International Poster Journal of Dentistry and Oral Medicine, Supplement PDA/2016

A 12 years old patient, female, wanted orthodontic treatment to improving the aesthetics of her smile. Extra-oral examination showed a convex facial profile, balanced facial thirds, nasolabial angle and smile line within the norm. Intraoral examination indicated a bilateral Class II molar and canine relationships; absence of 1.2 and 2.2 teeth; asymmetry of 1.3 and 2.3; crowding; mandibular line shifted to the right. The panoramic radiograph confirmed Maxillary lateral incisors agenesis. The cephalometric analysis indicated a skeletal Class I and alveolar, a hypodivergent pattern and the interincisal angle was decreased. It was a favorable prognosis. The treatment approach was bimaxillary orthodontic fixed appliance, closing space, torque compensation, and canines coronoplasty. There are several factors with influence on therapeutic decision making, including the patient's age, facial profile, smile line, canine characteristics, number of missing teeth, and malocclusion. According to the literature these cases are treated with space closing. Regarding to the hypodivergent facial pattern would be advised to open space, but the convex facial profile, Class II molar and canine, made the space closure a option that doesn't affect the profile; canines although asymmetrical, have shapes and sizes beneficial for coronoplasty. The high smile line is often a problem, but in this case was appropriate and was not a problemAccording to the diferents factors considered, closing space was the best treatment option for this patient, it was a early and definitive resolution for patients with MLIA. And despite the asymmetry of canines, it was achieved a harmonious smile. Keywords: Maxillary lateral incisor genesis, asymmetry canines, orthodontic close spaces, MLIA

Female patient, 15 years old, came to the Clinic of the Faculty of Dental Medicine of University of Oporto for a routine appointment. Teeth 11 and 21 showed enamel-dentin fractures (Figures 1 to 3). Patient had a history of fall at the age of 9, which caused the injury. Vitality tests were positive and the teeth were not sensitive to percussion. No radiographic abnormalities were found. A silicon palatal guide was taken from the mock-up (Figures 4 and 5) in order to create a palatal wall. A direct aesthetic rehabilitation with resin composite Z100 ™ Restorative (3M) was done (Figures 6 to 9). Keywords: palatal guide, dental trauma, permanent teeth, esthetic restauration

Introduction: Several root coverage (RC) procedures capable of meeting the patient's aesthetic demands have been proposed. Therefore, methods were developed to allow the postoperative aesthetic evaluation of obtained results, in an objective and reproducible manner. Aims: To systematically review and assess the applicability of objective aesthetic evaluation indexes after RC procedures. To evaluate retrospectively the aesthetic results after a modified tunnel technique (MTT) in the treatment of gingival recessions (GR), using the Root Coverage Esthetic Score (RES). Materials and methods: Electronic search in primary (PubMed) and secondary (b-on) databases using the search terms: "soft tissue evaluation"; "aesthetic index"; "esthetic score"; "esthetic assessment"; "esthetic outcomes"; "root coverage procedure" + bolean conector "AND", selecting only human studies between 2005 and 2015. 10 examiners evaluated 25 photographs (21 treated GR + 4 negative controls) using RES. Descriptive statistical analysis was used. Results: This review identified 9 objective aesthetic indexes. RES is the sole specifically centered on aesthetic results after RC procedures. The MTT allowed 93,45% mean RC in single or multiple Miller's classe I and II GR, with good esthetics (RES= 7.4±2.270) and 62% of the cases obtaining RES≥7. Conclusion: The MTT allowed a quantitative and qualitative improvement of clinical parameters. The RES seems to be a useful tool for assessing the aesthetic outcomes of RC procedures. However, RES may not be representative of clinical aesthetic reality. Clinical implications: New objective esthetic indexes with a balanced appreciation of parameters are desirable. Keywords: root coverage esthetic score, gingival recession, periodontal surgery, objective aesthetic assessment

Objective: This study wants to evaluate the bond strength of a self-adhesive flowable composite, in dentin surfaces prepared with Er,Cr:YSGG laser with two different settings. Methods: Fifteen healthy teeth were distributed in 3 groups. The dentin samples of the Control Group didn't have any laser treatment, the samples of the Group 2 were treated with Er,Cr:YSGG laser, with the settings 4,5W, 50 Hz, 50 ms, 70% air, 90% water, and the ones from Group 3 were treated with the same laser with a different laser frequency, 4,5W, 75 Hz, 50 ms, 70% air, 90% water. The samples were restored with VertiseTM Flow following the manufacturer instructions. The Shear Bond Strength (SBS) test and morphological analysis with Scanning Electron Microscopy (SEM) were performed. Results: The high mean of the SBS was from Group 2 (4,76 ± 3,99 MPa), followed by the Control Group (1,87 ± 1,61 MPa), and the lowest was from the Group 3 (0,81 ± 0,93 MPa). The means of SBS were not statistically different between each other. (p>0,05). Conclusion: Although the bond strength was influenced by the type of dentin surface and the laser parameters, there was not statistically differences between each group (p>0,05). The increase of the laser frequency resulted in lower SBS. Additional studies should be carried on. Keywords: laser, erbium, Er, Cr:YSGG, adhesion, self-adhesive flowable composite, dentin

Description of clinical cases: Case 1: A 60-year-old female patient was oberved with a single greyish macular lesion on the oral floor. Excisional biopsy was performed and the pathological examination confirmed the diagnosis of amalgam tattoo. Case 2: A 73-year-old male patient was observed with a single brown macular lesion on the hard palate. Excisional biopsy was performed and the pathological examination confirmed the diagnosis of oral melanotic macula. Case 3: A 66-year-old male patient was observed with a single bluish macular lesion on the hard palate. Excisional biopsy was performed and the pathological examination confirmed the diagnosis of blue melanocytic nevi. Case 4: A 72-year-old female patient was observed with a single brown macular lesion on the hard palate. Incisional biopsy was performed and the pathological examination confirmed the diagnosis of oral melanoma. Discussion: The color changes in the oral mucosa may correspond to a great variety of physiological or pathological, benign or malignant and local or systemic entities. The aim of this communication is to demonstrate through clinical cases which oral pigmented lesions are most relevant in the oral cavity. Conclusions: The differential diagnosis of oral pigmented lesions is usually a major challenge to the dentist. A biopsy is a valuable tool in establishing the definitive diagnosis, essential for the implementation of the appropriate therapy. Keywords: Amalgam tattoo, melanotic macula, blue melanocytic nevi, oral melanoma, pigmented lesions, differential diagnosis

Introduction:The remineralization of white spot lesions provides early treatment of dental caries, less invasive and more conservative for dental tissue. Objectives: To quantify the surface microhardness of enamel when using different remineralizing agents. Materials and methods: 16 enamel specimens were randomly subjected to a lactic acid buffer solution for induction of White Spot Artificial Lesions (WSAL) - (phase 1). 8 of them, were referred to as a control, and the remaining 8 were divided into 4 study groups (Stage 1 treatment) and then subjected to demineralization new cycle (phase 2). The study groups were: GA (n = 2) positive control / distilled water; GB (n = 2) GC Tooth Mousse, RecaldentTM; GC (n = 2) ClinproTM White Varnish; GD (n = 2) Profluorid® Varnish. It was measured Vickers hardness (HV) by HSV-30® identator (Shimadzu). Exploratory and descriptive analysis of the data was performed by SPSS21.0. Results: WSAL (Phase 1) have registered values of 93.99 HV. Step 1 (treatment) obtained values: GA - HV 56.70; GB - 290.00 HV; GC - 136 HV; GD - 224 HV. Phase 2, were verified the values: GA - 116.70 HV; GB - 266.80 HV; GC - 261.80 HV; GD - 158.80 HV. Conclusions: GC Tooth Mousse, RecaldentTM expressed a tendency to increase the microhardness of the enamel surface, in comparison to the fluoride varnish. Clinical implications: Early white spot lesions remineralization allows a greater preservation of dental tissue and greater convenience for the patient. Keywords: enamel, remineralization, White Spot, surface microhardness, remineralizing agents

Title: Prosthetic soft tissue conditioning in single implant restorations - Clinical Case Report Introduction: Single implant restorations, especially in the anterior sector, represent a complex challenge due to high aesthetic demands. Soft tissue conditioning takes an important role, as we intend to achieve the correct papillae growth as well a harmonious gingival contour. The goal of this clinical case report was to evaluate factors and technics used on the optimal treatment and conditioning of peri-implant soft tissues that allow us to achieve a harmonious and aesthetic restoration. We will present a clinical case photo report. Case Discription: Male patient aged 70, with a missing 11 tooth about 30 years ago and wanted clinical evaluation for treatment. The complaints were related to the functional and aesthetic limitations of the use of a removable prosthesis. He was hoping for a fixed solution with more natural aesthetics. Implant surgery with immediate loading was performed with the use of a screwed provisional crown. The provisional crown was periodically altered as to optimize soft tissue conditioning. After achieving correct form and aesthetics for the peri-implant soft tissue the results were duplicated with an impression used for the fabrication of the definitive crown. Conclusions: Soft tissue morphology and gingival contour can be improved through conditioning promoted by a provisional crown customization. A predictable and stable result depends on multiple factors being of biological, surgical and prosthodontic nature. Keywords: Implant, restoration, soft tissue, conditioning

Clinical case: Male patient, caucasian, 53 years, referred by its general dentist, because he could not find the canals. The tooth presented an initiated endodontic therapy and it was diagnosed with symptomatic apical periodontitis. The treatment plan consisted in endodontic therapy, with a good prognosis, followed by the realization of a post and crown, due to the big coronal destruction. The T-shaped modified access cavity was done, to identify the 2 vestibular canals and the palatal one. The working length has been determined with an electronic apex locator and the instrumentation has been done with ProtaperNext system. It has been done a copious irrigation with 5% sodium hypochlorite and the obturation has been done with thermoplastic techniques. Discussion: The incidence of 3 canals in maxillary premolars is low (0.5 - 6%), varying in the second premolar between 0.3 and 2%. It occurs mainly in caucasian population and it's almost nonexistant in asian population. It's necessary to do preoperative radiographs both centred and angulated, in order to detect the internal anatomy, as well as the number of roots. The use of cone beam computerized tomography is advised in the detection of a less usual anatomy. Conclusions: Through the correct access cavity in this type of anatomy, as well as the use of the operating microscope, the 3 canals were identified and treated. A good planification, associated with anatomical knowledge, a good diagnosis, and the use of magnification, allow the success of this type of treatments. Keywords: maxillary premolar, 3 canals

Introduction: In contrast to the high success rates of osseointegration (95% to 97%), mechanical complications are still common in implant dentistry (reported to be as high as 44.9%) Mechanical complications such as screw loosening, screw fracture, and framework fracture. Objectives: Evaluate the wear of the implant-abutments interface after a torsional fatigue test that simulates a loose abutment situation. Materials and Methods: 5 external hexagonal implants were embedded with acrylic resin and divided into 3 groups: - Control group: non engaging titanium abutment - Group A: two engaging titanium abutments - Group B: two engaging zirconia abutment Rotational freedom for each pair was access before and after testing. Each pair was torque to 35Ncm and placed on an Instron 8874 machine and loaded on a rotational test: +/3,3° 4Hz, with a compressive force of 100N for 250.000 cycles. Results: The screws in all groups were loose after testing. In group A and B there was an increase in the rotational freedom with wear of the hexagon but not on the control. There was evidence of adhesive wear and abrasion in group A and in group B there was adhesive wear, abrasion and 3 body abrasion. Conclusions: The loose screw in an implant prosthesis may lead to the wear of the hexagon on both parts. The wear is sufficient to compromise the implant-abutment connection beyond repair Clinical Implication When a patient presents a loose screw restoration, it should be removed and inspected Disclosure: MIS Implants Technologies Ltd; FCT IDMEC, LAETA, UID/EMS/50022/2013 Keywords: Wear, implants, abutments

Introduction: Teeth preparation for indirect restorations involves dentin exposure, which can induce tooth sensibility. Thus, it was suggested sealing exposed tubules with an adhesive that has to be sandblasted with aluminum oxide particles (AOP) in order to improve the wettability and therefore dental adhesion. Objective: To test the microtensile bond strength of immediate dentin sealing (IDS), after applying different types and sizes of aluminum oxide particles with different exposure times. Materials and Methods: Eighteen healthy molars received IDS technique after dentin exposure. They were randomly separated into six groups (n=3): divided following sizes and types of AOP (27μm, 30μm-silica-coated and 50μm) applied to the teeth's surface and exposure time to AOP (4 and 10 seconds). Eighteen resin composite discs were produced and luted to the teeth. Then, the specimens were cut in order to obtain sticks with 1±0.2mm2. These sticks were stressed to failure in tension using a universal testing machine. For the statistical analysis, ANOVA one-way and Tukey's HSD post-hoc test (p≤0.05) were used (SPSS 20.0). Results: The highest levels of adhesion were obtained in groups sandblasted with 30μm-silica-coated AOP (53.31MPa and 60.27MPa). No statistically significant differences were found between groups with different exposure times (p>0.05). Conclusion: Microtensile bond strength (μTBS) of immediate dentin sealing was influenced by different types of AOP. Clinical Implications: Sandblasting dentin's surface with silica-coated AOP after IDS technique acquires better bond strength values than other diameters or types of AOP. Keywords: Surface treatment, aluminium oxide, IDS, bond strength, indirect restorations, sandblast, silica-coating

Case Description: A 74 year old caucasian male patient was referred to the implantology and Oral Rehabilitation consult at the ISCSEM University clinic due to loss of osseointegration and migration of a dental implant into the left maxillary sinus. An ortopantomography was taken. A Computerized Tomography (CT) using Dentascan technique with 1mm cross-sectioning was prescribed. For the surgical removal of the implant, an external sinus access was performed and a collagen membrane was used. Discussion: The migration of dental fragments, endodontics material and dental implants into the maxillary sinus is described. The poor density bone of the posterior maxilla may cause loss of osseointegration. Inadequate bone preparation, perforation of the sinuses floor and/or Schneiderian membrane, as well as the lack of primary stability of dental implants placed in close range of the sinuses can be considered as possible causes of implant migration into the sinus cavities. The non removal of the migrated dental implants may cause its displacement into craniofacial structures, which can provoque further complications due to foreign body reactions, infections and tissue necrosis and collapse if sinus clearance. Conclusion: Dental implant migration into the maxillary sinuses must be swiftly and carefully managed. Keywords: Migration, dental implant, maxillary sinus, complication

Objectives of the procedure: Gain bone volume in the maxillary sinus region. Presentation of the case (clinical procedure step by step and scientific su-sized justifying the procedure); Female patient, 61 years old, with no systemic diseases, smoking 10 cigarettes/day. Lateral osteotomy technique described by Caldwell-Luc and modified by Tatum, increases bone volume in the posterior region of the maxilla and allows the implants placement. We performed a "Newman" incision between the 2nd premolar and 2nd molar opening the flap in order to open a bone window with a piezoelectric device and to elevate the Schneider membrane. Filled up the maxillary sinus with xenograft (Osteobiol Mp3), the bone window was covered with a collagen membrane (Evolution) and sutured with simple stitches and Supramid 4/0. Immediate results, short and medium term: After 6 months the bone gain and placed the implants was observed at the CT, the patient is rehabilitated. Discussion: The lateral osteotomy is a surgical technique widely used, reliable(1) and indicated when the residual bone height does not permit the placement of standard length implants or the use of less invasive techniques. The biphasic technique is used for residual bone heights between 1-4mm or for implant without primary stability(2). Bone grafts goal is to maintain space, mechanical stability and to guide bone formation, are crucial for osteogenesis. Six months of healing are suggested (3,4). The use of membrane to cover the lateral osteotomy together with roughened surface implants, shows the best implant survival rates (98.3%)(5). Conclusions: The lateral osteotomy technique is predictable, has great results in increasing the bone volume of posterior maxilla. Keywords: Bone grafting, sinus augmentation, sinus floor augmentation, bone substitutes, bone regeneration, case reports

Introduction: Sealing of the root canal entrance is an effective method of reducing microleakage in endodontically treated teeth. Although studies support the effectiveness of coronal barriers (CB), there is no universal protocol that incorporates it as part of the Endodontic Treatment. Objectives: In order to assess what is the best material to be udsed as CB, when applied on the entrance of the root canal after filling, an in vitro micro-leakage study was carried with four materials. Materials and Methods: 70 single root teeth were aleatory divided into 4 test groups (n=15) and 2 control ones (n=5). The materials tested were Ionoseal®, GC Fuji II LC®, GrandioSO® Flow and GrandioSO®. The teeth were subjected to thermal cycling and then immersed in a methylene blue dye 2% for leakage evaluation. The results were analysed using ANOVA and Tukey HSD statistic testes (α = 0.05). Results: Overall, Ionoseal® showed the greater amount of leakage and, compared to the other groups, the difference was statistically significant (p0.05). However, between GC Fuji II LC® , GrandioSO® Flow and GrandioSO®, there was no statistically differences. Conclusion: The results showed that LC Fuji II®, GrandioSo® Flow and conventional GrandioSo® are suitable as intra-canal barrierrs, promoting a CB to infiltration. When using Ionoseal®, its suggested the use of adhesive system to improve the sealing; in future, more studies are needed to analysed the behave of this material. Clinical Implications: Sealing of the root canal is essential suggesting their integration into routine clinical protocol. Keywords: coronal sealing, coronal barrier, endodontic sealing, endodontic infiltration, endodontic leakage, micro-leakage, canal reinfection

Case Report: A 46-year-old female patient went to our clinic with the absence of some teeth, showing interest in a fixed implant rehabilitation of the left central and lateral incisors. We decided to place one implant with a platform-switched morse-taper connection (IDCam 4,2 x 12 mm, IDI®) in the central incisor position with a screw-retained cantilevered restoration. Flap design included papillae-sparing incisions. Contour augmentation with guided bone regeneration was performed simultaneously to implant placement to correct the fenestration and for aesthetic purposes. After 3 months of osseointegration, second surgical stage was performed and provisionals were fabricated. Then there was a soft tissue modeling period through the necessary changes to temporary crowns. One month after the placement of the provisionals, we noticed that there was a groove on the papilla because of the crestal incision for the implant placement. Our option to solve that was to perform a plasty of the papilla with a diamond bur. The purpose was to deepithelize the area to promote new healing of the soft tissue. After 6 months, final impression was made and a screw-retained metal-ceramic restoration was fabricated. Discussion: Rehabilitation of two adjacent teeth with implants in the aesthetic zone is always a challenge, particularly in the same quadrant due to its assymetry. According to several authors, the placement of only one implant with two crowns can be advantageous, since it is likely to have more soft tissue height between one implant and one pontic than between two implants, where only 3.4 mm of tissue height is expectable on average,. The type of connection as well as the platform-switched abutment used in this case may also be beneficial since it may preserve more bone at the crestal level and thus contribute to better support of the soft tissue. Conclusion: The described procedure was successful in terms of function and esthetics, returning the patient's confidence in her smile. Keywords: implants, adjacent teeth, cantilever, papilla, esthetics

Introduction: Biodentine™ was developed by Septodont® as a new dental material. Its chemical composition is based on Ca3SiO5, which gives it a good bio-activity compared to MTA™, another well-known endodontic restorative cement. Objectives: To analyse the literature and present the results about the proprieties of Biodentine™, comparatively with MTA™. Materials and Methodology: Examination of the literature obtained conducting searches on PubMed, with the keyword "Biodentine". Criteria for inclusion: case-studies and research articles comparing Biodentine™ with other materials, written in English and published between 2013 and 2016. Further references were obtained by examining the references on the selected literature. A total of 105 articles were analysed. Conclusions: Biodentine™ is an alternative to MTA™ in endodontics, restorative dentistry and odontopediatrics. Long term studies are necessary to verify its longevity and effectiveness. Keywords: Biodentine

Description of the Case Report: 9-year-old male patient, presented at consultation because of excessive mobility in the permanent teeth. His mother wanted to have a second opinion, after he had been diagnosed with absence of the roots of the permanent teeth. The patient had no relevant background. Photographs and a panoramic radiograph were taken as complementary diagnosis exams. After analysing the radiography, the preliminary diagnosis is hypophosphatasia, as a result of the presence of two typical characteristics: enlarged pulp chambers and root defect. The proposted treatment is basically preventive and the prognosis is reserved. Discussion: Regular pediatric dental care from an early stage is recommended. Although there are many reports of hypophosphatasia in the literature, the documentation from a dental approach is scarce. In deciduous, mixed, and permanent dentition, the dental treatment must focus on rigurous dental hygiene and preventive diets in order to minimize the aggravation of the periodontal disease and the prevention of other diseases. Treatment can also include the substitution of exfoliated permanent teeth with, mainly, removable prosthesis. Careful monitoring is necessary to detect the progression of the periodontal disease, which can be indicative of the degree of systemic development. Conclusions: Hypophosphatasia is characterised by defects in dental and bone mineralization. It has genetic etiology, and affects both genders. The clinical manifestations are very variable and the earlier the onset age, the harsher its manifestations. Preventive methods are of extreme importance in these clinical cases. Keywords: Hypophosphatase, alkaline phosphatase, hypophosphatasia

Introduction: Apical extrusion debris (AED), an undesirable consequence of root canal instrumentation can be associated with pain / edema and may delay the periapical healing. The aim of our project was to evaluate and quantify the AED in root canal instrumented with continuous and reciprocating rotary instrumentation systems. Materials and Methods: 80 single root canal teeth without endodontic treatment were randomly divided into 4 groups (n = 20): One Shape®, Protaper NEXT®, Hyflex® EDM and WaveOne® Gold. An Eppendorf tube (ET) was weighed in advance with an analytical scale, and with an inserted tooth, it was mounted on a modified device similar to the method described by Myers & Montgomery. The root canals were instrumented and irrigated with distilled water. The instrumented teeth were removed from the ET and these were filled with distilled water up to 1.5 ml, incubated at 70°C for five days and weighed again, the difference between the initial weight and final was calculated determining the weight of debris. Data was statistically analysed using IBM SPSS Statistics 22, considering α = 0.05. Kruskal-Wallis test and post-hoc adjustment of ρ-value by Dunn-Bonferroni method was carried out. Results: There was AED in all instrumentation techniques. Statistical analysis showed significant differences in AED between the techniques used (α = 0.002). Among the WaveOne® Gold and One Shape®, techniques (α = 0.003), WaveOne® Gold and Protaper NEXT®, (α = 0.023) and WaveOne® Gold and Hyflex® EDM (α = 0.028). Conclusion: One Shape® technique presented lower AED while WaveOne® Gold technique with reciprocating movement is a major risk factor due to greater AED. The results of this study indicated that practitioners should be aware of the debris extrusion with each instrument, which could help with the decision for selection of a particular instrument. Clinical implications: The choice of root canal instrumentation system influences the extrusion of debris. Sponsorship: Micro-Mega, França, COLTÉNE e Dentsply Maillefer, Suíça. Keywords: apical extrusion debris, root canal instrumentation, continuous rotation, reciprocating movement, M-Wire, CM-Wire

Introduction: The purpose of this study was to characterize the fatigue resistance of the recently introduced ProTaper Gold RM system (PTG; Dentsply Tulsa Dental Specialities, Tulsa, OK) and to compare it with fatigue resistance of Protaper ® Universal (PTU; Dentsply/Maillefer, Ballaigues, CH) and Protaper Next TM files (PTN; Dentsply/Maillefer, Ballaigues, CH). Materials and Methods: A mechanical device that simulated a root canal system with a radius of curvature of 4.7 mm and an angle of curvature of 45˚ was used to perform the rotational bending tests. Sizes F2/X2 and F3/X3 of PTG, PTU and PTN instruments constituted 6 experimental groups that were analyzed within a rotational speed of 300 rpm and torque of 4 N.cm. Time to fracture and number of cycles to fracture (NCF) were recorded and statistical analysis was carried out using IBM SPSS software. Results: PTG F2 group showed higher NCF than PTU F2 and PTN X2 groups. Concerning F3/X3 instruments, the same tendency could not be stated: NCF of PTG F3 group was statistically higher than PTU F3, but lower than PTN X3. Conclusions: PTG system has proven to be more fatigue resistant than PTU. However, when PTN fatigue resistance concerns, it depends on the type of instruments and its diameter. During clinical practice, clinicians should be aware of this property in order to make an informed choice. Keywords: ProTaper Gold, ProTaper Universal, ProTaper Next, fatigue resistance, nickel-titanium instruments

Introduction: Nowadays, tooth whitening is the most conservative and more used option to remove the dental pigmentation. Objective: To evaluate the color variations (∆E) occurred in two distinct groups submitted to vitro whitening different techniques, and also to evaluate which technique achieves better clinical effectiveness. Materials and methods: Fifty four bovine teeth extracted (incisors mandibular central), were divided, randomly, into two study groups (N=24, each group). Teeth were pigmented in a coffe, black tea and cola solution. In group 1 dental bleaching was performed with Polanight 16% carbamide peroxide (SDI, Australia). In group 2 we combined Pola Office+ (SDI, Australia), hydrogen peroxide, associated with Polanight 16% carbamide peroxide. The color measurement was made with Vita Easyshade® spectrophotometer at the initial moment, after pigmentation, treatment finalization and follow-up after a week. Results: The ∆E, - after pigmentation and final - were statistically significant in both periods. It was not found statistically significant differences at the treatment finalization of treatment between group 1 and 2, however the group 2 presented a slightly higher ∆E. Conclusion: Both dental whitening treatments proved effective, however when compared, the two techniques didn't present statistically significant differences. Keywords: Dental bleaching, carbamide peroxide, hydrogen peroxide, vital tooth bleaching, home bleaching

Female patient, healthy, smoker, 44 years old, attended the clinic unhappy with the aesthetics of her smile due to the presence of extensive pigmented restorations and an old metal-ceramic crown. A diagnostic wax-up was made to plan and preview the final shape of the teeth. Tooth 22 presented periapical pathology, therefore endodontic treatment was executed. Composite restorations of teeth 11, 12 and 22 were replaced. It was also performed an external bleaching with carbamide peroxide at 10%. In tooth 22 was performed a gingivectomy to level the margin gums with tooth 12. Teeth 11, 12 and 22 were prepared for feldspathic veneers and tooth 21 for a feldspathic jacket. After the final impressions, the provisionals were made with a bis-acril resin. The veneers adhesion was accomplished through a resin cement, using a rubber dam isolation. Ceramic veneers are indicated in the rehabilitation of the second sextant when it is aesthetically compromised. Through a minimally invasive preparation, veneers allow us to change the color and shape of the teeth. Ceramic is a material with excellent optical properties, it has a similar appearance to the natural tooth. It also allows rehabilitation with a maximum preservation of dental structures, due to a high adhesive strength. In addition to these factors, ceramic ensures the longevity of the treatment, making it the ideal material for this rehabilitation. Keywords: oral rehabilitation, aesthetic, feldspathic veneers, feldspathic jacket

A healthy 34 year old male patient came to the surgery, unhappy with the aesthetics of his smile. His main concerns were to improve mastication and correct the aesthetics. After compiling a history, and following complete clinical and radiological examinations, orthodontic treatment was planned as well as fixed prosthodontics in order to replace tooth 11, which the patient had lost due to trauma and the edentulous area was rehabilitated with a Maryland bridge that needed replacement.The treatment consisted in aligning the dental arcades, and reestablishing occlusion, followed by a conservative fixed prosthesis, with the use of an implant to correct the edentulous area. Pink aesthetics, increasingly important these days, were remodelled and corrected during gingivectomy on the 1st, 3rd and 5th sextants. Finally, it was decided to apply veneers to 12 and 21, in order to harmonize the three anterior teeth. Fixed rehabilitation with ceramic veneers and crowns is accepted practice in the scientific community, achieving significant durability since this material has similar mechanical and esthetic properties to the natural tooth.The use of veneers in this case was driven by the desire for a minimally invasive intervention, as opposed to the more extensive dental preparations necessary to the use of crowns.The use of an implant to replace just one tooth was a more comfortable and attractive option for the patient, when compared to the use of an adhesive prosthesis, or a removable partial one, and is also a more conservative choice than the use of a bridge, since it doesn't require intervention on healthy teeth. Therefore, the choice in this clinical case was to preserve as much as possible the existing dental structures, while fulfilling the aesthetic and functional needs of the patient. The multidisciplinary approach to this clinical case proved very effective in meeting the aesthetic and functional needs of the patient, achieving dental and and soft tissue harmony of the anterior sector. The rehabilitation and prosthetic plan perfectly achieved the original requirements. Keywords: Minimally invasive dentistry, dental trauma, veneers, crown, implant, gingivoplasty, orthodontic treatment

Case Description: male, healthy, aged 23, attended the clinic unhappy with the aesthetics of his smile. The patient had large composite resin restorations on the teeth 11, 12, 21 and 22, with excess and bad aesthetics. The teeth 11, 21 and 22 had endodontic treatment without periapical pathology. A diagnostic wax-up was carried out to preview the final form of the restoration. The restorations of endodontic treated teeth were replaced with new restorations. Bleaching was performed with carbamide peroxide at 10%. The teeth 11, 21 and 22 were prepared to feldspathic veneers. After the final impression the provisionals were carried out with bis-acryl resin. Veneers were bonded with heated composite at 55° with rubber dam, and a direct restoration in composite was carried out on the tooth 12. Keywords: direct restorations, indirect restorations, composite resin, feldspathic ceramics, veneers, aesthetic zone

Case Description: Female patient, healthy, 42 years of age, attended the clinic unhappy with the aesthetics of her smile. After corrective anamnesis, clinical and radiographical evaluation and discussing with the patient the various treatment possibilities, and associated costs, the adopted treatment was: Endodontic treatment, internal whitening and direct restoration using compost resin on tooth 12; Endodontic retreatment, gingivectomy and rehabilitation with lithium disilicate ceramic crowns of teeth 11 and 21 and direct restoration of tooth 22. Discussion: The best treatment plan we can propose to a patient is one which meets aesthetical and functional objectives, the patient's expectations and capabilities. It is very important to clearly explain the risks and benefits of each treatment option, especially when the options are not ideal. In this case, we brought together the rehabilitation using resin composites and lithium disilicate ceramic materials and also with the help of various fields of dental medicine. The outcome was aesthetically/functionally satisfactory and met the patient's expectations. It has been scientifically proven that both materials have the same short term aesthetic outcome. Nonetheless, the colour stability and resistance to fracture in the long term are substantially greater for ceramic. Conclusion: By reconciling the various fields of Dental Medicine (namely Endodontics, Periodontology, Oral Rehabilitation, aestetics) and by using different rehabilitation materials (resin composites, and lithium disilicate ceramic), it was possible to achieve a favourable outcome both aesthetically and functionally. Keywords: ceramics, resin composite, gingivectomy, endodontics, disilicate lithium, aesthetics

Clinical Case Description: Female patient, 50 years old, who attended an emergency appointment, at ISCSEM, unhappy with the aesthetics of her smile. According to the clinical history, she had a depression and was under psychiatric treatment. Bite-wings and an orthopantomography were used as additional diagnosis procedures. The objective examination of the patient revealed attrition lesions in the 2nd and 5th sextants. The patient was diagnosed with the presence of a diastema in the antero- superior region. Several treatment solutions have been proposed, but due to financial constraints indicated by the patient, the selected approach was the rehabilitation with direct restorations. A diagnostic wax-up was carried out along with silicone keys to be used as a palatal guide and for the mock-up. The mock-up of bis-acrylic resin was applied to verify the final shape of the restorations. The strategy to be implemented for the restorations was based on the adhesive system Optibond FL (KerrHawe, Scafati, Italy) and the application of the composite Enamel Plus HRI (Micerium, Avegno, Italy) with UD2 and EU2 colors through the composite layering technique. Discussion: There are several treatment options to close a diastema, all with their advantages and limitations. It is possible to choose between orthodontic treatment, rehabilitation with crowns, rehabilitation with ceramic veneers, rehabilitation with resin composed veneers or rehabilitation through direct restorations. From the various options of treatment, the rehabilitation with composite resin directly through the composite layering technique is simple, economic and conservative. Conclusion: The closure of the diastema in anterior teeth, using direct restorations, is considered a viable option for the rehabilitation of the harmony of soft and hard tissues, matching to the aesthetic expectations of the patient. Keywords: diastemas, direct restorations, smile, mock up, resin composite, dental aesthetic

Introduction: Early tooth loss in young patients can provide undesired tooth movement, decreased length of arches, change in the eruption sequence of the permanent teeth, inadequate development of mastication, swallowing, deleterious habits, speech alterations, midline deviation that can possibly lead to facial asymmetries. Guidelines of the American Academy of Odontopediatrics claim that the use of space maintaining appliances is indicated to avoid loss of arch perimeter, maintaining the relative position of the existing teeth, the healthy devellopment of the facial muscles and the normal establishment of the definitive occlusion. Objectives: This study has the aim to demonstrate the clinical case of a young patient with premature loss of deciduous teeth. This way, we opted to use a removable space maintainer (with teeth and a screw). Clinical Case- Diagnosis: Six-year-old child with multiple caries; with associated fistula on teeth 51, 75 and 84; midline deviation; mouth breathing, tongue interposition and child swallowing disorder. Treatment procedures: Extraction teeth 51, 75, 84 e 85; multiple restorations; Inferior removable space maintainer with a vestibular arch and an middle expansion screw. Discussion: Removable appliances are indicated in the absence of multiple teeth, they can be designed with acrylic teeth to replace edentulous spaces and some type of retention system. Results: The mandibular removable appliance is for certain an important technique in maintaining the tooth space, restore physiological mastication and a good phonation. It's a functional appliance with a good patient compliance which was confirmed with a two months of follow-up. Keywords: premature tooth loss, space loss, space maintainer, tooth migration

Description of the case: A 27-year-old female patient presented to the dentist referring muscular pain regarding the masseter and dental sensitivity. Clinically there was tooth wear on the occlusal surface of the inferior molars, as well as the bicuspids. A questionnaire was also employed beforehand. The clinical features and patient history were compatible with nocturnal bruxism. To confirm this diagnosis first was ordered a polisomnography, then bruxchecker ® and finally portable electromyography using Grindcare®. Discussion: Sleeping bruxism is considered the third most common sleeping disorder. In order to characterize this individual case some diagnostic methods were used. All them diagnosed bruxism. The polysomnographic records were useful to establish the sleeping pattern and arousal periods, as well as to confirm the muscular activity associated with bruxism. Bruxchecker® revealed the specific grinding pattern and teeth involved, and finally, Grindcare® commenced the treatment and established the grinding frequency. The clinical observation and questionnaire were imperative in describing this individual bruxism case. All of the methods employed complemented each other. Conclusions: Despite the different diagnosis methods available today, the diagnosis of bruxism remains controverse due to the fact that a stand-alone method for its definite diagnosis is still lacking. The combination of these different methods proved to be effective in this clinical case as each of them hinted out something different and allowed the clinician to understand the situation as a whole. Keywords: bruxism, grindcare, bruxchecker, polysomnography

Systemic scleroderma is a rare connective tissue disease with significant orofacial consequences. Information on oral aspects of pediatric scleroderma is limited in the dental literature and current scientific evidence doesn't provide a differentiated approach to these patients. The proposed protocol was based on reference guidelines for pediatric dentistry and adjusted according to orofacial features observed during clinical evaluation of a child with systemic scleroderma. This project will provide a proper intervention of pediatric dentistry on approach of children with systemic scleroderma, contributing to oral and general health improvement of these special patients. Keywords: Scleroderma, juvenile systemic sclerosis, systemic sclerosis, child, childhood, pediatric dentistry, oral manifestations

Male patient, healthy, aged 23, previous orthodontic treatment, unhappy with the aesthetics of his smile. Following anamnesis and a clinical and radiographic evaluation, multiple caries lesions, teeth showing amelogenesis imperfecta and an antero-superior diastema were diagnosed. Treatment plan involved an at-home dental bleaching, the aesthetic restorative treatment with composite resin of the caries lesions and teeth with amelogenesis imperfecta as well as a ceramic mini-veneer to close the diastema between teeth 12 and 13. Keywords: ceramic, diastema, aesthetics, veneer

Case description: 74 year old female pacient without relevant clinical history arrived with traumatic lesion in the mucosa rim in the 3rd quadrant due to inferior prostetic. Surgical aproach was taken with na excisional biopsy of the lesion under local anestesia. Patient was previously treated with 875mg amoxicilin + 125mg clavulanic ac. and 100mg clonixin. One month after the surgery, was possible to see a lesion relapse therefore it was requested na ultrasound. Throught this examination it was concluded that there were still small lymphadenopathy in the left sub-maxillary space, also reaching the right lobe of the tyroid gland. It was perfomed a neck dissection surgery in the left facial side. Discussion: In all cases of oral cancer, 90% are squamous cell carcinoma (SCC) and 95 % of these patients are over 40 years of age at which the average age is 60. The relationship between denture and the appearance SCC continues to create controversy despite being proposed that maladaptation of the prosthesis and consequent trauma to the mucosa, can increase the risk of SCC. Thus the use of dental prostheses requires a regular and periodic checks. Parafunctional suction habits are also a possible cause hyperplasia of soft tissues, increasing the likelihood of injury thereof. Conclusion: Early diagnosis of lesions in the oral cavity, is based on clinical examination (inspection and palpation) and the benignity or malignancy characteristics should be confirmed using biopsy and pathological examination. The removal of the lesions, according to their dimensions, may be excisional and incisional. Keywords: Carcinoma, prosthesis, injury, gum, tooth

Description of a clinical case: A male farmer, 48 year old patient referred by the PIPCO, with social habits, and a lack of systemic diseases and rehabilitated with a removable bimaxillary prosthesis. After an intraoral examination, the patient shows changes in the jugal mucosa next to the labial commissure, star-shaped, red-white, whitish stretch marks, hard at palpation around the edges, without adenopathies, with dimensions of 1,3x0,7x0,5cm and prosthesis mucositis in the palate. Changes in the right lower lip vermillon with actinic- cheilitis and focal ulceration and crusting are visible. An excisional biopsy of the jucal mucosa bilateral lesions was performed and sun protection was advised. Discussion: The patient shows several risk factors (social habits and an excessive exposure to the sun) These erythroleukoplakialesions clinically detected are potentially premalignant lesions. Serious pathologies can be prevented with early diagnosis and correct treatment. The clinical characteristics recommend a bilateral excisional biopsy. The pieces were sent for an histological examination so that a differential diagnostic with pathologies with similar macroscopic aspects could be carried out (chronic biting lesions, keratoses, leukoplakia, erithroplakia, white sponge nevus, , lichen planus, lupus erythematosus and candidiasis). The eritroleukoplakia lesion shows a histological description of the stratified squamous epithelium with severe reactive aspects, undefined to dysplasia with infiltrated inflammatory polymorphic with no signs of malignancy. This microscopic and macroscopic description is compatible with lichenoid lesion. A lip protection as well as monitoring are recommended if the changes and the crusting/ ulceration will not disappear and thus a squamous cell carcinoma is suspected. Conclusion: The early diagnosis, the correct treatment and the follow up of these potentially malignant lesions in this patient contribute to lip and mucosa jugal tissue normalization. Keywords: Biopsy, oral cancer, lichenoid lesion

This case report discusses the management of a bilateral palatal inclusion canines in a patient with skeletal class III. The treatment plan was divided in 2 phases: Interceptive phase and in the second one the patient put a fixed orthodontic appliance and was also held a surgery for the exposure of the canines and their traction. The correction of the position of this canines entails a greater improvement in the function, aesthetics and general oral health to the patient. Keywords: maxillary canines, inclusion, traction, surgery approach

Male patient, 78 years old, healthy, attended the clinic unhappy with the aesthetics of his smile. After a complete clinical and radiographic examination, there were all the parameters needed to perform a complete implant-supported rehabilitation. Keywords: Total rehabilitation, implantology, immediate loading

Introduction: In the past 40 years, titanium has been considered the "gold standard" in the manufacture of implants. Zirconia ceramic (zirconium dioxide ZrO2) has emerged as an alternative, to the need to improve aesthetics. Studies confirm the advantages of zirconia implants conferring better aesthetics, more biocompatibility, greater resistance to masticatory forces, increased soft tissue tolerance and less potential for bacterial colonization, when compared to titanium implants. Objective: Analyse success and survival rates of zirconia implants in clinical trials. Can zirconia implants be recommended for clinical daily practice? Materials and Methods: Research in Medline/PubMed, COCHRANE CENTRAL and Scopus databases with the following keywords: "zirconia", "zirconium", "implant" and "implants" in different combinations. Results: In the studies that evaluated survival rates (SR), the values were 60-100% up to two years of follow-up, 86-100% between two to four years, and 58.5-97.6% for more than five years. The success rate values for most of the trials9, 15-16, 18-20, 22, 26-27 is between 91.7-100%, being only 66% in two studies10-11 from the same author. Conclusions: Recent trials with better macro y micro design implants achieved rates comparable to titanium. Keywords: Zirconia, dental implants, survival rate, success rate, systematic review

Female patient, 51 years old, healthy, full edentulous for 27 years, when extracted the maxillary anterior teeth and replaced them immediately. Then was rehabilitated with upper and lower removable denture. She came to us in order to perform new removable dentures. During intra-oral examination we observed poor reabsorption in both alveolar ridges and a markedly strangled conformation on anterior region of upper ridge with great palatine-vestibular volume. Although that anatomic deformation and after analyze the aesthetic profile we chose to perform mucous-supported dentures without surgery keeping the upper teeth crimped without lip flap. Although anatomical conditions of the patient appeared to be unfavorable to achieving a mucous-supported prosthesis without pre-prosthetic surgery, we take advantage of the superior alveolar conformation performing a quite satisfactory rehabilitation, either aesthetic and functional. Keywords: Complete denture, facial aesthetics, bony undercut, preprosthetic surgery

Stem cells are unspecialized cells capable of continuous self-renewal and differentiation into a variety of mature cell types when exposed to specific environments and stimulus. In the adult, it is possible to find stem cells from different sources, such as the bone marrow. However, dental stem cells represent a good alternative to other sources since they are easier to obtain than bone marrow stem cells and they keep similar characteristics like their ability to differentiate into various types of specialized cells. Keywords: Stem cells, dental, regenerative endodontics

Case Report: Male patient with 71 years old referred as main complaint that failing to eat properly. He was upper total edentulous and lower partial edentulous, showing severe wear attrition of the remaining teeth (42, 41, 31, 32, 33). The patient had an inadequate upper acrylic denture. We proposed the rehabilitation of the remaining teeth with the adhesion of indirect composite resins and the rehabilitation of the upper arch with a conventional acrylic resin denture and the mandibular rehabilitation with a new flexible acrylic resin denture. Conclusions: With this technique we were able to achieve adequate aesthetic and function in a short period of time. Discussion: Indirect resins, made on dental models, have been more used due to the decrease of polymerization contraction, easy technique with improved anatomy, better polishing, and stronger contact points. There are significant mechanical properties improvements of indirect resins, because of the higher monomer conversion rate. The technique used in this case (silicone key) enable the dentist to present a viable alternative and of easy making, allowing the restoration of function and aesthetic in severe teeth wear cases. Keywords: Esthetic indirect resin, pressed resin, indirect resin composites, full-mouth rehabilitation, attrition

Objective: To evaluate histologically the newly formed tissues following regenerative endodontic procedures (REPs) in dogs using either blood clot or two different formulations of a chitosan hydrogel as scaffolds Methods: Apical periodontitis were induced by inoculating immature teeth (n=96) with oral plaque in Beagle dogs (n=4). Teeth were divided into four test groups according to the treatment protocol: I- MTA apical plug or regenerative procedures using different scaffolds; II- blood clot; III- sodium hialuronate: chitosan scaffold (HA:CS); and IV-pectin: chitosan scaffold (P:CS). All root canals were disinfected with a triple antibiotic paste protocol prior to revascularization. Eleven weeks' post-treatment, the animals were sacrificed and the jaw blocks harvested for histologic processing and morphological and histomorphometric analysis and statistical analysis (Kruskal-Wallis and Mann-Whitney U tests) were performed with a level of significance set at P 0,05. Results: The lumen of the root canal completely filled with MTA with creation of an apical bridge between root canal walls in 83% of the samples in group I. A vital vascularized tissue was found in Groups II, III and IV. For these groups, apical closure happened in 66.7% of the treatments and root growth was detected more often as an increase in thickness (85.6%) than in length (45.6%). The greatest amount of mineralized tissue inside the canal were observed in group II (blood clot), with significant differences compared to group III (P = 0.006), and group IV (P = 0.025). Radiographic evaluation post-treatment revealed that the apical region was remineralized with reestablishment of a periodontal ligament space. Histological evaluation revealed that apical mineralization was composed of of cellular cementum and dentine, surrounded by periodontal ligament, containing epithelial rests of Malassez, exhibiting a similar composition to the walls of any ordinary root apex, including the presence of foramina. Conclusions: The addition of the scaffolds to the blood in regenerative procedures did not improve the formation of new mineralized tissues along the root canal walls and the histologic evidence of the regeneration of a pulp-dentin complex. Despite of the scaffolds used, REPs allowed the continued development of root walls with presence of bone-like tissue, cementum and periodontal ligament often observed into the canal space. In spite of the theoretical possibility of a more effective regeneration with different scaffolds (group 3, 4), our results sustain that better results were found with the induction, formation and stabilization of a blood clot (group 2).REP's should be considered as a potential option for the treatment of immature permanent teeth with irreversible pulpitis or pulp necrosis. Keywords: Immature permanent tooth, tissue regeneration, root canal, tissue engineering, chitosan scaffolds, apical papilla

Introduction: The level of self-perception is an indicator associated with the individual's actual health status. Objective: The aim of this study was to quantify the level of self-perception of removable prosthesis users. Materials and Methods: 30 geriatric patients from Clínica Universitária Egas Moniz with need for removable denture. They were divided into two groups Acrylic Prosthesis (AP), n=16 and Prosthesis in Chrome-Cobalt Alloy (PCCA), n=14. In each group was measured self-perception Before (BD) and 6 months After (AA) denture acquisition. SPSS software was used in descriptive and inferential analysis. Results: Both groups presented a low level of self-perception (μ=29.4GOHAI) BD, and a moderate level of self-perception (μ=31GOHAI) AA. The AP group presented an average GOHAI level of 28.88values BD and 30.31values AA, whilst the PCCA group presented an average level of 30values BD and 31.79values AA. The Spearman correlation test presented a -0.245(sig.0.192) level of correlation between psychosocial and physical dimensions, -0.085(sig.0.654) psychosocial and pain dimensions BD, -0.068(sig.0.721) between psychosocial and physical dimensions and 0.184(sig.0.332) between the psychosocial and pain dimensions AA. Conclusions: The use of PCCA improved the level of self-perception on the elderly, but the use of AP didn't show statistically significant differences. Clinical implications: The existence of clinical indicators and an indicator of self- perception show a tendency that the patient has to enhance his self-perceived oral health, which in turn is a prognostic factor in the establishment-based priorities in processing the needs of our patients. Keywords: Aging, GOHAI, self-perception, oral health, acrylic prosthesis, prosthesis in chrome-cobalt alloy