Quintessence International, 05/2010

The present report describes a minimally invasive technique for transcrestal sinus floor elevation, namely the Smart Lift technique, which is based on the controlled use of drills and osteotomes. The rationale of this technique is to provide predictable vertical bone augmentation into the sinus cavity by (1) using the existing residual bone as a viable graft and (2) limiting the incidence of membrane perforation and postsurgery morbidity. Surgical steps of the procedure are thoroughly illustrated by means of a paradigmatic case. The Smart Lift procedure was compatible with sinus floor elevation and implant stability for up to 1 year following surgery. No complications occurred during or after surgery. On periapical radiographs, a radiopaque area corresponding to the augmented sinus floor was present above the apical portion of the implant. Keywords: maxillary sinus, minimally invasive surgery, sinus lift, transcrestal approach

Patients with hopeless dentition often present difficulties in the management of the transitional phase to the final restoration. This article describes a staged approach to achieve a full-arch, implant-supported, removable prosthesis in patients with a hopeless dentition. The approach described allows the clinician to proceed in a staged manner and facilitate prosthetic steps by keeping fixed references for vertical dimension. This technique includes initial conservative periodontal care and, afterward, extraction of some strategic teeth, while others are temporarily maintained. At this point, the implants are positioned, and during the healing period, the remaining natural abutments are used for occlusal reference and to stabilize the removable provisional prosthesis. After osseointegration of the implants, the residual teeth are extracted and the final prosthesis is delivered. The main advantages of the technique include maintenance of function during treatment, stabilization of the removable provisional (especially in the mandibular arch), prosthetic-guided insertion of implants, and easier retrieval of prosthetic references. The main drawbacks are longer treatment time and the need for two surgical steps. Keywords: hopeless dentition, implant-supported overdentures, removable prosthesis

Studies have discussed the potential issues associated with the placement of implants in unfavorable locations. Today, it is possible to optimize implant placement despite the significant ridge resorption that often occurs after tooth extraction. This objective is achievable because techniques exist to augment resorbed alveolar ridges to prerequisite widths and heights for proper implant position. A group of surgical procedures have evolved that are considered to be the gold standard for achieving alveolar ridge width and height augmentation. This article discusses the purported gold standard procedure of onlay block grafts for ridge augmentation and contrasts those grafts with the equally successful, more time- and cost-effective tenting screw technology, in conjunction with guided bone regeneration, which has less morbidity and involves only one surgical site. Three cases are presented to illustrate the utilization and effectiveness of tenting screw technology. Keywords: alveolar ridge, augmentation, dental implant, guided bone regeneration, tenting screw technology

A 50-year-old white woman was referred to the emergency room of the University of Medicine and Dentistry of New Jersey with a major complaint of right facial pain of 3 months' duration. A comprehensive intraoral and extraoral examination was performed. She reported a limited mandibular opening and the need for a soft diet for approximately 1 month. Her medical history was noncontributory. The examiner, suspecting a lesion because of the lack of response to masseteric injection and the pateint's ongoing report of facial numbness, referred the patient for imaging. A CT scan and MRI revealed a large mass in the right nasopharyngeal submucosa that extended into the nasopharyngeal space. The magnitude of the finding was not anticipated. This case demonstrates several important aspects relative to dental care: Orofacial pain is complex; evaluation of the history of a patient with orofacial pain is quite different from evaluating a patient with dental pain; and more training is required to treat patients with unusual oral and facial pain complaints. Keywords: masseter muscle, nasopharyngeal, orofacial pain, temporomandibular joint

Stafne bone defects are nonprogressive yet nonhealing bone cavities situated near the angle of the mandible. Rare locations include the anterior mandible and the ramus. In most instances, salivary gland tissue can be found in these defects, which are of unclear pathogenesis. The case of a unilateral Stafne bone defect in the anterior mandible is presented. A 46-year-old man presented in an oral-maxillofacial practice with two panoramic radiographs, taken in 2001 and 2008, showing a progressive radiolucent region overlying the apices of the lateral incisor, canine, and first premolar in the left mandible. The patient did not report any symptoms or pain in the region of the radiolucency. The differential diagnosis was odontogenic cyst or neoplastic lesion. Following surgical exploration, histology showed inflamed connective tissue, fatty tissue, striated muscle, bony fragments, and salivary gland tissue but no cystic or neoplastic lesion. Keywords: cyst, histology, radiolucency, Stafne bone defect, surgical intervention

Psoriatic arthritis (PA) is a chronic systemic disease that is difficult to detect. The diagnosis is made on mainly clinical grounds based on the findings of psoriasis and inflammatory arthritis of the joints. Many reports have described the damaging effects of PA on the temporomandibular joints (TMJs), but no study has clearly reported the TMJ as the first articulation to be involved in PA. This article reports a case of PA that was diagnosed several years after TMD onset because no signs besides psoriasis were present. The missed early diagnosis resulted in severe TMJ damage. The TMJ can be the first joint involved in PA. For a correct, early diagnosis of PA, collaboration between dental clinicians and rheumatologists is very important. Keywords: erosion, MRI, psoriatic arthritis, sclerosis, temporomandibular joint

Objective: This longitudinal randomized controlled clinical trial evaluated composite resin inlays for clinical acceptability in single- or multisurface preparations and provides a survey of the results up to 3 years. Method and Materials: Twenty-one dental students placed 75 Artglass (Heraeus Kulzer) and 80 Charisma (Heraeus Kulzer) composite resin inlays in Class 1 and 2 preparations in posterior teeth (89 adults). Clinical evaluation was performed at baseline and up to 3 years by two other dentists using modified USPHS criteria. Results: A total of 89.8% of Artglass and 84.1% of Charisma inlays were assessed as clinically excellent or acceptable with predominating Alfa scores. Up to the 3-year recall, five Artglass and 10 Charisma inlays failed mainly because of postoperative symptoms, bulk fracture, and loss of marginal integrity. No significant differences between composite resin materials could be detected at 3 years for all clinical criteria (P > .05). The comparison of restoration performance with time within both groups yielded a significant increase in marginal discoloration (P .05) and deterioration of marginal and restoration integrity (P .05) for both inlay systems. However, both changes were mainly effects of scoring shifts from Alfa to Bravo. No significant differences (P > .05) were recorded comparing premolars and molars. Small inlays showed significantly better outcome for some of the tested clinical parameters (P .05). Conclusion: Clinical assessment of Artglass and Charisma composite resin inlays exhibited an annual failure rate of 3.4% and 5.3% that is within the range of published data. Indirect composite inlays are a competitive restorative procedure in stress-bearing preparations. Keywords: clinical study, composite resin, inlays, longevity, USPHS criteria

Objective: To assess the possible role of neutrophils in the pathogenesis of recurrent aphthous ulceration (RAU) by evaluating and comparing the phagocytic functions of salivary and peripheral blood neutrophils in patients with recurrent aphthous ulcers and in healthy subjects. Method and Materials: The study comprised 30 RAU and 30 healthy subjects. Neutrophils were separated from the unstimulated saliva and peripheral blood of RAU patients and healthy subjects. Then, the phagocytic activity and ingestion ability were determined using Candida as targets. Results: Salivary and peripheral blood neutrophils in RAU patients showed significant reduction (P .05) in phagocytic activity as compared to controls. The ingestion ability of salivary and blood neutrophils was reduced in RAU patients, but not significantly as compared to controls. The ingestion ability of salivary neutrophils was significantly reduced (P = .019) in comparison to blood neutrophils in RAU patients. There was no significant difference between the phagocytic activities of salivary and blood neutrophils in RAU. Conclusion: Phagocytic functions of salivary and peripheral blood neutrophils were reduced in RAU patients as compared to healthy subjects. The ingestion ability of salivary neutrophils was also decreased with that of peripheral blood neutrophils in RAU patients. All the above findings revealed that RAU is characterized by consistent changes in salivary and peripheral blood neutrophil functions, thus suggesting that the pathophysiology of RAU may be associated with reduction in phagocytic functions of neutrophils. Keywords: ingestion ability, neutrophils, phagocytic activity, recurrent aphthous ulcer

Objectives: Composite resin materials shrink during polymerization regardless of curing unit or polymerization program used. However, different polymerization programs lead to different shrinkage percentages. The aim of this study was to evaluate linear polymerization shrinkage for five composite materials polymerized with curing modes of two LED curing units. Method and Materials: Bluephase C5 (500 mW/cm2, 20 seconds) and Bluephase C8 (high-power mode-800 mW/cm2, 20 seconds; and soft-start mode- 650 mW/cm2 for the first 5 seconds, and 800 mW/cm2 for the next 15 seconds) (both curing units by Vivadent) were used for composite resin photopolymerization. The materials used were two fine-particle hybrid composite resins (Tetric Ceram and Artemis) and a nanohybrid composite (Tetric EvoCeram) of different shades (all by Vivadent). Polymerization shrinkage was recorded during each second of the polymerization process using laser interferometry. The results were analyzed by ANOVA, and Tukey post hoc test was used for finding significance levels. Results: The highest shrinkage values were obtained in the case of composite polymerization using the high polymerization mode of Bluephase C8 curing unit (0.61% for Tetric EvoCeram A1 and A3 and 0.69% for Artemis A2), while the lowest results were observed with the soft-start mode of Bluephase C8 LED (0.48% for Artemis A2, 0.41% for Tetric Ceram A3, and 0.35% for Tetric EvoCeram A3.5) and Bluephase C5 curing unit (0.40% for Tetric Ceram A1 and 0.44% for Tetric EvoCeram A3.5). Artemis A2 showed the greatest overall sample dimension change, regardless of the light-curing source used. The initial expansion was recorded for all composite resins and curing modes during the first 4 to 9 seconds of illumination. Conclusion: Negative consequences of polymerization shrinkage and temperature rise can be diminished by applying a polymerization program with lower initial light intensity, which prolongs the pregel phase of the polymerization process. Keywords: composite resin, curing mode, initial expansion, LED units, polymerization shrinkage

Objective: To verify the effect of scaling and root planing on the antimicrobial activity of intracanal medications on the external root surface of periodontally compromised teeth. Method and Materials: Forty single-rooted extracted teeth were randomly assigned for visible calculus removal or scaling and root planing. Samples were separated into four groups-chlorhexidine, tetracycline hydrochloride, calcium hydroxide, or saline solution- and immersed in semisolid media and seeded with Micrococcus luteus for 24 hours. The zones of inhibition were measured using a profile projector. Results: Calcium hydroxide and saline solution did not show bacterial growth inhibition. Chlorhexidine and tetracycline showed the occurrence of zones of inhibition in 70% and 40% of specimens, respectively. Conclusion: Partial antimicrobial activity on the external root surface was found when chlorhexidine and tetracycline solutions were used as intracanal medications; however, root planing procedures may modify this condition. Keywords: chlorhexidine, endodontics-periodontics, local antimicrobial therapy, periodontitis, scaling and root planing, tetracycline

Objectives: To determine the prevalence of psychiatric disorders in adult patients seeking general dental care because their presence can have a significant impact on how these patients should be managed. Method and Materials: Medical history questionnaires from 442 randomly selected patients who presented for examination at the Virginia Commonwealth University School of Dentistry were reviewed for a positive history of psychiatric conditions, whether they were being treated for their condition, and what medications were prescribed. Results: Twenty percent of the patients had a positive history of a psychiatric disorder. The most common disorder for both sexes was depression. Other disorders included anxiety, bipolar disorder, eating disorder, claustrophobia, attention deficit disorder, seasonal affective disorder, and schizophrenia. More than one disorder was reported by 50% of men and 37% of women, the most common combination being depression and anxiety. Seventy-seven percent of women and 69% of men were under active treatment. Commonly prescribed medications, which can have important adverse effects, included selective serotonin uptake inhibitors, benzodiazepines, lithium, and tricyclic antidepressants. Twenty patients reported taking more than one medication for their disorder. Conclusion: A significant number of dental patients have a psychiatric disorder. Because such disorders can affect the patient's response to dental treatment and require treatment modifications, and the adverse effects of the medications being used can alter the oral environment, clinicians need to be aware of their presence and the proper way to manage these patients. Keywords: adverse effects, general dental care, medical history, prevalence, psychiatric disorders, psychotropic drugs

Objective: Self-assessment of teeth shade was compared with professional assessment. Method and Materials: Patients' anterior teeth shade evaluation was conducted first by the patient (n = 193) and then by the clinician using the Vita shade guide. Results: In 18.7% of participants, self-assessment of teeth shade matched in hue and chroma to the clinician's evaluation. A positive correlation was found between participants' self-assessment of their shade and the clinician's assessment (P = .014; Pearson product moment correlation). Participants assessed their shade darker than the clinician (P .001; chisquare test). Only 3.6% were highly satisfied with the shade of their teeth, and 83.4% were interested in a future bleaching procedure. Tooth shade was more accurately assessed by women (P = .02) and nonsmokers (P = .03; chi-square test). Conclusion: A patient's preference toward a lighter shade should be addressed during treatment planning to match the patient's expectations for esthetics and increase patient satisfaction of treatment outcome. Patients may prefer white and shiny rather than a natural appearance. Keywords: appearance, dental esthetics, self-esteem, shade, tooth color, young adults

Objective: To investigate the influence of colored zirconia frameworks on the overall color match of zirconia- veneered restorations. Method and Materials: Identical natural and colored zirconia frameworks (Cercon Base, Degudent) were layered using a veneer ceramic (IPS e.max Ceram Dentin, Ivoclar Vivadent) applied either directly on the frameworks, over a thin layer of a masking liner (IPS e.max ZirLiner 1), or over a layer of a deep chroma dentin (IPS e.max Deep Dentin) of the required target color, A1. Color parameters were obtained using a spectrophotometer (Spectro Shade Micro, MHT) and were used to calculate color difference value with the preselected required color (A1 tab according to Vita Classical shade guide). Color difference value 2.2 was considered a clinically acceptable color match. Results: Only three combinations of tested variables had an acceptable color match compared with the target color: colored zirconia frameworks with liner material or deep chroma dentin and white zirconia frameworks directly layered with the veneer ceramic (P .001), all tested against a black background. The combination of yellow zirconia with deep chroma dentin over a white background produced a yellowish color shift, while white zirconia frameworks with either liner or deep chroma dentin were brighter and less yellow than the target color (A1). Conclusions: When properly veneered, colored zirconia frameworks could produce clinically acceptable color match and have the capacity to mask a dark background such as a dark tooth or core buildup material. Keywords: color, layering technique, zirconia framework

Objective: Ameloblastomas in Indians have rarely been studied. The present study was undertaken to retrospectively compare the clinical, radiologic, and histopathologic features of 73 cases of ameloblastoma in Indians. Method and Materials: Biopsy records of 73 histologically diagnosed cases of ameloblastoma over an 18-year period were retrieved and analyzed for age, sex, site distribution, clinical presentation, radiologic features, and histopathology. These cases were also evaluated for recurrence. Results: Ameloblastoma accounted for 60.3% of all odontogenic tumors in this study, with a mean age of presentation of 30.2 years. A slight male predilection and predominant occurrence in the mandibular molar-ramus area were noted. Radiologically, ameloblastoma presented as either unilocular or multilocular radiolucency, with a significant age difference noted between unilocular and multilocular lesions. Interestingly, findings such as cortical plate expansion, perforation, and involvement of the temporomandibular joint were more frequent in females. The most common histologic type in contrast to other studies was unicystic ameloblastoma followed by follicular and acanthomatous ameloblastoma. Specific correlations between histologic type and age, sex, site, and radiologic features were also observed. Recurrence was seen in 13.3% of patients, predominantly in males, in the molar-ramus area, and the common histologic type was follicular ameloblastoma followed by unicystic ameloblastoma. Conclusion: The finding of unicystic ameloblastoma being the second most common recurrent variant of ameloblastoma, especially when associated with cyst wall invasion or intramural proliferation, may warrant a more aggressive treatment than traditional enucleation/curettage for this entity to prevent recurrence. Keywords: ameloblastoma, clinicopathologic, histologic, unicystic ameloblastoma