
• Another trial compared 10 patients receiving Bio-Oss versus 10 patients receiving Bio-Oss plus a resorbable barrier at
immediate single implants placed in fresh extraction sockets at maxillary anterior or premolar sites up to 3 years post-loading.
These two groups were compared to a third control group of 10 patients who received no barrier and no graft After 3 years,
three patients dropped out from the Bio-Oss group and five patients from the Bio-Oss plus barrier group. There were no
prosthesis or implant failures. Two complications occurred in the Bio-Oss plus barrier group: one abscess developed during
the healing period around one implant (the site was re-treated with the same procedure); another implant displayed a chronic
inflammation of the perimplant tissues (perimplant mucositis) for the entire study period. No statistically significant differences
in bone gain were found between the two procedures. With respect to treatment time, the differences among groups may not
be clinically significant. The only difference in cost between the two procedures was the additional cost of the barrier.
• The fact that five different augmentation procedures were tested in these two trials which were conducted by Chen et al. and
included 56 patients, eliminated the already scarce possibility to find any possible statistically significant difference, therefore
the findings were inconclusive.
Discussion
The meta-analyses of two trials (Lindeboom 2006; Block 2009) comparing immediate versus delayed implants found no
statistically significant differences for prosthesis and implant failures, though trends clearly suggested that more implant failures
occurred at immediate implants. No other meta-analysis could be done, nor other outcome was significant.
One trial (Cornelini 2004) which showed some statistically significant difference but has to be excluded from this systematic
review update, because it was decided to include only trials having a follow-up of at least 1 year after loading, worth
mentioning. This trial, having a follow-up to abutment connection/implant loading, compared 10 patients with an immediate
post-extractive implant covered by a resorbable barrier versus 10 patients treated with a resorbable barrier plus anorganic
bovine bone (Bio-Oss) at implants placed in fresh extraction sockets. No failures, complications or drop-outs occurred. A
statistically sig- nificant higher position of the soft tissue margins in relation to the implant shoulder was found at the buccal
aspects of implants treated with barrier plus Bio-Oss.
Authors’ Conclusions
Implications for practice
There is insufficient evidence to determine possible advantages or disadvantages of immediate, immediate-delayed or delayed
implants, therefore these preliminary conclusions are based on few underpowered trials often judged to be at high risk of
bias. There is a suggestion that immediate and immediate-delayed implants may be at higher risk of implant failures and
complications than delayed implants; on the other hand the aesthetic outcome might be better when placing implants just
after teeth extraction. There is not enough reliable evidence supporting or refuting the need for augmentation procedures at
immediate implants placed in fresh extraction sockets or whether any of the augmentation techniques are superior to the others.
Implications for research
There is a definite need for randomized controlled trials evaluating the best timing for placing dental implants after teeth
extractions. These trials must be powered to detect a difference for primary outcomes such as prosthesis/implant success
and complications, should evaluate objective aesthetic outcomes assessed by blind outcome assessors and the patient’s own
perception of aesthetics, and should be reported according to the Consolidated Standards of Reporting Trials (CONSORT)
guidelines (www.consortstatement.org). We also need to understand when bone augmenta- tion procedures are needed and
which are the most effective. Trials evaluating the efficacy of non/slow resorbable bone substitutes in alternative to autogenous
bone should be prioritised.
Smile Dental Journal | Volume 6, Issue 2 - 2011| 45 |

Lisa and Lina
W&H Sterilizers Created for You!
Lisa and Lina, two type-B sterilizers with one single aim:
to meet your needs, through Lisa’s exclusive “made-tomeasure”
type-B cycles and integrated automatic traceability
system featuring a load release option, and with Lina, the
new addition to the range, that has everything you would
expect of a W&H sterilizer as well as the possibility to adapt
to your practice requirements when needed.
Lisa “fully automatic”
W&H invents the “made-to-measure” cycle
Lisa is designed for intensive use and therefore features new
type-B cycles, that automatically reduce and optimize the
whole sterilization cycle according to the number and type
of instruments to be sterilized, and shorten drying thanks
to the patented ECO-Dry system. Lisa therefore becomes a
premium performing sterilizer for medium loads as there is
no longer the need to wait until having a full load. The result
is time savings of 15 to 25 minutes for these smaller loads
and your valuable instruments are also less exposed to heat,
increasing their lifespan.
Lina: Simple but expandable
As well as staying true to the W&H concept by offering
exclusively type-B cycles and a short ECO-B cycle for your
small loads, and by ensuring ease-of-use through its
practical key-pad, the Lina sterilizer was also designed to
evolve according to the requirements of your practice. When
needed, it is therefore
possible to add the
optional Multiport which
allows the saving of
cycles on USB stick and
the printing of bar-code
labels via the LisaSafe
printer.
www.wh.com
Hydrorise, the Innovation that
Did Not Exist
Nowadays, dentists can count on an innovative new
impression material:
Hydrorise, the first hyperhydrophilic A-silicone that is
suitable for any kind of impression technique, in all clinical
conditions.
Hyperhydrophilic technology has been exclusively developed
by Zhermack research, making hydrorise extremely flowable
like water.
With a contact angle less than 10° and thanks to the effects
of the AMDA System (Advanced Moisture Displacement
Action), Hydrorise is able to move fluids from the gingival
sulcus and reproduce impression margins with maximised
precision, like no other material on the market.
The attention paid by researchers in the Zhermack
impression materials development phase is focused on the
company's aim to create clinically relevant products. An
impression material must guarantee extremely accurate and
reliable results, even in particularly difficult clinical situations.
The perfect synergy between physical and mechanical
properties found in Hydrorise ensures clinical success at each
use, drastically improving the flowability of the silicone deep
within the gingival sulcus.
Hydrorise is available in different viscosities: putty - heavy
body – regular body – light body – extra light body –
monophase, all available both in normal set or fast set.
BCS ® Basal Implants
Basal implants are today the devices of first choice, when
it comes to loading immediately, treating patients with
compromisted health and smokers. BCS ® implants with
proven long term success rates above 99% are offering
all options for successful treatments both in the mandible
and in the maxilla.
BCS implants are resistant to peri-implant infections and
safe to use even for the non experienced implantologist.
Avaiable diameterts range from 3.5mm - 12mm, with
lengths from 10mm to 38mm. BCS ® implants are
suitable for placement into healed bone areas as
well as for fresh extraction sockets or
after losses of other implants. The
implants may be combined
with lateral basal
implants (BOI)
or any
other brand
of screw
implants.
www.implant.com
www.zhermack.com
| 46 | Smile Dental Journal | Volume 6, Issue 2 - 2011

Morita introduces a new Rotary outbreak:
The Tri Auto Mini
The high-performance Tri Auto mini endodontic motor excels with its extremely high level of
flexibility. With its compact dimensions and low weight, it fits perfectly into the hand and opens
up a new degree of freedom in treatment possibilities due to its rechargeable battery operation.
The user can adjust file speed, torque values and various safety functions at the touch of a
button and in this way increase safety for patients. And the various parameters for individual
indications can be stored for even easier handling.
In combination with the Root ZX mini apex locator, you have an endometric and treatment
instrument of the very highest quality. Special display setting for left-handers
Flexibility
• Tri Auto mini is suitable for all standard NiTi files
• Rotational handpiece (250°) for optimum visibility in all quadrants
• Speed range from 50 - 1,000 rpm
• Suitable for both right-handers and left-handers
• Battery-operated (rechargeable) and cable-free
Treatment Comfort
• Easy-to-handle angle piece with extremely small
head (9mm) for high patient comfort
• Clear, energy-saving LC coloured display
• Selectable signal tones
• Variable file speeds
• Variable torque values
• 6 storage locations for treatment parameters
www.morita.com
WaveOne brings simplicity to Endodontics
WaveOne, from DENTSPLY Maillefer, is the new endodontic system designed to provide simplicity and efficiency to the
root canal shaping procedure.
The WaveOne motor works in a reciprocating mode with a large rotating angle in the cutting direction provides high
efficiency, whereas a smaller angle in the reverse direction allows the WaveOne file to safely progress along the canal
path, respecting the root canal anatomy. The optimised angles also reduce the risk of a screwing effect and file breakage.
Single file technique
The reciprocating technique makes it possible to shape most root canals using only one single WaveOne Nickel-
Titanium(NiTi) file. No time is wasted changing NiTi instruments during the root canal shaping procedure and the global
shaping time is decreased by up to 40% versus a traditional continuous rotary technique, whilst still providing premium
quality root canal treatments.
The WaveOne file geometry was conceived specifically to benefit from the optimised preprogrammed
reciprocating movement of the WaveOne motor. The proprietary DENTSPLY
M-Wire Nickel-Titanium technology provides additional flexibility and greater resistance to cyclic
fatigue, the leading cause of file separation.
Single patient use
DENTSPLY Maillefer advocates single patient use as a new standard of
care, by proposing the WaveOne reciprocating NiTi files exclusively in
presterilized blister packs and fitted with a non autoclavable handle. The
advantages are:
• Simplicity
• No risk of cross contamination
• Optimal cutting efficiency
• Better control of file breakage
www.dentsply.com
| 48 | Smile Dental Journal | Volume 6, Issue 2 - 2011

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"Pentron Clinical" Launching Ceremony
Organized by Prodent s.a.l.
Pentron Clinical launching ceremony organized by Prodent s.a.l. counts as
one of the most successful events of the year 2011.
During the evening hours of the Day May 30, 2011 and under the Prodent’s
Skies, more than 100 dentists visited Prodent to inspect the new restorative
line of products.
The President of the LDA, Dr. Ghassan Yared, Dean of the Lebanese
University Prof. Mounir Doumit, Dean of the Arab university Prof. Essam
Osman and Dr. Carina Mehanna Zoghaib representing the Saint-Joseph
University were present to give a round of applause for this achievement.
Dr. Gregori Kurtzman from Pentron Clinical, who has been selected annually
since 2006 as one of the “TOP DENTAL” lecturers by Dentistry Today, was
honored to be surrounded by the huge number of dentists and answered to
their detailed and qualified questions.
The soft music and the original exotic food were also a part of this friendly
gathering which added pleasant and fun to this event.
www.prodent-me.com
Planmeca launches a full Digital Intraoral Scanning Solution:
World’s first dental unit integrated intraoral scanner Planmeca PlanScan
The new patient-friendly, high-performance process delivers complete clinical information about the patient anatomy by
combining the surface data from Planmeca PlanScan intraoral scanner with Planmeca Promax 3D CBVT X-ray data and
the 3D facial photo acquired from Planmeca Promax 3D ProFace. Unique 3D combination of these three cutting edge
3-dimensional data enables more accurate treatment planning, procedures, and more satisfied patients.
Making the treatment process faster and more accurate
Planmeca PlanScan intraoral scanner allows the dentists to capture the complete intraoral situation directly and save it as a
highly accurate 3D digital model. This model is instantly ready to use for design. Dentists can omit the taking of impressions
and bypass related disadvantages such as inaccuracies, material costs, impression retakes and manual handling. Patient
satisfaction soars – due to less chair time, reduced remakes, faster treatment completion, better fits and an overall improved
chair-side experience. Planmeca PlanScan intraoral scanner is fully integrated to dental unit, which enhances ergonomics
and all-digital workflow. Planmeca PlanScan is, however, also offered as Cart delivery when preferred.
Planmeca PlanScan - Enabling labs to tighten relationships with dentists
Labs can strengthen their professional ties with their dentist clients by offering new digital services that include receiving the
dentist’s Planmeca PlanScan scanner data directly. They will be effectively helping dentists transition into digital impression
taking while enabling them to enjoy the full range of indications and high
quality results that come with professional dental technician expertise.
The lab will also experience workflow benefits – more accurate case input
and shorter turnaround times because restoration design work can start
immediately without creation of a physical model.
Digital Perfection – revolutionary integration of three 3D data
The innovative combination of intraoral surface data, 3D X-ray data and
facial soft tissue image delivers clear benefits for different specialists.
Integrating surgical planning and prosthetic planning, the 3D digital model
helps defining the ideal position of implant. Furthermore, the implant
planning data can be used in crown design.
The 3D X-ray data alone contains accurate information about the bone
structure. Now with the combined data, periodontal tissues can be evaluated
in relation to bone. For Orthodontic treatment no gypsum models are no
longer necessary, and the treatment follow up can be done using radiation
free Planmeca ProFace images.
www.planmeca.com
| 50 | Smile Dental Journal | Volume 6, Issue 2 - 2011

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together through world-class products and service.
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Smile's Content is Now Included in
ALMANHAL Electronic Database
Smile Dental Journal signed an agreement with
ALMANHAL; an electronic publishing company established
in 2009, which permits to include the content of Smile
in Al Manhal full-text searchable electronic database of
scholarly, professional and peer-reviewed documents.
As ALMANHAL is a Joint Venture between Wolters Kluwer,
Ebrary, HRH Prince Bandar Bin Sultan and TechKnowledge,
and it will utilize the distribution channels of its investor/
partnerWolters Kluwer (Ovid) in order to make its Journals
available in universities, hospitals, governments and public
libraries throughout the world.
Mr. Basheer Alnasser; General Manager of ALMANHAL,
stated that ALMANHAL aims to fulfill the increasing
demand of the medical and academic institutions in the
Arab world for the digital content originating from the
Arab countries, thus providing search systems similar to
those that are trusted by thousands of publishers around
the world to publish their books and periodicals to more
than 17 million user and more than 14000 institution in
over 40 countries.
Dr. Issa Bader; Founder and Chief Editor of Smile,
declared that this agreement will enhance the exposure
of Smile's content all over the world and this would boost
Smile's impact factor and provides the authors who choose
to publish their articles in Smile the opportunity to reach a
greater number of readers and achieve more citation of
their articles in the related published material worldwide.
Neo AutoChip Maker
Easy & Simple Auto Bone
Collector
Everyone knows auto graft bone is very good for
bone formation, but there were limitations which
the Quantity is limited and it is hard to get.
Neo Autochip maker solves
these problems.
Easy and safe method to get 1cc
autobone within 10 seconds.
Features
• Gathers bone while drilling
• No bone loss
• Reduce healing time
• Control particle size
• Gather fresh bone
www.neobiotech.co.kr
QuickLase Launches a New
Dual Laser
The NEW QuickLase 8w Dual wavelengths of 4w 810nm
AND 4w 980nm at the same time. It is the ONLY laser
on the market with ultimate coagulation and cutting, NO
OTHER LASER LIKE IT with this technology. Its so powerful
but controlled.
In addition to the 8w Dual, the 3.5w is an entry level for
most of soft tissue management such as gum re-contouring,
with its touch screen technology, weighing under 1.6kg
is small enough to fit into a briefcase and has audio
confirmation and help screens for procedures as well built-in
fibre optic housing making it easy to move from surgery
to surgery. With
far reaching
applications from
gingivectomy and
crown lengthening
to laser
curettage and
operculectomy,
plus many
more uses too
numerous to
mention.
www.quicklase.com.
Open your Doors to More Patients
Become a LASER Dentist
The New Cordless PowerPen Laser has been talked about by
many dentists and compared to by its closest competitor:
• Half the price of its competitor
• Lightweight & easy to balance in one hand
• Easy to operate
• Cutting tips are easy to bend and have more uses before
changing
• Battery charges faster and lasts longer
QuickLase have a range of soft tissue management
lasers. Starting with the cordless PowerPen 2w 810nm,
the 3.5w 810nm diode laser and the famous Dual 8w
810nm+980nm for ultimate coagulation and ultimate
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| 52 | Smile Dental Journal | Volume 6, Issue 2 - 2011

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6 - 7 April , 2011, Amman, Jordan
7 th Jordanian Orthodontic Congress
Prepared by Dr. Shadi Samawi
Under the patronage of HE the Jordanian Minister of Health, the Jordanian Orthodontic Society (JOS) held its 7 th
Jordanian Orthodontic Congress, at the Sheraton Hotel in Amman on the 6 th & 7 th of April 2011, under the main theme
of “Early Orthodontic Treatment... An Ounce of Prevention”
The congress’ memorial lecture was dedicated to the memory of the late Prof. Samir Bishara, one of the most influential
figures in the world of Orthodontic research, and was presented by Guest speakers Prof. Abbas Zaher (Egypt) and Dr.
Roy Sabri (Lebanon).
In addition to the main scientific program
spanning two full days - which included
speakers from Jordan, Egypt, Palestine, Saudi
Arabia, Syria, Lebanon & USA - among
others, the conference’s scientific agenda
also included two clinically-oriented pre- &
post-congress courses by renowned guest
speakers Professors Peter Ngan (West Virginia
University - USA) and Bakr Rabie (University of
Honk Kong). It also witnessed the introduction
of the 7 th JOC’s first-ever Scientific Interactive
Day which included various clinicallyrelevant
table clinics, round table discussions
and poster presentations covering major
clinical orthodontic topics and state-ofthe-art
technology currently trending in the
profession.

Middle East
Symposium
7 - 8 Dec. 2011
Jordan

9 - 11 April , 2011, Kuwait, Kuwait
The 15 th Kuwait
Dental Association
International Scientific
Conference
“Invitation to a Practical
World of Dentistry”
Prepared by Dr. Yousef Sadik Marafie
The Kuwait Dental Association has organized the
15 th International Scientific Conference and their
2 nd workshops at Radisson SAS Hotel Kuwait - Al
Hashimi under the auspices of His Excellency the
Minister of Health Dr. Hilal Al-Sayer.
The Dental Association of Kuwaiti through this
congress aimed to focus on 3-objective axes: local,
Arab and international as follows:
Local objectives:
1. To raise the level of the dental profession in Kuwait
for citizens to achieve the greatest health care.
2. To contribute to the organization of practicing
dentistry in the government sector and private
companies, and overseeing the application of
laws and health regulations and to ensure the
submission of proposals developed for the benefit
of citizens and the profession.
Arab goals:
1. To improve the health of the Arab people and to
ensure better health services.
2. To encourage cooperation and exchange of
experience among dentists in the Arab world.
3. Arabization of medical terminology in
collaboration with trade associations and dentists
in the Arab world.
Global goals:
The Association in cooperation with similar bodies in
foreign countries and international organizations as
well as the union of dentists aims to serve the global
objectives of the association and its members.
In addition to invaluable up-to-date clinical and
scientific lectures and workshops, there was an
exhibition organized by the congress committee in
co-operation of leading international companies
which aimed to present their latest equipment and
dental technology. This of-course in addition to
the very popular tourist entertainment program
organized by the congress committee for the
conference guests who were shown the traditional
touristic and the modern commercial and leisure sites
in the State of Kuwait.

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15 - 16 April , 2011, Erbil, Iraq
1 st Iraqi Dental Reunion 2011
CAPP, IDA and KDA Open the Doors of the
Dental Market in Iraq
The conference was vibrant with excitement the 1 st Iraqi Dental Reunion in 10 years reuniting old friends and colleagues
from dental industry from across the region. 1 st Iraqi Dental Reunion 2011 was a great success, achieving record
attendance and further establishing a reputation as the dental industry’s leading regional event. It took place at the
Saad Palace, in a new and strikingly modern environment on 15 - 16 April, Erbil, Iraq. The conference was organized
in the mutual cooperation of CAPP (Centre for Advanced Professional Practices), Iraqi Dental Association and Kurdistan
Dental Association. Minister for Health, Dr. Taher Abdullah Hussein Hawrami opened the conference and expressed his
pleasure to announce that this conference open the way for new business and scientific opportunities.
Dr. Raffi M. Aljobory, President of Iraqi Dental Association and Dr. Shakhawan Qadir Khoshnaw, President of the Dental
Association Kurdistan greeted all participants with a warm welcome and expressed their thanks and appreciation to the
sponsors and supporters of this conference.
The event welcomed more than 1200 and 400 visitors including dentists and dental technicians form the government
and private sector and students coming from all provinces of Iraq. Participants accumulate the latest opinions, trends
and insights from industry thought leaders, shared experiences with colleagues, made new contacts and bound exciting
relationships and exchange their ideas and knowledge.
There was a significant presence of all Iraqi Colleges and Universities:
Sulaimani, Al-Anbar University ( Mosul), Baghdad Al-Mustanserriyah, Isfahan, University of Medical Sciences and Health
Services Faculty of Islamic Republic of Iran, Guilan University of Medical Sciences Islamic Republic of Iran, Qazvin
University of Medical Sciences Islamic Republic of Iran, Medical College Site Sadr Teaching Hospital, Kufa City, Najaf
Governorate, Iraq, Sulaimani, Iraq.
The main conference schedule included four plenary sessions. The scientific program offered a wide variety of topics.
16 different lectures with a variety of topics in addition to 8 workshops were held.
A sophisticated exhibition accompanied the 1st Iraqi dental Reunion, featuring 22 dental companies from different
countries - Germany, USA, UK, Brazil, Netherlands, Switzerland, and Turkey. 18 Distributor companies from Iraq,
UAE, Lebanon, Turkey and Jordan represented 115 dental manufacturers. Participants circulated through the dynamic
area throughout the conference, learning about the latest services and products, speaking with representatives from
exhibiting companies and using the space as a central meeting and networking point.

12 - 13 May , 2011, Dubai, UAE
5 th
CAD/CAM
& Computerized Dentistry International
Conference
To welcome its 5 th Anniversary this year, CAD/CAM & Computerized Dentistry Int’l
Conference embarked on a brand new journey.
The organizers, CAPP and Emirates Dental Society achieve for the 5 th time great record of
attendance and established a reputation as the industry’s leading international conference.
The Address Dubai Marina Hotel hosts 726 participants in the very elegant atmosphere.
Technology is changing the world of dentistry. In an increasingly inter-linked global
environment. New threats and challenges have created an urgent need for new responses.
Nowhere is this more true than in the area of education and training where technology is
bringing new advantages and opportunities.
“A quick glance at the last IDS in Koln, Germany shows not only the extraordinary
improvements to computerized technology, but the extraordinary improvements to this
technology, but the vast number of manufacturers that are joining the market as well” Dr.
M Silwadi.
Bringing together leading experts and practitioners, the conference proved an excellent
opportunity for networking and sharing experiences in the application of technology
throughout the learning cycle - from primary and secondary education through to
professional development and lifelong learning.

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REGISTRATION
Sponsored by
Fill in and send to CAPP by fax: +971 4 3686883
or email: events@cappmea.com
www.cappmea.com/aesthetic2011

AED 1.750/US $480
Conference registration package
Conference Pass + 2 Nights Byblos Hotel
(2 days pass to the conference, certificate,
lunch and coffee breaks for the conference,
2 nights stay in Byblos Hotel “4 stars
single/double room” inclusive of breakfast
and transportation to the conference venue)
AED 1.200/US $330
Only Conference Registration
(2 days pass to the conference, certificate,
lunch and coffee breaks for the conference)
*Book now limited spaces available
Registration Sponsored by Smile Dental Journal
Name:
Speciality:
Clinic:
Country:
City:
P.O.Box:
Tel:
Fax:
Mobile:
METHOD OF PAYMENT
Credit Card
Visa MasterCard
Email:
AUTHORIZATION NOTE
Please debit my credit card with an amount of AED
Card Number:
Expiry:
Billing Adress:
Name on Card:
for the 3 rd Dental – Facial Cosmetic
International Conference.
The card holder will honor this transaction
and not hold CAPP responsible if the credit
card number has been compromised.
Country/Emirate: Date: Signature:
Bank Transfer:
Account Name: CAPP FZ LLC.; KV,
Dubai, U.A.E.; Account No:
1011-178649-301; SWIFT Code:
EBILAEAD; Bank Name: Emirates
Bank; Al Karama Branch, U.A.E.
Cheque payment on the
name of CAPP

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2 - 4 June , 2011, Beirut, Lebanon
12 th Lebanese University Dental Congress
The 12 th Lebanese University Dental Congress in Beirut was attended by more than 1200 dentists to hear about some of
the up to date clinical techniques and scientific publications in dentistry. The objective of this three day congress was to
focus on challenges encountered in dental daily practice, new treatment approaches, researches, latest techniques and
biomaterials used in dentistry. To this extent, the scientific committee chaired by Ass Prof. Elie Azar Maalouf managed to
attract high profile faculty of 22 national and 32 international speakers from more than twelve countries, who presented
up to date clinical lectures on various dental specialties.
Few of the many prominent speakers contributed at this successful event were Prof. Clarck Stanford, Dr. Edgard El Chaar
and Dr. Daniel Perez from the United states, Prof. Tara Renton and Dr. Hassan Maghaireh from the United Kingdom
and Dr. Gilles Chaumanet, Dr. Radhouane Dallel and Prof. Paul Pionchon from France, in addition to many other high
profile speakers from Canada, Germany, Denmark, Austria, Egypt and of course Lebanon.
In addition to oral presentations, the program included specialized pre-congress forums and workshops, young podium,
live transmissions, posters and research sessions and oral presentations.
A comprehensive exhibition ran alongside the congress programme, and this year the Lebanese university welcomed
more than 60 different exhibitors. Attendees enjoyed meeting suppliers, picking up samples and learning about the new
products and services being demonstrated at the event.

Two Minutes with
Dr. Marco Esposito
PROFILE
Prof. Dr. Marco Esposito, DDS PHD
• Editor of the Cochrane Oral Health Group
• Associate Professor in Biomaterials with the Sahlgrenska
Academy at Göteborg University- Sweden
• Editor in Chief of the European Journal of Oral Implantology
Marco graduated with honors in dentistry at the University of
Pavia, Italy, in 1990 and was awarded a PhD in Biomaterials
from the Göteborg University in 1999. He worked as Guest
Researcher at NIOM (The Nordic Institute of Dental Materials),
Haslum, Norway and is a specialist in Periodontics (UK). He
also acted as the Director of the Postgraduate Dental Specialties
courses in Dental Implantology, School of Dentistry, University
of Manchester, UK between 2007 and 2011, but now he has
decided to be a freelance researcher and devote his time
entirely to evidence based research in dental implantology.
He authored more than 90 scientific publications in
international peer-reviewed journals. His main research interests
are the assessment of the effectiveness of various therapeutic
interventions with particular emphasis on dental implants.
Marco is worldwide well-known lecturer and leading speaker
and author on evidence based dental Implantogy. He will be
lecturing at the European Association of Oral Implantology
Congress in Athens in October 2011.
We are delighted at Smile Dental Journal that Prof. Esposito is
now on our international advisory board.
Questions/Answers:
Why did you choose to be researcher in implant dentistry?
I started my research training in Sweden as a requirement for
my clinical postgraduate training, I got stuck in it, then I started
to enjoy it and now I see it as a mission.
What are the best/worst aspects of your job?
The nicest part of being a researcher is that it gives you the
opportunity to understand how things work, and the worst part
is the bureaucracy linked with initiating research.
Where do you live?
After 21 years abroad, now I live in a small village called
Arcore near Milan in Italy, quite famous for the “bunga-bunga”
activities.
What do you drive?
I seldom drive as I spend most of my time flying outside Italy
What drives you?
Curiosity
What’s your favorite food?
Buffalo mozzarella
What’s your hobby?
Military history as I enjoy collecting world war II uniforms from
the North African region
What’s your favorite film?
I enjoy historical and comedy films
Favorite holiday destination?
As I spend most of my time outside Italy, I always look forward
to visiting central and south Italy for holiday.
What inspires you?
The willingness to understand more
What really annoys you?
People trying to stop other people from achieving things
What keeps you awake at night?
I am a very good sleeper, but those situations in which I feel I
have no control keeps me awake
What makes you smile?
The innocence of kids
What is your best characteristic?
Perseverance
Worst fault?
Sometimes I can be impulsive
Can you describe yourself in three words?
Analytical, objective and curious
What do you do to relax?
Visit historical places and talk with people with different
backgrounds
If you weren’t a dentist, what would you have liked to
have been?
An archeologist
Do you read and recommend Smile Dental Journal
regularly?
I am delighted that my friend Dr. Hassan Maghaireh has been
appointed as the Editorial Director, therefore i can recommend
Smile Dental Journal as one of the leading evidence based
dental journals in the Middle East area.
What would be your motto in life?
“Provando and riprovando” by Galileo which translates into
“trying and trying again”
| 68 | Smile Dental Journal | Volume 6, Issue 1 - 2011

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المؤتمر السعودي العالمي الرابع عشر لجامعة الملك سعود لطب الأسنان
الثالث والعشرون للجمعية السعودية لطب الأسنان
King Saud University 14th International Dental Conference
the 23rd for the Saudi Dental Society
مركز معارض الرياض الدولي
خلال الفترة من ١٤-١٦ ربيع الأول ‎١٤٣٣‎ه - الموافق – ٦ ٨ فبراير ‎٢٠١٢‎م
Venue Riyadh International Exhibition Center
14 – 16 Rabi’ 1 1433H . 6 – 8 February 2012
4677763 / 4677743 / 4677764 / 4677534
www.sds.org.sa

Quality
Quality and guarantee of
effectiveness and trouble-free
process of prosthetics is the main
duty of Implasa Höchst company.
Research & Development
Is there a limit in development of
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look to the way which the Implasa
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Materials & Technologies
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Quality
Quality and guarantee of
effectiveness and trouble-free
process of prosthetics is the main
duty of Implasa Höchst company.
Research & Development
Is there a limit in development of
dental practice? The answer to this
question opens by itself, if we take a
look to the way which the Implasa
Höchst company passed for 10 years
in the field of the newest technologies
of the cure and prosthetics of teeth.
Materials & Technologies
The high-quality materials +
constantly improving technologies =
the guarantee of our quality and
your success
Production Cycle
ImPlasa Höchst company specialists
diligently control the quality of the
released production at all the stages
of technological process
and production.
Microscopy
The surface of implants is prepared
by unique technology of ImPlasa
Höchst company, named
ImPlapore, which allows to reach
minimal traumatizing in the area of
implant installation, and such way
maximally eases the
osseointegration process.
The Sole Representative in the
Middle East and Africa
E: dr.munther@implasa.de
Syria
Kingdom Medical &
Dental Instruments
Tel: +963 21 5732052
majedajami01@hotmail.com
Lebanon
Kingdom Medical &
Dental Instruments
Tel: +961 6 426462
kingdom_est@hotmail.com
Turkey
ASYA DENTAL
Tel: +902164957287
gulcan_celebi@mynet.com