Quintessence International, 03/2010

An altered cast impression technique is routinely used for fabricating distal-extension partial dentures. The advantages of an altered cast impression technique are that it evenly distributes stresses between hard and soft tissues and reduces stresses to the abutment teeth. However, there is some controversy among clinicians as to the technique and requirements of both tooth and tissue management of the distal-extension partial denture. A modified approach of fabricating a distal-extension partial denture is presented using a laboratory-processed functional reline method. The functional reline is performed after the removable partial denture is processed to perfect the fit of the denture base to the residual ridge. This enables the partial denture to be constructed from a cast made from a single impression and results in a prosthesis that is stable and has well-extended borders. Not only is it easy and less technique-sensitive for the operator, but it also results in increased comfort and reduced need for multiple adjustment visits for the patient. Keywords: altered cast, distal extension, partial denture

Supernumerary teeth are a relatively frequent disorder of odontogenesis. They may occur alone or in multiple; be unilateral or bilateral; and appear in the maxilla, mandible, or both. Mesiodens is a supernumerary tooth in the anterior maxilla between the two central incisors. This case report describes the treatment of maxillary central incisors displaced and impacted because of the presence of four mesiodens in a 12-year-old boy. After clinical and radiographic examination, surgical removal of the mesiodens and exposure of the maxillary right central incisor was performed. This resulted in a 14-mm space between the displaced central incisors. Successively, fixed orthodontic treatment was planned with cephalometric analysis. The central incisors were brought to the occlusal plane and aligned, and the space between the incisors was redistributed. Remaining minor spaces between the incisors were closed with composite resin buildup. Keywords: composite resin buildup, displaced, impacted, mesiodens, orthodontic treatment, surgical removal, supernumerary teeth

Advanced atrophy of the partially edentulous maxilla necessitates bone augmentation as a prerequisite for successful implant osseointegration. This case shows that sinus grafting at the left first molar (free-end gap) by means of particulated mineralized solvent-preserved cancellous bone and sealing of the recipient site with a bioabsorbable xenogenic collagenous membrane provides optimum conditions for a staged implant placement. Four months after sinus membrane elevation, a trephine biopsy was recovered from the augmented floor and a microtextured implant placed into the augmented area. The ultrastructural observations testify to the biocompatibility and osteoconductivity of the grafting material used. Keywords: bioabsorbable membrane, delayed placement, grafting, microtextured implant, mineralized allograft, sinus floor elevation, transmission electron microscopy

A 58-year-old patient presented with a dislodged crown and post and core on the maxillary right first premolar. After endodontic retreatment, two tapered glass-fiber posts were adhesively cemented. The core foundation was completed by retrofitting the existing crown with a self-curing composite core material. The intaglio surface was lubricated with petroleum jelly, which allowed for easy removal of the crown. Adequate cement thickness was ensured by the finishing procedures of the core buildup that respected the existing tooth margins. The glass-fiber posts and composite buildup provided adequate stability and retention to the original casting. The technique described in this short clinical report enables clinicians to rebuild a post-and-core foundation using the existing crown without the original die or its replica in a simple and time-saving way. Keywords: adhesion, buildup material, endodontic retreatment, endodontically treated teeth, fiber post, marginal fit

Ameloblastomas are benign aggressive odontogentic tumors that exhibit insidious growth rates with attainment of extensive dimesions. Because ameloblastomas are not usually symptomatic unitl late in their clinical course, few are detected early. This article reports an atypical case of a small, painful ameloblastoma arising between the roots of the mandibular left canine and lateral incisor in a 66-year-old female. The patient underwent an en bloc resection of the mandible, and no recurrence was demonstrated on an 11-month recall examination. Histopathology revealed a "hybrid" ameloblastoma with a pronounced desmoplastic pattern and acanthomatous changes. Practitioners should be vigilant for diminutive radiolucent lesions of the jaws with poorly defined borders. Timely recognition and intervention of ameloblastomas may improve treatment outcomes. Keywords: acanthomatous, ameloblastoma, desmoplastic, diminutive, hybrid lesion, tumor

This case report describes the clinical application of the coronally advanced flap procedure associated with the subepithelial connective tissue pedicle graft in the reconstruction of interdental papilla. This procedure was used in two distinct situations: to reconstruct missing papilla and cover two Miller Class IV gingival recessions between the maxillary right lateral incisor and canine (case 1) and to improve esthetics and restore missing papilla between the maxillary left central and lateral incisors (case 2). In case 1, there was a clinical attachment level gain, complete root coverage (canine), and an increase in papillary height. Case 2 showed similar improvements for the interdental papilla, ie, significant reduction of the black triangle. Subepithelial connective tissue pedicle graft associated with a coronally advanced flap yielded satisfactory esthetics and may be considered a viable approach for the treatment of missing papilla associated or not with recession-type defects. However, further investigation is required. Keywords: connective tissue, dental esthetics, gingival recession, gingival surgery, methods, surgical flaps

Objective: Oral lichen planus (OLP) is a chronic mucocutaneous disease with unknown etiology. Oral lichenoid reactions (OLRs) comprise a family of lesions with different recognized etiologies. OLR lesions have clinical and histopathologic characteristics similar to those of OLP, although their management is different from that for OLP. Discrimination between OLP and OLR has always been a major challenge for both clinicians and pathologists. For this purpose, this study evaluated mast cells in the lamina propria of OLP and OLR lesional tissues. Method and Materials: The study was performed on 23 cases of OLP and 23 cases of OLR categorized based on clinical examination, histopathology evaluation, and history in accordance with WHO definitions of OLP. Mast cells in the reticular layer of the lamina propria for OLP and OLR lesions were evaluated both quantitatively (total number) and qualitatively (degranulation status) using light microscopy. Two staining methods-toluidine blue (histochemistry) and antitryptase (immunohistochemistry)-were used for identification and mapping of the mast cells. Results: No significant difference was observed in the total number of mast cells between the two disease groups (P = .74 toluidine blue, P = .47 antitryptase). A statistically significant difference was noted between the number of degranulated mast cells of OLP and OLR lesions with only toluidine blue stain (P .001 toluidine blue, P = .14 antitryptase). A statistically significant difference in the ratio of degranulated mast cells to the total population was observed between OLP and OLR lesions with both staining methods (P .001 for both methods). Conclusion: The observed difference in the ratio of degranulated to total mast cell population in the reticular zone of the lamina propria may be a useful criterion for histopathologic distinction between OLP and OLR. This may also explain the different therapeutic approaches toward these two lesions. Keywords: differentiating, histochemistry, immunohistochemistry, mast cell, oral lichenoid reaction, oral lichen planus

Ample studies have reported on the association between periodontal diseases, a persistent inflammatory process, and other chronic ailments such as cardiovascular diseases, diabetes mellitus, Alzheimer disease, and cancer. Other conditions such as low birth weight and premature delivery due to chorioamnionitis are also known to be linked to poor periodontal health. Although much epidemiologic data support these associations, a cause-and-effect relationship has not been established. The receptor for advanced glycation end products (RAGE) is a multiligand receptor expressed on various cell membranes, including immune, endothelial, and epithelial, and cells of the central nervous system. This receptor, which is frequently associated with proinflammatory responses, has been shown to be activated by various ligands such as high mobility group box-1 (HMGB1/amphoterin), amyloid fibrils, transthyrein, Mac-1 (Integrin Mac-1), as well as advanced glycation end products (AGEs). Recent studies indicate that signaling through RAGE has been implicated as an underlying condition in diverse pathologies including periodontal disease, cardiovascular diseases, diabetes mellitus, Alzheimer disease, cancer, and neurologic conditions. Review of the literature supports the hypothesis that activation of RAGE by ligands in a variety of cell types and tissues may play a role in oral systemic associations. In addition, the ligand cell source and timing of RAGE stimulation may determine the disease produced by this axis. Understanding the distribution and functions of RAGE and its ligands would enhance clinicians' knowledge on pathogenesis of the oral-systemic connection. Keywords: cardiovascular disease, diabetes, periodontal disease, RAGE

Objective: To investigate the relationship of coronary heart disease (CHD)-associated factors- C-reactive protein (CRP) and lipid profiles-with periodontitis in an ethnic Han population. Method and Materials: Forty healthy individuals as control, 40 patients with chronic periodontitis (CP), 28 patients with CHD, and 47 patients with both CP and CHD were included in the study. Serum CRP levels, lipid profile concentrations, and three periodontal clinical parameters (probing depth, clinical attachment level, and bleeding on probing) were measured and analyzed. The chi-square test, Student-Newman-Keuls test, analysis of covariance, and a logistic regression analysis were used in this study. Results: The mean CRP level of patients with CP alone was 2.4 ± 1.5 mg/L. There were significant differences in mean serum CRP levels among groups after confounders were adjusted, with CP+CHD patients having the highest level (7.3 ± 5.7 mg/L) and the controls the lowest (1.0 ± 0.6 mg/L) (P .001). Mean HDL cholesterol level of CP patients (1.1 ± 0.7 mmol/L) was significantly lower than that of controls (1.4 ± 0.6 mmol/L) (P .05), although it was significantly higher than that of the other two groups with CHD (0.8 ± 0.5 mmol/L and 0.7 ± 0.4 mmol/L) (P .001). Significant correlations of CRP and HDL cholesterol with the three clinical periodontal parameters were apparent (P .05). CRP and HDL cholesterol were found to be significantly associated with an increased frequency of CHD in this regression model (OR = 3.7 and OR = 1.9, respectively, P .05). Conclusions: In an ethnic Han population with a low normal range of serum CRP levels, chronic periodontitis is associated with increased CRP levels and decreased HDL cholesterol concentrations, which suggests that there may be some relationship between periodontal inflammation and CHD. Keywords: chronic periodontitis, coronary heart disease, C-reactive protein, high-density lipoprotein cholesterol, inflammation, lipid profiles

Objective: Mechanical instrumentation is fundamental to periodontal treatment. However, independent of the instrument used in scaling, an immediate attachment loss occurs at the bottom of the periodontal pocket. This study aimed to determine the influence of tip diameter on attachment loss and the influence of attachment loss on the periodontal response to nonsurgical treatment. Method and Materials: Fifteen patients presenting periodontal pockets with a probing depth of 3.5 mm or more in bilateral teeth were divided into two groups: test group-instrumented with a thin tip, and control group-instrumented with a traditional tip. Probing depth, relative gingival position, and relative attachment level were evaluated immediately before and after and at 1 and 3 months after treatment using an electronic computerized probe. The data were analyzed using ANOVA and Tukey tests (P = .05). Results: Both groups presented attachment loss immediately after instrumentation; however, the thin tip resulted in statistically higher immediate clinical attachment loss than the traditional tip (0.85 and 0.15 mm, respectively; P .0001). However, both groups showed a similar healing after the ultrasonic therapy, at all parameters evaluated (P > .05). Conclusion: In spite of the higher immediate clinical attachment loss inflicted by thin ultrasonic tips during instrumentation, this did not affect the clinical response to the nonsurgical treatment. Keywords: adverse effects, dental scaling, periodontitis, randomized clinical trial, thin tips, ultrasonic device

Objectives: The purpose of this in vitro study was to quantify the alterations in human root dentin permeability after exposure to dietary acids and to evaluate the effect of toothbrushing after acid application. Method and Materials: Extracted human third molars had their crowns sectioned above the CEJ, pulp tissue removed, and cervical root dentin exposed using a high-speed bur (approximately 1 mm in depth of substance loss). From each root fragment, one specimen was prepared. A total of 25 specimens were used and distributed randomly into five groups. The specimens were attached to a hydraulic pressure apparatus to evaluate the alterations of root dentin permeability after exposure to different acids. Dentin permeability was measured after the following sequential steps: (1) treatment with EDTA for 3 minutes to obtain the maximum permeability; (2) root planing to create a smear layer; (3) exposure to different acidic substances for 5 minutes (vinegar, cola drink, lemon juice, white wine, and orange juice); and (4) brushing for 3 minutes. Results: All acidic substances increased dentin permeability after root planing. Lemon juice produced higher values for permeability when compared to the other substances (P = .009); moreover, orange juice showed similar results (P .02) except when compared to vinegar (P = .12). Brushing right after acid exposure significantly reduced dentin permeability except in the vinegar group (P = .07). Conclusion: Under the experimental conditions, dietary acids increased root dentin permeability, and immediate brushing reduced permeability levels. Keywords: acids, dentin hypersensitivity, dentin permeability, prevention, toothbrushing, treatment

Objective: Salivary gland impairment is a major problem that can result in hyposalivation and a decrease in quality of life. Causes for mouth dryness can be grossly classified into three major groups: iatrogenic, immunogenic, and metabolic. At present, insufficient therapies exist to ease morbidity in this growing number of affected individuals. A need for new products to relieve oral dryness is mandatory. The aim of this study was to evaluate a mucoadhesive lipid-based bioerodable tablet as a novel device to decrease signs and symptoms associated with mouth dryness. Method and Materials: Twenty xerostomic patients were divided into two groups. In group 1, the mucoadhesive tablet was applied to the hard palate, while in group 2, Biotène mouthwash was applied and served as a control. Sialometry measurements, as well as a questionnaire assessing mouth dryness, were obtained before and after treatment. Results: Application of the mucoadhesive tablets resulted in a significant reduction in the sensation of the mouth dryness (P = .016) compared to Biotène. Moreover, a 1.5-fold increase in unstimulated whole saliva flow was obtained after 30 minutes in the treatment group. Conclusion: A lipidbased mucoadhesive tablet has a beneficial role in reducing the sensation of dryness in patients with xerostomia. Keywords: Biotène mouthwash, hyposalivation, mouth dryness, mucoadhesive tablet, saliva, salivary glands, xerostomia

Objective: To determine the sulcus penetration ability of hydrophilic and hydrophobic polyvinyl siloxane (PVS) impression materials by impression technique, temperature, and sulcus width. Method and Materials: Hydrophilic Flexitime (FLE; Heraeus Kulzer) and its hydrophobic counterpart (EXP) without surfactant were investigated, using light (L), monophase (M), and heavy (H) consistencies. A truncated steel cone surrounded by a 2-mm-deep and 50-, 100-, or 200-µm-wide sulcus, simulating the gingival tissue with agar, served as the test model. Impressions were made with single-mix (L or M) and doublemix (LM or LH) techniques at 23°C and 37°C, respectively. The reproduced sulcus heights were measured with a 3D laser scanner. Data were analyzed by ANOVA and Tukey HSD (P .05). Results: Irrespective of sulcus widths and temperature FLE-L penetrated deepest (> 1.9 mm); FLE-M, -LM, and -LH reproductions were shorter with narrow sulci. Reproductions of 50- and 100-µm sulci with EXP-L were shallower than with FLE-L. The shortest reproduction was, however, greater than 1.6 mm. Conclusions: In spite of some significant differences found in sulcus-reproducing ability with hydrophilic and hydrophobic impression materials applied at different impression-making temperatures and with different techniques, the practical relevance is limited. Keywords: consistency, elastomeric impression materials, hydrophilicity, impression temperature, polyvinyl siloxane, sulcus reproduction

Lipid proteinosis, also known as Urbach-Wiethe disease, is a rare autosomal recessive disorder. It presents in early childhood with hoarseness of voice, skin infiltration and thickening, beaded papules on the eyelid margin, and facial acneform scars. Oral findings such as woody tongue and papules on the oral mucosa are common findings. To the authors' knowledge, only about 250 cases have been reported to date. The occurrence of this disease in this part of the world is rare. Keywords: hoarseness, hyaline material, lipid proteinosis, macroglossia, moniliform blepharosis, PAS positive

Objective: To quantify the relative risk of multiple occlusal variables for muscular disorders of the stomatognathic system. Method and Materials: Thirteen occlusal features were clinically assessed by the same three operators: partial unilateral posterior reverse articulation, anterior open occlusal relationship, vertical anterior overlap (normal value 4 mm), complete unilateral posterior reverse articulation, anterior overjet (normal value 5 mm), incisor midline discrepancy (normal value 2 mm), Angle Class I canine and molar relationship; plus dynamic occlusion features such as length and symmetry of retruded contact position-intercanine position (RCP/ICP) slides (normal value 2 mm), occlusal guidance patterns, and mediotrusive and laterotrusive interferences. The sample consisted of 156 women with only muscular disorders according to the Group I Research Diagnostic Criteria for temporomandibular disorders and 82 healthy women (control group). A stepwise multiple logistic regression model was used to identify the significant correlation between occlusal features and disease. Results: The odds ratio for myofascial pain was 2.6 for absence of canine guidance, 2.0 for laterotrusive interference, 2.3 for mediotrusive interference, and 1.9 for reverse articulation. Other occlusal variables did not reveal statistical significance. The percentage of the total log likelihood for myofascial pain explained by the significant occlusal factors was acceptable with a Nagelkerke R2 = 0.2. The final model including the significative occlusal features revealed an optimal discriminant capacity to predict patients with myofascial pain with a sensitivity of 62.2%, or healthy subjects with a specificity of 93.6%, and an accuracy of 82.8%. Conclusions: Few occlusal features show a significative predictive value for myofascial pain. Keywords: dental occlusion, muscular oral disorder, myofascial pain, stepwise multiple regression, temporomandibular disorders, temporomandibular joint