Quintessence International, 07/2011

High-quality esthetic veneers can be produced in a single treatment session only by means of chairside CAD/CAM technology. With efficient therapy, the duration of the relatively long treatment cycle can be optimized: planning casts and a diagnostic wax-up are steps that simplify therapy decisions, the same as with veneers produced by laboratories. After production of a mock-up and preparation of the teeth, removable composite veneers can be prepared and gradually replaced by ceramic veneers. Modern, three-dimensional presentation by use of the Cerec 3D system facilitates construction of veneers seen in relation to the other teeth. A very helpful aspect is that the mock-ups can be adjusted to patients' needs during the complete production process. After individualization by a dental ceramic technician, there is no recognizable esthetic difference from veneers produced by a laboratory. Keywords: CAD/CAM, chairside technology, veneering

This article illustrates the surgical and prosthetic rehabilitation of an extensive defect in the area of a mandibular lateral incisor following explantation of a dental implant. Bone and soft tissue defects existed after removal of the implant. Guided bone regeneration, a subepithelial connective tissue graft, and gradual pontic contouring were used to attempt correction of the defect. The missing tooth was replaced by a single-retainer, all-ceramic, resin-bonded fixed partial denture. The gingival contours were reestablished, but without complete regeneration of the interdental papillae. This article describes the use of several regenerative techniques in the treatment of dental defects and underscores the difficulty of complete correction of papilla deficiencies. Keywords: all-ceramic resin-bonded fixed partial denture, esthetic zone, explantation implant loss, hard tissue defect, pontic contouring, soft tissue defect

Objective: Radiographic appearance of pulp reactions to partial pulpotomy in young permanent molars with deep caries may determine the efficiency of the procedure. The objective of this study was to determine the value of this procedure by analyzing the pulpal and periapical appearance of permanent molars after long-term follow-up periods. Method and Materials: Based on predetermined radiologic criteria, periapical radiographs of 49 young permanent molars of 31 females and 13 males, aged 6.9 to 17.7 years (mean, 11.4 years) treated with partial pulpotomy were evaluated and compared to their antimeres. Follow-up time ranged from 7 to 154 months (mean, 49 months). Results: Based on clinical and radiographic findings, the success rate was considered 93.9% (46 of 49 teeth). Three teeth had chronic pulpitis with periapical exacerbation. In 14 (30.4%) of the 46 teeth, normal radiographic pulp appearance was found, and in 2 (4.3%), pulpal calcifications were similar to their antimere tooth. Dentinal bridges were observed underneath the partial pulpotomy site in 27 molars (58.7%), while radiopacities in the pulpotomized pulp horns of 5 teeth (10.9%) suggested development of obstructive calcifications. Increased calcifications of the pulp were seen in 13 (28.3%) molars, in comparison with their antimeres. Six of the 46 molars with immature root development completed full apexogenesis. No periapical pathoses, total pulp obliteration, or resorption were observed. Conclusion: The long-term radiologic interpretation of the pulp after partial pulpotomy in young permanent molars supports the clinical impression that it is a warranted treatment in well-chosen cases. Keywords: deep caries, dental radiology, partial pulpotomy, pulp

The aim of the study was to evaluate the impact of smoking on a prolongated chlorhexidine digluconate regimen after scaling and root planing. Forty-two smokers (test group) and 85 nonsmoking patients (control group) with generalized chronic periodontitis were examined for clinical attachment level (CAL), probing depth (PD), bleeding on probing (BoP), and Plaque Index (Pl) at baseline and after 1 and 3 months. During scaling and root planing, a 0.2% chlorhexidine digluconate solution and a 1% chlorhexidine digluconate gel were used. The subjects used a 0.2% chlorhexidine digluconate solution twice daily for 3 months. The Mann-Whitney U and Wilcoxon tests were used for statistical analysis. There were significant improvements of all studied variables after 1 and 3 months in both groups. After 3 months, the mean improvement in the test group was 1.62 mm for CAL, 2.85 mm for PD, and 48% for BoP; in the control group, the values were 2.18 mm for CAL, 2.81 mm for PD, and 47% for BoP. Only the maximum changes of CAL between 1 and 3 months (test group, 0.32 mm vs 0.69 mm in the control group) and PD (test group, 0.47 mm vs 0.76 mm in the control group) were significantly different between the groups (P .05 and P = .05, respectively). The present data appear to suggest that the use of chlorhexidine digluconate twice daily during a period of 3 months following nonsurgical periodontal therapy may result in significant clinical improvements in smokers and nonsmokers. Keywords: chlorhexidine, periodontitis, scaling and root planing, smoking

Objectives: To investigate the formation of oral biofilm on various dental ceramics in vivo. Method and Materials: Five different ceramic materials were included: a veneering glass- ceramic, a lithium disilicate glass-ceramic, a yttrium-stabilized zirconia (Y-TZP), a hot isostatically pressed (HIP) Y-TZP ceramic, and an HIP Y-TZP ceramic with 25% alumina. Test specimens were attached to individually designed acrylic appliances; five volunteers wore these appliances for 24 hours in the maxillary arch. After intraoral exposure, the samples were removed from the appliances and the adhering biofilms vitally stained. Then, the twodimensional surface coating and thickness of the adhering biofilm were determined by confocal laser scanning microscopy. Statistical analysis was performed using one-way ANOVA with the level of significance set at .05. Results: Significant differences (P .001) in the bacterial surface coating and in the thickness of the biofilm were found between the various ceramic materials. The lowest surface coating (19.0%) and biofilm thickness (1.9 µm) were determined on the HIP Y-TZP ceramic; the highest mean values were identified with the lithium disilicate glass-ceramic (46.8%, 12.6 µm). Conclusion: Biofilm formation on various types of dental ceramics differed significantly; in particular, zirconia exhibited low plaque accumulation. In addition to its high strength, low plaque accumulation makes zirconia a promising material for various indications (including implant abutments and telescopic crowns) that previously were met only with metal-based materials. Keywords: bacteria, biofilm, dental ceramics, in vivo, zirconia

Objective: Dentists play an important role in the early diagnosis and treatment of oral lesions. However, treatment based solely on a clinical impression of the diagnosis, without histologic confirmation, can result in serious consequences, particularly when the lesion is precancerous or cancerous. The purpose of this study was to determine the overall accuracy of clinical diagnoses made by dentists as well as to compare the diagnostic ability of general practitioners with members of various dental specialties. Method and Materials: The biopsy reports of 976 specimens submitted to the Department of Oral and Maxillofacial Pathology, Virginia Commonwealth University School of Dentistry, between January 2009 and January 2010 were reviewed. The presumptive clinical diagnosis made by the practitioner and the final histologic diagnosis on each specimen were recorded in addition to whether the submitting dentist was a general practitioner or a specialist. Results: Of the clinical diagnoses made by the submitting dentists, 43% were incorrect. General dentists misdiagnosed 45.9%, oral and maxillofacial surgeons 42.8%, endodontists 42.2%, and periodontists 41.2% of the time. The most commonly missed clinical diagnoses were hyperkeratosis (16%), focal inflammatory fibrous hyperplasia (10%), fibroma (8%), periapical granuloma (7%), and radicular cyst (6%). Cancerous lesions were misdiagnosed 5.6% of the time. Conclusions: The high rates of clinical misdiagnosis by dental practitioners indicate that all excised lesions should to be submitted for histologic diagnosis. Keywords: cancer diagnosis, clinical misdiagnosis, diagnostic accuracy

Objective: To assess the influence of ormocer, nanofilled, nanoceramic, and microhybrid composite restorative systems on the fracture resistance of maxillary premolars with Class II mesio-occlusodistal (MOD) cavities. Method and Materials: Eighty-four sound maxillary human premolars were divided into six groups of 14 teeth each. Teeth in the first group were left intact and tested as unprepared positive controls. Teeth in the remaining five groups were prepared with MOD cavities. Teeth in one of the five groups were unrestored and tested as negative control. The remaining four groups were restored with an ormocer (Admira), a nanofilled composite (Filtek Supreme), a nanoceramic composite (CeramX mono), and a microhybrid composite (Tetric Ceram). All groups were stored in water at 37°C for 24 hours and thermocycled 500 times between 5°C and 55°C. The specimens were loaded occlusally in a universal testing machine using a metal sphere that contacted only the teeth on the cuspal inclines until fracture occurred. The results were analyzed by Kruskal-Wallis and Mann-Whitney U tests. The level of significance was set at .05. Results: The difference between the mean cuspal fracture resistance of the unprepared positive control teeth and those restored with ormocer, nanofill, and microhybrid composite was found to be statistically significant (P .05). No statistically significant difference in cuspal fracture resistance was found between the unprepared positive control teeth and those teeth restored with nanoceramic composite (P > .05). Conclusion: Under compressive load testing, teeth with microhybrid, ormocer, and nanofilled composite restorations had lower cuspal fracture resistance than those with nanoceramic composite restorations. Keywords: fracture resistance, maxillary premolars, nanoceramic composite, nanofilled composite, ormocer

Sialolithiasis of the minor salivary glands, especially in the lower lip, is rare. We report a case of sialolithiasis of the lower lip simulating a mucocele as well as review four additional cases affecting the lower lip and 39 cases affecting the upper lip, together with details of the clinical and histopathologic findings. Keywords: lip, mucocele, sialolithiasis

Objective: Childhood obesity is a looming epidemic affecting western society, caused by a sedentary lifestyle and high-energy diet, and is associated with a severe morbidity. Obesity in adults has been associated with increased incidence and prevalence of periodontal disease. This association is considered to be bidirectional: Not only are obese subjects prone to periodontal disease, but periodontal disease may also exacerbate dyslipidemia. The objective of this study was to review the current literature on the association between obesity and periodontal diseases in children. Methods: Using Medline, Cochrane, and Current Contents Clinical Medicine databases, we searched the literature for articles published in the English language between 1990 and 2009. Key words used were "periodontal disease," "periodontitis," and "tooth loss," linked with "obesity," "BMI," "weight," "overweight," and "children." Results: Only a few relevant studies have been conducted in children of specific age groups. Further studies are needed to support the hypothesis that obesity in children may be associated with increased rates of periodontal disease. Conclusion: Since periodontal disease is a rare finding in children, general practitioners should be aware of the link among obesity, dyslipidemia, and periodontal disease. Keywords: children, metabolic state, obesity, periodontal disease

We report one case of ligneous periodontitis, which is a clinical sign of hypoplasminogenemia. It appears as massive, painless ulcerated gingival enlargements and alveolar bone destruction in the affected area. The course of the disease is progressive and typically ends with early loss of teeth. At present, no efficient treatment option seems to be available. To investigate the cause of the rapid bone destruction in this disease, gingival tissue specimens were taken from one patient and a healthy control patient to compare the function of fibroblastic cells. Our results showed that diseased fibroblasts (1) reorganized collagen lattices more rapidly than normal cells, (2) demonstrated a greater overall production of pro and active matrix metalloproteinase-2 (MMP-2) and increased activation of this protease, and (3) showed a more active phenotype than healthy fibroblastic cells. From these preliminary results, there seems to be increased MMP-2 production and activation, which might be one compensatory (but insufficient) mechanism for the decreased (plasmindependent) pericellular fibrinolysis in plasminogen-deficient patients. Further studies on this subject should evaluate the exact pathomechanism of plasminogen on this enzymatic bone and connective tissue destruction. Keywords: hypoplasminogenemia, ligneous conjunctivitis, ligneous periodontitis, pseudomembranous lesions, treatment options, type I plasminogen deficiency

As the population ages, an increased prevalence of gingival recessions and root surfaces exposed to the oral environment has been reported. This in turn causes an increased risk for caries; it is estimated that the incidence of root caries in those older than 65 years of age is 23.7%. Published data support the use of glass ionomer as a restorative material that seems particularly suitable for restoring root lesions; the material has good esthetic and anticariogenic properties and has gained wide acceptance among practitioners. A minimally invasive approach for restoring interproximal root caries lesions with glass ionomer is described.

Renal osteodystrophy refers to a spectrum of bone diseases caused by pathologic alterations in the metabolism of calcium, phosphate, and bone in the context of end-stage renal disease and secondary hyperparathyroidism. Radiographic alterations affecting the jaw and facial skeleton are common and among the earliest signs of renal bone disease. Renal osteodystrophy also shares clinical, histologic, and radiologic similarities with several benign fibro-osseous conditions affecting the craniofacial region, and its recognition is critical to prevention, choice of therapy, and overall prognosis. The aim of this article is to review the craniofacial manifestations of renal osteodystrophy, describe the work-up of a patient with macrognathia and facial disfigurement caused by renal bone disease, discuss the challenges in arriving at a definitive diagnosis, and highlight an interdisciplinary approach to evaluation and timely diagnosis in overall management. Keywords: end-stage renal disease, renal osteodystrophy, uremic leonthiasis ossea