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Original article Biomimetic hydroxyapatite used in the treatment of periodontal intrabony pockets: clinical and radiological analysis Michele Mario Figliuzzi, MD, DDS, PhD1 Conclusions. Within the limitations of this study, Amerigo Giudice, MD, DDS, PhD1 the absence of anatomical variables, except the Settimia Pileggi, MD1 morphology of the bone defect, emphasizes the Francesco Scordamaglia, MD1 importance of the proper surgical approach and Massimo Marrelli, MD, DDS2 the graft material used. Marco Tatullo, MD, DDS, PhD2# Leonzio Fortunato, MD, DDS, PhD1# Key words: biomimetic, hydroxyapatite, intrabony pockets, clinical, radiological. 1 Department of Periodontics and Oral Sciences, University “Magna Graecia” Catanzaro, Italy Introduction 2 Maxillofacial Unit, Calabrodental Clinic, Crotone, Italy Bone substitutes represent one of the most widely used options for the regeneration of bone defects de- # These Authors contributed equally to this veloped after a severe periodontal disease. article. According to Ripamonti (1), correct bone regenera- tion is mainly based on 4 factors: Corresponding author: • osseo-inductive abilities Michele Mario Figliuzzi • scaffold able to support bone regeneration Department of Periodontics and Oral Sciences, • mesenchymal stem cells able to be simulated by University “Magna Graecia” these signals and able to differentiate towards the Via T. Campanella 115 osteoblast phenotype 88100 Catanzaro, Italy • appropriate timing of growth and proper environ- E-mail: figliuzzi@unicz.it ment. Grafting materials are commonly classified, based on the potential osteogenic activity, into: osteogenic, osteoinductive and osteoconductive Summary materials (2). Autogenous bone is the only graft material showing os- Aim. Hydroxyapatite (PA) has a chemical compo- teogenic, osteoinductive and osteoconductive abilities. sition and physical structure very similar to natur- However, the limited amount of bone obtainable from al bone and therefore it has been considered to an intra-oral donor site, as well as the morbidity follow- be the ideal biomaterial able to ensure a bio- ing surgery of the donor site and the fast resorption of mimetic scaffold to use in bone tissue engineer- the autogenous bone graft represents some of the most ing. The aim of this study is to clinically test hy- important limitations of this surgical procedure (3). droxyapatite used as osteoconductive biomaterial On the other hand, according to Berglundh & Lindhe in the treatment of periodontal bone defects. (4), heterologous grafting materials possess only os- Clinical and radiological evaluations were conduct- teoconductive properties. Among these materials, the ed at 6, 12 and 18 months after the surgery. bovine bone matrix was the most investigated in peri- Materials and methods. Forty patients with 2- and 3- odontal-related literature. This class of grafting mater- wall intrabony pockets were enrolled in this study. ial showed a long resorption time, since bovine bone PPD, CAL, radiographic depth (RD) and angular de- matrix particles were found even after more than 9 fects were preoperatively measured. After surgery, months (5). patients were re-evaluated every 6 months for 18 Homologous bone graft holds intermediate features: months. Statistical analyses were also performed to studies on DBDFA reported that the freeze-drying investigate any differences between preoperative process causes demineralization of the mineralized and postoperative measurements. component, so freeing the BMPs able to regulate Results. Paired t-test samples conducted on the MSCs differentiation towards osteoblast phenotype (6). data obtained at baseline and 18 months after, Scientific progress has developed new synthetic bio- showed significant (p<0.01) differences in each materials. Studies on grafting materials based on hy- measurement performed. The role of preoperative droxyapatite showed controversial outcomes: some RD was demonstrated to be a significant key fac- Authors (7) demonstrated that the hydroxyapatite tor (p<0.01). A relevant correlation between pre- grafted in a bone defect induces new bone formation, operative PPD and CAL gain was also found. without fibrotic tissue formation. 16 Annali di Stomatologia 2016;VII (1-2): 16-23 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Biomimetic hydroxyapatite used in the treatment of periodontal intrabony pockets: clinical and radiological analysis On the contrary, other studies (8) demonstrated that hydroxyapatite works as an inert filling material, with no evidence of osteogenesis activity. According to literature, the geometry of the grafting material could represent a differentiating key-factor able to influence the clinical outcomes. In fact, sever- al studies demonstrated that the surface geometry is a critical factor for cell adhesion and differentiation (9, 10). In the light of these chemical and physical features, biomaterials with a surface geometry similar to hu- man bone represent the last generation of synthetic devices. These materials are supposed to produce molecular signalling able to modify the environment, so to facilitate a physiologic bone regeneration (11). Figure 1. Preoperative probing. Additionally, their stoichiometric instability potentially allows a fast and complete resorption (12). Aim of this study was to clinically and radiographically evaluated and in all the reported cases the periodon- evaluate the regenerative properties of synthetic hy- tal surgery was indicated to have a probing pocket droxyapatite in the surgical treatment of periodontal depth (PPD) reduction, clinical attachment level intrabony defects. (CAL) gain and defect filling. All patients were in- formed about the procedures and a signed informed consent form was obtained. Materials and methods This study was carried out with 40 patients affected Clinical data by periodontal disease: the main inclusion criterion was that patients presented at least one periodontal The clinical data were evaluated, by means of a cali- intrabony defect. Patients were enrolled at the “Poli- brated periodontal probe (Click-Probe®, Kerr, Bioggio, clinico Universitario Mater Domini”, in the Department Switzerland), at the beginning of the study (baseline) of Dental Diseases of the University “Magna Grecia” and 6, 12 and 18 months after the surgery (Fig. 1). of Catanzaro. This study was approved by the Uni- In this study we evaluated the probing pocket depth versity Ethical Committee (n.997 of 17/Septem- (PPD), measured from the free gingival margin to the ber/2010). bottom of the pocket together with the Gingival Re- The research was performed following the principles cession index (REC), measured from the Cement- of the Declaration of Helsinki on experimentation in- Enamel Junction (CEJ) to the free gingival margin, volving human subjects. and the clinical Attached Level (CAL), which is the sum of PPD+REC. Inclusion criteria Surgical Procedure From January 2008 to July 2009, 40 patients affected Antibiotic therapy (Amoxicillin and Clavulanic Acid 2g by at least one intrabony defect were selected con- a day for 6 days, starting the day before the surgery) secutively. Defects showed the following characteris- and antiseptic therapy with Chlorhexidine 0.2% rinses tics: real 2- or 3-walls defects (radiographic intrabony component > 4mm), probing pocket depth (PPD) > 7mm, angular defect <30°. Inclusion criteria were: 1. age >18 2. good oral hygiene 3. non smokers 4. no systemic disease 5. no previous periodontal surgery 6. no chronic assumption of NSAIDs 7. no allergy related to the used materials 8. no use of drugs such as nifepidine, steroids, al- lantoin, estrogens, cyclosporine, bisphosphonates 9. no pregnancy during the whole period of the study. The selected patients underwent a non-surgical peri- odontal treatment. After one month, patients were re- Figure 2. X-ray of the intrabony defects. Annali di Stomatologia 2016;VII (1-2): 16-23 17 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  M. M. Figliuzzi et al. for 8 days were administered to patients. Before surgery, an X-ray was performed with the “parallel cone” technique (Fig. 2). After the local anesthesia (Mepivacain plus Adrenalin 1:100.000, Pierrel Italia), according to Cortellini et al. (13) an intrasulcular inci- sion, was made with a blade (Beaver 64, Becton, Dickinson & Co, USA) between the mesial and distal tooth. The flap was raised at a split thickness. Granu- lation tissue was removed with ultrasonic tools and curettes. Defect morphology (2- or 3- walls) was char- acterised after flap elevation and the surgical de- bridement (Fig. 3). Once the defect depth was measured, a topical thera- py on the root surface was performed with tetracy- cline 0.5%. In addition, a biomaterial made by hydrox- Figure 5. Flap sutured and coronally repositioned. yapatite was customised to this bone defect (Engi- pore®, Finceramica, Faenza, Italy) (Fig. 4). We fill the bone defect with the biomaterial to be investigated, no membrane was used to cover this graft, while the flap was coronally repositioned (Poliglycolic Acid, di- ameter 4.0, Distrex Spa Italia) (Fig. 5). In all the re- ported cases, a periodontal dressing was placed to preserve the flap. After 8 days, periodontal dressing and sutures were removed and patients were careful- ly visited in order to evaluate the healing process. Clinical and radiographic controls were performed 6, 12 and 18 months after surgery by an independent trained examiner (Figs. 6-9). Figure 6. Clinical control at 6 months from baseline. Radiographic analysis Standard X-ray analyses were performed by using a custom-made resin bite with the “parallel cone” tech- nique, at the baseline and 6, 12 and 18 months after surgical therapy. The radiographic depth of the intra- bony defect (RD) was evaluated as a vertical dimen- sion between the projection of the coronal bone crest onto the root surface and the most apical bone level where the periodontal ligament was considered to have a normal width. A computerised measuring technique was applied to digital periapical radiographs. The evaluation of the Figure 3. Assessment of defect after flap elevation and de- bridement. Figure 4. Defect filled with the biomaterial. Figure 7. Intraoral X-rays at 18 months from baseline. 18 Annali di Stomatologia 2016;VII (1-2): 16-23 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Biomimetic hydroxyapatite used in the treatment of periodontal intrabony pockets: clinical and radiological analysis significant differences between RD, PPD, REC and CAL values before surgery and the same variables 18 months after surgery. A general linear model was achieved in order to eval- uate the role of variables preoperative RD, angular and number of bone walls on the realisation of the dependent variable (Bone Gain, calculated as RD at 18-month follow-up- preoperative RD). In particular, we measured direct and indirect effects between the variables included in the model. Pearson’s correlation coefficient was calculated to determine the relation- ship between CAL Gain (calculated as CAL at 18- month follow-up - preoperative CAL) and PPD values. Figure 8. Clinical control at 18 months from baseline. Results Forty patients were observed (24 females, 16 males), aged from 18 to 65 years old (mean 42.2 ± 4.97 years old). Intraoperative evaluations assessed that 17 cases showed 2-wall defects and 23 cases showed 3-wall defects. No patient reported intra-operative or post-operative pain. No patient dropped out during the study. Clinical evaluation As reported in Table 1, clinical results at 18 months showed a complete filling of the defect, with a mean PPD of 3 mm, and a mean CAL of 3.3 mm. Paired sample t-tests carried out on PPD, REC and Figure 9. Control probing at 18 months from baseline. CAL before surgery and after 18 months showed strongly (p<0.01) significant differences for each measurements performed between pre- and post (18 defect sizes were assessed in mm and performed us- months) operative steps. ing an image analysis software with RVG equipment The Pearson coefficient shows a relevant correlation (CDR Dicom 4.5, Schick Technologies, Long Island (0.797) between preoperative PPD and CAL gain. City, NY). Radiographic evaluation Statistical analysis The radiographic evaluation was performed by ana- Paired sample t-test was carried out to evaluate any lysing both the radio-opacity on digital periapical radi- Table 1. Clinical and radiographic mean values (mm values) at the time of surgery, 6, 12 and 18 months from baseline. Pre-operative 6-months follow-up 12-months follow-up 18-months follow-up PPD 10.52 4.57 5.30 2.98 SD: 1.36 SD: 0.65 SD: 0.67 SD: 0.50 CAL 11.77 4.84 5.59 3.32 SD: 1.37 SD: 0.65 SD: 067 SD: 0.54 REC 1.26 0.288 0.34 0.35 SD: 0.75 SD: 0.44 SD: 0.43 SD: 0.49 Rx Depth 8.95 2.41 2.35 1.10 SD: 1.46 SD: 0.60 SD: 0.44 SD: 1.02 Annali di Stomatologia 2016;VII (1-2): 16-23 19 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  M. M. Figliuzzi et al. ographs and the defect depth in mm measured from of synthetic materials, mostly hydroxyapatites, is the bone crest to the bottom of the defect, during the growing every day because of their mechanical prop- surgery and after 6, 12 and 18 months. erties very similar to human bone characteristics. So At baseline, the angular defect was 23.05° on aver- these “Miming bone materials” were studied for their age (SD: 1.64). At the following follow-ups, these da- ability to trigger the Guided Tissues Regeneration ta resulted in 0. In fact, after 6 months, the biomateri- (GTR) mechanisms (15-17). al showed a radio-opacity very similar to the sur- The present study was aimed to evaluate the capabil- rounding bone. At 12 months, the radio-opacity was ity of new bio-mimetic hydroxyapatite biomaterial to even more similar to surrounding bone, while at 18 treat the complex periodontal intrabony defects. Hy- months it was indistinguishable from the native bone droxyapatite (PA) has a composition and structure tissue and was well integrated. On the pre-surgery very similar to natural bone tissue and therefore it digital periapical radiographs, the depth of the defect, has been considered to be the ideal biomaterial to evaluated from the bone crest to the bottom of the use in bone tissue engineering, also in the light of its defect, was on average 8.9 mm. This value de- osteoconductivity and a likely osteoinductivity. creased to an average of 2.4 mm, 2.3 mm and 1.1 PA has already been proven to show good biocom- mm. On the digital periapical radiographs performed patibility with many human cells and tissues, probably 6, 12 and 18 months after the surgery, there were thanks to its similarity to collagen (18). several (p<0.01) significant differences shown. Nano-structured hydroxyapatite presents chemical Our linear model was built to determine how the vari- and morphologic properties similar to natural bone. ables preoperative RD, angular and number of walls PA porosity was demonstrated to reach 90% of the were crucial in contributing to the achievement of entire volume, with macro-pores ranging between bone gain, and it showed interesting results (R 200 and 500 μm, and pores of interconnection rang- Squared: 0.84). The single effect of preoperative RD ing between 80 and 200 μm. Additionally, its Ca/P was strongly significant (p<0.01), while the other sin- (Calcium/Phosphate) ratio is almost to the same as gle effects and all the cumulative effects played no the natural bone Ca/P ratio. These features allow the statistically significant role (Tab. 2). material to present a geometric configuration similar to natural bone and, according to Ripamonti et al. (12), allow this material to adsorb the bioactive pro- Discussion teins and the grow factors concentrated in the clot. It allows the progressive releasing of these factors, Bone regeneration mechanisms depend on mechani- able to induce migration, adhesion and proliferation cal factors and physical factors such as humidity, of cells inside the pore network and to promote a mineral content, density, porosity, collagen fiber ori- faster angiogenesis and a more effective osteo-gene- entation and interfacial bonding between constituents sis inside these pores (19-21). Theoretical data was (14). confirmed by clinical outcome (22). In fact, according In the field of periodontal tissue regeneration, the use to several studies (23-26), new generation hydroxya- Table 2. Analysis of variance, tests of between-subjects effects - dependent variable: bone gain. Source Type III Sum Df Mean F Sig. of Squares Square Corrected Model 299.306 29 4.338 2.281 0.007 Intercept 2635.376 1 2635.376 1386.027 0.000 Rx depth preop 136.729 12 11.394 5.992 0.000 Angle preop 4.745 11 0.431 0.227 0.994 Number of walls preop 1.692 1 1.692 0.890 0.353 Rx depth preop * Angle preop 9.649 23 0.420 0.221 1.000 Rx depth preop * Number of walls preop 2.276 6 0.379 0.199 0.974 Angle preop * Number of walls preop 4.548 5 0.910 0.478 0.789 Rx depth preop * Angle preop * Number of walls preop 3.278 5 0.656 0.345 0.881 Error 57.042 10 1.901389 Total 6510.750 40 Corrected Total 356.348 39 R Squared = 0.840 (Adjusted R Squared = 0.472) Df: degrees of freedom F: statistical result of F Test 20 Annali di Stomatologia 2016;VII (1-2): 16-23 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Biomimetic hydroxyapatite used in the treatment of periodontal intrabony pockets: clinical and radiological analysis patites demonstrated high osteo-conductive proper- membranes alone was reported (23). ties when used in sinus-lift procedure and in vertical However, the lack of a control group suggests the ridge-augmentation of atrophic posterior mandible need to perform further clinical trials. (27). Moreover, the osseointegration period was con- In our clinical study no statistical differences regard- firmed to range between 9 and 18 months. On the ing the probing depth reduction values, the clinical at- other hand, bovine bone matrix showed, in the same tachment level (CAL) gain and the defect fill were ob- conditions, a longer resorption time, even with contro- served, both in contained (3 wall) and non-contained versial histomorphometrical outcomes (28). (2 wall) periodontal defects. Even if such clinical out- At the end of this study, the reported outcomes comes are not investigated by histology assay, it can showed a strong bone regeneration, with a bone re- be argued that the periodontal defects can be suc- generation mean value of 7.85±1.9 mm. These data cessfully regenerated only by means of the tested report a bone regeneration slightly higher than the biomaterial without any use of membrane. outcome reported by Trombelli et al. (6) which com- Statistical analyses found no statistically differences pared different grafting materials, and the outcome in tree-wall intrabony pockets compared to two-wall reported by Sculean et al. (28) which used bovine defects. These data are in agreement with Cortellini & bone matrix with or without membrane. It might be Tonetti (29), which described the same healing pat- explained because of the bio-mimetic properties of tern in three- and two-wall intrabony pockets. the hydroxyapatites associated to the surgical tech- Furthermore, after having analyzed the results, we nique used and to proper soft tissue management. found that angular defects seemed not to influence Split thickness flap used has ensured an adequate the final outcomes of the study; we have to consider, blood supply to the soft tissues during the surgical however, that the inclusion criteria required a preop- treatment and the possibility to replace the gingival erative angular defect <30°. flap more coronally. On the other hand, the length of the defect appeared The surgical technique used exploited the reparative to be another key factor: in fact, the better results and regenerative properties of underlying bone tis- were demonstrated in the deeper defects. sue, given that periosteum is rich in totipotential sta- Results of the reported study seem to disagree with minal cells. Moreover, this flap technique allowed for Needleman et al. (34), which stated that a better complete flap stability, which is a key condition to ob- healing can be obtained in the three-wall defects. tain good healing of the tissues (29). At the end of our study, the marginal soft tissue level Trombelli et al. (6) and Cortellini & Tonetti (29), ac- was found to be healed more coronally than we ex- cording to a Literature systematic review, stressed pected. REC reduction after surgery might be ex- the importance of the surgical approach. In fact, it plained by the overfilling of the defect, to maintain an was shown that a minimally invasive technique with adequate space, and by the possibility to move and or without regenerative materials resulted in signifi- suture coronally the flap, to obtain a perfect soft tis- cant clinical and radiographic improvements. In this sue closure and the stability of the coagulum for a light, our results from the present study showed that, by using the nano-structured hydroxyapatite as filling proper healing process. This data seems to be in biomaterial, a membrane might not be a critical factor contrast with the Literature (35) which suggests to for bone regeneration, even in non-containing bone place the soft tissues at the same level or slightly api- defects. cally after the surgery. The data from published controlled clinical studies do not seem to clearly indicate improved clinical out- comes related to probing pocket depth (PPD) reduc- Conclusions tion, clinical attachment level (CAL) gain and defect fill when the combination of grafting materials and a In the presented study, the absence of anatomical covering membrane is compared with the membrane determinants, with the exception of the length of the alone or with the grafting materials alone (30-33). It defect, might suggest the importance of surgical ap- was shown that treatment of intrabony defects with a proach and of the grafting material used as well. With complicated, non-containing morphology by using an accurate patients selection and the proper surgical membranes and grafting materials showed better technique, the here investigated biomaterial gives an clinical outcomes if compared with the use of the important aid in the treatment of periodontal intrabony membranes alone (30, 33). Such better clinical out- defects, leading to a normalisation of the clinical and comes are confirmed by more suggestive histological radiological parameters. These assumptions were pictures describing a good bone repair, after the sur- supported by histological evidence, as previously gical technique combining grafting materials and demonstrated by Figliuzzi et al. (36). membranes in non-containing periodontal defects. Otherwise, in containing bone defects (i.e. fenestra- tion defects, three-wall intrabony defects or Class II Source of Funding furcation defects) no additional advantage by a com- bination of grafting materials and barrier membranes The study was self-funded by the Authors and their compared with grafting materials alone or barrier institutions. Annali di Stomatologia 2016;VII (1-2): 16-23 21 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  M. M. Figliuzzi et al. Acknowledgements mation of calcium phosphate collagen composites trough min- eralization of collage matrix. J Biomed Mater Res. 2000; 50(4):518-27. We highly appreciated the skills and commitment of 15. Götz W, Reichert C, Canullo L, Jäger A, Heinemann F. Cou- Dr. Audrenn Gautier in the supervision of the study, Dr. pling of osteogenesis and angiogenesis in bone substitute Marco Clementini and Dr. Gaia Rosa Pellegrini for the healing – A brief overview. Journal of Anatomy. 2011;10: 12- scientific support. Additionally the Authors sincerely 14. thank Dr. Giuliano Iannello for statistical analysis. 16. Neel EAA, Chrzanowski W, Salih VM, Hae-Won K, Knowles JC. Review. Tissue engineering in dentistry journal of den- tistry. 2014;42:915-928. References 17. Fricain JC, Schlaubitz S, Le Visage C, Arnault I, Derkaoui SM, Siadous R, Catros S, Lalande C, Bareille R, Renard M, 1. Ripamonti U. 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Treatment of intraosseous Journal of Periodontology. 2008;79:567-574. defects with bioabsorbable barriers alone or in combination 36. Figliuzzi M, De Fazio R, Tiano R, De Franceschi S, Pacifi- with decalcified freeze-dried bone allograft: a randomized con- co D, Mangano F, Fortunato L. Histological evaluation of a trolled clinical trial. Journal of Periodontology. 2000;71:1852- biomimetic material in bone regeneration after one year from 1861. graft. Ann Stomatol (Roma). 2014 Jul 20;5(3):103-7. Annali di Stomatologia 2016;VII (1-2): 16-23 23 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited. 

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Original article Pediatric patients tolerance: a comparative study about using of Er:YAG laser and self-adhesive flowable composite for treatment of primary i decayed teeth al Iole Vozza, DDs, PhD sociation with self-adhering composite, is very ef- n Daniela Mari, DDS fective in pediatric dentistry and is a good treat- Edoardo Pacifici, DDS, PhD ment option especially for non cooperative pa- io Valeria Luzzi, DDS, PhD tients. Gaetano Ierardo, DDS, PhD Gian Luca Sfasciotti, MD, DDS Key words: Er:YAG laser, occlusal cavities, self- az Antonella Polimeni, MD, DDS adhesive flowable resin, pediatric tolerance, pedi- atric dentistry. Pediatric Dentistry Division, Oral and Maxillo-facial rn Sciences Department, “Sapienza” University of Rome Introduction Minimal invasive dentistry has been promoted with Corresponding author: the development of new adhesive materials so to pre- te Iole Vozza Department of Oral and maxillo-facial Sci- serve healthy tooth tissue. It has allowed to complete ences Sapienza University of Rome smaller preparations by minimizing the requirement Via Caserta 6 In for retention and resistance form (1). Therefore, alter- 00161 Rome native methods, such as lasers, have been suggest- E-mail: iole.vozza@uniroma1.it ed for caries cavity preparation. Lasers have been used in dentistry for more than 20 years (2). Erbium: Yttrium- Aluminum Garnet (Erbium:YAG) lasers offers Summary ni an alternative to conventional bur preparation with minimal tissue loss thanking to its 0.8mm spot beam Aim. To verify the tolerance of children aged be- (3, 4). Erbium:Yag lasers emits energy in the wave- tween 3 and 8 years, having class I caries and length of 2.94 μm and is well absorbed by all biologi- io treated with Er:YAG Laser in association with a cal tissues, including enamel and dentin (5). Once new self-adhesive flowable resin in comparison light from the laser is absorbed, it is converted to with a high-speed diamond bur and a convention- heat. The overheated water vaporizes and causes iz al flowable resin treatment. Methods. A group of micro-explosions of tooth fragments without the risk 80 healthy children (43 male and 37 female) rang- of micro- and macrofractures, which have been ob- ing in age from 3 to 8 years, who had been diag- served when conventional rotating instruments are Ed nosed with at least one active occlusal non-cavi- used (6). So it is very effective for enamel and dentin tated superficial carious lesions in first or second etching, caries removal and cavity preparation of pri- deciduous molars, were selected for the present mary and permanent teeth (3, 7-9). It determines a study. They were divided in 4 groups: group A: reduction of patient discomfort according to the ab- Class I occlusal cavities prepared using an sence of contact between rotary instruments and Er:YAG laser and a self-adhesive flowable resin; tooth that allows an atraumatic treatment without IC Group B: Class I occlusal cavities prepared using noise, pressure and vibration (6). Then reduced need an Er:YAG laser and a conventional flowable for local anesthesia takes advantage for collaboration resin; Group C: Class I occlusal cavities prepared and tolerance of patients, above all for pediatric pa- using a high-speed diamond bur and a self-adhe- tients (10). It has been found that laser irradiated sur- C sive flowable resin; Group D: Class I occlusal faces show a rough, clean surface without smear lay- cavities prepared using a high-speed diamond er covering bur prepared cavities. This could be more bur and a conventional flowable resin. Before and favorable for the adhesion of restorative materials after the treatments the patient tolerance was (10-11). Actually flowable resin composites are the @ tested with the modified Wong-Baker pain level most used materials due to their fluid injectability and scale. Results. In the first group, the tolerance non-stickiness characteristics (12). Recently, new rate was 95% with 0 score (no hurt) for 19 pa- self-adhering flowable resins have been developed. tients; in Group D, the tolerance rate was 75%. They have shown greater usefulness in uncoopera- Just one child of group D experienced hurting tive patients. Yazici et al. have also found in vitro that worst because of non cooperative patient. Con- Laser treatment increased the dentin bonding values clusion. From these results it emerged that, al- of the self-adhesive flowable resin (13). The aim of though the limits of the study, Er:Yag laser in as- this study was to verify the tolerance of children aged 24 Annali di Stomatologia 2016;VII (1-2): 24-28  Pediatric patients tolerance: a comparative study about using of Er:YAG laser and self-adhesive flowable composite for treatment of primary decayed teeth between 3 and 8 years, having class I caries and and dried for 5 seconds, leaving the dentin slightly treated with Er:YAG Laser in association with a new moist. All the flowable resin composites were applied self-adhesive flowable resin in comparison with a according to the manufacturer’s recommendations. high-speed diamond bur and a conventional flowable For the conventional flowable resin the adhesive resin treatment. used (Optibond Solo Plus, Kerr, Orange, CA, USA) i was applied onto the dentin surface according to the al manufacturer’s instructions (Figs. 2, 3). All the proce- Materials and methods dures were performed without local anesthesia. All the restorations were done by the same operator n Selection Criteria (DM) with cotton roll isolation and a chairside assis- tant. Of the 40 laser-prepared restorations, 29 were A group of 80 healthy children (43 male and 37 fe- placed in lower molars and 11 in upper molars. In io male) ranging in age from 3 to 8 years, who had been bur-prepared cavities, 24 restorations were placed in diagnosed with at least one active occlusal non-cavi- lower molars and 16 in upper molars. Before and af- tated superficial carious lesions in first or second de- ter the treatments the patient tolerance was tested az ciduous molars, were selected for the present study. with the modified Wong-Baker pain level scale (15) Exclusion criteria were the presence of frank occlusal (Fig. 1). A descriptive statistics was used to evaluate cavitation, poor oral hygiene, serious systemic dis- the results. eases and bruxism. A written informed consent was rn obtained from all parents of little patients. The re- search was conducted in full accordance with the Results World Medical Association Declaration of Helsinki te and the research protocol and consent form for the The results of the present study are summarized in current study were reviewed and approved by the Table1. Medical Ethics Committee of Sapienza University of Just one child of group D experienced hurting worst Rome. Caries lesions in the selected sites were as- because of non cooperative patient. In the first group, sessed by visual inspection performed with patients In where Class I occlusal cavities were prepared using positioned in a dental chair with reflector light, air/wa- an Er:YAG laser and a self-adhesive flowable resin, ter spray and a plane buccal mirror using the visual- the tolerance rate was 95% with 0 score (no hurt) for ranked method developed by Ekstrand et al. (14) un- 19 patients; in the second group, where Class I oc- ni der standardized conditions. They patients enrolled clusal cavities were prepared using an Er:YAG laser were divided randomly into 4 groups of 20 children and a conventional flowable resin the tolerance rate each: was 90%; in the third group, where Class I occlusal io Group A: Class I occlusal cavities were prepared us- cavities were prepared using a high-speed diamond ing an Er:YAG laser (Fidelis Plus II, Emmeciquattro bur and a self-adhesive flowable resin, the tolerance Fotona, Italy) with wavelength 2,940 nm, 200 mJ en- rate was 80%; in the last group, where Class I oc- iz ergy and 15 Hz and a self-adhesive flowable resin clusal cavities were prepared using a high-speed dia- (Vertise Flow, Kerr Corp, Orange CA, USA). mond bur and a conventional flowable resin, the toler- Group B: Class I occlusal cavities were prepared us- ance rate was 75%. Ed ing an Er:YAG laser (Fidelis Plus II, Emmeciquattro Fotona, Italy) with wavelength 2,940 nm, 200 mJ en- ergy and 15 Hz and a conventional flowable resin Discussion and conclusion (Premise Flow, Kerr Corp). Group C: Class I occlusal cavities were prepared us- Anxiety in Dentistry is frequent and includes both chil- ing a high-speed diamond bur (835/010-4ML, Diatech dren and adults. It has been found that most of dental IC Dental AG, Heerbrugg, Switzerland) under constant fears origin probably from mismanagement by the water cooling and a self-adhesive flowable resin (Ver- dentists during childhood (16). Nature of pain is vari- tise Flow, Kerr Corp, Orange CA, USA). able and depends on objective and subjective factors Group D: Class I occlusal cavities were prepared us- (17). Until children reach school age, they cannot dif- C ing a high-speed diamond bur (835/010-4ML, Diatech ferentiate between pain and anxiety so it’s very im- Dental AG, Heerbrugg, Switzerland) under constant portant to manage pain and fear successfully (18). water cooling and a conventional flowable resin The use of laser can be an efficient strategic therapy (Premise Flow, Kerr Corp). in pediatric dentistry due to minimal invasion (19) al- @ Visual and tactile feedback from an explorer was though no statistical differences were reported by dif- used to determine the end of caries removal. No ad- ferent authors between Er:YAG laser and air-rotor ditional “extension for prevention” and no visible method in the effectiveness of caries removal (20, preparation of undercuts was performed after the le- 21). The development of flowable composites im- sions were completely excavated. The etching was proved the management of uncooperative patients. performed for 15 seconds with a 37.5% phosphoric Some authors (22) proposed a self-adhesive flowable acid etchant (Gel Etchant, Kerr, Orange, CA, USA) resin for the restoration of small class I cavities, class then rinsed for 15 seconds with an air-water spray V cavities, non-carious cervical lesions, and for a lin- Annali di Stomatologia 2016;VII (1-2): 24-28 25  I. Vozza et al. Figure 1. Wong Baker scale. i n al io az rn te In ni io iz Ed IC C @ Figure 2. Case report of group A and C. ing in class I and class II restorations, pit and fissure as this new self-adhering flowable resin composite sealings, and porcelain repairs (22). Salerno et al. established on primary dentin bond strengths values showed remarkably strong elastic capacities of a self- similar to those of glass ionomer cements routinely adhesive flowable resin (23). Pacifici et al. (24) found used for restorations of primary teeth. From these re- 26 Annali di Stomatologia 2016;VII (1-2): 24-28  Pediatric patients tolerance: a comparative study about using of Er:YAG laser and self-adhesive flowable composite for treatment of primary decayed teeth i n al io az rn te In Figure 3. Case report of group B and D. ni Table 1. Results of technique acceptance from different groups of patients using Wong-Baker scale io 0 (no hurt) 2 (hurts 4 (hurts 6 (hurts 8 (hurts 10 (hurts little bit) little more) even more) whole lot) worst) iz GROUP A 19 1 GROUP B 17 1 2 GROUP C Ed 14 2 3 1 GROUP D 13 2 1 1 2 1 sults it emerged that, although the limits of the study, in paediatric patients following minimally invasive dentistry concepts. European Journal of Paediatric Dentistry. IC Er:Yag laser in association with self-adhering com- posite is very effective in pediatric dentistry and is a 2008;9(2):81-87. 4. Eberhard J, Bode K, Hedderich J, Jepsen S. Cavity size dif- good treatment option especially for non cooperative ference after caries removal by a fluorescence-con- trolled patients. Er:YAG laser and by conventional bur treatment. Clinical Oral C Investigations. 2008;12(4):311-318. 5. Matsumoto K, Hossain M, Hossain MM, Kawano H, Kimu- References ra Y. Clinical assessment of Er, Cr: YSGG laser application for cavity preparation. Journal of Clinic Laser Medicine and @ 1. Murdoch-Kinch CA, McLean ME. Minimal invasive dentistry. Surgery. 2002;20(1):17-21. Journal of the American Dental Association. 2003;134(1):87- 6. Fornaini C, Riceputi D, Lupi-Pegurier L, Rocca JP. Patient 95. responses to Er:YAG laser when used for conservative den- 2. Yazici AR, Baseren M, Gorucu J. Clinical comparison of bur- tistry. Lasers Med Sci. 2012 Nov;27(6):1143-9. and laser-prepared minimally invasive occlusal resin com- 7. Hossain JM, Nakamura Y, Yamada Y, Murakami Y, Mat- posite restorations: two-year follow-up. Oper Dent. 2010 Sep- sumoto K. Compositional and structural changes of human Oct;35(5):500-7. dentin following caries removal by Er, Cr: YSGG laser irra- 3. Kornblit R, Trapani D, Bossù M, Muller-Bolla M, Rocca JP, diation in primary teeth. Journal of Clinical Pediatric Dentistry. Polimeni A. The use of Erbium: YAG laser for caries removal 2002;26(4):377-382. Annali di Stomatologia 2016;VII (1-2): 24-28 27  I. Vozza et al. 8. Cehreli SB, Gungor HC, Karabulut E. (2006) Er,Cr:YSGG agement. J Am Dent Assoc. 1983 Jul;107(1):18-27. laser pretreatment of primary teeth for bonded fissure 17. Genovese MD, Olivi G. Laser in paediatric dentistry: patient sealant application: a quantitative microleakage study. acceptance of hard and soft tissue therapy. Eur J Paediatr Journal of Adhesive Dentistry. 2006;8(6):381-386. Dent. 2008 Mar;9(1):13-7. 9. Parkins F. Lasers in pediatric and adolescent dentistry. Den- 18. Zurfluh MA, Daubländer M, van Waes HJ. Comparison of two tal Clinics of North America. 2000;44(4):821-830. epinephrine concentrations in an articaine solution for local i 10. Aranha AC, De Paula Eduardo C, Gutknecht N, Marques MM, anesthesia in children. Swiss Dent J. 2015;125(6):698-709. al Ramalho KM, Apel C. Analysis of the interfacial micromor- 19. Nazemisalman B, Farsadeghi M, Sokhansanj M. Types of phology of adhesive systems in cavities prepared with Er, Lasers and Their Applications in Pediatric Dentistry. J Cr: YSGG, Er:YAG laser and bur Microscopy Research and Lasers Med Sci. 2015;6(3):96-101. n Technique. 2007;70(8):745-751. 20. Shigetani Y, Tate Y, Okamoto A, Iwaku M, Abu-Bakr N. A 11. Delmé KI, De Moor RJ. Scanning electron microscopic eval- study of cavity preparation by Er:YAG laser. Effects on the uation of enamel and dentin surfaces after Er: YAG laser marginal leakage of composite resin restoration. Dent io preparation and laser conditioning. Photomedicine and Mater J. 2002 Sep;21(3):238-49. Laser Surgery. 2007;25(5):393-401. 21. Bohari MR, Chunawalla YK, Ahmed BM. Clinical evaluation 12. Bayne SC, Thompson JY, Swift EJ Jr, Stamatiades P, Wilk- of caries removal in primary teeth using conventional, az erson M. A characterization of first-generation flowable com- chemomechanical and laser technique: an in vivo study. J posites. J Am Dent Assoc. 1998;129(5):567-577. Contemp Dent Pract. 2012 Jan 1;13(1):40-7. 13. Yazici AR, Agarwal I, Campillo-Funollet M, Munoz-Viveros 22. Salerno M, Derchi G, Thorat S, Ceseracciu L, Ruffilli R, C, Antonson SA, Antonson DE, Mang T. Effect of laser prepa- Barone AC. Surface morphology and mechanical properties ration on bond strength of a self-adhesive flowable resin. of new-generation flowable resin composites for dental rn Lasers Med Sci. 2013 Jan;28(1):343-7. restoration. Dent Mater. 2011 Dec;27(12):1221-8. 14. Ekstrand KR, Ricketts DN, Kidd EA. Reproducibility and ac- 23. Goracci C, Margvelashvili M, Giovannetti A, Vichi A, Ferrari curacy of three methods for assessment of demineralization M. Shear bond strength of orthodontic brackets bonded with depth of the occlusal surface: an in vitro examination. Caries a new self-adhering flowable resin composite. Clin Oral In- te Research. 1997;31(3):224-231. vestig. 2013 Mar;17(2):609-17. 15. Wong DL, Baker CM. Pain in children: comparison of as- 24. Pacifici E, Chazine M, Vichi A, Grandini S, Goracci C, Fer- sessment scales. Pediatr Nurs. 1988 Jan-Feb;14(1):9-17. rari M. Shear-bond strength of a new self-adhering flowable 16. Ayer WA Jr, Domoto PK, Gale EN, Joy ED Jr, Melamed BG. restorative material to dentin of primary molars. J Clin Pe- In Overcoming dental fear: strategies for its prevention and man- diatr Dent. 2013 Winter;38(2):149-54. ni io iz Ed IC C @ 28 Annali di Stomatologia 2016;VII (1-2): 24-28 

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Original article Benchmarking matching color in composite restorations Guido Migliau tions are to obtain morphologic, optical, and biologic Luca Piccoli result miming natural enamel and dentine. This color Laith Konstantinos Besharat matching is performed in order to obtain harmony Umberto Romeo with the surrounding anatomical structures. Literature shows many analysis in fields like facial aesthetic parameters (2), the influence of dental Department of Oral and Maxillo Facial Sciences, treatments on smile and of their proper relationship School of Dentistry, “Sapienza” University of Rome, between function and aesthetic (3), the color proper- Italy ties of dental tissues (4) and (5) restorative materials and the effectiveness of methods for assessing the color (6, 7). Corresponding author: Our study focuses on the main element of restorative Laith Konstantinos Besharat treatment: the composite resin. Department of Oral and Maxillo-Facial Sciences, The industry provides the operator with a wide range School of Dentistry, “Sapienza” University of Rome of composite resins to reproduce a certain color of Vi- Via Caserta, 6 ta reference scale (8-10); for this reason, we tried to 00161 Roma, Italy answer to the following question: can these materials E-mail: besharatlk84@yahoo.it really provide the desired color? Thus, we compared three different brands of compos- ite resin and, using a spectrophotometer, analyzing three basic parameters: Value, Chroma and Hue Summary (11). The purpose of this study was to investigate the color samples (A2, A3 and B1) of three different Materials and methods brands of resin composites using dentine mass- es.135 discs were prepared (5 plates for each thickness, color and brand of composite materi- Three different resin composites with dentine mass- al). A colorimetric evaluation, using white and es, colors A2, A3 and B1 were selected for in vitro black background, was performed just after study: Opallis (Isasan® srl, Italy), Artist (Pentron Clin- preparation. The color was measured correspond- ical®, USA) and Amelogen plus (Ultradent Prod- ing to “Vita” scale and ΔL, Δa, Δb and ΔE values ucts®, Inc, USA). The choice to work only with dentin were calculated using a spectrophotometer.The was dictated by the difficulty to overlap enamel and results showed that Value, Chroma and Hue often dentine known thickness plates, without the risk of differ even if the same commercial color and distorting the final chromatic results. Furthermore, it same thickness is used. In conclusion, this study is known that the readings provided by the spectrom- showed that the perfect aesthetics restoration is eter are greatly influenced by small air bubbles and possible combining individual abilities, experi- discontinuities in the composite mass (12). This can ence and correct techniques. deflect the light emitted from the spectrometer distort- ing the size and direction of the reflected light caus- Key words: composite, color, aesthetic restora- ing errors in numerical results (13). It was therefore tion. necessary to realize discs with very smooth and pol- ished surface, a condition difficult to satisfy. A metal matrix was then used for the realization of composite Introduction platelets (discs), 1 cm thick and bearing along its en- tire thickness holes of 1 mm diameter. Resin composite is the material of choice used in di- Metallic cylinders of 1 mm in diameter and height rect restorations, as it offers an aesthetic, conserva- ranging from 5 mm to 9 mm. For each hole fits close- tive, durable and economic treatment solution (1). ly for each hole (Fig. 1). It was possible, by including The major requirement of composite resin is the abili- several cylinders within the array, to modify the re- ty to achieve an excellent color matching with the nat- maining thickness of the matrix, obtaining known ural teeth and the maintenance of the optical proper- thickness (ex. if we introduce a 8 mm cylinder high in ties over time. The goals for aesthetic dental restora- the 1 cm deep hole, the final depth will be 2 mm). Annali di Stomatologia 2016;VII (1-2): 29-37 29  G. Migliau et al. laterally, causing only minimum increases in thick- ness (in the range of one tenth of a millimeter). The contact between glass plate and composite gener- ates a disc with smooth and glossy surface, suitable for subsequent spectrophotometric analysis (Fig. 3). Microscope slide allowed, due to its transparency, to the subsequent polymerization of the material by a halogen curing lamp (Elipar, 3M ESPE®) (Fig. 4). After polymerization, the slide was then carefully sep- arated from the plate and matrix, in order to minimize the distortion of the disc surface and the development of any microscopic defects that could skew the final results. Despite these precautions, however, has not been possible to avoid the separation of small frag- ments from composite plate margins. However, this does not affect the results of the experiment. This be- cause the spectrophotometer was able to zoom the Figure 1. Materials: metal matrix, metallic cylinders, a spat- object examined and allows to select a precise spot ula and glass plate. for color analysis, avoiding areas of defects even when not visible at lower magnification. After removing the slide with a blunt screw placed in Thus, we used 1.5 mm, 2 mm and 2.5 mm thickness, using 7.5 mm, 8 mm and 8.5 mm height cylinders. Each cylinder was inserted into the hole of the array using a common hammer, adapting the two metal parts to each other. Furthermore, in the remaining depth of the hole of the matrix, composite was applied enough to fill the hole. This procedure was made using a composite spatula and in a single mass, in order to limit the possibility of air bubbles incorporation, resulting from the manual stratification of several layers (Fig. 2). Composite was then compressed against the cylinder by using a microscope slide (Thermo Scientific®, U.S.A.); a circular motion was imposed to the slide with constant pressure to remove air bubbles. With this technique, the exceeding material is displaced Figure 3. Glass plate application over the cylindrical metal matrix with exceeding material. Figure 2. The material was applied in the cylinder in the re- Figure 4. The material was light-cured with a halogen maining depth. lamp. 30 Annali di Stomatologia 2016;VII (1-2): 29-37 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Benchmarking matching color in composite restorations Figure 5. 135 plates, 45 of which are made with Opallis, 45 with Artiste and 45 with Amelogen Plus. It is important to underline that, with the help of a double and symmetrical light source, the results given by the equipment are in no way influenced by other sources of light. After calibration, the instrument was placed on a suit- able support to ensure that the angle between light beam and the surface of the discs remain constant (the Spectro Shade Micro was positioned with a 90° angle from the disc in order to generate an angle of 45° between the two light beams and the disc itself), Figure 6. Discs performed over black background. then two digital images for each plate were made: the first on a black background (oral cavity), the other on a white background (tooth) (Figs. 6, 7). Each image is composed as follows: a zoomed pic- ture of the disc is showed on the left side, on the right its color distribution and below a table. This table in- cludes, from left to right, the details of Value, Chroma and Hue (or Value, quantity of red and yellow), the Vita scale for that color and thickness, and their nu- merical difference; on the right side there is a graphi- Figure 7. Discs performed over white background. cal representation of this numerical difference; on the lower side ΔE is showed (ΔE = √ [(ΔL *) 2 + (Δa *) 2 + (Δb *) 2]), expressing in mathematical terms how contact with the rear surface of the cylinder and with much the overall color of the disc differs from its cor- the help of the hammer, the cylinder was slid through responding Vita scale; beneath the ΔE are represent- the hole and the plate was separated from its sup- ed visually, from left to right, the color of the disc, that port. Those procedures may in some cases crack the corresponding Vita, and finally the two colors are rep- edges of the plate without influencing, as seen be- resented side by side in order to reveal any differ- fore, the final analysis. ences (Fig. 8). Thus, 5 plates for each thickness and for each color of each different brand of composite material were made. 135 plates were obtained, 45 was made with Results and discussion Opallis, 45 with Artiste and another 45 with Amelo- gen Plus. From this pool of 45 plates, 5 were A2 to Numerical values were then extrapolated from each 1.5 mm, 5 A2 2 mm, 5 A2 to 2.5 mm, 5 A3 of 1.5 mm, image and reorganized into three Tables. Table 1 5 A3 of 2 mm, 5 A3 of 2.5 mm, 5 B1 of 1.5 mm, 5 B1 shows the analysis of 1.5 mm thickness composite of 2 mm and 5 B1 of 2.5 mm (Fig. 5). discs. Table 2 shows data on the 2 mm thickness The discs, grouped, packaged and labeled, were then discs. Table 3 shows 2.5 mm thickness. sent to a professional technician who has selected In each Table are shown from left to right, the name the chip that has lower defects from this pool of 5 for of the composite used; the color of the background providing numerical data. This analysis was conduct- used; the color printed on composite tubes; the Value ed using spectrophotometer (Spectro Shade Micro, of the disc of the corresponding Vita scale and their MHT, Italy). difference; the Chroma of the disc of the correspond- Annali di Stomatologia 2016;VII (1-2): 29-37 31 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  G. Migliau et al. Figure 8. The disc color dif- ference according Vita scale. Table 1. The analysis of composite discs 1.5 mm thickness. L C H Composite Background Color ∆E Tooth Vita Diff. Tooth Vita Diff. Tooth Vita Diff. A3 74,82 73,28 1,54 27,89 22,78 5,1 76,84 85,98 -4,02 6,68 White A2 76,42 75,6 0,82 27,41 18,87 8,54 80,04 87,92 3,12 9,13 B1 86,3 77,76 8,54 16,6 12,77 3,84 96,61 92,64 1,01 9,41 Amelogen Plus A3 69,03 72,98 -3,95 19,5 21,15 -1,64 84,71 84,63 0,03 4,34 Black A2 70,86 75,98 -5,11 18,66 19,59 -0,93 91,32 85,99 1,78 5,49 B1 77,43 77,84 -0,41 7,53 12,74 -5,21 111,24 93,17 3,07 6,07 A3 74,9 73,36 1,54 31,95 22,48 9,47 79,93 85,83 -2,76 9,99 White A2 78,21 75,84 2,37 31,18 19,2 11,98 80,27 87,02 -2,88 12,55 B1 77,96 77,88 -0,25 23,89 13 10,89 84,65 92,55 -2,43 11,16 Opallis A3 67,03 72,41 -5,38 22,57 21,9 0,67 86,76 84,89 0,72 5,47 Black A2 70,04 75,96 -5,92 20,36 19,56 0,79 89,68 85,96 1,3 6,12 B1 67,83 76,66 -8,83 12,2 13,74 -1,54 101,36 93,79 1,71 9,12 A3 73,02 73,33 -0,31 33,67 21,93 11,74 77,52 85,8 -3,92 12,38 White A2 77,17 75,77 1,39 31,11 18,94 12,17 79,92 86,69 -2,86 12,58 B1 82,52 78,28 4,24 18,53 13,54 4,99 88,54 92,18 -1 6,63 Artiste A3 63,25 72,64 -9,39 21,74 22,8 -1,06 84,31 84,62 0,12 9,45 Black A2 67,19 76,27 -9,08 18,88 19 -0,11 85,26 87,41 -0,71 9,11 B1 77,19 77,52 -0,33 13,31 13,31 0 97,17 94,15 0,49 0,59 ing Vita scale and their difference, the Hue of the disc Before examining the numerical data, is important to of the corresponding Vita scale and their difference; focus directly on the images obtained by the comput- the ΔE. er software. In most cases there is an uneven distrib- 32 Annali di Stomatologia 2016;VII (1-2): 29-37 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Benchmarking matching color in composite restorations Table 2. The analysis of composite discs of 2 mm thickness. L C H Composite Background Color ∆E Tooth Vita Diff. Tooth Vita Diff. Tooth Vita Diff. A3 72,84 73,46 -0,62 26,72 21,94 4,78 76,21 86,35 -4,28 6,45 White A2 78,31 75,99 2,32 26,92 19,28 7,64 78,75 87,63 -3,53 8,73 B1 84,5 77,8 6,7 18,29 13,42 4,87 94,62 92,73 0,52 8,3 Amelogen Plus A3 72,04 72,18 -0,14 20,46 20,24 0,21 85,36 86,17 0,29 0,38 Black A2 73,11 75,95 -2,84 19,26 19,23 0,03 88,02 86,52 0,5 2,88 B1 80,05 78,27 1,78 9,53 13,47 -3,94 110,16 92,25 3,53 5,58 A3 73,07 73,37 -0,3 31,32 21,7 9,63 78,79 85,81 -3,19 10,15 White A2 77,13 75,83 1,03 30,75 18,89 11,86 78,66 87,51 -3,72 12,5 B1 75,64 77,78 -2,14 22,12 12,73 9,39 82,62 91,81 -2,69 10 Opallis A3 67,04 72,92 -5,89 22,72 21,17 1,55 86,01 85,98 0,01 6,09 Black A2 70,36 74,86 -4,51 20,92 17,81 3,12 87,51 88,18 -0,22 5,48 B1 70,66 77,66 -6,97 19,47 13,58 5,89 97,1 88,74 2,37 9,43 A3 70,81 73,07 -2,26 33,03 21,39 11,64 75,75 86,52 -4,99 12,87 White A2 76,31 75,47 0,84 31,08 18,51 12,57 77,45 87,37 -4,15 13,26 B1 81,28 78,37 2,91 19,21 13,03 6,17 87,45 90,83 -0,93 6,89 Artiste A3 63,81 73,16 -9,35 23,63 22,54 1,09 82,39 83,61 -0,49 9,42 Black A2 68,89 76,05 -7,16 21,82 19,57 2,24 84,38 86,67 -0,82 7,55 B1 77,94 78,31 -1,37 12,11 12,05 0,05 95,53 93,64 0,4 1,43 ution of the material used (Fig. 8); only Amelogen It is interesting to note that background greatly influ- Plus in color B1 (Fig. 9) has an approximately uniform ence the color of the composite disc. The white back- color map. This issue is due in part to the manual lay- ground, that simulate dentin (miming vestibular tooth ering and partly to excessive viscosity of the material. face restoration at 1/3 cervical), reflects all the inci- Figure 9. Amelogen Plus (B1) uniform color map. Annali di Stomatologia 2016;VII (1-2): 29-37 33 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  G. Migliau et al. Table 3. The analysis of composite discs of 2.5 mm thickness. L C H Composite Background Color ∆E Tooth Vita Diff. Tooth Vita Diff. Tooth Vita Diff. A3 72,22 73,07 -0,85 25,65 23,03 2,62 76,23 84,38 3,45 4,42 White A2 77,82 74,74 3,08 26,55 17,86 8,69 78,77 87,96 -3,49 9,86 B1 85,25 78,16 7,09 18,1 13,29 4,81 94,27 89,26 1,36 8,68 Amelogen Plus A3 69,31 72,88 -3,57 21,62 21,25 0,37 83,36 85,59 -0,84 3,68 Black A2 74,18 75,97 -1,78 20,73 20,1 0,63 86,96 86,53 0,15 1,9 B1 79,6 77,99 1,61 11,71 13,03 -1,32 104,83 92,46 2,66 3,38 A3 71,87 73,23 -1,37 29,54 22,47 7,07 78,12 83,98 -2,63 7,66 White A2 75,89 76,21 -0,33 28,92 18,84 10,08 77,33 87,35 -4,07 10,88 B1 74,99 77,86 -2,88 22,61 12,79 9,81 83,93 93,19 -2,75 10,59 Opallis A3 68,32 72,99 -4,67 23,78 20,93 -2,84 85,34 86,15 0,32 5,48 Black A2 71,07 74,46 -3,39 21,69 18,65 3,04 85,28 88,01 0,96 4,65 B1 70,03 78 -7,98 15,67 12,92 2,75 90,59 91,77 -0,29 8,44 A3 69,52 73,38 -3,86 31,97 21,82 10,15 73,96 85,97 -5,53 12,19 White A2 76,08 75,98 0,1 32,1 19,07 13,03 75,96 87,23 -4,86 13,91 B1 80,83 77,99 2,84 18,86 13,53 5,34 84,98 91,52 -1,82 6,31 Artiste A3 63,44 72,98 -9,53 23,25 20,95 2,3 78,29 86,09 -3 10,26 Black A2 69.81 75,99 -6,19 23,03 18,48 4,45 83,44 86,6 -1,14 7,76 B1 75,43 77,95 -2,52 13,07 12,98 0,09 92,19 92,38 -0,04 2,52 dent light; the black background simulate a restora- tion with the oral cavity as background (for example fractured incisal angles restoration), will absorb all the light directed on it. These differences in absorp- tion would certainly influence the overall color of the restoration in terms of Value and Chroma, which would be much higher if the composite is placed on a white background rather than on a black one. Con- trariwise, Hue increase on black background if com- pared to white. It is important to observe that white and black repre- sent only two extremes of colors that can be found as background during restorations in the oral cavity. Figure 10. Value decreases with increasing thickness over a white background. Value Analyzing the results for what concerns the Value of trophotometer analysis due to limitations in the manu- the composite (L) we can see that, on a white back- al technique, even if standardized, and to the exces- ground (7 samples out of 9) normally L decreases sive viscosity of the material. with increasing thickness (Fig. 10); this shows that in- On a black background L is significantly reduced if creasing the thickness and thus the opacity, compos- compared with white background; this because black ite is less influenced by the background which en- absorbs and reflects light, appearing darker to an ob- hances its Value making it brighter. Only in 2 samples server. this is not shown (Amelogen A2-B1). However, A2 Furthermore, the samples of 1.5 mm thickness are al- plate with 1.5 mm thickness and B1 of 2.5 mm, dis- ways the darkest (except for Artiste B1, where the 2.5 plays surface defects that may have influenced spec- mm sample is the darkest, probably due to an error 34 Annali di Stomatologia 2016;VII (1-2): 29-37 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Benchmarking matching color in composite restorations Figure 11. Value is significantly reduced over a black back- Figure 12. Chroma tends to decrease over the white back- ground. ground. during stratification), while 2 mm and 2.5 mm sam- ples, present in most cases (6 times out of 9) small differences in Value that are imperceptible to seen (Fig. 11); clinical trials have shown that the human eye cannot distinguish ΔL of -1 <x> 1. A trained and experienced eye can refers ΔL of -0.05 <x> 0.05. This data shows a substantial difference in L value between composites with same color and thickness but from different manufacturer: the Amelogen B1 is brighter than B1 from other 2 brands. Regarding ΔL on a white background, we noticed that 10 samples out of 27 show good correspondence with Vita scale (difference -1 <x> 1), 12 are brighter Figure 13. Chroma increases with the thickness over black and 5 darker than baseline color. Analyzing each background. manufacturer we observe that AMP, for example, in A3 2 mm and 2.5 mm cover well the background and OP, already perceived dark as we have seen on has a good correspondence with Vita scale; with 1.5 white background, shows low Value; we noticed the mm thickness is strongly influenced by the back- same effects for ART A3 and A2. ART B1 at 1.5 mm ground and appear brighter. Contrariwise AMP A2 is thickness, result to be similar in L to Vita scale, influenced from the background, showing an accept- whereas at 2 mm and 2.5 mm, covering black back- able ΔL at 1.5 mm, but appears too bright in 2 mm ground, it is obviously brighter. and 2.5 mm thickness. This inconstant chromatic be- havior with different thickness could be explained by Croma the defects during stratification mentioned above. AMP B1 is always very bright with white background On a white background we observed that Croma (C) at all thickness. decrease with increasing thickness, This occurs be- Opallis (OP) A3 at 1.5 mm and 2 mm thickness, cause, reducing thickness, the composite is more in- shows higher ΔL than Vita, but at 2.5 mm it is no fluenced by the background that reflects light, caus- longer influenced by the underlying background, ap- ing an increasingin saturation (Fig. 12). pearing darker. OP A2 behaves as OP A3, showing This behavior is followed by 5 samples out of 9. In an acceptable Value matching even at 2.5 mm. OP other cases the differences between discs regarding B1 displays acceptable ΔL at 1.5 mm, but appears Croma, are almost imperceptible; clinical studies darker at 2 mm and 2.5 mm. have shown that a ΔC of -3 <x> 3 is not distinguish- Artiste (ART) A3 shows same behavior like OP B1 in able to the untrained human eye. Furthermore, in 7 terms of ΔL. ART A2 is very bright to 1.5 mm, where- samples out of 9, the thinner ones reveal more in- as at 2 mm and 2.5 mm displays correct ΔL. ART B1 tense color. is always too bright. Regarding ΔL on a black back- On a black background C is greatly reduced; this be- ground, we noticed that only 3 samples out of 27 cause black background absorbs light, and therefore show good correspondence with Vita scale (differ- the color. Consequently, the saturation is reduced ence -1 <x> 1), 22 are Darker and 2 brighter than too. Normally, C value should increase with the thick- baseline color. AMP A3 is too dark except at 2 mm, ness, being the samples less influenced by the back- where matches perfectly. AMP A2 is always too dark ground. This happens for 6 samples out of 9; in the even if, increasing the thickness, the background has remaining 3, 2 of them have subtle differences. The lesser influence in ΔL. AMP B1 at 1.5 mm, appears other 1, OP B1 and 2 mm thickness, differs from the very similar to Vita scale; at 2 mm and 2.5 mm, cov- previous due to some small surface defects that ering the background, shows an increase in ΔL. The could modify C value (Fig. 13). Annali di Stomatologia 2016;VII (1-2): 29-37 35 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  G. Migliau et al. Figure 14. The tool shows nu- merical and visual feedback of color variations. By an examination of values showed in Tables 1-3 our samples is the hue (H). Observing the values of H we can assess that for the same commercial color taken from discs lying on a white and a black back- and thickness, the three different brands of composite ground, it is not difficult to understand how this ap- show different characteristics regarding Croma. proach can influence our color perception: clinical tri- Analyzing the values of ΔC expressed by the com- als show that the vast majority of the population is posites on the white background, we noted that 26 unable to perceive ΔH of -5 <x> 5. samples out of 27 show an excess in saturation than The Hue is an intrinsic component of the material the Vita scale. Only one disc displays C values that generally well represented. Just in one case H devi- match the corresponding Vita (AMP A3 2.5 mm thick- ates significantly from the Vita value, showing a slight ness). tendency to red; note also that there is a good corre- Examining ΔC we noted that in 21 samples out of 27 spondence between the discs of same thickness and the black background reduce the C value so as to color and of different manufacturer. Thus, H, com- bring them near to Vita scale baseline; 4 samples pared to L and C is less influenced by the back- shows a too much intense color whereas the remain- ground color. ing 2 appears above board. Focusing on each composite manufacturer we noted that AMP A3 shows C slightly weaker at 1.5 mm (in- Conclusions fluenced by the black background), but is almost per- fect at 2 mm and 2.5 mm. AMP A2 is always superim- Identification of color is the first issue to deal with. posed on Vita scale. AMP B1 at 1.5 mm has low C The picture provided by the spectrometer, shows how value, it is also above board at 2 mm, whereas at 2.5 the tooth color is far from being homogeneous. mm covers the black background showing a C corre- Furthermore this color map can be used for aesthet- sponding to Vita scale. Furthermore OP A3 1.5 mm, ics reconstruction of the anterior sector (Fig. 14). attenuated by the background, matches color perfect- The second issue is choosing the most suitable com- ly. At greater thickness, Croma differs from Vita, but posite for restoration. A solution should be using a remains appropriate. OP A2 at 1.5 mm is acceptable, brighter dentin if we working with a single mass, or to slightly intense at 2 mm and 2.5 mm (less influenced superimpose a white enamel if we work on two mass- by the fund). OP B1 presents low ΔC to 1.5 mm, is es. Regarding Croma, however, the most composit more intense at 2.5 mm, whereas at 2 mm has high C examined shows an excessive color intensity: even in value due to small imperfections (as mentioned be- this case will be sufficient to use a dentin of above- fore). ART A3 has a C superimposed to Vita scale on board color or to superimpose an enamel that would black background for all samples. ART A2 has a low mitigate the C. Generally, the Hue is not a problem, ΔC at 1.5 mm but too saturated at 2 mm and 2.5 mm. because is not able to modify the general chromatic ART B1 is almost perfect in terms of ΔC for all sam- effect (14). ples. A third issue comes from problems in the layering tech- nique. The study shows how, almost in whole samples, Hue the color distribution is not uniform. In fact the computer images show a patchy color map, underlining how the The third and last parameter that defines the color of color differs from what we expect (Fig. 15). 36 Annali di Stomatologia 2016;VII (1-2): 29-37 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Benchmarking matching color in composite restorations Figure 15. The spectropho- tometer color analysis shows that color is not uniform. Composites from different brands can be slightly resin composites and other conservative esthetic procedures. brighter or darker when compared, slightly more or Eur J Esthet Dent. 2008 Spring;3(1):14-29. less opaque than the underlying background, more or 4. Yu B, Ahn JS, Lee YK. Measurement of translucency of tooth enamel and dentin. Acta Odontol Scand. 2009 Feb;67(1):57-64. less intense in color, but generally show similar be- 5. Kim SJ, Son HH, Cho BH, Lee IB, Um CM. Translucency and havior when used during clinical practice. Thus, it is masking ability of various opaque-shade composite resins. important to choose the correct composite in relation J Dent. 2009 Feb;37(2):102-7. Epub 2008 Nov 22. to the background used and be able to recognize 6. Kuzmanović D, Lyons KM. Tooth shade selection using a col- when to apply a different composite layers, enamel or orimetric instrument compared with that using a conventional dentin, in order to adjust effects or excesses in L shade guide. N Z Dent J. 2009 Dec;105(4):131-4. and/or C values. We also emphasize that, even in 7. Judeh A, Al-Wahadni A. A comparison between conventional this case, spectrophotometry can meet the needs of visual and spectrophotometric methods for shade selection. the neophyte, guiding the management of any adjust- Quintessence Int. 2009 Oct;40(9):e69-79. 8. Magne Bruzi G, Carvalho AO, Giannini M, Maia HP. Eval- ments in color choosing. uation of an anatomic dual laminate composite resin shade In conclusion, we can assess that, although the most guide. J Dent. 2013 Aug;41 Suppl 3:e80-6. recent restoration materials offer a greater range of 9. Park SK, Lee YK. Shade distribution of commercial resin com- colors, although the color properties of these materi- posites and color difference with shade guide tabs. Am J Dent. als are similar to the dental tissues, as our study 2007 Oct;20(5):335-9. shows, the realization of a perfect aesthetic restora- 10. Paravina RD, Kimura M, Powers JM. Color compatibility of tion is possible only where a certain individual manu- resin composites of identical shade designation. Quintessence al dexterity joins the experience and acquisition of Int. 2006 Oct;37(9):713-9. appropriate technique. 11. Ahn JS, Lee YK. Color distribution of a shade guide in the value, chroma, and hue scale. J Prosthet Dent. 2008 Jul;100 (1):18-28. 12. Chirdon WM, O’Brien WJ, Robertson RE. Mechanisms of go- References niochromism relevant to restorative dentistry. Dent Mater. 2009 Jun;25(6):802-9. Epub 2009 Feb 8. 1. Morley J. The role of cosmetic dentistry in restoring a youth- 13. Ferraris F, Diamantopoulou S, Acunzo R, Alcidi R. Influence ful appearance. J Am Dent Assoc. 1999 Aug;130(8):1166- of enamel composite thickness on value, chroma and 72. Review. translucency of a high and non high refractive index resin com- 2. Sarver D, Jacobson RS. The aesthetic dentofacial analysis. posite. Int J Esthet Dent. 2014 Fall;9(3):382-401. Clin Plast Surg. 2007 Jul;34(3):369-94. Review. 14. Vimal K Sikri. Color: Implications in dentistry. J Conserv Dent. 3. Dietschi D. Optimizing smile composition and esthetics with 2010 Oct-Dec; 13(4): 249-255. Annali di Stomatologia 2016;VII (1-2): 29-37 37 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited. 

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Original article Fracture resistance of endodontically treated teeth restored with a bulkfill flowable material and a resin composite Almira Isufi, DDS, PhD1 was recorded as favorable or unfavorable. Data Gianluca Plotino, DDS, PhD1 were statistically analyzed with one-way analysis Nicola Maria Grande, DDS, PhD2 of variance (ANOVA) and Bonferroni tests Pietro Ioppolo3 (P<0.05). Luca Testarelli, DDS, PhD1 Results. No statistically significant differences Rossella Bedini3 were found among groups (P<0.05). Fracture re- Dina Al-Sudani, DDS4 sistance of endodontically treated teeth restored Gianluca Gambarini, MD, DDS1 with a traditional resin composite and with a bulk fill flowable composite (SDR) was similar in both maxillary and mandibular molars and showed no 1 Endodontics Unit, Department of Oral and Maxillo- significant decrease in fracture resistance com- Facial Sciences, “Sapienza” University of Rome, Italy pared to intact specimens. 2 Department of Endodontics, Catholic University of Conclusions. No significant difference was ob- Sacred Heart, Rome, Italy served in the mechanical fracture resistance of 3 Istituto Superiore di Sanità, Technology and Health endodontically treated molars restored with tradi- Department, Rome, Italy tional resin composite restorations compared to 4 Department of Restorative Dental Sciences, College bulk fill flowable composite restorations. of Dentistry, King Saud University, Riyadh, Saudi Arabia Key words: fracture resistance, endodontic treat- ment, bulk fill flowable composite, resin compos- ite. Corresponding author: Almira Isufi Endodontics Unit, Department of Oral and Maxillo- Introduction Facial Sciences, “Sapienza” University of Rome Via Caserta 6 The functional and aesthetic rehabilitation of en- 00161 Rome, Italy dodontically treated teeth has been the subject of dif- E-mail: almiraisufi@yahoo.it ferent studies (1). The restoration should not only provide function, aesthetic and marginal sealing, but also protect the remaining tooth structure (2, 3). Dif- Summary ferent studies have shown that the preparation of en- dodontic access cavities reduces the strength of the Aim. To determine and compare the fracture re- teeth, because of deep and extended cavity prepara- sistance of endodontically treated teeth restored tions which critically reduce the amount of dentin (4- with a bulk fill flowable material (SDR) and a tradi- 8) and increase cuspal deflection during function (9). tional resin composite. The importance of conserving the bulk of dentin was Methods. Thirty maxillary and 30 mandibular first demonstrated in maintaining the structural integrity molars were selected based on similar dimen- and in the prognosis of endodontically restored teeth sions. After cleaning, shaping and filling of the (10-13), as the fracture resistance and stress distribu- root canals and adhesive procedures, specimens tion of endodontically treated teeth is directly affected were assigned to 3 subgroups for each tooth type by the amount of residual coronal dentin (4, 14-18). (n=10): Group A: control group, including intact In posterior preparations, especially when the cervi- teeth; Group B: access cavities were restored cal margin is located in dentin, the polymerization with a traditional resin composite (EsthetX; shrinkage effects can be significant, producing mar- Dentsply-Italy, Rome, Italy); Group C: access cav- ginal defects and gaps despite careful application ities were restored with a bulk fill flowable com- (19). Several techniques and a variety of restorative posite (SDR; Dentsply-Italy), except 1.5 mm layer materials, which would minimize the stresses gener- of the occlusal surface that was restored with the ated on the interface of the restoration by modifying same resin composite as Group B. The speci- some physical and mechanical properties have been mens were subjected to compressive force in a proposed to reduce the effects of polymerization material static-testing machine until fracture oc- shrinkage (20-22). Furthermore, inadequate polymer- curred, the maximum fracture load of the speci- ization throughout the restoration may compromise its mens was measured (N) and the type of fracture physical properties and increase elution of monomer 4 Annali di Stomatologia 2016;VII (1-2): 4-10  Fracture resistance of endodontically treated teeth restored with a bulkfill flow able material and a resin composite (23-26) and may lead to undesirable effects, such as dures and were restored with a resin composite gap formation, marginal leakage, recurrent caries. It (EsthetX; Dentsply-Italy, Rome, Italy); may also negatively affect pulp tissue and may lead • Group C, which included 10 maxillary and 10 to premature failure of the restoration (27, 28). mandibular molars, which were subjected to en- Several manufacturers have recently developed and dodontic access cavity and endodontic proce- introduced new types of resin composites, so-called dures and were restored with a bulk fill flowable “bulk fill” materials, which can be applied to the cavity composite (SDR; Dentsply-Italy), except 1.5 mm and light cured to a maximal increment thickness of 4 layer of the occlusal surface that was restored mm (29-32) with enhanced curing, shrinkage and with the same resin composite as Group B. physical properties (33). Bulk fill flowable resin com- The access cavity was prepared using water-cooled posites are used in association with conventional round-ended cylindrical diamond burs and non-end- composites for aesthetic restorations in posterior cutting diamond burs mounted on a high-speed hand teeth, having lower polymerization stress, better flow piece with different diameters. Root canals were ne- with easy placement, an excellent adaptation to the gotiated with size 10 K-type files (Flexofile; Dentsply cavity walls and low modulus of elasticity, which can Maillefer, Ballaigues, Switzerland) to the major apical reduce the stress generated on the cavity walls (34). foramen and canals instrumented to length with NiTi The purpose of this in vitro study was to compare the rotary instruments (Mtwo; Sweden & Martina, Padova, fracture resistance of endodontically treated upper Italy) up to the #25 tip size and 0.06 taper file. During and lower molars restored with direct traditional and the endodontic treatment 5.25% sodium hypochlorite bulk fill flowable resin composite restorations. The (Niclor 5, Ogna, Muggiò Milan, Italy) for irrigation was null hypothesis tested was that there was a difference intermittently deposited using Pro Rinse side-vented in the fracture resistance and the mode of failure be- 30-G needles (Dentsply Tulsa Dental Specialties, Tul- tween endodontically treated maxillary and mandibu- sa, OK). The canals were dried with paper points and lar molars restored with traditional and bulk fill flow- filled with gutta-percha (single-cone #25/0.06 taper) able resin composite. and a resin-based endodontic sealer (AH-Plus, Dentsply Maillefer, Ballaigues, Switzerland). After the cleaning, shaping and filling procedures, post-opera- Materials and methods tive radiographs were taken in the two perpendicular dimensions (MD and BL) to evaluate the endodontic Sixty intact recently extracted human maxillary and treatment. Then, the enamel and dentin of the access mandibular molars with completely formed apices cavity were etched with 37% phosphoric acid for 30 were used in this in vitro study. The exclusion criteria and 15 seconds respectively, rinsed for 30 seconds for tested teeth were the presence of caries, previous with a water/air spray, and gently air-dried to avoid restoration and visible fracture lines or cracks. After a desiccation. A light-polymerizing primer-bond adhe- debridement with hand scaling instruments and sive (XP Bond, Dentsply International, York, USA) cleansing with rubber cup and pomice, the teeth were was applied, gently air-thinned and exposed to LED stored in individually numbered containers with 0.1% polymerization for 40 seconds. In group B access cav- thymol solution at 4° C until used. Thirty maxillary ities were restored with direct resin composite (Es- first molars with three separate roots and 30 thetX; Dentsply-Italy, Rome, Italy) with material incre- mandibular first molars with two separate roots were ments of maximum 2 mm. The specimens in Group C selected based on similar anatomical crown height, were restored with a bulk fill flowable composite with measured from the occlusal surface to the cemento- maximal increment thickness of 4 mm (SDR; enamel junction on the four sides of the teeth, and Dentsply-Italy), except for 1.5 mm layer of the occlusal bucco-lingual (BL), mesio-distal (MD) dimensions at surface that was restored with the same resin com- the occlusal surface. Tooth measurements were tak- posite as Group B (Fig. 1). en with a digital caliper. Preliminary radiographs were All the specimens were marked 2 mm below the ce- taken in two perpendicular directions (MD and BL) to mento-enamel junction and were covered with approx- determine root canal anatomy and measure the imately 0.25 mm-thick wax. The specimens were em- length and degree of canal curvature using the bedded in autopolymerizing acrylic resin (SR Ivolen; Schneider method (35). Specimens were subse- IvoclarVivadent, Schaan, Lichtenstein) in metallic cylin- quently assigned to 3 groups (n=10) for each tooth drical molds in position with their long axis parallel to that type creating homogenous groups considering the of the cylindrical molds. To simulate the periodontal average of teeth dimensions in order to minimize the ligament, at the first signs of the beginning of polymer- influence of size and shape variations on the results: ization, the teeth were removed from the resin blocks • Group A, the negative control group, which includ- and the wax was cleaned from the root surfaces. A ed 10 maxillary and 10 mandibular molars that standardized silicone layer was created using a light- were left intact for fracture testing, without any body silicone-based impression material (Aquasil ultra cavity preparation or root canal treatment; light bodies, Dentsply International, York, USA) which • Group B, which included 10 maxillary and 10 was injected into the polymerizing resin bases. The mandibular molars, which were subjected to en- teeth with now wax-free root surfaces were inserted in- dodontic access cavity and endodontic proce- to the resin bases immediately after the silicone injec- Annali di Stomatologia 2016;VII (1-2): 4-10 5 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  A. Isufi et al. Figure 1. Representative images of enamel and dentin of access cavity etched with 37% phosphoric acid (A), application of a light-polymerizing primer-bond adhesive (B), application of a bulk fill flowable composite with maximal increment thickness of 4 mm (C) , and final restoration of 1.5 mm layer of the occlusal surface restored a traditional resin composite (D). tion (36). All the specimens were stored in buffered man-Keuls test for multiple comparisons (Prism 5.0; saline plus 1.5% thymol at room temperature (24-28° C) GraphPad Software, Inc, La Jolla, CA) with the sig- until the fracture testing procedure. nificance level established at 5% (P < .05). All the 60 specimens were mounted in a mechanical material testing machine (LR30K; Lloyd Instruments Ltd, Fareham, UK) equipped by a (5k ± 5) N load Results cell. The teeth were loaded at their central fossa at a 30° angle to the long axis of the tooth (Fig. 2). The The mean of the bucco-lingual (BL) and mesio-distal continuous compressive force at a cross- head (MD) dimensions at the occlusal surface and the speed of 1.6 mm/s was applied with a 6 mm diame- anatomical crown height of the teeth tested are pre- ter ball-ended steel compressive head until visible sented in Table 1. No significant difference was found or audible evidence of fracture was shown. The comparing all teeth dimensions in control and test force at fracture was measured in Newton (N) and groups (P > .05). type of fracture was recorded as “favorable” be- No statistically significant differences were found cause restorable, when the failures were above the among groups (P<0.05). Fracture resistance of en- level of bone simulation (site of fracture above the dodontically treated teeth restored with a traditional acrylic resin) and as “unfavorable” because non-re- resin composite and with a bulk fill flowable compos- storable, when the failures were extending below ite (SDR) was similar in both maxillary (Group B: the level of bone simulation (site of fracture below 1072±525N; Group C: 1241±388N) and mandibular the acrylic resin). The data were verified with the molars (Group B: 1332±318N; Group C: 1527±449N). Kolmogorov-Smirnov test for the normality of the Restored teeth showed no significant decrease in distribution and the Levene test for the homogeneity fracture resistance compared to intact specimens of variances. Thus, they were statistically evaluated similar in both maxillary (Group A: 1183±313N) and by the analysis of variance test and Student-New- mandibular molars (Group A: 1620±170N) (Tab. 2). 6 Annali di Stomatologia 2016;VII (1-2): 4-10 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Fracture resistance of endodontically treated teeth restored with a bulkfill flow able material and a resin composite Figure 2. Simulated occlusal loading using a 6-mm-diameter steel sphere placed on the central fossa with lingual orientation in& axio-occlusal & line at 30° angle to the long axis of a mandibular molar tooth. Table 1. Mean and Standard Deviation of the Mesio-Distal (MD) and Buccal-Lingual (BL) dimensions and the anatomical crown height (measured at the four sides of the tooth) of the tested teeth in each group. Groups Control Bulk fill material (SDR) Traditional resin composite Tooth Type Occlusal Anatomical Occlusal Anatomical Occlusal Anatomical (n=10) Surface Crown Surface Crown Surface Crown Height Height Height MD BL MD BL MD BL a a b a a b a Upper 9.9 9.7 5.4 (0.1) 10.0 10.1 5.6 (0.6) 9.9 10.1a 5.4 (0.4)b Molars (0.6) (0.7) (0.5) (1.1) (0.5) (0.9) Lower 10.7 a 10.3 a 5.7 (0.4)b 10.6a 10.1a 5.5 (0.4)b 10.4a 10.2a 5.6 (0.7)b Molars (1.2) (0.6) (0.8) (0.7) (1.2) (0.8) Similar upper letter case in the same row indicates no statistically significant differences (P > .05). Table 2. Load at fracture (mean ± standard deviation) and type of fracture, Favorable (F) or Unfavorable (U) for intact teeth (control, Group A), and teeth restored with traditional resin composite (Group B) or with bulk fill flowable material (SDR) (Group C) assessed after the static test using the Instron Universal Machine. Tooth Type Load at Fracture (N) Type of Fracture (n=10) F U F U F U Group A Group B Group C Group A Group B Group C Upper Molars 1172 (598)a 1001 (453)a 1313 (428)a 8a 2b 3b 7a 3b 7a Lower Molars 1572 (639)a 1375 (310)a 1484 (471)a 7a 3b 3b 7a 2b 8a Similar upper letter case in the same row indicates no statistically significant differences (P > .05). Annali di Stomatologia 2016;VII (1-2): 4-10 7 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  A. Isufi et al. 60.8% of the failures in total were unfavorable (Group teeth. These findings may be attributed to the elastic B 70%; Group C, 75%; control group, 25%). No sig- buffer effect of using low viscosity flowable composite nificant differences were found in the mode of failure and the characteristic low contraction stress and low of the differently restored teeth between Group B and modulus of elasticity of SDR flow (44, 45). High flex- Group C, while intact teeth presented significantly ural modulus can inhibit the ability of a material to re- more favorable fractures compared to restored speci- sist deformation due to loading and promote the ac- mens (both Group B and Group C). cumulation of surface and bulk defects, which may lead to premature failure (46, 47). These findings are in agreement with those of Atiyah et al. (48), who re- Discussion ported increased fracture resistance of endodontically treated premolars restored with SDR. The null hypothesis investigated in the present study In the present study 75% of the samples in the intact can be rejected, as the results obtained support that control teeth presented favorable fracture type that there is no difference in the fracture resistance and in was an important statistical difference with the re- the mode of failure between endodontically treated stored groups. In fact, the majority of the teeth re- maxillary and mandibular molars restored with a bulk stored with SDR (75%) and with a traditional resin fill flowable resin composite (SDR) or a traditional composite (70%) reported unfavorable type of frac- resin composite. ture. However, no significant differences were found Fracture susceptibility of root-filled teeth is affected in the mode of failure between restored teeth. Fur- mostly by the amount of the remaining dentin (4, 37) thermore, all failures of the restored teeth were cohe- and it is not related to its biomechanical properties af- sive fractures, regardless of the type of restoration. ter endodontic treatment, such as hardness and The low elastic modulus may explain the severity of toughness (38). Some studies have shown that the fracture type presented in restored teeth groups and reduction of tooth structure results in weaker teeth the occurrence of unfavorable fracture. These find- due to restorative procedures (6-8). However, accord- ings are in agreement with previous reports that ing to Reeh et al. (4), endodontic procedures have found an increased frequency and severity of cuspal only a small effect on the tooth, reducing the relative fracture due to removal of cervical dentin (49). rigidity by 5%, which is contributed entirely by the ac- The limitations of this study must be recognized. The cess opening. Restorative procedures and, particular- experimental methods used for in vitro analyses do ly, the loss of marginal ridge integrity, were the great- not accurately reflect intraoral conditions, in which fail- est contributors to loss of tooth resistance. The loss ures occur primarily due to fatigue. Future research in of 1 marginal ridge resulted in a 46% loss in tooth this area should use cyclic loading and other fatiguing rigidity, and a MOD preparation resulted in an aver- simulation to more accurately reproduce the clinical age loss of 63% in relative cuspal rigidity. environment. Additional clinical studies are necessary Several studies were conducted to determine the ide- to determine the long-term prognosis of endodontical- al materials and techniques to restore endodontically ly treated maxillary and mandibular molars restored treated teeth because their long-term prognosis de- with bulk fill flowable resin composite. pends on the quality of the final restoration (39-42). Within the limitations of this in vitro study, endodonti- Usually, to restore endodontically treated teeth sever- cally treated upper and lower molars restored with al resin increments are required to fill the cavity bulk fill flowable resin composite presented a resis- preparation because of the large volume of the tance to fracture under simulated compressive force restoration. Thus, the clinician must compensate the not significantly different than that of traditional resin polymerization shrinkage of traditional resin-based composite restorations. Restored teeth showed no composite, by filling the cavities in several increments significant decrease in fracture resistance compared (43). A new category of flowable resin-based com- to intact specimens. Furthermore, no differences posites has been introduced as bulk fill base material were found in the mode of failure of the differently re- that can be applied in 4 mm thick bulks instead of us- stored teeth, while intact teeth presented statistically ing the incremental placement technique, without more favorable fractures. negatively affecting the polymerization shrinkage, Bulk fill flowable composites can be used to restore cavity adaptation or the degree of conversion (30). endodontically treated posterior teeth using 4 mm The results of the present study show that there were maximum increments and 1.5 mm occlusal traditional no significant differences in the static fracture resis- layer because this does not reduce the mechanical tance of endodontically treated molars restored with resistance of the restored teeth, while making the bulk fill flowable resin composite (SDR) and a tradi- procedure easier, less stressful and with a reduced tional resin composite. Moreover, the mean fracture chair side time. load for teeth restored with SDR was higher com- pared with the mean fracture load of specimens re- stored with traditional resin composites, without any Acknowledgements statistical significance. Furthermore, the results of this study showed that there was no significant differ- The Authors deny any conflicts of interest. ence between teeth restored with SDR and intact The Authors affirm that we have no financial affiliation 8 Annali di Stomatologia 2016;VII (1-2): 4-10 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Fracture resistance of endodontically treated teeth restored with a bulkfill flow able material and a resin composite (e.g., employment, direct payment, stock holdings, re- treated bovine anterior teeth. J Prosthet Dent. 2010;104:306- tainers, consultant ships, patent licensing arrange- 317. ments or honoraria), or involvement with any com- 18. Dietschi D, Scampa U, Campanile G, Holz J. Marginal adap- mercial organization with direct financial interest in tation and seal of direct and indirect Class II composite resin restorations: an in vitro evaluation. Quintessence Int. the subject or materials discussed in this manuscript, 1995;26:127-138. nor have any such arrangements existed in the past 19. Furness A, Tadros MY, Looney SW, Rueggeberg FA. Effect three years. Any other potential conflict of interest is of bulk/incremental fill on internal gap formation of bulk-fill disclosed. composites. J Dent. 2014;42(4):439-449. 20. Lindberg A, van Dijken JW, Lindberg M. Nine-year evalua- tion of a polyacid-modified resin composite/resin compos- References ite open sandwich technique in Class II cavities. J Dent. 2007;35(2):124-129. 1. Meyenberg K. The ideal restoration of endodontically treat- 21. Aguiar FH, Ajudarte KF, Lovadino JR. 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Review article Endo-restorative treatment of a severly discolored upper incisor: resolution of the “aesthetic” problem through Componeer veneering System i al on Guido Migliau, MD, DDS, PhD sive agent (for example a “three steps”) and then Laith Konstantinos Besharat, DDS, MSc, PhD with composite stratification it’s possible to apply Afrah Ali Abdullah Sofan, DDS, PhD the componeer veneer (choosing the right mea- Eshrak Ali Abdullah Sofan, DDS, PhD sure, modified as necessary) as the last covering Umberto Romeo, MD, DDS, PhD aesthetic layer. zi Result. The evaluation of result of this multidisci- plinary treatment was essentially clinical and ra- Department of Oral and Maxillo Facial Sciences, diological; in fact it’s possible to observe, from a na School of Dentistry, “Sapienza” University of Rome, clinical point of view, the good aesthetic aspect Italy of the direct composite restoration with com- poneer veneer that offers also some advantages: Corresponding author: conservative preparation with minimal lost of tooth tissue, easy standardized technique, low er Laith Konstantinos Besharat Department of Oral and Maxillo Facial Sciences, cost and immediate restoration of the tooth (with- School of Dentistry, “Sapienza” University of Rome out provisional passage). From a radiological Via Caserta, 6 point of view it’s possible to check the good qual- 00161 Rome, Italy t ity of endodontic retreatment on the post-opera- E-mail: besharatlk84@yahoo.it In tive periapical X-ray. To verify the long-term re- sult Authors consider follow up at six months and one year. Summary Conclusion. A multidisciplinary approach is al- ways necessary to program a treatment plan in ni Aim. Re-establishing a patient’s lost dental aesthet- dentistry; in the case reported Authors decide to ic appearance is one of the most important topics perform an endo-conservative treatment with dif- for contemporary dentistry. New treatment materi- ferent steps: io als and methods have been coming on the scene, - root canal therapy to resolve endodontical day by day, in order to achieve such an aim. Most problem dentists prefer more conservative and aesthetic ap- - glass fiber post to reinforce the conservative proaches, such as direct or indirect veneer restora- restoration iz tions, instead of full-ceramic crowns for anteriors - direct composite veneer restoration (after where aesthetics is really important. bleaching) to obtain the resolution of anterior The aim of the study is to evaluate clinically the aesthetic problems. Ed effectiveness of a direct composite veneering system in resolving aesthetic problem of an up- Key words: restorative dentistry, componeer. per incisor with a multidisciplinary treatment ap- proach. Methods. Patient with a severe discolored upper Introduction incisor came to our attention; at the X-ray exam IC there was an evidence of a past not good root Increasing demands for aesthetic restorative treat- canal treatment and also old and incongruent ments and recent advances in adhesive dentistry composite obturation. After removing all the ma- have led to the development of materials and tech- terial inside the root canal was performed a new niques aimed at restoring the natural tooth appear- C correct endodontic filling, then Authors tried to ance, especially in the anterior segment. bleach the tooth trough “walking-bleach” tech- Anterior tooth discoloration is one of the most frequent nique with a hydrogen peroxide (30 volumes) and causes of dental treatment. In the past years, dentists sodium perborate solution without excellent re- had been using several techniques and materials, © sults. So it was decided to insert a glass-fiber such as resin and porcelain to correct aesthetic prob- post and than to perform a direct composite ve- lems caused by various clinical conditions. Porcelain neer with Componeer System (Coltene). Com- and other all-ceramic veneers are rated as the best poneer System is a system of prefabricated com- veneer restorations (1-3) for discolored or malformed posite veneers that are abled to be applied direct- anterior teeth. Veneers have evolved over the last ly in the first appointment: after a conservative several decades becoming one of the most popular preparation of the tooth, it must be used an adhe- restoration tools in aesthetic dentistry. The veneer is Annali di Stomatologia 2015; VI (3-4): 113-118 113  G. Migliau et al. considered as an alterative to full coverage and en- 1) (8). Importantly, the accurate diagnosis of discol- hances the aesthetic appearance of the anterior denti- oration is a condition with multifactorial etiology; it is tion. Veneers can be divided into 3 categories: 1) free- classified as extrinsic and intrinsic and can occur due hand layering with direct composite resins; 2) pre- to a number of metabolic diseases, systemic condi- formed acrylic laminates; 3) laboratory-fabricated ve- tions and local factors (Tab. 2) (9). i neers (acrylic resins, composite resins, porcelains, al and glass ceramic veneers) (4-6). Excellent results can be achieved with the modern advanced composite Classification of tooth discoloration resin and adhesive systems; in contrast to conserva- on tive restorations they are able to correct existing ab- Intrinsic discoloration: intrinsic discoloration oc- normalities, aesthetic deficiencies (fractured, mal- curs following a change to the structural composi- formed or malposed teeth), and discolorations where tion or thickness of the dental hard tissues. The it is difficult to recreate harmonious tooth shape and normal color of teeth is determined by the blue, color. Disadvantages of the direct composite veneers green and pink tints of the enamel and is reinforced zi include long term color changing, less wear resis- by the yellow through the brown shades of dentine tance, which means that they often require repair or beneath. A number of metabolic diseases and sys- replacement, whereas disadvantages of ceramic ve- temic factors is known to affect the developing den- na neers include irreversible removal of tooth structure, tition and cause discoloration as a consequence. In technique sensitivity, cost and length of time needed addition, local factors such as injury are also recog- from the initial stage of tooth preparation until the nized. restoration is finally seated (7). Extrinsic discoloration: extrinsic color discoloration er The tooth can be discolored by deposition of pig- is outside the tooth substance and lies on the tooth ments in its internal structure and on its surface (Tab. surface or in the acquired pellicle. Table 1. Causes of tooth discoloration and types of stains. t Intrinsic discoloration In Extrinsic discoloration Internalized discoloration Types of stains 11. Alkaptonuria 1. Metallic 1. Developmental defects 1. Brown stain 12.Congenital erythropoietic porphyria 2. Non-metallic 2. Acquired defects 2. Black stain 13.Congenital hyperbilirubinaemia 1a) Tooth wear and gingival 3. Orange stain 1a) recession ni 14. Amelogenesis imperfect 1b) Dental caries 4. Green stain 15.Dentinogenesis imperfect 1c) Restorative materials 5. Metallic stain 1a) (Manuel et al., 2010) io 16. Tetracycline staining 6. Yellowish brown stains 17. Fluorosis 7. Violet to black 18. Enamel hypoplasia 8. Red-black iz 19.Pulpal hemorrhagic products 10. Root resorption 11. Ageing Ed Table 2. Extrinsic and intrinsic factors and their characteristics. Extrinsic factors Characteristics Intrinsic factors Characteristics Chromogenic bacteria stains Green, black-brown and orange Dentinogenesis imperfecta Yellow or grey-brown Tobacco Black, brown Amelogenesis imperfecta Yellow-brown IC Amalgam Black, grey Dental fluorosis Opaque white to yellow-brown patches Medicaments Silver-nitrate: Grey black Sulphur drugs Black staining Stannous-fluoride: Black brown C Chlorhexidine: Black brown Foods and beverages Coffee, tea, wine, berries, etc.: Tetracyclines: Color of corresponding food item Chlortetracycline Grey-brown hue Oxytetracycline Brown-yellow to yellow © Tetracycline HCL Brown-yellow to yellow Dimethylchlortetracycline Brown-yellow to yellow Minocycline Blue-grey to grey Doxycycline No change Iron Black cervical discoloration Dental trauma Transiently red through to black Ochronosis Brown 114 Annali di Stomatologia 2015; VI (3-4): 113-118  Endo-restorative treatment of a severly discolored upper incisor: resolution of the “aesthetic” problem through Componeer veneering System Internalized discoloration: internalized discoloration 1. Pre-restorative stage is the incorporation of extrinsic stain within the tooth substance following dental development. It occurs in a) Endodontic retreatment: enamel defects and in the porous surface of exposed After the anamnesis collection of data and an overall dentine. examination of oral status to exclude existing patholo- i gies, the tooth needing retreatment was diagnosed. al The diagnosis for retreatment was made according Composite veneer to the signs and symptoms reported by the patient and the preoperative radiographs showing apical ra- on Several Authors have suggested the use of compos- diolucency. The crucial factor for achieving success- ite resin veneers as direct or indirect method for ful retreatment is thorough reshaping and cleaning restoring anterior teeth instead of full-ceramic crowns of the canals to eliminate bacteria (18-20). During which provide well-functioning and aesthetic results retreatment the operators used bio orange solvent (OGNA) with hand K-file and ultrasonic device (Mec- zi (10-12). Nevertheless, to date, no restorative material has been more effective than the properties of the tron) to remove the broken instrument, gutta-percha natural dental structures themselves. Prefabricated and sealer (Fig. 3). Subsequently the tooth was pre- pared with Mtwo (Sweden & Martina) rotary Ni-Ti in- na composite resin veneers have been recently intro- duced (13). Specifically Componeer (Coltene, Altstat- struments to working length and irrigated with 5.25% ten, Switzerland) prefabricated veneers are thin com- NaOCl and refilling with the Thermafil system posite resin shells (0.3 mm cervically and 0.6-1.0 mm (Dentsply; Tulsa Dental, Tulsa, OK, USA) (21) the to the incisal edge), made of a pre-polymerized hy- Canal orifices were sealed with temporary material er brid composite resin, synergy D6 (Coltene). The ve- (Fig. 4). neers are cemented with the same hybrid composite resin that they are made from, which has the potential of making the complete restoration as a monoblock b) Chemical bleaching technique: unit (14). These veneers can be trimmed and bonded t to the tooth structure using direct hybrid composite In Given the appropriate indication, the bleaching of non-vital teeth is a relatively low-risk intervention to resin. One Coat Bond (Coltene) is the dentin adhe- improve the aesthetics of endodontically treated teeth sive included in the system, which is used to bond the (22-24). Depending on the situation, the walking prefabricated composite shells to the tooth structure bleach technique can be an uncomplicated and con- using an etch-and-rinse bonding strategy (15, 16). ni Composite veneers take on special importance in Restorative Dentistry, as they are less expensive, which makes this practice a feasible option, mostly to io people with a lower income and satisfy the patient’s restorative needs and aesthetic desires (17). This case report describes a clinical case performed by iz means of prefabricated Composite veneers to correct a variety of generalized color defects on the upper central incisor, aimed at the aesthetic and functional Ed reconstruction with a multidisciplinary treatment ap- proach. Figure 1. Preoperative view of central incisor. Case report IC A 45-year-old female patient came to our Department with a discolored tooth, a maxillary left central in- cisor, which was compromising the aesthetic of her smile (Fig. 1). On elaborating the medical history of C the patient, it was noted that the same tooth had been traumatized previously. The tooth has an old in- congruous root canal therapy (short filling), with a broken instrument inside the canal, observed through pre-treatment X-ray (Fig. 2). Furthermore, by clinical © examination the defect of an old composite obtura- tion was evident. From the above mentioned findings, in agreement with the patient, a conservative aesthetic rehabilita- tion was decided. The treatment was divided into two stages: Figure 2. Pre-treatment X-ray. Annali di Stomatologia 2015; VI (3-4): 113-118 115  G. Migliau et al. venient method for both patients and dentists: the the access cavity after each operation (26-28). The bleach agent is collocated inside the pulp chamber, procedure was repeated tree times. after putting a seal with glass-ionomeric cement at the coronal portion of the canal. Some tooth discolorations in endodontically treated 2. Restorative stage i teeth are caused by dental treatments. In this case al the type of root-canal filling material and medication Discolored anterior teeth are often perceived as an agent, played a role in the discoloration tendency of aesthetic detraction. An array of treatment, like ce- the tooth (25). ramics or composite veneering, is available for the re- on The walking bleach technique was carried out by in- maining discoloration after the bleaching technique. ternal whitening treatment with an Opalescence endo In this case a glass-fiber posts (Sweden & Martina) (Ultradent) respectively, in the pulp chamber then us- was placed into the root canal to achieve retention for ing Cavit as temporary filling material to properly seal the restoration (29), before performing the composite veneer. zi The treatment consists of prefabricated Componeer direct Composite veneering System (coltene) to en- hance the aesthetics of smile (14). This technique is na less traumatic and more conservative for patients with the additional advantage that it can be performed efficiently in just a single session. er a) Preparatory phase: Shade and size selection: the shade is selected t with the use of the Componeer synergy D6 shade In guide (Coltene). The color guide comes with six dentin cores and two enamel shells (Fig. 5). After the teeth are cleaned, the enamel and dentin shades are evaluated separately. The enamel shell guide is su- perimposed over the dentin core to determine the ap- ni Figure 3. Intraoperative X-ray. proximate final color. The size of the composite shell for a specific patient is selected with Componeer con- tour Guides. A wider and longer size is recommended io rather than a short and narrow shape, as the clinician will have the possibility of trimming and customizing the prefabricated veneer with an abrasive disk to iz match the shape of the natural tooth as close as pos- sible. Ed b) Tooth preparation: After local anesthesia and rubber dam application, the old restoration is removed first by using a ta- pered-cylinder, round-end diamond bur. Tooth mar- gins and prepared surfaces were then etched for 15 IC seconds with a 37% phosphoric acid etchant gel (Scotchbond Universal, 3M ESPE). The tooth were Figure 4. Postoperative X-ray. rinsed and dried, and thereafter separated by inter- C Figure 5. Componeer synergy D6 shade guide. © 116 Annali di Stomatologia 2015; VI (3-4): 113-118  Endo-restorative treatment of a severly discolored upper incisor: resolution of the “aesthetic” problem through Componeer veneering System proximal matrices. A dental bonding agent (One durability. Further investigation is needed to deter- Coat Bond, Coltène Whaledent) was applied to all mine the longevity of this new treatment from six prepared surfaces, followed by gentle air-drying from months to one year at least (Figs. 7, 8) in order to re- the cervical to the incisal aspect and light-curing for port that no failure of the restoration was detected. 20 seconds. Dentin shaded composite was free- i handed and then used to restore with the corre- al sponding preparations of a conventional direct com- Conclusion posite restoration and light-curing for 40 seconds. The size and mould required were re-checked, and On the basis of the results, it can be concluded that in on the corresponding veneers adjusted. A similar layer anterior aesthetic problems it’s important to under- of adhesive was applied to the bonding surface of stand the etiology of the discoloration: in the case pre- the veneers and thereafter a thin layer of composite sented the corrosive products of the broken instru- (Synergy D6, A1 enamel shade, Coltène Whaledent) zi evenly distributed with accurate marginal adaptation. The veneer was transferred to the corresponding tooth. The prefabricated veneer was pressed gently na into position and shielded (without excessive pres- sure). While holding the veneer in position, the obvi- ous excess was removed and the composite smooth- ly adapted to the Componeer with a sable brush. The entire restorative complex was then light-cured from er the lingual side for at least 40 seconds, and from the facial side for 40 seconds cervically and 40 seconds incisally. Contours and occlusal interferences were adjusted with a high speed bur and margins were re- fined and polished by strips for interproximal areas, t In flexible aluminum oxide discs, which are ideal to ad- just the incisal angles, and silicone rubber polishers were used for the polishing steps. Figure 6. Periapical X-ray postoperative. ni Discussion The facial anatomical shape template in the form of a io thin composite shell simplifies direct veneering of one or more front teeth. The extremely thin veneer coat- ings from 0.3 mm allow a high level of conservation of iz hard tooth substance during preparation. The shiny and naturally designed surface adds a look of vitality to the restoration. Ed The Componeer system is an affordable and less time consuming alternative for patients who cannot sustain the cost of porcelain veneers and presents many advantages: Figure 7. Postoperative clinical vision. 1) minimally invasive (30); 2) simple and versatile application; IC 3) no impression required; 4) cementation using high quality permanent venee- ring material; 5) highly polished surface giving long-lasting, natural C looking aesthetic clinical results (31); 6) shine can be refreshed by polishing at any time, unlike porcelain veneers and they can be easily repaired (31). The other major advantage of this “different” veneer- © ing approach is straightforward solution in only one appointment with the same outcome. It has also been reported that a good quality of endodontic retreat- ment on the postoperative periapical X-ray (Fig. 6) may enhance the long-term aesthetic results of this method, resulting in good aesthetics, function and Figure 8. Follow up after 1 year. Annali di Stomatologia 2015; VI (3-4): 113-118 117  G. Migliau et al. ment inside the canal were the cause of the grey ap- 15. Perdigão J, Sezinando A, Muñoz MA. Prefabricated veneers- pearance of the left superior incisor. A multidiscipli- bond strengths and ultramorphological analyses. J Adhes nary approach is to consider it necessary to resolve Dent. 2014;16:137-46. 16. Sahin G, Albayrak AZ, Bilgici ZS, Avci D. Synthesis and eval- the problem: at first endodontic retreatment, succes- uation of new dental monomers with both phosphonic and car- sively bleaching and coronal restoration. To improve i boxylic acid functional groups. J Polym Sci Part A Polym the aesthetic result a prefabricated adhesive compos- al Chem. 2009;47:1953-65. ite veneer was applied. Prefabricated composite ve- 17. Pontons-Melo JC, Furuse AY, Mondelli J. A direct composite neers are useful adjuncts to dentist armamentaria and resin stratification technique for restoration of the smile. Quin- they help in resolving aesthetic problems, in a single tessence Int. 2011;42:205-11. on appointment, minimizing the dental tissue reduction. 18. Ingle JI, Bakland LK, Beveridge EE, Dudley H. Glick, Hoskinson AE. Modern Endodontic Therapy. In: Ingle JI, Bak- land LK. Endodontics, 5th Edition. Bc Deckler. 2002;16-17. References 19. Rocas IN, Jung IY, Lee CY, Siqueira JF, Jr. Polymerase chain reaction identification of microorganisms in previously root- zi 1. Peumans M, Meerbeek BV, Lambrechts P, Vanherle G. filled teeth in a South Korean population. J Endod. 2004; Porcelain veneers: a review of the literature. J Dent. 2000; 30:504-8. 28:163-177. 20. Sjogren U, Figdor D, Persson S, Sundqvist G. Influence of na 2. Conrad HJ, Seong WJ, Pesun IJ. Current ceramic materi- infection at the time of root filling on the outcome of endodontic als and systems with clinical recommendations: A system- treatment of teeth with apical periodontitis. Int Endod J. atic review. J Prosthet Dent. 2007;98:389-404. 1997;30:297-306. 3. Spear F, Holloway J. Which all-ceramic system is optimal for 21. Samadi F, Jaiswal J, Saha S. A Comparative Evaluation of anterior esthetics? J Am Dent Assoc. 2008;139:19S-24S. Efficacy of Different Obturation Techniques used in Root 4. Christensen GJ. A veneering of teeth: state of the art. Dent Canal Treatment of Anterior Teeth: An in vitro Study. Int J er Clin North Am. 1985;29:373-391. Clin Pediatr Dent. 2014;7:1-5. 5. Meijering AG, Creugers NHJ, Roters FJM, Mulder J. Survival 22. Fasanaro T S. Bleaching teeth: history, chemicals and meth- of three types of veneer restorations in a clinical trial: a 2.5 ods used for common tooth discolorations. J Esthet Dent. year interim evaluation. J Dent. 1998;26:563-568. 1992;4:71-78. 6. Lin CY, Lee BS, Lee MS. Patients with discolored and t 23. Amato M, Scaravilli MS, Farella M, Riccitiello F. Bleaching improvement after restoration with CAD/CAM (Cerec 3D) In malaligned anterior teeth able to obtain significant esthetic teeth treated endodontically: longterm evaluation of a case series. J Endod. 2006;32:376-378. porcelain veneers - case report. J Dent Sci. 2006;1:88-93. 24. Marongiu N, Cochran T. Conservative cosmetic dentistry post- 7. Ritter AV. Porcelain Veneers. J Esthet Restor Dent. 2002; trauma. Gen Dent. 2014;62:26-31. 14:55. 25. Krastl G, Allgayer N, Lenherr P, Filippi A. Tooth discoloration ni 8. Watts A, Addy M. Tooth discoloration and staining: a review induced by endodontic materials: a literature review. Dent of the literature. Br Dent J. 2001;190:309-16. Traumatol. 2013;29:2-7. 9. Sulieman M. An overview of tooth discoloration: extrinsic, in- 26. Watts A, Addy M. Tooth discoloration and staining: a review trinsic and internalized stains. Dent Update. 2005;32:463- of the literature. Br Dent J. 2001;190:309-16. io 4, 466-8,471. 27. Weisman HN. Bleaching non-vital teeth. Dental Survey. 10. Acevedo RA, Suarez-Feito JM, Tuero CS, et al. The use of 1968;44:52-3. indirect composite veneers to rehabilitate patients with den- 28. Leendert B, Jordan RE, Skinner DH. A Conservative bleach- tal erosion: A case report. Eur J Esthet Dent. 2013;8:414-31. iz ing treatment for the non-vital discolored tooth. Compendium 11. Vanini L, De Simone F, Tammaro S. Indirect composite of Continuing Education in Dentistry. 1984;5:471-5. restorations in the anterior region: A predictable technique for 29. Bandèca MC, EL-Mowafy O, Shelbl A. Nonmetallic post-en- complex cases. Pract Proced Aesthet Dent. 1997;9:795-802. dodontic restorations: A Systematic Review. Int J Dent Re- Ed 12. Mangani F, Cerutti A, Putignano A. Clinical approach to an- cife. 2010;57-62. terior adhesive restorations using resin composite veneers. 30. Furuse AY, Soares JV, Cunali RS, Gonzaga CC. Minimum Eur J Esthet Dent. 2007;2:188-209. intervention in restorative dentistry with V-shaped facial and 13. Dietschi D, Devigus A. Prefabricated composite veneers: His- palatal ceramic veneers. The Journal of Prosthetic Dentistry. torical perspectives, indications and clinical application. Eur 2016 Jan 7. J Esthet Dent. 2011;6:178-87. 31. Pimentel W, Teixeira ML, Costa PP, Jorge MZ, Tiossi R. Pre- 14. Gomes G, Perdigão J. Prefabricated Composite Resin Veneers dictable Outcomes with Porcelain Laminate Veneers: A Clin- IC – A Clinical Review. J Esthet Restor Dent. 2014;26:302-313. ical Report. Journal of Prosthodontics. 2015 Dec 1. C © 118 Annali di Stomatologia 2015; VI (3-4): 113-118 

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Review article Laser-assisted treatment of dentinal hypersensitivity: a literature review i al on Roberto Biagi, MD, DDS1 Introduction Gianguido Cossellu, DDS, PhD1 Michele Sarcina, DDS1 Dentinal hypersensitivity (DH), or cervical dentinal Ilaria Tina Pizzamiglio, RDH 2 sensitivity, is a frequent clinical disorder. It is defined Giampietro Farronato, MD, DDS1 as pain arising from exposed dentine typically in re- zi sponse to thermal, chemical, tactile or osmotic stim- uli, and it appears to be a common problem with vari- ous reports indicating an incidence between 4 to 74% na 1 Department of Biomedical, Surgical and Dental Sci- among the population. The high variation in preva- ences, Unit of Orthodontics and Paediatric Den- lence rate among most studies on dentin hypersensi- tistry, School of Dentistry, University of Milan; Fon- tivity should be explained by the bias concerning the dazione Cà Granda IRCCS Ospedale Maggiore highly selected population such as patients at dental er Policlinico, UOC di Chirurgia Maxillo-Facciale ed clinics, students, or hospitalized patients (1-8). Odontostomatologia, Milan, Italy Dentinal hypersensitivity may be caused by several 2 Private Practice of Dental Hygiene conditions such as a result of periodontal patholo- gies, trauma, dental bleaching, professional oral hy- t giene, acid foods and beverages, bad oral hygiene Corresponding author: In habits or incorrect brushing techniques with conse- quent gingival recessions, etc. Even the removal of Roberto Biagi orthodontic fixed appliances could expose teeth to Fondazione Cà Granda IRCCS Ospedale Maggiore hypersensitivity. It seems that DH is rarely a result of Policlinico, UOC di Chirurgia Maxillo-Facciale ed just one of above factors, but rather a combination of ni Odontostomatologia more than one. Via della Commenda, 10 Patients are usually treated with topical desensitizing 20122 Milano, Italia fluorine pastes and sealants. Even the aesthetic filling io E-mail: roberto.biagi@unimi.it of eroded or exposed dental necks seems to be a good practice for pain reduction. Only in last decades these procedures have been supported by a laser-assisted treatment, often combined with classic desensitizing. iz Summary The use of lasers for DH treatment dates back to the ’80s with the advent of the erbium laser. Although the The purpose of this literature review was to evalu- initial results were quite disappointing, the improvement Ed ate the effectiveness of the laser-assisted treat- of technologies and scientific knowledge over the years ment of dentinal hypersensitivity. A review with optimized instrumentation and created new lasers with inclusion and exclusion criteria was performed wavelengths suitable for the treatment (9-11). from January 2009 to December 2014 with elec- Most of the studies conducted with various types of tronic data-bases: MedLine via PubMed, Science lasers, at different wavelengths and application times, Direct and Cochrane Library. Research of paper reveal the effectiveness of this treatment, both imme- IC magazines by hand was not considered. Forty- diately and during follow-up after approximately 6 three articles were selected between literature re- months from the first treatment. As a result, the pain views, in vitro studies, clinical trials, pilot and is reduced and in many cases it even disappears. Of- preliminary studies. The items were divided into ten the laser therapy is integrated with the use of de- C laser-used groups for an accurate description, sensitizing agents based on fluorine or newly discov- and then the reading of results into various ty- ered substances, and this can lead to an improve- pologies. Laser-assisted treatment reduces denti- ment in results (9, 12, 13). nal hypersensitivity-related pain, but also a psy- Referring to the course of action, it was shown how © chosomatic component must be considered, so the low-power lasers, including the GaAlAs diode further studies and more suitable follow-ups are laser with a wavelength between 780 and 900 nm, necessary. acts on the nervous level, thus eliminating the sensi- tivity. The medium-power lasers, including Nd:YAG, Key words: dentinal hypersensitivity, dentinal CO2 and Er:YAG laser, desensitize causing narrow- tubules, desensitizing agent, laser therapy. ing and occlusion of dentinal tubules (10, 11). Annali di Stomatologia 2015; VI (3-4): 75-80 75  R. Biagi et al. The purpose of this literature review is to evaluate the Inclusion criteria: effectiveness of the various types of lasers used in - in vivo and in vitro studies dentistry for the DH treatment, and to assess their va- - literature reviews, pilot studies, preliminary studies lidity both in the immediacy and after a follow-up. and clinical trials with and without use of placebo substances i - studies in which the laser-assisted desensitization al Materials and methods treatment was effected by means of the medium- or low-power. Research strategies on The following electronic databases have been evaluated: Results MEDLINE (via PubMed; www.ncbi.nlm.nih.gov/pubmed), Science Direct (www.sciencedirect.com) and the regis- Studies selection ter of clinical trials and Cochrane reviews (Cochrane Li- zi brary; www.cochranelibrary.com). There has been no Forty-three articles have been selected. The ap- research done manually with paper magazines. The proach starts from selection between literature re- time limit was from January 2009 to December 2014. views, in vitro studies, clinical trials, pilot and prelimi- na The databases were consulted using the following nary studies per annum. key words crossed in various ways: The items will be divided into laser-used groups for (dental OR dentine OR tooth OR teeth OR cervix OR an accurate description, and then the reading of re- cement) AND (sensitive OR hypersensitivity) AND sults into various typologies. er laser. Initially, the research was set without the use of Boolean values and removing the parentheses: dental sensitive laser, dental hypersensitivity laser, Nd:YAG laser dentine sensitive laser, dentine hypersensitivity laser, t tooth sensitive laser, tooth hypersensitivity laser, cer- The efficiency of the Nd:YAG laser (neodymium- In vical sensitive laser, cervical hypersensitivity laser, cement sensitive laser, cement hypersensitivity laser, doped yttrium aluminium garnet; Nd3+:Y3Al5O12) and common desensitizing pastes for the reduction of the teeth sensitive laser, teeth hypersensitivity laser. dentinal tubules lumen have been evaluated. Far- The second type of research involved the Boolean makis et al. (14) evaluated the efficacy of the Nd:YAG value “AND”: against a desensitizing paste (Novamine®). Subjects ni dental AND sensitive AND laser, dental AND hyper- were divided into groups depending on the use of on- sensitivity AND laser, dentine AND sensitive AND ly paste, only laser (0,5 W) or both. The SEM analy- laser, dentine AND hypersensitivity AND laser, tooth sis showed that the first group expressed greater oc- io AND sensitive AND laser, tooth AND hypersensitivity clusion of dentinal tubules than the second one. A AND laser, cervix AND sensitive AND laser, cervix year later, Farmakis et al. (15) proposed another AND hypersensitivity AND laser, cement AND sensi- study with different laser powers, both 0,5 and 1 W. tive AND laser, cement AND hypersensitivity AND In this case the 1 W laser, either alone or in combina- iz laser, teeth AND sensitive AND laser, teeth AND hy- tion with desensitizing paste, was more effective persensitivity AND laser. The third type of the re- compared to 0,5 W laser. search has been carried out using both AND and OR Al-Saud and Al-Nahedh (16) used other types of de- Ed Boolean values: sensitizing paste (Gluma®, TenureQuicl®, Quell and (dental OR dentine OR tooth OR teeth OR cervix OR VivaSens®) instead and divided subjects in random cement) AND sensitive AND laser, (dental OR den- groups in order to highlight that the best method to tine OR tooth OR teeth OR cervix OR cement) AND completely occlude or reduce the dentinal tubules di- hypersensitivity AND laser. The last research method ameter was Nd:YAG anyway. was achieved by keywords: An in vivo study evaluated the difference in reducing IC laser, hypersensitivity without Boolean values. The DH among the Nd:YAG laser and Gluma®. Patients research methodology has identified about 150 scien- were divided into three groups (only Gluma®, only tific papers. laser and both) and pain levels were analyzed 5’, 1 week, 1-3-6 months after with VAS. Although all pro- C tocols have demonstrated a marked reduction in pain Criteria even after six months, the combination of laser and paste remains the most significant treatment (17). Exclusion criteria have been selected: Some Authors introduced a potassium binoxalate gel © - presence of pediatric patients and evaluated the efficacy in combination with laser - studies without complete statistical data or alone with VAS after cold air and hot water stimu- - at least 3 months’ follow-up studies lation. Data were carried out immediately, 3-6-9 - in vivo studies without measuring by Visual Ana- months after with the aid of electron microscope. log Scale (VAS) and Verbal Rating Scale (VRS) Thanks to the merger of dentinal tubules, laser treat- - case series ment is better in durability, even if the gel appears as - case reports. a valid aid for its micro-crystals penetration (18). 76 Annali di Stomatologia 2015; VI (3-4): 75-80  Laser-assisted treatment of dentinal hypersensitivity: a literature review Abded et al. divided subjects into three groups, with The in vitro studies, after SEM observation, produced laser (1 W for 60’’), with a new desensitizing agent very positive results concerning the immediate occlu- (Seal & Protect™) and no-treatment. Thanks to the sion of dentinal tubules. Aranha and Eduardo (32) set use of the SEM, the Author noted that the new resin laser to a power of 0,25 and 0,5 W and highlighted was more effective than laser treatment (19). carbonization and dentin fracture as well as lacking i closure of dentinal tubules. Yilmaz et al. (33) con- al firmed immediate pain relief in the group treated with Diode laser laser compared to placebo. The association between laser and glutaraldehyde desensitizing paste on In the last years, the diode laser (DL) has been the (Gluma®) confirms the usefulness of this treatment in most used by dental hygienists during daily work. The the long term (up to 6 months later) (34). literature contains a good amount of studies about Always Aranha and Eduardo (35) have divided 28 sub- this type of laser, particularly its effectiveness against jects into 4 groups. The first group received instructions zi dentinal hypersensitivity (20, 21). about nutrition and oral hygiene, and no-power laser Hashim et al. (22) carried out an in vivo study on 14 treatment (0 W), the second was treated with Er:YAG teeth of five different patients using a diode laser (0,5 laser for 20’’, while the third and fourth one with na W). Moreover, subjects have been divided into two Er,Cr:YSGG (respectively with 0,25 and 0,5 W for 30’’). groups based on laser exposure (30 and 60’’) and Data underlined how each treatment reduces, although checked 15’ and seven days after. Authors demon- partially, the hypersensitivity pain, but treatments with strated that the 60’’ exposure is the most effective. 0,25 W Er,Cr:YSGG laser are the most efficient. Often, this type of laser has been used in combina- A recent study combines the laser sealing effect with er tion with 3% potassium nitrate or potassium oxalate a tooth paste nano-carbonate apatite made. Data are gel (23-25). Even fluoride gels are often aid in the hy- encouraging new research with statistical analysis persensitivity treatment (26). and long-term results (36). In 2012, Romeo et al. (27) divided subjects into three t groups: with fluoride gel (60’’), with 0,5 W laser and with both. The VAS reduction and better results over time In Comparison between different lasers were detected in both groups, although laser treatment reported a marked improvement over the initial situation. After the previous disquisition regarding studies on a Aranha et al. (28) compared different types of prod- single type of laser, associated or not to other agents, ucts. Gluma® has been applied for 30’ with cotton it is interesting to evaluate the comparative works be- ni swab on tooth surfaces (Heraeus Kulzer, Armonk, NY, tween various commercial types of lasers. These USA), Seal & Protect™ (Dentsply, Petrópolis, RJ, studies are very heterogeneous, both in wavelengths Brazil) for 20’’, 3% Oxa Gel potassium oxalate for 2’ and frequency used, for both samples and the treat- io and APF (acidulated phosphate fluoride) for 1’. Lastly, ment duration (37). Also in this section the effective- the laser treatment has been used. Although all these ness of CO2 laser will be debated, despite the paucity protocols have led to a hypersensitivity reduction, of literature on its individual use in last years. iz laser therapy has very long term desensitizing effects. Romano et al. (38) indeed stress the sealing power of The recent introduction of cyanoacrylate has invali- the CO 2 laser. Subjects have been divided into 7 dated the diode laser as the excellence therapeutic groups and treated with only laser (0,5-1-1,5 W) or Ed tool. Flecha et al. (29) have shown how cyanoacry- with laser and a calcium hydroxide paste. The tubular late has the same efficiency, but with lower cost and occlusion has been detected in each study group al- without side effects. Lin et al. (30) could evaluate how though the paste produced a higher reduction in hy- there are no real differences in terms of pain reduc- persensitivity. Furthermore, samples treated exclu- tion between laser therapy, desensitization of the sively with laser have also highlighted dentinal car- nerve or their combination. bonization or cracks. IC A recent in vitro study, however, focuses on both the Two clinical studies, on the other hand, compared the sealing ability and the potential danger of laser at the CO2 and Er:YAG lasers. Patients have been random- expanse of dental pulp. Umana et al. (31) have used ly assigned to the different groups, treated with only different laser powers (0,8 - 1 - 1,6 - 2 W) on 24 extract- laser therapy, in association with fluoride gel or just C ed teeth and concluded that the 0,8 or 1 W laser irradi- placebo. The best results have been obtained with ation for 10’’ can seal dentinal tubules without damage. the aid of the laser in association to gel (39, 40). In a comparative in vitro study the Er,Cr:YSGG (0,25 W), the Nd:YAG (1 W), the CO2 (1 W) and the diode Er:YAG and Er,Cr:YSGG lasers (810 nm, 2 W) lasers have been evaluated. Although a © diameter reduction of dentinal tubules has been de- A more thorough analysis reserved to the old and tected in all groups, the best result was obtained with more powerful lasers, such as the Er:YAG (erbium- Nd:YAG laser (53%) (41). Another study compares doped yttrium aluminium garnet; Er3+:Y3Al5O12) and similar types of lasers: CO2 and Er:YAG lasers are ef- the Er,Cr:YSGG (erbium, chromium: yttrium-scandi- fective in treating DH and reducing its symptoms, even um-gallium garnet; Er3+:Y3Sc2Ga3O12). if the Er:YAG laser has a more significant effect (42). Annali di Stomatologia 2015; VI (3-4): 75-80 77  R. Biagi et al. Table 1. Summary of the main conclusions of the studies considered for the review. Pro laser treatment Against laser treatment All types of laser treatments are more effective than Resins recently released onto the market appear to be in traditional methods when used in association with gel or some studies more effective than laser treatment i desensitizing tooth paste al Laser treatment combined with home therapy using Also some adhesives such as cyanoacrylate are more a specific toothpaste produces longer lasting effects effective than laser compared with traditional methods on Compared with other lasers, diode lasers produce SEM analysis show a similar reduction of the tubular a gradual symptoms improvement that also lasts longer diameter in both treatments Other kinds of laser induce an immediate pain reduction, The laser treatment can produce a significant placebo but the results don’t last as long effect zi Some Authors have shown the superiority of Nd:YAG, tists. Studies are clarifying the follow-up results within Er:YAG and CO2 treatment compared to conventional the interference of the placebo effect. The DL has na topical products, but between these and the diode specific wavelengths resulting very safe for the pa- laser the situation is not well defined (43-46). tient and, above all, not causing side effects or dam- Taking into consideration the placebo effect, it is absent age on the pulp as it is the case in older and powerful for the diode laser, Er:YAG and Nd:YAG, except the systems such as Er,Cr:YSGG or Er:YAG lasers. er Er,Cr:YSGG results (47). Blatz (48) obtained further da- However, in vitro studies confirm a real effectiveness ta: the Nd:YAG, Er:YAG and CO2 laser-treatments are of these lasers. Thanks to the SEM analysis, the per- slightly higher than the classic desensitizing topical centage of occlusion appears to be complete and the products, but Yilmaz et al. (49) in a randomized con- diameter of dentinal tubules reduced (50, 51). trolled clinical trial, highlighted the equal effectiveness t of the diode laser (60’’) and the Er,Cr:YSGG laser (30’’). Therefore data indicated a small difference be- In Conclusions tween two laser treatments, thus underlining contradic- tions in literature. Although it would seem that the laser treatment effec- Table 1 summarizes the main conclusions of the tively reduces pain symptoms, further studies and ni studies included in this review. more suitable follow-ups are necessary. Another im- portant consideration regards the reduced presence of side effects in the matter of new generation lasers, io Discussion already set up by the manufacturer and supplied with specific protocols for each treatment. The Diode This literature review proposes to analyze recent Laser has to be preferred for DH treatment thanks to years’ publications, although they were a lot and its use in safety and beneficial clinical results. iz sometimes at odds with each other, related to differ- More clarity should be obtained on the topic “placebo ent lasers for dental hypersensitivity treatment. effect”. In many cases it was found that patients un- The laser-assisted treatment of dentine hypersensitiv- dergoing placebo still receive benefits with a reduc- Ed ity is a good method to solve immediate and long- tion of the VAS values. These considerations do not term pain. Compared to conventional desensitizing exclude a psychosomatic component of dentinal hy- topical agents, the laser treatment, although more ex- persensitivity. pensive, leads to rapid results with less application In consideration of all data gathered, it can be said time and more quickly for the patient. In most of the that laser is an innovative and faster treatment both articles, fluoride gel or desensitizing substances used in terms of therapy time and results, with minimal IC in combination with laser light can potentiate effects. side effects and greater comfort for patients, which The same line of reasoning is considered valid for the appear more satisfied with traditional methods. association with desensitizing pastes. New substances as cyanoacrylate, glutaraldehyde C and potassium binoxalate are spreading for the prop- Acknowledgements erties to stimulate laser beneficial effects and they can be used alone as preventative measures in pa- The Authors would like to thank Dr. Silvia Faverzani tients with mild hypersensitivity. However, the effec- Gibbs for editing the English text. © tiveness of these treatments has clashed sometimes with the existence of a placebo effect. 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Review article Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS) i al Luca Levrini, MD1 - mild or moderate OSAS, in patients who prefer n Franco Sacchi,MD, DDS2 OAs to continuous positive airway pressure (CPAP) Francesca Milano, DDS3 or who are not suitable candidates for CPAP, be- io Antonella Polimeni, MD4 cause of its failure or failure of behavioral approach- Paola Cozza, MD5 es like weight loss or positional therapy; - severe Edoardo Bernkopf, MD, DDS6 OSAS, in patients who do not respond to or do not az Marzia Segù, MD7 tolerate CPAP and in whom no indication for either Italian dentist work group about OSAS maxillofacial or ENT surgery appears applicable. Collaborators: Marco Zucconi, Claudio Vicini, Conclusions. The application of oral appliances is Enrico Brunello highly desirable in cases of simple snoring or mild rn to moderate OSAS, whereas considerable caution is warranted when treating severe OSAS. It is fun- 1 Università degli Studi dell’Insubria, Varese, Italy damental to ensure that the patient understands 2 Società Italiana Medicina del Sonno Odontoiatrica, his problem and, at the same time, to present all te Milano, Italy the various treatment options. 3 Società Italiana Medicina del Sonno Odontoiatrica, Bologna, Italy In Key words: obstructive sleep apnea syndrome, 4 Dipartimento di Scienze Odontostomatologiche e snoring, guidelines, oral appliance. Maxillo Facciali, Università di Roma “Sapienza”, Roma, Italy 5 Università degli Studi di Roma “Tor Vergata”, Ro- Introduction ni ma, Italy 6 Associazione Nazionale Dentisti Italiani, Vicenza, Italy Recent decades have seen dentists becoming in- 7 Unità per lo Studio del dolore orofacciale e dei disor- creasingly involved in the treatment of disorders that dini temporomandibolari, University of Pavia, Italy also fall within the domain of other medical specialists. io These disorders include obstructive sleep apnea syn- drome (OSAS), sleep bruxism and temporomandibular Corresponding author disorders. The fact that dentists today are more aware iz Luca Levrini of sleep disorders, in which they could potentially play Università degli Studi dell’Insubria a diagnostic and therapeutic role, stems from a grow- Via Piatti, 10/a – Velate ing recognition of orofacial characteristics as impor- Ed 21100 Varese, Italy tant developmental factors, and from the realisation E-mail: luca.levrini@uninsubria.it that they have therapeutic implications in disorders such as OSAS, snoring and bruxism. These trends in- dicate the need for an interdisciplinary approach to Summary these disorders and, therefore, for optimal collabora- tion among the different specialists involved (1-4). IC Background. The aim of the present article is to In this paper, we focus on the role of dentists in the present a set of proposed clinical recommenda- screening and treatment of sleep-disordered breathing tions aimed at Italian dentists involved in the man- (ranging from snoring to OSAS) in adult patients. From agement of patients with obstructive sleep apnea the screening perspective, it can immediately be re- C syndrome or snoring. marked that dentists, on account of their contact with Methods. With the purpose of creating a study many members of the general population, are ideally group, some of the most important Italian scientific placed to screen for potential OSAS sufferers. This societies operating in fields relevant to the issue of could be done using simple questionnaires. As regards @ sleep medicine in dentistry were asked to appoint a the treatment of sleep-disordered breathing, an in- representative. Each member of the study group creasing body of published literature reflects the grow- was required to answer questions regarding the ing worldwide recognition that oral devices have a role clinical management of OSAS and snoring. to play in the treatment of OSAS. Indeed, the various Results. Oral appliances can be used to treat: - sim- possible therapeutic strategies in adults with OSAS in- ple snoring, in patients who do not respond to, or do clude the application of removable oral appliances simi- not appear to be suitable candidates for behavioral lar to those normally employed in orthodontics. As long measures such as weight loss or positional therapy; ago as 1902 Pierre Robin proposed the “monobloc”, a Annali di Stomatologia 2015; VI (3-4): 81-86 81  L. Levrini et al. device used to obtain mandibular and lingual protrusion • Associazione Italiana Medicina del Sonno, Marco as a means of increasing the opening of the tracheal Zucconi and esophageal tract and freeing the oropharynx (the • Surgical commission, Associazione Italiana Medi- “vital confluent” in his conception) and the upper air- cina del Sonno (ENT representative) and Asso- ways from obstruction. The numerous devices market- ciazione Otorinolaringologi Ospedalieri Italiani, i ed today for the treatment of sleep apnea or snoring Claudio Vicini al are essentially based on the same principle (5). • Collegio dei Docenti di Odontoiatria, Paola Cozza As regards the situation in Italy, it is to be considered • Associazione Nazionale Dentisti Italiani, Edoardo that dentists, given the number currently practicing Bernkopf n across the country and their extensive contact with the • Associazione Italiana Odontoiatri, Marzia Segù general population – they see approximately 30% of • Associazione Italiana Pazienti con Apnee del the entire population –, could play an important role in Sonno, Enrico Brunello. io terms of the interception and treatment of patients with Scientific associations were chosen as representative sleep disordered breathing, and in this sense could be of Italian dental sleep medicine, all of which have a valuable resource for the country’s national health been officially directly involved by the Italian Associa- az system. During the anamnesis, asking a simple ques- tion of Sleep Medicine (founded in 1990 and active in tion, such as “Do you snore?” or “Do you feel refreshed promoting scientific research and clinical training for in the morning?” could be the first step, of considerable sleep disorders in Italy). All the study group members diagnostic significance, in a complex, diagnostic and declared that they had no conflicts of interest. rn therapeutic process. Involving dentists in this kind of activity would also change the way they are viewed by patients. Indeed, patients, appreciative of the care re- Questions ceived and finding themselves able to sleep better, te would see that they are the focus of clinical attention Each delegate proposed questions regarding the clin- that goes beyond their teeth, and thus develop a differ- ical management of OSAS and snoring patients; del- ent perception of the dentist’s expertise and role. Sub- In egates were aware that responses would be results stantially, they would see the dentist as someone who of literature, evidence and experience of the working provides care and not just treatment. A further consid- group, in accordance with the indications of the Ital- eration, not to be underestimated, is that the treatment ian national Guidelines program (7). The proposed provided by dentists often enhances the patient’s quali- questions were jointly discussed and the delegates, ni ty of life. This, in itself, is fulfilling, but if we consider on the basis of these discussions, decided unani- that enhanced quality of life promotes wellness and mously to address the following four questions: general health, then it also underlines the status of den- • What approaches, anamnestic and clinical, might tists as full members of the medical profession. be helpful to dentists seeking to identify adult pa- io The literature already contains specific and precisely tients affected by OSAS or snoring? defined protocols, both diagnostic and therapeutic, • When can an intraoral device be applied in an for the treatment of adults affected by OSAS and adult patient with OSAS or snoring? iz snoring (2, 5, 6). However, to provide a customised • What are the features of a device employed for medical service, these protocols need to take into ac- the treatment of adult patients affected by OSAS count the differences between different settings, both or snoring? Ed local and national. For this reason, and also because • What therapeutic process should the dentist fol- of the growing number of dentists in Italy becoming low in the case of an adult patient affected by involved in the treatment of this condition, we decided OSAS or snoring? to propose a set of “Italian guidelines” on adult OSAS in dentistry. The German Society of Dental Sleep Medicine have issued similar recommendations (3). Answers IC The group coordinator drafted an initial document on the Material and methods basis of the delegates’ answers and considerations. A general overview was also drafted. The document was C Study Group then forwarded to the delegates individually for revision. On the basis of their amendments, a second document The head of this project (Luca Levrini, Como, Italy) was drafted in which the coordinator highlighted the appointed the coordinator of the study group (Franco conclusions that had not been reached unanimously. @ Sacchi, Milan, Italy) and also asked the most impor- The process was repeated, with the coordinator continu- tant Italian scientific societies operating in fields rele- ing to modify the answers, until a final document, ap- vant to the issue of sleep medicine in dentistry to ap- proved by all the delegates, was obtained. The answers point delegates willing to take part to this project. The contained in the final document are based on the avail- participating scientific societies and their delegates, able literature data; where data were absent, conclu- who formed the study group, are as follows: sions were reached on the basis of a combined evalua- • Società Italiana Medicina del Sonno Odontoiatri- tion of the clinical and practical evidence together with ca, Francesca Milano expert opinion. Each conclusion is associated with a lev- 82 Annali di Stomatologia 2015; VI (3-4): 81-86  Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS) el of evidence and a power of recommendation, in ac- tions and check-ups, professional oral hygiene proce- cordance with the indications of the Italian national dures or other therapies. For this reason, dentists are Guidelines program (Piano Nazionale Linee Guida) (7) ideally placed to perform OSAS screening. An appro- the levels of evidence assigned are defined as follows: priately trained dentist can also evaluate whether or • I: evidence based on meta-analysis of random- not a single patient meets the requirements for treat- i ized controlled studies; ment with oral appliances and can also carry out the al • II: evidence based on at least one randomized necessary follow-ups. The dentist must have a role controlled study; in screening patients with snoring or OSAS: during in- • III: evidence based on at least one controlled non- terdisciplinary managing, he will decide with the sleep n randomized study; specialist (in relation to his culture and experience) to • IV: evidence based on at least one non-controlled treat or not patients with snoring or OSAS if he has experimental study; characteristics defined by clinical recommendations. io • V: evidence based on non-experimental descrip- tive studies (including comparative studies); • VI: evidence based on a high level of consent Oral appliances az and/or experts’ clinical experience. The power of recommendation was instead classified The first descriptions of the use of oral appliances as follows: (OAs) in OSAS treatment date back to the 1980s. • A: performance of the specific procedure (or diag- Many devices have been proposed and, of these, the rn nostic test) is highly recommended. “A” indicates a most widely studied are mandibular advancing de- recommendation supported by good quality scientific vices (MADs) (1-10). These appliances are designed evidence, albeit not necessarily type I or II evidence; to keep the mandible and the tongue in a more ad- te • B: there is some doubt over whether the particular vanced position during the night time, and also to in- procedure should always be recommended, but crease the vertical dimension. As a result of a direct the possibility of performing it should always be mechanical effect, and probably also a reflex muscu- given careful consideration; lar action, a MAD increases the opening of the lumen • C: there is still considerable uncertainty over In of the pharynx, mainly at its lateral portion. Numerous whether or not performance of the procedure should instrumental and clinical studies have assessed the be recommended; clinical efficacy of OAs in OSAS and snoring, leading • D: performance of the procedure is not recom- to an increase in the relevant scientific evidence over ni mended; recent years. The features of the various devices • E: performance of the procedure is highly discour- have been modified many times and, as a result, to- aged. day’s OAs are much more comfortable, better tolerat- io ed and less bulky than those of the past. In addition, their side effects have become far less severe. Even Results though continuous positive airway pressure (CPAP) iz has given better results in terms of reducing airway General overview obstruction indices, OAs are far more comfortable for patients. As a consequence, compared with the past, Ed Snoring is common among the general population. OAs are now recommended internationally for a Around 30% of adults are habitual snorers and this broader spectrum of clinical conditions. In this regard, percentage increases rises in those aged 60 years or it is useful to examine the evolution within the AASM more (to up to 60% of males and 40% of females) (2). (American Academy of Sleep Medicine) over the past In addition to being a sometimes severe source of dis- two decades; indeed, the statements issued by this turbance for the individual’s sleeping partner, snoring organization in 1995, 2005 and 2009 (2, 11,12) seem IC can be a symptom of OSAS, a frequent (4% preva- to provide very clear indications. lence) (8) and severe disease which is related to a possible increase in daytime sleepiness and an in- creased risk of developing hypertension, cardiovascu- Questions and answers C lar diseases and stroke. Not all snorers suffer from sleep apnea, however snoring is present in almost A – What approaches, anamnestic and clinical, might every OSAS patient. General population screening can be helpful to dentists seeking to identify adult patients therefore be a useful means of detecting individuals af- affected by OSAS or snoring? @ fected by OSAS, a disease that continues to be diag- A1. Dentists can make a major contribution to screen- nosed and treated in only a small amount of cases (9). ing for OSAS. This can be done through: a. The inclusion, in the history, of specific questions (1, 6, 12, 13) designed to identify patients with: The role of dentists - a history of chronic snoring; - daytime sleepiness and/or non-restful sleep; A very high percentage of the general population at- - nightly awakenings associated with air hunger tends a dental office at least once a year for inspec- and/or apneas reported by the sleeping partner; Annali di Stomatologia 2015; VI (3-4): 81-86 83  L. Levrini et al. - other OSAS-related symptoms such as mouth ing an important link and making a valuable contribu- dryness, headache, difficult awakening, noc- tion to the addressing of this important but still very turia, chronic weakness, deficit of memory and little known disorder. concentration, libido disorders. (Level of evidence 4; Power of recommendation A). (Level of evidence 1; Power of recommendation B). A3. The instrumental procedure (polysomnography or i b. The use of specific approved questionnaires that any other method approved by the AIMS-AIPO diag- al can help to quantify daytime sleepiness. These in- nostic guidelines) (6) allowing diagnosis of OSAS and clude the “Epworth Scale” and the “Stop-Bang assessment of its severity should be performed before questionnaire” (1, 14, 15), which allows the risk of dental treatments. In this way, it is possible to estab- n OSAS to be determined on the basis of the binary lish, at the time of the clinical work-up, the certainty of (yes/no) answers to 8 simple questions. “Epworth the diagnosis and the different therapeutic options and Scale” or “Stop-Bang questionnaire” (1) allow to subsequently to evaluate the results obtained, com- io evaluate and share with the patient the relief of paring them with the basal conditions (AASM 2009*). OSAS symptoms; later the final follow-up for treat- The assessment of case severity can be considered ment evaluation must be performed by a sleep completed only after evaluation of any comorbidities az physician with cardio-respiratory parameters. present (cardiovascular and respiratory diseases pri- (Level of evidence 1; Power of recommendation B). marily, and also malocclusions) (1, 2, 6, 12, 16, 17). c. Evaluation of clinical characteristics frequently associ- (Level of evidence 1; Power of recommendation A). ated with sleep respiratory disorders: for example, rn obesity, older age (over 45 years for males or post- B – When can an intraoral device be applied in an menopause for females), hypertrophic tonsils or other adult patient with OSAS or snoring? signs of obstruction of the upper airways, large neck As regards the use of intraoral devices (or oral appli- te circumference and retrognathia. Dentists should also ances, OAs), we here refer to what was been agreed carefully assess patients’ dental and periodontal by the AASM task force (1). According to its docu- health status, dental occlusion, TMJ and masticatory ment, OAs can be applied in the following conditions: muscle function and assess the presence of related • simple snoring, in patients who do not respond to In diseases, particularly bruxism, gastroesophageal re- therapy or do not appear to be suitable candi- flux disease and orofacial pain (1, 2, 6, 12). dates for behavioral measures such as weight (Level of evidence 1; Power of recommendation A). loss or positional therapy. d. In-depth diagnosis with instrumental examination. • mild or moderate OSAS, in patients who prefer ni (Level of evidence 1; Power of recommendation A). OAs rather than CPAP or who are not suitable A2. It would be preferable to achieve a multidisciplinary candidates for CPAP, because of its failure or fail- approach to OSAS and snoring that also involves den- ure of behavioral approaches like weight loss or io tists in the various phases of the diagnostic work-up positional therapy. (clinical and instrumental) and in the treatment strategy • severe OSAS, in patients who do not respond to decision-making process. Reports of instrumental ex- or do not tolerate CPAP and in whom no indica- iz aminations (polysomnography or any other method ap- tion either for maxillofacial or ENT surgery ap- proved by the AIMS-AIPO diagnostic guidelines) (6) pears applicable (1, 18-20). should be arranged by a specialist in sleep medicine, (Level of evidence 1; Power of recommendation A). Ed who would assume full responsibility for them. The den- The application of OAs is highly desirable in cases of tist should be involved in general diagnostic work-up, simple snoring or mild to moderate OSAS, whereas evaluating the patient’s dental, periodontal and func- considerable caution is warranted when treating se- tional status and craniofacial morphology, and should vere OSAS. It is fundamental to ensure that the pa- also contribute to decision making during the treatment- tient understands his problem and, at the same time, planning phase, by identifying predictive factors of to present all the various treatment options. In other IC treatment efficacy. In addition, the dentist should partic- words, it is important, together with the patient, to es- ipate in the intercepting of OSAS-affected patients tablish what his needs are and then to choose, to- (screening) (see point A1). The dentist should also as- gether, the best solution to his disorder. sume sole responsibility for the selection, construction (Level of evidence 6; Power of recommendation A). C and adjustment of OAs, as well as for the management of their side effects (point 4) (1, 3, 4). C – What are the features of a device employed for the (Level of evidence 4, Power of recommendation B). treatment of adult patients affected by OSAS or snoring? If a diagnosis of OSAS or snoring, moderate or mild, 1. Tongue retaining devices (TRD), which seem to be @ is confirmed, the dental analysis and the decision re- less efficacious and are also less comfortable than garding the application of an OA, as well as its char- mandibular advancement devices (MADs); they are acteristics, are exclusively within the competence of indicated in edentulous patients, or patients who the dentist, irrespective of his academic training. cannot tolerate, or do not qualify as candidates for, We desire dentists to promote awareness about mandibular advancement (1, 20-22). OSAS and snoring so as to bring to light affected in- (Level of evidence 2; Power of recommendation C). dividuals among the population. In this way, dentists 2. Mandibular advancement devices (MADs, also re- may interface with sleep medicine specialists, provid- ferred in the literature as mandibular advance- 84 Annali di Stomatologia 2015; VI (3-4): 81-86  Italian recommendations on dental support in the treatment of adult obstructive sleep apnea syndrome (OSAS) ment splints – MASs; mandibular repositioning extended to cover all the different types of OA, devices – MRDs; or mandibular repositioning ap- since no one device appears to fit all patients. pliances – MRAs), which can be: • Dentists should monitor the device over time, con- 3. Boil and bite devices: these are less efficient than sidering the patient’s adaptation to different de- customized devices in terms of reduction of respi- grees of repositioning of the mandible and its tol- i ratory events and also in terms of compliance; erance to protrusion. al these devices are still not indicated as a definitive • In the case of simple snoring, the assessment of treatment for OSAS. There are not sufficient data efficacy is limited to the amount of information available to establish their ability to predict the ef- provided either by the patient or his/her partner. n ficacy o customized devices (23, 24). In situations in which certain signs or symptoms (Level of evidence 2; Power of recommendation C). of OSAS persist, a more in-depth study of the 4. Monobloc devices: these are fabricated in the lab case is required in order to select the best thera- io starting from the patient’s impressions; with these py. This may involve the use of a cardiac-respira- devices, the interarch relationship can be fixed or tory monitoring instrument or other approved in- slightly modifiable (25-27). strument (AIMS-AIPO guidelines). az (Level of evidence 1; Power of recommendation A). • Once the efficacy of the therapy has been con- 5. Adjustable advancement devices: these also fab- firmed, the patient should attend dental check-ups ricated in a dental laboratory, customized for each every 6 weeks for the first year and once a year patient. This type of device consists of two parts thereafter for verification of his/her dental, peri- rn kept together by an articulation system (screws or odontal, functional and occlusal status. sliding surfaces) that allows it to be regulated. • It is the dentist’s responsibility to manage, on the ba- The possibility of regulating the advancement of sis of information provided by the patient, the vari- te the mandible and thus gradually modifying its po- ous OA-related side effects that could arise. These sition means that this solution allows the best include both transitory ones (hypersalivation, dental compromise between the different outcomes (ver- pain, muscular problems, occlusal complications in ified by polysomnography or other validated in- the morning) and more persistent ones (changes in strumental examination) and the patient’s comfort In the position of teeth and in occlusion). The dentist (19, 26, 28-30). should take steps to limit these side effects as they (Level of evidence 1; Power of recommendation A). are perceived negatively by the patient. The term oral appliance is too generic, in the future, • Dentists involved in the treatment of sleep respi- ni in both the research and the clinical setting, it will be ratory disorders, are encouraged to undertake necessary to specify the main features of the consid- continuous and targeted education about these ered device. problems through frequent attendance of refresh- io (Level of evidence 6; Power of recommendation A). er courses (1, 10, 17, 19, 20, 31). We desire universities to include the subject of “sleep D – What therapeutic process should the dentist fol- dentistry” in their dentistry courses, in particular iz low in the case of an adult patient affected by OSAS Gnathology in the Dental School. or snoring? (Level of evidence 4; Power of recommendation A). • It is highly desirable that therapy with OAs be per- Ed formed exclusively by dentists who have received specific training in sleep medicine/dentistry and Conclusion the use of OAs. • The dentist should be familiar with the indications The role of the dentist in sleep-disordered breathing can for and contraindications to maxillomandibular ad- be summarized in the following tasks: screening for vancement, and thus able to identify patients OSAS; management of treatment with OAs, including IC needing to be referred to a maxillofacial surgeon. titration of the appliance in order to maximize the results • The dentist should be trained to carry out combined and reduce side-effects; assessment and management, treatments involving the use of OAs and soft tissue within the limits and scope of the dental profession, of surgery (otorhinolaryngology), or treatments com- related pathologies such as sleep bruxism, orofacial C bining OAs with CPAP. pain and related headache. The diagnosis of SDB and • To determine whether or not to apply an OA, a the final follow-up for treatment evaluation must be per- preliminary evaluation of the conditions of the oral formed by a sleep specialist and not by the dentist, also mucosa, teeth and periodontal structures and of for simple snoring. If the doctor in charge of the interdis- @ oral function is recommended, focusing especially ciplinary team, often a sleep physician, has determined on the masticatory muscles and TMJ and looking that therapy with an OA is feasible, then he/she should for any malocclusions and dysgnathia. inform the dentist of this. It will then be up to the dentist • Selection of the device is exclusively the respon- to establish whether this treatment is advisable, consid- sibility of the dentist who will make the choice tak- ering the conditions of the patient’s teeth and oral tis- ing into consideration the peculiarities of the sin- sues, and what type of device is most appropriate for gle case and drawing on his own specific knowl- the case in question. The application of OAs is highly edge. We suggest that this knowledge should be desirable in cases of simple snoring or mild to moderate Annali di Stomatologia 2015; VI (3-4): 81-86 85  L. Levrini et al. OSAS, whereas considerable caution is warranted when 14. Johns MW. A new method for measuring daytime sleepiness: treating severe OSAS. It is fundamental to ensure that the Epworth sleepiness scale. Sleep. 1991;14(6):540-5. the patient understands his clinical problem and, at the 15. Sil A, Barr G, Marin JM, Agusti A, Villar I, Forner M, Nieto same time, to present all the various treatment options. D, Carrizo SJ, Barbé F, Vicente E, Wei Y, Nieto FJ, Jelic S. Assessment of predictive ability of Epworth scoring in In other words, it is important, together with the patient, screening of patients with sleep apnoea. J Laryngol Otol. i to establish what his needs are and then to choose, to- 2012;126(4):372-9. al gether, the best solution to his disorder. 16. Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA. Treatment of snoring and obstructive sleep apnea with mandibular repo- sitioning appliances. Sleep Med Rev. 2004;8(6):443-57. n Conflict of interest statement 17. Hoffstein V. Review of oral appliances for treatment of sleep- disordered breathing. Sleep Breath. 2007;11(1):1-22. The Authors declare to have no conflict of interest. 18. Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for io obstructive sleep apnoea. Cochrane Database Syst Rev. 2006. 19. 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Review article Management and treatment of sinonasal inverted papilloma i al on Claudio Ungari, MD, PhD1 ment. Also, endoscopic approach can be taken in- Emiliano Riccardi, MD2 to account when tumors are localized median to a Gabriele Reale, MD, PhD2 sagittal plan crossing the orbit median wall and Alessandro Agrillo, MD, PhD1 when they did not massively compromised Claudio Rinna, MD1 paranasal sinus walls. zi Valeria Mitro, MD2 Fabio Filiaci, MD2 Key words: inverted papilloma, papilloma diagno- sis, papilloma surgery, sinus open surgery, sinus na endoscopic surgery. 1 Department of Oral and Maxillo-Facial Sciences, “Sapienza” University of Rome, Italy 2 Department of Maxillo-Facial Surgery, Policlinico Introduction er Umberto I, “Sapienza” University of Rome, Italy Inverted papilloma (IP) is a benign sinonasal epithelial neoplasm, rising from the ectodermal schneiderian Corresponding author: membrane. The correct etiology of IP is unknown, al- Emiliano Riccardi t though either chronic inflammation and human papillo- In Department of Maxillo-Facial Surgery, Policlinico Um- berto I, “Sapienza” University of Rome ma virus have been inconsistently associated (1, 2). Sinonasal papillomas were first described by Ward and Via Valentino Banal, 31 Billroth in the 1850s, but it was Hyams (3) who classi- 00177 Rome, Italy fied IP, on the basis of its histological features (4). Al- E-mail: emiliano.riccardi@hotmail.it though IP is a tumor of benign entity, it often erodes ad- ni jacent bone and it may potentially extend to the orbit or to the intracranial cavity. Also, it is associated to a risk Summary of malignancy (5-7) ranging from 5 to 15% and it tends io to recur. Because of its high recurrence (8, 9) rate and Aims. The aim of this paper is to describe the sur- aggressive nature, the management of IP has changed gical experience of 35 patients with Inverted Pa- from conservative intranasal piecemeal excision to a pilloma (IP) of paranasal sinuses and its recur- more aggressive wide excision by lateral rhinotomy iz rence rate after a year of follow-up. combined with a medial maxillectomy. Materials. A retrospective chart review was performed IP involving the paranasal sinus is rare; an endonasal on patients presenting with IP of paranasal sinuses. endoscopic approach is difficult to perform due to the Ed Thirty-five patients comprised the focus of this study. nature of the anatomic border of the paranasal recess, For all patients was performed a pre-surgery TC, and but, in the 1980s, it was introduced and it proved to for more 5 patients it was necessary to perform a have favorably low recurrence rates (10, 11). Magnetic Resonance (MR) with gadolinium. Now, with the refinement of endoscopic techniques, a Results. Among 35 patients selected, 18 patients resection of these challenging lesions may be amenable underwent to open surgery, 4 patients had a com- to an endoscopic approach. IC bined approach with endoscopy and open surgery, Recent studies have demonstrated the efficacy of the while 13 patients were managed only with an endo- endoscopic approach in management of this kind of scopic approach, with a minimum of 1 year of fol- neoplasm (12-16), in a number of selected cases low-up. Our results highlighted that the global per- where the tumor extension is limited. C centage of success 12 months after the treatment This report describes the surgical experience of 35 was 93% and it not vary according to the tipology of patients with IP of paranasal sinuses treated at the the approach used if a radical excision of the lesion Department of Maxillo-Facial Surgery of the Policlini- is achieved. More in depth, among 35 cases, only 2 co Umberto I of Rome, and it recurrence rate after (at least) a year of follow-up. © patients were found to have recurrences and were treated with coronal and endoscopic approach. Conclusion. It is fundamental to underline that surgery must be carried on in a radical manner to Materials and methods treat these tend to recur. A complete removal of the lesion and bone peripheral border filing are Retrospective chart review was performed on pa- essential to perform a correct and definitive treat- tients presenting with IP of paranasal sinuses from Annali di Stomatologia 2015; VI (3-4): 87-90 87  C. Ungari et al. October 2003 to October 2011. Thirty-five patients During pre-operative analysis all patients had a thor- with sinonasal papilloma were observed and treated. ough head and neck evaluation to assess for regional Data points collected included age, extend of the tu- disease. The face was evaluate to identify asymmetry mor, location(s), follow-up, surgery technique and of distortion, and a complete cranial nerve examina- histopathological diagnosis. For all patients it was tion was also necessary. Then, for all patients it was i performed a pre-surgery TC in the three projections carried on a CT scan in the three projections with no al with no contrast and for 5 more patients it was nec- contrast. CT scans can give more information about essary to perform a Magnetic Resonance Imaging the extention of the neoplasm, its association with the (MRI) with gadolinium to better define the lesions. skull base or orbit, its nature and the eventual recur- on Concerning the surgical approach, we started identi- rence of bony alteration. Moreover, for 5 patients a fying localization and extension of the lesions; after- Magnetic Resonance Imaging (MRI) with gadolinium wards, we performed 18 open surgeries, 13 endo- was required to better discern between inflammation scopic approach and 4 combined approach (open pouring and pathologic tissue among the breast itself. and endoscopic). A subsequent magnetic RI can improve understand- zi After surgery was performed, all patients were put be- ing of a neoplasm by defining its limits and its post- fore a thorough follow-up, with periodical check-ups obstructive effect on secondarily involved sinuses. at 1-4-8-12 months. Among 35 patients that were Eleven patients of the study group underwent biopsy na treated, 33 resulted free of any symptoms within a with referral to definitive histological examination con- year, while 2 recurrences were noted by radiographic firmed the diagnosis of IP. surveillance and were promptly treated with coronal Medical therapy is initiated preoperatively to reduce and endoscopic approach. inflammation in all patients. This can help to minimize er eventual bleeding, to reduce tissue edema, and to enhance visualization. Among 35 patients selected, Results 18 patients underwent to open surgery, 4 patients had a combined approach with endoscopy and open Thirty-five patients, 21 males and 14 females, com- t surgery, while 13 patients were managed only with an prised the focus of this study. Mean age of patients was 47 years. The minimal length of their follow-up In endoscopic approach. The histological diagnosis was always IP without any was 12 months and all patients had a control TC after evidence of dysplasia. (at least) 8 months. Location of the tumor included No intra or post-operative complications were en- the ethmoid-frontal sinus in 17 cases, the frontal-eth- countered in this group of patient. ni moid-maxillary sinus in 13 cases and the frontal sinus Our results highlighted that the global percentage of in 5 cases (Tab. 1); no case involved the sphenoid si- success 12 months after the treatment was 93%. More nuses and the orbital cavity; skull base violation was in depth, among 35 patients that underwent the treat- io not noted in any cases. Initial symptoms were unilat- ment, after a follow up of 1 year only 2 recurrences were eral nasal obstruction (18), epistaxis (5), rhinorrhea noted by radiographic surveillance and were promptly (3), facial pain (3), headaches (2), nasal mass (3) treated with open surgery and endoscopic approach. and hyposmia (1) (Tab. 2). iz Table 1. Localization site of attachment of IP. EFS: eth- Discussion Ed moid frontal sinus; FEMS: frontal ethmoid maxillary sinus; FS: frontal. Sinonasal IP is a relatively rare entity that poses unique challenges given the difficulty tumor location. Site of Inverted Papilloma N. of cases IP has an incidence of 0.74-1.5 cases for 100.000 in- EFS 17 habitants per year and accounts for approximately FEMS 13 70% of all sinonasal papillomas (17-19). It prevails in FS 4 the fifth decades of life and males are four to five IC times frequently affected than females. Total 35 From October 2003 to October 2011, 35 patients with sinonasal papilloma were observed and treated in our Table 2. Sympton of presentation of Inverted Papilloma experience. C IP treatment has involved from limited intranasal exci- Presenting symptom N. of cases sions to complete and aggressive surgical resection, as IP demonstrates an intrinsically aggressive behav- Nasal obstruction 18 ior with a propensity for local invasion and potential Epistaxis 5 © risk of malignant transformation. For a long time, ex- Rhinorrhea 3 Facial pain 3 ternal approaches have been the standard treatment, Headaches 2 providing the surgeon with good exposure and a Nasal mass 3 favourable tumor control rate. Hyposmia 1 The aggressive lateral rhinotomy and medial maxil- lectomy approach has been the gold standard treat- Total 35 ment for many years. 88 Annali di Stomatologia 2015; VI (3-4): 87-90  Management and treatment of sinonasal inverted papilloma Another important procedure to treat the desease is More in depth, among 35 cases, after a year of follow- the Midfacial degloving. It was first described by Cas- up. 30 patients were totally free of symptoms, while 2 son in 1974 in the management of extensive lesions recurrences were noted by radiographic surveillance. of the sinonasal tract (20). Buchwald et al. (21) found In the first recurrence, after about 17 months, the pa- that midfacial degloving was easily performed and re- tient reported, at clinical control, again difficulty i vealed this method instead of or as a supplement to breathing with the right nostril. A RM shown the recur- al traditional lateral rhinotomy. rence of the disease at the frontal-ethmoid-maxillary si- Shohet and Duncavage (22) described 2 patients with nus. The patient consequently underwent an endoscop- frontal sinus IP who were treated successfully with ic biopsy that shown IP so another surgery was per- on osteoplastic flap. formed through coronal and endoscopic approach and With the advent of minimally invasive endoscopic ap- she is now free of symptoms from 11 months. proaches, many Authors have shown a growing trend In the second recurrence the disease reappeared toward endoscopic technique (23-27). 11 months after surgery was carried on with epis- taxis. Taken a new maxilla-facial CT, the reappear- zi It is fundamental to underline that surgery must be carried on in a radiacal manner to treat these neo- ance of disease was shown at the frontal-ethmoid- plasms that tend to recur, in 8% of cases in malignant maxillary sinus. A combined approach with endo- scopic and frontal osteoplastic surgery was then na forms (28). Patients comprised in this analysis were treated either performed and now the patients is free of symptoms with open surgery (18 patients), and with endoscopic from 14 months. approach (13 patients), and with combined approach (4 patients), depending on the location of the lesion. We er tried, where possible, to start with an endoscopic ap- Conclusions proach, to eventually turn it afterwards in open surgery, as happened for 4 cases where lesions had already Often, open procedures like osteoplastic flap are es- massively invaded the paranasal sinus walls. sential for a complete excision of IP, depending on t Of 18 patients treated with frontal osteoplastic, presurgery the extend and location of the lesion. TC shown a massive tumor invasion of the paranasal In It should be noted that imaging studies are often im- sinuses, involving, in 13 cases, even the back bony perfect and intraoperatively the extent of disease may walls of the sinuses. exceed what is predicted. Therefore, in most IP cases In 13 cases treated with endoscopic approach, le- of paranasal sinuses the patient should be prepared sions were always localized at the median spot of and should agree on an osteoplastic flap approach, to ni sagittal plan crossing the orbit medial wall, as report- have a complete tumor removal. The ideal approach ed in international literature as well, and they did not is frequently determined intraoperatively, based on massively compromised the paranasal sinus walls. the IP attachment sites. io Choosing the right approach is always an uncomfort- On the basis of clinical and radiological results able decision and depends on several variables as le- shown in this report and in accordance with the Inter- sions localization and size and patients compliance. national literature we noted that endoscopic ap- iz Compared to open surgery, endoscopic excision is proach can be taken into account when tumors are associated with several advantages, like superior vi- localized median to a sagittal plan crossing the orbit sualization, preservation of normal sinonasal physio- median wall and if they did not massively compro- Ed logic function and achievement of mucociliary clear- mised paranasal sinus walls. ance patterns, absence of external scars, minimal Because of its tendency to recur and to harbor carci- morbidity and low recurrence rates. Perhaps, there noma IP is an aggressive invasive lesion. are two major disadvantages for the successful ac- A complete removal of the lesion and bone peripheri- complishment of endoscopic approach: the need of cal border filing are essential to perform a correct and considerable familiarity with the endoscopic tech- definitive treatment. IC nique and its inability to adequately provide access to Careful preoperative planning coupled with meticu- the anterior and lateral walls of the maxillary sinus. lous surgical technique are absolute requisites for Open surgery is preferable as it grants better surgical successful management of these difficult tumors. view, better control of bleedings, stronger confidence C in removing the neoplasm. Disadvantages might be found in longer hospitaliza- References tions (6 days average in our cases), less compliance for patients, possible lesions of the cervical-frontal 1. Mirza N, Montone K, Sato Y, Kroger H, Kennedy DW. 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Buchwald C, Franzmann MB, Tos M. Sinonasal papillomas: 8. Benninger MS, Lavertu P, Levine H, Tucker HM. Conservation a report of 82 cases in Copenhagen County, including a lon- surgery for inverted papillomas. Head Neck. 1991 Sep- gitudinal epidemiological and clinical study. Laryngoscope. Oct;13:442-445. 1995 Jan;105:72-9. zi 9. McCary WS, Gross CW, Reibel JF, Cantrell RW. Preliminary 22. Shohet JA, Duncavage JA. Management of the frontal sinus report: endoscopic versus external surgery in the manage- with inverted papilloma. Otolaryngol Head Neck Surg. 1996 ment of inverting papilloma. Laryngoscope. 1994 Apr; 104: Apr;114:649-52. na 415-419. 23. Han JK, Smith TL, Loehrl T, Toohill RJ, Smith MM. An evo- 10. Stammberger H. The inverting papilloma of the nose. HNO. lution in the management of sinonasal inverting papilloma. 1981 Apr; 29:128-133. Laryngoscope. 2001 Aug;111:1395-1400. 11. Giovannetti F, Filiaci F, Ramieri V, Ungari C. Isolated 24. Wang C, Han D, Zhang L. Modified endoscopic maxillary me- sphenoid sinus mucocele: etiology and management. J Cran- dial sinusotomy for sinonasal inverted papilloma with at- iofac Surg. 2008 Sep;19:1381-1384. tachment to the anterior medial wall of maxillary sinus. ORL er 12. Han JK, Smith TL, Loehrl T, Toohill RJ, Smith MM. An evo- J Otorhinolaryngol Relat Spec. 2012;74:97-101. lution in the management of sinonasal inverting papilloma. 25. Gotlib T, Krzeski A, Held-Ziółkowska M, Niemczyk K. En- Laryngoscope. 2001 Aug;111:1395-1400. doscopic transnasal management of inverted papilloma in- 13. Tufano RP, Thaler ER, Lanza DC, Goldberg AN, Kennedy volving frontal sinuses. Wideochir Inne Tech Malo In- DW. Endoscopic management of sinonasal inverted papil- t wazyjne. 2012;7:299-303. loma. Am J Rhinol. 1999;13:423-26. 14. Schlosser RJ, Mason JC, Gross CW. Aggressive endoscopic In 26. Carta F, Blancal JP, Verillaud B, Tran H, Sauvaget E, Ka- nia R, Herman P. Surgical management of inverted papilloma: resection of inverted papilloma: an update. Otolaryngol Head Approaching a new standard for surgery. Head Neck. Neck Surg. 2001;125:49-53. 2013;35:1415-20. 15. Giovannetti F, Giona F, Ungari C, Fadda T, Barberi W, Po- 27. Kamel RH, Abdel Fattah AF, Awad AG. Origin oriented man- ni ladas G, Iannetti G. Langerhans cell histiocytosis with orbital agement of inverted papilloma of the frontal sinus. Rhinol- involvement: our experience. J Oral Maxillofac Surg. ogy. 2012;50:262-68. 2009;67:212-16. 28. Nakamaru Y, Furuta Y, Takagi D, Oridate N, Fukuda S. 16. Wormald PJ, Ooi E, van Hasselt CA, Nair S. Endoscopic re- Preservation of the nasolacrimal duct during endoscopic me- io moval of sinonasal inverted papilloma including endoscop- dial maxillectomy for sinonasal inverted papilloma. Rhinol- ic medial maxillectomy. Laryngoscope. 2003;113:867-73. ogy. 2010;48:452-56. 17. Thorp MA, Oyarzabal-Amigo MF, du Plessis JH, Sellars SL. 29. 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Review article A rare case of synovial chondromatosis of the inferior TMJ compartment. Diagnosis and treatment aspect i al on Davide Sozzi, MD1 In all the cases treated for SC in the lower com- Gabriele Bocchialini, MD1 partment, both in literature and in our case report, Giorgio Novelli, MD1 surgical treatment led to healing. Maria Gabriella Valente, MD2 Francesca Moltrasio, MD2 Key words: inferior compartment, synovial chon- zi Alberto Bozzetti, MD1 dromatosis, temporomandibular joint. na 1 Maxillofacial O.U.S.Gerardo Hospital Monza, De- Introduction partment of Medicine and Surgery, School of Medi- cine, University of Milano-Bicocca, Milan, Italy Synovial chondromatosis (SC) is an uncommon, be- 2 Pathology O.U. S.Gerardo Hospital Monza, Italy nign lesion characterized by formation of small, multi- ple, metaplastic nodules of cartilage generally within er the joint space. SC usually affects large synovial joints such as the Corresponding author: elbow, knee, wrist and hip. 3% of cases occurs in the t Davide Sozzi temporomandibular joint (TMJ) (1). Maxillofacial O.U.S.Gerardo Hospital Monza, Depart- In ment of Medicine and Surgery, School of Medicine, According to the literature more than 200 cases of SC of the TMJ have been described (2) and the majority University of Milano-Bicocca of these arises in the upper compartment with various Via Cadore, 48 degrees of extension (3-7). This type of condition can 20090 Monza, Italy be locally aggressive and cases with intracranial ex- ni E-mail: davide.sozzi@unimib.it tension have been previously described (8-10). International literature shows only eleven cases origi- nating in the inferior compartment, before this case io Summary (11-17). This disease is also known as sinoval osteochondro- Aim. Synovial Chondromatosis (SC) is a rare, be- matosis, synovial chondrometaplasy, synovial chon- nign non neoplastic arthopathy characterized by drosis, synovial metaplasy, sinovialoma, and periar- iz the metaplastic development of cartilaginous ticular tenosynovial chondrometaplasy (3). nodules within the synovial membrane. In only 3% In literature Milgram (18), Gerard (19) and Chen (17) of all cases does it affect the temporomandibular have offered three different classifications. Ed joint (TMJ) and cases that arise from the lower Milgram, in 1977, categorized the disease process in- compartment are rarely found in literature. The to 3 distinct phases where we can find the relation- aim of this paper is to report a new case of SC of ship between the cartilage foci and the synovium. the inferior TMJ compartment with the description In phase I, metaplasia of the synovial intima occurs. of the clinical, therapeutic and histopathological Active synovitis and nodule formation is present, but findings. no calcifications can be identified. IC Case report. This article presents a 68-year-old In phase II, nodular synovitis and loose bodies are woman with preauricular swelling on the right present in the joint. The loose bodies are primarily side, pain, crepitus and limited joint motion. This still cartilaginous. patient was evaluated by preoperative clinical In phase III, the loose bodies remain but the synovitis C manifestation, CT scan and MR images. Both has resolved. The loose bodies also have a tendency showed multiple, calcified loose bodies in the in- to unite and calcify. ferior compartment. Based on these images as The Gerard’s classification was completed in 1993 well as the patient’s signs and symptoms, a surgi- and was based on the synovial activity of the disease and we can find 4 stages: © cal intervention was performed. A good functional recovery with no signs of recurrence at 36 months Stage 1: presence of cartilaginous of fibrocartilagi- of follow up was obtained. nous nodules with plenty of ground substance in the Conclusion. Among cases of synovial chondro- synovium. matosis in literature, only twelve originating in Stage 2: presence of a very thick synovium with nu- the lower compartment have been reported, this merous small calcification or ossification cartilaginous one included. nodules. Annali di Stomatologia 2015; VI (3-4): 91-95 91  D. Sozzi et al. Stage 3: presence of large and ossified nodules. Stage 4: the synovium is nearly normal or atrophic without any signs of metaplasia. Only in 2012 Chen et al. made an essential clinical- radiological classification according to the different i structures involved; they classified SC in the inferior al compartment of the TMJ into 3 stages. Stage 1 involves multiple loose bodies that are noted with expansion of the inferior compartment with no on bony erosion. Stage 2 involves multiple calcified nodules that are conglutinated to the condyle, the condyle is enlarged by pressure erosion but the disc is intact. zi Stage 3 involves multiple calcified nodules congluti- a nated to the condyle, the condyle in destroyed as a re- sult of a pressure erosion or by direct bony invasion of na the mass, the inferior surface of the disc is involved, and the lesion can’t be detached from the disc. The aim of this paper is to report a new case of syn- ovial chondromatosis of the inferior TMJ compart- ment with the description of the clinical, therapeutic er b and histopathological findings. Figure 1 a-b. CT axial and coronal view showing calcifying lesion and the normal contour of the right condyle (arrows). Case report t In A 68-year-old woman was referred to the O.U. of Maxil- lo-Facial Surgery, Monza S. Gerardo Hospital, Universi- ty of Milano-Bicocca School of Medicine with right sided preauricular swelling lasting 4 months, a limitation of mouth opening and pain aggravated by joint palpation ni and mastication. There was no history of trauma or oth- er event contributing to the onset of symptoms. The patient was edentulous and the maximal mouth io opening was 20 mm with a deviation on the right side. The physical examination revealed that no facial nerve disfunction, hearing or facial sensation distur- iz bances were detected. A computer tomographic scan (CTs) revealed the normal contour of the right condyle, no destruction of Ed the glenoid fossa or temporal bone on the same side, no widening of the joint space, no bony changes of Figure 2. MRI sagittal view showing nodular images in the the skull base. It did reveal, however, several calcify- inferior compartment with a little involvement in the superi- ing lesions in the right TMJ region (Fig. 1 a-b). or compartment even (arrow). Magnetic resonance (MRI) showed multiple, calcified loose bodies in the inferior compartment; the disc IC was irregular and patchy and its position was anterior to the condyle (Fig. 2). Because the CT and MRI imaging powerfully indicat- ed a benign lesion, no exploration biopsy was done. C According to Chen’s classification (Stage I) a surgical intervention was performed under general anaesthe- sia with a right preauricular approach. The incision was followed by the exposure of the right temporo- mandibular region and cartilaginous nodules of vary- © ing size were visible floating in the lower compart- ment (Fig. 3). All these cartilaginous fragments were removed to- gether with the affected synovium (Fig. 4). Figure 3. Intraoperative view of the preauricular approach of Removed the nodules, the articular disc resumed its the TMJ region during the removal of the loose bodies (White proper position. arrow – external meatus, Black arrow – Zygomatic arch). 92 Annali di Stomatologia 2015; VI (3-4): 91-95  A rare case of synovial chondromatosis of the inferior TMJ compartment. Diagnosis and treatment aspect i al on zi a na Figure 4. Macroscopic image of nodules of variable size from the lower compartment. After careful analysis and macroscopic description, er the surgical specimens were fixed in 4% buffered for- malin and paraffin-embedded. Subsequently, four-micron hematoxylin and eosin-stained sections of tumor were examined microscopically. Diagnostic criteria for SC included lobulated chon- t In droid proliferation with foci of hypercellularity and cal- cification within synovium and no underlying arthritis. Microscopically, our case presents nodules of hyaline cartilage lining by flattened synovial epithelium. b These nodules were composed by clusters of chon- Figure 5. (a) Photomicrograph of a typical loose body of ni drocytes and separated by a cartilaginous matrix. The hypercellular cartilage covered with a layer of synovium chondrocytes showed nuclear hyperchromasia, en- (EE, 40x). (b) High power view of lesion shows variable ar- largement and binuclear forms (Fig 5a-b). eas of atypia and hypercellularity (EE, 200x). io According to the radiological and histopathological as- pects, the SC in this patient was classified as a phase III in Milgram’s classification, as a stage II in Gerard’s classification and as a stage I in Chen’s classification. iz One week after surgery the patient started physiothe- rapy for 45 days in order to improve and increase mouth opening and movement capability. Ed The CT was repeated at 6, 12 months and 24 months after the operation and confirmed the total removal of the tumor without any recurrence during the follow up period (Fig. 6 a-b). The patient was able to open her mouth to 35 mm with no deviation even though she reported slight pain during mandibular movement. IC The follow up period is currently 36 months. a Discussion C Synovial chondromatosis (SC) is a rare disease char- acterized by the formation of nodules of metaplastic cartilage under the surface of synovial membranes, © joints, tendons and bursae. It was first described according to Ginaldi in 1558 by Ambrosio Pare (20); in 1764 Albrecht von Haller showed the first report in Elemental physiologiae cor- b poris humani (21) and Axhausen in 1933 composed Figure 6 a-b. CT axial and coronal view confirm the total the first detailed scientific work (22). removal of the tumor with no recurrence (24 months). Annali di Stomatologia 2015; VI (3-4): 91-95 93  D. Sozzi et al. Afterwards, descriptions of this pathology have been between the cartilage foci and the synovium is characterized by discrepancies of nomenclature. placed, while Gerard’s classification (19) is based on The aetiology of SC is not clearly recognized but the the synovial activity of the disease where 4 stages presence of clonal chromosomal aberrations sug- can be recognized. gests the neoplastic nature of this condition (23). An aggressive surgical treatment in the early stages i Cases are divided into two categories: primary SC, is recommended both in Milgram’s and Gerard’s clas- al without specific aetiological factors that represent an sification. active cartilaginous metaplasy originating in the syn- The most recent clinical-radiological classification ovial membrane, and secondary SC related to previ- was made by Chen et al. according to the different on ous trauma, repetitive microtrauma and degenerative structures involved. They classified SC in the inferior arthritis or other arthropathies where a less cellular compartment of the TMJ into 3 stages (17). atypia was found (24). As above mentioned, different stages point out that Primary SC is deemed more aggressive (3). different structure are engaged; consequently differ- ent stages was supposed to have different principles zi The most common signs and symptoms that we found in the SC of the inferior compartment of the of management (5). TMJ were: pain, swelling, limited mouth opening, joint Guidelines for surgical treatment in these patients now derive from this latest and highly important classifica- na crepitus and malocclusion. These symptoms were nonspecific. tion; so that in the first stage we can only remove both The differential diagnosis includes chondrosarcoma, os- the loose bodies and the affected synovium, in the sec- teoarthritis, rheumatoid arthritis, avascular necrosis (25), ond stage we could perform condilectomy, in the third osteochondrytis, intracapsular condylar fractures (24). stage we could perform a condilectomy and discectomy. er The type of imaging techniques used for diagnosis The reconstruction in the stage two and three could and surgical planning were CT scan and MRI. be made with costocondral graft or/and a pedicled CT scan findings consist in: multiple, calcified loose deep temporal fascia fat flap (17). bodies in the joint space, widening of the joint space, As previously revealed in our case report we found erosion of the glenoid fossa, bony changes of the t multiple, calcified loose bodies in the inferior com- skull base and condyle head (26, 27). In partment with a normal contour of the right condyle. The MRI found: intra-articular loose bodies present Thus the removal of the loose bodies and affected as small areas of low signal intensity, massive expan- synovium is generally enough, as Chen’s classifica- sion of the joint capsule, fluid accumulation within the tion state; according to the radiological and clinical joint space and an irregular articular disc (27). findings we perform this type of treatment in our pa- ni The histopathological aspects are represented macro- tient with a preauricular approach. scopically by cartilaginous bodies that remain confined No recurrence has been observed in the current 36- to the synovial membrane that may present as diffuse- month-follow up period. io ly thickened with a cobblestone appearance or may Open surgery has always been proposed as the ther- break off and protrude into the joint cavity as loose apy of choice even though some Authors support a bodies. They may be large or small, cartilaginous, os- less invasive procedure such as arthroscopy. This lat- iz seous or both, ranging in number from a few to hun- ter option is very difficult to carry out due to the posi- dreds. Microscopically there are several histopatholog- tion of the disease (2). ical differences between primary and secondary forms Ed of SC (28, 29). Primary SC presents alterations such as crowding Conclusion and irregularity of the cell nests, varying degrees of atypia of chondrocytes with plumped and binucleated The case that we reported is the twelfth described in elements, which do not necessarily indicate a malig- the literature. The treatment performed by us, after a nant transformation. thorough evaluation of the literature, has proved ef- IC Although the same increased cellularity occurs in fective with low morbidity. secondary SC, it is uniformly distributed with more or- In all the cases treated for SC in the lower compart- ganized cellular growth; chondrocytes also appear ment, both in literature and in our case report, no re- regular and homogeneous. currence has occurred so far. C In addition, a further difference lies in the histological pattern of calcification: the primary form is patchy and diffuse whereas the secondary form is zonal with References “ringlike” aspects. A distinctive trait of secondary SC is the presence of nor- 1. Hohlweg-Majer B, Metzger MC, Bohm J, et al. Advanced © imaging findings and computer-assisted surgery of suspected mal articular cartilage fragments with subchondral bone. synovial chondromatosis in the temporomandibular joint. 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A case of synovial chon- 2003;32:143-147. dromatosis of the temporomandibular joint secondary to 4. Fernandez Sanroman J, Costas Lopez A, Anton Badiola I, preauricolar trauma. Int J Oral Maxillofax Surg. 2009; i et al. Indication of arthroscopy in the treatment of synovial 38:1212-1215. al chondromatosis of the temporomandibular joint: Report of 17. Chen MJ, Yang C, Cai XY, et al. Synovial chondromatosis 5 new cases. J Oral Maxillofax Surg. 2008;66:1694-1699. in the inferior compartment of the temporandibular joint: Dif- 5. Ardekian L, Faquin W, Troulis MJ, et al. Synovial chondro- ferent stages with different treatments. J Oral Maxillofax Surg. matosis of the temporomandibular joint: Report and analy- 2012;70:e32-e38. on sis of eleven cases. J Oral Maxillofax Surg. 2005;63:941-947. 18. Milgram JW. Synovial osteochondromatosis: A histopatho- 6. Valentini V, Arangio P, Egidi S, Capriotti M, Vellone V, Cas- logical study of thirty cases. 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Fortschr Zahnheilk. 1933;9:171. 9. Quinn P, Stanton D, Foote J. Synovial chondromatosis with 23. Hart ES. Synovial chondromatosis. Orthop Nurs. 2012 intracranial extension. Oral Surg Oral Med Oral Pathol. Jan-Feb;31(1):44-45. er 1992;73:398-402. 24. Martin-Granizo R, Sanchez JJ, Jorquera M, et al. Synovial 10. Xu WH, Ma XC, Guo CB, et al. Synovial chondromatosis of chondromatosis of the temporomandibular joint: A clinical, the temporomandibular joint with middle cranial fossa ex- radiological and histological study. Med Oral Patol Oral Cir tension. Int J Oral Maxillofax Surg. 2007;36:652-655. Bucal. 2005;10:272-276. 11. Forssell K, Happonen RP, Forssell H. Synovial chondro- t 25. Nussenbaum B, Roland PS, Gilcrease MZ, et al. Extra-ar- In matosis of the temporomandibular joint. Report of a case and review of the literature. Int J Oral Maxillofax Surg. ticular synovial chondromatosis of the temporomandibuar joint: pitfalls in diagnosis. 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Review article Preventive strategies in oral health for special needs patients i al on Iole Vozza, DDS PhD requirements: handicapped, special, exceptional, Edoardo Cavallè, DDS disabled, special needs (1-3). A person is considered Denise Corridore, DDS disabled when a long-term mental or physical disor- Francesca Ripari, DDS der or condition affects the ability of performing daily Andrea Spota, MD, DDS activities (Tab. 1) with a real difficulty, as well as zi Orlando Brugnoletti, MD, DDS consideration is paid to possible recurrences, pro- Fabrizio Guerra, MD, DDS gressive impairing conditions, cancer, HIV infection, multiple sclerosis, blindness and former suffering na from disabilities (4). Department of Oral and Maxillo Facial Sciences, Recently, the main trend is to consider disability as “Sapienza” University of Rome, Italy the outcome of the interaction between the individual impaired condition and the environmental barriers (behavioral, social, physical, intellectual, etc.) that er Corresponding author: “limit their complete and effective participation in the Iole Vozza society in relation to feeling different from all the oth- Department of Oral and Maxillo Facial Sciences, ers” (5). “Sapienza” University of Rome t Disparity in social acceptation and sustain are the main Via Caserta 6 00161 Rome, Italy In obstacles that should be avoided. In the UN Conven- tion on the Rights of Persons with Disabilities, held in E-mail: iole.vozza@uniroma1.it New York in 2006, the right of disabled people to be equal with other persons has been declared, along with “support for their specific cultural and linguistic identity, ni Summary as well as for their signs language and deafs’ culture” and “the right to get the highest standard of health with- As regards to the most common oral disease in out any kind of discrimination”, whereas States should io pediatric patients, intellectual disability is not a guarantee access – either social, professional and lo- risk factor for caries disease itself, but it rather gistic – to sanitary services (6-8). reduces the individual capability to self-care and The need of this sort of declarations itself means that therefore to his own oral care. Children suffering some kind of discrimination and disparity in general iz of systemic pathologies and/or with different health-care strategies, rehabilitation and prevention is stages of disability are to be considered at high still present for disabled persons for their status, even risk for dental caries development. According to in the most evolved societies (9). Ed recent guidelines for oral health prevention in childhood, individual additional strategies for a preventive care should be applied for these pa- Health promotion and access to oral care services tients. All the health providers, family and care- givers should be involved with the aim of being On a general basis, disease prevention and health aware, motivated and informed on oral health is- promotion are more effective if focused on the indi- IC sues, and a better access system to the dental care structure, both logistic, professional and Table 1. Variables for normal daily activities performance economical should be assured. assessment. C Key words: prevention, special needs, oral care, Normal daily activities (4) health promotion. Mobility Manual ability Physical coordination Introduction © Continence Ability to heave, transport or move daily-life objects Defining “disability” is complex and controversial. Language, hearing, sight During the decades, several terminologies have Memory or concentration skill, acknowledge and been used for people with physical, intellectual or comprehension mental conditions who also require health care and Awareness of the risk to have physical damage services of a type or quantity beyond the common 96 Annali di Stomatologia 2015; VI (3-4): 96-99  Preventive strategies in oral health for special needs patients vidual risk assessment. According to Beck (1998) a nant factor for willingness to treat patients with dis- risk factor is “a biological, environmental and behav- ability or chronic conditions (15-17). ior factor that, throughout time, increases the possi- bility of pathology; if removed or absent, it reduces the probability. It is part of a casual chain or leads the Oral health prevention and treatment issues i host to the casual chain. When the pathology has al been set off, the removal of it does not necessarily According to Casamassimo (3), pediatric dentistry reduce it” (10). has automatically become the dental assistance ref- As regards to the most common oral disease in pedi- erence for children as well as adults with special on atric patients, intellectual disability is not a risk factor health needs, because pediatric practitioners are for caries disease itself, but it rather reduces the indi- used to manage communication and uncontrolled vidual capability to self-care and therefore to his own movements. But pediatric dentists do not represent oral care. In these patients caries pathology is there- the majority of the dental care offer in most of the ar- zi fore quite high (9, 11). eas, consequently adult patients with special health For that reason, along with the acknowledgement of care needs have to attend general dental practices. intrinsic oral disease risk of some general pathology, Loeppky and Sigal (16) observed in their study that na children suffering of systemic pathologies and/or with most of pediatric dentists limited their practice to dis- different stages of disability are to be considered at abled patients under 18 years of age, while general high risk for dental caries development. According to dentists treat patients with special health care needs recent guidelines for oral health prevention in child- of all ages. In the pediatric dentists practices, many hood, individual additional strategies for a preventive of the disabled patients have conditions that were er care should be applied for these patients, such as the congenital or acquired during childhood. General use of fissure sealants and fluoride gel and varnish- dentists visit instead special needs adults who pre- es, along with clinical check-ups on a regular basis sent conditions or disabilities consequent to aging (12-14). pathologies, as stroke, dementia and failing organ Limited access to dental care services for disabled t systems. This kind of patients may be more at ease persons is mostly due to: In in a general dental practice than in a pediatric one. • availability of dentist to treat patients with special Therapy also differs significantly: general dentists health care needs; provide rehabilitative care such as prosthodontics, • awareness of the oral health issue in the patient periodontal procedures and endodontic therapies, environment (“halo effect”). while pediatric dentists tend to provide more preven- ni In particular, the dentists’ availability is dependent by tive procedures such as restorative, oral hygiene, the time committed in treatment of disabled persons, scaling, fluoride, sealants and orthodontics. educational experience and training in treating pa- In order to respond to dental care needs and concur- io tients with disabilities or chronic conditions, economic rent medical conditions or low level of cooperation, factors and age (educational debt, financial practices, some patients with intellectual/physical impairment or family expenses, more frequent in younger dentists), systemic disease may require treatment in general iz setting of the dental practice (public/private dental anesthesia. However disabled patients’ pattern of service, small/large communities), reimbursement age, treatment need and caries experience is not pro- programs (15, 16). portional, as one can imagine, to the severity of the Ed Moreover, accessibility is dependent on the National impairing condition. Haubek et al. (18) report that, in Health System: national programs of reimbursement a group of patients who underwent to general anes- or financial coverage for health expenses is crucial thesia for dental treatment, special needs children for improving access leeway of disabled patient to “were older at referral and had a less comprehensive dental health services. Disabled patient have also lo- total treatment need than non-special needs pa- gistic difficulties in receiving the dental care services, tients”, supporting as a possible explanation that at- IC due to architectonical barriers, public transportation, tention to preventive oral health attitude is often paid problems in scheduling the treatment within the daily by caregivers and specialized personnel, so that practice (15). these children develop a treatment need only at high- Dentists’ willingness to treat people with special er ages. C health care needs is affected by the uncooperative- Similarly, Camilleri et al. (19), compared the level of ness of some patients during the dental treatment: dental disease and the pattern of dental treatment perceiving it as a barrier depends by the type of per- under general anesthesia for children with different formed practice of the dental providers and by their ASA Physical Status Classification System level. educational experience (e.g. pediatric dentists com- Children of both groups were about to undergo to © monly raise minor obstacles in treating disabled per- general anesthesia for dental treatment and had high sons, since their training and practice are focused on caries experience indices. They report that children behavioral management of younger patients). Data on with severe systemic diseases had significantly lower dentists’ availability are in reality controversial: no ev- caries experience in both dentitions than normal idence is clear which among personal vocation, age, healthy or mild systemic diseases affected children. education or clinical experience is the main determi- In this case, too, the Authors explain their result with Annali di Stomatologia 2015; VI (3-4): 96-99 97  I. Vozza et al. the high level of medical and preventive care of these References patients, that make children referral possible at an earlier stage, as soon as carious lesions are detect- 1. American Academy of Pediatric Dentistry. Definition of ed, allowing “a significantly higher level of preventive special health needs patient. Pediatr Dent. 2004;26(suppl):15. and restorative care” with an average rate of extract- 2. Australian Institute of Health and Welfare (AIHW) 2003. ICF i ed teeth per patient which was significantly lower. Australian User Guide. Version 1.0. Disability Series. AIHW al Cat. No. DIS 33. Canberra: AIHW. In addition, multi-specialized examinations in general 3. Casamassimo PS. Children With Special Health Care anesthesia were done to treat the patients with pre- Needs; Patient, Professional and Systems Issues. Pediatric ventive treatments as pit and fissure sealants. Pro- Oral Health Interfaces Background Paper. 2006. cdhp.org:1- on fessional team (dental hygienist, medical assistants, 23. Available from http://www.cdhp.org/downloads/inter- doctors, parents/tutors) appears to be essential to faces/interfaces%20special%20health%20care.pdf. (last the achievement of better level of oral health in these access January, 3rd, 2010). patients. Kakaouanaki et al. (20), studying further 4. UK Disability Discrimination Act (DDA) 2005. Available at http://www.opsi.gov.uk/acts/acts2005/20050013.htm (last zi dental treatment needs in children after exodontia in access January, 3rd, 2010) general anesthesia, focus on the importance of pre- 5. UK Department for International Development. Disability, ventive oral health approach in children as well as for Poverty and Development. DFID. 2000 Issue, February. na parents/tutors to reduce the risk of new carious 6. U.N. Convention on the Rights of Persons with Disabilities. processes. In fact, a high percentage of follow-ups New York, December 6, 2006. and new treatments was related to new dental 7. Italian Ministry of Foreign Affairs (MAE). Guidelines of Ital- pathologies, developed after 6 years from the gener- ian cooperation on the issue of Handicap. 2002 July. al anesthesia. 8. German Federal Ministry for Economic Cooperation and De- er velopment (BMZ). Health, Education, Social Protection. Sec- tor Initiative Systems of Social Protection. Disability and De- velopment. A contribution to promoting the interests of per- Conclusions sons with disabilities in German Development Cooperation. t Policy Paper. 2006 November. To guarantee equal access opportunities for treat- 9. Hennequin M, Moysan V, Jourdan D, Dorin M, Nicolas E. In- In ment to patients with special health care needs, is im- equalities in Oral Health for Children with Disabilities: A French portant to accomplish a participation and a full con- National Survey in Special Schools. PLoS ONE. 2008; sent from families. 3(6):e2564. All the health providers, family and caregivers should 10. Burt BA. Definitions of Risk. J Dent Edu. 2001;65(10):1007-8. be involved with the aim of being aware, motivated 11. Beltran-Aguilar ED, Beltran-Neira RJ. Oral diseases and con- ni ditions throughout the lifespan. II. Systemic diseases. Gen and informed on oral health issues, and a better ac- Dent. 2004 Mar-Apr;52(2):107-14. cess system to the dental care structure, both logis- 12. Campus G, Condò SG, Di Renzo G, Ferro R, Gatto R, Giuca tic, professional and economical should be assured. io MR, Giuliana G, Majorana A, Marzo G, Ottolenghi L, Petti S, As stated before, regular dental check-ups are deci- Piana G, Pizzi S, Polimeni A, Pozzi A, Sapelli PL, Ugazio A. sive to achieve and maintain a high standard of oral National Italian Guidelines for caries prevention in 0 to 12 years- health. In patients with disabilities in fact, in the oral old children. Eur J Paediatr Dent. 2007;Sep;8(3):153-9. iz health problems are essentially due to poor oral hy- 13. Italian Ministry of Health. National guidelines on Oral Health Pro- giene, which often results in an increase of caries motion and Prevention of Oral Pathologies in Childhood. 2013 Update. Available at http://www.salute.gov.it/imgs/C_17_pub- and gingivitis (13). Poor oral hygiene is fundamentally Ed blicazioni_2073_allegato.pdf due to a limited cooperation by the patient to daily 14. Guidelines on the use of fluoride in children: an EAPD pol- oral hygiene procedures, the difficulty during mastica- icy document. European Archives of Paediatric Dentistry. tion and to cariogenic diet (21, 22). In this perspec- 2009;10(3). tive, could be useful to anticipate the first dental ex- 15. Casamassimo PS, Seale NS, Ruehs K. General Dentists’ Per- amination in children with special health care needs ceptions of Educational and Treatment Issues Affecting Ac- at 1 year of age, scheduling regular dental recalls at cess to Care for Children with Special Health Care Needs. IC least on a four/six-month basis (23, 24). Journal of Dental Education 2004 Jan;(68)1:23-28. 16. Loeppky WP, Sigal MJ. Patients with Special Health Care Besides, the other strategic area for oral health in dis- Needs in General and Pediatric Dental Practices in Ontario. ables children and adults is to improve the dentists’ J Can Dent Assoc. 2006;72(10):915. willingness to treat persons with special health care 17. Milnes AR, Tate R, Perillo E. A survey of dentists and the C needs. This could be attained by means of: (i) lec- services they provide to disabled people in the province of tures and hands-on education in the specific topic of Manitoba. J Can Dent Assoc. 1995;61(2):149-58. dental therapy in persons with special health care 18. Haubek D, Fuglsang M, Poulsen S, Rolling I. Dental treat- needs in the pre- and post- graduate education, also ment of children referred to general anaesthesia – associ- for non-pediatric dentists curricula, with the purpose ation with country of origin and medical status. Int J of Pae- © of guarantee better access to treatment also to adults diatric Dentistry. 2006;16:239-246. 19. Camilleri A, Roberts G, Ashley P, Scheer B. Analysis of pae- with special health care needs; (ii) economical incen- diatric dental care provided under general anaesthesia and tives (productivity bonuses and others); (iii) coordina- levels of dental disease in two hospitals. British Dental Jour- tion of the professional team through an integrated nal. 2004;196:219-223. education (dentists, medical providers, dental hygien- 20. Kakaouanaki E, Tahmassebi JF, Fayle SA. Further dental ist, caregivers, parents/tutors). treatment needs of children receiving exodontia under gen- 98 Annali di Stomatologia 2015; VI (3-4): 96-99  Preventive strategies in oral health for special needs patients eral anaesthesia at a teaching hospital in the UK. Int J of Pae- health care needs: implications for oral health care providers. diatric Dentistry. 2006;16:263-269. Pediatr Dent. 2010;32:333-42. 21. American Academy of Pediatric Dentistry (AAPD) Council 23. Nowak AJ, Casamassimo PS. The dental home: A primary on Clinical Affairs. Guideline on management of dental pa- care oral health concept. J Am Dent Assoc. 2002;133:93-98. tients with special health care needs. Pediatr Dent. 2008- 24. Avenali L, Guerra F, Cipriano L, Corridore D, Ottolenghi L. i 2009a;30 (7 Suppl):107-11. Disabled patients and oral health in Rome, Italy: long-term al 22. Moursi AM, Fernandez JB, Daronch M, Zee L, Jones CL. Nu- evaluation of educational initiatives. Ann Stomatol (Roma). trition and oral health considerations in children with special 2011 Mar;2(3-4):25-30. Epub 2012 Jan 27. on zi na t er In ni io iz Ed IC C © Annali di Stomatologia 2015; VI (3-4): 96-99 99 

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Original article A tooth preparation technique in fixed prosthodontics for students and neophyte dentists i al on Daniele Rosella, DDS1 sonal experience with the novel technique. It Giancarlo Rosella, MD, DDS2 could helps dental students and neophyte denti- Edoardo Brauner, DDS, PhD1 sts in their learning curve. Piero Papi, DDS1 Luca Piccoli, DDS, PhD1 Key words: tooth preparation, fixed prosthodon- zi Giorgio Pompa, MD, DDS1 tics, dental education, prosthodontics. na Introduction 1 Department of Oral and Maxillofacial Sciences, “Sapienza” University of Rome, Italy Tooth preparation for fixed prosthesis is a common pro- 2 Private Practitioner, Italy cedure in clinical practice, which all general dentists should perform correctly. However, it could be difficult to er obtain always a predictable result, especially for dental students or young doctors: they could make mistakes in Corresponding author: their learning curve leading to inadequate results. Daniele Rosella t Unlike other human substance, dental tissues don’t Department of Oral and Maxillofacial Sciences, “Sapienza” University of Rome In have regenerative capacity. Therefore, the removal of dental biological material should be planned and exe- Via Caserta 6 cuted with maximum attention (1). 00161 Rome, Italy The purpose of a fixed prosthodontic therapy may E-mail: daniele.rosella@gmail.com vary from the restoration of a single tooth to the reha- ni bilitation of the complete occlusion. A single tooth can be fully restored both functionally and aesthetically. A missing tooth can be replaced by a fixed prosthesis, io Summary increasing patient masticatory competence and main- taining or improving dental arches function, often ele- Purpose. The aim of this study was to evaluate a vating patient’s self-image (2). novel technique of tooth preparation in fixed Tooth preparation should have specific geometrical cha- iz prosthodontics suitable for dental students and racteristics to provide necessary retention and resistance neophyte dentists. to the vertical and lateral forces acting on the restoration. Materials and methods.Twenty-four dental stu- The most important element of retention is the presence Ed dents of the sixth-year class were recruited to ve- of two opposing vertical surfaces. The axial walls of the rify the predicibility of this technique. Each stu- preparation should taper slightly to allow the cementation dent prepared two mandibular second premolars of the artificial crown. The more parallel are the axial wal- on a typodont for a dental crown with a 90° shoul- ls the greater is the retention. However, it is impossible to der finishing line. One tooth was prepared using obtain parallel surfaces without producing undercuts. standard procedures taught in the prosthodontic Goodacre et al. (3) suggest an angle of convergence be- IC dental course; the other tooth was prepared with tween 10 and 20°. Moreover, the occlusocervical length the new technique. Three Professors of Prostho- is another fundamental factor for both retention and re- dontics of the same University evaluated the re- sistance. The longer is the preparation the greater is the sult on the basis of 10 criteria. retention. Teeth with larger diameter need a greater C Results. A statistically significant difference be- length to prevent dislodgement (4). Proper occlusal and tween the two techniques was found in 8 out of 10 axial reductions are essentials to provide enough space, criteria. The new technique showed higher values allowing a good functional morphology and structural (p<0.05) in 7 criteria, while the conventional tech- durability. Moreover, no more than necessary dental tis- © nique had better results in just 1 criterion. More- sues should be removed in order not to jeopardize tooth over, the total sum of values was higher for the structure and retention of the restoration (2). new technique (total 41.2±3.98, p<0.05) compared Preston (5) and Miller (6) suggest starting the tooth prepa- to the conventional technique (total 38.12±5.18, ration producing depth-orientation groves on the vestibu- p<0.05). lar and incisal surfaces, with a round-end tapered dia- Conclusions. This study showed that the results mond as reference for removing tooth structure. The oc- were less dependent on manual abilities and per- clusal reduction is performed by removing the tooth por- 104 Annali di Stomatologia 2015; VI (3-4): 104-109  A tooth preparation technique in fixed prosthodontics for students and neophyte dentists tions between the orientation groves with the same bur. • Bur N°2: diamond-coated depth marker of 2 mm After the functional cusp bevel is made, a no. 17L bur is with a round and angled stopping surface; used to smooth the planes of the occlusal reduction. • Bur N°3: cylindrical diamond of 1 mm with no dia- Three vertical groves are performed in the vestibular sur- mond head; face with a flat-end tapered diamond. All tissues between • Bur ANT: football diamond bur. It is the only one i the depth-orientation channels are removed. The proximal conventional bur of the kit; al reduction is performed with a needle narrow diamond, • Bur N°4: cylindrical bur with the only 2 final mm avoiding damage to the adjacent teeth. The lingual and diamond-coated; proximal surfaces are then cut with a torpedo diamond • Bur N°5: truncated cone diamond bur with no dia- on (2). Different finishing line may be created. A chamfer is mond head. considered the preferred choice for veneer metal restora- The innovation of this technique is the easier control tion. Several Authors have shown how this finishing line of depth and direction of the removing procedures. In- exhibits the least stress, with the lowest failure rates (7). A deed, due to flat and no diamond-coated stopping shoulder finishing line is used for all-ceramic crowns, mini- surfaces, the dentist can dominate easier the bur du- zi mizing stresses with its wide and preventing the possibility ring tooth reduction. Every bur tracks a guide for the of the porcelain fracture. However, it is the more destruc- following one. There are less variables to consider, tive finishing line for the tooth tissues. On the other hand, so the error-probability is lower. na the knife-edge is the more conservative finishing line, but The technique consists in four phases (Fig. 1): it may results in an over-contoured restoration. 1. First phase: axial and occlusal reduction depths The most demanding challenges for prosthodontists 2. Second phase: reduction are the control of depth and direction of tissue remo- 3. Third phase: finishing line preparation er val. None of the Authors in the current literature had 4. Fourth phase: tooth surface refining. proposed a systematic procedure in which every bur of the previous step produces a stopping surface on the tooth for the next one. 1. Axial and occlusal reduction depths The aim of this paper is to present a novel technique t of tooth preparation in fixed prosthodontics, capable to decrease the importance of dentist’s manual skill in In Depth-orientation grooves are placed with the N°1 bur along the vestibular and oral gingival margin of the order to obtain a proper result. tooth (Fig. 2A). The round and flat stopping surface of the bur doesn’t allow to go beyond a depth of 1 mm. Anterior teeth: two or three grooves are completed on ni Methods the incisal surface with the N° 2 bur. Posterior teeth: following the tooth occlusal anatomy, Novel technique the dentist creates longitudinal and trasversal deep io guide channels on the occlusal surface with the N° 2 The new technique consists of six burs (Fig.1): bur (Fig. 2B). The angled stopping surface of the bur • Bur N°1: diamond-coated depth marker of 1 mm makes it easier between the cusps. It doesn’t allow with a round and flat stopping surface; the dentist to go deeper than 2 mm. iz 2. Actual reduction Ed 2.1 Incisal/occlusal reduction Anterior teeth: the tooth incisal reduction is made between the grooves with the N° 3 bur. Posterior teeth: the no diamond head of the N° 3 bur IC Figure 1. Burs and phases of the novel technique. is placed at the bottom of the central sulcus on the Figure 2. A, Depth-orientation groove placed with the N°1 C bur along the vestibular gingi- val margin of a mandibular second premolar. B, Longitu- dinal and trasversal deep © guide channels on the oc- clusal surface made with the N° 2 bur. Annali di Stomatologia 2015; VI (3-4): 104-109 105  D. Rosella et al. i al on Figure 3. A, Vestibular view of a deep guide grove made with the N° 3 bur. B, Interproximal reduction made with the N° 3 bur orientated perpendicularly to the major axis of the tooth. C, Circumferential axial reduction. zi occlusal surface. The occlusal reduction is made convention way, it could be practicable to start using using as reference the trasversal deep guide chan- a normal flame bur. na nels. An uniform reduction of 2 mm is easily obtained The N° 3 bur could now easily remove the axial cir- just moving the bur in the mesiodistal way. cumferential surface through the reference of the axial and the cervical grooves (Fig. 3C). The ANT bur is used in the anterior teeth only to re- 2.2 Axial reduction duce the occlusal area between the cingolum and the er incisal margin. An axial deep guide grove is made with the N° 3 bur. It should be directed in a perfectly vertical way and in pa- rallel with the tooth major axis. The no diamond head 3. Finishing line preparation doesn’t allow to remove dental tissue beyond the 1 t mm depth of the gingival margin groove (Fig. 3A). In The N° 4 bur is used to prepare the finishing line. The The same bur is used to separate the tooth from the smooth proximal portion of the bur allows to use the proximal one. The interproximal cut is made with the axial surfaces of the cast to guide the dentist in the N° 3 bur orientated perpendicularly to the major axis preparation (Fig. 4). of the tooth (Fig. 3B). If it isn’t possible, or the dentist ni prefers an approach to the interproximal cut in the 4. Tooth surface refining io The N° 5 bur refines the tooth surface. It is used to round the line angle of the stump and eliminates any undercut (Fig. 5A, B). iz Study sample selection Ed Twenty-four students of the 6th years dental school were recruited to test the novel technique. They vo- lunteered for the study by responding to an email sent to the sixth-year class. All participants gave ver- bal and written consent to take part of the study, ac- cording to the World Medical Association’s Declara- IC Figure 4. Vestibular view of the 90° shoulder finishing line tion of Helsinki. made with the N° 4 bur. Figure 5. A, Refining proce- C dures made with the N° 5 bur. B, Final vestibular view of a mandibular second premolar prepared with the novel tech- nique. © 106 Annali di Stomatologia 2015; VI (3-4): 104-109  A tooth preparation technique in fixed prosthodontics for students and neophyte dentists Each student prepared two mandibular second pre- 33). It also facilitate pouring impressions and in- molars (#4.5) on a typodont for a dental crown with a vesting wax patterns without trapping air bubbles 90° shoulder finishing line. One tooth was prepared and to ease removing casting modules. using standard procedures (1, 2) taught in the pro- 9. Surface texture: sthodontic dental course; the other tooth was prepa- The restorations fitting appears better in smooth i red with the new technique. Prior to the beginning of tooth preparation (34, 35). The retention of zinc al the study, the students were given a thirty-minute phosphate cement is increased by surface rough- training session on how to use the novel technique ness (35-41); its effect has not been as definitely with the first Author, DR. determined with adhesive cements. on Three Professor of Prosthodontics (SDC, GP and LP) of Another criterion was added for the assessment: the same University evaluated the result on the basis of 10. Lesion of the proximal teeth. 9 scientific principles described by Goodacre et al. (3). 1. Total occlusal convergence (TOC): The grading sheet contains ten criteria above-mentio- zi TOC is the angle of convergence formed between ned, associated with a specific point value and added the two opposite axial surfaces of the preparation; together to generate the total score. These criteria it should vary between 10 and 20°. appear in rows, while the associated letter grades (A, na 2. Occlusocervical dimension: B, C, D and F) appear in columns. There are point The minimal size of incisors and premolar pre- values for letter grades on each criterion: A=5, B=4, pared with 10-20° of TOC is 3 mm (8). 4 mm is C=3, D=2, F=0. The total score is the sum of the all the minimal dimension of molars prepared within points in the columns. 10-20°of total occlusal convergence (9). After each student completed the first tooth, perfor- er 3. Ratio of occlusocervical/incisocervical dimension med with a standard procedure, the second Author to faciolingual dimension: (GR) has given to everyone an identification number For all teeth it should be 0.4 or higher (4). and each tooth was placed into a sealed envelope. 4. Circumferential morphology: The identification numbers were assigned progressi- Everytime is possible, facioproximal and linguo- t vely from the first student to finish (id n° 1) to the last In proximal corners of the teeth should be preserved one (id n° 24). After each student completed the se- (10). cond tooth, performed with the new technique, the sa- 5. Finish line location: me Author has given to every student an identification Whenever possible, a supragingivally finish lines letter and each tooth was placed in a different sealed should be preferred (11-19); when subgingival fin- envelope. The identification letters were assigned pro- ni ish lines are required, they should preserve the gressively from the first student to finish (id letter A) to epithelial attachment (20-22). the last (id letter X) in the same way for the identifica- 6. Finish line form and depth: tion numbers above-mentioned. Therefore, every stu- io A chamfer finish lines of 0.3 mm is deep enough dent had a double code with a number and a letter for all-metal crowns (23, 24). The different finish (i.e. 1F). Next, the typodonts were given to the eva- line chosen for use with metal-ceramic crowns luator, who was blinded to the student’s identity. iz should not be related to marginal fit but on per- sonal preference (25, 26). Although metal-ceram- ic finish line depths of 1.0 mm or more is recom- Statistycal analysis Ed mended, the optimal depth has not been deter- mined. Both chamfer and shoulder can be used A specific statistical software (IBM SPSS V10 Statis- with all-ceramic crowns bonded to the prepared tics, IBM, Armonk, USA) was used to analyze the da- teeth (27, 28). A greater depth than 1 mm is not ta. Descriptive statistics (mean, frequency, range, necessary when a semitranslucent type of all-ce- standard deviations) were computed for each group ramic crown is used (29). of students, a T test was performed with a significant IC 7. Axial and occlusal reduction depths P value < 0.05. All-metal crowns should be reduced at least 0.5 mm on the axial surface and 1.0 mm on the oc- clusal surface. For metal-ceramic crowns, axial Results C reductions beyond 1 mm can prejudice the resid- ual tooth structure external to the pulp (30); a 2.0 A statistically significant difference between the two tech- mm of occlusal reduction is generally possible niques was found in 8 out of 10 criteria: only “surface tex- even on a young tooth (2, 23, 24, 31). With all-ce- ture” and “line angle form” had p value > 0.05. ramic crowns, it is not required a greater depth The new technique showed higher values (p<0.05) in © than 1 mm of axial reduction and 2 mm incisal/oc- 7 criteria, while the conventional technique had better clusal reduction with semitranslucent systems results in just 1 criterion (“lesion of the proximal (29). teeth”). 8. Line angle form: Moreover, the total sum of values was higher for the Line angles of tooth preparations should be new technique compared to the conventional tech- rounded to reduce stress in the restoration (31- nique (p<0.05). Data were summarized in Table 1. Annali di Stomatologia 2015; VI (3-4): 104-109 107  D. Rosella et al. Table 1. Assessment criteria. Assessment criteria Conventional technique New technique P value Total occlusal convergence 3.82 ± 0.43 4.23±0.78 <0.05 Occlusocervical dimension 3.67 ± 0.67 4.04±0.75 <0.05 i Occlusocervical / faciolingual dimension 3.87 ± 0.54 4.12±0.67 <0.05 al Circumferential morphology 3.64 ± 0.78 4.25±0.6 <0.05 Finish line location 3.84 ± 0.77 4.21±0.56 <0.05 Finish line form and depth 3.77 ± 0.69 4.33±0.63 <0.05 on Axial and occlusal reduction depths 3.93 ± 0.52 4.37±0.62 <0.05 Line angle form 3.83 ± 0.63 4.08±0.65 >0.05 Surface texture 3.81 ± 0.83 3.78±0.81 >0.05 Lesion of the proximal teeth 3.94 ± 0.57 3.79±0.56 <0.05 zi Total 38.12 ± 5.18 41.2± 3.98 <0.05 Discussion cularly for neophyte dentists: they can use it as a trai- na ning procedure in their learning curve. It could be also According to our results, the new preparation techni- possible the use of the technique in combination with que is more predictable than the conventional techni- other methods. Hence, due to the small size of the que for no experienced doctors. The reason is that re- sample (N students = 24, N teeth = 48), which could be er sults are less dependent on manual abilities and per- affected by selection and information biases, these da- sonal experience. This study has shown benefits in ta need to be evaluated carefully, however the novel te- control of depth and direction of tooth tissue removal chnique is a valid alternative in the landscape of fixed as well as a better definition of the tooth finishing line. prosthodontic preparation techniques. The total occlusal convergence (TOC) is an essential t In criterion to be considered in tooth preparation. Okuya- ma et al. (42) made a quantitative evaluation of axial Conflict of interest wall taper in artificial teeth prepared by pre-clinical stu- dents. After a fixed prosthodontics course, they have No potential conflict of interest relevant to the study been instructed to reduce 54 artificial teeth for comple- was reported. ni te cast restorations. Statistically significant higher TOC than required have been detected. The greatest diffe- rences were produced in the vestibular region with a References io mean taper value of 21.7° instead of 2-5° required. Si- milarly, Aleisa et al. (43) evaluated 355 tooth prepara- 1. Castellani D. La preparazione dei pilastri per corone in metal tion for fixed prosthesis carried out by final year under- ceramica. Bologna: Edizioni Martina, 2015. iz 2. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. graduate dental students. Only 32.7% of the prepara- Fundamentals of fixed prosthodontics. 3rd ed. Chicago, IL: tions have been included inside the total occlusal con- Quintessence Publishing Co, 1997. vergence range recommended by the Authors.The 3. Goodacre CJ, Compagni WV, Aquilino SA. Tooth prepara- Ed above mentioned studies demonstrate a difficult taper tions for complete crowns: An art form based on scientific control by students. According to our study, the novel principles. J Prosthet Dent. 2011 Apr;85(4):363-76. technique shows more predictable results regarding 4. Parker MH, Calverley MJ, Gardner FM, Gunderson RB. New the management of the angle of convergence. guidelines for preparation taper. J Prosthodont. 1993;2:61-6. Another important element of tooth preparation is the 5. Preston JD. Rational approach for tooth preparation to ce- reduction depth. Indeed, is necessary to make ade- ramo-metal restoration. Dent Clin North Am. 1977;21:683- 698. IC quate space for the restoration materials. Belinda et 6. Miller L. A clinician’s interpretation of tooth preparations and al. (44) evaluated 63 single complete gold crown and the design of metal substructures for metal-ceramic restora- 151 single ceramometal crown preparations perfor- tions in McLean JW (ed): Dental Ceramics; Proceedings of med by dental students. They found a generally ina- the First International Symposium on Ceramics. Chicago, C dequate reduction as well as greater axial convergen- Quintessence Publ Co. 1983;173-206. ce angles than recommended. The presence of stop- 7. Farah JW, Craig RG, Payton FA. Experimental stress ping surfaces on the bur facilitates reliable outcomes analysis of a restored axisymmetric first molar. J Dent Res. for the new technique. 1974;53:859-866. The stump finished with the new technique have shown 8. Maxwell AW, Blank LW, Pelleu GB Jr. Effect of crown prepa- © ration height on the retention and resistance of gold castings. statistically significant higher results. On the other side, Gen Dent. 1990;38:200-2. the impossibility to vary the preparation depth as well 9. Woolsey GD, Matich JA. The effect of axial grooves on the as the only chance to finish with a 90° shoulder could resistance form of cast restorations. J Am Dent Assoc. be a limitation. The dentist should use this technique 1978;97:978-80. only in well-defined clinical situations.The novel techni- 10. Hegdahl T, Silness J. Preparation areas resisting displace- que may be a valuable option in tooth preparation parti- ment of artificial crowns. J Oral Rehabil. 1977;4:201-7. 108 Annali di Stomatologia 2015; VI (3-4): 104-109  A tooth preparation technique in fixed prosthodontics for students and neophyte dentists 11. Waerhaug J. Histologic considerations which govern where complete coverage restorations and effect of internal surface the margins of restorations should be located in relation to acid etching, tooth position, gender, and age. J Prosthet Dent. the gingiva. Dent Clin North Am. 1960;4:161-76. 1999;81:23-32. 12. Karlsen K. Gingival reactions to dental restorations. Acta 29. Douglas RD, Przybylska M. Predicting porcelain thickness Odontol Scand. 1970;28:895-904. required for dental shade matches. J Prosthet Dent. 1999; i 13. Marcum JS. The effect of crown marginal depth upon gin- 82:143-9. al gival tissue. J Prosthet Dent. 1967;17:479-87. 30. Doyle MG, Goodacre CJ, Munoz CA, Andres CJ. The effect 14. Larato DC. The effect of crown margin extension on gingi- of tooth preparation design on the breaking strength of Di- val inflammation. J South Calif Dent Assoc. 1969;37:476-8. cor crowns: 3. Int J Prosthodont. 1990;3:327-40. 15. Bergman B, Hugoson A, Olsson CO. Periodontal and pros- 31. Craig RG, el-Ebrashi MK, Peyton FA. Experimental stress on thetic conditions in patients treated with removable partial den- analysis of dental restorations. Part II. Two-dimensional pho- tures and artificial crowns. A longitudinal two-year study. Acta toelastic stress analysis of crowns. J Prosthet Dent. 1967; Odontol Scand. 1971;29:621-38. 17:292-302. 16. Renggli HH, Regolati B. Gingival inflammation and plaque 32. Walton CB, Leven MM. A preliminary report of photoelastic accumulation by well-adapted supragingival and subgingi- tests of strain within jacket crowns. J Am Dent Assoc. zi val proximal restorations. Helv Odontol Acta. 1962;16:99-101. 1955;50:44-8. 17. Valderhaug J, Birkeland JM. Periondontal conditions in pa- 33. Nicholls JI. Crown retention. I. Stress analysis of symmet- tients 5 years following insertion of fixed prostheses. Pock- ric restorations. J Prosthet Dent. 1974;31:179-84. na et depth and loss of attachment. J Oral Rehabil. 1976; 34. Charbeneau GT, Peyton FA. Some effects of cavity instru- 3:237-43. mentation on the adaptation of gold castings and amalgam. 18. Newcomb GM. The relationship between the location of sub- J Prosthet Dent. 1958;8:514-25 gingival crown margins and gingival inflammation. J Peri- 35. Tjan AHL, Sarkissian R. Effect of preparation finish on re- odontol. 1974;45:151-4. tention and fit of complete crowns. J Prosthet Dent. 1986; 19. Jameson LM. Comparison of the volume of crevicular fluid 56:283-8. er from restored and nonrestored teeth. J Prosthet Dent. 1979; 36. Tuntiprawon M. Effect of surface roughness on marginal seat- 41:209-14. ing and retention of complete metal crowns. J Prosthet Dent. 20. Nevins M. Attached gingival-mucogingival therapy and 1999;81:142-7. restorative dentistry. Int J Periodontics Restorative Dent. 37. Felton DA, Kanoy BE, White JT. The effect of surface rough- 1986;6:9-27. t ness of crown preparations on retention of cemented cast- In 21. Carnevale G, Sterrantino SF, Di Febo G. Soft and hard tis- sue wound healing following tooth preparation to the alve- 38. ings. J Prosthet Dent. 1987;58:292-6. Oilo G, Jorgensen KD. The influence of surface roughness olar crest. Int J Periodontics Restorative Dent. 1983;3:36-53. on the retentive ability of two dental luting cements. J Oral 22. Tarnow D, Stahl SS, Magner A, Zamzok J. Human gingival Rehabil. 1978;5:377-89. attachment responses to subgingival crown placement. Mar- 39. Juntavee N, Millstein PL. Effect of surface roughness and ni ginal remodelling. J Clin Periodontol. 1986;13:563-9. cement space on crown retention. J Prosthet Dent. 1992; 23. Dykema RW, Goodacre CJ, Phillips RW. Johnston’s mod- 68:482-6. ern practice in fixed prosthodontics. 4th ed. Philadelphia, PA: 40. Witwer DJ, Storey RJ, von Fraunhofer JA. The effects of sur- WB Saunders. 1986:24, 36-9, 249-55, 277-84. face texture and grooving on the retention of cast crowns. io 24. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed J Prosthet Dent. 1986;56:421-4. prosthodontics. 2nd ed. St. Louis, MO: Mosby-Year Book. 41. Ayad MF, Rosenstiel SF, Salama M. Influence of tooth sur- 1995;137-8, 170-3, 184-5, 229. face roughness and type of cement on retention of complete iz 25. Richter-Snapp K, Aquilino SA, Svare CW, Turner KA. cast crowns. J Prosthet Dent. 1997;77:116-21. Change in marginal fit as related to margin design, alloy type, 42. Okuyama Y, Kasahara S, Kimura K. Quantitative evaluation and porcelain proximity in porcelain-fused-to-metal restora- of axial walltaper in prepared artificial teeth. J Oral Sci. 2005; tions. J Prosthet Dent. 1988;60:435-9. 47:129-33. Ed 26. Syu JZ, Byrne G, Laub LW, Land MF. Influence of finish-line 43. Aleisa K, Al-Dwairi ZN, Alwazzan K, Al-Moither M, Al-Sham- geometry on the fit of crowns. Int J Prosthodont. 1993;6:25-30. mari M, Lynch E. Convergence angles of clinical tooth prepa- 27. Bernal G, Jones RM, Brown DT, Munoz CA, Goodacre CJ. rations achieved by dentalstudents at King Saud Universi- The effect of finish line form and luting agent on the breaking ty, Saudi Arabia. J Dent Educ. 2013;77:1154-8. strength of Dicor crowns. Int J Prosthodont. 1993;6:286-90. 44. Belinda K, Poon M, Smales RJ. Assessment of clinical prepa- 28. Malament KA, Socransky SS. Survival of Dicor glass-ceramic rations for single gold and ceramometal crowns. Quintessence dental restorations over 14 years. Part I. Survival of Dicor- Int. 2001;32:603-10. IC C © Annali di Stomatologia 2015; VI (3-4): 104-109 109 

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Original article Aesthetic restoration in maxillo-mandibular malformations: the role of genioplasty i al on Claudio Ungari MD, PhD1 three-dimensional display, which are of great help Emiliano Riccardi, MD2 in the course of diagnosis and evaluation of the Gabriele Reale, MD, PhD2 displacements to be carried out, in order to obtain Alessandro Agrillo, MD1 optimal aesthetic results. Claudio Rinna, MD1 zi Valeria Mitro, MD2 Key words: orthognathic surgery, plastic surgery, Fabio Filiaci, MD, PhD2 genioplasty, maxillo-mandibular malformations, facial profile change. na 1 Department of Oral and Maxillo-Facial Sciences, “Sapienza” University of Rome, Italy Introduction 2 Department of Maxillo-Facial Surgery, Policlinico Many adult patients consult an orthodontist and/or er Umberto I, “Sapienza” University of Rome, Italy maxillofacial surgeon wanting to improve their facial and dental aesthetics because beauty has great so- Corresponding author: cial power and results in more social contacts (1). Or- Emiliano Riccardi t thognathic surgery was performed in order to correct In Department of Maxillo- Facial Surgery, Policlinico Umberto I, “Sapienza” University of Rome several skull and face abnormalities. It aims to restor- ing a correct occlusive relation, though the reposition- Via Valentino Banal, 31 ing of the maxillo-mandibular skeleton basis, to in- 00177 Rome, Italy crease in balance the stomatognatic system with neu- E-mail: emiliano.riccardi@hotmail.it ro-muscular and articular components. Furthermore, ni while restoring the dental-skeletal relation and the oc- clusive ratio, it significantly helps to harmonize the Summary face contour, achieving great cosmetic results (2). io Nowadays, orthognathic surgery can be associated to Aim. The aim of this study was to determinate how other surgical treatments, such as either reductive and orthognatic surgery aids to cure many skull and augmentative genioplasty (3). In 1942, Hofer first re- face abnormalities and to help re-establishing the ported the use of genioplasty as surgical intervention, iz correct occlusive relation thanks to the reposition- performing an anterior horizontal mandibular osteoto- ing of the maxillo-mandibular skeleton basis. my; later on, in 1947, Sir Harold Gillies performed a Methods. The study included 183 male patients and sliding genioplasty on a patient affected by the Treach- Ed 338 female patients, with an average age of 23 er-Collins syndrome. Finally, in 1964 Convers and years. The sample series was divided according to Wood-Smith published their first significative literature. specific pathologies. All patients underwent surgi- In 1948, for the first time, Rubin introduced the use of cal procedures and the therapeutic strategy was alloplastic implants, whose practice, however, was determined based on the anomalies presented. going to be limited to augmentative genioplasty cases Results. 113 patients had a II class dental skeletal of minor entity (4). During the 1950s, there has been IC occlusion, 180 patients had a III class dental-skele- a significant improvement in implants and materials tal occlusion and 222 patients had skull-facial ab- quality, that leds to the creation of implants extremely normalities. 5 patients underwent only a genioplas- close to the natural anatomic shape. ty, 82 patients underwent a genioplasty associated Genioplasty as a cosmetic procedure is performed C with BSSO, 175 patients underwent a genioplasty when skull and face malformations occur, causing an associated with Le Fort I osteotomy and the re- alteration of size and chin abnormalities in all three maining 253 patients underwent a genioplasty as- dimensions. Among this group of abnormal morbidi- sociated with BSSO and Le Fort I osteotomy. ties, there are dental-skeleton malformations and © Conclusion. The experience shows that genio- mandibular asymmetries (5). plasty has been successfully introduced in or- The type of abnormality that needs to be addressed thognathic surgical therapeutic procedures, for determines the technique to be used and the type of dental-skeleton abnormalities and mandibular displacement that needs to be performed. In fact, asymmetries treatment. In recent years, the evolu- sliding genioplasty can both be performed, according tion of computer systems has allowed an accura- to the nature of the case, through osteotomies or allo- te assessment and programming, by means of the plastic implants. 110 Annali di Stomatologia 2015; VI (3-4): 110-112  Aesthetic restoration in maxillo-mandibular malformations: the role of genioplasty This study wants to describe the experience acquired ple) underwent only a genioplasty, 82 patients (16% by the Authors concerning genioplasty planning, re- of the sample) underwent a genioplasty associated sults and surgical methods. with BSSO, 175 patients (34% of the sample) under- went a genioplasty associated with Le Fort I osteo- tomy and the remaining 253 patients (49% of the i Materials and methods sample) underwent a genioplasty associated with BS- al SO and Le Fort I osteotomy. From January 2009 to December 2014, 515 genio- Only 50 patients of the study group have experienced plasties were performed, in association with orthog- a postoperative complication. 4 patients (0,7% of the on nathic surgery at the Department of Odontostomatol- sample) reported anesthesia of the lower lip, 10 pa- ogy and Maxillofacial Surgery, Policlinico Umberto I, tients (2% of the sample) reported alloplastic implants “Sapienza” University of Rome, Italy. migration, followed by a second treatment for reposi- Among the most frequent pathologies addressed, tioning, 36 patients (7% of the sample) reported an zi there were dental-skeleton malformations and infection, with abscess in the site of implant. mandibular asymmetries. Patients, 183 males and 338 females, were aged 23 Discussion na years average. The sample series was divided ac- cording to specific pathologies: 22% (113 patients) with II class dental skeletal occlusion, 35% (180 pa- The experience acquired, confirmed by the International tients) with III class dental-skeletal occlusion and Literature (7-10), shows that genioplasty has been suc- 43% (222 patients) with skull-facial abnormalities. cessfully introduced in orthognathic surgical therapeutic er All patients underwent surgical procedures after com- procedures, for dental-skeleton abnormalities and pleting the following diagnostic tests: orthopanoramic X- mandibular asymmetries treatment. There are a few rays, skull teleradiography in laterolateral and postero- dental-skeleton abnormalities, such as II class ipo-di- anterior projection, statigraphy of articulations and, in re- verging with tight mandibular angle, that usually require cent years, magnetic resonance imaging to visualize the t advancement, set back or drop genioplasty. II class hy- temporomandibular joint. Surgical procedures and In per-diverging with wide mandibular angle usually re- movement to perform was determinated according to quires advancement or drop genioplasty. III class ipo-di- the abnormality that had to be addressed. Patients un- verging with tight mandibular angle usually requires set derwent various types of surgery: 1% (5 patients) only back and drop genioplasty. On the other side, III class genioplasty, 16% (82 patients) genioplasty associated hyper-divergin with wide angle may need advancement, ni with BSSO, 34% (175 patients) genioplasty associated set back or even rise genioplasty (10-13). with Le Fort I osteotomy, 49% (253 patients) genioplasty For some mandibular asymmetries (both inborn or ac- associated with BSSO and Le Fort I osteotomy. While quired), such as microsomia, anchilosis and others, sur- io preparing surgical intervention, either morpho-structural gical treatment includes the restoration of chin propor- features of stomatognatic system and specific parame- tions and often the return to vertical and transversal di- ters for chin evaluation have to be considered. ameters of the mandibular angle. Therefore, it is manda- iz In our Department we exploit an integration of data tory to achieve the complete restoration of the mandibu- obtain from a profile-metric exam and the Legan’s an- lar profile. Superior repositioning and advancement of gle exam. Lega’s angle is an ideal angle created by the chin and myocutaneous structures produce both Ed the line projected through the sub-nasal and the pro- functional and aesthetic benefits for the patient (8). jected through the sub-nasal and the pogonion point, While preparing surgical intervention, either morpho- and it helps in evaluating morpho-structural features structural features of stomatognathic system and spe- on the sagittal plane (6). On the vertical plane we use cific parameters for chin evaluation have to be con- a profile-metric exam implementing the thirds rule. sidered. Surgical methods, in addition to entity and direction of surgical movements, will be determined IC integrating data obtained from the above mentioned Results parameters. According to our experience, before 1989, 65% of patients, after their first maxillo- Between January 2009 to December 2014, 515 pa- mandibular re-positioning surgery, needed extra com- C tients with maxillo-mandibular malformations were plementary cosmetic procedures. Nowadays, thanks submitted to an intervention of genioplasty. to the improvements made in the technology of se- Of the 515 patients, 113 patients (22% of the sample) curing tools (RIF), and in surgical and anesthetic had a II class dental skeletal occlusion, 180 patients techniques, it is now possible to perform at the same (35% of the sample) had a III class dental-skeletal tie combined treatments. © occlusion and 222 patients (43% of the sample) had In most cases, dental-skeletal abnormalities can be as- skull-facial abnormalities. 183 patients were males sessed during a single intervention (10). The planning of and 338 were females with a ratio M:F of 1:2, with an surgical treatment for inborn mandibular asymmetries, average age of 23 year. such as microsomia, is more complicated, due to soft-tis- The therapeutic strategy was determined based on sues deficit involvement. In these cases, surgery must be the anomalies presented: 5 patients (1% of the sam- performed, in our opinion, on a two-time approach basis. Annali di Stomatologia 2015; VI (3-4): 110-112 111  F. Fabio et al. At the same time, as for acquired mandibular asym- References metries, such as TMJ ankylosis, the planning of surgi- cal treatment is again complicated, as the real posi- 1. Rhodes G. The evolutionary psychology of facial beauty. Annu tion of the chin cannot be determined, due to the hori- Rev Psychol. 2006;57:199-226. zontal rotation of the mandible (14-18). During the first 2. Sarver DM, Johnston MW. Orthognathic surgery and aes- i surgical approach, skeletal basis will be repositioned, thetics: planning treatment to arcieve functional and aesthetic al goals. Br J Orthod. 1993;20:93-100. while surgical assessment will perform both genio- 3. Guyron B, Raszewski RL. A critical comparison of osteoplastic plasty and a remodeling of the body and mandibular and alloplastic augmentation genioplasty. Aesthet Plas angle. The only postoperative complications, we de- Surg. 1990;14:199-206. on tected, that may occur include: 4. Hofer D. Operation der Prognathie und Mikogenie. Dtsch Zahn - alloplastic implants migration after augmenting Mund Kiefer-heilkd. 1942;9:121. implant genioplasty, that eventually will require a 5. Bell R, Kiyak HA. Perceptions of facial profile and their in- second treatment for re-positioning; fluence on the decision to undergo orthognathic surgery. Am - possible rise of infections, with abscess forma- J Orthod. 1985;88:323-332. zi tions, that may be due to patient’s clinical condi- 6. Gibson FB, Calhoun KH. Chin position in profile analysis. Comparison of techniques and introduction of the lower fa- tions, materials used, implants site, vascolariza- cial triangle: Arch Otolaryngol Head Neck Surg. 1992;118:273- tion of the pouch that receives the implants, surgi- na 276. cal technique, bacteria ability to stick and colonize 7. Converse JM, Wood-Smith D. Horizontal osteotomy of the the implants, and to the implants peculiar features; mandible. Plast Reconstr Surg. 2001;34:464. - downfall of plates and stick used for securing the 8. Precious DS, Delaire J. Correction of anterior mandibular ver- segment that was repositioned; tical excess: the functional genioplasty. Oral Surg Oral Med er - anesthesia of the lower lip deficit for the third Oral Pathol. 1985;59:229-235. branch of the trigeminal nerve. 9. Edward W, Samuel M. Sliding genioplasty for correction of All the complications that occurred during our experi- chin abnormalities. Arch Facial Plast Surg. 2001;3:8-15. ence were related to: 0,7% (4 patients) with anesthe- 10. Mah Ong. Spectrum of dentofacial deformities: a retrospective t survey. Ann Acad Med Singapore. 2004;33:239-42. sia of the lower lip, 2% (10 patients) with alloplastic 11. Riley RW, Powell NB. Maxillofacial surgery and obstructive In implants migration, followed by a second treatment for repositioning, 7% (36 patients) rise of infections, with sleep apnea syndrome. Otolaryngol Clin North Am. 1990; 23:809-826. abscess in formation in the site of implant. Occurrence 12. Filiaci F, Riccardi E, Ungari C, Agrillo A, Quarato D. Varia- of complications was not related to a particular move- tion of the upper airways in pediatric patients with OSAS and ment of the chin or to the surgeon’s experience. retrusion of the midface. Ann Ital Chir. 85:22-7. ni 13. Rosen HM. Osseous genioplasty. In Aston SJ, Beasley RW editors. Grabhand Smith’s Plastic Surgery. 5th ed. Philadel- Conclusions phia, PA: Lippinocott-Raven Publishers. 1997;705-10. 14. Sykes JM, Frodel JL. Genioplasty. Operative Techniques Oto- io laryngol. 1995;6:319. The possible effects of orthodontic/surgical treatment on 15. Cascone P, Ungari C, Paparo F, Marianetti TM, Ramieri V, facial aesthetics will influence treatment planning, so the Fatone M. A new surgical approach for the treatment of chron- iz following discussion gives special emphasis to soft tissue ic recurrent temporomandibular joint dislocation. J Cranio- changes (19). Genioplasty is a procedure of support that fac Surg. 2008 Mar;19(2):510-12. helps to maximize the aesthetic results of orthognathic 16. Parascandolo S, Spinzia A, Parascandolo S, Piombino P, Cal- ifano L. Two load sharing plates fixation in mandibular condy- Ed surgery. It aims to resetting a perfect profile-metric bal- ance and general facial harmony, that is determined by lar fractures. Biomechanical basis J of Craniomaxillofac Surg. the structural balance of various anatomic areas. 2010;38:385-390. 17. Wilson DM. Report of ankylosis of the temporomandibular Osteotomy is considered the first choice technique, joint: treatment with a temporalis muscle flap and augmen- as it is easy to perform, has few complications, can tation genioplasty. J Contemp Dent Pract. 2006;1-5. be associated with orthognathic surgery and has very 18. Ungari C, Quarato D, Gennaro P, Riccardi E, Agrillo A, Mitro short postoperative course. V, Cascino F, Reale G, Rinna C, Filiaci F. A retrospective IC Alloplastic implants usage is limited to mild genio- analysis of the headache associated with temporomandibular plastic augmentations. joint disorder. Eur Rev Med Pharmacol Sci. 2012;16:1878- In patients affected by severe asymmetries, based on 81. our experience, genioplasty or angle reshaping are rec- 19. Moscatiello F, Jover JH, González Ballester MÁ, Carreño C ommended only at a second surgical approach (20). Hernández E, Piombino P, Califano L. Preoperative digital three-dimensional planning for rhinoplasty. Aesthetic Plas- In recent years, the evolution of computer systems tic Surgery. 2010;34:232-38. has allowed an accurate assessment and program- 20. Filiaci F, Ramieri V, Fatone FM, Gennaro P, Arangio P, Rin- ming, by means of the three-dimensional display, na C, Vellone V, Agrillo A, Ungari C, Cascone P. New pa- © which are of great help in the course of diagnosis and rameter for the evaluation of diagnosthic patient’s surgical evaluation of the displacements to be carried out, in planning: a preliminary report. Eur Rev Med Pharmacol Sci. order to obtain optimal aesthetic results. 2012;16:1430-32. 112 Annali di Stomatologia 2015; VI (3-4): 110-112 

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Original article F360 and F6 Skytaper: SEM evaluation of cleaning efficiency i al on Alberto Dagna, DMD, PhD1 Results. This study did not reveal differences Giulia Gastaldo, DMD, PhD1 among two groups at the coronal and apical third. Riccardo Beltrami, DMD, PhD2 The apical third showed the highest values of Marco Chiesa, DMD, PhD1 scores for all Ni-Ti systems used. Significant dif- Claudio Poggio, MD, DDS1 ferences in smear layer scores were recorded zi among the Ni-Ti systems at middle canal level (P < 0.05), where F6 Skytaper showed significantly 1 Department of Clinical, Surgical, Diagnostic and lower scores than F360. na Pediatric Sciences - Section of Dentistry, University Conclusions. Within the limitation of this study, of Pavia, Italy F360 and F6 Skytaper rotary instruments seem to 2 Department of Brain and Behavioral Sciences, Uni- be effective in shaping root canals with good de- versity of Pavia, Italy bridement from canal walls, without significant differences between the two systems as it re- er gards the coronal third and the apical third, the Corresponding author: area where more debris is still visible. Instead, in Claudio Poggio the middle third F6 Skytaper seems to be more ef- Department of Clinical, Surgical, Diagnostic and Pedi- t fective than F360, with statistically significative In atric Sciences - Section of Dentistry, University of Pavia Piazzale Golgi 3 differences between the two systems. 27100 Pavia, Italy Key words: debris, Ni-Ti, single-use instruments, E-mail: claudio.poggio@unipv.it single-file systems, SEM, smear layer. ni Summary Introduction io Aim. Root canal preparation may produce a large Effective root canal treatment is based on cleaning, quantity of smear layer that covers canal walls. shaping and sealing the root canal system (1) and its Single-file systems have recently appeared, with aim is the elimination of microorganisms from the root the aim of reducing the number of steps and files canal system and the prevention of recontamination af- iz to reach a correct endodontic treatment. The pur- ter therapy (2-5). Irrigating solutions are used to pro- pose of this study was to evaluate by SEM the root mote the disinfection and the debridement of the root canal walls after instrumentation with F360 (Komet, canal and are considered to be crucial for the success Ed Brasseler GmbH & Co., Lemgo, Germany) and F6 of treatment (6-10). The instrumentation alone cannot Skytaper (Komet, Brasseler GmbH & Co., Lemgo, efficiently eliminate bacteria from the root canal system Germany), in order to evaluate the presence/ab- (11) and modern rotary systems generate a huge sence of smear layer and the presence/absence of quantity of smear layer that covers root canal walls. open tubules on the root canal walls at coronal, Many nickel-titanium (Ni-Ti) instruments have been in- middle, and apical third of each sample. troduced to improve root canal preparation and several IC Methods. Twenty single-rooted freshly extracted studies (12-14) demonstrated that they can create a teeth were selected and divided into 2 groups. For smooth funnel-form shape with minimal risk of ledging each group root canals were shaped with F360 or transporting the canals. Irrigating solutions are (Komet, Brasseler GmbH & Co., Lemgo, Germany) needed to facilitate the debridement of the canals dur- C and F6 Skytaper (Komet, Brasseler GmbH & Co., ing mechanical preparation (11, 15). Sodium hypochlo- Lemgo, Germany) instruments under irrigation with rite (NaOCl) is the most commonly used irrigant and 5,25% NaOCl and 17% EDTA. Specimens were frac- although it is a highly effective antimicrobial agent, it tured longitudinally and analyzed by SEM at stan- does not remove the smear layer from the dentin walls © dard magnification of 5000x. The presence/absence (16-22). EDTA is considered a moderate antibacterial of smear layer and the presence/absence of open agent but it is appreciated for its ability to chelating tubules at the coronal, middle, and apical third of hard tissue as decalcifying agent (1). each canal were evaluated using a 5-step scale for Numerous attempts have been made to further im- scores. Numeric data were analyzed using Kruskall- prove and facilitate mechanical root canal preparation Wallis and Mann-Whitney U statistical tests and sig- with different Ni-Ti instruments being available to nificance was predetermined at P <0.05. achieve this goal (23). Actually new single-file and Annali di Stomatologia 2015; VI (3-4): 69-74 69  A. Dagna et al. single-use Ni-Ti systems have been launched to Samples were prepared by the same trained opera- make the root canal treatment easier (due to the re- tor. The root canals were preliminary scouted using a duction of the files necessary for complete root canal stainless steel #10 K-file (KometBrasseler GmbH & shaping) and safer (due to the reduction of stresses Co., Lemgo, Germany) and then instrumented with related to reuse, to disinfecting procedures and to 015 PathGlider rotary Ni-Ti instrument (KometBras- i thermal cycles in autoclave). seler GmbH & Co., Lemgo, Germany) in order to cre- al The first single-use and single-file systems launched ate a glide path, and then shaped with two different were made for reciprocating motion. But reciprocating Ni-Ti rotary systems: files showed a marked tendency to produce debris - group A) F 360 (KometBrasseler GmbH & Co., on along dentinal walls of root canals, much more than Lemgo, Germany) rotating instruments (24, 25). So new single-file and - group B) F6 Skytaper (KometBrasseler GmbH & single-use systems made for rotary motion were re- Co., Lemgo, Germany). cently launched. All instruments were set into permanent rotation with The F360 (Komet, Brasseler GmbH & Co., Lemgo, 6:1 contra-angle handpiece (Sirona, Bensheim Ger- zi Germany) is a new single-use and multi-file Ni-Ti sys- many) powered by a torque-limited electric motor tem: basic sequence is based on two files with tip di- (VDW Silver Reciproc motor; VDW). For each rotary ameter of 25 and 35 and taper 0.04; accessory files file, the individual torque limit and rotational speed na for apical shaping are available with the same taper programmed in the file library of the motor were used. and tip diameter of 45 or 55. The files are made of a The root canals of group A were prepared using the F conventional austenite 55-45 Ni-Ti alloy. A modified 360 system at 300 rpm and 1.8 N/cm torque. The instru- S-shaped cross sectional design is used for the entire mentation sequence was: first red instrument (25/04) er working part of the file. and then green instrument (35/04). All instruments were The F6 Skytaper is a new single-use and single-file used at WL with gentle in- and out-motion. For each root Ni-Ti system: only one instrument, available in five canal, a new set of F 360 instruments was used. different sizes (of 20, 25, 30, 35, and 40) with a con- The root canals of group B were prepared using the F6 stant taper of 0.06 is necessary for root canal shap- t Skytaper system at 300 rpm and 2.2 N/cm torque. The tional design of F360, a S-shaped section. In ing. Each file is characterized by the same cross-sec- instrument (25/06) was used at WL with gentle in- and out-motion. For each root canal, a new F6 was use. Both F360 and F6 Skytaper instruments are devel- The flutes of each instrument were cleaned after three oped for use in continuous clockwise rotation. in-and-out movements and root canals were irrigated The purpose of this ex vivo study is to investigate by with 1 ml of 5.25% NaOCl and with 1 ml of 17% EDTA. ni SEM image the endodontic dentinal surfaces after After preparation 4 ml of 17% EDTA were left in situ for canal shaping with both the single-use Ni-Ti systems, 120 sec followed by 1 ml of 5.25% NaOCl for 60 sec as under irrigation with 5,25% NaOCl and 17% EDTA final rinse. The same manufacturer (Ogna Laboratori io solutions, in order to evaluate the presence/absence Farmaceutici, Muggiò, Italy) prepared the endodontic ir- of smear layer and the presence/absence of open rigating solutions. The irrigating solutions were fre- tubules on the root canal walls at the coronal, middle, quently replaced to maintain their effectiveness. Small and apical third of each canal. 27G endodontic needless (Kendall Monoject, Mans- iz The null hypothesis of the study is that there are no field, Ma, USA) allowed to reach the apical third with significant differences in debris scores and open the reflux of irrigating solutions. At the end all the tubules scores among the two systems. canals were washed with ethanol for 30s and dried with Ed calibrated paper points (Absorbent Paper Points, Den- stply-Maillefer, Konstanz, Germany). Material and methods Twenty single-rooted human teeth freshly extracted SEM preparation and examination for periodontal reasons were selected for this study IC and placed in saline at room temperature immediately Each sample were dipped in liquid nitrogen immedi- after extraction. The inclusion criteria are: morpholog- ately after canal preparation and split longitudinally ical similarity, single-canal roots, straight roots, ab- into two halves with a stainless steel chisel. The sec- sence of root decay, absence of previous endodontic tions were then prepared for SEM analysis. The sec- C treatment, root length of at least 13 mm and apical di- tions were then allowed to air-dry overnight in a des- ameter of at least #20. iccator at room temperature, sputter-coated with gold The crown of each tooth was removed at the level of the and prepared for SEM analysis (EVO MA 10 Carl cementum-enamel junction (CEJ) in order to obtain root Zeiss SMT AG, Germany). © segments similar in length. Two longitudinal grooves SEM observations were obtained at standard magnifi- were prepared on the palatal/lingual and buccal sur- cation of 5000X. Six photomicrographs were taken in faces of each root with a diamond bur used with a high- three areas (coronal, middle and apical). In a blind speed water-cooled handpiece to facilitate vertical split- manner, three trained operators scored the presence ting with a chisel after canal instrumentation. or absence debris and smear layer on the surface of All the roots were randomly assigned to two groups of the root canal at the coronal, middle, and apical por- 10 specimens each. tion of each canal. The rating system was proposed 70 Annali di Stomatologia 2015; VI (3-4): 69-74  F360 and F6 Skytaper: SEM evaluation of cleaning efficiency by Hulsmann et al. and the criteria for the scoring are an, minimum and maximum values were calculated reported following (26). for all groups. Score of the debris: A non-parametric analysis of variance (Kruskal-Wallis • Score 1: clean root canal wall, only few small de- ANOVA) and the post-hoc Bonferroni test were applied bris particles. to investigate significant differences among treatments i • Score 2: few small agglomerations of debris. and among the three thirds of the canals. Significance al • Score 3: many agglomeration of debris covering for all statistical tests was predetermined at P < 0.05. less than 50% of the root canal wall. • Score 4: more than 50% of the root canal wall on covered by debris. Results • Score 5: complete or nearly complete root canal wall covered by debris. Data derived from scoring are reported in Tables 1 Score of the smear layer: and 2, respectively for debris and smear layer scores. • Score 1: no smear layer, orifices of dentinal tubules Kruskal-Wallis ANOVA for debris and smear layer zi open. scores showed significant differences among the • Score 2: small amount of smear layer, some three thirds of the canal (P < 0.05). The apical third dentinal tubules open. showed the highest values of scores for all Ni-Ti sys- na • Score 3: homogenous smear layer covering the tems used. As reported in Table 3, significant differ- root canal wall, only few dentinal tubules open. ences in smear layer scores were recorded among • Score 4: complete root canal wall covered by a ho- the Ni-Ti systems at middle canal level (P < 0.05). mogenous smear layer, no open dentinal tubules. Figures 1 to 4 show representative samples of scan- er • Score 5: heavy, homogenous smear layer cover- ning electron micrographs at different magnifications ing the entire root canal wall. (2500x and 5000x) of the root canal dentine surface of groups A and B. Statistical analysis t Statistical analysis was performed with Stata 12.0 In Discussion and conclusion software (Stata, College Station, Texas, USA). De- The null hypothesis of the present study has been par- scriptive statistics for ordinal data, including the medi- tially accepted. No significant differences were found be- ni Table 1. Summary score of the debris. Group Canal level Score=1 Score=2 Score=3 Score=4 Score =5 io F360 Coronal 7 1 2 0 0 Middle 6 2 2 0 0 Apical 2 3 3 2 0 iz F6 Coronal 7 2 1 0 0 Middle 7 3 0 0 0 Apical 2 3 4 1 0 Ed Table 2. Summary score of the smear layer. Group Canal level Score=1 Score=2 Score=3 Score=4 Score =5 F360 Coronal 7 2 1 0 0 Middle 6 1 2 1 0 IC Apical 3 3 2 2 0 F6 Coronal 7 2 1 0 0 Middle 8 1 1 0 0 Apical 3 4 2 1 0 C Table 3. Comparison between the Ni-Ti systems at the same canal level. © F6 Canal level Coronal Middle Apical F360 Coronal 0.388 Middle 0.012* Apical 0.124 * significant differences Annali di Stomatologia 2015; VI (3-4): 69-74 71  A. Dagna et al. i al on a b c Figure 1. Representative samples of scanning electron micrographs of the root canal dentin surface instrumented with F360 (group A) at coronal (a), middle (b) and apical (c) third of the root (2500×). Dentinal tubules are visible at the coronal and zi middle third (Smear layer score = 2). The apical third is the area where more debris is still visible (Debris score = 4). na t er a b c In Figure 2. Representative samples of scanning electron micrographs of the root canal dentin surface instrumented with F360 (group A) at coronal (a), middle (b) and apical (c) third of the root (5000×). ni io iz Ed a b c Figure 3. Representative samples of scanning electron micrographs of the root canal dentin surface instrumented with F6 Skytaper (group B) at coronal (a), middle (b) and apical (c) third of the root (2500×). Dentinal tubules are visibile at the coro- nal third, but at the middle third there are smear layer and some open tubules (Smear layer score = 2). At the apical third more than 50% of the root canal wall covered by debris (Debris score = 4). IC C © a b c Figure 4. Representative samples of scanning electron micrographs of the root canal dentin surface instrumented with F6 Skytaper (group B) at coronal (a), middle (b) and apical (c) third of the root (5000×). 72 Annali di Stomatologia 2015; VI (3-4): 69-74  F360 and F6 Skytaper: SEM evaluation of cleaning efficiency tween the two groups of Ni-Ti rotary instruments at the spite some structural differences, single-file rotating coronal and at the apical third. Significant differences Ni-Ti instruments are able to remove smear layer pro- were found at the middle third of the samples, where F6 duced during instrumentation and subsequently dis- Skytaper showed significantly lower scores than F360. solved by EDTA. Previous SEM studies investigated It is well known that during root canal preparation the the effect of other Ni-Ti rotary instruments on dentine i action of endodontic instruments produces debris and and obtained similar results (27-30). The combination al smear layer, which is compacted along dentinal walls of NaOCl and EDTA was probably responsible for the (3). Its elimination seems to be of great importance, removal of smear layer and for the removal of a great since it could allow NaOCl to penetrate into the denti- portion of circumferential dentine collagen and miner- on nal tubules, thus enhancing its bactericidal action (7, alized dentine wall from the most part of tubules, as 10). Moreover, smear layer may affect the sealing effi- confirmed by Foschi et al. The present study also ciency of root canal filling materials, acting as physical confirmed that the apical third is the area where more barrier to sealers (4, 5). All Ni-Ti rotary instruments debris is still visible under SEM inspection (30). Rotary Ni-Ti instruments produced fine dentine parti- zi have been shown to produce smear layer that needs to be removed with the use of irrigating solutions (27). cles and shavings that were spread and compacted The chelating agents like EDTA are currently used to along dentine walls and then partially dissolved by EDTA and removed coronally via flute spaces. F360 na remove the smear layer formed during preparation of the root canals. The association of EDTA and NaOCl and F6 Skytaper, thanks to their cross section, fa- solutions is the gold standard in chemo-mechanical vorite debris elimination and gave SEM images gen- preparation of the root canals. EDTA acts upon the in- erally free from smear layer, with major part of denti- organic components of the smear layer and decalci- nal tubules completely opened. Both of them have a er fies the peri- and intertubular dentine and leaves the S-curve design with two blades and a thin instrument collagen exposed. Subsequently, the use of NaOCl core to deliver a high level of cutting efficiency while dissolves the collagen, leaving the entrances of the respecting natural root canal morphology. dentinal tubules open. For this reason an irrigation The main differences between these two systems are regimen similar to the methodology purposed by Fos- t the taper, F360 0.04 and F6 Skytaper 0.06, and the chi et al. was used, with alternation of EDTA and In number of instrument used: F360 requires two file to shape the canal, while F6 Skytaper is characterized NaOCl at each change of instrument. The first single-file and single-use files launched on the by only one instrument (27). The 0.06 taper of F6 market were made for reciprocating motion. Although Skytaper can explain the better debridement of the single-file reciprocating systems have been shown to middle third of the root canals. ni offer advantages over multi file rotary systems, greater The pre-sterilized, single-use files are designed to prevent cross-contamination, eliminate the need to amounts of debris were packed laterally over dentinal clean, disinfect and sterilize the instruments and re- walls and in isthmuses and protrusions of the root io duce the risk of fracture due to cyclic fatigue (31). canals, and this may be clinically significant finding be- In conclusion, within the limitation of this study, F360 cause this debris may harbor bacteria (24). The contin- and F6 Skytaper rotary instruments seem to be effec- uous forward motion of the rotary file enables constant iz tive in shaping root canals with good debridement exit of debris up the flute of the file; however, each from canal walls, without significant differences be- back ward motion of the reciprocating file might pro- tween the two systems as it regards the coronal third vide the opportunity for debris to build up in protrusions and the apical third. Instead, in the middle third, F6 Ed and isthmus areas (25). In addition, the reciprocating Skytaper seems to be more effective than F360, motion of the file may not allow the blade to cut into probably thanks to the increased taper. the dentine as cleanly, resulting in a burnishing-type effect and pushing debris into recesses and isthmuses (24). Today the last single-use systems are developed Acknowledgements for continuous rotation and not for reciprocating mo- IC tion. F360 and F6 Skytaper belongs to them. They are We are grateful to Dr. Clara Cassinelli (Nobil Bio Ricerche made by the same manufacturer, with the same cross S.r.l., Portacomaro, Asti, Italy) for providing the SEM section but two main differences: F360 is a multi-file images and technical assistance. system (two files are required for the root canal shap- C ing) with 4% tapered instruments; F6 Skytaper is a sin- gle-file system with 6% tapered files. Conflict of interest statement All tested instruments were evaluated in accordance with the manufacturers’ direction. All protocol se- The Authors of this study have no conflict of interest quences and instruments operative settings were re- © to disclose. spected: irrigation procedures were standardized for all experimental groups and the same trained opera- tor shaped all root samples. References SEM analysis revealed that F360 and F6 Skytaper associated to EDTA and NaOCl irrigation leave den- 1. Torabinejad M, Walton RE. Endodontics: principles and prac- tine surfaces substantially free from smear layer. De- tice. 4th edition. Saunders Elsevier. St. Louis, Missouri, 2009. Annali di Stomatologia 2015; VI (3-4): 69-74 73  A. Dagna et al. 2. Abou-Rass M, Piccinino MV. The effectiveness of four clin- Oral Pathology Oral Radiology and Endodontics. 1979; ical irrigation methods on the removal of root canal debris. 47:558-61. Oral Surgery Oral Medicine Oral Pathology Oral Radiology 18. Mentz TC. The use of sodium hypochlorite as a general en- and Endodontics. 1982;53:524-6. dodontic medicament. International Endodontic Journal. 3. Briseño BM, Wirth R, Hamm G, Standhartinger W. Efficacy 1982;15:132-6. i of different irrigation methods and concentrations of root canal 19. Byström A, Sundqvist G. Bacteriologic evaluation of the ef- al irrigation solutions on bacteria in the root canal. Endodon- fect of 0.5 percent sodium hypochlorite in endodontic ther- tics and Dental Traumatology. 1992;8:6-11. apy. Oral Surgery Oral Medicine Oral Pathology Oral Radi- 4. Kaplan AE, Picca M, Bonzalez MI, Macchi RL, Molgatini ology and Endodontics. 1983;55:307-12. SL. Antimicrobial effect of six endodontic sealers: an in vit- 20. Ohara PK, Torabinejad M, Kettering JD. Antibacterial effects on ro evaluation. Endodontics and Dental Traumatology. of various endodontic irrigants on selected anaerobic bac- 1999;15:42-5. teria. Endodontics and Dental Traumatology. 1993;9:95-100. 5. Mickel AK, Nguyen TH, Chogle S. Antimicrobial activity of 21. Siqueira JF, Machado AG, Silveira RM. Evaluation of the ef- endodontic sealers on Enterococcus faecalis. Journal of En- fectiveness of sodium hypochlorite used with three irrigation dodontics. 2003;29:257-8. methods in the elimination of Enterococcus faecalis from the zi 6. Brown JI, Doran JE. An in vitro evaluation of the particle flota- root canal, in vitro. International Endodontic Journal. 1997; tion capability of various irrigating solutions. Journal of Cal- 30:279-82. ifornian Dental Association. 1975;3:60-3. 22. Türkün M, Cengiz T. The effect of sodium hypochlorite and na 7. Jeansonne MJ, White RR. A comparison of 2.0% chlorhex- calcium hydroxide on tissue dissolution and root canal clean- idinegluconate and 5.25% sodium hypochlorite as antimi- liness. International Endodontic Journal. 1997;30:335-42. crobial endodontic irrigants. Journal of Endodontics. 1994; 23. Peters OA. Current challenges and concepts in the 20:276-8. preparation of root canal systems: a review. J Endod. 8. Jeansonne J Jr, Batista M, Fraga R, Uzeda M. Antibacter- 2004;30:559-67. ial effects of endodontic irrigants on black-pigmented Gram- 24. Robinson JP, Lumley PJ, Cooper PR, Grover LM, Walms- er negative anaerobes and facultative bacteria. Journal of En- ley AD. Reciprocating root canal Technique induces greater dodontics. 1998;24:414-6. debris accumulation than a continuous rotary technique as 9. Sundqvist G, Figdor D, Persson S, Sjogren U. 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In vitro an- Endod. 1997;23(5):301-306. timicrobial efficacy of MTAD and sodium hypochlorite. 27. Wadhwani KK, Tikku AP, Chandra A, Shakya VK. A com- Journal of Endodontics. 2003;29:450-2. parative evaluation of smear layer removal with ethylene- io 12. Rodig T, Hulsmann M, Kahlmeier C. Comparison of root canal diaminetetraacetic acid in different states: a SEM study. In- preparation with two rotary NiTi instruments: ProFile .04 and dian J Dent Res. 2011;22:10-5. GT Rotary. Int Endod J. 2007;40:553-62. 28. Yang G, Wu H, Zheng Y, Zhang H, Li H, Zhou X, et al. Scan- iz 13. De-Deus G, Garcia-Filho P. Influence of the NiTi rotary system ning electron microscopic evaluation of debris and smear lay- on the debridement quality of the root canal space. Oral Surg er remaining following use of ProTaper and Hero Shaper in- Oral Med Oral Pathol Oral Radiol Endod. 2009;108:71-6. struments in combination with NaOCl and EDTA irrigation. 14. Cheung GS, Liu CS. 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Case report The gingival Stillman’s clefts: histopathology and cellular characteristics i al on Maria Antonietta Cassini, DDS, MS1,2 Introduction Loredana Cerroni, BSc, DDS, MS, PhD2 Amedeo Ferlosio, MD3 Stillman’s cleft is a mucogingival triangular-shaped de- Augusto Orlandi, MD3 fect predominantly seen on the buccal surface of a root, Andrea Pilloni, MD, DDS, MS1 first described by Stillman as a recession related to oc- zi clusal trauma, either associated with marginal gingivitis or with mild periodontitis (1). It can be found as a de- 1 Department of Oral and Maxillofacial Sciences, pression or as a sharply defined fissure extending up to na Section of Periodontology “Sapienza”, University of 5-6 mm of length (Fig. 1). This particular type of ulcera- Rome, Italy tive gingival recession occurs as single or multiple cleft 2 Department of Clinical Sciences and Translational and it can be classified as simple (one direction shape) Medicine, “Tor Vergata” University of Rome, Italy or composed (multiple and differently directed shape) 3 er Department of Biomedicine and Prevention, Insti- (2, 3). Other possible etiological factors are assumed to tute of Anatomic Pathology, “Tor Vergata” Universi- be periodontal inflammation (2), which leads to prolifer- ty of Rome, Italy ation of the pocket epithelium into the gingival corium and its subsequent anastomosis with the outer epitheli- t um (4). In addition, the traumatic tooth-brushing and Corresponding author: Maria Antonietta Cassini In the incorrect use of the interdental floss have been de- scribed among the possible causes (5, 6). A recent sys- Department of Oral and Maxillofacial Sciences tematic review concluded that although the majority of “Sapienza” University of Rome the observational studies confirmed a relationship be- Via Caserta 6 tween tooth brushing and gingival recessions the data ni 00161 Rome, Italy to support or question the association are inconclusive E-mail: dr.cassini@libero.it (7). To date, the etiology and pathogenesis of this de- fects remain unclear even though the assumptions are io related to chronic factors that ulcerate the epithelium Summary and healing occurs through the anastomosis of the ex- ternal and internal epithelium in the gingival sulcus, cre- Aim of the study. Stillman’s cleft is a mucogingi- ating a triangular defect (8). When flossing trauma is in- iz val triangular-shaped defect on the buccal surface volved, superficial gingival tissue clefts are ‘red’ be- of a root with unknown etiology and pathogene- cause the injury is confined within connective tissue. In sis. The aim of this study is to examine the Still- this case the lesion is reversible: flossing procedures Ed man’s cleft obtained from excision during root have to be interrupted for at least 2 weeks and chemi- coverage surgical procedures at an histopatho- cal plaque control only (i.e. chlorexidine rinses) should logical level. be performed. If the cleft appears ‘white’ the whole con- Materials and method. Harvesting of cleft was ob- nective tissue thickness is involved and the root surface tained from two periodontally healthy patients becomes evident; in this case the gingival lesion is irre- with a scalpel and a bevel incision and then versible (9, 10). IC placed in a test tube with buffered solution to be In case of Stillman’s clefts, home oral hygiene could processed for light microscopy. become very difficult to be performed and bacterial or Results. Microscopic analysis has shown that Stillman’s cleft presented a lichenoid hand-like in- C flammatory infiltration, while in the periodontal patient an inflammatory fibrous hyperplasia was identified. Conclusion. Stillman’s cleft remains to be investi- © gated as for the possible causes of such lesion of the gingival margin, although an inflammatory re- sponse seems to be evident and active from a strictly histopathological standpoint. Key words: Stillman’s cleft, recessions, gingival margin, histological analysis, inflammation. Figure 1. Stillman’s cleft. 100 Annali di Stomatologia 2015; VI (3-4): 100-103  The gingival Stillman’s clefts: histopathology and cellular characteristics viral infections may induce the formation of a buccal The surgical protocol consisted of the excision of the probing pocket of sufficient depth to reach the peri- cleft, as indicated by previously validated techniques apical areas of the tooth. Sometimes a delayed diag- (12), in order to create a better manageable contour nosis is made only when an endodontic abscess oc- of the gingival recession for subsequent treatment. curs (10). The prognosis of the clefts is variable: they Preparation of the surgical site followed the same i can heal uneventfully or remain as superficial lesions surgical protocol of the treatment of a single gingival al combined with deep periodontal pockets. recession with a subepithelial connective tissue graft, In 2013 Pilloni showed how a laterally moved, coro- that allows the coverage of the exposed root surface nally advanced technique could modify and eliminate (11). Patients received ibuprofen twice daily for three on this kind of anatomical lesion. He demonstrated that days and a 0.12% chlorhexidine rinse every 12 hours such surgical approach was effective in treating an for 7 days. No systemic antibiotics were used. isolated Stillman’s cleft and the result remained sta- The tissue samples were fixed in 10% neutral buffered ble over a 5-year period (11). formalin for 24 hours and than were oriented in order to correctly identify the cleft and sectioned perpendic- zi Analysis of gingival clefts indicate an apically-directed spread of an inflammatory exudate through the gingi- ularly longitudinally by 2 mm cuts. The biopsies were val connective tissues, with concurrent epithelial re- sampled in toto in two histological biocasettes: the representative sample of cleft was placed within the na sorptive and proliferative reactions, with collagen re- sorption being mediated by an hydrolytic enzymatic first one (one or two samples) and the lateral part of activity (8). surgical biopsies into the second one. Finally, they The aim of this study was to examine the Stillman’s were embedded in paraffin wax and 4 µm serial sec- cleft histological features in two different patients and tions were cut at different levels and stained with er compare them with the clinical aspects (healthy vs haematoxylin and eosin for each block. The slides non healthy periodontal tissues). were examined with a Nikon Eclipse E1200 light mi- croscope and pictures taken with a Nikon camera system. Case report t Patient A: at scanning magnification, a lichenoid In band-like inflammatory infiltrate is observed with focal Two patients with in common the presence of an epithelial ulceration corresponding to cleft floor. asymptomatic Stillman’s cleft on a vital and stable el- At higher magnification, the epithelium shows reac- ement, without any restoration, were selected for the tive atypia with many mitoses, spongiosis, acantosis study. They presented with two different periodontal and occasional diskeratotic cells. ni conditions: patient A was periodontally healthy, The inflammatory infiltrate is mainly constituted by meanwhile patient B was healthy but previously treat- small lymphocytes with sligthly irregular nuclei and ed for mild periodontitis. Patient B showed a deeper only scarce plasma cells. The lamina propria shows io lesion (5 mm) than patient A (2 mm). fragmentation of elastic fibers (Fig. 2). Figure 2. Histological analysis iz patient A. Ed IC C © Annali di Stomatologia 2015; VI (3-4): 100-103 101  M. A. Cassini et al. Figure 3. Histological analysis patient B. i al on zi na t er In Patient B: a different aspect resembling inflammatory cells response with only few plasma cells and chronic fibrous hyperplasia could be seen. In fact, at scan- scarring of lamina propria. ning electron microscopy, a pseudoepitheliomatous This preliminary study aimed at also defining a pre- hyperplasia overlying sclerotic lamina propria has dictable methodology to obtain proper amount of soft ni been observed. tissue from the lesion to then fully obtain comprehen- At higher magnification, far from the lymphocyte-rich sive histological evaluation. The future perspectives inflammation, mainly plasma cells could be seen are to analyze the cleft sample also on an ultrastruc- around small vessels (Fig. 3). tural level by transmission electron microscopy to io better describe the presence and amount of both col- lagen and other matrix components. Moreover, an im- Discussion and conclusion munohistochemical study should be carried out in or- iz der to understand the cellular composition and the To date, only a few cases have been published on expression of inflammatory mediators within the le- the etiology and pathogenesis of Stillman’s clefts and sion. For these reasons, a larger sample is needed to Ed with the aim of explaining their histological features. reach a better understanding of the pathogenesis of This may depend both on the rarity of such lesion and this common lesion. on patient’s agreement in accepting surgical proce- dures to modify it, particularly in asymptomatic cases. Moreover, in recent years, literature has focused pri- References marily on different surgical techniques aimed at the IC resolution of esthetics with primarily the aim of seek- 1. Stillman PR. Early clinical evidences of diseases in the gin- gival and pericementum. J Dent Res. 1921;3:25-31. ing at the maintenance of the health of periodontal 2. Box HK. Gingival cleft and associated tracts. N Y State Dent tissues. For this reasons, we decided to investigate J. 1950 Jan;16(1):3-10. the histological characteristics of two different Still- 3. Tishler B. Gingival clefts and their significance. Dent Cosm. C man’s clefts and correlate them with their clinical pre- 1927;69:1003. sentation. According to our preliminary results, the 4. Goldman HM, Schluger S, Fox L, Cohen DW. Periodontal case A (cleft from healthy periodontal tissues) Therapy. ed 3, St. Louis, C. V. Mosby Co, 1964. showed histological features resembling acute and 5. Hirschefeld I. Traumatization of soft tissues by tooth-brush. Dent Items Int.1933;55:329. © mild gingivitis. The first one with predominantly T 6. Greggianin BF, Oliveira SC, Haas AN, Oppermann RV. The small lymphocytes was sided in correspondence of incidence of gingival fissures associated with tooth brush- the cleft and the mild type with few plasmacells ing: crossover 28-day randomized trial. J Clin Periodontol. around the cleft in apparent clinically healthy gingiva. 2013;40:319-326. Case B (periodontal disease-treated associated cleft) 7. Rajapakse PS, McCracken GI, Gwynnett E, Steen ND, showed histological features similar to chronic gin- Guentsch A, Heasman PA. Does tooth brushing influence givitis or mild periodontitis with a predominantly B the development and progression of non-inflammatory gin- 102 Annali di Stomatologia 2015; VI (3-4): 100-103  The gingival Stillman’s clefts: histopathology and cellular characteristics gival recession? A systematic review. J Clin Periodontol. riodontology. 2000;68:10.1111/prd.2015.68.issue-1:333- 2007;34:1046-1061. 368. 8. Novaes AB, Ruben MP, Kon S, Goldman HM, Novaes AB Jr. 11. Pilloni A, Dominici F, Rossi R. Laterally moved, coronally ad- The development of the periodontal cleft. A clinical and vanced flap for the treatment of a single Stillman’s cleft. A histopathologic study. J Periodontol. 1975 Dec;46(12):701-9. 5-year follow-up. Eur J Esthet Dent. 2013;8(3):390-396. i 9. Zucchelli G. Chirurgia estetica mucogengivale. Quintessenza 12. Hallmon W, Waldrop T, Houston G, Hawkins B. Flossing al Edizioni, 2012. clefts. Clinical and histologic observations. J Periodontol. 10. Zucchelli G, Mounssif I. Periodontal plastic surgery. Pe- 1986;57:501-504. on zi na t er In ni io iz Ed IC C © Annali di Stomatologia 2015; VI (3-4): 100-103 103 

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Review article A comparative, randomized, controlled study on clinical efficacy and dental staining reduction of a mouthwash containing Chlorhexidine 0.20% i al and Anti Discoloration System (ADS) on Massimo Marrelli, MD1,2 Key words: dental plaque, oral hygiene, dental ed- Massimiliano Amantea, MD1 ucation, Chlorhexidine, dental pigmentation, den- Marco Tatullo, DDS, PhD1,2 tal staining. zi 1 Unit of Maxillofacial Surgery, Calabrodental, Cro- Introduction tone, Italy 2 Tecnologica Research Institute, Biomedical Sec- The plaque control is the most important aim that the na tion, Crotone, Italy clinician together with the patient must achieve to ob- tain an effective prevention of periodontal disease. Many studies conducted in animal models have es- Corresponding author: tablished that the presence of pathogenic bacteria is Marco Tatullo an indispensable condition that makes possible the er Tecnologica Research Institute, Biomedical Section onset and development of gingival and periodontal Dept. of Oral Hygiene and Periodontics, Calabroden- diseases (1). tal Clinic Additional studies have verified that the control of St. E. Fermi t bacterial plaque through proper procedures of oral 88900 Crotone, Italy E-mail: marco.tatullo@tecnologicasrl.com In hygiene at home allows the complete resolution of the inflammatory process (2). Other studies have found that a good control of bac- terial plaque is an essential factor for the success of Summary surgical and non-surgical periodontal therapy (3, 4). ni On the contrary, Becker et al. (5) have demonstrated Introduction. A good control of bacterial plaque is that without an optimal control of plaque, periodontal an essential factor for the success of periodontal therapy alone is poorly effective in restoring peri- io therapy, therefore it is the main objective that the odontal health. This suggests that it is possible to clinician together with the patient must get to achieve similar clinical outcomes through different have a healthy periodontium. The plaque control surgical procedures, provided, however, that a regu- with mouthwashes is the most important home lar and proper control of bacterial plaque is done. iz therapy as it helps to reduce the formation of The chemical control of plaque can be obtained with dif- plaque between the mechanical removal with a ferent pharmacological categories, including antibiotics toothbrush. (6) essential oils (7), and antibiotics biguanides (8). Ed Aim. Authors analyzed the clinical data from a tri- Among the therapies commonly used to maintain al carried out with 3 different mouthwashes con- control of plaque, the antiseptic Chlorhexidine (CHX) taining 0.2% Chlorhexidine (CHX). In addition, the (9) is certainly the most studied and the most effec- ADS (Anti Discoloration System - Curaden Health- tive for the inhibition of plaque and for the prevention care) was tested in comparison with the other of gingivitis: it is recognized by more than twenty mouthwashes without this system. years as the gold standard for its anti-plaque and an- IC Materials and methods. We tested antiplaque ac- ti-bacterial activity in oral hygiene. tivity showed by 3 of the most commercialized Some studies (10) have also verified that the con- mouthwashes, moreover, we tested the ability in stant use of CHX did not give rise to the development reducing the dental staining related to the oral as- of resistant microorganisms: these results have al- C sumption of Chlorhexidine. lowed us to assert that Chlorhexidine is a safe drug, Discussion and conclusion. Our results demon- even if used for long periods. strated the clinical efficacy of the 3 mouthwashes However, even the CHX showed unfavorable charac- with CHX. Particularly performing was the anti teristics, in fact, after administration of the CHX mouthwash, a temporary alteration of taste occurs © discoloration system (Curaden Healthcare), with a clinical detection of dental stainings significantly (11); hypogeusia induced by Chlorhexidine concerns less than the others tested. This study demon- specifically salty and bitter taste. strated the clinical efficacy of ADS system in the Among the well known side effects occurring with a reduction of tooth staining, without a loss of an- frequent use of CHX, the most unaesthetic one is un- tiplaque activity with respect to the competing doubtedly the brownish pigments that accumulate on mouthwashes containing CHX. the surfaces of teeth, as well on prosthetic crowns Annali di Stomatologia 2015; VI (2): 35-42 35  M. Marrelli et al. and tongue: these pigmentations restrict the use of The patients selected and involved in this study gave CHX and patient compliance (12). their signed informed consent, according with the The biochemical pathways underlying the formation guidelines approved by Calabrodental dental clinic of pigmentations due to Chlorhexidine are the Mail- (Crotone, Italy). The study and the related procedures lard reaction with a reaction of protein denaturation: were conducted in compliance with guidelines ap- i the triggering factor is represented by the interaction proved by the Calabrodental Ethics Committee (Prot. al between food or drinks rich in chromogens after ad- n°3 July-2011/HIAP). Calabrodental ethics committee ministration of Chlorhexidine. specifically approved this study. The study was con- ducted in compliance with the “Ethical principles for on medical research involving human subjects” of Aim of the work Helsinki Declaration. The study was conducted in ac- cordance with Italian laws and regulations. Authors analyzed data carried out from a randomized controlled clinical trial, using three products for oral zi hygiene, commonly sold in the dental market, with the Study Design same concentrations of CHX: • Curasept mouthwash (Curaden Healthcare) The 3 mouthwashes, Control 1 mouthwash 0,20% na 0,20% CHX CHX, Curasept mouthwash (Curaden Healthcare, • Control 1 mouthwash 0,20% CHX Saronno, Italy) 0,20% CHX, and Control 2 mouth- • Control 2 mouthwash 0,20% CHX. wash 0,20% CHX, were marked respectively with the In addition, we evaluated whether the ADS influences letters C, D and E: operators and patients were not er the antiplaque activity of CHX in the formulation informed about the correspondence between the 0,20% compared to other formulations without ADS; name of the mouthwash and the corresponding letter. finally, we evaluated the effectiveness of the ADS on In addition, the blinded mouthwashes were included the reduction of the Lobene Staining Index compared in a similar packaging, with no signs or references to products without ADS. t that could indicate the name of the mouthwash: on In the bottle was shown only the letter C, D or E, corre- sponding to the group of the same name. Materials and methods The patients were mainly female (Male/Female = 36/64%) and under 50 years old (<50yrs = 84%): they We compared 3 commercially available mouthwash- were randomly allocated in 3 groups named “Group ni es: Control 1 mouthwash 0,20% CHX, Curasept C”, “Group D” and “Group E”; each group was treated mouthwash (Curaden Healthcare, Saronno, Italy) with the same protocol of oral hygiene but with a dif- 0,20% CHX, and Control 2 mouthwash 0,20% CHX. ferent mouthwash. The mean age of the patients in io Our study was aimed to assess the effectiveness of the 3 groups was homogeneous; moreover, it was as- CHX anti-plaque action by means of the clinical sessed the percent of smokers in the three groups evaluation of periodontal indices and clinical out- and the group E was the one with the higher percent- comes; moreover we evaluated the presence/ab- age of smokers, while the group C showed the lowest iz sence of the unaesthetic pigmentation of the tooth percentage (Tab. 1). surfaces, usually following the administration of oral Each patient has been identified with a different pro- CHX, by means of the recording of Staining-Index gressive code, represented by the name of the dental Ed values. hygienist who has carried out the entire treatment of 200 subjects were recruited at the Department of the patient, together with the indication of the group “Oral Hygiene and Periodontics” of Calabrodental where the patient has been allocated after the random- dental clinic (Crotone, Italy): this study was conduct- ization (for example: Hygienist Name-number / C-1). ed among September 2011 and March 2012 and was The recruitment was conducted according to the protocol. commissioned by Curaden Healthcare. Exclusion criteria in this study were: absence of sys- IC Table 1. Prevalence of smokers in the 3 groups. C © 36 Annali di Stomatologia 2015; VI (2): 35-42  A comparative, randomized, controlled study on clinical efficacy and dental staining reduction of a mouthwash containing Chlorhexidine 0.20% and Anti Discoloration System (ADS) temic diseases, such as diabetes, coagulopathies, Table 2. Baseline data of the 3 values investigated in each uncompensated heart diseases, vascular diseases, of the 3 groups. metabolic bone diseases, gastro-esophageal dis- eases allergy, etc. Patients with erosions, abrasions Group C Group D Group E and abfractions of the enamel, patients affected by P. Index m.v. 1,88 m.v. 1,82 m.v. 2,0 i the bruxism and patients with mouth breathing were B. Index Y Y Y al also excluded. S. Index m.v. 0,68 m.v. 0,56 m.v. 0,59 Inclusion criteria were: Legend: 1. Age ± 18 years old m.v. : mean value on 2. Non-smokers or slight smokers (<10 cigarettes/day) Y: yes (according to mB.Index described in the Methods 3. Non-drinkers or slight drinkers (<3 glasses of section) wine/day) 4. Good compliance with the dental hygienist recorded before the previously described first oral hy- zi The following indices were analyzed and stored: giene treatment (T 0 ) (Tab. 2). The analyzed data a. Plaque Index (PI, according to Silness and Löe, showed a correct randomization. Follow-up evalua- 1963) (13); tions were performed after 7 days (T1) and after 14 na b. Bleeding Index (mBI, modified Bleeding Index so days (T2) from the first visit (T0). Photographic docu- to assess the presence/absence of bleeding after mentation was archived at baseline, T0,T1 and T2. probing of the gingiva) (14); In order not to influence the formation of the pigmen- c. Staining Index (SI, according to Lobene, 1968) (15); tations, the patients were advised to limit the chewing Plaque Index was assessed according to the follow- and drinking of chromogenic foods such as tea, cof- er ing clinical criteria (13): fee, red wine, spinach, during the 15 days of duration • Value 0: Absence of bacterial plaque of the study: every assumption of these substances • Value 1: Evident plaque by sliding the probe on was to be reported in the appropriate schedule pro- the surface of the teeth vided them in the T0 visit. • Value 2: Visible plaque t • Value 3: Abundant plaque. In Modified Bleeding Index was assessed according to “Reverse” motivation the following clinical criteria (14): • No: Visible gingival inflammation with bleeding During the study, patients were required not to use caused only by the passage of the probe on the the daily mechanical oral hygiene, while they were ni gingiva required only to rinse with 10 ml of solution of the • Yes: Evident gingival inflammation with sponta- assigned mouthwash, twice a day, not before 30 neous bleeding. minutes from their meals, for a duration of about 60 io The tooth is examined with a calibrate probe (di- seconds. ameter 0.63mm) on the lingual, mesial, distal, and The reverse motivation finds its rational application in buccal surfaces, and probed to test the degree of our study, and was reported in literature in a study by iz firmness. Bleeding can be more prevalent if a site Ross et al. (16), in which subjects who had heard is continually probed, thus it’s important to insert messages that dissuaded to perform the oral hy- the probe in four sites, removing the probe after giene, showed a significantly more negative attitude Ed the insertion. Moderate force (< 25g) should be toward this practice and remembered fewer episodes used during the probing. in which they had washed their teeth. Staining (only area) Index was assessed according to the following clinical criteria (15): • Value 0: Absence of pigmentations Statistical analysis • Value 1: Pigmentation covering up to 1/3 of the IC region The collected data were analyzed by means of the sta- • Value 2: Pigmentation covering 1/3 to 2/3 of the tistical software SPSS/PC version 10.1 for Windows. region The statistical evaluations were carried out by means • Value 3: Pigmentation covering 2/3 of the region. of Student’s t test for paired samples 2-tailed. The re- C Staining (only intensity) Index was assessed accord- sults were obtained by comparing, for each group of ing to the following clinical criteria (15): patients analyzed, the values detected at time T1 and • Value 0: No stain the values measured at time T2 [T1 vs T2]. The test • Value 1: Light pigmentations was considered significant with p-value <0.05. • Value 2: Moderate pigmentation © • Value 3: Marked pigmentation. Patients were properly visited and they were subject- Results ed to supragingival calculus removal employing ultra- sonic scaler tips; polishing and tooth stains removal At the end of the study, data were analyzed from was also performed in the first visit (T 0). Baseline pa- many points of interest, and results were investigated rameters of PI, mBI and SI index were properly per groups and per single value. Annali di Stomatologia 2015; VI (2): 35-42 37  M. Marrelli et al. P. Index The P. Index distribution in the 3 groups appears sub- stantially homogeneous with the exception of Group E, in which we detected few patients with P. Index i values between 2 and 3. al P. Index values show that the Group C has an in- crease of 0.03 points/media from T1 to T2; Group D shows a clear reduction of P. Index values, a de- on crease of 0.26 points/media. Group E is the only one with very high values if compared with the other two groups, with a decreasing of points/media of just - Table 4. Comparison of S.Index mean values between T1 0.06; however, the Group E is also the one who start- and T2 in the 3 groups. ed with mean values of P.Index equal to 2 before the zi initial hygiene performed in T 0; therefore, it is sup- static and anti-plaque action of CHX 0.20%; however, posed that the patients allocated in Group D are less this specific result may also depend in substantial prone to plaque control. It should be noted that the part by the clinical condition at baseline of the Group na Group D starts with a P. Index at baseline equal to E, as previously stated (Tab. 3). 1.82 and after 7 days it has a P. Index equal to 1.7, which constantly tends to stabilize itself at lower val- ues (1.44) in the following days (Tab. 3). S. Index er After the data evaluation, we can assert that P. Index variations detected in the 3 Groups C, D and E are S. Index data in the 3 groups show that the Group C not statistically significant, with the exception of presents an increase in the average value of the stain- Group D which shows a high significance. This data ing index computed in 0.29 points/media, between the allows us to observe a better clinical outcome t control at 7 days and the control at 15 days. Group E, showed by mouthwash with ADS, in relation to the control of dental plaque. In instead, shows an increasing in the average value of S.Index of 0.34 points/media, when you compare the control values at 7 days and the control values at 15 days; however, the detected average value of S.Index mB. Index at 14 days is lower than the one observed in the ni Group C. Finally, the Group D shows a variation of the The modified B. Index values of the Group C show average value of S. Index assessed in 0.28 points/me- that the bleeding persists even after the first week of dia between the control at 7 days and the control at 15 io treatment with the mouthwash C, however, starting days, however, it’s important to emphasize that the from the second week the leakage of blood stops. absolute values at T2 control reveal a pigmenting abili- The Group D shows an absence of bleeding at the ty of Curasept mouthwash significantly lower than the first follow-up and this finding remains unaltered even iz other tested mouthwashes: this mouthwash has a for- during the final visit at T2. The Group E is the only mulation containing the anti discoloration system one that does not seem to benefit from the bacterio- (ADS) that has just the function of reducing the dental Ed pigmentations (Tabs. 3, 4). Table 3. Comparison between T1 and T2 data of the 3 val- ues investigated in each of the 3 groups. T1 T2 Discussion Group C Oral care is an essential part of the general health of IC P.Index 1,82 1,85 the population. Dental bacterial plaque has been re- P.Index (≥2) 2,09 2,07 lated to several systemic diseases such as pneumo- B.Index Y N nia and endocarditis (17). The development of oral S.Index 0,52 0,81 diseases is often associated with the composition and C Group D the quantity of dental plaque, with the diet, and with P.Index 1,7 1,44 the typology of the salivary flow (18). P.Index (≥2) 2,1 2 CHX has been investigated for over 30 years as an B.Index N N antimicrobial agent for the chemical control of plaque formation. Different concentrations are available on © S.Index 0,21 0,49 the market, mainly ranging from 0.02 to 0.3%; howev- Group E er, recently, the Food and Drugs Administration P.Index 2,1 2,04 (FDA) introduced high concentration solution (3.5%) P.Index (≥2) 2,04 2,04 to be diluted with water before use. As shown by in B.Index Y Y vivo studies (19), the mechanism of action of the S.Index 0,3 0,64 Chlorhexidine seems to be dose-dependent: bacterio- 38 Annali di Stomatologia 2015; VI (2): 35-42  A comparative, randomized, controlled study on clinical efficacy and dental staining reduction of a mouthwash containing Chlorhexidine 0.20% and Anti Discoloration System (ADS) static at very low concentrations (0.02-0.06%), and Although CHX is unanimously recognized as one of bactericidal at higher concentrations (0.12-0.20%). the most effective cationic antiseptic compound cur- FDA suggested a use of CHX (at 0.12 and 0.2% con- rently used in medical practice (34), different re- centrations) administered as oral rinses of 10-15 mL, search groups have investigated the antiplaque ac- for about 30 seconds, for a limited period of time (re- tion of other mouthwash products containing different i spectively, 1 month or 2 weeks) (20, 21). principles rather than CHX (36). All these works failed al CHX would appear to have dose-dependent effects to find an alternative antiplaque solution as effective also in terms of its most common local adverse ef- as CHX, such as Listerine (without CHX) which has fects: dysgeusia and tooth pigmentation (22). Be- been demonstrated to have a significantly lower an- on cause of this, different concentrations have been sug- timicrobial activity than CHX-based products (35). gested over time, trying to balance beneficial and ad- Notwithstanding, some studies demonstrated that verse effects of CHX, in order to improve the patient CHX elicits a low efficacy in the treatment of severe compliance. periodontal diseases (36), or in the presence of coro- zi As recently reported in the literature (23, 24), the use nal caries (37), if it is not associated to a mechanical of mouthwashes containing 0.2% of CHX showed a removal of bacterial plaque. It is likewise important to substantial reduction of gingival inflammation and emphasize that in the presence of advanced peri- na plaque indexes (23, 24). Several studies demonstrat- odontal disease the use of CHX could result not suffi- ed that subjects that performed their oral care with cient to improve the periodontal condition, if not asso- mouthwashes containing 0.2% of CHX improved sig- ciated with subgingival treatment (38). nificantly their P. Index (25), the B. Index (26, 27), On the other hand, it has been demonstrated the possi- and the S. Index (28). bility of interaction and mutual inactivation of chlorhexi- er Recently, it has been investigated the possibility of dine and toothpaste that contains a common detergent reducing brown pigmentations associated with the compound, sodium lauryl-sulfate (38). Therefore, we use of CHX-based products, particularly the mouth- recommend the use of CHX after an interval of 30 min- washes (29), by interrupting the Maillard reaction. To utes by the use of other products for oral hygiene. date, the efficacy of antiseptic solutions containing t Previous works evidenced also an antagonist action 0.20% CHX has been consistently carried out by In of CHX with monofluorophosphate content in some some peer-reviewed publications (30-32), and ac- mouthwashes (39). cording to these studies, it was highlighted that CHX Gusolley (40) provided in the 2010 a ranking of the an- products with effective anti-staining additives, led to a tiplaques and antigingivitis effects of the three mouth- reduction of CHX antimicrobial activity (33). washes containing CHX, essential oils (EOs) and ce- ni In our work we have analyzed the antiplaque activity of typyridinium chloride (CPC). Among these three, EOs 3 of the most frequently used mouthwashes on the was reported as the second best antiplaque and anti-in- market, moreover, we have assessed their ability to flammatory mouthwash right after CHX (41). io avoid the typical pigmentations occurring after a lasting Phenols and essential oils have been used for a long of oral CHX treatment with a duration of several days. time to rinse the oral cavity. One of the main products We compared the three mouthwashes. Patients treat- is Listerine, made of essential oils, thymol and euca- iz ed with Curasept mouthwash, based on a formulation lyptol combined with alcohol-based menthol. Al- with ADS, showed a fairly constant antiplaque activi- though this product is not as effective as chlorhexi- ty, compared to baseline values stored in this re- dine (34) it obtained significant reductions in the level Ed search. This finding is fully confirmed by the sub- of plaque and gingivitis in various studies. EOs were analysis performed in patients with full-mouth P. In- also demonstrated to represent a reliable alternative dex ≥2: in fact, even into this sub-group, we can ob- to chlorhexidine mouthwash in long-term use (41). serve a noticeable reduction of the plaque index in Antiplaque and antimicrobial mouth rinses used thus Curasept group; although the observed plaque con- far in periodontal practice also contain ingredients trol in this group is not clinically satisfactory, we must such as alcohol or sugar (42). These ingredients en- IC consider the concomitant relative absence of me- hance the cariogenic potential of the substrate and chanical oral hygiene required by the “reverse moti- promote halitosis. A recent study evaluated the effects vation” described in the methods section, as required of the use of an herbal mouth rinse on oral hygiene im- by the protocol. provement (43). In this study emerged that the Indian C We evaluated the effectiveness of the ADS on the herb Triphala (44-46) exhibits similar antiplaque effica- reduction of the S. Index. In the Group C (Control 1) cy to that of CHX and was more effective in inhibiting the average value of S. Index resulted increased be- plaque formation with lesser or no side effects (47). tween the control at 7 days and at 15 days. In the Together with EOs, CHX is still considered the gold group E (Control 2) we observed a similar trend, standard against plaque formation (48). CHX is also © with average S. Index values increased between the available in gel at different concentrations ranging T 1 and the T 2 . Finally, the Group D (treated with from 1 to 0.2 and 0.12% (49); studies proved the an- Curasept) showed some variations of the average S. tibacterial activity of CHX gels at the high concentra- Index values, revealing that Curasept mouthwash tions available (2%, 1%) while at the lower concentra- has a lower pigmenting ability, with respect to the tions (0.2%) CHX gel action resulted inhibited by other tested mouthwashes. dentin matrix and type I collagen (50). Furthermore, Annali di Stomatologia 2015; VI (2): 35-42 39  M. Marrelli et al. some studies reveal that the gel cannot reach all sur- cio, Curaden Healthcare, for their precious contribu- faces of the tooth. tion to this clinical research; Alternatively, instead of rinse, there is a spray (18) Dr. Marta Giovannardi, Curaden Healthcare, for her that allows for convey the compound directly on the valuable contribute to the study design and to the crit- surfaces of the teeth making a dosage, normally low- ical analysis of the outcomes; i er than that used in mouthwashes, effective. Spray Dr. Roberto Cimmino, Curaden Healthcare, for his al formulations would appear to be particularly indicated kind support in the organizations of the research ac- in patients with mental and physical impairments, tivities; leading to a significant reduction in plaque and gingi- Dr. Dora Marrelli, Dr. Sandro Sestito, Dr. Domenico on val bleeding indexes (51-53). Tarsitano, Department of Oral Hygiene and Periodon- tics of Calabrodental Clinic, for their hard and profes- sional work in the collection of the data. Conclusions A sincere thank you to the Department of Oral Hy- giene and Periodontics of Calabrodental Clinic, to all zi Our trial has clinically showed, once again, the efficacy the administrative area and to all the operators of of chlorhexidine mouthwashes. All mouthwashes ana- Marrelli Group that participated to the organization of the research activities. na lyzed showed an action not only in reducing the ability of plaque formation in the absence of brushing, but also in the protection of the gingival tissues, which showed a less erythematous appearance, and with a lower index List of Abbreviations of spontaneous bleeding. But, the major and significant er evidence we had it in assessing the optimal response Anti Discoloration System (ADS) of the system ADS, by Curasept, to the formation of Chlorhexidine (CHX) pigmentation on tooth enamel. This response has al- Plaque Index (PI) lowed to combine aesthetics and antiplaque action, modified Bleeding Index (mBI) without reducing the effectiveness of each of them in t Bleeding Index (BI) oral hygiene at home. In Staining Index (SI) Time 0, 1, 2 (T0, T1, T2) Essential oils (EOs) Consent Statement Cetypyridinium chloride (CPC) ni Written informed consent was obtained from the pa- tient for publication of this case report and accompa- References nying images. A copy of the written consent is avail- io able for review by the Editor-in-Chief of this journal. 1. Quirynen M, Bollen CM, Vandekerckhove BN, Dekeyser C, Papaioannou W, Eyssen H. Full-vs. partial-mouth disinfec- tion in the treatment of periodontal infections: short-term clin- iz ical and microbiological observations. J Dent Res. 1995 Availability of supporting data Aug;74(8):1459-67. 2. Pongnarisorn NJ, Gemmell E, Tan AE, Henry PJ, Marshall A copy of all the supporting data of this study is avail- RI, Seymour GJ. Inflammation associated with implants with Ed able for everyone who requests it. different surface types. Clin Oral Implants Res. 2007 Feb;18(1):114-25. 3. Drisko CH. Nonsurgical periodontal therapy. Periodontol. Competing Interests 2000. 2001;25:77-88. 4. Heitz-Mayfield LJ, Lang NP. Surgical and nonsurgical peri- The Authors declare that they have no competing in- odontal therapy. Learned and unlearned concepts. Peri- odontol. 2000. 2013 Jun;62(1):218-31. Review. IC terests. 5. Becker W, Becker BE, Caffesse R, Kerry G, Ochsenbein C, Morrison E, Prichard J. A longitudinal study comparing scaling, osseous surgery, and modified Widman procedures: Authors’ contributions results after 5 years. J Periodontol. 2001 Dec;72(12):1675- C 84. MM and MA: ideated, directed and conducted the 6. Mohan RR, Doraswamy DC, Hussain AM, Gundannavar G, study protocol. Subbaiah SK, Jayaprakash D. Evaluation of the role of an- MT: drafted the manuscript and participated to all the tibiotics in preventing postoperative complication after rou- research activities. tine periodontal surgery: A comparative clinical study. J In- © dian Soc Periodontol. 2014 Mar;18(2):205-12. 7. Marchetti E, Mummolo S, Di Mattia J, Casalena F, Di Mar- tino S, Mattei A, Marzo G. Efficacy of essential oil mouthwash Acknowledgements with and without alcohol: a 3-day plaque accumulation mod- el. Trials. 2011 Dec 15;12:262. The Authors would like to thank the following people: 8. Ennibi O, Lakhdar L, Bouziane A, Bensouda Y, Abouqal R. Dr. Stefano Giovannardi and Dr. Restituta Castellac- Chlorhexidine alcohol base mouthrinse versus Chlorhexidine 40 Annali di Stomatologia 2015; VI (2): 35-42  A comparative, randomized, controlled study on clinical efficacy and dental staining reduction of a mouthwash containing Chlorhexidine 0.20% and Anti Discoloration System (ADS) formaldehyde base mouthrinse efficacy on plaque control: cacy of two cetylpyridinium chloride mouthrinses. Am J Dent. double blind, randomized clinical trials. Med Oral Patol Oral 2005;18 spec No:24A-8A. Cir Bucal. 2013 Jan 1;18(1):e135-9. 30. Addy M, Sharif N, Moran J. A non-staining chlorhexidine 9. Varoni E, Tarce M, Lodi G, Carrassi A. Chlorhexidine mouthwash? Probably not: a study in vitro. Int J Dent Hyg. (CHX) in dentistry: state of the art. Minerva Stomatol. 2012 2005;3:59-63. i Sep; 61(9):399-419. 31. Cortellini P, Labriola A, Zambelli R, Prato GP, Nieri M, Tonet- al 10. Schlett CD, Millar EV, Crawford KB, Cui T, Lanier JB, Trib- ti MS. Chlorhexidine with an anti discoloration system after ble DR, Ellis MW. Prevalence of chlorhexidine-resistant me- periodontal flap surgery: a cross-over, randomized, triple-blind thicillin-resistant Staphylococcus aureus following pro- clinical trial. J Clin Periodontol. 2008;35:614-20. longed exposure. Antimicrob Agents Chemother. 2014 32. Bernardi F, Pincelli MR, Carloni S, Gatto MR, Montebugnoli on Aug;58(8):4404-10. doi: 10.1128/AAC.02419-14. L. Chlorhexidine with an anti discoloration system. A com- 11. Marinone MG, Savoldi E. Chlorhexidine and taste. Influence parative study. Int J Dent Hyg. 2004;2:122-6. of mouthwashes concentrate on andof rinsing time. Miner- 33. Solis C, Santos A, Nart J, Violant D. 0.2% chlorhexidine va Stomatol. 2000 May;49(5):221-6. mouthwash with an antidiscoloration system versus 0.2% 12. Eriksen HM, Nordbø H, Kantanen H, Ellingsen JE. Chemi- chlorhexidine mouthwash: a prospective clinical compara- zi cal plaque control and extrinsic tooth discoloration. A review tive study. J Periodontol. 2011;82:80-5. of possible mechanisms. J Clin Periodontol. 1985 May; 34. Guggenheim B, Meier A. In vitro effect of chlorhexidine mouth 12(5):345-50. Review. rinses on polyspecies biofilms. Schweiz Monatsschr Zahn- na 13. Löe H, Silness J. Periodontal disease in pregnancy. I. Preva- med. 2011;121(5):432-41. lence and severity. Acta Odontol Scand. 1963; 21:533-551. 35. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. 14. Löe H. The Gingival Index, the Plaque Index and the Re- Guideline for prevention of surgical site infection, 1999. Hos- tention Index System. J Periodontol. 1967;38:610- 616. pital Infection Control Practices Advisory Committee. Infect 15. Lobene RR. Effect of dentifrices on tooth stains with controlled Control Hosp Epidemiol. 1999;20:250-78. er brushing. JADA. 1968;77:849-855. 36. Goutham BS, Manchanda K, Sarkar AD, Prakash R, Jha K, 16. Ross M, McFarland C, Fletcher G J. The effect of attitude Mohammed S. Efficacy of two commercially available Oral on the recall of personal histories. Journal of Personality and Rinses - Chlorohexidine and Listrine on Plaque and Gingivitis Social Psychology. 1981;40:627-634. - A Comparative Study. J Int Oral Health. 2013 Aug;5(4):56- 17. Ravald N, Hamp SE, Birkhead D. Long-term evaluation of 61. Epub 2013 Aug 28. t root surface caries in periodontally treated patients. J Clin 37. Medaiah S, Srinivas M, Melath A, Girish S, Polepalle T, Dasari Periodontol. 1986; 13:758-767. In AB. Chlorhexidine chip in the treatment of chronic periodonti- 18. Puig Silla M, Montiel Company JM, Almerich Silla JM. Use tis: a clinical study. J Clin Diagn Res. 2014; Jun;8(6):ZC22-5. of chlorhexidine varnishes in preventing and treating peri- 38. Papas AS, Vollmer WM, Gullion CM, Baber J, Laws R, Fel- odontal disease. A review of the literature. Med Oral Patol lows J, Hollis JF, Maupomé G, Singh ML, Synder J, Blan- Cir Bucal. 2008; 13:E257-60. chard P and the PACS Collaborative Group. Efficacy of ni 19. Jenkins S, Addy M, Wade W. The mechanism of action of chlorhexidine varnish for the prevention of adult caries: a ran- chlorhexidine. A study of plaque growth on enamel inserts domized trial. J Dent Res. 2012; 91(2):150-155. in vivo. J Clin Periodontol. 1988;15:415-24. 39. Barkvoll P, Rolla G, Svendsen K. Interaction between 20. www.drugs.com. Chlorhexidine- FDA Official Information, side chlorhexadine digluconate and sodium lauryl sulfate in io effect and Use. www.drugs.com; 2011. Available at: vivo. J Clin Periodontol. 1989 Oct 16(9):593-5. http://www.drugs.com/pro/chlorhexidine.html 40. Barkvoll P, Rolla G, Bellagamba S. Interaction between 21. Ellepola AN, Samaranayake LP. Adjunctive use of chlorhex- chlorhexidine digluconate and sodium monofluorophos- iz idine in oral candidoses: a review. Oral Dis. 2001;7:11. phate in vitro. Scand J Dent Res. 1988 Feb;96(1):30-3. 22. Hoffmann T, Bruhn G, Richter S, Netuschil L, Brecx M. Clin- 41. Gunsolley JC. Clinical efficacy of antimicrobial mouth-rins- ical controlled study on plaque and gingivitis reduction un- es. J Dent. 2010 Jun;38 suppl 1:S6-10. der long-term use of low-dose chlorhexidine solutions in a 42. Van Leeuwen MP, Slot DE, Van der Weidjen GA. Essential Ed population exhibiting good oral hygiene. Clin Oral Investig. oils compared to chlorhexidine with respect to plaque and 2001;5:89-95. parameters of gingival inflammation: a systemic review. J Pe- 23. Berchier CE, Slot DE, Van der Weijden GA. The efficacy of riodontol. 2011;82(2):174-94. 0.12% chlorhexidine mouthrinse compared with 0.2% on 43. Leyes Borrajo JL, Garcia VL, Lopez CG, Rodriguez-Nunez plaque accumulation and periodontal parameters: a systemic I, Garcia FM, Gallas TM. Efficacy of chorhexidine mouthrines review. 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Role of triphala 137:1649-57. in the management of periodontal disease. Anc Sci Life. © 27. Chaves ES, Kornman KS, Manwell MA, Jones AA, Newbold 1997;17:120-7. DA, Wood RC. Mechanism of irrigation effects on gingivitis. 47. Bajaj N, Tandon S. The effect of triphala and clorhexidine J Periodontol. 1994;65:1016-21. mouthwash on dental plaque, gingival inflammation, and mi- 28. Russell AD. Chlorhexidine: antibacterial action and bacter- crobial growth. Int J Ayurveda Res. 2011;2:29-36. ial resistance. Infection. 1986;14:212-5. 48. Narayan A, Mendon C. Comparing the effect of different 29. Stookey GK, Beiswanger B, Mau M, Isaacs RL, Witt JJ, Gibb mouth-rinses on the novo plaque formation. J Contemp Dent R. A 6-months clinical study assessing the safety and effi- Res Pract. 2012;13:460-3. Annali di Stomatologia 2015; VI (2): 35-42 41  M. Marrelli et al. 49. Jones CG. Chlorhexidine: is it still the gold standard? Peri- iodide and chlorhexidine digluconate against Enterococcus odontol. 2000. 1997;15:55-62. faecalis by dentin, dentin matrix, type-I collagen and heat killed 50. Prabhakar AR, Taur S, Hadakar S, Sugandhan S. Com- microbial whole cell. J Endod. 2002;28(9):634-637. parison of antibacterial efficacy of calcium hydroxide paste, 52. Montiel-Company JM, Almerich-Silla JM. Efficacy of two an- 2% chlorhexidine gel and turmeric extract as an intracanal tiplaque and antigingivitis treatments in a group of mental- i medicament and their effect on microhardness of root ly retarded patients. Med Oral. 2002;7:136-43. al dentin: an in vitro study. Int J Clin Pediatr Dent. 2013 53. Chibinski ACR, Pochapski MT, Farago PV, Santos FA, Czlus- Sep;6(3):171-7. niak GD. Clinical evaluation of chlorhexidine for the control 51. Porteneir J, Haapsolon, Ostrovik D, Yamauchi M, Haapasalo of dental biofilm in children with special needs. Community M. 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Original article Discriminant canine index – a novel approach in sex determination i al on Chennoju Sai Kiran, MDS Introduction Pachigolla Ramaswamy, MDS Erva Swathi, MDS The four leading features of biological identity are Balla Smitha, MDS sex, age, stature, and ancestry background. The Shankaran Sudhakar, MDS forensic anthropologists wish to authenticate these zi traits for an individual from their skeletal remains. As- Department of Oral medicine and Radiology, St. sessment of sex has significant contribution in con- Joseph Dental College, Eluru, India struction of a physical profile of the decedent along na with other parameters like race, stature and age. Sex can be assessed with high precision using pelvic Corresponding author: and cranial bones. But the demerit of using these Chennoju Sai Kiran bones is that they easily get fragmented which may be Department of Oral medicine and Radiology, St. er major hindrance for assessment of sex. The dentition is Joseph Dental College considered as an useful adjunct in skeletal sex estima- Duggirala tion, particularly since teeth are resistant to postmortem 534001 Eluru, India destruction and fragmentation (1). Teeth are the first- E-mail: iamchennojukiran@gmail.com t rate material for genetic and forensic investigations. In Teeth show signs of changes in morphology and they are easily accessible for examination. It is the hardest Summary and chemically most stable structure in the body. They are selectively preserved and fossilized, thereby provid- Context. Assessment of sex has significant contri- ing the best proof for evolutionary alteration. Their re- ni bution in construction of a physical profile of the silience in the case of fire and bacterial decomposition decedent along with other parameters like race, makes them important for identification in forensic sci- stature and age. Sex determination with aid of ence. Sex determination with aid of skeletal remains is io skeletal remains is difficult procedure when, only difficult procedure when, only a part of the body is ob- a part of the body is obtainable. To solve this diffi- tainable. To solve this difficulty, tooth size standards culty, tooth size standards based on odontometric based on odontometric data can be used in age and data can be used in age and sex determination. sex determination (2). iz The present study was undertaken with the objec- “Sexual Dimorphism” refers to differences in size and tive to evaluate the reliability of sex determination form between males and females that can be applied using discriminant canine index (DCI). to dental identification. In contemporary human popu- Ed Methods. A total of 120 subjects, with healthy peri- lations, males have larger tooth crowns than females. odontium and between the age groups of 15 to 40 Consequently, tooth size standards based on odonto- years were selected randomly. Subjects with hard metric investigations could be a reliable method in tissue abnormalities were excluded from the study. sex determination when limited skeletal remnants are The maximum mesiodistal widths of left mandibular recovered (3). canines were measured intraorally with the help of Sex determination using dental features is primarily IC divider and digital vernier caliper. Data was collect- based upon the comparison of tooth dimensions in ed and analyzed statistically. males and females, or upon the comparison of fre- Results. A significant increase in the mesiodistal quencies of nonmetric dental traits, like Carabelli’s width of canines in males (7.21 ± 0.45 mm) when trait of upper molars. Mesiodistal and buccolingual di- C compared to females (6.77 ± 0.29 mm) was ob- ameters of the permanent tooth crown are the two served. The discriminant canine index (DCI) has most commonly used and studied features in deter- identified 68.3% of males and 76.7% of females mining sex on the basis of dental measurements (4). correctly with an overall accuracy rate of 72.5%. Tooth sexual dimorphism is often related to body Conclusion. The present study indicated that the © size. In living people today, body size dimorphism av- DCI can produce reliable results and can be used erages 10%. Human dental dimorphism is on the or- as an alternative for mandibular canine index der of 2-6%. Canines vary from other teeth with re- (MCI), for sex determination. spect to survival and sex dichotomy (1). Of all the teeth in the human dentition, canines are the least Key words: canine tooth, forensic sciences, sex di- frequently extracted teeth (possibly because of the morphism, personal identification, gender identity. relatively decreased incidence of caries and peri- Annali di Stomatologia 2015; VI (2): 43-46 43  Chennoju Sai Kiran et al. odontal disease). Mandibular canines are considered ±0.01 mm (Fig. 1). The measurements were per- to be the key teeth for sexual dimorphism. Also, ca- formed by a single experienced examiner after nec- nines are reported to withstand extreme conditions essary training. 30 patients were re-evaluated and and have been recovered from human remains even the measurements were repeated to determine the in air disasters and hurricanes (5). intraobserver error. The collected data was entered in i Many studies were reported in the literature where a spreadsheet (Excel 2007, Microsoft office) and was al mandibular canine index (MCI) was used for sex de- analyzed using statistical analysis software (SPSS termination. But very few studies were reported version 16.01, SPSS.inc, Chicago, 1989-2007). Sig- where discriminant analysis was used for gender dif- nificance was set at 0.05 level (P<0.05). The mean on ferentiation. Hence the present study was undertaken mesiodistal widths of canine were compared in males with the objective to evaluate the reliability of sex de- and females using t-test. Discriminant equation was termination using discriminant canine index (DCI). derived with gender as a classifying variable and mesiodistal widths as independent variables. zi Materials and methods Results A cross sectional study was planned after the proto- na col was approved by the institutional committee of re- A total of 120 individuals were studied (60 males and search ethics. A total of 120 living subjects were ran- 60 females) with an age range of 15 to 36 years. The domly selected comprising of 60 males and 60 fe- measurements were made by an experienced oral males between the age groups of 15 to 40 years. physician with necessary training. The reproducibility er Subjects with healthy periodontium with no evidence of the measurements was tested by re-evaluating a of previous orthodontic treatment were included for subset of 30 patients after a period of 3 weeks. The the study. Subjects with dental or occlusal abnormali- Cohen’s kappa value obtained from the analysis was ties (rotation, crowding, occlusal disharmony, etc.), 0.87 which was interpreted to be in almost perfect physiologic or pathologic wear and tear (e.g. attrition, t agreement with the previous measurements. abrasion, abfraction, erosion) and deleterious oral habits (like bruxism) were excluded for the study. In Measurements included the mesiodistal widths of the left canines at their maximum diameter. The t-test re- The maximum mesiodistal widths of left mandibular vealed a significant increase in the mesiodistal width canines were measured intraorally with the help of di- of canines in males (7.21 ± 0.45 mm) when compared vider and digital vernier caliper (Hangzhou Maxwell to females (6.77 ± 0.29 mm). The Wilks’ lambda val- ni tools Co. Ltd, Zhejiang, China) with an accuracy of ue obtained in the study was 0.74 (Tab. 1). The given data were subjected to discriminant analy- sis using gender as a grouping variable and width of io left mandibular canine as an independent variable. The final equation obtained was: DCI = (-18.656) + (2.668 X D), where DCI is discriminant canine index and “D” is mesiodistal width of mandibular canine. A iz greater DCI value (DCI > 0) indicates male gender, while a lesser DCI value (DCI < 0) indicates the prob- ability of female gender. In the present study the dis- Ed Figure 1. Figure showing measurement of left mandibular criminant canine index (DCI) has identified 68.3% of canine width clinically. The armamentarium includes di- males and 76.7% of females correctly with an overall vider and vernier callipers. accuracy rate of 72.5% (Tab. 2). Table 1. Mean measurements of canine in males and females. IC Gender N Mean Std. Std. Wilks’ p-value of the patient Deviation Error Mean Lambda Clinical measurement Males 60 7.21 0.45 0.06 0.74 0.001 C of canine Females 60 6.77 0.29 0.04 Table 2. Measurement of accuracy of the study. © Gender of the patient Percentage of accurate prediction Females Males Total 76.7% 68.3% 72.5% Function at group centroids -0.588 0.588 Classified as male if D >0 Classified as female if D <0 44 Annali di Stomatologia 2015; VI (2): 43-46  Discriminant canine index – a novel approach in sex determination Discussion canine index, when compared to the present study (12, 13). But our results strictly support the use of Teeth are the finest human remains that can be pre- DCI over MCI for better and reliable results. This can served for a longer period of time. Although many ac- be attributed to the fact that MCI is a relative value curate techniques (DNA analysis) are available for obtained from the ratio of mesiodistal width of canine i sex determination, lack of facilities and cost factor be- and inter - canine arch width, while DCI is an ab- al come sabotage for their usage in developing coun- solute measurement. Acharya et al. has explained tries like India. In such conditions teeth provide an this with an excellent example in his article, where he excellent source, as they are easily available, robust considered a male canine with 8 mm of mesiodistal on in extreme environments and the procedure of sex width and 32 mm of inter-canine arch width, and a fe- determination is simple and economical. male canine with 6 mm of mesiodistal width and 24 Odontometrics is the study of tooth measurements mm of inter-canine arch width. Though the male di- which play a crucial role in anthropology as they were mensions were 33.33% larger than the female, MCI was interestingly the same in both the genders (8/32 zi known to show significant dimorphism in gender. Ca- nines were observed to show higher sexual dimor- = 6/24 =0.25) (10). Hence the degree of dimorphism phism among all teeth. This can be attributed to many also depends on the influence of parameters (mesiodistal width and inter canine arch width) over na factors which include: a) Influence of environmental factors and eating one another in MCI. Therefore DCI has a definite ad- habits (6). vantage over MCI in sex determination. b) Evolutionary differences in the size of canines in The degree of sexual dimorphism in a given population males and females where the size of canines were varies according to their evolutionary change, genetic er related to threat of aggression in primates (7). factors and ethnic background (1). Schield et al. ob- c) Genetic influence of Y chromosome in determina- served higher sexual dimorphism in Ohio Caucasians tion of size of the canine (8). and Australian aborigines than pima Indians and tris- d) Influence of steroid hormones on tooth size and tanite populations (14). Interestingly Acharya et al. shape (9). t found reverse sexual dimorphism (females showed Khangura has conducted a study among 100 dental In larger teeth compared to males) in Nepalese population students (50 males and 50 females). He found signifi- (15). These results conclude that individual discriminant cant difference in the mesiodistal diameters of left and analysis should be done based on the ethnic origin and right canines in males. He also found higher sexual di- separate discriminant equations must be derived for morphism in left side canines than right side (4). Simi- better and accurate sex determination. ni lar results were also reported by Ayoub et al. and Forensic odontology is an emerging field in countries Kapila et al. (3, 5). Hence we included only left like India. Hence a comprehensive database must be mandibular canines in order to eliminate discrepancy established using all the possible morphometric io of canine measurements based on sides and to obtain measurements of tooth and their accuracy or varia- the highest sexual dimorphism possible in the study. tions in degree of sex determination must be ana- Mandibular canine index (MCI) is a regularly used lyzed. The present study indicated that the DCI can iz method for determining sex using canine teeth. But produce reliable results and can be used as an ad- Acharya et al. suggested that MCI has insignificant junct tool along with other accepted procedures for use in sex determination and its application has to be sex determination. Ed restricted or discontinued in forensic and anthropo- logical sex predictions (10). Sherfudhin et al. com- pared MCI with DCI in his study, and concluded, DCI References to be a better indicator for sex determination (11). Hence we confined our study to discriminant analysis 1. Hosmani JV, Nayak RS, Kotrashetti VS, Pradeep S, Babji D. Reliability of Mandibular Canines as Indicators for Sex- for obtaining better results. ual Dichotomy. J Int Oral Health. 2013 Feb;5(1):1-7. IC Discriminant equation is a statistical method used to 2. Yuwanati M, Karia A, Yuwanati M. Canine tooth dimorphism: classify individuals into groups on the basis of set of An adjunct for establishing sex identity. J Forensic Dent Sci. measurements. It is more commonly used in forensic 2012;4(2):80-3. studies for sex determination. Hence we used dis- 3. Ayoub F, Shamseddine L, Rifai M, Cassia A, Diab R, C criminant analysis in the present study to derive the Zaarour I, et al. Mandibular Canine Dimorphism in Es- discriminant canine equation. The DCI derived from tablishing Sex Identity in the Lebanese Population. Int J this equation represents a value based on which the Dent [Internet]. 2014 [cited 2014 May 16];2014. Available gender of the patient can be predicted. The results from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3941160/ showed 76.7% accuracy in females, 68.3% accuracy 4. Khangura RK, Sircar K, Singh S, Rastogi V. Sex determination © using mesiodistal dimension of permanent maxillary incisors in males and an overall accuracy of 72.5% in deter- and canines. J Forensic Dent Sci. 2011;3(2):81-5. mining the gender using DCI. The results in the pre- 5. Kapila R, Nagesh KS, Iyengar AR, Mehkri S. Sexual Di- sent study were much higher when compared to the morphism in Human Mandibular Canines: A Radiomorpho- results of Hosmani et al. (1). metric Study in South Indian Population. J Dent Res Dent Many studies in the literature have proposed higher Clin Dent Prospect. 2011;5(2):51-4. accuracy rate of sex determination using mandibular 6. Lew KK, Keng SB. Anterior crown dimensions and relationship Annali di Stomatologia 2015; VI (2): 43-46 45  Chennoju Sai Kiran et al. in an ethnic Chinese population with normal occlusions. Aust of canine dimorphism in establishing sex identity: com- Orthod J. 1991 Oct;12(2):105-9. parison of two statistical methods. J Oral Rehab. 1996; 7. Osborne RH, Horowitz SL, De George FV. Genetic variation 23:627-31. in tooth dimensions: a twin study of the permanent anterior 12. Nair P, Rao BB, Annigeri RG. A study of tooth size, sym- teeth. Am J Hum Genet. 1958 Sep;10(3):350-6. metry and sexual dimorphism. J Forensic Med Toxicol. i 8. McLaren A. Sex determination. What makes a man a 1999;16:10-3. al man? Nature. 1990 Jul 19;346(6281):216-7. 13. Muller M, Lupipegurier L, Quatrehomme G, Bolla M. Odon- 9. Garn SM, Lewis AB, Kerewsky RS. The relationship between tometrical method useful in determining gender and dental sexual dimorphism in tooth size and body size as studied with- alignment. Forensic Sci Int. 2001;121:194-7. in families. Arch Oral Biol. 1967 Feb;12(2):299-301. 14. Schield ED, Altschuller A, Choi EY , Michaud M. Odontometric on 10. Acharya AB, Angadi PV, Prabhu S, Nagnur S. Validity of the variation among American black, European and Mongoloid mandibular canine index (MCI) in sex prediction: Re- population. J Craniofac Genet Biol. 1990;10:7. assessment in an Indian sample. Forensic Sci Int. 2011;204 15. Acharya A, Mainali S. Univariate sex dimorphism in the (1):e1-4. Nepalese dentition and the use of discriminant functions in 11. Sherfudhin H, Abdullah MA, Khan N. A cross-sectional study gender assessment. Forensic Sci Int. 2007;173:47-56. zi na t er In ni io iz Ed IC C © 46 Annali di Stomatologia 2015; VI (2): 43-46 

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Original article Reproducibility and speed of landmarking process in cephalometric analysis using two input devices: mouse-driven cursor versus pen i al on Alice Cutrera, DDS1 are really minimal and they can be ignored in pri- Ersilia Barbato, DMD, MSD2 vate practice. We suggest the adequacy of pen in- Francesco Maiorana, PhD3 put in clinical setting. Daniela Giordano, MS, PhD3 Rosalia Leonardi, DMD, MSD4 Key words: computed aided cephalometric land- zi mark tracing, landmark identification errors, later- al cephalometry, intraexaminer reliability. 1 Department of Orthodontics, University of Catania, na Italy 2 Department of Oral and Maxillofacial Sciences, School Introduction of Dentistry, “Sapienza” University of Rome, Italy 3 Department of Electrical, Electronic and Computer Cephalometric analysis is one of the major diagnostic tool in orthodontic, since 1931 when Broadbent intro- er Engineering, University of Catania, Italy 4 Department of Medical and Surgical Science, Sec- duced a standard diagnostic method to analyze the tion of Dentistry, University of Catania, Italy lateral head film (1). The constant progress in tech- nologies has allowed the orthodontists to perform the t cephalometric analysis on digital head film by means Corresponding author: Alice Cutrera In of computer software simplifying the landmark identi- fication process, because of the image enhancement Department of Orthodontics, University of Catania (2-5), and eliminating the majority of the errors that Via S. Sofia, 78 usually occurs during the hand tracing (drawing lines 97019 Vittoria (Catania), Italy and use rulers and protractors for measuring dis- ni E-mail: alice.cutrera@gmail.com tances and angles) (6, 7). Additionally, the cephalo- metric analysis performed on digital images lets the decreasing of time spent during the private practice io Summary and lets to achieve many different analysis at one time (8). Aims. To define if the new portable appliances, However, landmark identification on lateral X-ray still like smartphone, iPad, small laptop and tablet can is the main source of error in cephalometric analysis iz be used in cephalometric tracing without drop- regardless of the kind of input devices used. Abelson ping out the validity of any measurement. compared the reliability of cephalometric landmark- Methods. We investigated and compared the re- ing using both mouse and pen input focusing on mi- Ed producibility and the speed of landmarks identifi- cro parameters differences (9, 10-18). The Author cation process on lateral X-rays in two input de- claimed that the landmarking process and cephalo- vices: a mouse-driven cursor and a pen used as metric tracing soft tissue and hard tissue outlines is input means in mobile devices. One expert locat- faster and more accurate using a pen tablet than a ed 22 landmarks on 15 lateral X-rays in a repeated mouse. Vogel (19) evaluated the hand occlusion with measure design two times, at time T1 and T2, af- tablet sized direct pen input. But, only few Authors IC ter at least one month. The Intraclass Correlation studied how new technological devices with their coefficient was used to evaluate the reproducibili- small monitors size (iPad, smartphone, tablets) could ty for each landmark tracing and the agreement affect the efficiency of the accuracy of cephalometric between the value derived from both input de- tracing process in orthodontics. Goracci and Ferrari C vices. Also, the mean errors in measurements, (20) analyzed the reproducibility of cephalometric the standard deviation and the Friedman Test sig- measurements performed with software for tablet nificans (P < 0.05) between both input were statis- (where the clinician had to identify the landmarks tically evaluated. with a stylus pen on the tablet screen) and for per- sonal computers. Those Authors concluded that Pc- © Results. All landmarks had a high agreement and the Friedman Test indicated statistically signifi- aided and tablet-assisted cephalometric tracing had cant differences (P<0.05) for the identification of good agreement, but they did not evaluate if the Na, Po, Pt, PNS, Ba, Pg, Gn, UIE, UIA, APOcc and landmarks are more affected to errors during their PPOcc landmarks. detection in both devices. However, in that study, the Conclusions. Even if the mouse input give higher speed efficiency for both digital appliances was not agreement for landmark tracing the differences analyzed. Annali di Stomatologia 2015; VI (2): 47-52 47  A. Cutrera et al. The aim of this study, therefore, is to compare two the quality levels found in daily clinical practice. A classical input devices, mouse and pen, by consider- sample collection was approved by the Local Re- ing macro results and performance on a real clinical search Ethics Committee and informed consent was task such as a complete cephalometric landmarking obtained from each patient’s parents before the analysis requiring great precision in pointing. Hence, study. The cephalometric radiographs were scanned i we wanted to understand if the two different input de- (Epson Expression 1680 Twain 2.10 Pro, Epson al vices affect: Company) at a resolution of 300 dpi with 256 gray 1. accuracy of landmarks detection in lateral levels to transform the analogue image into tiff digital cephalometric X-ray; format and stored blinded in a Personal Computer on 2. to quantify time spent to detect the landmarks. (Intel Pentium IV, 3.2 GH with 2 GB RAM, 300 GB Hard Disk, ASUSTeK Computer Incorporated). An ex- tension of a software developed in other analysis (14) Materials and methods was used to record landmark coordinates and their Euclidean distances in millimeters. Twenty-two com- zi All the cephalometric landmarks in both devices were monly used cephalometric landmarks were included recordered by the same investigator, just graduated in this study (10) (Tab. 1). The sequence of land- from the Department of Orthodontic at the University marks was enforced by the software interface. The na of Catania, performed complete cephalometric analy- software tool also logged the time elapsing between sis on 15 X-rays, randomly collected from the any two consecutive landmarks, the total time spent archives of the Orthodontics Department from 2010 recording the landmarks and the whole set up of till 2014. To simulate common clinical practice, we mouse movements. er didn’t deliberately focus on gender, type of occlusion The observer recorded the 22 landmarks on the im- and skeletal patterns. The subjects (5 males and 10 ages displayed on a Toshiba Portege M205 with a females) were aged between 10 and 15 (mean age 1200 TFT polysilicon display with a native 1400 X 12.9 ± 1.7). Exclusion criteria were: (1) unerupted or 1050 resolution (Toshiba America Inc., New York, missing incisors or (2) unerupted teeth overlying the t USA). The equipment was used in tablet mode with In incisor apices; (3) obvious malpositioning of the head in the cephalostat; (4) no unerupted or partially erupt- the pen parallel to the desk and in laptop mode when the mouse was used as landmarking device. The ed teeth that would have hindered landmark identifi- scanned images maximum size was 2700 X 2500 pix- cation; (5) patients with severe cranio-facial deformi- els and they were resized keeping the original propor- ties; (6) posterior teeth not in maximum intercuspa- tions by a resampling procedure available in Adobe ni tion and (7) facial asymmetries. Image quality was Photoshop CS4 software (Adobe, Inc. San Jose, Cali- not used as an exclusion criteria since the selection fornia, USA) in order to obtain images with a vertical was made from a pool of images representative of side of 900 pixels maximum in order to display all the io Table 1. The twenty-two commonly used cephalometric landmarks included in this study. Landmarks iz Name Abbreviation Definition Nasion Na Junction of the frontal nasal bones at the naso-frontal suture Ed Sella S The midpoint od Sella Turcica Orbitale Or The most inferior point of the infraorbital margin Porion Po The most superior point of infraorbital margin Basion Ba The lowest point on the anterior margin of the foramen magnum in the midline Pterigo- Maxillary Fessure Pt The intersection of the posterior border of the foramen rotundum with the posterior wall of the pterigomaxillary fessure Anterior Nasal Spine ANS Tip of the Anterior Nasal Spine IC Point A A The deepest point in the concavity of the anterior maxilla between the anterior nasal spine and the alveolar crest Posterior Nasal Spine PNS Tip of the Posterior Nasal Spine Point B B The deepest in the concavity of the anterior mandible between the alveolar C crest and Pogonion Menton Me The most inferior point of the Chin Gonion Go The most outward point on the angle of the mandible formed by the conjunction of the rams and the body of the mandible Condilion Co The most upper-posterior point of the condile © Upper Incisal Edge UIE Tip of the crown of the upper central incisor Lower Incisal Edge LIE Tip of the lower central incisor Upper Incisal Apex UIA Tip if the apex of the upper central incisor Lower Incisal Apex LIA Tip of the apex of the lower central incisor Anterior Occlusal Plane APOcc Contact point between the first upper and lower premolars Posterior Occlusal Plane PPOcc Contact point between the first upper and lower molars 48 Annali di Stomatologia 2015; VI (2): 47-52  Reproducibility and speed of landmarking process in cephalometric analysis using two input devices: mouse-driven cursor versus pen X-ray without scrolling bars. The participant didn’t After outliers removal the mean and standard devia- have any previous experience with software tool and tions of the distances between the landmark coordi- he was briefed about the purpose of the experiment. nates at T1 and T2 for each landmark, and the time The landmarking process was performed directly on spent to locate each landmark were computed for the monitor displayed X-ray with a mouse-controlled each of the two experimental conditions. i cursor. This cursor consisted of an empty arrow. A red For each input devices were calculated the mean er- al dot on the selected pixel was used to signal the se- rors and the standard deviations (in millimeters) of lected landmark on the screen. The landmark position the Euclidean distance in landmark pointing between could be corrected until the operator was satisfied. T1 and T2. It was also detected the Friedman’s test on A repeated measure design was chosen. The first significance between T1 and T2 for mouse cursor time (T1), the observer performed the identification of and pen input device where the significance level was 22 landmarks on all the 15 X-rays, without any time 5% (P<0.05). Non-parametric Friedman’s test was limit, on each of the two input devices. A rotation used to analyze the variance in a repeated measures scheme was used to ensure that any X-ray head film design because the data sets had a non-normal dis- zi was displayed to the examiner at the same frequency tribution with non homogeneous variance. All statisti- on each one of the two input devices, in order to cal analysis were done with the software MATLAB avoid any learning effect. No more than 5 radi- version 7.10.0.499 (R2010a) (The Mathworks, Natik, na ographs per day were analyzed to avoid the examiner MA, USA) and its Statistics toolbox. fatigue (21). The landmarking process was repeated a second time (T2) for all X-rays and in both advices at least one month after the first session. Overall in Results er the experiment 3,960 data points from the investiga- tor, two input devices, 15 radiographs, 22 landmarks Table 2 shows the ICC values of landmarking and 2 repeated measures were collected. The Euclid- process with the mouse-cursor devices for both times ean distance between each cephalometric point lo- (T1 and T2) and Table 3 shows the ICC of landmark- cated at T1 and T2 for both devices was used as the t ing process between T1 and T2 using the pen device. gold standard measurement to assess repeatability. In The Intraclass Correlation Coefficient was calculated for All the pointing processed had ICC >̳ 0.95: this result was indicative of a very high agreement among the each Euclidean distance landmark detection to define landmarking process for both devices. The mouse- the reliability of the point identification for each used in- cursor device had the highest values of correlation, put device. The ICC was computed using the more re- ICC > 0.996, for Menton (X-axis), Orbitale (X-axis) ni strictive index of absolute agreement on the basis of the and Basion (X-axis). The pen device had the highest vector distance of the landmark position from the origin values of correlation, ICC > 0.996 for Sella (X-axis), of the coordinates system (10). Overall the rate of Porion (X-axis) and Pterigo-maxillary fissure (X-axis). io agreement was considered low for an ICC < ̳ 0.80 and After outliers removal the mean and standard devia- an ICC > 0.80 was indicative for good agreement. tions of the distances between the landmark coordi- iz Table 2. The Intra-Class Correlation for the mouse cursor devise evaluates the agreement among the landmarking process in T1 and T2. The agreement is high when ICC>0.80. Mouse-Cursor Device X-axis Y-axis Ed Nasion 0,997535404229079 0,99752295715014 Sella 0,999401854224947 0,987099486029854 Orbitale 0,999666897017603 0,99005469272275 Porion 0,999569537007793 0,980427303078359 Basion 0,999156109755965 0,996381499987584 Pterigoid maxillary fessure 0,999697903832193 0,999454418826513 IC Anterior Nasal Spine 0,998665572003988 0,992379285485212 A Point 0,9971841105861 0,98115227811275 Posterion Nasal Spine 0,989655916459857 0,989261997063066 B Point 0,999502641163362 0,998076974380408 C Pogonion 0,994347093257402 0,983123759705164 Gnation 0,987763576302059 0,988314973962179 Menton 0,998168211697634 0,99575280126277 Gonion 0,99611348877175 0,969128526136086 Condylion 0,992494024483712 0,995058661875066 © Occlusal Point Upper Incisor 0,988628251924127 0,998653318730979 Occlusal Point Lower Incisor 0,952687899194511 0,986275922263936 Apex Upper Incisor 0,953401022916771 0,991830699536617 Apex Lower Incisor 0,99625081352735 0,983498206000574 Anterior Occlusal Point 0,993671053793834 0,955790067372581 Posterior Occusal Point 0,997407175137818 0,988157332078623 Annali di Stomatologia 2015; VI (2): 47-52 49  A. Cutrera et al. Table 3. The Intra-Class Correlation for the pen devise evaluates the agreement among the landmarking process in T1 and T2. The agreement is high when ICC > 0.80. Pen device X-axis Y-axis Nasion 0,997535404229079 0,99752295715014 i Sella 0,999401854224947 0,987099486029854 al Orbitale 0,999666897017603 0,99005469272275 Porion 0,999569537007793 0,980427303078359 Basion 0,999156109755965 0,996381499987584 on Pterigoid maxillary fessure 0,999697903832193 0,999454418826513 Anterior Nasal Spine 0,998665572003988 0,992379285485212 A Point 0,9971841105861 0,98115227811275 Posterion Nasal Spine 0,989655916459857 0,989261997063066 B Point 0,999502641163362 0,998076974380408 zi Pogonion 0,994347093257402 0,983123759705164 Gnation 0,987763576302059 0,988314973962179 Menton 0,998168211697634 0,99575280126277 na Gonion 0,99611348877175 0,969128526136086 Condylion 0,992494024483712 0,995058661875066 Occlusal Point Upper Incisor 0,988628251924127 0,998653318730979 Occlusal Point Lower Incisor 0,952687899194511 0,986275922263936 Apex Upper Incisor 0,953401022916771 0,991830699536617 er Apex Lower Incisor 0,99625081352735 0,983498206000574 Anterior Occlusal Point 0,993671053793834 0,955790067372581 Posterior Occusal Point 0,997407175137818 0,988157332078623 t In Table 4.The mean error, the standard deviation and the Friedman’s test significance between T1 and T2 in millimeters for the cephalometric landmarks detected with the two input devices: mouse and pen. NS = not significant. P < 0.05. Landmark Mouse Pen Significance Na 0,37±0,21 0,57±0,31 * ni S 0,30±0,10 0,38±0,19 NS Or 0,91±0,58 0,91±0,48 NS Po 0,68±0,21 0,72±0,35 NS io Ba 0,59±0,28 1,34±0,90 * Pt 0,92±0,54 1,63±1,00 * ANS 0,76±0,42 0,76±0,42 NS A 0,44±0,18 0,65±0,26 * iz PNS 0,79±0,42 0,99±0,57 NS Ba 0,81±0,40 0,73±0,40 NS PM 0,57±0,25 0,66±0,40 NS Ed Pg 0,39±0,21 0,54±0,31 * Gn 0,54±0,24 0,80±0,42 NS Me 0,37±0,21 0,72±0,26 * Go 1,10±0,65 1,48±0,43 NS Co 1,22±0,63 1,56±0,91 NS UIE 0,27±0,12 0,29±0,18 NS IC LIE 0,32±0,17 0,37±0,16 NS UIA 0,98±0,45 0,95±0,34 NS LIA 0,97±0,41 1,24±0,52 NS APOcc 0,84±0,24 1,63±1,00 NS PPOcc 0,97±0,37 1,58±0,63 * C nates at T1 and T2 for each landmark, and the time tically significant difference, with P < 0.05, in land- spent to locate each landmark, were computed for mark detection repeatability under the two experi- © the two experimental conditions. mental conditions. In all the cases with statistically The mean errors and the standard deviations (in mil- significant difference the lowest error was obtained limeters) of the Euclidean distance in landmark detec- with the mouse as input device. tion between T1 and T2 and the significance of the Table 5 shows the mean values, standard deviations Friedman’s test are reported in Table 4 for each input and the significance of the Friedman’s test of the time device. The Friedman test indicates that, except for employed by the observer to locate each cephalomet- Na, Ba, Pt, A, Pg, Me and PPocc there was no statis- ric landmark (averaged over all users and images 50 Annali di Stomatologia 2015; VI (2): 47-52  Reproducibility and speed of landmarking process in cephalometric analysis using two input devices: mouse-driven cursor versus pen Table 5. The mean, standard deviation and Friedman’s test significance for the time, in hundreds of seconds, required to digitize each landmark. Data have been averaged over all users, all X-rays at T1 and T2 for each of the two input devices: mouse and pen. NS = not significant. p < 0.05. Landmark Mouse Pen Significance i Na 439,29±253,51 718,94±652,18 * al S 252,25±92,88 298,74±91,28 NS Or 164,72±48,81 222,61±26,37 NS Po 166,94±73,64 214,42±65,45 * on Ba 257,50±97,64 286,44±95,92 NS Pt 148,04±67,66 202,52±71,82 * ANS 256,03±84,73 300,62±68,93 NS A 265,88±124,29 225,54±139,94 NS PNS 248,25±121,93 312,24±132,17 * zi Ba 158,39±64,60 278,90±52,46 * PM 338,63±115,25 359,37±209,16 NS Pg 216,21±109,94 398,53±152,87 * na Gn 192,96±86,22 288,58±135,58 * Me 204,41±107,19 223,60±117,58 NS Go 346,25±106,06 465,50±220,38 NS Co 203,58±79,22 264,84±34,85 NS UIE 98,73±71,75 170,77±90,20 * er LIE 247,46±77,80 228,44±94,90 NS UIA 106,58±48,84 227,19±108,98 * LIA 271,24±104,59 277,52±98,89 NS APOcc 146,45±63,95 250,65±33,13 * PPOcc 368,68±130,36 t 489,57±156,23 * In during both experiments i.e. T1 and T2), for the two bitale, and Lower Incisor Apex are unreliable because of input devices. Statistically significant differences the superimposition of many anatomic structures that (P<0.05) were found for landmarks Na, Po, Pt, PNS, causes great variation. This difference could be be- ni Ba, Pg, Gn, UIE, UIA, APOcc and PPOcc. cause the digital images can be manipulated to improve the quality of the lateral head films so to reduce errors due to the superimposition of other anatomical struc- io Discussion tures or to the low contrast of the X-ray (4, 5, 7). About the time spent to point the landmarks on lateral The development of technology introduced the ortho- X-rays, even if a statistically significant difference ex- dontists to a new approach for diagnosis by the use ist for half of the landmarks, the difference of the sum iz of digital systems for tracing and analyzing cephalo- of average time spent is 51 seconds when the mouse metric head films. Digital radiology has many advan- is used as input device and 67 seconds when the pen tages: reduced radiation dose, easier information ac- is used as input device. This difference is reduced if Ed cess and image manipulation (22, 23), however the we avoid considering the first landmark that usually reproducibility of digital cephalometric analysis has to requires more time to be located due to the habit of be high and has to reduce to the minimum the errors. the expert to obtain an overall impression of the To avoid the inter examiner errors and to standardize X-ray. In this case the time required using the mouse the protocol for a comparative study, all the tracings is 47 seconds and the time required using the pen is were done by the same investigator. 60 seconds. In any case a difference between 16 and IC Based on the Friedman test outcomes, there is no 13 seconds for an entire analysis is not so relevant in statistically significant difference on the repeatability clinical practice. of landmark detection for the two input device, except The difference in landmarking using the pen can be for Nasion, Basion, Pterigo-Maxillary Fessure, A due to the parallax error experienced and reported by C Point, Pogonion, Menton and Posterio Occlusal the expert in a post interview and in a questionnaire Plane. For all those landmarks with statistically differ- that requires an inspection to precisely locate the ence, the lowest error was obtained using the mouse. landmarks. However, the characteristic method of This can be due to the parallax error using the pen. In landmark detection by touching the screen needed to © some cases locating some landmarks, such as Me, be tested in an independent study. requires to move the hand down to avoid hand occlu- In conclusion this work is a quantitative study to eval- sions of the area where the landmark lies. uate the differences between two different input de- Our findings are not in line with Chen, Polat-Ozsoy and vices, mouse and pen, in accuracy and speed land- Celik’s results (22-24), who analyzed the reproducibility marking process. Hence we claim: of the landmarking process during conventional hand- • Landmarks, in most of the cases, were pointed with tracing. These Authors claimed that Gonion, Porion, Or- more accuracy by mouse device respect the pen; Annali di Stomatologia 2015; VI (2): 47-52 51  A. Cutrera et al. • Less time was needed to identify the landmarks 11. Giordano D, Leonardi R. Web-trace and the learning of vi- with the mouse device. sual discrimination skills. 1st International Workshop on Pen- The difference in accuracy with the advent of more Based Learning Technologies. PLT. 2007. 12. Leonardi R, Giordano D, Caltabiano M. Interactive online pro- sophisticated devices will probably decrease and it gram to improve cephalometric tracing skills. Am J Orthod could be interesting to extend the analysis to new pen i Dentofacial Orthop. 2004;126;256-258. devices as well as to evaluate the performance when al 13. Abelson M. Potpourri II. Digital Imaging Update. Am J Or- touch input is used. thod Dentofacial Orthop. 1999;115;599-601. 14. ISO, Ergonomic requirements for office work with visual dis- play terminals (VDTs), Part 9: Requirements for non-keyboard on References input devices. International Organization for Standardisation. 2000. 1. Liu JK, Cheng KS. Accuracy of computerized automatic iden- 15. Fitts PM. The information capacity of the human motor sys- tification of cephalometric landmarks. Am J Orthod Dento- tem in controlling the amplitude of movement. J Exp Psy- facial Orthop. 2000;118:535-540. chology. 1954;47;381-391. zi 2. Major PW, Johnson DE, Hesse KL, Glover KE. Landmark 16. MacKenzie IS, Sellen A, Buxton W. A comparison of input identification error in posterior anterior cephalometrics. An- devices in elemental pointing and dragging tasks. Proc CHI, gle Orthod. 1994;64:447-54. New York: ACM.1991;161-166. na 3. Sicurezza E, Greco M, Giordano D, Maiorana F, Leonardi 17. Accot J, Zhai S. Beyond Fitts’ law: models for trajectory-based R. Accuracy of landmark identification on postero-anterior HCI tasks. In Proceedings of the ACM SIGCHI Conference cephalograms. Prog Orthod. 2012;13;132-140. on Human factors in computing systems. ACM. 1997;295- 4. Leonardi RM, Giordano D, Maiorana F, Greco M. Accura- 302. cy of cephalometric landmarks on monitor-displayed radi- 19. MacKenzie IS, Kauppinen T, Silfverberg M. Accuracy mea- ographs with and without image emboss enhancement. Eur sures for evaluating computer pointing devices. In Pro- er J Orthod. 2010;32;242-247. ceedings of the SIGCHI conference on Human factors in com- 5. Giordano D, Maiorana F, Leonardi R. Effects of monitor size puting. New York, ACM. Systems. 200;9-16. on accuracy and time needed to detect cephalometric radi- 20. Vogel D, Cudmore M, Casiez G, Balakrishnan R, Keliher L. ographs landmarks. Displays. 2012;33;206-213. Hand occlusion with tablet-sized direct pen input. In Pro- 6. Tsorovas G, Karsten AL. A comparison of hand-tracing and t ceedings of the SIGCHI Conference on Human Factors in cephalometric analysis computer programs with and with- out advanced features-accuracy and time demands. Eur J In Computing Systems. ACM. 2009;557-566. 21. Goracci C, Ferrari M. Reproducibility of measurements in Orthod. 2010;32:721-728. tablet-assisted, PC-aided, and manual cephalometric analy- 7. Leonardi R, Giordano D, Maiorana F. An evaluation of cel- sis. Angle Orthod. 2014;84;437-442. lular neural networks for the automatic identification of 21. Erkan M, Gurel HG, Nur M, Demirel B. Reliability of four dif- ni cephalometric landmarks on digital images. J. Biomed. ferent computerized cephalometric analysis programs. Eur Biotechnol. 2009;1-12. Article ID 717102. J Orthod. 2012;34:318-321. 8. AlBarakati SF, Kula KS, Ghoneima AA. The reliabiity and the 22. Chen YJ, Chen SK, Chan HF, Chen KC. Comparison of land- reproducibility of cephalometric measurements: a compar- mark identification in traditional versus computer-aided io ison of conventional and digital methods. Dentomaxillofac digital cephalometry. Angle Orthod. 2000;70:387-392. Radiol. 2012;41:11-17. 23. Celia E, Polat-Ozsoy O, Ufuk Toygar Memikoglu T. Com- 9. Trpkova B, Major P, Prasad N, Nebbe B. Cephalometric land- parison of cephalometric measurements with digital versus iz marks identification and reproducibility: a meta analysis. Am conventional cephalometric analysis. Eur J Orthod. J Orthod Dentofacial Orthop. 1997;112:165-70. 2009;31:241-246. 10. McClure SR, Sadowsky PL, Ferreira A, Jacobson A. Relia- 24. Polat-Ozsoy O, Celik E, Ufuk Toygar Memikoglu T. Differ- bility of digital versus conventional cephalometric radiology: ences in cephalometric measurements: a comparison of dig- Ed a comparative evaluation of landmark identification error. In ital versus hand-tracing methods. Eur J Orthod. 2009;31:254- Seminars in Orthodontics. 2005;11:98-110. WB Saunders. 259. IC C © 52 Annali di Stomatologia 2015; VI (2): 47-52 

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Original article Craniofacial growth and respiration: a study on an animal model i al on Luca Levrini, MD,DDSc,MSc1 Conclusion. An altered nasal respiration is able to Alessandro Mangano, DDS,MSc1 influence the patterns of facial growth and in par- Alessandro Ambrosoli, DDS,MSc1 ticular to induce an increase in the growth of the Paola Merlo, DDS,MSc1 mandible. Carlo Mangano, MD,DDSc2 zi Alberto Caprioglio, DDS,MSc1 Key words: craniofacial growth, respiration, or- thodontics, growth patterns. na 1 Department of Surgical and Morphological Sci- ences, University of Insubria, Varese, Italy Introduction 2 Private practice Numerous studies conducted on animals have demonstrated a strict correlation between craniofacial er Corresponding author: morphogenesis and the onset of functional anomalies Alessandro Mangano (1). It has been shown that in bipedal rats (created by Department of Surgical and Morphological Sciences, amputation of two paws) variations in body and head University of Insubria t posture have been brought about, with consequential Via Ravasi, 2 21100 Varese, Italy In alterations in the craniofacial region (2). These varia- tions consist above all in an opening of the angle of E-mail: ale.mangano10@gmail.com the base of the skull and an anterior displacement of the occipital foramen. A theory has been put forward that the craniofacial alterations may occur as a con- ni Summary sequence of a lack in nasal airflow, which is indepen- dent from the onset of oral respiration (3-5). Signifi- Aims. The aim of this study was to analyse the ef- cant correlation between oral respiration and cranio- io fects of nasal obliteration with regards to the lin- facial modifications were found in a study carried out ear dimensions of dissected hemimandibles of a on a sample of 80 rats, in which one or both nostrils homogeneous sample of young rats. were occluded. Besides a reduction in overall growth Methods. 68 pure breed male Sprague-Dawley rats, of the animals, where a clear-cut ponderal reduction iz aged four weeks, were divided into four groups of was shown, a reduction in the general dimensions of 17: two control groups and two test groups. The first the skull was also demonstrated. Important variations control group was sacrificed at the beginning of the were found not only in the mandible but also in the Ed observation period and the other one at the end. The pterygoid and tympanal areas. In particular, a post- test groups, one of which had the right nostril oc- rotation of the viscerocranium and of the mandible cluded by silicon material while the other had the left were noted, probably due to induced oral respiration. occluded, were sacrificed after eight weeks, at In fact, under these conditions, the rodent is forced to twelve weeks. After isolating the hemi-mandibles, an obligatory raising of the head in order to increase four vertical and four sagittal measurements were the opening of the pharynx (6). In another study IC taken; comparison was then made between the con- made on rats, where a monolateral nostril occlusion trol groups and the experimental groups. The sagit- had been carried out, a significant deviation of the tal measurements are articular surface of the midline towards the side of the occlusion was noticed. condyle-neck incisor (SARCIN), articular surface of This has therefore led to the belief that a lack of air- C the condyle-mental foramen (SARFORO), articular flow in the occluded fossa inhibits morphogenesis surface of the condyle-margo incisalis (SARMI), ar- and, therefore, the passage of airflow through the ticular surface of the condyle-surface mesial of the nasal cavity constitutes in itself a morphogenetic first molar (SARSMM). The vertical measurements stimulus for the viscerocranium development (7). The anatomic and structural differences between © are superior condyle surface-base (SCOSUB), mesial surface of the first molar-base (SUMESM), maximum man and other animals often make it difficult to com- inferior arched concavity-base, (XCOARIB), maxi- pare the results obtained in these studies (8,9), par- mum sigmoid notch concavity-base (XCOINSB). ticularly when comparing human anatomy with ro- Results. The sagittal and vertical measurements dents’ anatomy. From this point of view, studies showed an increase in the values of the experi- made on primates would appear to be much more re- mental group when compared to the controls. liable (10,11). In all mammals respiration requires a Annali di Stomatologia 2015; VI (2): 53-57 53  L. Levrini et al. highly specialised structure able to adapt to the vari- test p=0.03. Using a general anaesthesia for animals ety of needs of every specie and to the different evo- (Chetamine cloridate i.m.) the nostrils of groups A lutionary pressures (12). In the albino rat, even and B were occluded with silicon material. In order to though skeletal segments are comparable in number verify a comparison between the experimental mod- to those of the human skull (13), the respiratory func- els and evaluate whether different ways of breathing i tion is carried out differently. The topographic proxim- had any influence on the health of the rats they were al ity between the epiglottis and the soft palate makes weighed at the beginning and end of the observation the passage of air through the oral cavity extremely period. The animals were then sacrificed at 12 difficult thus making the rat’s respiration mainly nasal. weeks. Soft tissues were then carefully removed from on Many studies conducted on human patients (14-28) the head until the cranium was completely isolated have shown cephalometrically a correlation between and the mandibles could be separated. The respiration and craniofacial development, but also an mandibles were then divided into two hemi- interesting possible correlation between growth hor- mandibles. Checking whether the nasal cavities had mone levels and the morphologic development of the indeed been obstructed, only 29 obstructions resulted zi upper and lower jaw (15). out of 31 (the total number of possibly obstructed A very recent study conducted on newborn rats (29) nostrils corresponds to 31 due to the fact that 3 out of showed that a diet-induced hypermethioninemia in rat the 34 rats with obstructed nostrils had died). The fi- na dams results in growth retardations and histomorpho- nal number of specimens of mandible was 29 be- logical changes of the spheno-occipital synchondro- cause two rats’ nasal cavities were not totally ob- sis, an important craniofacial growth centre in new- structed and were discarded from the study. The 29 borns: this may elucidate facial dysmorphoses report- useful hemi-mandibles were photographed using a er ed in patients suffering from hypermethioninemia. digital camera (Polaroid Digital Microscope Camera): The hypothesis for this study is the possibility that they were put onto the stage plate of a stereomicro- respiratory function may also modify skeletal growth scope, on a black background with a millimetre mark- in the animal model. The type of modification induced er and identity signs for the groups (Fig. 1); in order is not clinically relevant, due to the reasons cited t to guarantee the same position of the hemi- above concerning the lack of comparison possibilities between man and rat. In mandibles during the analysis, the latter where glued to a support that made the external face of the mandible parallel to the surface of the stage plate. The photographs were then transferred to a software Materials and methods system (IMAT R-D) which allowed measurements up ni to approximately 0.1 mm to be taken. The linear mea- This study was carried out according to the declara- surements were divided into sagittal (S) and vertical tion of Helsinki (1964). In this study 68 male pure (V); we decided not to evaluate the thickness of the io breed Sprague-Dawley rats were used. At the begin- mandibles because we considered that this value ning of the experiment the rats were 4 weeks old. The was not useful to the purpose of our research, in that animals have been randomly divided into four groups of 17 (two experimental and two controls); of the two iz experimental group, one had the right nostril occlud- ed with silicone material, while the other had the left nostril occluded. The animals belonging to two control Ed groups (groups C and D) had no nostril occluded and were sacrificed at two different times; respectively af- ter 4 weeks and after 12 weeks. Accommodation was made putting five rats per cage with water and food at their disposal (Tab. 1). A Student t-test was applied. The level of significance was set at 0.05. All statisti- IC cal analyses were run on the statistical package SPSS (SPSS 17.0; SPSS Inc., Chicago, IL,USA). At the beginning of the observation period rats be- longing to Group C were sacrificed, in order to verify C whether the growth of the rats was homogeneous or not: the measurements were quite the same, with a t- Figure 1. One of the sample analyzed. Table 1. Subdivision of the rats in the four groups. © Group type Number of rats Nostril occluded Sacrifice time Average weight Group A experimental 17 left 12 weeks Gr 384 ± 23 Group B experimental 17 right 12 weeks Gr 395 ± 32 Group C control 17 none 4 weeks Gr 72 ± 19 Group D control 17 none 12 weeks Gr 388 ± 27 54 Annali di Stomatologia 2015; VI (2): 53-57  Craniofacial growth and respiration: a study on an animal model the volume of the superior aerial column shall not be S4: Articular surface of the condyle – Mental foramen modified by the thickness of this particular bone. (SARFORO) The acquired data concerning the linear measure- The average, standard deviation, mode and median ments measured on the rats’ mandible may be divid- were calculated for every variable measured. The ed into two main groups: sagittal measurements (Fig. statistical significance of the increases in evidence i 2) and vertical measurements (Fig. 3). were ascertained with the use of t-test (p<0.05) for al With regard to the vertical values they were identified correlated samples (matched data) in the sample and perpendicular to a reference line passing from the up- the control group. Due to the uniform genetic and per reference point, the following distances were con- phenotypical characteristics of the sample it was not on sidered: necessary to apply non parametric statistical tests, V1: Superior condyle surface - Base (SCOSUB) where the conclusions obtained are valid indepen- V2: Maximum concavity sigmoid notch - Base dently from the normality of the population and the (XCOINSB) homogeneity of the variance between the groups. V3: Medial surface of the first molar - Base (SUMESM) The application of the t-test was, therefore, consid- zi V4: Maximum concavity inferior arch - Base (XCOARIB) ered to be sufficient. With regard to the sagittal values, the following dis- tances were considered (Figure below): na S1: Articular surface of the condyle - Incisal margin Results (SARMI) S2: Articular surface of the condyle – Medial surface The sagittal measurements demonstrate a homoge- of the first molar (SARSMM) nous increase in the values together with a reduction er S3: Articular surface of the condyle - Incisal neck of the standard deviations (p<0.05). The SARCIN val- (SARCIN) ues increase compared to the control; after 8 weeks of obstruction in the upper nasal airways, a notice- able increase in the values and a decrease of the t standard deviation was observed. In The values of SARFORO, SARMI and SARSMM also present a similar trend with an increase in the dis- tances and a compression of the standard deviations (Tab. 2). When analysing the data concerning the vertical dis- ni tances a tendency towards an increase in the linear values is noted, accompanied by a modest growth in the standard deviation. io The values SUMESM, XCOARIB, and XCOINSB all Figure 2. Sagittal measurements. demonstrate an increase in the linear dimensions and a modest increase in the standard deviation. Three rats died after nasal obstruction and, as al- iz ready said before, the real obstruction of the nasal cavities was found in 29 out of 31. Considering the weight, no significant differences were observed be- Ed tween the test group and the control group. Discussion The lack of experimental studies on the modification IC Figure 3. Vertical measurements. of maxillofacial growth in rats following obstruction of Table 2. Measurements found analysing the rats after they were sacrificed. C Control Experimental Mean (mm) S.D. T-Test p<0.05 Mean (mm) S.D. T-Test p<0.05 SARCIN 24,5 0,6100 0 24,8 0,6080 0 SARFORO 20,2 0,6661 0 20,5 0,4740 0 © SARMI 29,9 0,5690 0 29,9 0,8480 0 SARSMM 18,4 0,4930 0 18,7 0,3760 0 SCOSUB 11,5 0,4410 ns 11,5 0,4500 ns SUMESM 6,8 0,2150 0 7 0,3930 0 XCOARIB 4,6 0,1586 0 4,8 0,2650 0 XCOINSB 10,7 0,3750 0 10,9 0,4080 0 Annali di Stomatologia 2015; VI (2): 53-57 55  L. Levrini et al. the primary nasal airways does not allow us to corre- References late our collected data with pre-existing data except for the publications of Deli and colleagues of 1991 1. Babero BB, Yousef MK, Wawerna JC. Comparative histol- and 1992 (2, 3). However there are many articles in ogy of the respiratory apparatus of three desert rodents and the literature investigating the craniofacial modifica- the albino rat: a view on morphological adaptations. Comp i tions occurring in humans with breathing alterations Biochem Physiol A. 1973;44:585-597. al 2. Deli R, Deli G, Germano D, Asciutto T. Craniofacial growth during the growing phase (18-22). Zucconi et al. (18) after experimental nasal obstruction in rats. J Dent Res. showed how patients with high values of mandibular 1991;760:70. angle had a posterior rotation of the mandible result- 3. Deli R, Deli G, Ursini R. Nasal obstruction and cranio-facial on ing in minor craniofacial anomalies. The role of na- growth. Eur J Orthod. 1992;14:76. sorespiratory characteristics, it’s influence on respira- 4. Harvold EP, Vargervik K, Chierici G. Primate experiments tory patterns and the diagnostic tools used to investi- on oral respiration. Am J Orthod. 1981;79:359-73. gate this condition have been debated for years (23- 5. Nespoli L, Caprioglio A, Brunetti L, Nosetti L. Obstructive sleep 25). Kluemper et al. indicated that cephalometric apnea syndrome in childhood. Early Hum Dev. 2013;3:33-37. zi evaluation can be considered a poor diagnostic tool 6. Moss ML. Rotation of the otic capsule in bipedal rats. Am J when it comes to objectively evaluate a nasal impair- Phys Anthropol. 1961:19:301-7. 7. Schlenker WL, Jennings BD, Jeiroudi MT, Caruso JM. The ment (23). Many investigators showed how the respi- na effects of chronic absence of active nasal respiration on the ratory function is capable of influencing the growth of growth of the skull: a pilot study. Am J Orthod Dentofacial craniofacial structures and how a respiratory impair- Orthop. 2000;117:15-27. ment has an important effect on the development and 8. Song HG, Pae EK. Changes in orofacial muscle activity in growth of these structures (25-28). A correlation be- response to changes in respiratory resistance. Am J Orthod er tween the growth pattern and respiration has been Dentofacial Orthop. 2000;119:22-32. established (18, 26, 27) showing how a retroposi- 9. Svendsen T, Hau J. Handbook of laboratory animals science. tioned mandible induces a vertical growth of the face Florida: CRC Press Inc. 1994. resulting in a final incremented vertical dimension 10. Tomer BS, Harvol EG. Primate experiments on mandibular t (18, 26, 27). growth direction. Am J Orthod. 1982;82:114-9. 11. Vidić B, Taylor JJ, Rana MW, Bhagat BD. The respiratory In In our study the data showed how the respiratory pat- tern was able to affect the growth of the facial struc- glandular system in the rat’s lateral nasal wall in normal and polluted environments. Verh Anat Ges. 1971;66:83-85. tures. In the rat, a decrease or in any case a negative 12. Weijs, WA. Mandibular movements of the albino rat during alteration of the opening of the superior airways sig- feeding. J Morphol. 1975;145:107-124. nificantly modifies the patterns of structural growth of 13. Youseff, EH. The chondrocranium of the albino rat. Acta ni the mandible, although we are speaking of differ- Anatomica. 1966;64:586-617. ences in the range of tenths of millimetres (30). 14. Bakor SF, Enlow DH, Pontes P, De Biase NG.. Craniofacial Moreover, the sagittal values, with a reduction of their growth variations in nasal-breathing, oral-breathing, and tra- io standard deviations, show that anomalies in respira- cheotomized children. Am J Orthod Dentofacial Orthop. 2011 tory function induce an increase in mandible growth Oct; 140(4):486-92. 15. Peltomäki T. The effect of mode of breathing on craniofacial and also that the reduction of air flow is able to level growth revisited. Eur J Orthod. 2007 Oct; 29(5):426-9. out the test group almost reducing the individual vari- iz 16. Bakor SF, Enlow DH, Pontes P, De Biase NG.. Craniofacial ability of growth of physiologically developed rats. growth variations in nasal-breathing, oral-breathing, and tra- The animals demonstrate a growth behaviour more cheotomized children. Am J Orthod Dentofacial Orthop. 2011 similar in the pathology rather than in the complete Ed Oct;140(4):486-92. anatomic structures. 17. Harari D, Redlich M, Miri S, Hamud T, Gross M. The effect Although it is extremely complex to identify the patho- of mouth breathing versus nasal breathing on dentofacial and genic mechanisms that cause growth alteration in craniofacial development in orthodontic patients. Laryngo- correlation to reduced nasal respiration, it would scope. 2010 Oct;120(10):2089-93. seem possible to assume that an important factor for 18. Zucconi M, Caprioglio A, Calori G, Ferini-Strambi L, Oldani A, Castronovo C, Smirne S. Craniofacial modifications in chil- the increased sagittal development of the mandible IC dren with habitual snoring and obstructive sleep apnoea: a could be found in the lowering of lingual posture. case-control study. Eur Resp J. 1999;13(2):411-417. Analogically the increase in skeletal verticality would 19. D’Ascanio L, Lancione C, Pompa G, Rebuffini E, Mansi N, appear to confirm data referring to more complex Manzini M. Craniofacial growth in children with nasal septum mammals with post-rotation induced by the new pos- deviation: a cephalometric comparative study. Int J Pediatr C tural order of the skull and the mandible. An altered Otorhinolaryngol. 2010 Oct;74(10):1180-3. Epub 2010 Aug 9. nasal respiration is able to influence the patterns of 20. Sousa JB, Anselmo-Lima WT, Valera FC, Gallego AJ, Mat- facial growth and in particular to induce an increase sumoto MA. Cephalometric assessment of the mandibular in the growth of the mandible in rats. growth pattern in mouth-breathing children. Int J Pediatr Otorhinolaryngol. 2005 Mar;69(3):311-7. Epub 2004 Dec 15. © From a clinical point of view, confirmation of the 21. Mattar SE, Anselmo-Lima WT, Valera FC, Matsumoto MA. Skele- anatomical-functional correlation of the animal model tal and occlusal characteristics in mouth-breathing pre-school of the rat, much more basic compared to the com- children. J Clin Pediatr Dent. 2004 Summer;28(4):315-8. plexity of primates, further emphasizes the need for 22. Kawashima S, Peltomäki T, Sakata H, Mori K, Happonen RP, other investigations, mainly on the human being, Rönning O. Craniofacial morphology in preschool children about the correlations between respiratory functions with sleep-related breathing disorder and hypertrophy of ton- and skeletal development of the splanchnocranium. sils. Acta Paediatr. 2002;91(1):71-7. 56 Annali di Stomatologia 2015; VI (2): 53-57  Craniofacial growth and respiration: a study on an animal model 23. Kluemper GT, Vig PS, Vig KW. Nasorespiratory character- ing. Am J Orthod Dentofacial Orthop. 1991 Jul;100(1):1-18. istics and craniofacial morphology. Eur J Orthod. 1995 28. Jennings BD, Schlenker WL, Boyne PJ, Walters RD. The ef- Dec;17(6):491-5. fects of chronic absence of active nasal respiration on the 24. Principato JJ. Upper airway obstruction and craniofacial mor- growth of the skull. Prog Clin Biol Res. 1985;187:403-12. No phology. Otolaryngol Head Neck Surg. 1991 Jun;104(6):881- abstract available. i 90. Review. 29. Linder-Aronson S, Woodside DG, Lundström A. Mandibu- al 25. Klein JC. Nasal respiratory function and craniofacial growth. lar growth direction following adenoidectomy. Am J Orthod. Arch Otolaryngol Head Neck Surg. 1986 Aug;112(8):843-9. 1986 Apr;89(4):273-84. 26. McNamara JA. Influence of respiratory pattern on craniofa- 30. Römer P, Weingärtner J, Desaga B, Kubein-Meesenburg D, cial growth. Angle Orthod. 1981 Oct;51(4):269-300. Reicheneder C, Proff P. Effect of excessive methionine on on 27. Woodside DG, Linder-Aronson S, Lundstrom A, McWilliam J. the development of the cranial growth plate in newborn rats. Mandibular and maxillary growth after changed mode of breath- Arch Oral Biol. 2012 Sep;57(9):1225-30. zi na t er In ni io iz Ed IC C © Annali di Stomatologia 2015; VI (2): 53-57 57 

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Original article Disseminated necrotic mediastinitis spread from odontogenic abscess: our experience i al on Fabio Filiaci MD, PhD1 nosis can prevent further increasing of the inflam- Emiliano Riccardi MD1 mation process. Valeria Mitro MD1 Conclusions. A late diagnosis and an inadequate Pasquale Piombino MD, PhD2 draining represent the major causes of the elevat- Claudio Rinna MD1 ed mortality rate of disseminated necrotizing me- zi Alessandro Agrillo MD1 diastinitis. Claudio Ungari MD, PhD1 Key words: odontogenic abscess, mediastinitis, na pulpal abscess. 1 Oral and Maxillofacial Sciences Department, Policlini- co Umberto I, “Sapienza” University of Rome, Italy 2 Maxillofacial Surgery Department, Federico II Uni- Introduction er versity of Naples, Italy Mediastinitis is a severe inflammatory process involv- ing the connective tissues that fills the intracellular Corresponding author: spaces and surrounds the organs in the middle of the Emiliano Riccardi t chest. This pathology has both an acute and a chron- In Oral and Maxillofacial Sciences Department, Policlini- co Umberto I, “Sapienza” University of Rome ic form and, in most cases, it has an infectious etiolo- gy. Major sources of mediastinal infections can be: Via Valentino Banal 31 direct contamination, haematic or lymphatic dissemi- 00177 Rome, Italy nation, spreading from the neck or retroperitoneal E-mail: emiliano.riccardi@hotmail.it space, from the lung or the pleura (1). ni The disseminated necrotic mediastinitis (DNM) is, on the other hand, a suppurative acute infection of the Summary mediastinal tissue always coming from infective io pathologies of the neck or odontogenic abscesses Aims. Deep neck infections are rare but potential- (2). This rare pathology includes a high mortality rate ly fatal complication of pulpal abscess of the (between 25 and 40%) which is made worse by de- teeth. If an infection can progress rapidly from a layed diagnosis and therapy (2). Whenever on odon- iz toothache to a life threatening infection, then it is togenic or cervical abscess fails to respond to the critical that dentists be able to recognize the dan- therapy, it spreads into the mediastinum and the ger signs and identify the patients who are at risk. pleura, causing a severe and generalized sepsis. Ed Mediastinitis is a severe inflammatory process in- Patients suffering from this pathology are admitted to volving the connective tissues that fills the intra- hospitals in very critical conditions and in many cases cellular spaces and surrounds the organs in the the therapy is not effective even if started on time. In middle of the chest. This pathology has both an fact, DNM mortality rate is still very high (about 40%) acute and a chronic form and, in most cases, it and comes with many complications, such as septic has an infectious etiology. This study want to ex- shock, occlusion of respiratory airways, jugular IC pose the experience acquired in the Oral and Max- thrombosis and erosion of major vascular structures illo-facial Sciences Department, Policlinico Umber- with consequent blood overflowing (3). to I, “Sapienza” University of Rome, regarding two With this research we want to show the experience clinical cases of disseminated necrotizing medias- acquired at the Maxillo-facial Department of Policlini- C tinitis starting from an odontogenic abscess. co Umberto I, “Sapienza” University of Rome, regard- Methods. We report two clinical cases of dissemi- ing two patients with disseminated necrotizing medi- nated necrotic mediastinitis with two different astinitis starting from an odontogenic abscess. Their medical and surgical approaches. The radi- clinical character, diagnosis and treatment were ana- lyzed. A protocol is recommended for managing sus- © ographic and photographic documentation of the patients was collected in the pre-and post-opera- pected cases. tively. All patients underwent a CT scan and MRI. Results. Mediastinitis can result from a serious odontogenic abscess, and the extent of its inflam- Patients and methods mation process must be never underestimated. Dental surgeons play a key role as a correct diag- A retrospective review was conducted of patients who 64 Annali di Stomatologia 2015; VI (2): 64-68  Disseminated necrotic mediastinitis spread from odontogenic abscess: our experience were diagnosed with odontogenic abscess and dis- Patient 2 A 50-year-old patient was admitted to the seminated necrotizing mediastinitis from December maxillofacial Department with a phlegmon in the bilat- 2009 to December 2011. Two patients were included eral latero-cervical area and in the anterior-superior in this study. Their etiology, associated systemic dis- mediastinal area. The patient suffered from a slight eases, bacteriology, radiology, treatments, duration toothache at the left mandibular mid-arcade, and was i of hospitalization, complications and outcomes were therefore under antibiotic therapy with clindamycin al review. The diagnosis of disseminated necrotizing and amoxicillin. mediastinitis was confirmed through clinical examina- Afterwards, he had fever and on clinical examination he tions and thoracic CT scans. presented swelling in the left mandibular and sub- on mandibular area, lasting for about a month, loss of func- Patient 1. A 26-year-old patient admitted to the tion of ATM, fever with shivers and breathing difficulties. Emergency Room with fever (39° C), a tense-elastic At CT of the neck was performed. This showed a vo- bruised area in the right buccal region and spread luminous swelling (6 cm approximately) with visible side-cervical bilateral, with massive pain, hyperemic gas-filled bubbles in the left sub-mandibular and un- zi skin and bilateral trismus. CT scan results showed a der chin area, with impregnated tissues in the deep voluminous abscess mass involving the right parotid peripheral area. and laterocervical area up to the carotid bifurcation, The patient underwent a tracheotomy and the phleg- na and the bilateral under-chin and sub-mandibular area mon drainage through a percutaneous laterocervical that was displacing the laryngeal lamp to the left up and sub-mandibular incision. to the plan over the tongue. There was also a thick- He was then administered an antibiotic therapy with ening and edema of right genial area soft tissues, but clindamycin and amoxicillin; due to the persistence of er there was no remarkable fluid collection in the medi- his critical conditions, after 7 days he underwent a astinum, or presence of lymphadenopathy. neck and chest CT that showed many abscesses Later on, the patient underwent an incision in the emerging in the left latero-cervical sub-mandibular under chin area, with drainage of purulent materials; area with gas-filled bubbles. These bubbles were t the pull-out of the third molar with drainage of puru- spreading upwards, involving the massetere muscle, In lent materials on the level of the alveolus and finally the positioning of a drainage. Cultures exams found and downwards involving the parotid up to the biking area, involving also the para-pharingeal space. The gram positive cocci and gram negative bacilli; inad- collection was extending medially to the pre-vertebral diction, streptococcus anginosus and ralstonia pick- area and right latero-cervical space, where a fluid col- etti, both sensitive to ampicillin (MIC<2), were iso- lection with air bubbles was detected, involving left ni lated. supra-clavear area and anterior-superior mediastinum, There was an improvement of the patient’s general where fluid collections, delimitated by vascular walls, condition, together with lower body temperature and occupied the right para-tracheal region (10 cm). For io an enhancement of ABG values. The mediastinal ex- these reasons the patient underwent a toilette and tension with the fluid collection in the right para-tra- phlegmon drainage through laterocervical access. cheal area, was 30x35 mm and there was a spread- Later on, a new angio-CT of the neck and the chest ing for 15 cm in pre- and retro-tracheal spaces. After- was performed: it showed a slight improvement of ab- iz wards, he was treated with beta-lactam antibiotic 2 g scess lesions, that fairly change at the latero-cervical every 8 hours and aminoglycoside 1,5 g every 24 level, and the presence of increasing abscess lesions hours, while therapy was started with enoxaparin at the anterior-superior mediastinum, localized mostly Ed sodium 6000 U every 24 hours. Due to the persis- to the right side. Because of these complications the tence of breathing difficulties, the patient underwent a patient had a right cervicotomy and a right thoracoto- right videothoracoscopy that showed the lung com- my 10 days after hospitalization in order to evacuate pletely adherent to the mediastinum. those fluid collections. There was an improvement of A right thoracotomy was then performed, which re- general conditions and no fever. Microbiological cul- vealed parietal pleura with intense inflammatory reac- ture found the presence of Streptococcus and Candi- IC tion. On the pleural dome there was a purulent ab- da. Thorax X-ray didn’t show any important alteration. scess, that was drained washing the pleural cavity CT of neck and thorax showed parenchymatous in- with iodine solution and with the resection of the lung flammatory tissue (about 5 cm) in the left sub- apex, hemostasis and drainage catheters positioning. mandibular area spreading to parapharyngeal and C So the patient started improving his condition. 7 days vascular space, which caused a light compression of after surgery another CT of neck and thorax was per- the left lateral wall. There was also a little abscess (3 formed that showed a big reduction of the many su- cm) in the laterocervical area which obliterated the perior abscesses with normal and symmetric airways. left pyriform sinus. In the mediastinum there was in- © The right pre-tracheal and the small localized fluid flammatory tissue (4 cm) that spread in the right collection at the mediastinum disappeared. There para-tracheal area, but was reduced compared to was just a fluid collection behind the right bronchus previous control (8 cm). The post-surgery course and pulmonary vein (2 x 2 cm). showed a slow improvement of the patient’s clinical After three weeks of antibiotic therapy, the patient conditions. He underwent regular washings with dis- was discharged in good clinical conditions, after the infectant and peroxide while daily medications were removal of draining wires. carried on with the neck exposed and plugged with Annali di Stomatologia 2015; VI (2): 64-68 65  F. Filiaci et al. iodoform gauze. Finally, after 2 weeks, the patient ship between mediastinitis and oropharyngeal infec- was discharged in good general condition. tion is clearly established. Primary sites of infection are periodontal abscess, retropharyngeal abscesses and peritonsillar abscess. According to Wheatley et Discussion al. (11) most common primary oropharingeal infection i is odontogenic with mandibular second or third molar al Descending mediastinitis is an acute infection sec- abscess. ondary to severe cervical infection, and odontogenic Soft tissues infections with odontogenic origins tend abscess is the most common primary infection. Infec- to spread through the tissue surrounding the teeth, on tions in the head and neck can spread down into the through locus minori resistentiae, up to all closest ar- retropharyngeal space (71% of cases) or carotid eas (12). sheath (21% of cases), gravity-facilitated, breathing and negative intrathoracic pressure (4, 5). Clinical symptoms: periodontal infections include According to the International Literature, the clinical gum disease, periodontitis, fascial plans infections zi cases above described, show most of the potential can cause trysmus, pain of the body and the corner emergencies that might arise from on odontogenic in- of the mandible, swelling and disfagia. It can spread: fection. Their complications can cause systemic on- through inferior hole of the orbit or through the orbit na sets that might compromise to the death the patient’s itself, causing a cellulitis with proptosis, optic neuritis general conditions. It was reported that 49% of pa- and abducent nerve plasty. The infection can also tients died during their treatment in the first know arti- spread in extra-oral position and present like an evi- cle published about mediastinitis in 1938 (6). dent swelling, a low pain, trysmus, and just few gen- er An example of most critical clinical evolution of odon- eral symptoms. Potentially it could spread to perior- togenic infections, that usually spread directly, is Lud- bitary tissues and paranasal sinuses. Moreover it wing’s Angina, a necrotic fasciitis of head and neck could be an intraoral extension without swelling and that finally reaches the mediastinum causing medias- drainage. We could find a swelling in parotid space tinitis (7). t with pain and clinical signs. Potentially it could spread Odontogenic infections can be divided into: den- toalveolar, periodontal, and facial plans. They can In to posterior pharyngeal space (so called “danger space”). Finally the infection can affect sublingual spread through contiguity causing jaws sinus, space, causing sub-chin edema with rash and tense mandibular osteomielitis, cavernous sinus throm- skin bilaterally. bophlebitis, internal jugular vein thrombophlebitis, ni erosion of the internal carotid artery, Ludwing’s Angi- Ludwig’s angina: it’s a neck and mouth floor soft tis- na and discending necrotic mediastinitis (7). They sue gangrenous cellulitis (4). Both patients, at the can also spread in an hematogenic way causing an moment of hospitalization, were suffering from Lud- io infective endocarditis, infections of articular prothesis, wig’s Angina. spondilodiscitis, streptococcus sepsis (in patients af- Diagnostic criteria are: fected by leukemia) (7). 1) bilateral involvement Delayed diagnosis and inadequate drainage process- 2) submandibular and sublingual areas involvement iz es were primary underlying factors contributing to this 3) rapidly progressive cellulitis with no abscess or high mortality (8). The earlier detection and treatment lymphatic involvement as a result of contrast-enhanced CT imaging con- 4) the infection must be begin from the mouth floor, Ed tributed to decrease in mortality rate. and in 80% of cases, from the II and III molar (4, 13). Microbiology: intravenous antibiotic therapy is the Gram positive cocchi and anaerobics are the ethio- initial treatment, and empirical medication is often logic agents involved with the infection. Leaning fac- used. The bacteriological results of these patients tors are: cavities, recent dental treatments, diabetes show that pus culture and sensitivity tests are essen- mellitus, malnutrition, alcoholism, immunodepression IC tial. The most common organism isolated seem to be and trauma (4). streptococcus sanguis, mutans and actinomyces vis- On a clinical examination, it can be identified as a se- cosus, that live mostly on the tooth area (9), also vere pathology with fever, septic status, pain wooden- streptococcus salivarius and veillonella, that are easi- hard swelling, uplist and protrusion of the tongue, C ly detected on the tongue and in the mucous mem- trysmus (50%), disfagia, disartria, disfonia, neck stiff- brane, together with fusobacterium, bacteriodes pig- ness (13). Clinical complications are due to airways mentati and spirochete anaerobie. They establish obstruction. compounds within the gum recess (6). Dental cavi- According to the International Literature, therapy in- © ties, gum diseases and several forms of periodontitis cludes the constant monitoring of airways, difficult in- are associated to different patterns of bacterial com- tubation and a preventive tracheotomy (4). pounds, such as mutans streptococcus, usually de- The following medications must be administered: tected on teeth with cavities (9, 10). - Desametasone (10 mg bolus followed by 4 mg every 6 h to 48 h) Anatomic considerations: diagnosis of disseminat- - Nebulized epinephrine (1 ml 1:1000 in 5 ml of ed necrotic mediastinitis mandates that the relation- physiological solution 0.9%) 66 Annali di Stomatologia 2015; VI (2): 64-68  Disseminated necrotic mediastinitis spread from odontogenic abscess: our experience - High doses of antibiotics intravenously: G peni- Mediastinitis cillin + metronidazole or clyndamicine; amoxi- cillin/clavulanic acid It’s an acute or chronic inflammatory disease of medi- - Patient must be remained seated astinic connective tissue. Acute mediastinitis are due to - Surgical draining and/or tissue decompression Gram positive cocci which cause a mediastinic suppu- i from on side (13). ration; they can be primitive or often follow esophageal al Clinical symptoms of Ludwig’s angioma infections of lesions for trauma, foreign body or tumors; they are the facial plans can affect the lateropharyngeal area, characterized by fever, retrosternal pain, leukocytosis; that is divided through the stiloideus process into they can affect mediastinic organs (lung, heart, large on front compartment (soft and connective tissues) and vessels) with really serious complications. back compartment (vascular-nervous wreck). This Therapy is based on antibiotics administration, checking partition is fundamental to detect the different syn- general conditions and removing the cause if possible. drome that may arise (4, 13). Chronic mediastinitis are characterized by fibrotic scle- Front compartment syndrome, is characterized by rosis of mediastinic space, with serious functional com- zi fever with shiver, high pain, trysmus, swelling of the plications for circulation and breathing; they often follow mandibular corner, dysphagia and medial displace- granulomatous lesions (TBC, syphilis) in the medias- ment of the pharyngeal lateral wall (4, 7). tinic connective tissue or autoimmunitary disease. We na Back compartment syndrome, is characterized by sep- must also consider that a mediastinitis could cause a tic status, low pain, cranial nerves involvement (IX- mediastinic syndrome (Tabs. 1-3) (15). XII), airways obstruction due to laryngeal edema, in- ternal jugular thrombosis, internal carotid erosion (7). Table 1. Diagnostic examination. er Retro-pharyngeal infections present in back visceral compartment (esophagus, trachea, thyroid), that goes Microbiology: all the way down to the superior mediastinum. It also compromises the “danger space” that goes from the • Collection, through an aspiration needle, of deep samples back of the mediastinum to the diaphragm. Clinical t • Immediate ground transfer for anaerobics and aerobics • Bacteriological examination symptoms include high fever, dysphagia, dispnea, In neck stiffness, esophagus regurgitation, spontaneous Imaging: draining of airways with suction, laryngeal spasm, • Scintigraphy with marked leukocytes: useful to mark bronchial erosion and jugular vein thrombosis (4). eventual osteomielitis According to the Literature and with regard to our ex- • Ultrasound: useful to analyzed collections from the sur- ni perience, although we analyzed two patients only, face where serious inflammatory processes are already • Lateral neck X-Ray: it allows to estimate tracheal devia- ongoing, we usually adopt the diagnostic and thera- tion or compression, and the presence of gas within io peutic pattern as indicated in the charts below. necrotic tissues • CT: useful for evaluation of head, neck and facial areas (must be extended to the chest inany cases) Complications iz We can divide them in: Table 2. Surgical approach. 1) Hematogenic complications: transient bacteremia, Ed infective endocarditis, infections of articular pros- • Sick toot extraction thesis (7). • Surgical drainage and necrotic tissues removal 2) Contiguity complications: jaws sinus, mandibular • Drainage optima Timing osteomyelitis, cavernous sinus thrombophlebitis, • Systematic monitoring of fascial areas internal jugular vein thrombophlebitis (Lemierre Syndrome), erosion of the internal carotid artery IC and descending necrotic mediastinitis (7). Table 3. Medical Therapy. • Antibiotic therapy (antibiotics retain local Lemierre Syndrome diffusion and prevent the hematogen diffusion): C A. Clinical findings: It’s a serious oro-pharynx infection with bacteremia, a. Localised infection, no sepsis internal jugular vein pyogenic thrombophlebitis with  Clyndamicine septic embolism. It’s unusual (<1/1.000.000), but it  Amoxicillin/clavulanic acid or ampicillin/ © has been increasing during last year because sulbactam changes in antibiotic therapy for high airways infec-  Metronidazole (no in monotheraphy) tions. It arises in young people, after EBV infection or b. Life-threatening infection pharyngitis caused by streptococco. The main etio-  Piperacillin/tazobactam or ticarcillin/ logic agent is fusobacterium necrophorum. Main clini- clavulanic acid or carbapenemics cal findings are: high fever, cervical pain, septic • Broad spectrum empirical therapy for immunnodepressed people shock, thrombocitopeny (14). Annali di Stomatologia 2015; VI (2): 64-68 67  F. Filiaci et al. Conclusions ical relevance and implications for diagnosis and treatment. Acta Otolaryngol. 2009;129:62-70. 2. Estrera AS, Landay MJ, Grisham JM, Sinn DP, Platt MR. De- From data collected at the Oral and Maxillo-facial Sci- scending necrotizing mediastinitis. Surg Gynecol Obstet. ences Department, Policlinico Umberto I “Sapienza” 1983;157:545-52. University of Rome and according to the International i 3. Kiernan PD, Hernandez A, Byrne WD, Bloom R, Dicicco B, Literature, we reached the following conclusions: me- al Hetrick V, Graling P, Vaughan B. Descending cervical me- diastinitis remains a potential lethal infection that can diastinitis. Ann Thorac Surg. 1998;65:1483-88. result from a serious odontogenic abscess, and the 4. Furst IM, Ersil P, Caminiti M. A rare complication of tooth ab- extent of its inflammation process must be never un- scess-Ludwig’s angina and mediastinitis. J Can Dent Assoc. on derestimated. Dental surgeons play a key role as a 2001;67:324-27. correct diagnosis can prevent further increasing of the 5. Mihos P, Potaris K, Gakidis I, Papadakis D, Rallis G. Man- inflammation process. They should identify as soon as agement of descending necrotizing mediastinitis. J Oral Max- illofac Surg. 2004;62:966-972. possible the infection symptoms, especially when it’s 6. Pearse HE. Mediastinitis following cervical suppuration. Ann reaching deeper tissues. These symptoms are: fever, zi Surg. 1938;108:588-611. mouth floor swelling, inferior mandibular swelling, 7. Furst IM, Ersil P, Caminiti M. A rare complication of tooth ab- asymmetric pharyngeal walls swelling, trysmus. scess-Ludwig’s angina and mediastinitis. J Can Dent Assoc. A late diagnosis and an inadequate draining repre- na 2001;67:324-27. sent the major cause of the elevated mortality rate of 8. Mihos P, Potaris K, Gakidis I, Papadakis D, Rallis G. Man- DNM. The use of CT scan is highly recommendable agement of descending necrotizing mediastinitis. J Oral Max- in cases with deep cervical inflammation in order to illofac Surg. 2004;62:966-972. identify still showing no sign. To effectively contrast 9. Lautermann J, Lehnerdt G, Beiderlinden M, Sudhoff H. In- fections of the deep neck spaces with accompanying me- er the elevated mortality rate, an aggressive surgical diastinitis. Laryngorhinootologie. 2005;84:171-75. drainage, the removal of residues from neck area and 10. Hardie JM, Bowden GH. The normal microbial flora of the mediastine drainage through a postero-lateral toraco- mouth. Soc Appl Bacteriol Symp Ser. 1974;3:47-83. tomy performed by a multi-function medical team are 11. Wheatley MJ, Stirling MC, Kirsh MM, Gago O, Orringer MB. necessary. t Descending necrotizing mediastinitis: transcervical drainage Moreover, it is extremely important to research and In 12. is not enough. Ann Thorac Surg. 1990;49:780-84. Kang SK, Lee S, Oh HK, Kang MW, Na MH, Yu JH, Koo BS, register all symptoms of an imminent collapse of air- ways, that include muffled voice, tongue or mouth Lim SP. Clinical features of deep neck infections and pre- floor uplift, beside the inability to tolerate or even disposing factors for mediastinal extension. Korean J Tho- rac Cardiovasc Surg. 2012;45:171-76. swallow salivary secretions. ni 13. Saifeldeen K, Evans R. Ludwig’s angina. Emerg Med J. 2004;21:242-43. 14. Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ. The evo- References lution of Lemierre syndrome: report of 2 cases and review io of the literature. Medicine (Baltimore). 2002;81:458-65. 1. Kinzer S, Pfeiffer J, Becker S, Ridder GJ. Severe deep neck 15. Bulut M, Balci V, Akköse S, Armağan E. Fatal descending space infections and mediastinitis of odontogenic origin: clin- necrotising mediastinitis. Emerg Med J. 2004;21:122-23. iz Ed IC C © 68 Annali di Stomatologia 2015; VI (2): 64-68 

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Case report Treatment timing and multidisciplinary approach in Apert syndrome i al on MariaTeresa Fadda, MD, DDS, PhD1 anatomical abnormalities may have a negative im- Gaetano Ierardo, DDS, PhD2 pact on the ability to perform essential functions. Barbara Ladniak, DDS, PhD2 Due to the complexity of the syndrome a multidis- Gianni Di Giorgio, DDS, PhD2 ciplinary (respiratory, cerebral, maxillo-mandibu- Alessandro Caporlingua MD1 lar, dental, ophthalmic and orthopaedic) approach zi Ingrid Raponi, MD1 is necessary in treating the psychological, aesthet- Alessandro Silvestri, MD, DDS3 ic and functional issues. The aim of this paper is to analyse the different functional issues and surgical na Group of Apert syndrome, Policlinico Umberto I, “Sa- methods trying to enhance results through a treat- pienza” University of Rome, Italy ment plan which includes different specialities in- volved in Apert syndrome treatment. Reduced in- 1 Department of Oral and Maxillofacial Sciences, Max- tellectual capacity is associated to the high num- ber of general anaesthesia the small patients are er illofacial Surgery Unit, Policlinico Umberto I, “Sapien- za” University of Rome, Italy subject to. Therefore the diagnostic and therapeu- 2 Department of Oral and Maxillofacial Sciences, Pe- tic treatment plan in these patients has established diatric Unit, “Sapienza” University of Rome, Italy integrated and tailored surgical procedures based t 3 Department of Oral and Maxillofacial Sciences, Or- on the patients’ age in order to reduce the number In thognathodontic Unit, “Sapienza” University of Rome, Italy of general anaesthesia, thus simplifying therapy for both Apert patients and their family members. Key words: Apert syndrome, multidisciplinary ap- Collaborators: A. Polimeni4, M. Bossù4, E. Barbato4, proach, congenital disorders. ni G. Ierardo4, A. Silvestri4, A. Pizzuti4, A. De Luca4, V. Guida4, A. Giancotti4, C. Moretti4, P. Papoff4, A. Spa- lice4, F. Ursitti4, G. Gualdi4, C. Di Biasi4, C. Andreoli4, Introduction io C. Colaiacono4, R. Delfini4, A. Santoro4, A. Caporlin- gua4, F. Caporlingua4, M. De Vincentis4, A. Greco4, Apert syndrome is a rare congenital disorder charac- P. Cascone4, V. Valentini4, M.T. Fadda4, C. Ungari4, terized by craniosynostosis, midface hypoplasia and M. Gharbiya4, M. Marenco4, B. Carlesimo4, A. Spa- symmetric syndactyly of hands and feet. Apert syn- iz gnoli4, V. Mazzone4, M. Amabili4, L. Silvestrini4 drome was first reported by Wheaton in 1894 and a French paediatrician, Eugene Apert, published a se- ries of nine cases in 1906. Ed Corresponding author: Apert syndrome is estimated to affect 1 in 160,000 live Maria Teresa Fadda births. It is most frequently caused by a de novo muta- Department of Oral and Maxillofacial Sciences, tion in the male gameter. Two missense mutations in Maxillofacial Surgery Unit, Policlinico Umberto I the fibroblast growth factor receptor 2 (FGFR2) gene “Sapienza” University of Rome on chromosome 10 (1), have been found to account for Via Caserta 6 the disorder in approximately 98% of patients (1): the IC 00161 Rome, Italy p.P253R mutation accounts for 33% of the cases and is E-mail: mariateresa.fadda@uniroma1.it associated with more severe syndactyly when com- pared to other mutations that cause Apert syndrome: p.S252W, which accounts for 66% of cases is strongly C Summary associated with cleft palate (2). These mutations lead to loss of ligand specificity of receptor, causing abnor- Apert syndrome is a rare congenital disorder malities in extracellular matrix composition and prema- characterized by craniosynostosis, midface hy- ture calvarial ossification. The syndrome may be inher- © poplasia and symmetric syndactyly of hands and ited in an autosomal dominant trait. In these cases, ad- feet. Abnormalities associated with Apert syn- vanced parental age is often associated with a higher drome include premature fusion of coronal su- risk in having an affected child (3). With the present tures system (coronal sutures and less frequently work we emphasize the need of an integrated and mul- lambdoid suture) resulting in brachiturricephalic tispecialistic approach to the syndrome. We want to de- dismorphism and impaired skull base growth. fine main therapeutic steps performed by our group on After this brief explanation it is clear that these patients affected by Apert syndrome. 58 Annali di Stomatologia 2015; VI (2): 58-63  Treatment timing and multidisciplinary approach in Apert syndrome Clinical features A B Abnormalities associated with Apert syndrome in- clude premature fusion of the coronal sutures system (coronal sutures and less frequently lambdoid suture) i resulting in brachiturricephalic dismorphism and im- al paired growth of the skull base. When the lambdoid suture is involved, the resulting underdevelopment of the posterior cranial fossa may evolve toward an on Arnold-Chiari malformation with chronic tonsillar her- Figure 3. A and B Severe syndactyly of a hand with com- niation and increased risk of hydrocephalus (4). Hy- plete fusion of all five digits at the level of the terminal and drocephalus is associated with raised intracranial middle phalanges, the hand has a cup-like appearance. pressure leading to clinical manifestations such as somnolence, irritability, vomiting, sixth cranial nerve In addition to midface hypoplasia, the pharynx is small zi palsy and cephalalgia. Other typical findings are mal- and the bony nasal cavity is narrowed. These abnor- formations of brain gyri and heterotopia of the gray malities may cause severe respiratory distress, espe- matter, ventriculomegaly, the malformations of limbic cially during the neonatal period when patients are na structures and an ipoplastic or even absent corpus nasal breathers. Therefore most neonates require air- callosum (5), absence or cystric septum. Patients way interventions such as tracheostomy. Older pa- may present or develop intervertebral fusion, mainly tients should be screened with polisomnograms for ob- involving the cervical spine. structive sleep apnea (8). Conductive hearing loss is er In the orbital region there are retrusion of the upper common in Apert syndrome. This results from chronic or lower orbital margin, associated with hyper- otitis media and occasionally from middle ear anom- telorism, eyelid antimongoloid, proptosis, strabismus alies (9). The ears are set low and may be enlarged. and eyebrow cleft (Fig. 1). Orbital retrusion in Apert Bilateral symmetrical complex syndactyly of hands syndrome may extend to the midface, causing maxil- t and feet always occur with this syndrome. The hands In lary hypoplasia with a V-Shaped maxillary dental arch (6). An anterior open bite with Angle class III maloc- have the following four common features regardless of severity (Fig. 3): clusion is also common. The palate is high and nar- 1. Complex syndactyly exists between the index, row with lateral hypertrophic swellings (Fig. 2). Cleft- middle and ring fingers ing of the soft palate or uvula occurs in 30% of pa- 2. The thumb is shortened, with the proximal or di- ni tients. Delayed or ectopic tooth eruption, cross bite stal segment deviated radially (clinodactyly) and dental crowding are common (7). The nose has a 3. The fourth interdigital space exhibits simple syn- flattened dorsum and a small bulbous tip. dactyly io 4. The phalanges exhibit brachyphalagism. At birth the cuneiform bones are well segmented. Progressive fusions interest the tarsal fist, but during childhood it will progressively involve the metatarsal iz shafts and eventually involve fusions between distal and proximal phalanges of toes. Most patients with Apert syndrome have neurologic Ed involvement. Slow intellectual development occur in approximately 50% of cases, however most of these patients have only mild intellectual deficiency. Treatment plan IC Figure 1. Orbital dystopia, hypertelorism, eyelid antimon- After this brief explanation it is clear that these anatomi- goloid and globous nose in a patient affected by Apert syn- cal abnormalities may have a negative impact on the drome. ability to perform essential functions. C A B Figure 2. Intraoral features in Apert syn- drome. A: cleft palate, V-Shaped maxil- lary dental arch, shovel-shaped incisors; © B: open bite, Angle class III malocclusion, crossbite, dental crowding, eruption anomalies. Annali di Stomatologia 2015; VI (2): 58-63 59  M.T. Fadda et al. Due to the complexity of the syndrome a multidiscipli- of age, while posterior vault expansion is performed nary (respiratory, cerebral, maxillo-mandibular, den- at 6-12 months. Monobloc advancement or Le Fort III tal, ophthalmic and orthopaedic) approach is neces- osteotomy and facial bipartition (Fig. 5) are per- sary in treating the psychological, aesthetic and func- formed at 6-7 years (10). tional issues. Oberoi et al. advice to perform frontal-orbital advance- i We believe that the best functional and aesthetic results ment at 6-12 months and midface Le Fort III advance- al can be achieved only through an integrated multidiscipli- ment at 9-12 years (11). Correction of syndactyly nary approach on the bases of the experience gained at treatment is recommended at 13 months (12) for sep- the centers of cranio-facial surgery. Other considera- aration of the finger to gain manipulation movement. on tions deal with high number of operations that must be Cleft palate repair should be performed in this period performed at an early age, during growth and at the end to rehabilitate speech and swallow disorders. of development. It has been shown that the high number of general anaesthesia in small patients is to be corre- lated with intellectual limitations and with the offset of zi cognitive impairment. This data gives the chance to re- flect on both, the need to anticipate or postpone the planned measures and on the need to perform multiple na operations at the same time to reduce the number of general anaesthesia. The aim of the paper is to analyse the different functional problems and the different surgi- cal methods trying to optimize results according to a er timetable that provides the integration of different spe- cialities involved in the Apert syndrome treatment. We decided to divide treatment plan in three steps: - step 1 — from birth to age 2 - step 2 — growth period t - step 3 — adult age. The latter will be described for each age group with In relative diagnostic and treatment options in order to Figure 4. Fronto-orbital advancement. optimize the protocol. ni From birth to age 2 io At birth and in the first weeks cerebral, respiratory and ocular bulb emergencies should be taken into ac- count, particularly in severe cases of Apert syndrome. For these patients immediate surgical treatment is re- iz quired in order to prevent or correct papilledema, corneal ulcers, severe respiratory distress and inter- cranial hypertension. It is fundamental to start inte- Ed grated counselling with all medical team involved in the diagnosis and treatment protocol: genetists, neu- ropediatricians, pediatricians, maxillo-facial surgeons, neurosurgeons, hand surgeons, ophthalmologists. Working together they guarantee a valid and multidis- ciplinary support to Apert families. IC Surgery in Apert cases is important with respect to patient’s age, the degree of case-specific craniofacial dysmorphism and neuro-anatomical deformity. In this period cranioplasty and/or posterior vault expansion C associated with a fronto-orbital advancement (Fig. 4) should be performed in order to guarantee the physi- ological vault expansion. Surgical options and timing are still debated in litera- © ture: Fearon and Podner prefer to post-pone cranial vault expansion to the 15th month in cases of non ad- verse clinical features and at 5-9 years for second cranial vault expansion with separate Le Fort III dis- traction, if necessary (5). Allam et al., at the Los Angeles medical center, prefer to perform frontal-orbital advancement at 4-6 months Figure 5. Facial bipartition. 60 Annali di Stomatologia 2015; VI (2): 58-63  Treatment timing and multidisciplinary approach in Apert syndrome Growth Period vancement than traditional advancement and may re- duce complications such as meningitis. During growth (up to age 12) both the transversal di- For our patients treatment we always use an external mension of the orbital region (hypertelorism and anti- distraction device (Fig. 6B-7). In the past internal dis- mongolodin slant of the palpebral fissure) and retru- tractions were widely used (Fig. 6C), however from i sion of the middle third must be corrected. In the first our experience and in accordance with literature (8, al case surgeons may perform an orbital mobilization. In 17), the use of an external halo device offers greater the second case a Le Fort III osteotomy with external advancement and better vector control. distraction can be performed (Fig. 6). Facial biparti- Between 2 and 7 years, it is essential to follow cogni- on tion by external distraction may be performed (13-15) tive and language development especially after cleft with good results, hypertelorism and midface flatten- repair. This is particularly beneficial for rehabilitation ing are associated (Fig. 7). with lingual devices. Since growth of the midface (especially in Apert syn- In addition during this period the following must be drome) is not predictable, sometimes distraction ad- performed: zi vancement should be repeated at a later age to catch - eye surgery, correction of strabismus after the fi- up with mandibular growth. Thus we believe that mid- nal positioning of the orbits face advancement should be delayed at a later age in - hand and foot surgery preferably after 4-5 years na order to obtain predictable results and to reduce the - dental and orthodontic therapies to monitor teeth surgical load. eruptions, prevent caries, guide the eruption and If the patient has adequate projection of the superior or- allow dental alignment. bital ridge, Le Fort III osteotomy is the chosen proce- Hand, eye and dental surgery can be carried out si- er dure, whereas monobloc advancement, which advances multaneously in order to reduce the number of gener- the forehead simultaneously with the midface, may pro- al anaesthesia to which the patient must be exposed. duce better results if the forehead remains retruded (16). Oral clinical features in Apert syndrome are: maxillary Le Fort III or monobloc distraction provide greater ad- ipoplasia, bifid uvula, Byzantine-arch palate associat- t A B In C ni io iz Ed Figure 6. Middle third advancement A:Le Fort III osteotomy line; B: external distractor device applied in a patients after a Le Fort III procedure. C: internal distractor device applied in a patient after Le Fort III osteotomies. A B Figure 7. Third middle advancement in a 8 year-old child with external distraction. A: Pre surgical, B: Post surgical outcome. IC C © Annali di Stomatologia 2015; VI (2): 58-63 61  M.T. Fadda et al. ed with lateral swellings of the palatine process, den- tal plaque, dental calculus, congestion and swelling of the gingival and periodontal pseudo pockets, max- illary dental crowding, shovel-shaped incisors, dental agenesis and early dental loss (18). i In literature despite big interest in genetics and treatment al of the syndrome, today no emphasis is given to preven- tion and endodontic-conservative treatment. Often be- cause of the patients’ hand malformations unsatisfactory on oral care and dental problems occur. Early dental treat- ment consists in instructions for both patient and parents. It is important in our opinion to communicate the impor- tance of avoiding dental plaque, carious process that may cause peridontitis, pulpitis and dental loss. zi Dentists should evaluate the patients’ efficiency and Figure 9. Orthodontic presurgical treatment. In the picture it autonomy in using oral care devices and suggest the could be noticed the presence of a palate incisor. use of electric toothbrush, chlorhexidine mouthwash na twice a week. Regular check-ups and treatment with fluoride are also suggested (19). After having reached cranio-facial complex are combined with bone dis- a good level of oral care, patients could initiate en- traction method. dodontic-conservative treatment with materials and At the end of growth our surgical planning provides er techniques compatible with the disease. ancillary procedures necessary to adjust soft tissues and new skeletal architecture (rhinoplasty, lipofilling, plastic eyebrow, revision of the songs, autologous End of growth/Adult age grafts, implants Medpor). t Other surgical procedures are planned at the end of growth and concern the lower third of the skeleton In Conclusions and the ancillary procedures necessary to adjust the new skeletal architecture. In conclusion it can be said that diagnostic and thera- For surgical treatment of skeletal Class III accompa- peutic planning in patients with Apert syndrome em- ni nied by open bite, the use of standard techniques phasizes the need to integrate various specialities. such as Le Fort I osteotomy and sagittal split osteoto- It is necessary to frame the patient’s clinical picture my of the mandible (Fig. 8) is needed. It is important upon his arrival. io to note that the mandible is not particularly advanced Very important are also a multi-disciplinary plan and and that both Class III and open bite are mainly due clinical programmed check-ups in accordance to a ra- to maxilla malformation. tional therapeutic clinical widely agreed upon and The Orthodontist in the pre and post surgical phase is verified in its efficiency. iz essential in this age group. As noted in this paper establishing an integrated and Close monitoring of teeth eruption in Apert syndrome tailored surgery timing, scheduling, combining and is necessary due to their need for individualized plan- coordinating actions to be taken at different stages of Ed ning of dental element alignment (Fig. 9). Sometimes the patient’s age reduces the number of general surgical interventions that provide individualizes os- anaesthesia thus simplifying therapy for both Apert teotomies in order to normalize the architecture of the patients and their families (Tab. 1). IC A B Figure 8. Inferior Third surgery: A: Le Fort I osteotomies and advancement; B: Bilat- eral split osteotomy of mandible. C © 62 Annali di Stomatologia 2015; VI (2): 58-63  Treatment timing and multidisciplinary approach in Apert syndrome Table 1. Surgical timing in Apert syndrome. a case with emphasis on oral manifestations. J Dent. 2011 Spring;8(2):90-95. Life period Surgical treatment 8. Moore MH. Upper airway obstruction in the syndromal cran- iosynostoses. Br J Plast Surg. 1993 Jul;46(5):355-362. Within two yrs Emergencies 9. de Jong T, Toll MS, de Gier HH, Mathijssen IM. Audiologi- Cranioplasty i cal profile of children and young adults with syndromic and Cleft Palate Correction al complex craniosynostosis. Arch. 2011 Aug;137(8):775- Hand Surgery 778. Growth period Middle Third Correction 10. Allam KA, Wan DC, Khwanngern K, Kawamoto HK, Tanna Strabismus Correction N, Perry A, et al. Treatment of apert syndrome: a long-term on Hand And Foot Surgery follow-up study. Plastic and Reconstructive Surgery. 2011;127:1601-1611. Orthodontic Treatment 11. Oberoi S, Hoffman WY, Vargervik K. Craniofacial team man- End of growth Inferior Third Correction agement in Apert. Am J Orthod Dentofacial Orthop. 2012;Vol. Individualized Surgery 141:S82-7 . zi Ancillary Techniques 12. Mazzone V. Apert’s syndactyly: strategies in surgical treat- ment. Riv Chir Mano. 2006;2:124-127. 13. Mulliken JB, Bruneteau RJ. Surgical correction of the cran- na iofacial anomalies in Apert syndrome. Clin Plast Surg.1991 Apr;18(2):277-289. References 14. Posnick JC, Armstrong D, Bite U. Crouzon and Apert syn- dromes: intracranial volume measurements before and af- 1. Ciurea AV, Toader C. Genetics of craniosynostosis: review ter cranio-orbital reshaping in childhood. Plast Reconstr of the literature. J Med Life. 2009 Jan-Mar;2(1):5-17. Surg.1995 Sep;96(3):539-548. er 2. Heuzé Y, Singh N, Basilico C, Jabs EW, Holmes G, 15. Mulliken JB, Kaban LB, Evans CA, Strand RD, Murray JE. Richtsmeier JT. Morphological comparison of the craniofa- Facial skeletal changes following hypertelorbitism correction. cial phenotypes of mouse models expressing the Apert Plast Reconstr Surg. 1986 Jan;77(1):7-16. FGFR2 S252W mutation in neural crest- or mesoderm-de- 16. Dai J, Wang X, Yu H, Cheng J, Yuan H, Gui H, Shen S, Shen rived tissues. Bone. 2014 Jun;63:101-9. t G. Simultaneous Le Fort I, II, and III osteotomies for correction In 3. Goriely A, Wilkie. Paternal age effect mutations and selfish sper- matogonial selection: causes and consequences for human of midface deficiency in Apert disease. J Craniofac Surg. 2012 Sep;23(5):1391-1395. disease. AO. Am J Hum Genet. 2012 Feb 10;90(2):175-200. 17. Nadal-López E, Gonzalez-Ramos J, Dogliotti PL, Routabul 4. Cinalli G, Renier D, Sebag G, Sainte-Rose C, Arnaud E, C, Zuccaro G. Simultaneous fronto-orbital advancement and Pierre-Kahn A. Chronic tonsillar herniation in Crouzon“s and dynamic posterior cranial vault expansion in Apert syndrome. ni Apert”s syndromes: the role of premature synostosis of the J Craniofac Surg. 2012; 23(1):178-180. lambdoid suture. J Neurosurg. 1995;83:575-582. 18. Letra A, de Almeida AL, Kaizet R, Esper LA, Sgarbosa S, 5. Fearon JA, Podner C. Apert syndrome: evaluation of a treat- Granjeiro JM. Intraoral features of Apert’s syndrome. Oral ment algorithm. Plastic and Reconstructive Surgery. 2013; Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 io 131:132-142. May;103(5):e38-4l. 6. Ileri Z, Goyenc YB. Apert syndrome: A case report. Eur J Dent. 19. Vadiati Saberi B, Shakoorpour A. Apert Syndrome: Report 2012;6(1):110-113. of a Case with Emphasis on Oral Manifestations. J Dent iz 7. Vadiati Saberi B, Shakoorpour A. Apert syndrome: report of Tehran. 2011;Vol. 8(2):90-5. Ed IC C © Annali di Stomatologia 2015; VI (2): 58-63 63 

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Review article The role of fluoride tablets in the prophylaxis of dental caries. A literature review i al on Lisa Tomasin, DDS better to replace this practice with other prevention Luca Pusinanti, DDS methods. Nicoletta Zerman, MD, SDS A literature review was done to answer the question: Do fluoride tablets prevent dental caries among chil- dren and adolescents? zi Department of Pediatric Dentistry, Dental School, University of Verona, Italy Materials and methods na Corresponding author: A review of the existing literature edited in English Lisa Tomasin has been performed using the following databases: Department of Pediatric Dentistry, Dental School, PubMed, CINAHL, Cochrane Library, Embase, NHS University of Verona, Policlinico G.B. Rossi er Evidence Oral Health, PsycINFO, Web of Knowledge, P.le L.A. Scuro, 10 Metalib. The keywords used have been: dental fluo- 37134 Verona, Italy ride, fluoride tablets. E-mail: nicoletta.zerman@univr.it The objective is to evaluate the effects of the ingestion t of fluoride supplements in the form of tablets (chew- Summary In able or not) for preventing dental caries in children. Do fluoride tablets prevent dental caries among chil- dren and adolescents? Aim. Doing a meta-analysis to answer the ques- The studies selection process has been conducted tion: “Does fluoride tablets prevent dental caries according to the Cochrane Oral Health Group criteria ni among children and adolescents?” described in detail by Tubert-Jeannin et al. in 2009 Materials and methods. A review of the literature (1); according to these criteria only randomized con- is performed using the following databases: trolled clinical trials (RCTs) with randomization at the io PubMed, Embase, CINAHL, Cochrane Library, Em- level of the child or at the level of a group have been base, NHS Evidence Oral Health, PsycINFO, Web analyzed. of Knowledge, Metalib. The keywords used are Other study designs as non-randomized controlled dental fluoride, fluoride tablets. The studies ana- clinical trials, prospective cohort studies, historical iz lyzed was limited to English language with free control studies and retrospective epidemiological abstract. For the studies selection was taken into studies have been excluded. Studies with an inter- consideration the criteria proposed by the vention or follow-up period of less than 2 years have Ed Cochrane Oral Health Group. been excluded as well. Studies where the active in- Results. Few studies with good quality were iden- tervention consisted of any other systemically deliv- tified in general. Only 3 out of 779 studies were ered fluoride (water, milk, salt) provided in addition to acceptable. fluoride supplements have been excluded. Conclusions. Evident disagreements among the Studies in which a topical fluoride based measure or results show that there’s a limited effectiveness a non-fluoride based preventive measure applied in a IC on fluoride tablets. control group was different from the one administered in the intervention group (in addition to fluoride sup- Key words: fluoride tablets, dental fluoride. plements) have been excluded. Surveys reporting only on changes in plaque, fluoride C uptake by enamel or dentin or fluoride salivary secre- Introduction tion have been excluded. Children or adolescents aged 16 or less at the start of The prophylaxis with fluoride tablets represents an in- the study have been included (irrespective of initial © teresting topic for dentists because there are ques- level of dental caries, background exposure to fluo- tions still remain open. rides, dental treatment level, nationality, setting In view of recommendations and national and interna- where intervention is received or time when it start- tional guidelines that clear the doubts on the issue, ed). Older participants have been excluded to avoid the practical problem consists in understanding how the selection of studies concerning the use of fluoride useful it is to suggest the use of fluoride supplements supplements to prevent root caries or to improve to patients, in which quantity and time-frame, or if it is bone density. Annali di Stomatologia 2015; VI (1): 1-5 1  L. Tomasin et al. Types of interventions Dental fluorosis has to be assessed with a specific in- dex and any other possible negative effects has to be Ingestion of fluoride tablets, with or without the use sought. of vitamins, at any concentration, amount, frequency For each RCT the following data will be recorded: of use, duration of application, and with any tech- • Author(s), year of publication, number of reports i nique of application (sucked or not, chewed or not, on the study, country. al diluted or not before being swallowed, with or without • Methods: study design, research objective, study the use of topical fluoride based measures) has been duration, randomization, unit (individual/cluster), evaluated. comparability of baseline characteristics, blind- on The control group has to be formed by children who ness of participants, blindness in outcome assess- have not taken fluoride supplement or have ingested ment, reliability of primary outcome measurement, a placebo supplement (with or without the use of vita- co-intervention and/or contamination, institutions mins), subjected to topical fluoride based measures and manufacturers involved, local characteristics. as topical fluoride application, fluoride varnish or fluo- • Participants: setting where participants were re- zi ride tooth paste or not undergone topical fluoride cruited, criteria for inclusion, demographic charac- based measures but who have undergone non-fluo- teristics (age, gender, socio-economical status), ride based measure (chlorexidine, xylitol, sealants, caries severity, exposure to fluoride, number at na oral hygiene interventions, etc.). start and at the end of the study. • Intervention: tablets, treatment duration and appli- cation frequency, fluoride doses, combination of Assessment parameters methods, compliance (supervision of partici- er pants). For permanent and deciduous dentition, changes in • Details of the outcomes: method of assessment caries increment, as measured by the difference be- (clinical/radiographic), mean duration of study. tween the number of decayed, missing and filled • Measures: units measured (tooth/surface), index teeth (dmft/DMFT) or surfaces (dmfs/DMFS) at base- t used (DMFT/S), types of tooth/surface considered line and at the time of final evaluation for the same children. In (deciduous, permanent). • Adverse effects – fluorosis – is recorded. DMFT (Decayed, Missing, Filled Teeth) is determined by calculating the number of decayed, reconstructed or extracted permanent elements in a patient com- Results ni pared with the total number of present teeth (general- ly 28 in the permanent dentition, excluding the third Many studies were identified, among which 3 have molars). The dmft refers to the deciduous dentition. been judged usable and these have subsequently io The DMFS/dmfs considers the teeth surfaces as well. been analyzed in detail (Tab. 1). The difference in the caries incidence in permanent and deciduous dentition is measured this way in the treatment and control groups (if the groups are com- Discussion iz parable at baseline). The method of assessment executed has been record- According to Limeback and other Authors weak sci- ed (clinical and radiographic). entific evidence support the effectiveness of fluoride Ed Adverse effects will be recorded and noted. supplements (2-5). Table 1. Studies considered for the review. Author Study Patient Intervention/control group Results (>DMFS) Side effects type characteristics IC Driscoll WS, RCT Mean age APF (acidulated 7.70 Not investigated Heifetz SB, DB 6.6 yr. phosphate-fluoride) Brunelle JA. tablet daily dosage 1 mg F. 1979 Daily dosage APF 2 mg F. 7.64 C USA Placebo tablets. 11.53 Lin YT, RCT 22-26-month-old Daily NaF tablet 0.25 mg F. 4.10 Not investigated Tsai CL. children with No fluoride supplement. 8.35 2000 cleft lip and/or © Taiwan palate. Stecksén-Blicks C, RCT 10-12-year-old Daily dose 2.5g xylitol in 2.7 Not investigated Holgerson PL, children with 2 tablets x3 times daily. Twetman S. hight caries risk. Xylitol as above but tablets 2008 did also contain 0.25 mg F. Sweden DB 2.7 2 Annali di Stomatologia 2015; VI (1): 1-5  The role of fluoride tablets in the prophylaxis of dental caries. A literature review The American Center for Disease Control (CDC) also ed information on the adverse effects associated with has published in 2001 recommendations for using flu- the use of fluoride supplements” (10). oride to prevent and control dental caries. They con- Driscoll’s study of 1979 was conducted with children’s cluded that the quality of evidence to support use of supervised intervention in school; tablets were not giv- fluoride supplements by children aged less than 6 en in weekends, holidays, or vacations (max 145 days i years was low (6). with tablets per year). No radiographs were used in al The Swedish Council on Technology Assessment in the evaluation and to an objective analysis it seems Health Care has also conducted a systematic review that tablets are most effective in approximal surfaces. on the effectiveness of different measures for caries The study was conducted in North Carolina, where the on prevention. Five studies related to the effect of fluo- water fluoridation rate is lower than 0,03 ppm. ride supplements on permanent teeth were included The Author concludes recommending the use of fluo- in this review. The authors concluded that there was ride tablets in schools in areas where there is no wa- no clear evidence that the use of fluoride supple- ter fluoridation (11). zi ments prevents dental caries on permanent teeth. In Lin’s study (12) 59 males and 56 females (22-26- They noticed that the only study that found a signifi- month-old children with cleft lip and/or palate) were cant preventive effect of fluoride supplements was an selected. The study was conducted in Taiwan, where na old study conducted during the 70s (7). there is no water fluoridation. The test group was ad- Hasson et al., in 2008, examined evidence regarding ministered with 0.25 mg of fluoride a day. After two the effectiveness of fluoride supplements in prevent- years, the DMFS analysis results stated that children ing caries and their association with dental fluorosis. taking F-tablets showed a borderline difference, not They concluded that “there is weak and inconsistent statistically relevant compared to the control group (p er evidence that the use of fluoride supplements pre- = 0,065). vents dental caries in primary teeth. There is evi- Children suffering from cleft lip and palate are, ac- dence that such supplements prevent caries in per- cording to Lin, considered individuals with a high-risk manent teeth. Mild-to-moderate dental fluorosis is a of developing dental caries. As a matter of fact they significant side effect” (8). t have a high prevalence of S. Mutans from the age of In 2009 Espelid conducted a systematic review on In 18 months. In the Author’s opinion it is important to the efficacy of fluoride tablets in dental caries pre- establish an early dental health program and to ade- vention. He found 7 satisfying studies according to quately inform parents in order to prevent potential the considered criteria. This happened because, un- future problems. like in this study, he modified the criteria described In Stecksèn-Blicks’s study, 160 children aged 10-12 ni by Cochrane review (9). years with high caries risk were selected and ran- However the Author resolved that “very few studies of domly divided into two groups. The test group was good quality were identified in general” and that administered with xylitol (2.5 g) and fluoride (1.5 g) in io “there is limited evidence that F tablets are effective” two tablets three times a day, while the control group hoping that there will be new, well-designed studies was administered only with xylitol (2.5 g). Clinical as- within this field in the future. sessment was followed by radiographic assessment. iz Espelid classifies the studies we explored with a 1- The compliance analysis showed that 29% of sub- level of evidence, meaning RCTs with a high risk of jects rated as having poor compliance, 30% good bias. On the contrary, among the ones he identified compliance and 41% excellent compliance. Ed only 2 are worth a 1+ level, being RCTs with a low The study results show that “no statistical significant risk of bias. However, in his opinion, these studies difference in dental caries incidence can be found be- are very old. tween the two study groups (p > 0.05)”. The popula- The most recent review of the existing literature was tion of this study developed an average DMFS of 2.7 done by Tubert-Jeannin for the Cochrane Oral Health during this 2-year study, among which the majority Group at the end of 2011. In their review the Authors (1.8) were lesions to approximal surfaces. IC took into account fluoride supplements in general The Author concludes that “the results of this 2 years (tablets, drops, lozenges and chewing gums). Only study do not support the administration of tablets con- 11 out of the 7196 studies were considered accept- taining fluoride and xylitol for dental caries prevention able. The results of this review suggest that the use among young adolescents with a high caries risk” (13). C of fluoride supplements was associated with a reduc- Burt stated as well that “little firm evidence exists for tion in DMFS between 95 and 16% in permanent the efficacy of dietary fluoride supplements when taken teeth. The effect of fluoride supplements was unclear from birth or soon after” adding that “fluoride supple- on primary teeth. In one study, no caries-inhibiting ef- ments are a risk factor for fluorosis” and that “the pre- fect was observed on deciduous teeth while, in anoth- eruptive cariostatic benefits of fluoride are minor” (14). © er study, the use of fluoride supplements was associ- According to the Author, “fluoride supplements, when ated with a substantial reduction in caries increment. ingested for a pre-eruptive effect by infants and young The Authors rated “10 trials as being at unclear risk children, therefore carry more risk than benefit”. of bias and 1 at high risk of bias, and therefore the tri- In the existing literature there are actually very few als provide weak evidence about the efficacy of fluo- exceptions against the use of fluoride tablets, the ma- ride supplements”. Moreover the review found “limit- jority support the administration of these supplements Annali di Stomatologia 2015; VI (1): 1-5 3  L. Tomasin et al. proving the benefits derived from consumption. Ac- this reason, according to Burt, “fluoride supplements cording to Burt, design faults are common in these should no longer be used for young children” (14). studies. Some of these problems, for example, can In conclusion, only 3 studies met the inclusion criteria be found in a 1978 review where Burt noticed that the and they show contrasting results: Driscoll supports studies took into account selected participants with- the efficacy of fluoride tablets to prevent caries, Lin i out randomization and that there was no control maintains that children in the test group presented a al group. According to this review prophylaxis with fluo- borderline, but non-significant statistical difference ride tablets entails a caries reduction fluctuating be- when compared with the control group, while Steck- tween 50 and 80% in the primary dentition and be- sén-Blicks doesn’t find any reason for the utilization. on tween 20 and 40% in the permanent dentition (15). Differences between the different study designs don’t Burt mentions other studies in which the design faults help the comparison. For the same reason it is not are so serious that they can call the results validity in- easy to increase the examined sample aggregating to question. For example, in a retrospective study, different studies. F-doses as well are dissenting, this being an impor- zi Aasenden and Peebles (16) maintain an 80% reduc- tion in caries prevalence among children who were tant start point for the evaluation of effects, given that administered with fluoride supplements from birth, it is well known that the effect on caries prophylaxis is dose dependent. na compared with children who didn’t take any. However in this study there was a serious mistake; children be- Therefore, there is a limited evidence about fluoride longing to the group administered with fluoride were tablets efficacy. not randomly chosen. Burt noticed that children be- There is a need for new, well-designed studies within longing to this group turned out to have a decidedly this field, taking into account possible negative ef- er better oral hygiene compared to the ones who were fects as well, allowing a better search of advantages not taking any tablets and they were mainly females. and disadvantages of this prophylaxis method. This fact, according to the author, is the reason of re- Despite the fact that results discourage a systemic sults alteration (14). and prenatal administration, this is still in use, show- t According to Riordan it is difficult to conduct ethical and ing low professional updating. adequate studies on fluoride supplements and on den- In tal caries prevention (17). Studies should include a very high number of participants, given the continuous de- References crease of dental caries prevalence; this raises consid- 1. Tubert-Jeannin S, Tramini P, Gerbaud L, Amsallem E, Schulte erably the cost of the study (18). Moreover the testing ni A, Auclair C, Ismail A. Fluoride supplements (tablets, drops, should last long enough to allow caries to appear, but lozenges or chewing gums) for preventing dental caries in this doesn’t happen often because of the population’s children. Editorial Group: Cochrane Oral Health Group. Pub- mobility and because of many parents reluctance to lished Online: 21 JAN 2009. io comply with the dosage schedule for an extended peri- 2. Limeback H, Ismail A, Banting D, DenBesten P, Feather- od of time. Furthermore, some individuals could leave stone J, Riordan PJ. Canadian Consensus Conference on the study in long time scales. Riordan maintains that all the appropriate use of fluoride supplements for the pre- iz these variables can alter the testing results (17). vention of dental caries in children. J Can Dent Assoc. 1998 Only a few supplement studies have taken account of Oct;64(9):636-9. 3. Clark DC. Appropriate uses of fluorides for children: guide- factors such as socio-economic status or parent’s ed- lines from the Canadian Workshop on the Evaluation of Cur- Ed ucational level, but these studies suggest that such rent Recommendations Concerning Fluorides. J Can Med variables are more important for caries prevention Assoc. 1993;149:1787-93. than the use of supplements (19-21). 4. Ismail A. Fluoride supplements: current effectiveness, side According to Spencer “fluoride can prevent caries up effects and recommendations. Community Dent Oral Epi- to 71%” but just 2% of this reduction is due to the demiol. 1994;22:164-72. contribution of tablets and the reasons for the low 5. Nojwack-Raymer R, Driscoll WS, Selwitz R, Li S-H, Heifetz IC contribution of fluoride supplements were poor effica- SB. A comparison of the caries preventive effects of fluo- ride mouth rinsing, fluoride tablets and both procedures com- cy in a time when caries incidence is low, and poor bined: final results after eight years. J Public Health Dent. compliance with recommendations to use it (22). 1992;52;111-6. Therefore the statement of any preventive procedure 6. Centers for Disease Control and Prevention. Recommen- C should occur, as much as possible, according to the dations for using fluoride to prevent and control dental caries existence of clinical studies that meet given quality in the United States. Morbidity and Mortality Weekly Report: criteria. Recommendation Report. 2001;50(RR-14):1-42. From this studies one can infer that while some pre- 7. The Swedish Council on technology assessment in health ventive benefits are possible, especially with regard care. Prevention of dental caries. A systematic review. 2002; © to topical action, the evidence of efficacy of fluoride Vol. report n.161. 8. Hasson H, Ismail A. Fluoride supplements, dental caries tablets used from birth or from childhood is not strong and fluorosis: a systematic review. J Am Dent Assoc. 2008; enough. Comparing risks and benefits the balance is 139(11):1457-68. against the use of this methodology because, as said 9. Espelid I. Caries preventive effect of fluoride in milk, salt before, fluoride has little effect on caries prevention and tablets: a literature review. Eur Arch Paediatr Dent. but involves an evident risk for dental fluorosis. For 2009;10(3):149-56. 4 Annali di Stomatologia 2015; VI (1): 1-5  The role of fluoride tablets in the prophylaxis of dental caries. A literature review 10. Tubert-Jeannin S, Auclair C, Amsallem E, Tramini P, Ger- tion from birth on deciduous and permanent teeth. Arch Oral baud L, Ruffieux C, Schulte AG, Koch MJ, Rège-Walther M, BioI. 1974;19:321-6. Ismail A. Fluoride supplements (tablets, drops, lozenges or 17. Riordan PJ. The place of fluoride supplements in caries pre- chewing gums) for preventing dental caries in children (Re- vention today. Aust Dent J. 1996;41(5):335-42. view). The Cochrane Library. 2011, Issue 12. 18. O’Rourke CA, Attrill M, Holloway PJ. Cost appraisal of a flu- i 11. Driscoll WS, Heifetz SB, Brunnelle JA. Treatment and oride tablet program to Manchester primary schoolchildren. al post-treatment effects of chewable fluoride tablets on den- Community Dent Oral Epidemiol. 1988;16(6):341-4. tal caries: findings after 7 1/2 years. J Am Dent Assoc. 19. Friis-Hasche E, Bergmann J, Wenzel A, et al. Dental health 1979;99(5):817-21. status and attitudes to dental care in families participating 12. Lin YT, Tsai CL. Comparative anti-caries effects of tablet and in a Danish fluoride tablet program. Community Dent Oral on liquid fluorides in cleft children. J Clin Dent. 2000;11(4):104-6. Epidemiol. 1984;12:303-7. 13. Stecksén-Blicks C, Holgerson PL, Twetman S. Effect of xyl- 20. Kalsbeek H, Verrips GH, Backer Dirks O. Use of fluoride tablets itol and xylitol-fluoride elozenges on approximal caries de- and effect on prevalence of dental caries and dental fluoro- velopment in high-caries-risk children. Int J Paediatr Dent. sis. Community Dent Oral Epidemiol. 1992;20:241-5. 2008;18(3):170-7. 21. Tijmstra T, Brinkman-Engels M, Groeneveld A. Effect of so- zi 14. Burt BA. The case for eliminating the use of dietary fluoride cioeconomic factors on the observed caries reduction after supplements for young children. J Public Health Dent. 1999 fluoride tablet and fluoride toothpaste consumption. Com- Fall;59(4):269-74. munity Dent Oral Epidemiol. 1978;6:227-30. na 15. Binder K, Driscoll WS, Schutzmannsky G. Caries-preventive 22. Spencer AJ. Contribution of fluoride vehicles to change in fluoride tablet programs. Caries Res. 1978;12:22-30. caries severity in Australian adolescents. Community Dent 16. Aasenden R, Peebles TC. Effects of fluoride supplementa- Oral Epidemiol. 1986;14:238-41. t er In ni io iz Ed IC C © Annali di Stomatologia 2015; VI (1): 1-5 5 

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Original article Evaluation of over-etching technique in the endodontically treated tooth restoration i al on Guido Migliau, MD, DDS, PhD Enamel, dentin and cementum represent different ad- Luca Piccoli, DDS, PhD hesive surfaces due to the composition, morphology Laith Konstantinos Besharat, DDS, MSc, PhD and biomechanical characteristics (1, 2). Adhesion ob- Stefano Di Carlo, MD, DDS tained through adhesive systems is both chemical and Giorgio Pompa, MD, DDS micro-mechanical, with the formation of the hybrid layer zi (3) and resin tags achieved through etching which in- creases the available surface contact with the resin (4). Department of Oral and Maxillo Facial Sciences, In endodontically treated teeth, the substrate with na School of Dentistry, “Sapienza” University of Rome, which adhesion is obtained is the dentin, pulp cham- Italy ber and root canal (5, 6). The presence of contaminants (intermediate medica- tions, cements, gutta-percha) (7-9) the passage of irrigat- Corresponding author: er ing solutions which destroy collagen fibers (10-12), the Laith Konstantinos Besharat loss of the intrinsic humidity (13), the presence of a Department of Oral and Maxillo Facial Sciences, smear layer produced by the endodontic instruments (14) School of Dentistry, “Sapienza” University of Rome and other factors related to the endodontic treatment are Viale Regina Elena, 287/A t an obstacle to adhesion of the post. An endodontically Via Caserta, 6 00161 Rome, Italy In treated tooth is far weaker than a vital tooth, because of the loss of the dental substance (15) so the post is a key E-mail: besharatlk84@yahoo.it element in the post-endodontic restoration (16-18). Adhesion problems are accentuated by the “C factor”, which is very high in the post-space, like a first-class ni Summary conservative cavity. The cavity shape is deeper than broader, with a consequent polymerization shrinkage The main purpose of a post-endodontic restora- stress of composite cements (19, 20), and is charac- io tion with posts is to guarantee the retention of the terized by a lower accessibility and visibility of the restorative material. The aim of the study was to area, which makes it difficult for correct execution of examine, through the push-out test, how bond the adhesive protocols. strength between the post and the dentin varied The principal aim of the study was to evaluate and iz with etching time with 37% orthophosphoric acid, compare the bond strength values obtained during the before cementation of a glass fiber post. More- cementation of the glass fiber posts with etching-time. over, it has been examined if over-etching (appli- Ed cation time of the acid: 2 minutes) was an effec- tive technique to improve the adhesion to the en- Materials and methods dodontic substrate, after highlighting the prob- lems of adhesion concerning its anatomical char- Forty dental monoradicular elements, with no decay acteristics and the changes after the endodontic and extracted for periodontal reasons, kept in bal- treatment. Highest bond strength values were anced salt solution. Crown of all teeth was removed IC found by etching the substrate for 30 sec., while using a diamond cylindrical bur under water cooling over-etching didn’t improve bond strength to the at cemento-enamel junction, plumb to the tooth axis. endodontic substrate. Roots were treated endodontically with simultaneous technique using nickel-titanium (NiTi) instruments “Mt- C Key words: endodontic substrate, etching time, wo” (Sweden & Martina), following the manufactures in- dental bonding, glass fiber posts. structions, namely 10/.04 taper - 15/.05 taper - 20/.06 ta- per- 25/.06 taper. The irrigation protocol used 5% sodi- um hypochlorite (Niclor 5, Ogna), during the preparation, Introduction © with a final irrigation for 2 minutes with 5% sodium hypochlorite warmed to 37°C. EDTA was used at the The development of the materials and techniques in end of preparation in order to remove smear layer. Root dentistry has recently took steps forward and suc- canal filling was carried out with the lateral condensation ceed in preserving teeth instead of extracting them. technique with ISO standardized gutta-percha points Most of these improvements were evident in conserv- and cement containing epoxy resin Top Seal (Dentsply, ative dentistry and in particular, adhesive dentistry. Maillefer). Then the experimental protocol established 10 Annali di Stomatologia 2015; VI (1): 10-14  Evaluation of over-etching technique in the endodontically treated tooth restoration the preparation of the post space, realized with Largo 1 and 2 burs at a length of 10 mm for each sample. The samples were divided into four groups and re- stored, as following: - Group A (10 samples): etching for 15 seconds i using 37% orthophosphoric acid (Superlux – al Thixo etch – DMG), using a 3 steps dual-curing adhesive system (Luxabond – Total etch – DMG), dual-cured resin-composite cement (LuxaCore – on DMG) and glass fiber posts (LuxaPost – DMG). - Group B (10 samples): etching for 30 seconds using 37% orthophosphoric acid (Superlux – Thixo etch – DMG), using a 3 steps dual-curing adhesive system (Luxabond – Total etch – DMG), zi dual-cured resin-composite cement (LuxaCore – DMG) and glass fiber posts (LuxaPost – DMG). - Group C (10 samples): etching for 2 minutes us- na ing 37% orthophosphoric acid (Superlux – Thixo etch – DMG), using a 3 steps dual-curing adhe- sive system (Luxabond – Total etch – DMG), Figure 1. Slices of samples after the push-out test. dual-cured resin-composite cement (LuxaCore – er DMG) and glass fiber posts (LuxaPost – DMG). - Group D or control group (10 samples): without an optical microscope (Zeiss laser scan). We used for the etching time step, using a 3 steps dual-curing each picture the same angle of view and enlargement adhesive system (Luxabond – Total etch – DMG), (50x) after the push-out test (Fig. 1). dual-cured resin-composite cement (LuxaCore – t Similarly, we took a picture of a marked size (1 mm). DMG) and glass fiber posts (LuxaPost – DMG). In Image processing software provided with the optical microscope-Zeiss laser scan was used to analyze the pictures after calibrating the space using the marked Preparation of the samples for the mechanical size. The visible circumference size was found, fol- tests lowing the line of the fracture. ni Knowing the thickness of the sample (1 mm) and the The portion of each roots corresponding to the bond- taper of the apical surface of the post, we calculated ed fiber post was transversally sectioned into 1 mm- the lateral surface area of a truncated cone which is io thick serial slices, using a microtome, the Micromet the bonded surface area through the formula: (Remet) posting a low-speed saw (Norton – Dia SL = π (R + r)[(h2 + (R – r)2]0,5, where R is the coronal Wheel), 0.2 mm thick, under water-cooling operating post radius, r the apical post radius, and h the thick- at 2.240 spins per minute. ness of the slice. iz The sections, were realized in apical-coronal direc- Each section was submitted to the same procedure. tion and each section was marked on the apical sur- Statistical analysis was performed using SPSS Inc, face to put it exactly under the punch of the machine ver. 13.0, Chicago, IL, USA. Chi-squared test was Ed for the push-out test. A number was assigned to each used for statistical evaluation of proportions. In cas- root and a progressive alphabetical letter to each es with more than 2 independent means we used slice from the apical surface to the coronal one. the ANOVA test. A p-value of less than 0.05 was considered significant. A 95% CI was used in all analysis. In order to assure data reliability data were The push-out test entered in two different personal computers by the IC two examiners, the two data files were compared in Push-out load was applied using a universal testing order to detect entry errors. The two files resulted machine Galdabini- Sun 500 at a crosshead speed of identical. 0.5 mm/min to obtain the extrusion of the post. C The punch was positioned to touch the post only, without stressing the surrounding dentinal walls. The Results load was applied on the apical surface of the slice in apical-coronal direction, with the purpose of prevent- For each analyzed section we obtained the bond © ing the conical shape of the canal from withstanding strength between the post and the dentin (MPa). the dislodgement of the post. Then, the average values, between the section of Push-out strength data was in Newtons (N) which every single root, between the roots of the same was converted to MegaPascals (MPa) by dividing the group were calculated to follow up the variations of load by the bonded surface area. the bond strengths of the different groups. There are In order to obtain the bonded surface area of each the results obtained in Table 1. sample, we took pictures of the apical surface using Results were analyzed using the ANOVA test. Annali di Stomatologia 2015; VI (1): 10-14 11  G. Migliau et al. Table 1. Results of the bond strength between the post and the dentin. Group A Samples MPa Group B Samples MPa A1 3 9,24 B1 4 18,73 A2 5 18,8 B2 5 9,98 i A3 5 6,854 B3 5 15,01 al A4 6 7,861 B4 5 9,47 A5 6 6,08 B5 5 6,25 A6 6 6,743 B6 5 10,14 on A7 5 11,08 B7 3 16,5 A8 5 7,8298 B8 5 17,23 A9 4 8,52 B9 3 11,33 A10 7 14,81 B10 4 11,2 Average 7,026 Average 12,584 zi Group C Samples MPa Group D Samples MPa C1 5 5,01 D1 5 5,54 na C2 4 12,36 D2 4 9,58 C3 4 13,87 D3 4 5,55 C4 4 10,812 D4 5 10,6 C5 5 6,05 D5 4 11,07 C6 4 11,49 D6 5 5,753 er C7 4 11,85 D7 4 4,43 C8 5 18,87 D8 5 4,45 C9 4 14,78 D9 5 4,41 C10 4 8,33 D10 5 3,91 Average 11,34 t Average 6,52 In Table 2. Descriptives. Descriptives Mpa ni N Mean Std. Std. Error 95% Confidence Minimum Maximum Deviation Interval for Mean Lower Bound Upper Bound io A 10 9.7638 4.08128 1.29061 6.8442 12.6834 6.08 18.80 B 10 12.5840 4.03647 1.27644 9.6965 15.4715 6.25 18.73 C 10 11.3512 4.14027 1.30927 8.3894 14.3130 5.01 18.87 iz D 10 6.4753 2.68710 .84974 4.5531 8.3975 3.91 11.07 Total 40 10.0436 4.31323 .68198 8.6641 11.4230 3.91 18.87 Ed Discussion and conclusions Yet, results cannot support the hypothesis of over- etching time as an effective technique to improve the After the experimental study, the results (Tabs. 1, 2, adhesion to the endodontic substrate or, at least, not Fig. 2) show that etching time is crucial in the cemen- considering the times of application of the acid for 2 tation of the posts. The lowest bond strength values minutes. IC were found in Group D, where the etching step was Literature is still very controversial about this issue not performed. because, even though acid etching allows to look for As far as the time of application of the orthophosphoric the collagen fibers which were destroyed during the acid, comparing Groups A (15 seconds), B (30 sec- endodontic treatment but which are necessary for the C onds), and C (2 minutes), highest bond strength values adhesion, over etching could be counter-productive obtained result in the group B. Differences that are sta- and lead to losing the normal structure of the dentinal tistically significant occur between Group B and D and tubules (21-27). between C and D, therefore etching for 15s or eliminate Further studies are required to be carried out on this © the etching step with the acid ortophosphoric doesn’t issue, taking into account the substrate, its character- guarantee a satisfying bond strength. On the other istics to enable to provide for its deficiencies. By ap- hand etching for at least 30s guarantees a better bond plying the proper operating procedures and valuing strength, an over-etching doesn’t improve or diminish the state of the dental element, we should be able to bond strength. As a result, it would be interesting to an- choose the appropriate direct or indirect restoration, alyze how the bond strength varies between 30 sec- which could assure the most reliable guarantees of a onds and 2 minutes of application of the acid. long-term prognosis. 12 Annali di Stomatologia 2015; VI (1): 10-14  Evaluation of over-etching technique in the endodontically treated tooth restoration 8. Windley W 3rd, Ritter A, Trope M. The effect of short-term calcium hydroxide treatment on dentin bond strengths to com- posite resin. Dent Traumatol. 2003 Apr;19(2):79-84. 9. Perdigão J, Gomes G, Augusto V. The effect of dowel space on the bond strengths of fiber posts. J Prosthodont. 2007 May- i Jun;16(3):154-64. al 10. Morris MD, Lee KW, Agee KA, Bouillaguet S, Pashley DH. Effects of sodium hypochlorite and RC-Prep on bond strenghts of resin cement to endodontic surfaces. J Endod. 2001;27(12):753-7. on 11. Hayashi M, Takahashi Y, Hirai M, Iwami Y, Imazato S, Ebisu S. Effect of endodontic irrigation on bonding of resin cement to radicular dentin. Eur J Oral Sci. 2005 Feb;113(1):70-6. 12. Wattanawongpitak N, Nakajima M, Ikeda M, Foxton RM, Tagami J. Microtensile bond strength of etch-and-rinse and zi self-etching adhesives to intrapulpal dentin after endodon- tic irrigation and setting of root canal sealer. J Adhes Dent. 2009 Feb;11(1):57-64. na Figure 2. Range of value for every group. 13. Dietschi D, Duc O, Krejci I, Sadan A. Biomechanical con- siderations for the restoration of endodontically treated teeth: a systematic review of the literature - Part 1. Composition and micro- and macrostructure alterations. Quintessence Int. Manufacturer’s details 2007 Oct;38(9):733-43. er 14. Serafino C, Gallina G, Cumbo E, Ferrari M. Surface debris • Sweden & Martina SPA, Via Veneto 10 - 35020 of canal walls after post space preparation in endodontically treated teeth: a scanning electron microscopic study. Oral Due Carrare (PD) – Italy. Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 • OGNA Laboratori Farmaceutici, Via Figini, 41 - Mar;97(3):381-7. Muggiò (MI) – Italy. t 15. Soares PV, Santos-Filho PC, Martins LR, Soares CJ. Influ- • DENTSPLY MAILLEFER, Chemin du Verger 3 - 1338 Ballaigues – Suisse. In ence of restorative technique on the biomechanical behav- ior of endodontically treated maxillary premolars. Part I: frac- • DMG Chemisch-Pharmazeutische Fabrik GmbH, ture resistance and fracture mode. J Prosthet Dent. 2008 Elbgaustrabe 248 – 22547 Hamburg – Germany. Jan;99(1):30-7. • Remet s.a.s, Via Scarlatti 2 – 40033 Casalecchio 16. Musikant BL, Deutsch AS. Post design and his impact on ni di Reno, Bologna – Italy. the root and crown. Compend Contin Educ Dent. 2006 • NORTON SAINT-GOBAIN, Worcester – 01606 Feb;27(2):130-133. 17. Ferrari M, Cagidiaco MC, Goracci C, Vichi A, Mason PN, Massachussetts – USA. Radovic I, Tay F. Long-term retrospective study of the clin- io • Galdabini, Via Giovanni XXIII 183 - 21010 Carda- ical performance of fiber post. Am J Dent. 2007;20(5):287- no al Campo (VA) –Italy. 91. • Carl Zeiss Microlmaging GmbH, Standort Göttin- 18. Salameh Z, Sorrentino R, Ounsi HF, Goracci C, Tashkan- iz gen – Vertrieb – Germany. di E, Tay FR, Ferrari M. Effect of different all-ceramic crown system on fracture resistance and failure pattern of en- dodontically treated maxillary premolars restored with and References without glass fiber posts. J Endod. 2007;33(7): 848-51. Ed 19. Bouillaguet S, Troesch S, Wataha JC, Krejci I, Meyer JM, 1. Marshall GW Jr, Marshall SJ, Kinney JH, Balooch M. The Pashley DH. Microtensile bond strenght between adhesive dentin substrate: structure and properties related to bond- cements and root canal dentin. Dent Mater. 2003;19 ing. J Dent. 1997;25(6): 441-58. (3):199-205. 2. Perdigao J. Dentin bonding as a function of dentin structure. 20. Tay FR, Loushine RJ, Lambrechts P, Weller RN, Pashley Dent Clin North Am. 2002;46(2):277-301. DH. Geometric factors affecting dentin bonding in root canals: a theoretical modeling approach. J Endod. 2005 IC 3. Nakabayashi N, Kojima K, Masuhara E. The promotion of adhesion by the infiltration of monomers into tooth substrates. Aug;31(8):584-9. J Biomed Mater Res. 1982;16(3):265-73. 21. Pioch T, Stotz S, Buff E, Duschner H, Staehle HJ. Influence 4. Brännström M, Noredenvall KJ. The effect of acid etching on of different etching times on hybrid layer formation and ten- enamel, dentin, and the inner surface of the resin restora- sile bond strength. Am J Dent. 1998 Oct;11(5):202-6. C tion: a scanning electron microscopic investigation. J Dent 22. Hashimoto M, Ohno H, Endo K, Kaga M, Sano H, Oguchi Res. 1977 Aug;56(8):917-23. H. The effect of hybrid layer thickness on bond strength: dem- 5. Ferrari M, Mannocci F, Vichi A, Cagidiaco MC, Mjör IA. Bond- ineralized dentin zone of the hybrid layer. Dent Mater. 2000 ing to root canal: structural characteristics of the substrate. Nov;16(6):406-11. Am J Dent. 2000 Oct;13(5):255-60. 23. Hashimoto M, Ohno H, Kaga M, Sano H, Tay FR, Oguchi © 6. Lopes GC, Cardoso Pde C, Vieira LC, Baratieri LN. Mi- H, Araki Y, Kubota M.Over-etching effects on micro-tensile crotensile bond strength to root canal vs pulp chamber dentin: bond strength and failure patterns for two dentin bonding sys- effect of bonding strategies. J Adhes Dent. 2004 Summer; tems. J Dent. 2002 Feb-Mar;30(2-3):99-105. 6(2):129-33. 24. Lopes GC, Vieira LC, Monteiro S Jr, Caldeira de Andrada 7. Tjan AH, Nemetz H. Effect of eugenol-containing endodon- MA, Baratieri CM. Dentin bonding: effect of degree of min- tic sealer on retention of prefabricated posts luted with adhesive eralization and acid etching time. Oper Dent. 2003 Jul- composite resin cement. Quint Int. 1992;23(12):839-44. Aug;28(4):429-39. Annali di Stomatologia 2015; VI (1): 10-14 13  G. Migliau et al. 25. Abu-Hanna A, Gordan VV, Mjor I. The effect of variation in and air-abrasion technique on dentin microtensile bond etching times on dentin bonding. Gen Dent. 2004 Jan- strength. Am J Dent. 2004 Dec;17(6):447-50. Feb;52(1):28-33. 27. Brajdić D, Krznarić OM, Azinović Z, Macan D, Baranović M. 26. Ahid F, Andrade MF, Campos EA, Luscino F, Vaz LG. In- Influence of different etching times on dentin surface mor- fluence of different dentin etching times and concentrations phology. Coll Antropol. 2008 Sep;32(3):893-900. i al on zi na t er In ni io iz Ed IC C © 14 Annali di Stomatologia 2015; VI (1): 10-14 

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Original article Effectiveness of a diode laser in addition to non-surgical periodontal therapy: study of intervention i al on Antonio Crispino, DDS, PhD Conclusions. Considered the better clinical out- Michele Mario Figliuzzi, DDS, PhD comes, diode laser can be routinely associated Claudio Iovane, DDS with SRP in the treatment of periodontal pockets Teresa Del Giudice, MD of patients with moderate-to-severe periodontitis. Simona Lomanno zi Delfina Pacifico, DDS Key words: periodontal diseases, diode laser, Leonzio Fortunato, MD scaling, root planning. Roberto Del Giudice, DDS na Introduction Department of Periodontics and Oral Sciences, “Magna Graecia” University, Catanzaro, Italy The periodontal disease is a chronic inflammatory process, characterized by bacterial etiology and cyclic er evolution, which determines a progressive, site-specif- Corresponding author: ic destruction of the supporting tissues of the tooth, Antonio Crispino and proceeds from the superficial periodontium (gum) Department of Periodontics and Oral Sciences, t to the deep periodontium (alveolar bone, periodontal “Magna Graecia” University Via Tommaso Campanella, 115 In ligament, cementum), resulting in typical pathological lesions (periodontal pockets, gingival recessions, ver- 88100 Catanzaro, Italy tical and/or horizontal bone resorption, bifurcation le- E-mail: crispino@unicz.it sions) to the loss of the dental element (1). From the epidemiological point of view, in the United ni States of America chronic periodontitis affects 47% of Summary the adult population over the age of 30, distributed in mild (9%), moderate (30%) and severe (8%) (2). io Background. Chronic periodontitis affects 47% of Although a number of risk factors can influence the adult population over the age of 30. The first phase of start, progression and prognosis of periodontitis (age, periodontal treatment is always represented by scal- sex, cigarette smoking, hormonal changes, immune ing and root planning (SRP), that is a causal, non-sur- system disorders, systemic diseases, diabetes, stress) iz gical therapy that recognizes as primary aims the (3-5), the main etiological factor is represented by den- control of bacterial infection and the reduction of pe- tal plaque and in particular by anaerobic gram-nega- riodontal plaque-associated inflammation. Yet, anoth- tive bacilli (6). For that reason, the first phase of peri- Ed er innovative causal therapy is represented by the ir- odontal treatment is always represented by the initial radiation of periodontal pockets with laser. preparation, which is a type of etiological, non-surgical Aim. To evaluate the effect of a 940-nm diode therapy, which recognizes as primary aims the elimina- laser as an adjunct to SRP in patients affected by tion or reduction of bacterial infection and the control of periodontitis. periodontal plaque-associated inflammation (7). We Materials and methods. Sixty-eight adult patients choosed to use laser therapy to personally verify the IC with moderate-to-severe periodontitis were se- actual efficiency, where the literature talks to us for a quentially enrolled and undergone to periodontal long time, of this treatment option in the treatment of examination (V1) in order to detect gingival index periodontally compromised patients and to evaluate (GI), plaque index (PI) and probing depth (PD). their satisfaction. In addition to SRP the use of laser C The patients were randomly divided into two therapy, as shown by several studies, appears to im- groups: the first (n=34) received SRP treatment prove and facilitate the healing of treated sites. Re- alone, the control group (n=34) received SRP and cently, Yilmaz et al. (2013) have shown that in the 940-nm diode laser therapy. sites treated with the use of laser Er:YAG in addition to SRP, reached statistically significant improvements in © Results. Data were analyzed by Student’s t-test, with two tails; for all clinical parameters, both terms of attachment gain and reduction in PD com- groups reported statistically significant differ- pared to sites treated with only srp or only topical ences compared to basal values (p<0.0001). Both gaseous ozone (8). Other study that compares, like procedures were effective in improving GI, PI and treatment options, Nd:YAG laser alone, SRP alone, PD, but the use of diode laser was associated and Nd:Yag plus SRP has demonstrated that the last with more evident results. option of treatment is the best in term of reduction of Annali di Stomatologia 2015; VI (1): 15-20 15  A. Crispino et al. PI, GI, PPD and GCF volume values (9). Another type GI and PI were detected on 6 index teeth: 12, 16, 24, of laser (KTP: potassium-titanyl-phosphate) has shown 32, 36, 44. to be a significant help in SRP, like demonstrated in a It was then measured the pocket depth (PD), which study of Romeo et al. (2010). In this study, treated consists in measuring the distance in mm between sites are divided into four groups and the best results the free gingival margin and the base of the pocket, i were obtained in the groups in which the laser has making six records for each dental element: mesial, al been used (10). A diode laser has a wavelength of central and distal probing of the buccal and lingual- 810-980 Nm, and there are many different laser used palatal sides of all teeth (14). The values in mm of in periodontology with a different wavelength; Ktp laser the survey were then converted into a score called on has a wavelength of 532 Nm, Nd:YAG laser of 1064 T-score: Nm, Er:Yag of 2940 Nm and CO2 laser of 9600-10600 • 0 = PD between 0 and 2 mm Nm (11). We used diode laser cause has an easier • 1 = PD between 2 and 4 mm learning curve and a more affordable price than others. • 2 = PD between 4 and 6 mm • 3 = PD over 6 mm. zi After having filled a complete medical records, pa- Aim of the study tients were randomly divided into two treatment groups. na To check and compare the possible improvement of The patients of the first group (n=34) received initial the periodontal indices in two groups of patients with preparation. It consists in the mechanical instrumen- periodontal disease: the first group undergone to tation of the root surface, in order to make it biologi- SRP, the second one to SRP with the addition of cally compatible with the healing of periodontal tis- er laser therapy. sues; that is made possible by two fundamental pro- cedures: • scaling, which consists in removing mucobacterial Materials and methods plaque and tartar from supragingival and subgin- t gival tooth surfaces, generally through the use of At the Department of Dentistry of the University Hos- pital “Mater Domini” of Catanzaro, sixty-eight adult In inserts fixed on an ultrasonic scaler; • root planning, which consists in the removal of patients (mean age of 56,3 years) with moderate-to- deposits of subgingival calculus, granulation tis- severe periodontal disease were sequentially enrolled sue and softened, infected or necrotic cementum, on a voluntary basis.Totally 1224 sites with periodon- eliminating the irregularities of the root surface to ni tal disease are treated. make it smooth and hard, typically through the The selected cases were based on the following inclu- use of manual tools such as the curettes. sion criteria: 1) patients 18 or older; 2) single or multi- The second group of patients (n=34) received the io rooted teeth; 3) patients that received the same laser same therapy did in the first group, but with the ad- treatment including: laser settings, procedural steps and dition of laser therapy through a 940 nm diode technique; 4) patients who undergone, after 4 months, laser (ezlase™ soft tissue diode laser - Biolase to follow-up and 5) patients that had no surgery for 12 Technology Inc.). This laser is extremely compact iz months prior to treatment. There was no exclusion of and easy to handle; the active medium is a semi- smokers or patients with medical conditions. conductor and the pumping system is an electric After having obtained a thorough medical and den- current (15); the wavelength’s laser of 940 nm Ed tistry anamnesis and the underwriting of a specific in- makes it considerably affine to molecules of hemo- formed consent, all the patients underwent a peri- globin and melanin (16). odontal examination (V1), in order to detect the most The operating protocol of the treatment of periodontal common indices of periodontal health. The experi- pockets in by 940 nm diode laser provides for the ap- mentation has followed the principles of Declaration plication of the following dosimetric values: of Helsinki. • power: 3 W IC The degree of gingival inflammation was assessed by • pulse frequency: 15 Hz gingival index (GI) of Löe and Silness (1967) (12), • fluence: 1,2 J/mm2 measured from 0 to 3 on each tooth: • emission mode of laser light: pulsed • 0 = healthy gingiva • on time (pulse duration): 10 ms C • 1 = mild inflammation, absence of bleeding on • time-off (relaxation time): 20 ms probing • average power: 1 W • 2 = moderate inflammation, bleeding on probing • optical diameter fiber and tips: 300-400 μ. • 3 = severe inflammation, spontaneous bleeding. The pulsed emission has two important clinical ad- © The level of hygiene was assessed by plaque index vantages: (PI) of Silness and Löe (1964) (13): • enables the thermal relaxation during the time-off, • 0 = absence of plaque avoiding the overheating and charring of radiated • 1 = presence of plaque detectable with probe tissues; • 2 = moderate accumulation of plaque, which is vi- • allows to operate without the use of anesthesia. sible to the naked eye Treatment should not begin before all the people in • 3 = abundant accumulation of plaque. the room have not been wearing protective glasses. 16 Annali di Stomatologia 2015; VI (1): 15-20  Effectiveness of a diode laser in addition to non-surgical periodontal therapy: study of intervention After connecting all the components (pedal and opti- Results cal fiber), it is essential to activate the tip on a dark cardboard (e.g., blue articulation paper) and check The biggest difference was found relatively to the av- that the spot of the light guide designs a perfect cir- erage gingival index (GI). In the group of patients un- cle, making sure that it has not a star-shaped appear- dergoing initial preparation alone, such clinical para- i ance; the activated tip presents a blackened and, at meter decreased from the value of 1.6 to the value of al this point, the laser is ready for use. Given the high 0.9, with a reduction of 44% as average, while in the affinity of the 940 nm diode laser for dark colors, we group of subjects treated with diode laser, the aver- were able to increase the bactericidal effect just irri- age gingival index was turned from the value of 1.5 to on gating the site to be treated with an exogenous chro- 0.3, demonstrating a decrease of 80%; therefore the mophore, that is a pigmented substance that makes addition of the laser-therapy allows to reduce the av- the tissues more suscettible to the light of the diode erage gingival index than double the SRP alone (80 laser. Substances such as povidone-iodine (Beta- vs 44%). dine®) and methylene blue contribute to reduce the Plaque index and probing depths were reduced by a zi bacterial load due to their disinfectant power; more- mean of 57 and 58% in the group of patients receiv- over these pigments bind to the cytoplasmic mem- ing SRP alone, while in the group of patients under- brane of bacteria, making them darker (17, 18). So going SRP + laser therapy, PI and PD underwent a na you have just to irrigate the quadrant to be treated mean percentage decrease of 67 and 76%. with such substances and wait 30 seconds, without Ultimately, the results of this study clearly shows that rinsing. Therefore fit the tip within the periodontal both procedures are effective in improving periodon- pocket, keeping at about 1 mm from the bottom of the tal indices (GI, PI, PD) compared to basal values, but er same and in the parallel direction to the long axis of the association of the diode laser to the initial prepa- the tooth to be treated. The tips have a metal core ration allows to obtain clinical results more evident which allows their inclination according to the needs than the single procedure of SRP (Tabs. 1, 2). of the operator and to the spatial arrangement of the pocket. Once the light beam is activated, the tip must t Table 1. Results of Group I (SRP therapy). be moved within the pocket in both horizontal and vertical directions, as to draw a pattern, with rapid In Parameter Middle Value P movements, leading the tip toward the inner wall of Average PI (V1) 2,1 the pocket, in order to remove junctional epithelium < 0.0001 Average PI (V4) 0,9 migrated and induce bleeding necessary for the for- ni mation of a clot. It is recommended to make for each Average GI (V1) 1,6 < 0.0001 Average GI (V4) 0,9 pocket 3 cycles of irradiation, each lasting 30 sec- onds. It is important during the treatment to maintain Average PD (V1) 2,6 < 0.0001 io the aspirator near the site, to avoid overheating. Average PD (V4) 1,1 When you remove the tip from the pocket, it might have residues of sulcular epithelium and infected Table 2. Results of Group II (SRP and laser therapy). granulation tissue, in which case you need to clean it iz up with a gauze soaked in disinfectant before pro- Parameter Middle Value P ceeding to the next pocket. Average PI (V1) 1,5 The clinical follow-up has been executed, in both < 0.0001 Ed Average PI (V4) 0,5 groups, after 4 months of treatment (V4). After an ap- propriate causal non-surgical therapy and an ade- Average GI (V1) 1,5 < 0.0001 quate oral hygiene at home by the patient, periodon- Average GI (V4) 0,3 tal tissues undergo a healing process that is complet- Average PD (V1) 1,7 ed after an average of 3 months. In particular, it as- < 0.0001 Average PD (V4) 0,4 sists to: IC • reduction in probing depth (PD), due to recolla- genation of the supracrestal fibers, obviously in Discussion function variable depending on the depth of initial probing (19,20); The remarkable difference between the two proce- C • reduction in gingival index (GI) and bleeding on dures in improving periodontal variables is attribut- probing, due to the reduction of the inflammatory able to the benefits from the use of diode laser in ad- infiltrate; dition to the traditional procedures of SRP in the • reduction in the plaque index (PI) and change of treatment of periodontal pockets (23, 24). They are: © supra- and subgingival bacterial flora, with a de- • bactericidal effect; crease of Gram-negative and an increase Gram- • curettage effect; positive (21, 22). • bio-stimulating effect. Data were analyzed by Student’s T test with two tails. Combining laser therapy with conventional proce- For all clinical parameters considered, both treatment dures is in fact achieved a more effective decontami- groups reported statistically significant differences nation of the pocket, with also a recolonization slower compared to baseline (p <0.0001). than sites treated only mechanically (25-29); some Annali di Stomatologia 2015; VI (1): 15-20 17  A. Crispino et al. Authors attribute this phenomenon to clot formation in in vivo in addition to SRP procedures, analyzing the the pocket, that would act as a seal to it. following parameters: residual debris, root surface Thanks to curettage effect, the laser eliminates the morphology, thermal side effects; he concluded that sulcular epithelium infected in a total and complete the laser therapy does not cause any mechanical al- way than conventional methods of treatment with teration or thermal damage to the cementum (47). i manual tools (30), without any kind of damage to the Regarding the tolerance and compliance of the patient, al underlying connective tissue and reducing the bac- the laser therapy of periodontal pockets does not in- terial load of Actinobacillus actinomycetemcomitans volve discomfort or intraoperative pain, nor requires, and Porphyromonas gingivalis (31), which easily as a rule, the execution of loco-regional anesthesia, on penetrate within the sulcular epithelium. Further- since the power values provided are relatively low (3 more there is a scientific evidence on the direct an- W) and the energy is supplied in pulsed mode (41). timicrobial effect of diode laser against levels of Tar- While recognizing these indisputable results, it should geted Periodontal Pathogens (32). According to be stressed, however, that the laser acts only as an Kreisler (2005) the greatest reduction in the degree adjunct to etiological non-surgical periodontal thera- zi of tooth mobility and probing depth in the group of py, not being able to replace traditional mechanical patients who underwent SRP + laser therapy can be procedures of SRP; in this regard, the study of Kam- mainly attributed not to the killing of bacteria in peri- ma et al. (2009) showed that combining mechanical na odontal pockets, but rather to the complete removal treatment (SRP) with diode laser therapy produces of infected sulcular epithelium, which leads to better results than the laser therapy alone, both in greater attack of the connective tissue (33). Further- clinical (probing depth and clinical attachment level) more, the removal of granulation tissue infected pro- and bacteriological terms (total bacterial count of pe- er motes the healing of connective tissue with a de- riodontal pathogens) (20). crease in probing depth, gingival index and tooth mobility and a recovery of clinical attacks signifi- cantly higher compared to the initial preparation only Conclusions (33-36); these results, in addition to being the best, t are longer lasting and more stable over time (37). However, according to De Micheli (2011) the results In The results show the adjunctive benefits that diode laser treatment can provide when it is used as an ad- of the two therapeutic procedures are similar with junct to non surgical periodontal treatment. regard to plaque index and bleeding on probing, for Considered the better clinical results, the laser diode which laser therapy does not lead to additional ben- can be routinely associated with the traditional me- ni efits (38). Also according to Dukic (2012) the results chanical non-surgical therapy (SRP) in the treatment of the two treatments are similar in terms of plaque of periodontal pockets of patients with moderate-to- index, bleeding on probing and clinical attachment severe chronic periodontitis. io level: the addition of laser therapy showed a marked The results of such studies encourage us in hoping improvement in PD, but only in periodontal pockets that the use of complementary low power laser in the of moderate depth (from 4 to 6 mm) (39). future will become a part of the standard protocol of Finally, because of the biostimulant effect (29,40-42), non-surgical periodontal therapy. iz laser therapy induces the acceleration of mitotic processes within the irradiated tissues, without caus- ing structural and/or functional alterations. According References Ed to the studies of Benedicenti (2008), the laser would stimulate mitochondrial activity, with a production of 1. Mitchell DA, Mitchell L. Oxford handbook of clinical dentistry. intracellular ATP >22% in irradiated cells compared Oxford University Press, 4th ed; Oxford 2003. to those not exposed to radiant energy, resulting in a 2. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. On halving of the times of cell duplication (43). In an in behalf of the participating members of the CDC Periodon- tal Disease Surveillance workgroup: James Beck, Gordon vitro study of Soares et al. (2013) has been demon- IC Douglass, Roy Page. Prevalence of Periodontitis in Adults strated as low-level laser irradiation (LLLI) has a posi- in the United States: 2009 and 2010. J Dent Res. 2012 Oct; tive stimulatory effect on the proliferation of 91(10):914-920. human periodontal ligament stem cells. This study 3. Heitz-Mayfield LJ. Disease progression: identification of high- was carried out on two healthy permanent third mo- risk groups and individuals for periodontitis. J Clin Periodontol. C lars extracted due to surgical indication (44). Conlan 2005;32Suppl 6:196-209. (1996) found an increase of about 50% of the prolifer- 4. Krejci CB, Bissada NF. Periodontitis- the risks for its devel- ation and differentiation of fibroblasts and collagen opment. Gen Dent. 2000 Jul-Aug;48(4):430-6; quiz 437-8. synthesis within the periodontal ligament (45), which 5. Timmerman MF, van der Weijden GA. Risk factors for pe- riodontitis. Int J Dent Hyg. 2006 Feb;4(1):27. © process, according to Choi (2010) begins to manifest 6. Haffajee AD, Socransky SS. Microbial etiological agents of between the next 24-48 hours to laser treatment, and destructive periodontal diseases. Periodontol. 2000. 1994 intensifies especially after the 72 hours (46); all these Jun;5:78-111. reactions accelerate the healing process and encour- 7. Drisko CH. Nonsurgical periodontal therapy. Periodontol. ages a speedy recovery in clinical attachment. 2000. 2001;25:77-88. In addition, Castro (2006) conducted a study on the 8. Yilmaz S, Algan S, Gursoy H, Noyan U, Kuru BE, Kadir T. histological evaluation of the use of the diode laser Evaluation of the clinical and antimicrobial effects of the 18 Annali di Stomatologia 2015; VI (1): 15-20  Effectiveness of a diode laser in addition to non-surgical periodontal therapy: study of intervention Er:YAG laser or topical gaseous ozone as adjuncts to ini- O, Wernisch J, Sperr W. Treatment of periodontal pockets tial periodontal therapy. Photomed Laser Surg. 2013 with a diode laser. Lasers Surg Med. 1998;22(5):302-11. Jun;31(6):293-298. 29. Saglam M, Kantarci A, Dundar N, Hakki SS. Clinical and bio- 9. Qadri T, Tunér J, Gustafsson A. Significance of scaling and chemical effects of diode laser as an adjunct to nonsurgical root planning with and without adjunctive use of a water- treatment of chronic periodontitis: a randomized, controlled i cooled pulsed Nd:YAG laser for the treatment of periodon- clinical trial. Lasers Med Sci. 2014 Jan;29(1):37-46. al tal inflammation. Lasers Med Sci. 2013 Sep 14. 30. Romanos GE, Henze M, Banihashemi S, Parsanejad HR, 10. Romeo U, Palaia G, Botti R, Leone V, Rocca JP, Polimeni Winckler J, Nentwig GH. Removal of epithelium in periodontal A. Non surgical periodontal therapy assisted by potassium- pockets following diode (980 nm) laser application in the an- titanyl-phosphate laser: a pilot study. Laseres Med Sci. 2010 imal model: an in vitro study. Photomed Laser Surg. 2004 on Nov;25(6)891-9. Jun;22(3):177-83. 11. Iaria G, Frati A. Il laser in odontoiatria e in chirurgia orale. 31. Kamma JJ, Vasdekis VG, Romanos GE. The effect of diode Ed UTET, Milano. 2001. laser (980 nm) treatment on aggressive periodontitis: eval- 12. Löe H. The Gingival Index, the Plaque Index and the Re- uation of microbial and clinical parameters. Photomed tention Index Systems. J Periodontol. 1967 Nov-Dec; Laser Surg. 2009 Feb;27(1):11-9. zi 38(6):Suppl:610-6. 32. 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Original article The impact of smoking and previous periodontal disease on peri-implant microbiota and health: a retrospective study up to 7-year follow-up i al on Alessandro Quaranta, DDS, PhD1 were observed. Non smoker, healthy patients: Bartolomeo Assenza, DDS, MD2 healthy clinical parameters, significant counts of Orlando D’Isidoro, DDS3 spirochetes in isolated patients. Non smokers Fabia Profili, RDH4 with previous periodontal disease: occasional Antonella Polimeni, MD, DDS5 positive BoP values, significant high counts of zi Iole Vozza, DDS, PhD5 pathogenic bacteria. Smokers with previous peri- odontal disease: clinical signs of inflammation in- cluding deep pockets and slight bone resorption, na 1 Division of Periodontology, Department of Oral Sci- significant counts of pathogenic bacteria. ences, Faculty of Dentistry, University of Otago, Conclusions. Over a follow-up of 5 to 7 years, it is New Zealand possible to state that the absence of smoking 2 Private Practice, Milano, Italy habit and previous periodontal disease positively 3 School of Dentistry, Division of Periodontology, Uni- influences the peri-implant microbiological and er versity Politecnica delle Marche, Ancona, Italy clinical conditions in partial edentulous patients 4 School of Dental Hygiene, University Politecnica restored with dental implants and enrolled in a delle Marche, Ancona, Italy strict regular supportive therapy. t 5 Department of Oral and Maxillo Facial Sciences, Sapienza University of Rome, Italy In Key words: microbiota, periodontal disease, smoking, dental implants, long-term maintenance. Corresponding author: Alessandro Quaranta Introduction ni Faculty of Dentistry, University of Otago 310 Great King Street, PO BOX 647, Dunedin, New The development of biofilm on implant surfaces Zealand io E-mail: alex.quaranta@otago.ac.nz The introduction of dental implants as surgical and- prosthetic procedures to replace lost natural teeth, due to dental caries, trauma or periodontal disease, Summary has been a major advance in the management of fully iz and partially edentulous individuals. The surfaces of Aim. To evaluate the impact of smoking and pre- the inserted implants represent a new opportunity for vious periodontal disease on peri-implant micro- bacterial colonization and lead to a microbial profile Ed biota and health in medium to long-term main- that might be substantially different from the one tained patients. found on natural teeth. The immune-blot technique, Methods. A retrospective evaluation of partial used for the study of bacterial colonization in os- edentulous patients restored with dental implants seointegrated implants, has led to the recognition of and enrolled in a regular supportive therapy was five different species: Porphyromonas gingivalis, Pre- performed. Inclusion criteria were: medium to votella intermedia, Actinomycesnaes lundii, Fusobac- IC long-term periodontal and implant maintenance terium nucleatum, Treponemasocranskii (1). The re- (at least 5 years), a minimum of 2 implants placed sults showed that implants in partially edentulous in each patient, absence of systemic diseases subjects were colonized by periodontal pathogens as that may affect osseointegration. 30 implants in early as 14 days after the exposure to the oral envi- C 15 patients were included in the study. Subjects ronment and that the establishment of a complex were divided in smokers or non-smokers and be- subgingival microbiota occurred as early as 28 days tween patients previously affected by periodontal after exposure. Biofilm development on teeth and im- disease and periodontally healthy. Peri-implant plants was also compared during a 3-week study of © and periodontal parameters were assessed experimental gingivitis and peri-implant mucositis us- (PD,BoP, mPI). Microbiological samples were col- ing phase contrast microscopy (2). It was evident that lected around implant and an adjacent tooth. Re- the biofilm revealed similar proportions of coccoid al-Time Polymerase Chain Reaction (RT-PCR) cells, motile rods, and spirochetes (spp) on both teeth analysis was performed. and implants at baseline and after three weeks of Results. In all the three groups no differences in plaque accumulation. The development of biofilms on bacterial counts between dental and implant sites titanium surfaces was also examined in partially Annali di Stomatologia 2015; VI (1): 21-28 21  A. Quaranta et al. edentulous subjects who required implants (3). High- of 10 years, statistically significant differences existed er counts of complex species were detected on the between implants and matching control teeth with re- tooth surfaces at all time points, particularly at 2 gard to most of the clinical and radiographic parame- weeks. At later time points, the differences between ters with the exception of plaque index and recession. the sampled sites were less marked, although com- Marginal bone level at implants at 10 years was also i plex species were still at higher levels in the dental associated to smoking and general health condition. al sites compared to implant ones. The above studies indicate that the early development of biofilms on im- plant surfaces is similar to the one observed on nat- Dental implant prognosis in periodontally com- on ural teeth. Studies about the development of biofilms promised partially edentulous patients on natural teeth showed that attachment of bacterial occurred within minutes and that the increase in spe- The outcome of implant treatment in periodontally cific species could be detected in a time period as compromised partially edentulous patients has not short as 2-6 hours. It is likely that biofilm develop- been completely clarified. In this regard, it is signifi- zi ment on the implant follows a similar course and that cant a recent review from Karoussis et al. (10). The maturation is well under way by 2 weeks as provided Authors completed a comprehensive and critical re- by Quirynen et al. (4). view of all the studies regarding the short-term and na long-term prognosis of osseointegrated implants placed in periodontally compromised patients. 15 The microbiological pattern in partially edentulous prospective studies were selected, including seven subjects short-term and eight long-term studies. The results of er this review revealed that no statistically significant dif- The literature comparing the bacterial profile around ferences in both short-term and long-term implant implants in fully edentulous subjects with the micro- survival exist between patients with a history of biota in partially edentulous subjects confirms the role chronic periodontitis and periodontally healthy individ- of the remaining dentition as a major source for colo- t uals. However, patients with a previous history of nization. Studies comparing the peri-implant micro- biota with the bacteria of adjacent teeth described In chronic periodontitis may exhibit significantly greater long-term probing pocket depths, peri-implant margin- several similar aspects in the two sites. In partial al bone loss and incidence of peri-implantitis com- edentulous subjects, bacterial counts did not signifi- pared with periodontally healthy subjects. Alterations cantly differ between subgingival dental and implant in clinical parameters around implants and teeth in ni samples (5). Moreover, the bacteria around healthy aggressive periodontitis patients may not follow the implant and dental sites were extremely similar. This same pattern, in contrast to what has been reported observation suggests that the major influence on the for chronic periodontitis patients. Therefore, more io peri-implant microbiota was the bacteria present on studies are required to evaluate implant prognosis in the remaining teeth. this form of periodontitis. Other systematic reviews (11-13) have provided the highest level of evidence supporting the favorable long-term prognosis of im- iz The association between periodontal and peri-im- plant therapy in the general population. However, plant conditions fewer data seem to be available concerning the prog- nosis of implants placed in periodontally compro- Ed It may be assumed that the peri-implant tissue re- mised patients and the incidence of implant biological sponse to the bacterial challenge may follow patterns complications appear to be higher in patients previ- similar to that of the periodontal tissues in a suscepti- ously affected by periodontitis. ble host (6, 7). So far, it has not yet been clarified whether a host susceptible for periodontitis will also be susceptible for peri-implantitis. However, there is Smoking and dental implant failure IC evidence for the association between periodontitis and peri-implantitis (8). It is sure also that smoke, lo- Cigarette smoking has been related with an in- cal and systemic conditions and the presence of sub- creased risk for peri-implantitis, marginal bone loss gingival pathogenic bacteria play an important role in around implants, and loss of implants (14-16). C the occurrence of complications. However, the biolog- It is therefore essential that the dental team explain ical impact of these factors on the long-term progno- the patient that smoking can contribute to complica- sis of oral implant is still to be defined. Karoussis et tions following implant insertion. al. (9) compared in a prospective study the clinical Several historical follow-up studies have shown that © and radiographic changes in periodontal and peri-im- cigarette smoking is a significant risk factor from im- plant conditions in a population susceptible to peri- plant failure (17, 18). odontal diseases. This study investigated the associ- Smokers are more susceptible to both periodontitis ation of changes in periodontal parameters and peri- and peri-implantitis because of impairment of immune implant conditions over a mean observation period of response (19) and compromised wound healing (20). 10 years (8-12 years) following implant installation. Increased probing depths, plaque indices and bleeding The results of this study indicated that after a period on probing values have been observed in smoker sub- 22 Annali di Stomatologia 2015; VI (1): 21-28  The impact of smoking and previous periodontal disease on peri-implant microbiota and health: a retrospective study up to 7-year follow-up jects restored with dental implants. A systematic re- Reproducibility of probing procedure was evaluated view of the literature that assessed implant loss, bone by clinical assessment in 9 implants in 5 patients dur- loss greater than 50%, implant mobility, persistent ing two separate sessions 1 week apart and linear pain, or peri-implantitis, reported that smokers had a weighted kappa (κ) score was calculated. significantly enhanced risk of peri-implantitis (21). Later, microbiological samples of the subgingival i The aim of the present study was to evaluate the im- biofilm were collected by carefully removing supra al pact of smoking and previous periodontal disease on gingival plaque and inserting five paper points in the microbiota and peri-implant health in a group of each implant site and an adjacent tooth. The samples partial edentulous patients restored with dental im- were then analyzed by Carpegen© Perio Diagnostics, on plants. All the subjects included in this retrospective Munster, Germany. This analysis is based on a Real- study had been enrolled in a regular supportive thera- time PCR procedure that detects and quantifies the py program fora medium to long term period (5-7 presence of the following bacterial species: Aggregati years of restoration function). bacter Actinomycetem comitans (A.a.), Fusobacteri- um nucleatum (F.n.), Porphyromonas gingivalis zi (P.g.), Prevotella intermedia (P.i.), Treponemadenti- Materials and methods cola (T.d.), Tannerella forsythia (T.f.). The PCR-Real Time parameters were the following: na Selection of patients: - a detection limit for each of the five pathogens of Patients were enrolled during January to February 100 bacteria within a patient’s sample; 2014 in a private dental practice (B.A.) in Milan, Italy. - a linear range for quantification that comprehends A retrospective search for patients restored with fixed seven orders of magnitude for each pathogen; er partial dentures supported by dental implants and en- - a coefficient of variation is 15%. rolled in regular supportive periodontal therapy (at The bacterial genomic DNA was isolated and purified least four times per year) was performed. The study with the AGOWAs mag DNA Isolation Kit Sputum was conducted in compliance with the “Ethical princi- (AGOWA GmbH, Berlin, Germany). Primers and ples for medical research involving human subjects” t probes for Carpagen Perio Diagnostics were de- of Helsinki Declaration. Inclusion criteria were the following: In signed to match highly specifically to ribosomal DNA (rDNA) of the five bacterial pathogens. The exact - medium to long-term implant and periodontal primer and probe sequences were selected with the maintenance (at least 60 months after the delivery Primer Express software (Applied Biosystems, Foster of the final implant supported restoration) City, CA, USA), which checks the primer and probe- ni - 2 to 3 dental implants (Bone System, Milan, Italy) sets for matching the guidelines that are recommend- previously inserted in each partial edentulous patient ed for real-time PCR with TaqMan’s probes. The - no uncontrolled diabetes primers and probes were obtained from Applied io - no pregnancy and lactation Biosystems. Real-time PCR was carried out with 2 ml - no use of antibiotic or corticosteroids in the last of the isolated DNA as template in a reaction mixture three months containing the appropriate primer probesets and the - no active, untreated periodontal infection of the nat- TaqMans Universal PCR Mastermix. The PCR was iz ural dentition assessed at the clinical evaluation. carried out in a real time PCR cycler (LightCycler® A total of 15 patients and 30 implants have been selected. 480 II” Roche Diagnostics Ltd., Rotkreuz, Switzer- Patients were subdivided in the following three sub- land). A laboratory code has been assigned to each Ed groups according to previous periodontal disease and patient (Tab. 1). smoking habit: All the data were assembled, results analyzed and - Group 1: Non smoker, periodontally healthy pa- manuscript written by first author (A.Q.) from August tients. to December 2014 at the Department of Oral Sci- - Group 2: Non smoker subjects previously affected ences, Faculty of Dentistry, University of Otago, New by periodontitis. Zealand. IC - Group 3: Smokers, previously affected by peri- odontitis. Periodontally healthy smoker patients that fulfill the Results inclusion criteria were not found within the entire pop- C ulation of the dental practice. A total of 15 patients (9 males-6 females) was en- rolled in the present study. The average age of male patients was 53.3 years; the average age of female Clinical and microbiological procedures patients was 53.4 years, the mean patients’ follow-up © was 60.5 months (range 5 to 12 years). All the patients were recalled for supportive therapy Microbiological results described the counts for each and the following procedures were carried out: pathogenic species and its proportion compared to first, on each implant site, the following biometric pa- the total bacterial load found in the analyzed sites. In rameters were evaluated: probing depth (PD), bleed- all the three groups, no significant differences in pro- ing on probing (BoP), modified plaque index (mPI), portions of bacterial species were observed between the presence of keratinized tissue (KT). dental and implant sites. Annali di Stomatologia 2015; VI (1): 21-28 23  © Table 1. Biometric parameters and microbiological profile of all the patients included in the study. 24 C name smoking sex age biotype position mes dist cent ml dl l bop bopl mPI keratinized previous Lab.-No. A.a. F.n. P.g. P.i. T.d. T.f. Total habit pd pd pd pd pd pd v tissue period bacterial disease load BA 0 m 59 T #20 3 3 3 2 2 2 1 0 0 1 N 1084749 <100 <100 <100 <100 <100 <100 3,4E+06 IC A. Quaranta et al. BA 0 m 59 T #21 2 2 2 2 2 3 0 0 0 1 N 1084750 <100 5,0E+02 <100 <100 <100 <250 1,7E+07 AG 0 f 70 T #25 2 2 2 2 2 2 1 0 0 1 y 1084751 <100 <100 <100 <100 1,5E+04 4,6E+04 2,4E+07 AG 0 f 70 T #23 3 4 3 3 4 3 0 0 0 1 y 1084752 <100 <250 <100 <100 2,2E+04 1,2E+04 1,1E+06 GM 1 m 48 T #24 2 2 1 2 2 1 0 0 0 1 y 1084753 <100 <250 3,4E+03 <250 <250 1,5E+03 5,0E+05 GM 1 m 48 T #12 3 3 2 3 3 2 0 1 1 1 y 1084754 <100 2,5E+03 2,7E+04 <100 2,8E+03 2,9E+03 3,0E+06 FR 0 f 45 T #29 3 3 2 3 3 2 0 0 1 1 N 1084755 <100 <100 <100 <100 <100 <100 4,5E+07 FR 0 f 45 T #14 3 3 2 3 3 2 0 0 0 1 N 1084756 <100 <100 <100 <100 <100 5,0E+02 2,0E+06 Ed FR 0 m 45 T #10 3 2 3 2 2 2 0 0 0 1 N 1084757 <100 <100 <100 <100 <100 <100 1,6E+06 MV 0 m 66 T #10 2 4 4 4 2 2 2 1 1 1 Y 1084758 <100 3,8E+04 2,9E+06 3,2E+05 8,2E+06 1,6E+06 7,6E+07 MV 0 m 66 T #9 3 3 2 3 3 2 1 1 1 1 Y 1084759 <100 <100 1,8E+03 <100 2,6E+03 9,4E+02 1,7E+06 iz FG 1 m 50 t #13 3 3 2 3 3 2 0 0 0 1 y 1084760 <100 <100 <100 <100 <100 <100 6,1E+04 FG 1 m 50 t #12 2 2 2 2 2 2 0 0 0 1 y 1084761 <100 1,2E+03 <100 <100 <100 <100 5,6E+05 T 1 f 50 t #2 4 3 3 4 4 3 0 io 0 1 0 y 1084762 <100 <100 <100 <100 <100 <250 2,5E+07 T 1 f 50 t #3 3 3 2 3 3 2 0 0 0 0 y 1084763 <100 <100 <100 <100 <100 3,6E+02 2,0E+06 Y 0 f 27 t #3 3 3 2 3 3 2 0 0 0 0 y 1084764 <100 <100 <100 <100 <100 <100 1,3E+06 Y 0 f 27 t #5 3 3 3 3 3 2 0 0 0 0 y 1084765 <100 <100 <100 <100 <100 <100 2,0E+06 MS 0 m 37 T #30 3 3 2 3 3 2 0 0 0 0 N 1084766 <100 2,2E+05 <100 <100 <100 8,1E+04 1,3E+07 ni MS 0 m 37 T #18 2 2 3 2 2 3 0 0 0 0 N 1084767 <100 3,7E+03 <100 <100 <100 <250 1,7E+06 CG 0 m 66 T #30 1 1 0 y 1084768 <100 <100 4,0E+03 2,3E+03 <100 4,6E+02 6,6E+06 CG 0 m 66 T #28 3 3 2 4 3 2 0 0 0 1 y 1084769 <100 4,0E+03 4,0E+02 <100 <250 <100 4,3E+06 In AG 1 m 66 T #20 4 7 3 4 7 3 1 1 0 1 y 1084770 <100 <100 3,3E+04 1,2E+04 3,7E+03 2,0E+03 9,4E+05 AG 1 m 66 T #21 3 3 2 3 3 2 0 0 1 0 y 1084771 <100 <100 4,3E+02 2,9E+02 <250 <100 3,0E+06 LGB 1 m 68 T #3 3 3 2 4 4 2 0 0 1 0 y t 1084772 <100 2,3E+04 3,8E+04 1,4E+04 5,4E+04 6,0E+03 3,9E+07 LGB 1 m 68 T #6 3 3 2 3 3 2 0 0 1 0 y 1084773 <100 6,2E+04 <100 <100 <100 <100 2,6E+06 VC 1 f 75 T #12 3 3 2 3 3 2 0 0 1 0 y 1084774 1,3E+03 <100 1,6E+04 <100 <100 3,1E+03 1,0E+05 VC 1 f 75 T #11 4 4 3 2 3 2 3 2 3 0 y 1084775 3,7E+04 <100 9,1E+03 <100 2,0E+03 8,6E+04 5,6E+06 er CR 0 m 53 T #5 3 3 2 4 4 3 0 0 0 0 y 1084776 <100 <100 7,0E+03 <100 <100 2,8E+03 2,5E+06 CR 0 m 53 T #28 4 4 3 3 3 2 0 0 0 0 y 1084777 <100 <100 <100 <100 <100 <100 1,1E+06 CC 0 f 21 T #19 3 2 3 3 2 3 0 0 0 1 N 2014028 <100 1,8E+03 4,8E+04 3,1E+03 1,2E+04 9,2E+03 1,7E+06 na CC 0 f 21 T #8 3 3 3 3 2 3 0 0 0 1 N 2014029 <100 <100 <100 <100 <100 <100 5,9E+04 0=NO (Under the columns “smoking habits” and “keratinized tissue”); 1=YES (Under the columns “smoking habits” and “keratinized tissue”); Y=yes; NA=not assigned; f=female; t=thin; m=male; T=thick; N=no A.a., T.f., P.g., P.i., T.d., F.n.: bacterial species as described in the section “Materials and methods” Note: Implant positions are reported according to the universal numbering system (also known as the “american dental numbering system”) zi Annali di Stomatologia 2015; VI (1): 21-28 on al i  The impact of smoking and previous periodontal disease on peri-implant microbiota and health: a retrospective study up to 7-year follow-up Intra-examiner reproducibility regarding the collection GROUP 2) Non-smoker patients previously affect- of clinical parameters was good with a linear weight- ed by chronic periodontal disease (Tab. 3) ed kappa (κ) score of 0.85. Seven implant sites in four patients showed signifi- cant counts of all the pathogenic species. The implant i GROUP 1) Non-smoker patients with healthy peri- site with the most severe biometric parameters was al odontal tissues; (Tab. 2) also characterized by the highest total bacterial load and number of single pathogenic bacterial counts. In Significant counts of isolated red complex species only 1 patient no significant presence of pathogenic on were observed in all the patients (Fig.1). species was observed around an implant site. However, this observation was not related to patho- Bleeding on probing was positive and profuse in 3 im- logical PD values or peri-implant inflammation. Only 1 plants in 2 different patients. In both the patients, this patient showed BOP+, but this clinical observation clinical observation corresponded to a microbiological did not correspond to a high total bacterial load nor profile with an extremely high total bacterial load. mPI zi significant single pathogenic counts. mPI values were values were considered relatively satisfactory in all considered satisfactory in all the subjects and ranged the subjects and ranged from 0 to 2. The presence of from 0 to 1. The presence of keratinized tissue did keratinized tissue was not related to healthier biomet- na not correspond with healthier biometric parameters. ric parameters (Fig. 2). Table 2. Clinical parameters and microbiological profile in non-smoker, periodontally healthy patients. er NO SMOKERS-NO PREVIOUS PERIODONTAL DESEASE PZ Implant BOP PD mPI K Lab.-No. A.a. F.n. P.g. P.i. T.d. T.f. Total position tissue bacterial load B.A. #20 vest + 1084749 t <100 <100 <100 <100 <100 <100 3,4E+06 #21 + 1084750 In <100 5,0E+02 <100 <100 <100 <250 1,7E+07 F.R. #19 + + 1084755 <100 <100 <100 <100 <100 <100 4,5E+07 #14 + 1084756 <100 <100 <100 <100 <100 5,0E+02 2,0E+06 #10 + 1084757 <100 <100 <100 <100 <100 <100 1,6E+06 ni M.S. #18 - 1084766 <100 2,2E+05 <100 <100 <100 8,1E+04 1,3E+07 #30 - 1084767 <100 3,7E+03 <100 <100 <100 <250 1,7E+06 C.C. #19 + 2014028 <100 1,8E+03 4,8E+04 3,1E+03 1,2E+04 9,2E+03 1,7E+06 io #8 + 2014029 <100 <100 <100 <100 <100 <100 5,9E+04 vest= buccal side; +=present; - =absent A.a., T.f., P.g., P.i., T.d., F.n.: bacterial species as described in the section “Materials and methods” iz Note: Implant positions are reported according to the universal numbering system (also known as the “american dental num- bering system”) Ed IC C © Figure 1. Peri-apical x-rays of a non-smoker, periodontally healthy patient over a period of 7 years. Annali di Stomatologia 2015; VI (1): 21-28 25  A. Quaranta et al. Table 3. Clinical parameters and microbiological profile in non-smoker patients with previous periodontal disease. NO SMOKERS-PREVIOUS PERIODONTAL DESEASE PZ Implant BOP PD mPI k Lab.-No. A.a. F.n. P.g. P.i. T.d. T.f. Total position tissue bacterial i load al A.G. #25 + + 1084751 <100 <100 <100 <100 1,5E+04 4,6E+04 2,4E+07 #23 + 1084752 <100 <250 <100 <100 2,2E+04 1,2E+04 1,1E+06 on M.V #10 vest- + + + 1084758 <100 3,8E+04 2,9E+06 3,2E+05 8,2E+06 1,6E+06 7,6E+07 ling #9 vest- + 1084759 <100 <100 1,8E+03 <100 2,6E+03 9,4E+02 1,7E+06 ling Y #3 - 1084764 <100 <100 <100 <100 <100 <100 1,3E+06 zi #5 - 1084765 <100 <100 <100 <100 <100 <100 2,0E+06 C.G. #30 - 1084768 <100 <100 4,0E+03 2,3E+03 <100 4,6E+02 6,6E+06 na #28 + 1084769 <100 4,0E+03 4,0E+02 <100 <250 <100 4,3E+06 C.R. #5 - 1084776 <100 <100 7,0E+03 <100 <100 2,8E+03 2,5E+06 #28 - 1084777 <100 <100 <100 <100 <100 <100 1,1E+06 vest=buccal side; ling=lingual side; +=positive; - =negative er A.a., T.f., P.g., P.i., T.d., F.n.: bacterial species as described in the section “Materials and methods” Note: Implant positions are reported according to the universal numbering system (also known as the “american dental num- bering system”) t In ni io iz Ed IC C Figure 2. Peri-apical x-rays of asmoker, periodontally healthy patient over a period of 6 years. GROUP 3) Smoker patients previously affected by Two implant sites in two patients were characterized by high mPI values (3) and two additional implant © chronic periodontitis (Tab. 4) sites in two subjects showed profuse bleeding on The microbiological analysis of peri-implant sites probing. The implant site with the most severe bio- showed significant pathogenic counts in all the patients metric parameters was characterized by a microbial (Tab. 4). T.f. morphotype was the bacterial specie with profile with the highest total and pathogenic bacterial the greatest counts in most of thesites. Four implant counts. The presence of keratinized tissue was not sites in four different patients showed deep PD values. related to healthier biometric parameters (Fig. 3). 26 Annali di Stomatologia 2015; VI (1): 21-28  The impact of smoking and previous periodontal disease on peri-implant microbiota and health: a retrospective study up to 7-year follow-up Table 4. Clinical parameters and microbiological profile in smoker patients with previous periodontal disease. SMOKERS-PREVIOUS PERIODONTAL DISEASE PZ Implant BOP PPD mPI K Lab.-No. A.a. F.n. P.g. P.i. T.d. T.f. Total position tissue bacterial i load al G.M. #24 + 1084753 <100 <250 3,4E+03 <250 <250 1,5E+03 5,0E+05 #12 ling + 1084754 <100 2,5E+03 2,7E+04 <100 2,8E+03 2,9E+03 3,0E+06 on F.G. #13 + 1084760 <100 <100 <100 <100 <100 <100 6,1E+04 #12 + 1084761 <100 1,2E+03 <100 <100 <100 <100 5,6E+05 T.M. #2 + + - 1084762 <100 <100 <100 <100 <100 <250 2,5E+07 #3 - 1084763 <100 <100 <100 <100 <100 3,6E+02 2,0E+06 zi A.G #21 vest- + + 1084770 <100 <100 3,3E+04 1,2E+04 3,7E+03 2,0E+03 9,4E+05 ling #22 + - 1084771 <100 <100 4,3E+02 2,9E+02 <250 <100 3,0E+06 na V.C. #5 - 1084774 1,3E+03 <100 1,6E+04 <100 <100 3,1E+03 1,0E+05 #28 + - 1084775 3,7E+04 <100 9,1E+03 <100 2,0E+03 8,6E+04 5,6E+06 L.G.B. #3 + - 1084772 <100 2,3E+04 3,8E+04 1,4E+04 5,4E+04 6,0E+03 3,9E+07 #6 - 1084773 <100 6,2E+04 <100 <100 <100 <100 2,6E+06 er vest=buccal side; ling=lingual side; +=positive; - =negative A.a., T.f., P.g., P.i., T.d., F.n.: bacterial species as described in the section “Materials and methods” Note: Implant positions are reported according to the universal numbering system (also known as the “american dental num- bering system”) t In ni io iz Ed IC C Figure 3. Peri-apical x-rays of a smoker patient previously affected by periodontitis over a period of 7 years. Discussion scientific evidence about the association between pe- © riodontitis and peri-implantitis (8). It is also possible It is well known that the peri-implant tissue response to state that smoke, local and systemic conditions to the bacterial challenge may follow patterns similar and the presence of subgingival, pathogenic bacteria, to that of the periodontal tissues in a susceptible play an important role in the occurrence of implant host, although it has not yet been clarified whether or complications, although the biological impact of these not a host susceptible for periodontitis will also be factors on the long-term prognosis of oral implant is susceptible for peri-implantitis. Nowadays there is still to be defined. In the present study, the absence Annali di Stomatologia 2015; VI (1): 21-28 27  A. Quaranta et al. of deep PDs around implants in non-smoker patients nization of “pristine” pokets. J Dent Research. 2005b; with healthy periodontal tissues, seems to validate 84:340-344. the positive role that the absence of modifying factors 5. Quyrinen M, Listgarten MA. Distribution of bacterial mor- photypes around natural teeth and titanium implants ad mod- plays in peri-implant health. The results of the pre- um Branemark. Clin Oral Implants Res. 1990;1:8-12. sent study shows that previous periodontal disease i 6. Seymour GJ, Gemmell E, Lenz LJ, Henry P, Bower R,Ya- has a role similar to smoking as risk factor for implant al mazaki K. Immunohistologic analysis of the inflammatory in- complications. The presence of both these factors do filtrates associated with osseointegrated implants. Int J Oral not make peri-implant clinical conditions worse. Un- Maxillofac Implants. 1989;4:191-8. fortunately, no data about the number of cigarettes 7. Liljenberg B, Gualini F, Berglundh T, Tonetti M, Lindhe J. on smoked per day were collected and this may be a Composition of plaque-associated lesions in the gingiva and confounding factor. the peri-implant mucosa in partially edentulous subjects. Clin The total bacterial load was not always related to the Periodontol. 1997;24:119-23. presence of significant pathogenic counts. 8. Karoussis IK, Salvi GE, Heitz-Mayfield LJ. Long-term implant prognosis in patients with and without a history of chronic pe- T.f. was the bacterial specie with the highest number zi riodontitis: a 10-year prospective cohort study of the ITI Den- of counts in each group but it was not associated to tal Implant System. Clin Oral Implants Res. 2003;14:329-39. significant counts of the other assessed bacteria. 9. Karoussis IK, Müller S, Salvi GE, Heitz-Mayfield LJ, Bräg- On the other hand, the inverse assumption resulted na ger U, Lang NP. Association between periodontal and peri- consistently valid: a greater count of pathological implant conditions: a 10-year prospective study. Clin Oral Im- species was found in patients with a greater total plants Res. 2004;15:1-7. bacterial load. 10. Karoussis IK, Kotsovilis S, Fourmousis. A comprehensive and In general, the total bacterial load was not related to critical review of dental implant prognosis in periodontally com- promised partially edentulous patients I. Clin Oral Implants er pathological biometric parameters nor presence or absence of keratinized tissue. Res. 2007;18:669-79. 11. Berglundh T, Persson L, Klinge B. A systematic review of the However, the implant site with the worst biometric pa- incidence of biological and technical complications in implant rameters was characterized by the greatest total bac- dentistry reported in prospective longitudinal studies of at least terial load and the larger number of single pathogenic t 5 years. J Clin Periodontol. 2002;29:197-212. species counts. Finally, in the present study significant pathogenic In 12. Lang NP, Pjetursson BE, Tan K, Brägger U , Egger M, M Zwahlen M. A systematic review of the survival and compli- counts were observed in both smoker and non smok- cation rates of fixed partial dentures (FPDs) after an obser- er subjects previously affected by periodontitis. vation period of at least 5 years. II. Combined tooth-implant- supported FPDs. Clin Oral Implants Res. 2004;15:643-53. ni 13. Pjetursson BE, Tan K, Lang NP, Brägger U, Egger M, Zwahlen M. A systematic review of the survival and com- Conclusions plication rates of fixed partial dentures (FPDs) after an ob- servation period of at least 5 years. M. Clin Oral Implants Res. io Within the limits of the present study it is possible to 2004;15:625-42. state that the absence of smoking habit and previ- 14. Rinke S, Ohl S, Ziebolz D, Lange K, Eikholz P. Prevalence ous periodontal disease positively influences the of peri-implant disease in partially edentulous patients: A prac- medium to long-term microbiological profile and iz tice-based cross-sectional study. Clin Oral Implants Res. peri-implant health in partial edentulous patients. 2011;22:826-833. Further studies on a larger number of patients and 15. Heitz-Mayfield LJ. Peri-implant diseases: Diagnosis and risk paying special attention to the number of cigarettes indicators. J Clin Periodontol. 2008;35(suppl 8):292-304. Ed smoked per day would be necessary in order to con- 16. Strietzel FP, Reichart PA, Kale A, Kulkarni M, Wegner B, Kuchler I. Smoking interferes with the prognosis of dental im- firm our conclusions. plant treatment: A systematic review and meta-analysis. J Clin Periodontol. 2007;34:523-544. 17. Bain CA, Moy PK. The association between the failure of den- References tal implants and cigarette smoking. Int J Oral Maxillofac Im- plants. 1993;8(6):609-15. IC 1. Koka S, Razzog ME, Bloem TJ, Syed S. Microbial colonization 18. Lindquist LW, Carlsson GE, Jemt T. Association between mar- of dental implant in partially edentulous subjects. J Prosthet ginal bone loss around osseointegrated mandibular implants Dent. 1993;70:141-144. and smoking habits: a 10-year follow-up study. J Dent Res. 2. Pontoriero R, Tonelli MP, Carnevale G, Mombelli A, Nyman 1997 Oct;76(10):1667-74. C SR, Lang NP. Experimentally induced peri-implant mucosi- 19. Johnson GK, Hill M. Cigarette smoking and the periodontal tis. A clinical study in humans. Clin Oral Implants Res. patient. Periodontol. 2004 Feb;75(2):196-209. 1994;5:254-259. 20. Labriola A, Needleman I, Moles DR. Systematic review of 3. Quyrinen M, Vogels R, Peeters W, van Steenberghe D, Naert the effect of smoking on nonsurgical periodontal therapy. Pe- I , Haffajee A. Dynamics of initial subgingival colonization of riodontol. 2000. 2005;37:124-37. © “pristine” peri-implant pokets. Clin Oral Implants Res. 21. Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. 2006;17:25-37. Nine- to fourteen-year follow-up of implant treatment. Part 4. Quyrinen M, Vogels R, Pauwels M, Haffajeed C, Socransky III: Factors associated with peri-implant lesions. J Clin Pe- SS, Uzel NG, van Steenberghe D. Initial subgingival colo- riodontol. 2006;33:296-301. 28 Annali di Stomatologia 2015; VI (1): 21-28 

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Original article Postextractive implants in aesthetic areas: evaluation of perimplant bone remodeling over time i al on Michele Mario Figliuzzi, DDS, PhD Key words: dental implants, post-extractive im- Amerigo Giudice, DDS, PhD plants, immediate loading, bone remodeling. Maria Giulia Cristofaro, DDS, PhD Delfina Pacifico, DDS Pasquale Biamonte, DDS Introduction zi Leonzio Fortunato, DDS, PhD Dental implants can be placed in edentulous sites at different times after tooth extractions. Some Authors na Department of Periodontics and Oral Sciences, Uni- (1) have indicated that the immediate placement versity “Magna Graecia” Catanzaro, Italy could offer advantages including time saving. An im- mediate implant is placed in an extraction socket as part of the same procedure. In the past, clinicians al- Corresponding author: lowed a socket healing time of up to 12 months or er Michele Mario Figliuzzi longer before placing implants to restore an edentu- Department of Periodontics and Oral Sciences, Uni- lous space (2), leading to compromised comfort, versity “Magna Graecia” Catanzaro function, and aesthetics for the patient. Via De Maria, 9 t To overcome this limitations, an immediate ap- 89900 Vibo Valentia, Italy Phone: +39 0963 592568 In proach was introduced (3) despite some potential disadvantages. The possible lack of keratinized mu- E-mail: figliuzzi@unicz.it cosa for flap adaptation makes primary closure more difficult to achieve and the incongruity of size and shape between implants and extraction sockets ni Summary presents challenges for primary implant stability. While initial implant stability is obtained by intimate Aim. The aim of this research was to assess peri- contact with the newly formed bone in healed sites, io implant bone remodeling of post-extractive im- residual bony defects always exist around implants plants over 2 years. in immediate implantation. Consequently, primary Material and methods. 30 patients meeting pre-es- stability is only achieved by anchoring the implant in tablished inclusion criteria were enrolled for the the apical bony region (3-4 mm), where cancellous iz study. One implant for each patient was inserted bone predominates. in the post-extraction sockets according to a de- Some studies with a mean follow-up time of 3 years fined surgical protocol (atramautic extraction, evaluated marginal bony alterations (4-9). It is Ed curettage of extraction socket, implant insertion, known that post-extractive implants do not prevent grafting with collagenated cortico-cancellous bone resorption (10). Such biological changes im- porcine bone, and a trimmed collagen membrane ply higher risk of marginal mucosal recession after to completely cover the socket, suture). A tempo- immediate implant placement, with possible aes- rary adhesive bridge, with an adequate profile, thetical damage especially when the facial socket was bonded to the adjacent teeth. X-ray evalua- wall and tissue biotype are thin (11). Bone remod- IC tion with a standardized stent was carried out at eling can be associated with three dimensional im- different times. Measurements were obtained plant position, presence/absence of platform from the implant edge to the bone peak. The val- switching, absence of facial bony wall, inter im- ues obtained at time 0 and at 2 years were com- plant/tooth distance. C pared by t-student test. It has been stated that a certain width of peri-implant Result. Our results showed that after one year mucosa is required to enable a proper epithelial-con- 73% of patient had 0 mm of bone reabsorption, nective tissue attachment. In case of inadequate di- 20% of patient had 0 mm ≤ x ≤ 0.5mm, 7% of pa- mension, crestal bone reabsorption will occur to en- sure the appropriate biological width. Recent studies © tient had 0.5 mm ≤ x ≤ 2 mm of bone reabsorption. After two years 62% of patient had 0 mm of bone have shown that for all two-piece implants, the bone reabsorption, 24% had 0 mm ≤ x ≤ 0.5mm, 14% crest level changes seem related to the microgap po- had 0.5 mm ≤ x ≤ 2 mm. sition (12, 13). Conclusions. The results showed no significant Histological and radiographic studies by Herman et differences in bone reabsorption in most patients al. have proven that a crestal bone loss of about 2 over 2 years. mm occurs with the submerged, two-pieces ap- Annali di Stomatologia 2015; VI (1): 29-34 29  M.M. Figliuzzi et al. proach, dependent on the microgap, and minimal or and postoperative antibiotic therapy (1 g amoxicillin no reabsorption occurs with non-submerged, one- or 300 mg clindamycin) for further 4 days. All pa- piece implants (14). They demonstrated that a tients rinsed for 1 minute with chlorhexidine mouth- rough/smooth border on the surface of one-piece im- wash 0.2% prior to surgery (and twice a day for the plants determines the crestal bone levels adjacent to following 3 weeks), and were treated under local i such implants. Regarding platform switching Calvo- anesthetic using lidocaine with adrenaline 1:50.000. al Guirado et al. (15) evaluated the survival rates at 12 All surgical procedures were undertaken by one sur- months of a platform switched implant placed in the geon. All the patients were treated with the same anterior and premolar areas of the maxilla and imme- surgical technique (periotomes were used around on diately restored with single crowns. They concluded each single selected tooth); moreover the extraction that the implants remained stable over the course of socket was thoroughly curetted and irrigated with 12 months and had an overall survival rate of 96.7%. sterile saline solution. To preserve vestibular bone Minimal crestal bone loss was recorded around the plate, some teeth extractions were performed using surviving implants. piezoelectric tips (Piezosurgery, EX2,Mectron, zi Furthermore, based on the finding that the bone crest Italy). Implants (Sweden Martina, Due Carrare, was more apically located at sites with <3 mm inter- Padova, Italy) were inserted placing the shoulder implant distance than at sites where the implants edge 1 mm deeper the cortical margin of palatal na were standing >3 mm apart, Tarnow et al. (16) sug- plate (Figs. 1, 2). Subsequently, the residual gaps gested that not only vertical bone loss but also lateral were filled and slightly condensed with collagenat- bone loss at implants could have an effect on the lev- edcortico-cancellous porcine bone (MP3, Osteobiol- el of the bone crest between two implants. Tecnoss, Coazze, Italy), and a trimmed collagen er The aim of this research is focusing on the perimplant membrane (Evolution, Osteobiol-Tecnoss, Coazze, bone remodeling of post-extractive implants over two Italy) was used to completely cover the socket. The years. t Materials and methods In Trial design ni Participants: Selected patients for the study meet the following in- clusion criteria: io - good health conditions (no systemic diseases in- cluding diabetes, rheumatic diseases, neoplasia) - non smokers or smokers less of 15 cigarettes a day - presence of adequate cortical bone at vestibular iz and palatal plates (at least 2 mm) - presence of adjacent teeth - sufficient vertical amount of bone (at least 3 mm Ed of residual bone evaluated thorough CT dental scan) to insert a stable post-extractive implant. Exclusion criteria were: - pregnancy and lactation Figure 1. Implant placement after extraction. - assumption of drugs such as biphosfonates which could negatively influence bone healing IC - active periodontitis. All patients required teeth extractions due to root fractures, destructive caries, endodontic failures. Each patients signed an informative approval form C before acceptance of treatment. The research was conducted with the approval of local ethical commit- tee nr. 926 of October 2010 and in accordance with the Helsinki Declaration. © Surgical procedures All patients received prophylactic antibiotic therapy (2 g of amoxicillin or 600 mg clindamycin - if allergic to penicillin) 1 hour before the extraction procedure Figure 2. X-ray evaluation immediately after placement. 30 Annali di Stomatologia 2015; VI (1): 29-34  Post-extraction implants in aesthetic zones soft tissues were only undermined and no releasing X-ray evaluation incisions were performed. Platelet-rich fibrin (PRF) membranes were prepared and used for better heal- X-ray evaluation was carried out at different timing: ing of soft tissues. The collagen membrane was left - time 0 at implant insertion intentionally exposed to the oral cavity and stabi- - 1 year after implant insertion i lized by sutures. - 2 years after implant insertion. al All patients were instructed to continue with prophy- Digital intra-oral periapical radiographs were taken lactic antibiotic therapy; naproxen sodium 550 mg (70 KVp, 7 mA) using a parallel cone technique with a tablets were prescribed as an anti-inflammatory to be digital sensor (Schick Technologies, Long Island City, on taken 2 times a day for as long as required. The tem- NY, USA). A paralleling device and individualised bite porary prosthetic restoration was bonded to the adja- blocks, made of polyvinyl siloxane impression materi- cent teeth with a light-curing composite which was, al (Flexitime, Heraeus/Kulzer, Hanu, Germany), were subsequently, carefully polished. The profile of a tem- used for the standardization of the x-ray geometry. porary restoration was adapted to the edentulous Bone loss was measured by using the radiographs zi space withflat profile at the buccal and proximal sites. taken at 0, 12 and 24 months after implant insertion This modified pontic profile would support the soft tis- (Figs. 6, 7). The marginal bone height (MBL) was set sues thus allowing for a more natural shape of the na gingivae and papillae; sutures were removed after 7 days. Clinical follow up was performed until 24 months after surgery (Figs. 3-5). Three months after surgery final er prosthetic restoration was delivered (Figs. 4, 5). t In ni Figure 5. Clinical condition after 90 days. io iz Ed Figure 3. Clinical condition of site after 30 days. IC Figure 6. Bone remodeling after 1 year. C © Figure 4. Clinical condition after 90 days and insertion of abutment. Figure 7. Bone remodeling after 2 years. Annali di Stomatologia 2015; VI (1): 29-34 31  M.M. Figliuzzi et al. as the distance between the implant-abutment con- mm mm 1.2 1.2 nection and the most apical point of the marginal bone level. Calibration was performed using the mm mm known thread-pitch distance of the implants (pitch = 1 1 1.0 mm). Previously known values, such as fixture di- i ameter and length, were used for calibration when the mm mm al 1.5 1.5 threads were not clearly visible on the radiographs. Measurements were taken to the nearest 0.1 mm us- mm mm ing computer software (UTHSCSA Image Tool, Ver- 2 2 on sion 3.00, University of Texas Health Science, San Antonio, TX). Bone changes were measured at the mm mm 1.4 1.4 mesial and distal peri-implant sites, and their average values were used calculating distance between corti- mm mm 1.7 1.7 cal edge and the fixture abutment junction. All mea- zi surements were taken by one examiner who was not mm mm 1.8 1.5 involved in performing the surgical treatment. The val- ues obtained at time 0 and at 2 years were compared na by test t-student. mm mm 1.8 1.8 mm mm 1.4 1.4 Results er mm mm Thirty-nine patients were initially screened for eligibility; 2 2 however, 9 patients were excluded from the study be- cause missing adjacent teeth and no integrity of the mm mm 1.6 1.6 tbuccal bone plate immediately after extractions; 3 pa- In tients refused to be enrolled in a prospective study. mm mm Thirty patients (18 females and 12 males, mean age of 1.5 1.5 Table 1. Mean values for mesial and distal bone reabsorption for each implant at Time 0 and Time 2. 48 ± 11.6 years) were considered eligible and were consecutively enrolled and treated. No patients drop- mm mm 1.8 ped out from the study and the data from all patients 2 ni was evaluated in the statistical analysis. Eleven teeth mm mm 1.3 1.3 (33%) were removed using a piezosurgery tip to reduce the risk for buccal plate fracture and thus reducing the io risk for further bone loss. mm mm mm mm 1.6 1.6 1.8 1.8 All treated sites allowed the placement of 3.75 or 4.25 mm implants. Implants were torqued at 30 N mm mm mm mm cm2. No complications were recorded during the heal- 1.4 1.4 iz 2 2 ing period. The mean values for the mesial and distal bone reab- mm mm mm mm 1.4 1.4 1.6 1.3 sorption for each implant at Time 0 and Time 2 (Tab. Ed 1) were compared by test t-student and show that there were no significant differences in bone reab- mm mm mm mm 1.7 1.4 1.6 1.6 sorption after two years of implant insertion (p= 0.5855) (Tab. 2). mm mm mm mm 1.3 1.3 1.5 1.5 All data were also selected and divided in three differ- ent categories: IC I patients who did not have bone remodeling mm mm mm mm 1.7 1.7 II patients who had up to 0.5 mm of reabsorption 2 2 III patients who had a reabsorption from 0.5 mm to mm mm mm mm 2 m. 1.6 1.6 1.8 1.8 C The results for each groups are summarized in Fig- ures 8, 9. mm mm mm mm 1.5 1.5 1.3 1.3 © Discussion mean values at T0 mean values at T2 mean values at T0 mean values at T2 Literature data showed that implants placed immedi- ately in fresh extraction sockets represent a reliable procedure. Some authors indicated a low annual fail- ure rate of 0.82% (95% CI: 0.48-1.39%) resulting in a survival rate of 98.4% at 2-year (16). In systematic re- 32 Annali di Stomatologia 2015; VI (1): 29-34  Post-extraction implants in aesthetic zones Table 2. T-student test from values at T0 and T2. mean Dev. Standard T Degrees of freedom P values at T0 1.6 mm 0.2613 0.5484 58 0.5855 values at T2 1.5633 mm 0.2566 i al faces. The small bony changes were in accordance with those reported in the RCT by Canullo et al. (23), on which showed that after about 2 years of loading, the platform-switching group experienced bone loss of 0.25 mm mesially and 0.36 mm distally; the bone loss was more significant in the platform-matching group, reaching 1.13 mm and 1.25 mm on mesial and distal zi surfaces, respectively. On the contrary, in the study by Crespi et al. (22), no significant differences in the bony changes between the two groups were found. The na bone loss ranged 0.73-0.84 mm at the 1- year follow- up and 0.68-0.80 mm at the end of the second year. Figure 8. Results after 1 year. Basing on our results, it should be hypothesized that platform switching could minimize bone remodeling af- ter prosthetic loading. In addition, also bone grafting er may have contributed to reduce bone remodeling. The placement of graft material has been indicated as an ideal procedure in order to maintain adequate bone levels, as demonstrated by Iasella et al. (24). Compa- t rable results have been found using similar techniques In by Serino et al. (25) and Camargo et al. (26), who con- cluded that a slight bone loss at buccal and lingual as- pects may occur despite preservation procedures. This remodeling in response to inadequate blood ni supply becomes more critical in the buccal region for Figure 9. Results after 2 years. characteristics naturally inherent to this region’s na- ture and anatomy (27). Current scientific literature re- ports that an alveolar ridge preservation technique io views (17, 18), survival rates and complication occur- rence of fixed dental prosthesis, formerly “fixed partial has some benefits including less ridge reabsorption dentures” (FPDs) and single crowns supported by of the post-extractive sites (28), but emphasises that post-extractive implants were estimated. The 5-year a complete preservation of the buccal area is never- iz survival rate of implants was >95% and that of FPDs theless difficult (28). This fact could explain the bone and SCs were approximately 95%. Technical and bio- remodeling up to 1 mm which we observed. logical complications were reasonably prevalent. In the This research has some limitations. First of all the ab- Ed review concerning peri-implant diseases (19), it was sence of a control group (only ridge preservation) found that after 5-10 years of function, peri-implant makes our research partially elusive. Furthermore, mucositis occurred in approximately 80% of subjects the study includes in the same group mandibular and and in 50% of implants. Peri-implantitis was found in maxillary implants. 28-56% of the subjects and 12-43% of the implants. In Our results need to be confirmed by other researches this research no complications from a technical or a bi- with a major numbers of mandibular and maxillary im- IC ological point of view were observed. In addition, our plants included in separated groups, and with a con- research highlighted bone changes similar to other trol group. studies (20). Generally, immediate implants in most studies experienced bone loss. The 1-year studies that C the bone loss was less than 1 mm (range: gain 1 mm- References loss 0.98 mm) in the first year, and longer-term studies demonstrated that after the first functioning year bone 1. Hämmerle CH, Chen ST, Wilson TG Jr. Consensus state- levels became stable (19). Our data indicated slightly ments and recommended clinical procedures regarding the placement of implants in extraction sockets.Int J Oral Max- © higher changes but similar at 1 and 2-year follow up. illofac Implants. 2004;19 Suppl:26-8. Three studies (21-23) reported changes of marginal 2. Adell R, Lekholm U, Rockler B, Brånemark PIA 15-year study bone levels around immediately placed and immedi- of osseointegrated implants in the treatment of the edentu- ately restored implants using the platform-switching lous jaw.Int J Oral Surg. 1981 Dec;10(6):387-416. method. In the study of Calvo-Guirado et al. (21), the 3. Schulte W, Kleineikenscheidt H, Lindner K, Schareyka R. The mean bone loss after 1 year of function was 0.08 mm Tübingen immediate implant in clinical studies. DtschZah- on the mesial surfaces and 0.09 mm on the distal sur- narztl Z. 1978 May;33(5):348-59. Annali di Stomatologia 2015; VI (1): 29-34 33  M.M. Figliuzzi et al. 4. Becker W, Becker BE, Hujoel P.Retrospective case series servation period of at least 5 years.Clin Oral Implants Res. analysis of the factors determining immediate implant place- 2004 Dec;15(6):667-76. ment. Compend Contin Educ Dent. 2000 Oct;21(10):805-8, 18. Jung RE, Thoma DS, HammerleCH.Assessment of the po- 810-1. tential of growth factors for localized alveolar ridge aug- 5. Huys LW. Replacement therapy and the immediate post-ex- mentation: a systematic review.J ClinPeriodontol. 2008 i traction dental implant. Implant Dent. 2001;10(2):93-102. Sep;35(8 Suppl):255-81. al 6. Bianchi AE, Sanfilippo F. Single-tooth replacement by im- 19. Zitzmann NU, Berglundh T Definition and prevalence of peri- mediate implant and connective tissue graft: a 1-9-year clin- implant diseases. J Clin Periodontol. 2008 Sep;35(8 Sup- ical evaluation.Clin Oral Implants Res. 2004 Jun;15(3):269- pl):286-91. 77. 20. Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence on 7. Botticelli D, Renzi A, Lindhe J, Berglundh T. Implants in fresh of subjects withprogressive bone loss at implants. Clin Oral extraction sockets: a prospective 5-year follow-up clinical Implants Res. 2005 Aug;16(4):440-6. study.Clin Oral Implants Res. 2008 Dec;19(12):1226-32. 21. Calvo-Guirado JL, Ortiz-Ruiz AJ, López-Marí L, Delgado-Ruiz 8. Mijiritsky E, Mardinger O, Mazor Z, Chaushu G. Immediate R, Maté-Sánchez J, Bravo Gonzalez LA.Immediate maxil- provisionalization of single-tooth implants in fresh-extraction lary restoration of single-tooth implants using platform zi sites at the maxillary esthetic zone: up to 6 years of follow- switching for crestal bone preservation: a 12-month study. up.Implant Dent. 2009 Aug;18(4):326-33. Int J Oral Maxillofac Implants. 2009 Mar-Apr;24(2):275-81. 9. Prosper L, Crespi R, Valenti E, Capparé P, Gherlone E. Five- 22. Crespi R, Capparè P, Gherlone E. Radiographic evaluation na year follow-up of wide-diameter implants placed in fresh mo- of marginal bone levels around platform-switched and non- lar extraction sockets in the mandible: immediate versus de- platform-switched implants used in an immediate loading pro- layed loading.Int J Oral Maxillofac Implants. 2010 May- tocol. Int J Oral Maxillofac Implants. 2009 Sep-Oct;24(5):920- Jun;25(3):607-12. 6. 10. Wang RE, Lang NP. Ridge preservation after tooth extrac- 23. Canullo L, Goglia G, Iurlaro G, Iannello G. Short-term bone tion. Clin oral Implant Res. 2012 Oct;23 Suppl 6:147-56. level observations associated with platform switching in im- er 11. De Rouck T, Collys K, Cosyn J. Single-tooth replacement in mediately placed and restored single maxillary implants: a the anterior maxilla by means of immediate implantation and preliminary report. Int J Prosthodont. 2009 May-Jun;22(3):277- provisionalization: a review. Int J Oral Maxillofac Implants. 82. 2008 Sep-Oct;23(5):897-904. 24. Iasella JM1, Greenwell H, Miller RL, Hill M, Drisko C, Bohra 12. Wend D, Nagata MJ, Bosco AF, de Melo LG. Influence of t AA, Scheetz JP. Ridge preservation with freeze-dried bone microgap location and configuration on radiographic bone loss around submerged implants: an experimental study in In allograft and a collagen membrane compared to extraction alone for implant site development: a clinical and histolog- dogs. Int J Oral Maxillofac Implants. 2011 Sep-Oct; 26(5): ic study in humans. J Periodontol. 2003 Jul;74(7):990-9. 941-6 25. Serino G1, Biancu S, Iezzi G, Piattelli A. Ridge preservation 13. Wend D, Nagata MJ, Leite CM, de Melo LG, Bosco AF. In- following tooth extraction using a polylactide and polyglycolide ni fluence of microgap location and configuration on radiographic sponge as space filler: a clinical and histological study in hu- bone loss in nonsubmerged implants: an experimental mans.Clin Oral Implants Res. 2003 Oct;14(5):651-8. study in dogs. Int J Oral Prosthodont. 2011 Sep-Oct; 24(5): 26. Camargo PM, Lekovic V, Weinlaender M, Nedic M, Vasilic 445-52. N, Wolinsky LE, Kenney EB. A controlled re-entry study on io 14. Hermann F, Lerner H, Palti A. Factors influencing the preser- the effectiveness of bovine porous bone mineral used in com- vation of the periimplant marginal bone. Implant Dent. 2007 bination with a collagen membrane of porcine origin in the Jun;16(2):165-75. treatment of intrabony defects in humans. J Clin Periodon- iz 15. Calvo-Guirado JL, Gómez-Moreno G, Aguilar-Salvatierra A, tol. 2000 Dec;27(12):889-96. Guardia J, Delgado-Ruiz RA, Romanos GE. Marginal bone 27. Novaes AB Jr, Suaid F, Queiroz AC, Muglia VA, Souza SL, loss evaluation around immediate non-occlusalmicrothreaded Palioto DB, Taba M Jr, Grisi MF. Buccal bone plate remod- implants placed in fresh extraction sockets in the maxilla: a eling after immediate implant placement with and without syn- Ed 3-year study. Clin Oral Implants Res. 2014 Jan 15 doi: 10.111. thetic bone grafting and flapless surgery: radiographic study 16. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant in dogs. J Oral Implantol. 2012 Dec;38(6):687-98. distance on the height of inter-implant bone crest. J Peri- 28. Barone A, Ricci M, Covani U, Nannmark U, Azarmehr I, Cal- odontol. 2000 Apr;71(4):546-9. vo-Guirado JL. Maxillary sinus augmentation using prehy- 17. Pjetursson BE, Tan K, Lang NP, Brägger U, Egger M, dratedcorticocancellous porcine bone: hystomorphometric Zwahlen M. A systematic review of the survival and com- evaluation after 6 months. Clin Implant Dent Relat Res. 2012 plication rates of fixed partial dentures (FPDs) after an ob- Jun;14(3):373-9. IC C © 34 Annali di Stomatologia 2015; VI (1): 29-34 

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Original article Deformations and cyclic fatigue resistance of nickel-titanium instruments inside a sequence i al on Gianluca Gambarini, MD,DDS1 ferences were found between green instruments Gianluca Plotino, DDS, PhD1 of both groups (P > 0.05), while a statistically sig- Lucila Piasecki, DDS2 nificant difference was found between the yellow Dina Al-Sudani, DDS3 instruments (P < 0.05), with group B showing an Luca Testarelli, DDS, PhD1 higher resistance to cyclic fatigue. zi Gianpaolo Sannino, MD, DDS4 Conclusions. A prolonged passive brushing mo- tion did not adversely affected mechanical resis- tance of the instrument used for this purpose. Re- na 1 Endodontics Unit, Department of Oral and Maxillo- sistance to both deformations and cyclic fatigue facial Sciences, “Sapienza” University of Rome, Italy of the second instrument within the TFA small se- 2 PUC University, Curitiba, Brasil quence was enhanced by the coronal flaring pro- 3 Department of Restorative Dental Science, College of vided by the brushing action of the first instru- ment used. er Dentistry, King Saud University, Riyadh, Saudi Arabia 4 University of Rome II, Tor Vergata, Italy Key words: nickel-titanium, brushing action, de- formations, cyclic fatigue. There are no disclosures for the present study. t In Introduction Corresponding author: Gianluca Gambarini In the last decades the use of nickel-titanium (NiTi) ro- Department of Endodontics Unit tary instruments has become the most effective and ni Oral and Maxillo-facial Sciences popular method amongst endodontists for shaping “Sapienza” University of Rome root canals, due to their greater elasticity, strength Via Calabria, 25 and cutting efficiency (1). Despite these advantages, io 00187 Rome, Italy fracture of NiTi rotary instruments caused by torsional E-mail: ggambarini@gmail.com stress and/or cyclic fatigue has remained a primary concern in endodontics practice, because they tend to break unexpectedly during intracanal use (2). Follow- iz Summary ing the introduction of NiTi alloy in endodontics, man- ufacturers have frequently changed the cross-section- Aim. To compare the effect of brushing motion on al design and geometrical features of instruments to Ed torsional and cyclic fatigue resistance of TF improve both torsional and cyclic fatigue resistance Adaptive instruments after clinical use. (3, 4). Since 2007, new alloys and new manufacturing Methods. 20 packs of TFA small sequence (Sybro- processes were adopted to optimize the microstruc- nEndo, Orange, CA, USA) were used for this ture of NiTi, basically through innovative thermome- study and divided into two groups. Each instru- chanical processing (5). NiTI instruments produced ment prepared one resin tooth, consisting in 4 with these technologies (M-wire, CM wire or Twisted IC canals with a complex anatomy. In group A, no Files) showed better properties in terms of flexibility brushing motion was performed. In group B, after and resistance to mechanical stress when compared the green instrument reached the working length, to traditional NiTi alloy and processing (5-7). brushing motion with circumferential filing was More recently, the use of single-file NiTi reciprocating C performed for 15 seconds in each canal (overall 1 instruments have been advocated as a simple, safe minute). All the instruments were then subjected alternative to rotary instrumentation techniques (8). to cyclic fatigue test and mean values and stan- Current literature data show that reciprocating motion dard deviation for time to fracture were evaluated. can extend both torsional and cyclic fatigue resis- © Data were subjected to one-way analysis of vari- tance of NiTi instruments when compared to continu- ance and Bonferroni t-test procedure with a sig- ous rotation, by reducing instrumentation stress (9- nificance set at P < 0.05. 12). Despite this improvement, the accumulation of all Results. No instruments were broken during instrumentation stress on one single-file may still be preparation of root canals. Two TF Adaptive high, and consequently new reciprocating movements green and 5 yellow showed unwinding after intra- were developed to be used within a sequence, such canal clinical use. No statistically significant dif- as TF Adaptive (TFA) (13, 14). 6 Annali di Stomatologia 2015; VI (1): 6-9  Deformations and fatigue resistance of endodontic instruments Other clinical factors, mainly related to individual 1 minute) to increase coronal flaring. Before any skill, sensitivity and operative choice, also affect brushing motion, instruments were withdrawn 1 mm torsional and cyclic fatigue resistance of NiTi instru- short of the working length, thus preventing any over ments: the applied pressure, the tendency to force engagement with the canal walls. After shaping pro- the instrument apically, the use of torque control cedures were completed all the 40 used NiTi instru- i motors, prolonged re-use, the creation of a glide ments were inspected under magnification (3x) to al path (15) and so on. It has been shown that resis- check any sign of plastic deformation or undwinding tance to fatigue is related to instrumentation time, of flutes. being significantly reduced after multiple clinical All the instruments were then subjected to cyclic fa- on use (16). tigue test using a testing device that was previously Traditionally, NiTi instruments are used as reamers, described (21-27). Briefly, all instruments were tested while progressing to the working length, More re- using the TFA motion powered by Elements motor cently, the use of a brushing motion in addition to (SybronEndo, Orange, CA, USA). After positioning the traditional reaming action was proposed to im- the instrument into a simulated root canal with a 60° zi prove safety and efficiency of NiTi instrumentation angle of curvature and 5-mm radius of curvature, as (17). The benefit of the brushing action is not only to soon as rotation started timing was initiated and then enhance the amount of canal walls touched by the stopped when instrument breakage was observed. na file, but also to provide more coronal enlargement For each instrument, the time to fracture in seconds for a safer progression of instruments within a se- was recorded by the same operator with a chronome- quence (18, 19). ter to an accuracy of 0.1 second. Since the motor au- Since the brushing motion increases instrumentation tomatically selects the mode of use and the recipro- er time, the aim of this study was to compare its effect cating angles depending on the canal anatomy, on torsional and cyclic fatigue resistance of TFA in- speed and number of cycles to failure could not be struments after clinical use. precisely calculated. Mean values and standard devi- ation (SD) for time to fracture were evaluated. To de- t termine any statistical difference between the groups, Material and methods In the data were subjected to a one-way analysis of variance. When the overall F test indicated a signifi- Twenty packs of TFA small sequence (SybronEndo, cant difference, the multiple-comparison Bonferroni t- Orange, CA, USA) were used for this study and ran- test procedure was performed to identify differences domly divided into two groups of ten each. To avoid among groups. Significance was set at the 95% confi- ni any changes related to anatomy, twenty plastic first dence level. maxillary molar 3D teeth with the same morphology (Real-T Endo, Aca Dental, Inc., Overland Park, KS, io USA) were used for this study as previously done Results (20). Each instrument prepared one tooth, consisting in 4 canals with a complex anatomy. Following the No instruments were broken during preparation of manufactures’ guidelines for the TF Adaptive small root canals. Two TF Adaptive green, tip size 20 and iz sequence, a manual glide path up to a ISO size 15 .04 taper (one in each group A and B), and 5 TF was performed using the stainless-steel (SS) K-file Adaptive yellow, tip size 25 and .06 taper (4 from instrument available in the package. Following the Group A and 1 from Group B) showed unwinding af- Ed traffic light concept given by the manufacturer ter intracanal clinical use. (http://axis.sybronendo.com/tfadaptive_confidence#ta Results of cyclic fatigue test are reported in Table 1. b6), the instrumentation was stopped at yellow, using No statistically significant differences were found be- only the first two instruments of the sequence: the tween green instruments of both groups (P > 0.05), green TFA instrument (tip size 20, .04 taper) followed showing that one additional minute of brushing mo- by the red TFA instrument (tip size 25, .06 taper). All tion did not decreased fatigue resistance. A statisti- IC instruments were used with the patented TFA motion cally significant difference was found between the in a specific endodontic motor (Elements Motor, yellow instruments (P < 0.05), with group B showing SybronEndo, Orange, CA, USA), which automatically an higher resistance to cyclic fatigue. These differ- selected the kinematics (continuous rotation or recip- ences are attributed to coronal flaring provided by the C rocation) according to intracanal stress applied on the green instrument used with a brushing motion, which instrument during instrumentation. All instruments reduced instrumentation stress for the next (yellow) reached the working length by incremental steps (1 instrument. mm) without being forced apically and the flutes were © always cleaned after each 1 mm apical progression. Table 1. Mean time to fracture in seconds (Standard Devi- Irrigation was performed with alchool every each in- ation) of the different instruments tested. strument. In group A, no brushing motion was performed. In Instrument Size Green (20/.04) Yellow (25/.06) group B, after the green instrument reached the work- ing length, brushing motion with circumferential filing Group A (No Brushing) 142 (20) 73 (6) was performed for 15 seconds in each canal (overall Group B (Brushing) 137 (15) 97 (7) Annali di Stomatologia 2015; VI (1): 6-9 7  G. Gambarini et al. Discussion a) the coronal flaring provided by the brushing action of the first green instrument of the TFA small se- Clinical performance of NiTi instruments can be relat- quence reduced the instrumentation stress exert- ed to the operative techniques. It has been suggested ed on the second instrument within the same se- that any NiTi instrument may be used both as a ream- quence. Resistance to both torsional stress i er cutting in advancement and with a brushing action (which may cause undwinding of the flutes) and al as a hedstroem file, to improve coronal and/or circum- flexural stress (which may affect resistance to ferential flaring (19), but safety and efficiency of the cyclic fatigue of used instruments) was enhanced; proposed technique needed further assessments. b) a prolonged passive brushing motion as per- on The present study demonstrates that a brushing ac- formed in the present study (60 seconds) did not tion can be performed up to 60 seconds with minimal adversely affected mechanical resistance of the or no risk of increasing instrument fatigue. The green instruments used for this purpose. Resistance to TFA instrument (tip size 20, .04 taper) which per- both torsional and flexural fatigue was not de- formed a brushing action for 15 seconds in each of creased. zi the four canals did not showed a significant decrease of resistance to cyclic fatigue. These findings are consistent with previously published results (17, 19). References na Incidence of instrument deformation was not affected 1. Peters OA. Current challenges and concepts in the prepara- by the brushing action. The green TFA instruments tion of root canal systems: a review. J Endod. 2004;30:559-67. were subjected to significant torsional stress while 2. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini progressing to the working length, which produced G. A review of cyclic fatigue testing of nickel-titanium rotary er undwinding of flutes of one instrument in both groups. instruments. J Endod. 2009;35:1469-76. On the contrary, no unwinding was observed while 3. Best S, Watson P, Pilliar R, Kulkarni GG, Yared G. Torsional performing the brushing action, instrument blades fatigue and endurance limit of a size 30.06 ProFile rotary in- were fully disengaged during passive brushing motion strument. Int Endod J. 2004;37:370-3. as performed in the present study. As a consequence, t 4. Grande NM, Plotino G, Pecci R, Bedini R, Malagnino VA, Somma F. Cyclic fatigue resistance and three-dimensional In lateral hedstroem-like cutting resulted in much less torsional stress applied on the instrument compared to analysis of instruments from two nickel-titanium rotary sys- tems. Int Endod J. 2006;39:755-63. a traditional reaming-like cutting, in which blades are 5. Gambarini G, Plotino G, Grande NM, Al-Sudani D, De Luca usually engaged. M, Testarelli L. Mechanical properties of nickel-titanium ro- TF Adaptive instruments were selected for the pre- tary instruments produced with a new manufacturing tech- ni sent study because the TF technology produces a Ni- nique. Int Endod J. 2011;44:37-41. Ti alloy which is more ductile. Similarly to stainless- 6. Plotino G, Testarelli L, Al-Sudani D, Pongione G, Grande NM, steel instruments, a ductile NiTi file tends to show vis- Gambarini G. Fatigue resistance of rotary instruments io ible plastic deformation before breakage, when sub- manufactured using different nickel-titanium alloys: a com- jected to high torsional loading (28). This can be con- parative study. Odontology. 2014;102:31-5. 7. Testarelli L, Plotino G, Al-Sudani D, Vincenzi V, Giansiracusa sidered as a safety feature. It allows to discard NiTi A, Grande NM, Gambarini G. Bending properties of a new iz instruments which have accumulated metal fatigue, nickel-titanium alloy with a lower percent by weight of nick- reducing the risk of unexpected breakage. Shen et al. el. J Endod. 2011;37:1293-5. (29) showed that the tendency to show plastic defor- 8. Yared G. Canal preparation using only one Ni-Ti rotary instru- mation can vary amongst instruments, focusing the Ed ment: preliminary observations. Int Endod J. 2008;41:339-44. attention mainly on differences in design and not on 9. Kiefner P, Ban M, De-Deus G. Is the reciprocating movement the alloy or manufacturing process TFA instruments per se able to improve the cyclic fatigue resistance of in- were also selected because of their unique motion, struments? Int Endod J. 2013;Jul 12. doi: 10.1111/iej.12166. which has never been investigated in relation with 10. Pedullà E, Grande NM, Plotino G, Palermo F, Gambarini G, Rapisarda E. Cyclic fatigue resistance of two reciprocating clinical resistance to torsional and flexural fatigue. nickel-titanium instruments after immersion in sodium The present study also demonstrated that increasing IC hypochlorite. Int Endod J. 2013;46:155-9. coronal flaring allowed a safer progression to the 11. Pedullà E, Grande NM, Plotino G, Gambarini G, Rapisarda working length of the instrument used immediately af- E. Influence of continuous or reciprocating motion on cyclic ter. In fact, the incidence of deformations (undwinding fatigue resistance of 4 different nickel-titanium rotary in- of the flutes) of the second instrument used within the struments. J Endod. 2013;39:258-61. C TF Adaptive sequence (yellow, tip size 25, .06 taper) 12. Plotino G, Grande NM, Testarelli L, Gambarini G. Cyclic fa- was higher when brushing and coronal flaring was tigue of Reciproc and WaveOne reciprocating instruments. not performed by the green instrument (tip size 20, Int Endod J. 2012;46:614-8. .04 taper) previously used in the same sequence. In 13. Gambarini G, Gergi R, Naaman A, Osta N, Al Sudani D. Cyclic fatigue analysis of twisted file rotary NiTi instruments used © addition, yellow instruments of group A (no brushing in reciprocating motion. Int Endod J. 2012;45:802-6. motion) showed a significant lower resistance to 14. Gambarini G, Testarelli L, De Luca M, Milana V, Plotino G, cyclic fatigue when compared to group B in which Grande NM, Rubini AG, Al Sudani D, Sannino G. The in- brushing with circumferential filing had been previ- fluence of three different instrumentation techniques on the ously performed by the green instrument. incidence of postoperative pain after endodontic treatment. In conclusion, based from the findings of the present Ann Stomatol. 2013;20:152-5. study, it may be concluded that: 15. Berutti E, Paolino DS, Chiandussi G, Alovisi M, Cantatore 8 Annali di Stomatologia 2015; VI (1): 6-9  Deformations and fatigue resistance of endodontic instruments G, Castellucci A, Pasqualini D. Root canal anatomy preser- facturing methods. J Endod. 2008;34:1003-5. vation of WaveOne reciprocating files with or without glide 23. Plotino G, Grande NM, Sorci E, Malagnino VA, Somma F. path. J Endod. 2012;38:101-4. A comparison of cyclic fatigue between used and new Mtwo 16. Fife D, Gambarini G, Britto Lr. Cyclic fatigue testing of Pro- Ni-Ti rotary instruments. Int Endod J. 2006;39:716-23. Taper NiTi rotary instruments after clinical use. Oral Surg Oral 24. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini i Med Oral Pathol Oral Radiol Endod. 2004;97:251-6. G. Measurement of the trajectory of different NiTi rotary in- al 17. Plotino G, Grande NM, Sorci E, Malagnino VA, Somma F. struments in an artificial canal specifically designed for cyclic Influence of a brushing working motion on the fatigue life of fatigue tests. Oral Surg Oral Med Oral Pathol Oral Radiol En- NiTi rotary instruments. Int Endod J. 2007;40:45-51. dod. 2009;108:e152-6. 18. Grande NM, Plotino G, Butti A, Messina F, Pameijer CH, Som- 25. Plotino G, Grande, NM, Mazza C, Petrovic R, Testarelli L, on ma F. Cross-sectional analysis of root canals prepared with Gambarini G. Influence of size and taper of artificial canals NiTi rotary instruments and stainless steel reciprocating files. on the trajectory of NiTi rotary instruments in cyclic fatigue Oral Surg Oral Med Oral Pathol Oral Radiol Endod. studies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103:120-6. 2010;97:e60-6. 19. Gambarini G, Tucci E, Bedini R, Pecci R, Galli M, Milana V, 26. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini G. zi De Luca M, Testarelli L. The effect of brushing motion on the Influence of the shape of artificial canals on the fatigue resis- cyclic fatigue of rotary nickel titanium instruments. Ann Istit tance of NiTi rotary instruments. Int Endod J. 2010;43:69-75. Sup San. 2010;46:400-4. 27. Plotino G, Costanzo A, Grande NM, Petrovic R, Testarelli L, na 20. Pedullà E, Plotino G, Grande NM, Scibilia M, Pappalardo A, Gambarini G. Experimental evaluation on the influence of au- Malagnino VA, Rapisarda E. Influence of rotational speed on toclave sterilization on the cyclic fatigue of new nickel-tita- the cyclic fatigue of Mtwo instruments. Int Endod J. 2013;Jul nium rotary instruments. J Endod. 2012;38:222-5. 23. doi: 10.1111/iej.12178. 28. Wycoff RC, Berzins DW. An in vitro comparison of torsion- 21. Al-Sudani D, Grande NM, Plotino G, Pompa G, Di Carlo S, al stress properties of three different rotary nickel-titanium Testarelli L, Gambarini G. Cyclic fatigue of nickel-titanium ro- files with a similar cross-sectional design. J Endod. 2012; er tary instruments in a double (S-shaped) simulated curvature. 38:1118-20. J Endod. 2012;38:987-9. 29. Shen Y, Cheung GS, Peng B, Haapasalo M. Defects in nick- 22. Gambarini G, Grande NM, Plotino G, Somma F, Garala M, el-titanium instruments after clinical use. Part 2: Fractographic De Luca M, Testarelli L. Fatigue resistance of engine-driven analysis of fractured surface in a cohort study. J Endod. rotary nickel-titanium instruments produced by new manu- t 2009;35:133-6. In ni io iz Ed IC C © Annali di Stomatologia 2015; VI (1): 6-9 9 

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Original article Identification of possible factors influencing temperatures elevation during implant site preparation with piezoelectric technique i al on Luca Lamazza, DMD, PhD1 piezoelectric implant site preparation. Irrigant Domenica Laurito, DDS1 temperature and clogging effect may also syner- Marco Lollobrigida, DDS1 gically contribute to the heat generation. Orlando Brugnoletti, MD, DDS1 Girolamo Garreffa, MP2 Key words: implant site preparation, piezo- zi Alberto De Biase, MD, DS1 surgery, heat. na 1 Oral and Maxillo-Facial Sciences Department, Introduction “Sapienza” University of Rome, Italy 2 Euro-Mediterranean Institute of Science and Tech- Overheating during implant site preparation has been nology (I.E.ME.S.T.), Palermo, Italy; Mediterranean recognized to be one of the main factors for early im- er Diagnostic (ME.DI.), Castellammare di Stabia, plant failure (1). Due to the low bone thermal conduc- Napoli, Italy tivity, heat generated by osteotomies is not effectively dissipated and tends to remain within the surrounding tissue increasing the possibility of thermal injury (2). Corresponding author: t Keeping in mind this unfavorable situation, several au- Alberto De Biase, MD, DS Oral and Maxillo-Facial Sciences Department, In thors stressed the need for “atraumatic” implant site preparations (3-5), taking into account both mechani- “Sapienza” University of Rome, Italy cal and thermal damage of bone. However, such an E-mail:alberto.debiase@uniroma1.it assertion has to deal with the real possibility to cut bone without causing any alteration that may compro- ni mise the healing process. The term “atraumatic”, in- Summary stead of an absence of trauma, should rather refer to a limited damage that reasonably will not impede a suc- io Background. Overheating during implant site cessful osseointegration. It is worthy to note, in fact, preparation negatively affects the osseointegra- that implant osseointegration is the overall result of a tion process as well the final outcome of implant bone healing process initiated by the surgical trauma. rehabilitations. Piezoelectric techniques seem to In this panorama, piezoelectric techniques have been iz provide to a gentle implant preparation although proposed as an alternative method for implant site few scientific reports have investigated the heat preparation. In 2000, Vercellotti (6) described piezoelec- generation and its underlying factors. tric technique as a novel device to perform osteotomies Ed Purpose. To investigate, through a proper metho- and osteoplasties in oral surgery. Two principal features dological approach, the main factors influencing characterize piezoelectric devices: micrometric cut and temperature rise during piezoelectric implant site selective cut with soft tissue preservation (7). Histologi- preparation. cal and biochemical studies reported promising results Materials and methods. Different piezoelectric about bone healing after piezoelectric bone surgery (8- tips (IM1s, IM2, P2-3, IM3, Mectron Medical Tech- 10) although the thermal effects are still considered a IC nology, Carasco, Italy) have been tested. The ex- critical aspect of the interaction between ultrasound de- perimental set-up consisted in a mechanical posi- vices and tissues (11, 12). tioning device equipped with a load cell and a flu- Heat is defined as a process in which energy flows oroptic thermometer. from hot to cold objects. Despite the simple definition, C Results. The first tip of the sequence (IM1s) gen- heat transfer is an extremely complex physical phe- erated the highest temperature increasing (ΔT). nomenon to analyze. A great deal of research has The diamond tips (IM1s and P2-3) determined been expended to measure heat production during higher ΔT values than the smooth tips (IM2 and bone cutting with drilling techniques (13). Several im- © IM3). Further tests with IM1s suggested that the portant issues arise when dealing with temperature temperature elevation during the first thirty sec- recording in bone tissue concerning the measuring onds may be predictive of the maximal tempera- device, the distance of the thermometer probe from ture as well as of the overall thermal impact. the heat source, the cooling system and the thermal Conclusions. Working load, working movements properties of bone (e.g. type and shape of bone sam- management and bone features resulted to be the ples, thermal conductivity and heat capacity). To main factors influencing temperature rise during overcome the limits related to the large number of Annali di Stomatologia 2014; V (4): 115-122 115  L. Lamazza et al. factors at stake, a proper methodological approach and dedicated technical environment is essential. In a previous report (14), an alternative method was proposed to record temperatures during implant site preparation with different drills in bovine bone. The i use of a fluoroptic thermometer revealed to be a reli- al able method for real-time data recording. Notwith- standing, concerns remained about the probe posi- tion reproducibility (measurement point) as well as on the working load applied by the operator’s hand. A dedicated mechanical device has been designed to obtain the reproducibility of the measurement point and to control the most important working parame- ters. The present study aims to identify main factors zi and phenomena that are or could be responsible for temperature elevation during implant site preparation with piezoelectric technique. na Materials and methods Figure 1. Micrometer-controlled tridimensional positioning device (MPD). er Bone samples The study specimens consisted of bovine bone ribs, The piezoelectric handpiece was secured to an angu- sectioned in blocks measured approximately 6x4x3 cm. lar transmission tool free to slide longitudinally. The t Bovine ribs represent a well established bone model for longitudinal movement was coupled with a rotational the ratio between cortical and cancellous bone and In the human mandible due to similarities in bone density, movement by moving a handle. This combined mo- tion was manually powered by an operator. thermal conductivity (2, 15-18). Density analysis A load cell equipped with a display showed in real demonstrated similar Hounsfield values between hu- time the applied load on bone in order to control and man cortical and cancellous bone and cortical and can- maintain it within pre-determined ranges. ni cellous bovine bone. Hounsfield units of cortical bone in an average human mandible have been observed to be 1400 to 1600 with a medullary of 400 to 600 Hounsfield Thermometer io units. The cortical bone in bovine ribs has been demon- strated to be 1400 Hounsfield units and the medullary The acquisition and recording of temperature data bone 470 Hounsfield units (19). According to Sedlin were performed by using an optic thermometry sys- and Hirsch guidelines (20), the bone samples were tem (Luxtron m 3300 Biomedical Lab Kit, Luxtron iz kept wet at all times, stored frozen in saline at -10°C, Corporation, Santa Clara, CA, United States) consist- and used within 3 to 4 weeks. ing of a principal unit and four non-metallic probes of 0.5 mm diameter. The instrument measures tempera- Ed tures in a range of 0 to +120° C with a response time Mechanical Positioning Device (MPD) of 0.25 sec using a patented fluoroptic technology based on a temperature sensitive phosphorescent MPD is a micrometer-controlled tridimensional posi- sensor located at the end of the optical fibers. Pulses tioning device (Fig. 1), originally designed to provide of light transmitted down the fiber optic probe cause a steady measurement point regardless of the bone the sensor excitation. The instrument detects and cal- IC sample shape and to reproduce handpiece move- culates the decay time of fluorescence after each ments similar to those in the clinical practice. pulse. The decaying light signal returns through the The device basically consists of three positioning fiber to the instrument where it is processed by con- stages incorporated into a highly rigid and crushproof verting the analogue signal into a digital value, which C structure. By the action of micrometer screws, it is pos- is then converted into a calibrated and corrected tem- sible to obtain three-dimensional movements of both perature. Data are then recorded and graphed using the study sample and the drill used to create the holes a dedicated software (TrueTemp, LumaSense Tech- for the thermometer sensors. The holes had a diameter nologies, Inc., Santa Clara, CA, United States). © of 0.6 mm and were drilled 2 mm down from the top of the sample to a depth of 2 mm. This ensured tempera- ture detection within the cortical layer. MPD provided a Tests description desired distance of (0.5±0.05) mm between the ther- mometer sensors and the tips; this distance was cali- Two different sets of tests have been performed in brated, for IM1s, on the tip surface at 9 mm in length the study. In the first set (40 osteotomies to a depth and on the tip maximum diameter for the other tips. of 9 mm) IM1s, IM2, P2-3, IM3 tips (Mectron Medical 116 Annali di Stomatologia 2014; V (4): 115-122  Identification of possible factors influencing temperatures elevation during implant site preparation with piezoelectric technique Technology, Carasco, Italy) were tested maintaining For each bone sample 3 osteotomies spaced 6 mm working loads in predetermined displayed ranges (50- were carried out. One thermometer probe was subse- 150 gr for IM1s and 200-500 gr for the other tips). quently moved in prepared holes corresponding to the IM1s and P2-3 are diamond coated tips with diameter osteotomies thus obtaining 3 separate measurements. of 2 mm and 2 to 3 mm respectively. IM2 and IM3 are The second set of data was collected with IM1s sole- i smooth shank tips with an end cut designed to en- ly. Differently from the first set, the experimental set- al large the initial osteotomy performed with IM1s. P2-3 up involved the use of 4 fibers in different measure- tip is dedicated to a coronal preparation after IM2 and ment points. A silicon heat compound sealing the before IM3. Differently from IM2, IM3 and P2-3, IM1s boundary of canal was used to isolate fiber sensors on is equipped with an external water cooling system. from cooling solution and outer environment. Three The piezoelectric unit (Piezosurgery, Mectron Medical measurement points were prepared with a 6 mm linear Technology, Carasco, Italy) was set in bone mode inter-distance. The fourth point was prepared down with special level power for IM1s and implant mode from the middle point to detect the bulk sample tem- for the other tips. A cooling saline solution at room perature then not directly related to the tip action. This zi temperature with a flow rate of 28 mL/min was used. set-up usefully provided different measurement condi- One operator manually managed the handpiece tions: 1) two adjunctive symmetric detections when movements. The osteotomies were obtained through drilling on the middle point and 2) two adjunctive asym- na an alternation of working cycles. Each cycle included metric detections when drilling on the left-most or right- one longitudinal action within a predetermined work- most point (Fig. 3). In the former, the further measure- ing load followed by a rotation action without load. ment points are both 6 mm from the main test point Working cycles were completed by the tip uplift phase whereas in the latter are at 6 and 12 mm, respectively. er interrupting any bone tip contact (Fig. 2). The drilling order was randomly followed. Figure 2. Drawing of the adopted working cycle with operative phases of action. t In ni io Figure 3. Methodological approach: symmetrical (down left) and asymmetrical (down right) condi- tions of temperature detection by random drilling iz of sites spaced 6 mm. Ed IC C © Annali di Stomatologia 2014; V (4): 115-122 117  L. Lamazza et al. All tests have been conducted at a room temperature within the cortical layer (22). However, different litera- (18-24° C). After a slide section of bone samples, radi- ture data have been reported on this issue (23-25). ographs were taken to check the distance for all tests. Stelzle et al. (26) observed a highest thermal impact in Further tests were also performed varying some condi- the cortical bone with both piezoelectric and rotating tions as described in the results and discussion section. techniques supporting the hypothesis that cortical i bone is more susceptible of temperature rise than can- al cellous bone. Analytical parameters In the first set of osteotomies the highest mean values for ΔTmax occurred with IM1s (Tab. 1). Mean tempera- on For the first set of data two parameters have been ture values detected for the diamond coated tips considered: (IM1s and P2-3) resulted higher than for the smooth - ΔTmax: temperature variation from the baseline to tips (IM2 and IM3). Nevertheless, the restricted cut- the maximum value; ting portions of IM2 and IM3 may also contribute to - ΔT30: temperature variation from the baseline to reduce contact surface and frictional heating. P2-3, zi the temperature value recorded at 30 seconds. despite the diamond coating, presents lower values For the second set of measurements, further parame- than IM1s. This can be ascribed to the shorter active ters were introduced and defined as following: portion of P2-3 (less contact surface) and to its pecu- na - ∑Nmax: sum of temperature values sampled each liar action consisting in a simple flaring of the os- second over the time period Δt, where Δt is the teotomy obtained with IM2. In addition, the lower time elapsed from the on-set to the maximum mean values of ΔT max of IM2, P2-3 and IM3 may recorded temperature value; arise from their internal irrigation system. er - ∑N max /Δt m : the value of the parameter defined These preliminary tests suggest IM1s to be the tip gen- above divided by Δtm; it represents the mean tem- erating the greater amount of heat. Differently from perature value on the time period Δtm; IM2, P2-3 and IM3, IM1s encounters compact bone - ∑N f : sum of temperature values sampled each without predrilling. Moreover, compared to the other second over the time period Δtf, where Δtf is the t tips, IM1s has an external irrigation. The external irri- time elapsed from the test on-set to the end; - ∑N f /Δt f : the value of the parameter defined as In gation plays an important role in the early working phases of IM1s, as indicated by the ΔT30 values (simi- above but divided by Δtf; it represents the mean lar to the tips with internal irrigation), but may result in- temperature value over the entire time period Δtf; adequate in the deepest portions of preparation, where - ∑N30: sum of temperature values sampled each the greater amount of heat is probably produced. A re- ni second over the first 30 seconds. duced irrigation efficiency could enhance the clogging All temperature measurements were reported on effect due to ineffective debris removal. A possible graphs with their time course values (1 second time compaction of a bone remains, determined by ultra- io scale); the average temperature of the 20 seconds sounds action, reduces cutting performance, inducing before the test onset was assumed as baseline value. the operator to increase the applied load. The result Each of the above parameters if appears with a dash will consist in an inevitable temperature rise. over the symbol represents an average value, for ex- While the first tests set aimed to detect the maximum iz ample ΔT max represents the average temperature temperatures, the second set, focusing on IM1s, was variation from the baseline to the maximum value. carried out to identify the main factors influencing temperature elevation. These measurements were Ed performed on two different bone samples (three for Results and discussions each one) as showed in Table 2. Differently from the preliminary tests, the overall du- The present research sought to identify the factors ration of the single trial was dilated of about 2-3 times that could be responsible of temperature rise during to obtain an apparent time resolution suitable to visu- the procedure of implant site preparation with piezo- alize the temperature line shapes related to the single IC electric technique. The MPD ensured a fixed distance working phases (Fig. 3). Regular working movements of (0.5 ± 0.05) mm between the detecting fiber and were also attempted. the tip surface (measurement point) regardless to the The simultaneous temperature measurements (time sample shape. The distance reproducibility of the courses) related to the four test points in one IM1s C measurement point was confirmed by radiographic in- spection. Furthermore, MPD was designed to provide Table 1. Mean temperature variations from the baseline to dynamically applied loads and handpiece movements the maximum value (ΔTmax) and from the baseline to the as in the clinical practice (longitudinal and rotational). temperature at 30 seconds (ΔT30) for each tip. © A fluoroptic thermometer was used to improve the ac- curacy of temperature measurements and to avoid ΔTmax ΔT30 those difficulties generally encountered using thermo- couples, e.g. the need for calibration and possible in- IM1s 19,13 7,71 trinsic measurement errors (21). IM2 7,45 5,57 P2-3 8,42 7,02 Expecting higher values than in cancellous bone, all IM3 8,22 7,15 temperatures measurements have been performed 118 Annali di Stomatologia 2014; V (4): 115-122  Identification of possible factors influencing temperatures elevation during implant site preparation with piezoelectric technique test is presented in Figure 4. A chevron-like pattern in site surgical preparation. A large number of scientific this test is clearly visible and seems to be strictly re- papers have been published on temperature rise with lated to the sequence of longitudinal-rotational ac- rotating technique. Speed, pressure, irrigation and tions and pauses. Differences in maximum tempera- bur shape have been identified as some of the most ture values and the time in which they occur increase important factors influencing temperatures rising (3). i with distance from the operating zone that behaves, The impact of pressure and irrigation has been also al for a given period, as a “heat source”. These findings investigated with respect to implant site preparation were almost constantly observed in all the tests. with piezoelectric instruments (26, 27). Some correlations (Fig. 5) between parameters can The main factors influencing temperatures should be on be noted. In particular, ΔT30 values seem to be corre- related to: 1) operating modalities; 2) bone sample lated with both ΔTmax (ρ=0,88) and ∑Nf/Δtf (ρ=0,92). features. This suggests that the temperature elevation in the first thirty seconds is somehow predictive of the maxi- mal temperature reached during the osteotomies as Operating modality zi well as of the overall thermal impact for each second. It is also reasonable that the adopted operating In relationship with operating modality, working load, modality may facilitate these correlations. irrigation and management of basic frame modules na Many factors can affect temperatures during implant for each cycle seem to play active role. Table 2. Parameters used for an objective discussion and identification of critical factors with IM1s. er ΔTmax ∑Nmax ∑Nmax / Δtm ∑Nf ∑Nf /Δtf ΔT30 ∑N30 (°C) (°C·s) (°C) (°C·s) (°C) (°C) (°C·s) Bone sample Test 1 14,26 859,52 6,87 1592,69 8,38 2,62 58,26 A Test 2 14,95 1095,76 t 6,33 1623,23 7,37 3,73 88,16 Test 3 16,52 1216,44 In 9,15 1697,84 9,81 4,23 86,13 Bone sample Test 4 20,19 1336,91 10,61 2323,97 11,43 5,59 105,46 B Test 5 31,81 1212,99 10,83 2698,31 14,2 6,43 107,96 Test 6 22,19 2001,37 13,17 2514,27 12,21 5,58 101,70 ni Figure 4. IM1s test with differences in tempera- ture values at different test points. The blue line io detect temperature variation in correspondence of site A; the red line is referred to the point B; cyan line to the point C and yellow line to the iz point O. Ed IC C Figure 5. Parameters correlations in the test re- sults reported in Table 2. © Annali di Stomatologia 2014; V (4): 115-122 119  L. Lamazza et al. Working load Management of basic frame modules The working load is related to the pressure applied Piezoelectric handpiece movements can largely af- by the operator’s hand. In the experimental condi- fect temperatures elevation although this particular tions the tip was perpendicular to the bone surface aspect is probably the less investigated in literature. i in order to avoid lateral forces allowing an accurate An adequate management of working cycles modules al measurement by the load cell, whereas in the clini- can interrupt the applied load, reduce the bone-tip cal context it is clearly difficult to guarantee this contact and facilitate the debris removal through the condition. irrigant solution minimizing the clogging effect. More- on It has been documented that higher working loads in- over, a well suited sequence of working cycles re- duce a higher temperature elevation (26, 28). The duces the contact time and allows the bone to cool working load can affect temperature elevation in dif- down (23). However, bone sample cortical thickness ferent ways such as increasing the efficiency of real couldn’t be discarded in heating analysis (as will be contact area and thermal coupling between tip and discussed later). The importance of the handpiece zi bone surface. Furthermore, a less controlled operat- movements is highlighted by tests with no working cy- ing mode (29, 30) could determine a variation of the cles simply contacting the tip to bone (Fig. 7). In optimal ultrasound operating frequency with a possi- these tests, a continuous fixed contact between the na ble thermal energy release in the body tip. Basing on tip and the bone surface was maintained applying two this hypothesis, the piezoelectric tip could become an different a constant load of 300 gr until a depth of 5 adjunctive source of heat. mm. The graph shows a sudden temperature rise, in relation to the applied pressure. These data confirm er the importance of the working cycle as well as the po- Irrigation tential detrimental effects on the healing process when not adopting it. The sudden temperature eleva- Although the irrigation was not a specific issue of this tion suggests that even brief hesitations in the clinical investigation, it was proven to play an important role t handpiece movements can cause a dramatic temper- in reducing temperatures (22, 27). In However, the irrigation efficacy in limiting tempera- ature rise in the bone tissue. It is very interesting to notice however, the high differences in temperature ture elevation is evident in tests with warmed bone values between the site operation test point and its samples (37° C) (Fig. 6). Differential values seem not nearest neighbor (about 60%) ascribed to the low to change significantly as well as the absolute value cortical bone specific heat (31). ni reached. This is related to the clear lowering of over- all baseline values during irrigation. In these tests red line is the nearest test point, blue and yellow refer to Bone sample features io the symmetrical test points. Interestingly, the outer- most test point (cyan) follows an almost-Newtonian Bone sample features should be considered as an cooling law and all test points shows an instanta- important factor of temperature rise during implant neous spatial thermal equilibrium of the sample in the site preparation. According to different studies, corti- iz left and right part of the graph. In these particular cal thickness can influence the thermal bone re- tests, performed with IM1s, the irrigant solution was sponse during drilling (31, 32). Observing the Table maintained at room temperature with a flow rate of 28 2, temperature parameters in the tests 1, 2 and 3 Ed mL/min. show globally lower average values of measurement Figure 6. Effect of cooling irrigation in a warmed bone sample. IC C © 120 Annali di Stomatologia 2014; V (4): 115-122  Identification of possible factors influencing temperatures elevation during implant site preparation with piezoelectric technique Figure 7. IM1s tests with no working cycle. High temperatures measured at a preparation deep of 5 mm. i al on zi na parameters compared to tests 4, 5 and 6. This ments associated with the temperature increase, fur- er seems to indicate that bone characteristics could not ther investigations must be performed on cortical be discarded in the heat production. Assuming that thickness, irrigant flow rate and temperature, and bone characteristics, cortical mineralization and blood flow effect. thickness, strongly affect heat production, higher av- erage values, already for ΔT30, should be expected, t in bone sample A, as occurred in our data. Further- more, a thicker cortical implies a wider contact tip In Acknowledgements surface, a longer contact time and an overall energy The Authors wish to acknowledge the help provided consumption. by Eng. M. Orazi for the project of the MPD; Dr. D. Di However, it is still an issue of debate whether higher Nezio for the graphic illustrations; Mr. A. Pecchia, Mr. ni temperatures arise in cortical rather than in cancel- A. Chirico, Eng. N. Cerisola and Dr. R. Bocchini for lous bone (24). The higher compactness of the corti- their technical support to the research. cal bone, requiring higher energies and more time for io preparation, was pointed out in explanation of differ- ent thermal alteration reported in cortical and cancel- References lous bone (26). Probably, different experimental con- ditions as well as the different thermal properties of iz 1. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological cortical and cancellous bone (33, 34) can explain the factors contributing to failures of osseointegrated oral implants. discordance of literature results. (II). Etiopathogenesis. Eur J Oral Sci. 1998;106:721-64. 2. Abouzgia MB, James DF. Temperature rise during drilling Ed through bone. Int J Oral Maxillofac Implants. 1997;12:342- Conclusions 53. 3. Eriksson AR, Albrektsson T. Temperature threshold levels for heat-induced bone tissue injury: a vital-microscopic study The present in vitro study has been conducted to in- in the rabbit. 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Int J confirmed the importance of the handpiece move- Periodontics Restorative Dent. 2000;20:358-65. 7. Vercellotti T. Technological characteristics and clinical in- © ments and the applied load to contain temperatures. dications of piezoelectric bone surgery. Minerva Stomatol. The indicated threshold level for thermal necrosis of 2004;53:207-14. 47° C for 1 minute has never been exceeded in the 8. Maurer P, Kriwalsky MS, Block Veras R, Vogel J, Syrowat- experimental conditions; however, it is to note that a ka F, Heiss C. Micromorphometrical analysis of conventional possible necrotic layer produced with the first tip will osteotomy techniques and ultrasonic osteotomy at the rab- be removed by the action of the following larger ones. bit skull. Clin Oral Implants Res. 2008;19:570-5. Despite the effort for considering all the possible ele- 9. Vercellotti T, Nevins ML, Kim DM, et al. Osseous response Annali di Stomatologia 2014; V (4): 115-122 121  L. Lamazza et al. following resective therapy with piezosurgery. Int J Peri- surgical inserts in vitro. Int J Oral Maxillofac Surg. 2012;41: odontics Restorative Dent. 2005;25:543-9. 1338-1343. 10. Preti G, Martinasso G, Peirone B, et al. Cytokines and growth 23. Wachter R, Stoll P. Increase of temperature during osteotomy: factors involved in the osseointegration of oral titanium im- in vitro and in vivo investigations. Intl J Oral Maxillofac Surg. plants positioned using piezoelectric bone surgery versus a 1991;20:245-9. i drill technique: a pilot study in minipigs. J Periodontol. 2007;78: 24. Rashad A, Kaiser A, Prochnow N, Schmitz I, Hoffmann E, al 716-22. Maurer P. Heat production during different ultrasonic and con- 11. O’Brien WD Jr. Ultrasound-biophysics mechanisms. Prog Bio- ventional osteotomy preparations for dental implants. Clin phys Mol Biol. 2007;93:212-55. Oral Implants Res. 2011;22:1361-5. 12. Humphrey VF. Ultrasound and matter-physical interac- 25. 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Original article Multitarget survey on the Finance Police personnel: assessment of the health condition i al on Giancarlo Barraco, MD, DDS1 work environment influence the quality of life. In the Stefano Pagano, DDS1 case of military health care, the specific military or- Grazia Lupoli, DDS1 ganization was useful to monitor the health condi- Alessandro Dolci, DDS2 tion of the population, maximizing the effectiveness Beniamino Colagrosso, MD3 of services, enhancing the information and carrying zi out prevention strategies and demand of care, which should be an example for the public health services. 1 Surgical and Biomedical Sciences Department, Uni- na versity of Perugia, Italy Key words: general health, prevention pro- 2 University of Tor Vergata, Rome, Italy gramme, life quality, questionnaire on health. 3 Operative Health Unit of the General Command of the Finance Police, Rome, Italy Introduction er Corresponding author: In the past 10-15 years Italy has changed from being Giancarlo Barraco, MD, DDS a nation with an entrepreneurial middle-class. The Surgical and Biomedical Sciences Department, Uni- t employee and working class has become economical- versity of Perugia, Italy Phone: +39 075 585 3516 In ly more stable and with a higher buying power. Upon this transformation the health condition of this social Fax: +39 075 585 5809 class could be defined as “tailor made” by describing E-mail: giancarlo.barraco@unipg.it its demand of health care (1-3). In this respect, to- gether with increased expectations of patients and life ni quality, it became a priority to prepare the social- Summary heath services to cope with new demands and differ- ent needs. The scientific literature and the epidemio- io Introduction. Over the past 10-15 years, Italy has logical analyses have shown that, on the whole, a undergone a social transformation, and the class middle-high socio-economic and cultural level, in as- of employees and workers has become more eco- sociation with an increase of high level specialized nomically stable with a higher buying power. performances, determines a better preservation of the iz Along with the increased expectations of patients health condition compared to subjects with low socio- on the quality of life, it has now become a priority economic and cultural level (2, 4, 5). to make health and social services ready to face This work, to be considered as preliminary, provides a Ed users bearing new requirements and different description of the health condition of a population sam- needs. ple yielding indications for planning the most appropri- Objectives. To provide a description of the state ate interventions in health promotion and prevention. of health of the operating personnel of the Fi- nance Police (Guardia di Finanza), including ele- ments for planning the most appropriate interven- Methods IC tions for health promotion and prevention. Methods. The study analyzed the health condition The General Command of The Finance Police, med- of a group of soldiers (178 subjects, divided into ical district service, and a team of the University of different age classes) by evaluating the effective- Perugia and the University of Tor Vergata, Rome, C ness of a training and information program and have carried out a project (2009-2012) to promote subsequently the level of benefit. health improvement of the operational personnel of Results. The study population showed a good the Finance Police through the adoption of social and state of health correlated to the quality of life. Al- health protocols and the prevention activity of educa- © though the population voluntarily submitted to tion and information by the health operators in charge health assessment, the rigour of the calls and of the control of the afore mentioned personnel. briefings carried out in the military health unit The subjects took part to the project on a voluntary and the attention of the group to follow instruc- base, filled an initial self-evaluation questionnaire of tions on prevention underlined a positive trend, their health status, and received information on epi- even in behaviours considered as health-risky. demiology and health hygiene concerning the opera- Conclusions. Socio-cultural components and the tional protocol of the study (6, 7). Annali di Stomatologia 2014; V (4): 123-127 123  G. Barraco et al. Thereafter, all the subjects underwent a medical visit compared to the national mean, underlining that the including anamnesis data with a digital record (record group showed a perception of excellent health condi- of the general health profile) that was integrated with tions, as it actually was (Fig. 1) (6, 7, 9). data coming from medical charts, radiodiagnostic Most subjects were admitted to hospital only once. analyses and analyses provided by the subjects Therefore, the analysed group would ensure a re- i themselves. markable working continuity as only 1/3 of the sub- al Following the analyses to provide and define a set of jects have been admitted to hospitals more than once indicators for the construction of the health profile of (Figs. 2, 3). From the available data (unfortunately the population to be examined, the subjects of the the results are not reliable) it was not possible to on study were reduced to 178 (eliminating those sub- identify whether the new admission to hospital was jects presenting gaps or incorrect data) (8, 9). due to the same pathology so to correlate it to a pos- This final sample underwent follow-up actions and the sible deficit of the health service of reference. final compilation of the self-evaluation questionnaire. Once the study sample was defined, the remaining zi Italian population was considered as control refer- ence (data obtained by ISTAT and epidemiological not in sources), assuming that the socio-economic condi- na good tions of the Italian citizens, and therefore the risk fac- health tors, were similar among them, but different from 1% those of the study sample (10, 11). good health good er health Results 99% not in good The comparison between the national data and those health of the study sample showed a remarkable divergence t for all the general health indicators. For example, the oncological assessments concern- In Figure 1. Perception of the health condition of the study ing the local plans of screening estimating the inci- population. dence and prevalence of oncological diseases strongly diverged from those of the analysed group. ni In fact, in the sampled population there was only one subject with oncological pathology (specifically, prostate cancer). DayH 32% io The 178 subjects had a biased gender distribution never with a female proportion of 6% and a male proportion admitted of 94%; the percent distribution in the work environ- 52% ment was considerably below the national mean iz (ranging between 10 and 16%). The lowest value standard recorded in the national data is the total absence of admission 16% women (as among ambassadors, the Court of Ac- Ed counts and the general power of attorney), while in the public administration as well as in the legal sys- Figure 2. Percent of subjects with standard admissions and tem the range lies between very low levels around day hospital. 7.4% and a value that is higher in politics (16%) and in between at University level. Within public health, among medical doctors of a complex structure the IC proportion of women is 10% (head physician women were 6.1% in 1993). multiple admission The study population was mature, with an average 32% age of 46 in men and 60 in women. C Although the population was homogeneous concern- single ing work and life environment, it was heterogeneous admission concerning geographic origin: 5% came from North- 68% ern Italy, 54% from Central Italy, 36% from Southern © Italy, and 5% from abroad. Sixty percent of women came from Central Italy and 40% from Southern Italy. Ninety nine percent of the subjects declared a good general health condition, and an accurate analysis of hospital admissions and therapies for ongoing Figure 3. Percent of single and multiple admissions to hos- pathologies actually highlighted a very low proportion pital. 124 Annali di Stomatologia 2014; V (4): 123-127  Finance Guard corps health survey The causes of admission to hospital were analysed according to the ICD9-CM. The most common causes of standard admission to 27% Dust hospital in men were represented by traumatic events (21%), for which the most frequent age classes in- i Drugs 9% volved were between 20 and 40, followed by dis- al eases of the digestive and respiratory trait for which Nickel and metal 5% the most frequent age classes were those between 50 and 60. Seasonal 59% on Day hospital admissions were instead referred to in- terventions of rhinoplasty followed by hernia and varicocele. For women the comparison with the Ital- Figure 5. Prevalence of allergic sensitizations. ian population showed the highest proportion of hos- pitalizations due to pathologies correlated to preg- zi nancy, parturition and postpartum, followed by dis- It must be pinpointed that initially the prevalence of eases of the urogenital and digestive system, while lung pathologies was attributed to pathologies linked for men the most common cause of admission to hos- to smoking habits, but indeed the prevalence high- na pital were cardiovascular diseases followed by dis- lights cases specifically correlated to allergic and al- eases of the digestive system. lergic-asthmatic pathologies, with subsequent BPCO We analysed the distribution of the pathologies. Since (bronco pneumonitis obstructive pathology). the prevalence of hospital admissions was due to trau- There were a proportion of subjects with dust allergy, er matic events, we assessed if there was a correlation which significantly diverged from the national base- with traumas associated to place and type of work. line. The analyses of the respiratory pathologies high- Most traumas were due to car and sport accidents, lighted that in the study population bronchial asthma the latter only involving men of young age classes constituted about one third of the pathologies, while (Fig. 4). It must be however noticed that a very low t dust allergies the remaining 2/3. number of work traumas occurred (two in total). In In relation to the aetiology of admissions for traumatic events the project of the present work had purpose- Discussion fully preventive aims including evaluation and identifi- cation of risky behaviours in order to reduce the so- The aim of this work was to analyse a population ni cial and health costs represented especially by the from the health point of view, evaluating its health numerous cases of day hospital. condition. An interesting result regards the prevalence of lung The goal was to adequately predispose interventions io diseases with asthmatic-allergic manifestations, es- of health education and prevention in an age class pecially those involving dust (Fig. 5), that diverged that could take advantage of such preventive pro- from the national mean and could be attributed to a grams, modifying where possible risky behaviours not ideal work environment, such as archives, dusty and lifestyles. iz environments, warehouses, unhealthy rooms with in- The adequate assistance within the military district adequate air turnover, represented by those places under investigation towards patients with respiratory where for work reasons (investigations, inspections) diseases, mediated by careful prevention and health Ed the personnel of the Finance Police must carry out and hygiene education has certainly determined the his duties; moreover, the increase with age of respi- natural course of diseases, showing that a good coor- ratory chronic pathologies is exponential, not linear, dination among general and specialized medicine al- and this strongly supports this hypothesis (12). lows improving the general profile of the patient and long-term prognosis. It is therefore evident that in the field of prevention it IC would be useful to monitor the work environments to n° of admissions for traumas/n° di admissions*100 reduce at most the possible presence of contami- nants with a particular attention to the reduction of risky behaviours and conditions. C However, owing to the nature of the respiratory 2% ligaments pathologies emerging from the results, among the ob- jectives at the health military level, it was started a programme of prevention and information with inter- 2% © fractures ventions aimed at contrasting the smoking habits as pathogen cofactor, also in relation to the fact that 23% of the subjects analysed were smokers (against 1% meniscus 22.7% in 2011 and 20.8% in 2012 at national level) (13-16). The number of smokers, showing a higher propor- Figure 4. Prevalence of traumatic events on lower limbs. tion than in the Italian population, is probably due to Annali di Stomatologia 2014; V (4): 123-127 125  G. Barraco et al. a work situation characterized by stress correlated Conclusion to the type of tasks, typically investigative and ac- counting, and to the often unhealthy environmental Selecting a homogeneous worker group has the ad- conditions during inquiries, and this could justify the vantage of examining a population with similar needs, contrast with the acquisitions emerging from the lit- common working habits and similar circadian rhythms. i erature. Indeed, as highlighted by research carried In spite of an heterogeneous geographic provenience, al out in Italy before 2003, the “employee” was the an homogeneous working life is commonly present high smoking category. Currently, the strict smoking (due o similar food and environmental habits). This ban in work environments has actively contrasted study aimed at analysing the health condition and al- on the working habit at workplaces with positive conse- lowed planning a standardization of the therapeutic pro- quences not only on the health and welfare of the cedures and prevention with a high cost-benefit ratio. workers, but also on the company budgets; howev- The improvement of the health condition is facilitated er, for an investigative company as the Finance Po- by: rigorous checks and respect of rules that have di- lice the actual work place is the place where the vio- zi minished risky behaviours; efficacy of the military lation with which the investigation is dealing, not the pyramidal structure with well defined roles, compe- office. tencies, organization, active presence at meetings, The other worrying result, strongly diverging from the na and distribution of informative materials; more effec- national mean and other administrative public envi- tive execution of therapeutic and preventive protocols ronments, is the number of gastric and duodenal with a consequent improvement of the assistance. pathologies that were crossed with more generic data The preliminary assessments already allowed modu- in order to verify the stress condition of the study lating the assistance response by orienting the activi- er population with evaluations on incorrect habits, ony- ties depending on the specific requests and the pre- cophagy, insomnia, anxiety, and other behaviours dictable needs of the workers. with an important mental load on the subjects. The continuous improvement of the quality of the For obvious reasons, we can’t conclude that the health assistance with technological instrumental in- causes originating the psychophysical discomfort un- t novations at the frontiers of medicine, the fund raising work conditions, since there could be environmental In derlined by the indicators should be attributed to the for the implementation of specialized units, the possi- bility to offer trained personnel and specific perfor- confounds and individual personality differences in mances with particular attention to the prevention and resistance. However, we believe that such prelimi- conformity to healthy lifestyles proved to be points of nary data deserve to be confirmed with a deeper in- ni excellence of the health service offered to the per- vestigation especially focussed on psychological and sonnel of the Finance Police. stress assessments. The recommendations of clinical behaviour constitut- The presence of chronic pathologies, constituting a ed a fundamental part in the project scheme together io major indicator to evaluate health condition in terms of worsening of life quality showed a lower frequency with the University team. The identification of “process of arthrosis-arthritis (the most common disorders in indicators” and “final result” provided an immediate advanced age) compared to the national mean but al- and evident validation; the individual performances of iz so of less common diseases with high impact such as the health district of the Finance Police in association diabetes and heart pathologies (4, 6, 7). In the evalu- with the activities of the university team, against the ations we inserted the currently present pathologies initial information recorded at time zero have shown a Ed and pharmacological therapies. We can conclude that validity of the informative activity of the members of only a minor proportion (10%) assumed drugs (anti- the project and was evident in the comparison be- hypertensive, antacid, intestinal antispasmodic, oral tween the self-evaluation forms. hypoglycemic, thyroid hormones, anxyolitic). The recommendations of medical preventive behav- In the study population 13% of the subjects reported iours and those more truly clinical have been checked migraine, differing from most epidemiological studies thanks to the epidemiological evaluations for compar- IC reporting proportions ranging from 18% in women ison with the control visits carried out with extreme ef- and 6% in men between age 25 and 55 and causing ficiency by the Head of the Health Service. work inability. It is therefore imperative an early and correct identifi- C cation of the affected subjects to guarantee an appro- References priate treatment. Education and updating of the per- sonnel of the health service in recognising and treat- 1. Materia E, Spadea T, Rossi L, et al. Diseguaglianze nel- ing on time the forms of migraine are some of the ob- l’assistenza sanitaria: ospedalizzazione e posizione socio- economica a Roma. Epidemiol Prev. 1999;23:197-201. © jectives of this prevention project. 2. Vineis P, Capri S. La salute non è una merce. Efficacia del- Considering the mature age of the study group, the la medicina e politiche sanitarie. Torino, Bollati Boringhieri. 1994. results of the present research show the efficacy of 3. Rapiti E, Perucci CA, Agabiti N, et al. Diseguaglianze so- the considerable health control, especially in terms of cioeconomiche nell’efficacia dei trattamenti sanitari. Tre e- prevention, obtained thanks to the calls, the periodic sempi nel Lazio. Epidemiol Prev. 1999;23:153-160. analyses, and the adoption of healthy behaviours in 4. Vannoni F, Burgio A, Quattrociocchi L, Costa G, Faggiano the lifestyle (17-19). F. Differenze sociali e indicatori di salute soggettiva, morbosità 126 Annali di Stomatologia 2014; V (4): 123-127  Finance Guard corps health survey cronica, disabilità e stili di vita nell’Indagine Istat sulla Salute 12. Scichilone N, Pedone C, Battaglia S, et al. Diagnosis and del 1994. Epidemiol Prev. 1999;23:215-229. management of asthma in the elderly. Eur J Intern Med. 5. Kunst E, Cavelaars AEJM, Groenhof F, et al. Socioeconomic 2014;25:336-342. inequalities in morbidity and mortality in Europe: a compar- 13. Mc Phillips JB, Eaton CB, Gans KM, et al. Dietary differences ative study. Rotterdam, Department of Public Health Eras- in smokers and non smokers from two south eastern New i mus University. 1996. England communities. J Am Diet Assoc 1994;94:287-292. al 6. Grant MD, Piotrowski ZH, Chappell R. Self-reported health 14. Morabia A, Wynder EL. Dietary abits of smokers, people who and survival in the longitudinal study of aging, 1984-86. J Clin never smoked and ex smokers. Am J Clin Nutr. 1990;59: Epidemiol. 1995;48:375-387. 11365-11425. 7. Hoyemans N, Feskens EJM, Kromhout D, Van Den Bos 15. Office on Smoking and Health: Smoking and Health: A Na- on GAM. Ageing and the relationship between functional sta- tional Status Report, Second Edition. A Report To Congress. tus and self-related health in elderly men. Soc Sci Med. available on line: http://profiles.nlm.nih.gov/ps/access/NNBB- 1997;45 (10):1527-1536. VP.pdf. (last access 23-06-2014). 8. Skov T, Deddens J, Petersen MR, Endhal L. Prevalence pro- 16. Townsend J. The burden of smoking. In Benzeval M, portion ratios: estimation and hypothesis testing. Int J Epi- Judge K, Whitehead M (eds). Tackling Inequalities in zi demmiol. 1998;27:91-95. Health. An agenda for action. London, King’s Fund Institute. 9. Stewart AL, Hays RD, Ware JE jr. The MOS short-form gen- 1995:82-94. eral health survey. Medical Care. 1988;26:724-731. 17. Whitehead M. Swimming Upstream: Trends and Prospects na 10. ISTAT: Direzione Centrale delle Statistiche su Popolazione in Education for health. Research Report n. 5. London, King’s e Territorio. Indagine Multiscopo sulle famiglie. Livello di pre- Fund Institute. 1989. cisione dei risultati. available on line: http://www.istat.it/it/files/ 18. WHO: Oral Health Country/Area Profile programme. disponi- 2014/06/met_-norme_06_31_il_sistema_di_indagini_mul- bile on line all’indirizzo: http://www.who.int/oral_health/data- tiscopo.pdf. (last access 23-06-2014). bases/malmo/en/. (last access 23-06-2014). 11. ISTAT: Codici dei Comuni, delle Province e delle Regioni. 19. WHO: Indagini sulla salute orale: metodi di base. Quarta edi- er disponibile on line all’indirizzo: http:// http://www.istat.it/it/archiv- zione-Traduzione Italiana Istituto di Scienze Biomediche San io/6789. (last access 23-06-2014). Paolo, Università degli Studi di Milano. 1997. t In ni io iz Ed IC C © Annali di Stomatologia 2014; V (4): 123-127 127 

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Original article Awareness of risks related to oral piercing in Italian piercers. Pilot study in Lazio Region i al on Iole Vozza, DDS, PhD level of awareness regarding the potential health Francesca Fusco, BSDH risks of oral piercing. Poor knowledge of anato- Ercole Bove, MD, DDS my and local and systemic risks and poor aware- Francesca Ripari, DDS ness of the importance of piercing maintenance Denise Corridore, DDS explanation. zi Livia Ottolenghi, DDS Key words: oral piercing, oral health, oral complica- tions. na Oral and Maxillo-facial Sciences Department, “Sapienza” University of Rome, Italy Introduction er Corresponding author: The practice of piercing has ancient origins. The main Iole Vozza DDS, PhD purpose was to distinguish the roles played by each Oral and Maxillo-facial Sciences Department member within the tribe, in order to regulate the rela- “Sapienza” University of Rome tionship between the various individuals daily and Via Caserta, 6 t during ceremonies (1). Over the past two decades 00161 Rome, Italy Phone: +390649976612 In body piercing exceed from the limits of the typically underground environment to become common prac- Fax: +390644230811 tice among youngsters and artists. Its recent spread E-mail:iole.vozza@uniroma1.it among young people rise the issue of potential health complications (2). The international guidelines pay at- ni tention especially on security measures and jewelry materials, but there are no directions on piercing in Summary terms of hygiene and maintenance (3), even though io in some country cardiopulmonary resuscitation, basic Objective. Specific regulations about education first aid and blood borne pathogens trainings from an and training for body piercing licensure courses agency-approved provider is required. have to be considered due to the great increase in Oral piercing can be applied in different anatomical iz oral piercing practices. The aim of the present areas: lips, tongue, cheeks, uvula, lingual and labial survey was to assess the local and systemic risk frenulum in decreasing percentage (4). awareness in the practice of oral piercing and Complications of oral piercings have been discussed Ed their prevention in a sample of Italian piercers. in literature and include local and general complica- Materials and methods. An anonymous 20-item tion, with potentially severe health consequences. questionnaire was administered to 30 body li- These include cross-infection (HIV, HCV, HAV, HBV censed piercers in a small town of central Italy. and HSV), bacterial and viral problems (endocarditis, Licenses certificates were issued by Lazio Region Focal Disease, Gingivitis, Lingual abscess), short and after the completion of an approved training pro- long-term local issues related to piercings (ageusia, IC gram for standard body piercing including 90 hypogeusia, gingival recession, diastema, chipping or hours of course and a final examination as pro- dental fracture and scialorrhea) and allergic reactions vided by regional law. The questionnaire sur- to the jewelry materials (2,5-8). veyed on oral cavity anatomy, local and systemic As trend of body piercing grow in popularity, under- C risks as result of oral piercing, piercing mainte- standing the procedures’risks as well as medical nance and need of a dental visit. and psychosocial implications of wearing piercing Results. Response rate was 66.6%. Only 20% of jewelry is important for health practitioners. It would respondents was aware about oral cavity anato- be advisable for sanitary authorities to establish reg- © my and none had knowledge about tongue and ulating legislation for body piercing license. Some gums anatomy. Only 10% enlightened the need of countries have already laid down different standards a dental visit and 30% was aware about piercing- and technical criteria, which in certain cases have related temporary paralysis. The piercing mainte- been appended to the legislation applied to hair- nance was habitually proposed only by 40% of dressers’ shops and beauty salons, as well as to se- respondents. curity measures applied in multiple fields to prevent Conclusion. The study participants showed a low the transmission of infectious diseases. However, in 128 Annali di Stomatologia 2014; V (4): 128-130  Awareness of risks related to oral piercing in Italian piercers. Pilot study in Lazio Region other cases, specific regulations have been consid- Results ered. European Standard UNI EN 18.10 on 10 th September 2002 focuses purely on sanitation stan- Twenty out of the 30 involved licensed piercers an- dards of sterilization and disinfection and on trade swered the survey, with a response rate of 66.6%. regulations. The results of this survey are summarized in Figures i In Italy, despite the strong expansion of the tattoo 1 and 2. al and piercing phenomenon, there is no methodical regulation of the matter. The only relevant national legislation dates back to 1998 and is represented by Anatomical knowledge on the “Guidelines issued by the Ministry of Health for the execution of tattoos and piercings in safety”. Only 4 out of 20 respondents (20%) showed aware- (Notes N. 2.8/156 of 5 February 1998 and n.2.8/633 ness of oral anatomy, while the remaining 16 de- of 16 July 1998). The objective of these guidelines is clared they had not discussed the issue during the to prevent improvised operators or malpractice (9). In training course. All the respondents (100%) were un- zi fact, although the tattoo and piercing are not medical aware of tongue and gums anatomy, the topic having practices, their execution is extremely delicate and not been addressed during the training course. requires appropriate safeguards in hygiene standards na (10). Requirements for licensees, education and training of piercers, number of hours to attend and Piercing-related risks, maintenance and dental visit topics to be discussed during the course, are taken by the Region of residence. This leads to a not uni- Only 6 out of 20 (30%) declared to habitually explain er form preparation of piercers/tattooists throughout the to their customer spiercing-related risks and mainte- country. In Lazio Region the training is based on 90 nance instructions. Methods of maintenance such as hours of course (Regional Law 4796/1998) while, for example, in Tuscan Region the hours to attend are 600 (Regional Law 28/2004). t The goal of this work is to assess the awareness of In risks in the practice of oral piercing and their preven- tion in a sample of Lazio Region-based piercers. ni Materials and methods In September 2013 an anonymous 20-item survey io was administered to 30 body piercers (both sexes, aged between 27 and 42 years old) living and working in the Province of Latina, Lazio Region. The question- naire collected data on oral cavity anatomy, local and iz systemic risks as result of oral piercing and piercing maintenance. All piercers were licensed by a certifi- cated Lazio Region training course, that includes the Ed Figure 1. Knowledge of anatomy, risks and maintenance of attendance of 90 hours and a final examination, as oral piercing among operators. provided by regional law. Each piercer answered the questions at his own office and the considered vari- ables were: - knowledge of the anatomy of oral cavity, tongue and gingivae; IC - knowledge of the methods of sterilization and blood-borne infections (HIV, HCV and HBV); - details on local piercing-related risks such as: ageusia, hypogeusia, endocarditis, allergic reac- C tions to the materials used, lingual abscesses, gum disease, gingival recession, tooth chipping or fracture, diastema and hypersalivation; - details on piercing maintenance through mouth- © washes rinses, antiseptic gels or creams, brush- ing of piercing bar and need of a dental visit. At the end of the survey we distributed to all partici- pants an explanatory brochure containing a brief de- scription of the potential complications, modes of piercing maintenance and the advice for a dental visit Figure 2. Knowledge of systemic risks related to piercing at least once after piercing. among operators. Annali di Stomatologia 2014; V (4): 128-130 129  I. Vozza et al. mouthwash rinses, antiseptic gels and creams and cessity that emerges from the results of the present piercing barbrushing, were explained by 8 out of 20 pilot survey is to operate in order to improve the operators (40%), whereas the remaining 12 habitually health-related contents of tattoo artists and piercers omitted this step (60%). course, and to increase information regarding these Dental visit was recommended by 2 respondents issues in schools among youngsters. Due to its po- i (10%) while the remaining 18 (90%) stated they had tential risks it is important for oral health care profes- al never thought about recommending a dental visit. sionals to become familiar with the characteristics of each type of piercing in order to act accordingly (14). How can users be aware of piercing-related health is- on Systemic and local risks related to piercing sues if the operators themselves are unaware? Fur- ther research in this area is necessary. The sustain- With regard to blood borne viral infection, knowledge ability of the collected data needs to be established in and understanding (11) was encouraging: the whole further studies with a greater samples. sample (100%) declared they had dealt extensively zi disinfection and sterilization methods and HIV cross- infections during the training course, 90% (18 out of References 20) reported to be aware of HCV infection risk and na 80% (16 out of 20) claimed to be aware of HAV and 1. Choe J, Almas K, Schoor R. Tongue piercing as risk factor HBV infection risk. to periodontal health. N Y State Dent J. 2005 Aug- Only 60% (12 out of 20) was aware about risks of en- Sep;71(5):40-3. docarditis. Only 6 operators were aware about risk of 2. Singh A, Tuli A. Oral piercings and their dental implications: a mini review. J Investig Clin Dent. 2012 May;3(2):95-7. er temporary paralysis (30%) and 8 operators (40%) 3. Randall JA, Sheffield D. Just a personal thing? A qualitative about permanent paralysis. account of health behaviours and values associated with body Only 6 out of 20 (30%) were aware about lingual ab- piercing. Perspect Public Health. 2013 Mar;133(2):110-5. scess risks, while only 2 of 20 (10%) reported knowl- 4. Hennequin-Hoenderdos NL, Slot DE, Van der Weijden GA. t edge on the risk of gingival infection and recession. Complications of oral and peri-oral piercings: a summary of All respondents (100%) showed awareness of the In risk of allergic reactions to the jewelry materials. case reports. Int J Dent Hyg. 2011 May;9(2):101-9. 5. Ziebolz D, Hornecker E, Mausberg RF. Microbiological find- About tooth chipping or fracture all respondents were ings at tongue piercing sites: implications to oral health. Int aware, while none of the respondents expressed J Dent Hyg. 2009 Nov;7(4):256-62. awareness about risk of diastema or hypersalivation. 6. Oberholzer TG, George R. Awareness of complications of ni oral piercing in a group of adolescents and young South African adults. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Dec;110(6):744-7. Discussion and Conclusion 7. Tabbaa S, Guigova I, Preston CB. Midline diastema caused io by tongue piercing. J Clin Orthod. 2010;44:426-8. Considering the continuous increase in the youth pop- 8. Plessas A, Pepelassi E. Dental and periodontal complica- ulation of piercings and tattoos, it is important that tions of lip and tongue piercing: prevalence and influencing awareness of health risks associated with this practice factors. Aust Dent J. 2012 Mar;57(1):71-8. iz is supported with adequate training and information to 9. Mansi A, Vonesch N, Tini MN, Di Mambro A, Cianotti R, Pal- all people involved (i.e. operators and users) (12). mi S, Spagnoli G.Semi-permanent make up and tattooing As mentioned above, the license training for profes- equipment: safety and health issues. Ig Sanita Pubbl. 2004 Ed sional piercers is different in each Italian Region and Nov-Dec;60(6):437-57. 10. Stein T, Jordan JD. Health considerations for oral piercing the content of the course is not always appropriate. In and the policies that influence them. Tex Dent J. 2012 this study emerges that not all the topics included in Jul;129(7):687-93. the training course program have been properly ad- 11. Ministry of Science, Technology and Innovation. A Frame- dressed, since the surveyed licensed piercers were al- work for Qualifications of the European Higher Education most completely unaware of oral anatomy. The pro- Area. Bologna Working Group on Qualifications Frameworks. IC vided hours of course (overall 90 hours including 2005;57-74. classroom teaching and practice) appear to be inade- 12. Palacios-Sánchez B, Cerero-Lapiedra R, Campo-Trapero J, quate to meet the expected professional requirements Esparza-Gómez G. Oral piercing: dental considerations and skills and knowledge. The piercers indeed resulted the legal situation in Spain. Int Dent J. 2007 Apr;57(2):60-4. C uninformed on issues that should be part of their pro- 13. Oberdorfer A, Wiggers JH, Bowman J, Burrows S, Cockburn J, Considine RJ. Monitoring and educational feedback to im- fessional background. The unawareness of operators prove the compliance of tattooists and body piercers with in- about the potential complications of piercing on health fection control standards: a randomized controlled trial. Am constitutes a further health risk factor for users. J Infect Control. 2004 May;32(3):147-54. © Piercers should therefore be appropriately trained in 14. Vieira EP, Ribeiro AL, Pinheiro Jde J, Alves S de M Jr. Oral order to be acquainted with the potential harm piercings: immediate and late complications. J Oral Maxillofac caused by their work mismanagement (13). The ne- Surg. 2011 Dec;69(12):3032-7. 130 Annali di Stomatologia 2014; V (4): 128-130 

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Original article Socio-demographic inequalities and teeth extraction in the last 12 months in Italy i al on Giuseppe La Torre, MD, MSC, DSC, MPH1 The prevalence of teeth extraction in the last 12 Umberto Romeo, MD, PHD2 months was 8.2%. Subjects who underwent teeth Gianluca Iarocci, MSC3 extraction in the last 12 months were prevalent fe- Orlando Brugnoletti, MD, DDS2 male (8.6%), smokers (10.4%), with a primary edu- Leda Semyonov, MD1 cation (9.2%), married (9.2%), in poor health con- zi Alexandros Galanakis, MD2 ditions (9.3%), age category of 55-64 years Ersilia Barbato, DDS, PHD2 (11.1%), from Northeast of Italy (8.5%), with scarce household income (8.4%). The multivariate na analysis confirmed most of the results of the uni- 1 Department of Public Health and Infectious Dis- variate analysis. eases, “Sapienza” University of Rome, Italy Conclusions. Inequalities in health among groups 2 Department of Oral and Maxillo-Facial Sciences, of various socioeconomic status constitute one er “Sapienza” University of Rome, Italy of the main challenges for public health; these in- 3 Istituto Superiore per la Protezione e la Ricerca Am- equalities might be reduced by improving educa- bientale (ISPRA), Rome, Italy tional opportunities, income distribution, health- related behaviour, or accessibility to health care. t Corresponding author: Leda Semyonov, MD In Key words: socio-demographic factors, inequali- ties, teeth extraction, health, Italy. Department of Public Health and Infectious Diseases “Sapienza” - University of Rome Piazzale Aldo Moro 5 Introduction ni 00185 Rome, Italy Phone: +390649694308 In recent years, much attention has been focused on Fax: +390649914562 oral health and teeth extraction worldwide (1). io E-mail: leda.semyonov@uniroma1.it In the past decades a limited number of epidemiologic investigations have been conducted to determine the reasons for the extraction of permanent teeth. In Italy Summary the progress of dental caries and their complications iz are the leading reason for extraction of permanent Aims. Teeth loss represents a major concern for teeth with an estimated overall prevalence accounting the global oral health status of a population. for 34.4% of the teeth lost, with periodontal problems Ed The aim of this study was to describe the preva- being the next most common reason. Moreover the lence of teeth extraction among the Italian adult mean number of extracted teeth increases with the population, analyzing the association between age (2). It is indubitable that teeth loss represent a teeth extraction in the last 12 months and socio- major concern for the global oral health status of a demographic characteristics. population. The need and efficacy for health policies Methods. This cross-sectional study is based on are verified through epidemiological studies (3, 4). IC the national survey ‘Health Conditions and So it is also for oral health policies. To achieve sus- Healthcare Services Use’, carried out by the Ital- tainable oral health improvements and reduce oral ian National Centre of Statistics (ISTAT) in 2005. health inequalities, both between and within coun- A univariate analysis was performed to investigate tries, reliable analyses on the population oral health C the association between the dependent and the in- status are required. dependent variables (teeth extraction Vs socio-de- Oral care in Italy is mostly provided by private practi- mographic characteristics). Multiple logistic re- tioners (90% of the care performances); public oral gression analysis was conducted to assess the in- care is mainly addressed to children and lower so- © fluence on the outcome (teeth extraction Yes/No). cioeconomic status population. Results. The present study highlights the relation- Specific programs are also active to prevent oral neo- ship between teeth extraction and socio-demo- plasm and to treat subjects with systemic pathologies graphic factors. Out of 128,040 individuals, the that involve the oral cavity. Risk groups and programs sampled population consisted of 124,677 sub- vary from region to region (5). jects, representing 56,400,323 individuals in the In Italy a great number of data for epidemiological Italian population. studies is available thanks to the periodic activity Annali di Stomatologia 2014; V (4): 131-135 131  G. La Torre et al. (every 10 years) of National Institute of Statistics (IS- Age groups were classified as follows: 15-24 years; TAT). Nevertheless, to date, no analysis of disparities 25-34 years; 35-44 years; 45-54 years; 55-64 years; in dental health and access to care in Italian popula- 65 years and older. tion has been published, even if scientific literature Educational level was described as follows: university reports some studies on oral health conditions for degree (reference group), upper secondary education, i smaller samples or specific age-groups (6-9). lower secondary education and primary education. al The aim of this study was to describe the prevalence Italian macro-regions of residence [north-west, north- of teeth extraction in a sample representative of the east, centre, south (reference group), isles] were in- Italian adult population, with particular reference to cluded because of the socio-economic differences on the association between this oral health indicator and existing between different regions (5). socio-demographic factors, such as gender, age, Concerning occupational status, the individuals were economical status. classified as employed, unemployed or in search of first occupation, housewives or students, other, fol- lowing the ISTAT classification. zi Materials and methods Marital status was categorized as married, single/se- parated/divorced (reference group), widow. Data source and study design Self assessed household income was classified as na good and no good, as well as the self-assessed This study is based on the national survey ‘Health health status (good and no good) (good as reference Conditions and Healthcare Services Use’, carried out group). by the Italian National Centre of Statistics (ISTAT) in er 2005 (10). The use of these data is justified, since this is the last available survey in Italy. A cross-sec- Statistical analyses tional study was performed according to the STOBE checklist (11) as the exposure status (socio-economic A univariate analysis was performed using the Chi- status, demographic characteristics, health status) t square test for qualitative variables, to investigate the and the outcome measure (teeth extraction) were measured simultaneously. In association between the dependent and the indepen- dent variables (teeth extraction Vs socio-demograph- For the ISTAT survey, a questionnaire was adminis- ic characteristics). To check the normality of the sam- tered every 3 months (March, June, September, De- ple, Kolmogorov-Smirnov goodness-of-fit test was cember 2005) in order to avoid the seasonal effects used; T-student test was used for normal distribu- ni as far as possible. The validity of the questionnaire is tions, otherwise Mann-Whitney test was applied. witnessed by several surveys on this issue, carried Multiple logistic regression analysis was conducted to out since the 1990’s. One-quarter of the sampled assess the influence on the outcome (teeth extraction io population was interviewed each trimester: 50,474 Yes/No). Only the covariates, including potentially families and 128,040 individuals, resident in 1465 confounders, which were p<0.25 at the univariate municipalities. analysis were selected. The goodness of fit of the re- A multi-stages municipalities families was chosen as gression model was assessed using the Hosmer and iz sample design and a stratification of municipalities Lemeshow test. was undertaken. For each municipality, a cluster The reference groups taken into account were: males sampling was conducted with the families of the clus- (gender); non-smokers (smoking habit); 15-24 years Ed ters; the minimum number of families for each munici- (age); university degree (educational level); resi- pality was 30. dence in Southern Italy (macro-region of residence); The sample population of this study was extracted unemployed (occupational status); single (marital sta- from the original ISTAT survey considering all individ- tus), no good health status (self-assessed health sta- uals aged 15 years and older. tus); and no good household income (self-assessed household income). IC Results are presented as odds ratios (OR) and 95% Measurement of dependent and independent vari- confidence intervals (95% CI). ables The level of statistical significance was set at P≤0.05. All statistical analyses were performed using Statisti- C Information regarding socio-demographic characteris- cal Package for the Social Sciences Version 19.0 tics were collected (as it is shown in Tab. 1). The pre- (SPSS Inc., Chicago, IL., USA). sent study analyzed the association between teeth extraction in the last 12 months (as the dependent Results © variable) and gender, smoking habit, age, educational level, Italian macro-region of residence, marital sta- tus, occupational status, self-assessed health status Out of 128,040 individuals, the sampled population and self-assessed household income (as the inde- consisted of 124,677 subjects, representing 56,400,323 pendent variables). individuals in the Italian population. Smoking habits were classified as smokers (refer- The prevalence of teeth extraction in the last 12 months ence group) and non smokers. was 8.2%. 132 Annali di Stomatologia 2014; V (4): 131-135  Inequalities and teeth extraction in Italy The univariate analysis (Tab. 1) revealed significant age category of 55–64 years appears to have twice differences. In this population, subjects who under- the risk (OR=2,05; 95% CI: 2,04 - 2,06). Concerning went teeth extraction in the last 12 months were marital status, married people shows the highest risk prevalent female (8.6%), smokers (10.4%), with a of teeth extraction (OR=1,23; 95% CI: 1,23 - 1,24). primary education (9.2%), married people (9.2%), in Furthermore, when analyzing smoking habits, i poor health conditions (9.3%). The age group with emerges that not smoking is a protective factor al the highest prevalence of teeth extraction was the (OR=0,68; 95% CI: 0,68 - 0,68), as well as not be un- age category of 55-64 years (11.1%) prevalently liv- employed (employed, housewife or student and other ing in Northeast of Italy (8.5%), with scarce house- working status conditions). on hold income (8.4%) and other working status condi- Finally, multivariate analysis, unlike the univariate tion (9.3%). one, also revealed that people who have no good Using multiple logistic regression model (Tab. 2), the household income is less prone to undergo a teeth relationship between the same socio-demographic extraction in the last 12 months (OR=0,99; 95% CI: variables and the outcome (teeth extraction) has 0,98 - 0,99). zi been examined. The multivariate analysis confirmed most of the results showed by the univariate analysis. Females (OR=1,20; 95% CI: 1,19 - 1,20), people with Discussion na a lower secondary education (OR=1,19; 95% CI: 1,19 - 1,20), living in Northern-east macro-region of Italy The present study highlights the relationship between and Isles (both OR=1,09; 95% CI: 1,08 - 1,09), in teeth extraction in the last 12 months related to socio- poor health conditions (OR=1,04; 95% CI: 1,03 - demographic factors in Italy, using a large database er 1,04) seem to have an increased risk of having a coming from the last available survey conducted at the teeth extraction in the last 12 months. In addition, the national level. Our aim was concerning the assessment Table 1. Univariate analysis. t In Teeth Extraction in the last 12 months No (%) Yes (%) Gender Male 92.2 7.8 Female 91.4 8.6 ni Smoking habit Smokers 89.6 10.4 Non smokers 92.4 7.6 Age 15-24 years 95.2 4.8 io 25-34 years 92.9 7.1 35-44 years 92.1 7.9 45-54 years 90.8 9.2 55-64 years 88.9 11.1 iz ≥ 65 years 89.0 11.0 Educational level University degree 92.8 7.2 Upper secondary education 92.5 7.5 Ed Lower secondary education 91.8 8.2 Primary education 90.8 9.2 Macroregion of residence North-west 91.7 8.3 North-east 91.5 8.5 Centre 91.6 8.4 South 92.4 7.6 IC Isles 91.7 8.3 Working status Employed 91.8 8.2 Unemployed 92.4 7.6 Housewife or student 92.5 7.5 C Other condition 90.7 9.3 Marital status Married 90.8 9.2 Single/Separated/Divorced 93.5 6.5 Widow 91.5 8.5 © Household income Good 91.9 8.1 No good 91.6 8.4 Health conditions Good 91.9 8.1 No good 90.7 9.3 Total 91.8 8.2 Annali di Stomatologia 2014; V (4): 131-135 133  G. La Torre et al. Table 2. Socio-demographic predictors of Teeth Extraction - Multiple logistic regression model. VARIABLES OR 95,0% C.I. Lower Upper Gender Male (reference) 1 i Female 1,20 1,19 1,20 al Smoking habit Smokers (reference) 1 Non smokers 0,68 0,68 0,68 on Age 15-24 years (reference) 1 25-34 years 1,33 1,32 1,33 35-44 years 1,38 1,37 1,38 45-54 years 1,61 1,60 1,62 55-64 years 2,05 2,04 2,06 zi ≥ 65 years 1,68 1,67 1,69 Educational level University degree (reference) 1 Upper secondary education 1,11 1,11 1,12 na Lower secondary education 1,19 1,19 1,20 Primary education 1,17 1,17 1,18 Macroregion of residence South (reference) 1 North-west 1,06 1,05 1,06 er North-east 1,09 1,08 1,09 Centre 1,07 1,07 1,08 Isles 1,09 1,08 1,09 Working status Unemployed (reference) 1 Employed t 0,93 0,93 0,93 In Housewife or student Other condition 0,81 0,92 0,81 0,91 0,82 0,92 Marital status Single (reference) 1 Married 1,23 1,23 1,24 Separated/divorced 1,12 1,11 1,12 ni Widow 1,04 1,03 1,04 Household income Good (reference) 1 No good 0,99 0,98 0,99 io Health conditions Good (reference) 1 No good 1,04 1,03 1,04 iz Constant = 0,048 of socioeconomic inequalities in oral health determined 64 and over 65. According to a review of 15 longitudi- Ed by gender, age, education, geographical region, self- nal studies from seven countries regarding tooth ex- assessed health status, and household incomes. tractions during varying observation periods (2-28 In the past decades it was generally accepted that, in years), the annual incidence of persons losing one or many industrialized countries, the sequelae of dental more teeth varied from 1 to 14% (13). Mean annual caries constituted the prime cause of tooth mortality prevalence in this study over a representative sample in younger adults, and that over the age of about 40 of an Italian population was 8.2%, which is in the IC years periodontal disease was the predominant range of tooth loss described in other studies in devel- cause of tooth loss (2). A great number of variables oped countries, even if it is higher than the incidence are associated with tooth loss, and there is no con- reported in a Norwegian population (6.5%), which is sensus whether dental-disease-related or socio-be- considered an even more developed country. C havioral factors are the most important risk factors As confirmed by the literature reviews, the mean (12). Studies using regression analyses to assess number of lost teeth increase with age, and many predictors have generally shown that oral disease-re- subjects aged 60 and over possibly need some kind lated factors were the most important, but demo- of prosthodontic treatment (12). © graphic, behavioral and attitudinal factors and educa- Several observations can be made when examining tion also made small contributions to variation in the results from the multiple logistic regression mod- tooth loss in some studies (12). el. An higher extraction risk for the unemployed sub- As demonstrated by other studies in other countries jects is observable, this result probably meaning that several years ago, tooth loss increases with the age this part of population has less access to conserva- (12), and so it can be noticed in this study, as inci- tive treatments if compared with other parts of the dence of tooth loss was higher in the people aged 55- population. 134 Annali di Stomatologia 2014; V (4): 131-135  Inequalities and teeth extraction in Italy One of the strong points of this study is the very large G, Leinsalu M, et al. European Union Working Group on So- population taken into account, that is representative cioeconomic Inequalities in Health. Socioeconomic in- of the whole Italian population. Thus the obtained re- equalities in health in 22 European countries. N Engl J Med. 2008;358(23):2468-81. sults can give a good picture of what oral health was 4. Dye BA, Thornton-Evans G. Trends in oral health by pover- in 2005, and this can be precious to understand if in i ty status as measured by Healthy People 2010 objectives. the next years, with a different socio-economical con- al Public Health Rep. 2010;125(6):817-30. ditions, the situation will change or not. 5. Available from: http://www.salute.gov.it/sorrisoSalute/pagi- When evaluating the results of this study, also the naInternaMenuSorrisoSalute.jsp?id=1484&menu=offerte modality of data acquisition must be noticed, as this [cited 2013 may 15] on is a self reported questionnaire. Generally other au- 6. Campus G, Solinas G, Cagetti MG, Senna A, Minelli L, Ma- thors have recognized little discrepancy between self jori S, et al. National Pathfinder survey of 12-year-old Chil- reported information about teeth loss and actual data, dren’s Oral Health in Italy. Caries Res. 2007;41(6):512-7. 7. Campus G, Cagetti MG, Senna A, Spano G, Benedicenti S, as happened in the Florida Dental Care Study, where Sacco G. Differences in oral health among Italian adolescents the incidence of tooth loss in a 24-month-period was zi related to the type of secondary school attended. Oral Health 23,8% when clinically recorded and 23% when self- Prev Dent. 2009;7(4):323-30. assessed (14). Other authors suggested that there 8. Pizzo G, Piscopo MR, Matranga D, Luparello M, Pizzo I, Giu- may be an overestimation of tooth loss in self report- na liana G. Prevalence and socio-behavioral determinants of den- ed data, when comparing results of a 12-month-peri- tal caries in Sicilian schoolchildren. Med Sci Monit. 2010; od study with those of a 2-week-period of the same 16(10):PH83-9. year, using clinical data (13). 9. Ferro R, Cecchin C, Besostri A, Olivieri A, Stellini E, Maz- zoleni S. Social differences in tooth decay occurrence in a A threat to the validity of self reported tooth loss in sample of children aged 3 to 5 in north-east Italy. Commu- er this study is recall bias because the population in- nity Dent Health. 2010;27(3):163-6. volved was asked about events in the last 12-months, 10. Italian National Centre of Statistics (ISTAT). Health condi- as proposed by other researchers working on similar tions and healthcare services use survey, 2005. Available studies (13). On the other hand, the development of a from: http://www.istat.it/dati/dataset/20080131_00 [cited longitudinal study on a large population, which would t 2013 may 15] give more accurate results, is difficult to carry out, In 11. STROBE Statement-checklist of items that should be included in reports of case-control studies. Version 4 as published in more time consuming and with high costs; further- more, longitudinal studies are subject of drop-outs Oct/Nov 2007. Available from: http://www.strobe-state- ment.org/index.php?id=available-checklists [cited 2013 may during the time of the study. 15] ni 12. Müller F, Naharro M, Carlsson GE. What are the prevalence and incidence of tooth loss in the adult and elderly popula- References tion in Europe? Clin Oral Implants Res. 2007;18 Suppl 3:2- 14. io 1. Nobile CG, Pavia M, Fortunato L, Angelillo IF. Prevalence 13. Haugejorden O, Klock KS, Trovik TA. Incidence and predictors and factors related to malocclusion and orthodontic treatment of self-reported tooth loss in a representative sample of Nor- need in children and adolescents in Italy. Eur J Public Health. wegian adults. Community Dent Oral Epidemiol. 2007;17(6):637-41. iz 2003;31(4):261-8. 2. Angelillo IF, Carmelo GA, Nobile CG, Pavia M. Survey of rea- 14. Gilbert GH, Miller MK, Duncan RP, Ringelberg ML, Dolan TA, sons for extraction of Permanent teeth in Italy. Community Foerster U. Tooth-specific and person-level predictors of 24- Dent Oral Epidemiol. 1996;24:336-40. month tooth loss among older adults. Community Dent Oral Ed 3. Mackenbach JP, Stirbu I, Roskam AJ, Schaap MM, Menvielle Epidemiol. 1999;27(5):372-85. IC C © Annali di Stomatologia 2014; V (4): 131-135 135 

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Original article Clinical evaluation with 18 months follow-up of new PTTM enhanced dental implants in maxillo-facial post-oncological patients i al on Piero Papi, DDS apical radiographs, 0.22±0.4 mm at 4 months, Sara Jamshir, DDS 0.3±0.46 mm at 6 months, 0.57±0.62 at 1 year and Edoardo Brauner, DDS, PhD 0.64±0.60 mm after 18 months. Stefano Di Carlo, MD, DDS Conclusions. The results of this study, even if Antonio Ceci, DDS limited by the number of implants placed indicate zi Luca Piccoli, DDS that PTTM dental implants have a clinical efficacy Giorgio Pompa, MD, DDS in prosthetic rehabilitation of post-oncological patients, due to trabecular structure of the porous na Ta metal that increases bone-implant connection Department of Oral and Maxillo-Facial Sciences, values. “Sapienza” University of Rome, Italy Key words: trabecular metal, PTTM dental im- er plants, oral cancer, prosthetic rehabilitation. Corresponding author: Piero Papi, DDS Department of Oral and Maxillo-Facial Sciences, Introduction “Sapienza” University of Rome, Italy t Via Campania, 6 00161, Rome, Italy In The treatment for patients with a malignant neoplasia of the oral cavity requires the cooperation of a team of Phone: +393934360087 different specialists that follow the patient through the E-mail: papi.piero@gmail.com phases of diagnosis, therapy and oral rehabilitation. Ablative surgery is followed by a reconstructive phase ni after which the patient may need to undergo radio- Summary therapy, a condition that may compromise the suc- cess of oral rehabilitation (1-3). io Aim. The aim of this study is to present 18 Radiotherapy side effects may include mucositis, xe- months follow-up results of porous tantalum tra- rostomia, damage of the salivary glands and osteora- becular metal-enhanced titanium dental implant dionecrosis, which could lead the surgeons to pro- (PTTM) in implant supported prosthesis in post- ceed to a partial jaw resection (4-6). Chemotherapy iz oncological patients. side effects are similar to those of radiotherapy and, Materials and methods. A total of 25 PTTM im- usually, is possible to perform dental surgery safely plants were placed in each jaw of 6 patients that before and after chemotherapy if the patient is not Ed met specific inclusion and exclusion criteria. Res- further compromised by also undergoing bisphospho- onance Frequency Analysis (RFA) was conducted nate drug therapy (7, 8). and Implant stability was recorded in ISQ values The options for a prosthetic rehabilitation are either (Osstell ISQ, Osstell AB, Goteborg, Sweden) at the tooth-supported prosthesis or implant-supported implant placement and after 2,4,6,12 and 18 overdenture (4, 5). However, deformation to the oral months of functional loading. structures, by surgical treatments, may prevent a IC Mean bone loss was also evaluated at the same proper osseointegration and result in failure and also interval of time on each periapical radiographs, conventional tissue-supported restorations may lead bone levels were calculated by measuring the dis- to soft tissue management problems (6, 9-13). tance from the implant shoulder to the first bone Over the years numerous implant surfaces and coat- C to implant contact. ings have been utilized to try to maximize on-growth Results. Cumulative implant survival rate is 100% potential and secondary stability, increasing bone to (n=25/25) to date and mean ISQ values recorded implant connection values (BIC). were: 72.14±5.61 (range= 50-81) at surgery, Improvement in surface roughness can be achieved by © 64.39±8.12 (range=44-74) after 2 months, 74.26±7.14 using Microtextured, Acid Etched, Sand Blasted/Acid (range=44-74) after 4 months, 76.84±7.65 (range=60- Etched, Phosphate Enriched, Hydoxyapatite (HA), Tita- 83) after 6 months, 78.13±4.14 (range=64-84) after nium Plasma Spray (TPS), or Nanotexturized implant 12 months and 80.22±6.23 (range=68-89) after 18 surfaces. months of functional loading. These surfaces promote the adherence of platelets Mean crestal marginal bone loss was 0.19±0.25 from the initial clot that releases platelet-derived mm after 2 months of functional loading on peri- growth factors (PDGFs), which are chemotactic and 136 Annali di Stomatologia 2014; V (4): 136-141  Clinical evaluation with 18 months follow-up of new PTTM enhanced dental implants in maxillo-facial post-oncological patients mitogenic for mesenchymal cells and osteoblast aminations were scheduled respectively 7,14 and 28 progenitor cells (14). days after surgery and then once a month (1/30 days) The current implant surface treatment seems to im- for the following 18 months. prove osteoblastic activities and reduces peri-implant The definitive restorations were made in a period be- bone loss, however 100% Bone to Implant Contact is tween 2 and 3 months post surgery. i not achievable because gaps and voids may occur Resonance Frequency Analysis (RFA) was conduct- al along the surface. ed and Implant stability was recorded in ISQ values A porous tantalum trabecular metal (PTTM), known (Osstell ISQ, Osstell AB, Goteborg, Sweden) at im- commercially as Trabecular Metal Material (Trabecu- plant placement and after 2,4,6,12 and 18 months of on lar Metal Technology, Zimmer Inc., Parsippany, NK, functional loading. USA), used since 1998 in orthopaedic reconstruc- Standardized (Rinn, Dentsply, York, PA, USA) peri- tions, has been adapted for dental implant use to apical radiographs were taken for each implant at achieve higher BIC values and bone ingrowth (15-18). placement and after 2, 4, 6, 12 and 18 months of The aim of this study is to evaluate the clinical efficacy functional loading. zi of porous tantalum trabecular metal-enhanced titani- Mean bone loss was also evaluated with the same time um dental implant (PTTM) in implant-supported pros- interval on each periapical radiograph, bone levels thesis in oral-maxillofacial post-oncological patients. were calculated by measuring the distance from the im- na plant shoulder to the first bone to implant contact. Materials and methods Results er This study was open to all patients that met specific in- clusion and exclusion criteria (Tab. 1) and that signed Cumulative implant survival rate is 100% (n=25/25) to informed consent, according to the World Medical As- date and all implants had at least 18 months of clini- sociation’s Declaration of Helsinki. cal follow-up after functional loading (Figs. 1, 2, 3). Six patients were enrolled in this study, 4 female t No serious complications or adverse reactions were (66,66%) and 2 male (33,34%) with a mean age of 55±25,45 years (age range 37-74), they were all post- In reported and all implants were stable and well os- seointegrated. oncologic patients treated for oral cancer (Tab. 2). Mean ISQ values recorded were: 72.14±5.61 at The inclusion criteria did not distinguish between pa- surgery, 64.39±8.12 after 2 months, 74.26±7.14 after tients receiving radiotherapy and non-irradiated pa- 4 months, 76.84±7.65 after 6 months, 78.13±4.14 af- ni tients, when radiotherapy was used it was included in ter 12 months and 80.22±6.23 after 18 months of the medical record. functional loading (Tab. 5). A total of 25 PTTM implants were placed in a period Mean crestal marginal bone loss was 0.19±0.25 mm io between June and July 2012. Each subject was treat- after 2 months of functional loading on periapical ra- ed with a number of implants based on their clinical diographs, 0.22±0.4 mm at 4 months, 0.3±0.46 at 6 need, bone quantity and quality (Tabs. 3, 4). months, 0.57±0.62 at 1 year and 0.64±0.60 after 18 For prophylaxis, one hour before surgery antibiotics months (Tab. 6). iz were given to the patients: 2 g of amoxicillin and clavulanic acid (Augmentin®, Roche S.p.A., Milan, Italy). Chlorhexidinedigluconate 0,12% mouth wash Discussion Ed (Dentosan® Collutorio Trattamento Mese, Recordati S.p.A., Milano, Italy) was prescribed every day for 7 ISQ results showed an optimal primary stability of the days after surgery. Patients were provided with writ- PTTM dental implants thanks to the trabecular structure ten instructions for oral hygiene and were recom- of the porous Ta metal, which is similar to cancellous mended to follow a soft diet for 4 to 5 days post bone. High initial ISQ results remained constant over surgery. Written consent for implant treatment was time, while lower initial ISQ values increased more IC signed by all patients prior to the study. Medical ex- once osseointegration was stabilized (Tab. 5). Measurements of the distance from the implant shoul- der to the first bone to implant contact on periapical Table 1. Patient inclusion criteria. radiographs demonstrated a minimal crestal bone loss C compared to the conventional titanium alloy dental im- Inclusion Male or female at least 18 years of age plants (Tab. 5). PTTM manufacturing process is ex- Benefit from the implant prosthesis tremely complex. It utilizes a chemical vapour deposi- Insertion torque >35 Ncm tion process (CVD), which deposits elemental tanta- Exclusion Subjects with bruxism or clenching © lum (Ta) onto a substrate and therefore creates a na- parafunctional habits notextured surface topography to build the Trabecular Mental disorders Metal Material. Uncontrolled systemic disease Ta is a transitional metal often extracted from the min- Untreated oral pathologies eral tantalite, its atomic number is 73, it’s highly bio- Pregnancy compatible and corrosion resistant (16). Ta is deposit- Use of Bisphosphonates ed onto a vitreous carbon skeleton to reproduce the Annali di Stomatologia 2014; V (4): 136-141 137  P. Papi et al. Table 2. Patient medical history. Patient Diagnosis Treatment Implant placement Prosthetic Rehabilitation D.S. Squamous cell Anterolateral thigh flap Six months later two Six months later Woman carcinoma of the right submerged PTTM-dental provisional acrylic resin i 52 year old edge of the tongue implants (4.1 x 10 mm) fixed partial denture with al in the right inferior canine a distal cantilever for and premolar locations second premolar occlusion. After one on month temporization, a definitive ceramometal restoration L.T. Unicystic ameloblastoma Radical resection of the Six months later two Five months later zi Woman of the right mandibular right posterior mandible submerged PTTM-dental provisional fixed partial 37 year old quadrant and simultaneous implants (4.1 x 10 mm, denture, definitive reconstruction with iliac 4.1 x 11.5 mm) in the ceramometal restoration crest flap right posterior mandible one month later na A.L. Left floor-of-mouth Partial mandibulectomy One year after radiotherapy, Six months later Woman cancer (FOM) from the lower left second seven submerged PTTM- definitive, screw-retained 74 year old premolar to the lower right dental implants in the prosthesis lateral incisor mandible (2 each 4.1 x er END levels I-IV 10 mm, 2 each 4.1 x 11.5, Simultaneous anterolateral two 4.7 x 11.5 mm and one thigh free flap 4.1 x 13 mm) Radiotherapy T.G. Right FOM cancer Segmental t One year after radiotherapy, Tissue-supported Man In mandibulectomy in the four PTTM- dental implants overdenture retained by 56 year old right posterior mandible were placed (2 each 4.1 x ball abutments after 6 Simultaneous pectoralis 10 mm and 2 each 4.7 x months from implant major flap 11.5 mm) placement Radiotherapy ni P.D. Osteosarcoma of the Partial maxillectomy Seven months later six Five months later fixed Man jaw located in the Simultaneous fibula free submerged PTTM- dental implant-supported 45 year old anterior region of flap reconstruction implants (3 each 4.1 x prosthesis io the maxilla 10 mm, 2 each 4.1 x 11.5 mm, 1 each 4.7 x 11.5 mm) iz C.E. Multicystic Maxillectomy performed Six months later four Six months later a Woman ameloblastoma of the from the right canine to PTTM- dental implants bar-retained overdenture 56 year old upper jaw the second left molar (2 each 4.1 x 10 mm, Ed Simultaneous fibula free 2 each 4.1 x 11.5 mm, flap reconstruction 4.7 x 11.5 mm) Table 3. Trabecular metal dental implants inserted. Table 4. Treatment sites. Lenghts (mm) Diameters (mm) ø Maxillary locations Lateral Incisor 1 IC 4,1 mm 4,7 mm Implants Canine 1 First premolar 1 10 mm 12 0 12 Second premolar 1 11,5 mm 5 6 12 First molar 6 13 mm 1 0 1 C Second molar 4 Mandibular locations Lateral Incisor 1 trabecular bone structure and its properties. Prof. Canine 5 Branemark was the first to use Ta in the implantology First premolar 1 © field however due to its production costs and difficulty Second premolar 2 of extraction it was quickly abandoned. First molar 1 Trabecular Metal material is a porous biomaterial with Second molar 1 up to 80% interconnected porosity. It has an open- cell three-dimensional dodecahedrical shape, that re- of 440 μm to allow vascularized bone ingrowth, which sembles trabecular bone and its 12 interconnecting requires a minimum size of 300 μm (19). hexagonal pores. These pores have an average size PTTM enhanced titanium dental implants (Trabecular 138 Annali di Stomatologia 2014; V (4): 136-141  Clinical evaluation with 18 months follow-up of new PTTM enhanced dental implants in maxillo-facial post-oncological patients i al on zi na Figure 1. Trabecular metal dental implant. Figure 2. Trabecular metal dental implants placements. er Table 5. Resonance frequency Analysis (RFA). t Interval ISQ Values Range In Surgery 72.14±5.61 50-81 2 Months 64.39±8.12 44-74 4 Months 74.26±7.14 52-80 6 Months 76.84±7.65 60-83 1 Year 78.13±4.14 64-84 ni 18 Months 80.22±6.23 68-89 Figure 3. Post-surgical orthopantomography. io Table 6. Crestal bone loss (mm). iz Interval Measurement Location Mean Bone level (mm) Range Surgery Mesial 0.5±0.48 0.07-1.8 Distal 0.62±0.70 0.03-2.3 Ed Average 0.56±0.48 0.03-2.3 2 Months Bone loss Mesial 0.21±0.46 -0.65-1.1 Bone loss Distal 0.18±0.23 -0.48-0.94 Bone loss Average 0.19±0.25 -0.48-1.1 4 Months Bone loss Mesial 0.24±0.48 -0.9-1.4 Bone loss Distal 0.20±0.22 -0.8-1.5 IC Bone loss Average 0.22±0.4 -0.8-1.5 6 Months Bone loss Mesial 0.28±0.49 -1.06-1.2 Bone loss Distal 0.33±0.48 -0.8-0.96 Bone loss Average 0.3±0.46 -0.8-1.2 C 1 Year Bone loss Mesial 0.55±0.71 -0.78-2.09 Bone loss Distal 0.59±0.53 -0.41-1.89 Bone loss Average 0.57±0.62 -0.78-2.09 © 18 Months Bone loss Mesial 0.62±0.73 -0.84-2.20 Bone loss Distal 0.66±0.52 -0.70-1.99 Bone loss Average 0.64±0.60 -0.70-2.20 Metal Dental Implant, Zimmer Dental Inc., Carlsbad, nium multi threaded self-tapping endosseous dental CA, USA) were introduced in 2012. They are com- implant (Tapered Screw-Vent Implant, Zimmer Dental posed of a PTTM material midsection added to a tita- Inc., Carlsbad, CA, USA). These dental implants con- Annali di Stomatologia 2014; V (4): 136-141 139  P. Papi et al. sist of a titanium cervical and internal core section pos of 2 cases followed for 8 years. Rev Somatol Chir Max- covered by a trabecular metal shell and joined by a Ti illofac. 1999;(5-6):231-234. apical section. The tapered titanium alloy (Ti-6Al-4V 11. Goiato MC, Ribeiro AB, Dreifus Marinho ML. Surgical and prosthetic rehabilitation of patients with hemimandibular de- grade 5) used in the cervical and apical sections pro- fect. J Craniofac Surg. 2009 Nov;20(6):2163-7. Review. vides the strength of traditional dental implants, while i 12. Hotz G. Reconstruction of mandibular discontinuity defect titanium alloy and PTTM components are produced al with delayed nonvascularized free iliac crest bone graft and separately and laser welded. endosseous implants: a clinical report. Prosthett. 1996;76:350- This structure allows to achieve Osseoincorporation, a 355. combination of osseointegration and bone in growth in- 13. Kovacs AF. Influence of the prosthetic restoration modality on to the porous structure as demonstrated by in vivo (20- on bone loss around dental implants placed in vascularised 22) and in vitro (23) studies and by histologic testing in iliac bone grafts for mandibular reconstruction. Otolaryngol transcortical canine (24, 25) and human (26) models. Head Neck Surg. 2000;123(5):598-602. With respect to the conventional titanium alloy implants 14. Pompa G, Bignozzi I, Cristalli MP, Quaranta A, Di Carlo S. Bisphosphonates and Osteonecrosis of the jaw: the oral sur- (27-31), the Secondary Stability is increased in PTTM zi geon’s perspective. European Journal of Inflammation. dental implants, which leads to achieve better results 2012;10(1):11-23. in critical situations such as maxillofacial trauma, cleft 15. Pompa V, Brauner E, Bresadola L, Di Carlo S, Valentini V, and lip palate (32, 33) and post-oncologic patients. na Pompa G. Treatment of facial vascular malformations with This study represents the first clinical trial of PTTM embolization and surgical resection. Eur Rev Med Pharmaco dental implants in post-oncological patients and our Sci. 2012 Mar;16(3):407-13. preliminary results indicate that PTTM dental implants 16. Miyazaki T, Kim HM, Kokubo T, Ohtsuki C, Kato H, Naka- could have a clinical efficacy in prosthetic rehabilita- mura T. Mechanism of bonelike apatite formation on bioac- er tion of these patients. tive tantalum metal in a simulated body fluid. Biomaterials. 2002;23:827-832. 17. Bobyn JD, Poggie RA, Krygier JJ, et al. Clinical validation of a structural porous tantalum biomaterial for adult reconstruction. References J Bone Joint Surg Am. 2004;86-A (Suppl 2):123-129. t 18. Cohen R. A porous tantalum trabecular metal: basic science. 1. Chan MF, Hayter JP, Cawood JI, Howell RA. Oral rehabil- itation with implant-retained prostheses following ablative In Am J Orthop. 2002;31:216-217. 19. Hacking SA, Bobyn JD, Toh K, Tanzer M, Krygier JJ. Fibrous surgery and reconstruction with free flaps. Int J Oral Max- tissue ingrowth and attachment to porous tantalum. J Bio- illofacial Implants. 1997;12:820-827. med Mater Res. 2000;52:631-638. 2. Chang YM, Santamaria E, Wei FC, Chen HC, Chan CP, Shen 20. Harrison AK, Gioe TJ, Simonelli C, Tatman PJ, Schoeller MC. ni YF, Hou SP. Primary insertion of osseointegrated dental im- Do porous tantalum implants help preserve bone? Evalua- plants into fibula osteoseptocutaneous free flap for mandible tion of tibial bone density surrounding tantalum tibial implants reconstruction. Plast Reconstr Surg. 1998;102:680-687. in TKA. Clin Orthop Relat Res. 2010; 468:2739-2745. 3. Chiapasco M, Lang NL, Karring T, LindheJ. Quintessence 21. Karageorgiou V, Kaplan D. Porosity of 3D Biomaterial Scaf- io Books. Berlin: 1999. Implants for patients with maxillofacial folds and Osteogenesis. Biomaterials. 2005; 26(27):5474-91. defect and following irradiation: Proceedings III European 22. Bencharit S, Byrd WC, Altarawneh S, et al. Development and Workshop on Periodontology. pp. 557-607. applications of porous tantalum trabecular metal-enhanced iz 4. Brauner E , Valentini V, Jamshir S, Battisti A, Guarino G, Cas- titanium dental implants. Clin Implant Dent Relat Res. soni A, Gaimari G, Fadda MT, Di Carlo S, Pompa G. Two 2013. DOI: 10.1111/CID.12059 clinical cases of prosthetical rehabilitation after a tumor of 23. Schelee M, Van der Schoor P, Wen HB, et al. European Mul- the upper maxilla. Eur Rev Med Pharmacol Sci. 2012;Vol. ticenter studies of a porous tantalum-titanium implant: one Ed 16 - N. 13:1882-1890. year interim results. Presented at the 28th Annual Meeting 5. Brauner E, Valentini V, Guarino G, Cassoni A, Jamshir S, of the Academy of Osteointegration. 2013, Tampa, Florida. Minasi R, Fadda MT, Pagnoni M, Pompa G. Osteora- 24. Schlee M, Van der Schoor P, Van der Schoor ARM. Imme- dionecrosis of a mandible: A case report of implant-supported diate loading of Trabecular Metal-enhanced titanium dental rehabilitation. European Journal of Inflammation. 2013;Vol- implants: interim results from an international proof-of-prin- ume 11, Issue 2:565-571. ciple study. Clin Implant Dent Relat Res. 2013. 6. Chiapasco M, Abati S, Ramundo G, Rossi A, Romeo E, Vo- IC 25. Collins M, Bassett J, Wen HB, Gervais C, Lomicka M, Pa- gel G. Behavior of implants in bone grafts or free flaps af- panicolaou S. Zimmer® Trabecular Metal™ Dental Implant ter tumor resection. Clin Oral Impl Res. 2000;11:66-75. Research: A Brief Overview. Zimmer Clinical Paper. 2012; 7. Periodontal considerations in the management of the can- V no 9. cer patients. Committee on research, science and therapy 26. Kim DG, Huja SS, Ching Tee B, et al. Evaluation of Trabecular C of the American Academy of Periodontology. J Periodontol. Metal dental implants in a canine model. Presented at the 1997;68:791-801. 19th Annual Scientific Meeting of the European Association 8. Chaveli López B, Gavaldá Esteve C, Sarrión Pérez MG. Den- for Osseointegration, Glasgow, Scotland, UK. 2010. tal treatment considerations in the chemotherapy patient. J 27. Kim DG, Huja SS, Ching Tee B, et al. Bone ingrowth and ini- Clin Exp Dent. 2011;3:e31-e42. tial stability of titanium and porous tantalum dental implants: © 9. Garrett N, Roumanas ED, Blackwell KE, Freymiller E, Abe- a pilot canine study. Implant Dent. 2013. mayor E, Wong WK, Gerratt B, Berke G, Beumer J 3rd, Ka- 28. Clemente de Arriba C, Bradbury K, Alobera Gracia MA, del pur KK. Efficacy of conventional and implant-supported Canto M, Wen H, Carlsbad CA. Osseoincorporation of Porous mandibular resection prostheses: study overview and treat- Tantalum Cylinders in Human Subjects: Interim Results. Pre- ment outcomes. J Prosthet Dent. 2006 Jul;96(1):13-24. sented at the 28th Annual Meeting of the Academy of Os- 10. Goga D, et al. Microvascular mandibular reconstruction and teointegration. 2013, Tampa, Florida. implantology. A Study of the stability of long term results, apro- 29. Battula S, Papanicolaou S, Lee J, Wen H, Carlsbad CA. Eval- 140 Annali di Stomatologia 2014; V (4): 136-141  Clinical evaluation with 18 months follow-up of new PTTM enhanced dental implants in maxillo-facial post-oncological patients uation of Trabecular Metal Material Dental Implant Assem- Evaluation of a Trabecular Metal dental implant design for bly in a Canine Periimplantitis Model. Presented at the 28th primary stability. Structural integrity and abrasion. Present- Annual Meeting of the Academy of Osteointegration. 2013, ed at the 27th Annual Meeting of the Academy of Osteoin- Tampa, Florida. tegration. 2012, Phoenix, Arizona. 30. Battula S, Papanicolaou S, Lomicka M, Wen HB, Carlsbad 32. Scopelliti D, Fatone FM, Cipriani O, Papi P. Simultaneous i CA. Mechanical and interfacial strenght evaluations of a tra- options for cleft secondary deforities. Ann Maxillofac Surg. al becular metal dental implant assembly. Presented at the 27th 2013 Jul;3(2):173-7. Annual Meeting of the Academy of Osteointegration. 2012. 33. Scopelliti D, Cipriani O, Fatone FM, Papi P, Amodeo G. Cleft Phoenix, Arizona. palate in Williams syndrome: a case report. Ann Maxillofac 31. Battula S, Papanicolaou S, Wen HB, Collins M, Carlsbad CA. Surg. 2013 Jan;3(1):84-6. on zi na t er In ni io iz Ed IC C © Annali di Stomatologia 2014; V (4): 136-141 141 

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Case report Safe approach in “All-on-four” technique: a case report i al on Marouene Ben Hadj Hassine, DDS1 authors state that the long-term performance of short Paolo Bucci, MD, DDS2 implants is less understood, especially in the posteri- Roberta Gasparro, DDS, PhD2 or maxilla with lower bone density (6). Vertical aug- Alessandro Espedito Di Lauro, DDS2 mentation procedures increase patient morbidity and Gilberto Sammartino, MD, DDS the outcome is less predictable, mainly in the posteri- zi or mandible. Cantilever prostheses might incur higher rates of prosthetic complications such as abutment 1 Department of Oral Medicine and Oral Surgery, Uni- loosening, denture fracture and implant failure. na versity of Dental Medicine, Monastir, Tunisia Due to the less predictable long-term prognosis asso- 2 University of Naples Federico II, Italy ciated with the above mentioned procedures, the “All- on-Four” technique was proposed for the rehabilita- tion in edentulous jaws. The“All-on-Four” concept is er Corresponding author: based on the placement off our implants (two axial Gilberto Sammartino, MD, DDS and two tilted implants) in the anterior part of fully Federico II University edentulous jaws to support a provisional, fixed, and Via Pausini, 5 immediately loaded full-arch prosthesis. 80131 Napoli, Italy t Combining tilted and straight implants for supporting E-mail: gilberto.sammartino@unima.it In fixed prostheses can be considered a viable treat- ment modality (7) resulting in a more simple and less time consuming procedure, in significantly less mor- Summary bidity, in decreased financial costs and a more com- fortable postsurgical period for the patients (8). ni The “All-on-Four” concept is based on the place- ment of four implants in the anterior part of fully edentulous jaws to support a provisional, fixed, Case presentation io and immediately loaded full-arch prosthesis. Combining tilted and straight implants for sup- A 58-year-old man, edentulous for a long period of porting fixed prostheses can be considered a vi- time due to periodontal disease, was referred to the able treatment modality resulting in a more sim- Department of Oral Surgery-University of Naples iz ple and less time consuming procedure, in signifi- Federico II, Italy, requiring a fixed prosthetic rehabili- cantly less morbidity, in decreased financial costs tation in the lower jaw. His past medical history was and a more comfortable postsurgical period for uneventful (Fig. 1). Ed the patients. The authors present a case report The panoramic radiograph revealed an advanced with mandibular atrophy and left mental foramina alveolar bone resorption, particularly in the mandible on the top of the residual crest. (Fig. 2). The Ct scan confirmed the mandibular atro- phy and showed the left mental foramina on the top Key words: edentulous jaw, dental implants, im- of the residual crest (Fig. 3). plant placement. The “All-on-Four” technique was scheduled to reha- IC bilitate the lower jaw. Under local anesthesia, a full thickness crestal inci- Introduction sion was performed from the right first molar region to the left first premolar one. A midline releasing incision C Current standards in implant dentistry are intended to was carried out to facilitate flap reflection and to iden- provide prosthetic restorations with the finest esthetic tify the left mental nerve emergence (Fig. 4). The 2 and functional outcomes. Several parameters have been mm osteotomy was made in the midline position and suggested to achieve gold standard results: adequate the guide was placed (Fig. 5). The vertical lines on © bone height, width and sagittal projection, adequate soft the guide were used as a reference to prepare the tissue quantity and quality, preservation of buccal sulcus implant sites in the correct position, with an angula- and adequate papillae and gingival contour (1) . tion which should not exceed 45°. All sites were pre- Solutions to inadequate ridge height include the use pared using the manufacturer’s guidelines (Tekka In- of short implants (2) , vertical ridge augmentation pro- kone®), under copious sterile saline irrigation. A con- cedures (3, 4), or cantilever prostheses (5). Although trol of a possible communication between implant having a comparable short-term survival rate, some sites was done before implant placement. 142 Annali di Stomatologia 2014; V (4): 142-145  Safe approach in “All-on-four” technique: a case report The two anterior implants (Tekka In-kone®) were placed out accidental displacement, when an alginate im- in the incisive area, whereas the two posterior implants pression was taken. were placed, following the diagonal of the rectangle (Fig. The polyvinylsiloxane impression of the complete re- 6), at an angle of 30° mesially to the mental foramina. movable prosthesis was made to detect the position After soft tissue management and closure, straight of implants and soft tissue. i and angulated abutments were placed onto the im- The definitive, immediate loaded prosthesis was giv- al plants (Fig. 7) and the multiunit impression copings en to the patient after 24 hours (Fig. 9). were attached to the prosthetic abutments and splint- The panoramic radiograph at 1-year-follow up re- ed using wire-bars and low shrinkage autopolymeriz- vealed a good bone healing and no sign of bone re- on ing resin (Fig. 8) to ensure an accurate transfer with- sorption around implant shoulders (Fig. 10). zi na t er Figure 1. Preoperative clinical view. In Figure 2. Preoperative panoramic radiograph. ni io iz Ed Figure 3. CT Scan showing the crestal position of the left mental nerve. IC C © Figure 4. Identification of the mental nerve: (left side). Figure 5. Identification of the mental nerve: (right side). Annali di Stomatologia 2014; V (4): 142-145 143  M.B. Hadj Hassine et al. i al on Figure 10. Panoramic radiograph after 1-year-follow-up. zi Figure 6. Placement of the mandibular guide. Discussion na A recent shift in practice paradigm has been to minimize treatment costs and patient morbidity while providing the most satisfying patient-centered treatment outcomes ac- cording to the state of the art of dental practice. The “All- er on-Four” treatment concept is an attempt to reach these objectives by providing relatively straight forward, pre- dictable treatment option to rehabilitate edentulous pa- tients with a high outcome of quality of life (9). t In this technique, the placement of the two posterior In implants in front of mental foramina and tilted with a distal direction avoids to injure the inferior alveolar nerve and decreases the cantilevers, allowing the in- crease of the polygonal area for a full fixed prosthesis Figure 7. Preparation of the distal implant site. and providing satisfactory molar support (10, 11). Ac- ni cording to Krekmanov et al., the gained mean dis- tance of prosthesis support in the mandible is 6,5 mm while it is 9,3 mm in the maxilla (12). The “All-on- io Four” procedure also improves cortical anchorage and primary stability, allowing the use of longer im- plants. In a three-dimensional finite element analysis about load transmission using different implant incli- iz nations and cantilever lengths, Bevilacqua et al. re- ported a reduction of stress around anterior implants in a full fixed prosthesis design, when tilted implants Ed were compared to straight implants (13). Furthermore there are no significant differences be- tween axial and tilted implants in terms of success rates and marginal bone loss (14). In the present case report, the crestal position of the Figure 8. Placement of straight and angulated abutments. mental nerve requested to change the flap design IC with respect to the surgical protocol, which consists of a linear incision performed from the first molar to the contralateral one, with or without two vertical dis- tal incisions. The midline releasing incision allowed C an easier reflection of the flap, a less difficult implant placement and nerve injury preservation. The bone growth around the implant shoulders might be justified by the subcrestal position and the implant © characteristics, such as platform switching and a morse taper connection. Moreover, the microstruc- tured surface texture extended onto the implant shoulder seems to play a role in minimizing the mar- ginal bone loss (0.11 mm, 0.08 mm) and in promoting bone formation on the implant platform, even when Figure 9. The definitive prosthesis. using tilted implants (15, 16). 144 Annali di Stomatologia 2014; V (4): 142-145  Safe approach in “All-on-four” technique: a case report Conclusion plications following augmentation with cancellous block al- lografts. J Periodontol. 2010;81:1759. The “All-on-4” treatment concept seems to be an al- 6. Hashemi HM. Neurosensory function following mandibular nerve lateralization for placement of implants. Int J Oral Max- ternative option for rehabilitating edentulous jaws illofac Surg. 2010; 39:452. compared with advanced surgical approaches without i 7. Vega LG, Bilbao A. Alveolar distraction osteogenesis for den- using removable prostheses. It is a cost-effective pro- al tal implant preparation: An update. Oral Maxillofac Surg Clin cedure, decreasing the treatment times, the morbidity North Am. 2010;22:369. and allowing a higher patient quality of life. 8. Peñarrocha Diago M, Maestre Ferrín L, Peñarrocha Oltra D, Marginal bone loss around splinted tilted implants to Canullo L, Calvo Guirado JL, Peñarrocha Diago M. Tilted im- on support full-arch fixed prosthesis doesn’t significantly plants for the restoration of posterior mandibles with horizontal differ from straight implants in short and medium- atrophy. An alternative treatment. J oral Maxillofac Surg. term. Nevertheless, long-term results are required to 2013;71.856-864. verify this finding. Furthermore, platform switching, 9. Rangert B, Jemt T, Jörneus L. Forces and moments on Bråne- mark implants. Int J Oral Maxillofac Implants. 1989;4:241-247. morse taper connection and microstructured surface zi 10. Sertgöz A, Güvener S. Finite element analysis of the effect texture extended onto the implant shoulder seem to of cantilever and implant length on stress distribution in an play a role in stabilizing the peri-implant bone, also implant-supported fixed prosthesis. J Prosthet Dent. when tilted implants are used. na 1996;76:165-169. 11. Butura CC, Galindo DF, Jensen OT. Mandibular all-on-four therapy using angled implants: a three-year clinical study of References 857 implants in 219 jaws. Oral Maxillofac Surg Clin North Am. 2011 May;23(2):289-300. er 1. Guerrero C, Lopez P, Figueroa F, et al. Three-dimensional 12. Malo P, Rangert B, Nobre M. ‘‘All-on-four’’ immediate-func- alveolar distraction osteogenesis. In: Bell W, Guerrero C, ed- tion concept with Branemark system implants for completely itors. Distraction osteogenesis of the facial skeleton. 1st edi- edentulous mandible: A retrospective clinical study. Clin Im- tion. Hamilton (Canada): BC Decker, 2007; 457-93. plant Dent Relat Res. 2003;5:2. 13. De Vico G, Bonino M, Spinelli D, Schiavetti R, Sannino G, t 2. Esposito M, Grusovin MG, Coulthard P, Worthington HV. The efficacy of various bone augmentation procedures for den- Pozzi A, Ottria L. Rationale for tilted implants: FEA consid- tal implants. A Cochrane systematic review of randomized In erations and clinical reports. Oral Implantol (Rome). 2011 controlled clinical trials. Int J oral Maxillofac Implants. Jul;4(3-4):23-33. 2006;21:696-710. 14. Krekmanov L, Kahn M, Rangert B, Lindstrom H. Tilting of pos- 3. Sorní M, Guarinós J, García O, Peñarrocha M. Implant re- terior mandibular and maxillary implants of improved pros- habilitation of the atrophic upper jaw: a review of the litera- thesis support. Int J Oral Maxillofac Implants. 2000;15:405- ni ture since 1999. Med Oral Patol Oral Cir Bucal. 2005;10 Sup- 414. pl 1:E45-56. 15. Bevilacqua M, Tealdo T, Pera F, et al. Three-dimensional fi- 4. Maestre-Ferrín L, Boronat-Lopez A, Penarrocha-Diago M, nite element analysis of load transmission using different im- et al. Augmentation procedures for deficient edentulous ridges, plant inclinations and cantilever lengths. Int J Prosthodont. io using on lay autologous grafts: An update. Med Oral Patol 2008; 21:539-542. Oral Cir Bucal. 2009;14:402. 16. Gowgiel JM. The position and course of the mandibular canal. 5. Chaushu G, Mardinger O, Peleg M, et al. Analysis of com- J Oral Implantol. 1992;18:383. iz Ed IC C © Annali di Stomatologia 2014; V (4): 142-145 145 

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Original article Histological evaluation of a biomimetic material in bone regeneration after one year from graft i al on Michele M. Figliuzzi, DDS, PhD1 demonstrated that, after a proper selection of pa- Rossella De Fazio, DDS1 tients and lesions, and applying an adequate sur- Rosamaria Tiano, DDS1 gical technique, this type of biomaterial in the Serena De Franceschi, DDS1 treatment of periodontal defects acts in an optimal Delfina Pacifico, DDS1 manner as a filler inducing the formation of new zi Francesco Mangano, DDS2 bone as evidenced by histological examinations. Leonzio Fortunato, MD, PhD1 Key words: biomimetic material, bone regenera- na tion, periosteum, intrabony defects. 1 Department of Periodontics and Oral Sciences, Magna Graecia University, Catanzaro, Italy 2 Department of Biomaterials, Insubria University, Introduction er Varese, Italy Advances in scientific research gave rise to a new ge- neration of biomaterials of synthetic origin stoichiome- Corresponding author: trically unstable and therefore really absorbable (1). Michele M. Figliuzzi t In recent years, studies in tissue regeneration in pe- Department of Periodontics and Oral Sciences, Magna Graecia University, Catanzaro In riodontology had a significant development of synthe- tic materials, starting from hydroxyapatite. In particu- Via Tommaso Campanella 115 lar, materials able to mimic the functions of the bone 88100 Catanzaro, Italy have been studied, and then trigger the mechanisms E-mail:raass@hotmail.it of their guided bone regeneration (1-3). However, in ni the literature, studies of hydroxyapatite-based bioma- terials reported conflicting data. Some authors have Summary shown that the hydroxyapatite implanted into the bo- io ne induces the formation of new bone, which adheres Aim. The use of substitute materials is one of the chemically to the surface of the biomaterial without solutions used in periodontology for the recon- the interposition of fibrous tissue (4-8). struction of intrabony defects. Advances in scien- Other authors have shown that hydroxyapatite acts iz tific research gave rise to a new generation of well as a filler, inert, but would always surrounded by biomaterials of synthetic origin stoichiometrically fibrous tissue with no evidence of osteogenesis (9-12). unstable and therefore really absorbable. By literature, a conflicting point was the “Geometry of Ed Our research is directed precisely towards a bio- Surface” (osteoinductive geometric configuration) of the material synthesis, Engipore® (Finceramica, biomaterial used. As demonstrated by the studies of Ri- Faenza, Italy) which is a bone substitute of the la- pamonti et al. (13), the geometry of the surface is criti- test hydroxyapatite-based generation, that pos- cal for the shape, locomotion and cell differentiation. In sesses chemical and morphological properties si- particular, the porosity and crystallinity of a biomaterial milar to those of natural bone in the treatment of confer a proper reabsorbability and differentiation (14). IC infrabony periodontal defects. Aim of this study Our research is directed precisely towards a biomate- was to evaluate the efficacy of Engipore® in the rial synthesis, the Engipore®, which is a bone substi- treatment of intrabony periodontal defects. tute of the latest generation hydroxyapatite-based Methods. The study was conducted on 100 paro- that possesses chemical and morphological proper- C dontopatics patients, which had gingival pockets ties very similar to those of natural bone. This type of of at least infrabonies 8/10 mm. The histological structure and its morphological and microstructural evaluation was performed with samples after one characteristic allows this material, just applied in situ, year from the graft. to absorb the full thickness bioactive proteins and © Results. The histological samples collected after growth factors present in the clot and releasing gra- one year showed an abundant new bone forma- dually, generating a rapid vascularization and making tion, with mature lamellar bone tissue surrounding more effective osteogenesis (15-17). the residual particles of Engipore® that appear It has high osteoconductive properties and kinetics of completely osteointegrated. The surrounding con- osseointegration of 9-18 months (2,3,18). It has ex- nective tissue shows no signs of inflammation. cellent adaptability and machinability and volumetric Conclusions. The results obtained in our research rendering, making it ideal for many applications. They Annali di Stomatologia 2014; V (3): 103-107 103  M.M. Figliuzzi et al. include: sinus lifts, periodontal defects and peri-im- anesthesia (Mepivacain plus Adrenalin 1:100.000, plant dehiscence (19, 20). Depending on the size of Pierrel Italia), according to Cortellini et al. (1999), an the defect, it can be taken advantage by the amount intra-sulcular incision with a papilla preservation tech- of material required limiting waste, as the product is nique was made by means of a lancet (Beaver 64, available in different packaging: in flakes from 0.5-1 Becton, Dickinson & Co, USA) between the mesial i mm in diameter, 0.5 g and g 2x0.5 easily shaped into tooth and the distal one. Flap was raised at a split al blocks of 10x10x10 mm and from 10x5x5 mm. thickness. Granulation tissue was removed with ultra- The aim of this work was to evaluate the efficacy of sonic tools and curettes (Fig. 2). Engipore® in the surgical treatment of infrabony pe- Once the defect depth was measured, root condition- on riodontal defects. ing with tetracycline 0.5% was performed. In addition, a biomaterial was adapted Engipore® (Fig. 3). No membrane was used and, after filling the defect, the Materials and methods flap was coronally positioned and closed by means of zi This study was conducted on 100 patients (40 male and 60 female) affected by periodontal disease which presented at least one infrabony defect. na Defects presented the following characteristics: pure 2- or 3-wall defects (radiographic intrabony compo- nent >4 mm), probing pocket depth (PPD) >6 mm, defect angle >30°, mobility of the tooth less than gra- er de 1-2. Patients were enrolled in a Department of Periodon- tics and Oral Sciences, Magna Graecia University, Catanzaro, Italy and was approved by the Ethical Committee (n.997 del 17/09/2010). t In The present study was performed following the princi- ples outlined of the Declaration of Helsinki on experi- Figure 1. A preliminary X-ray was taken with the parallel mentation involving human subjects. All enrolled pa- cone technique. tients signed and informed consent form after receiv- ing through oral and written information about the ni procedures and treatment plan. Inclusion criterium was: io Age >18 years Exclusion criteria were: Scarce oral hygiene; Smoking; iz Systemic disease or conditions that could influence the outcome of therapy and/or contraindicating surgery; Ed Previous periodontal surgery; Chronic NSAIDs assumption; Allergy to the used materials; Drugs use as nifepidine, steroids, allantoin, estro- gens, cyclosporine, bisphosphonates; Figure 2. Vision of the bone defect after preparation of the Pregnancy. flap. IC Selected patients underwent a non-surgical periodon- tal treatment (i.e., full-mouth scaling and root plan- ning). After three months, patients were re-evaluated C and the need of periodontal surgery was confirmed. Surgical Procedure © Patients were given an antibiotic therapy (Amoxicillin and Clavulanic Acid 1 g, 2 times a day for 6 days, starting the day before the surgery) and a local anti- septic therapy with Chlorhexidine 0.2% rinses for 10 days. Before surgery, a preliminary X-ray was taken with the parallel cone technique (Fig. 1). After local Figure 3. Defect filled with the biomaterial. 104 Annali di Stomatologia 2014; V (3): 103-107  Histological evaluation of a biomimetic material in bone regeneration after one year from graft mattresses sutures (Poliglycolic Acid, Distrex Spa Results Italia). In all cases a periodontal dressing was posi- tioned. After 10 days, periodontal dressing and su- Histological samples, one year after the graft (Figs. 6- tures were removed and patients were visited to eval- 10), showed abundant bone formation, with mature uate healing (Fig. 4). lamellar bone tissue surrounding the residual parti- i One year after grafting, a bone core was taken with a cles of Engipore® that appear completely osteointe- al diameter of 2 mm at the graft site, under local ane- grated. The surrounding connective tissue shows no sthesia (Fig. 5). The tissue samples were then sent at signs of inflammation. a Department of Pathology performing histological on analysis. The histological material maintained under 4% formalin. Than it was subjected to cuts of thick- Discussion ness 4-8 mm by microtome. Each section was colo- red by toluidine blue. In the present study, we wanted to evaluate the abi- lity of integration of a biomimetic material of last ge- zi neration, containing hydroxyapatite (21). The hydroxyapatite used in this search has morpholo- gical and chemical properties very similar to those of na natural bone. In fact, it has a porosity that reaches 90% of its volume in macropores with a range of 200- 500 μm and pores of interconnection in the range of 80-200 microns. Thanks to its porosity, Engipore ad- er sorb physiologic fluids so that cytokines and growth factors permeate in full thickness the material al- lowing bone forming cells to colonize and differentiate inside. t In Figure 4. Suture. ni io iz Ed Figure 7. Bone core. Figure 5. Healing of the soft tissues at 6 months. IC C © Figure 8. Presence of newly formed bone which surrounds Figure 6. Vision Clinic of bone core performed at 6 months. some Engipore particles. Annali di Stomatologia 2014; V (3): 103-107 105  M.M. Figliuzzi et al. pamonti (13), allow this material, just applied in situ, to absorb the full thickness bioactive proteins and growth factors present in the clot and releasing gra- dually, generating a rapid vascularization and making more effective osteogenesis (15,23,24). It has high i osteoconductive properties and kinetics of osteointe- al gration of 9-18 months (25-27). In addition to the material used, we want to emphasi- ze the importance that the surgical technique has in on these types of interventions, which must be minimally invasive. The surgery was performed using the partial thickness flap. This ensured adequate spraying of the surgical site throughout the duration of the treaty and allowed the zi suture anchor with subperiosteal guaranteeing the absolute stillness of the flap, a key condition to get a good recovery. Finally, it extolled the reparative and na regenerative properties of bone tissue and perio- steum, a locus of totipotent stem cells (26,27). Also the selection of the defects could be decisive in exalting the regenerative capacity of sites: those with er 3 remaining walls are healed better than the sites where the residual walls were 2 (28). The histologies performed have shown bone formation around the particles of inert biomaterial. t In Conclusions Histological observations testify the excellent biocom- Figures 9-10. Not necrosis or inflammatory reaction, the patibility and good osseointegration properties of the ni graft material was almost completely reabsorbed and were biomaterial used in connection with the newly formed obvious signs of osteogenesis. bone. The intimate relationship between the particles of the alloplastic material and the newly formed bone, io in its various stages of formation and mineralization, allows to assert the ability of the osteoconductive ma- terial, that provide the scaffold for osteogenic recon- structive process. iz References Ed 1. Cortellini P, Tonetti M. Clinical performance of a regenera- tive strategy for intrabony defects. Scientific evidence and clinical experience. J Periodontol. 2005 Mar;76(3):341-50. 2. Needleman I, Tucker R, Giedrys-Leeper E, Worthington H. A systematic review of guided tissue regeneration for periodontal IC infrabony defects. J Periodontal Res. 2002;37:380-388. 3. Murphy KG, Gunsolley JC. Guided tissue regeneration for the treatment of periodontal intrabony and furcation defects. A systematic review. Ann Periodontol. 2003;8:266-302. Figure 11. Engipore’s particle with newly formed bone and 4. Scabbia A, Tampieri A, Trombelli L. I materiali bioceramici C osteocitaries gaps. osteoconduttivi e il loro ruolo come sostituti dell’osso. Im- plantologia Orale. 2003; 4:9-25. 5. Ripamonti U. The morphogenesis of bone in replicas of Engipore causes a significant induction of osteoblast porous hydroxyapatite obtained from conversion of calci- transcriptional factors like SP7 and RUNX2 and of the um carbonate exoskeletons of coral. J Bone Joint Surg Am. © bone-related gene osteocalcin (BGLAP) (22). 1991;73:692-703. Furthermore, the Ca/P ratio is practically similar to 6. Zhang XD. A study of porous block HA ceramics and its osteogenesis. In: Ravaglioli AA, Krajewski A, eds. Bio- that present in the human bone. All this allows the ceramics and the Human Body. Amsterdam: Elsevier. material to have a similar surface geometry of human 1991:408-415. bone. This type of structure and the morphological 7. Yuan H, Li Y, Yang Z, Feng J, Zhang XD. An investigation microstructural characteristics, as pointed out by Ri- on the osteoinduction of synthetic porous phase-pure hy- 106 Annali di Stomatologia 2014; V (3): 103-107  Histological evaluation of a biomimetic material in bone regeneration after one year from graft droxyapatite ceramics. Biomed Eng Appl Basis Com. suitability as cell growth support surfaces. Biomaterials. 2008 1997;9:274-278. Nov;29(32):4275-4284. 8. Okumura M, Ohgushi H, Dohi Y, et al. Osteoblastic pheno- 18. Jones EA, Kinsey SE, English A, Jones RA, Straszynski L, type expression on the surface of HA ceramics. J Biomed Meredith DM, et al. Isolation and characterization of bone mar- Mater Res. 1997;37:122-129. row multipotential mesenchymal progenitor cells. Arthritis i 9. Iattelli A, Mangano C, Krajewski A, et al. Correlation between Rheum. 2002 Dec;46(12):3349-3360. al clinico-histological results and the hydroxyapatite phosphate 19. Scarano A, Degidi M, Iezzi G, Pecora G, Piattelli A, Orsini ratio of implanted ceramic granules. In Andersson OH, Yli- G, Caputi S, Perrotti V, Mangano C. Maxillary sinus aug- Urpo A (Eds.) Bioceramics, Vol.7 (Proceedings of the 7 th mentation with different biomaterials. A comparative histo- International Symposium on ceramics in medicine, Turku, Fin- logic and histomorphometric study in man. Implant Dent. on land, July 1994):177-182. 2006;15:197-207. 10. DaculsI G, Legeros RZ, Nery E, et al. Transformation of bipha- 20. Aspiello S, Rasicci P, Piemontese M. Potenziale rigenera- sic calcium phosphate ceramics in vivo: ultrastructural and tivo di gel piastrinico e bioceramica. Dental Cadmos. 2007. physicochemical characteristics. J Biomed Mater Res. 21. Bartold M, Shi S, Gronthos S. Stem cells and Periodontal re- 1989;23:883-894. generation. Periodontology. 2000, Vol. 40, 2006;164-172. zi 11. Nery EB, Legeros RZ, Lynch KL, Lee K. Tissue response to 22. Sollazzo V, Palmieri A, Girardi A, Farinella F, Carinci F. En- biphasic calcium phosphate ceramic with different ratios of gipore acts on human bone marrow stem cells. Saudi Dent HA/B-TCP in periodontal osseous defects. J Periodontal. J. 22, 161-6. na 1992;63:729-735. 23. Neiva RF, Tsao YP, Eber R, Shotwell J, Billy E,Wang HL. 12. Di Domizio P, Scarano A, Piattelli M, et al. Healing of bone Effects of a putty-formhydroxyapatite matrix combined with defects treated with hydroxyapatite particles. 76 th Gener- the synthetic cell-binding peptide P-15 on alveolar ridge al Session and Exhibition of International Association for Den- preservation. J Periodontol. 2008;79:291-299. tal Research (I.A.D.R.), Vancouver March 10-13, 1999. 24. Lechleitner T, Klauser F, Seppi T, Lechner J, Jennings P, 13. Ripamonti U, Richter PW, Nilen RWN, Renton L. Induction Perco P, et al. The surface properties of nanocrystalline di- er of bone formation by smart biphasic hydroxyapatite tricalcium amond and nanoparticulate diamond powder and their phosphate biomimetic matrices. Journal of Cellular and Mol- suitability as cell growth support surfaces. Biomaterials. 2008 ecular Medicine. 2008;12(6B):2609-2622. Nov;29(32):4275-4284. 14. Trisi P, Rao W. The bone growing Chamber: a new model 25. Jones EA, Kinsey SE, English A, Jones RA, Straszynski L, to investigate spontaneous and guided bone regeneration t Meredith DM, et al. Isolation and characterization of bone mar- 1998;18:151-159. In of artificial defects in human jawbone. Int J Periodor Rest Dent. row multipotential mesenchymal progenitor cells. Arthritis Rheum. 2002 Dec;46(12):3349-3360. 15. Crespi R, Capparè P, Gherlone E. Magnesium-Enriched Hy- 26. Cortellini P, Tonetti M. Microsurgical Approach to Periodontal droxyapatite Compared to Calcium Sulfate in the Healing of Regeneration. Initial Evaluation in a Case Cohort Journal of Human Extraction Sockets: Radiographic and Histomor- Periodontology. Apr 2001, Vol. 72, No. 4:559-569. ni phometric Evaluation at 3 Months. Journal of Periodontol- 27. Fickl S, Kebschull M, Schupbach P, Zuhr O, Schlagenhauf ogy. February 2009, Vol.80,No. 2: 210-218. U, Hürzeler MB. Bone loss after full-thickness and partial- 16. Neiva RF, Tsao YP, Eber R, Shotwell J, Billy E,Wang HL. thickness flap elevation. J Clin Periodontol. 2011 Effects of a putty-formhydroxyapatite matrix combined with Feb;38(2):157-62. io the synthetic cell-binding peptide P-15 on alveolar ridge 28. Cortellini P, Tonetti MS. Clinical and radiographic out- preservation. J Periodontol. 2008;79:291-299. comes of the modified minimally invasive surgical technique 17. Lechleitner T, Klauser F, Seppi T, Lechner J, Jennings P, with and without regenerative materials: a randomized-con- iz Perco P, et al. The surface properties of nanocrystalline di- trolled trial in intra-bony defects. J Clin Periodontol. 2011 amond and nanoparticulate diamond powder and their Apr;38(4):365-73. Ed IC C © Annali di Stomatologia 2014; V (3): 103-107 107 

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Original article Nano-hydroxyapatite and its applications in preventive, restorative and regenerative dentistry: a review of literature i al on Erlind Pepla, MD Key words: nano-HA, preventive, restorative, re- Lait Kostantinos Besherat, MD generative. Gaspare Palaia, DDS Gianluca Tenore, DDS Guido Migliau, DDS Introduction zi The purpose of this work is to analyze what, up to Department of Oral and Maxillo-Facial Sciences, now, is reported in the literature about the advan- na “Sapienza” University of Rome, Italy tages of nano-hydroxyapatite in dentistry, especially in preventive and restorative dentistry, up to its use in oral surgery, such as implantology and periodontal Corresponding author: regeneration. We also attempt to provide a broad er Erlind Pepla overview of the new materials that are being born Department of Oral and Maxillo-Facial Sciences from experimental research, with particular attention “Sapienza” University of Rome to the materials commonly used in restorative den- Viale Regina Elena 278/a tistry, such as composite resins. 00198 Rome, Italy t Tooth enamel is the most mineralized tissue of human E-mail: kledion2004@libero.it In body. Its composition is 96 wt.% inorganic material and 4 wt.% organic material and water. In dentin, the inorganic material represents 70 wt.%. This inorganic Summary material is mainly composed by a calcium phosphate related to the hexagonal hydroxyapatite, whose chem- ni This study aims to critically summarize the litera- ical formula is Ca10(PO4)6·2(OH). X-ray energy disper- ture about nano-hydroxyapatite. The purpose of sive spectroscopy (EDS) analysis of enamel and this work is to analyze the benefits of using nano- dentin also indicated the presence in small quantities io hydroxyapatite in dentistry, especially for its pre- of other elements such as Na, Cl and Mg. ventive, restorative and regenerative applications. Hydroxyapatite (HA) is the main component of enam- We also provide an overview of new dental materi- el, which gives an appearance of bright white and als, still experimental, which contain the nano-hy- eliminates the diffuse reflectivity of light by closing iz droxyapatite in its nano-crystalline form. Hydroxya- the small pores of the enamel surface. Hydroxyap- patite is one of the most studied biomaterials in the atite has long been among the most studied bioma- medical field for its proven biocompatibility and for terials in the medical field for both its proven biocom- Ed being the main constituent of the mineral part of patibility and for being the main constituent of the bone and teeth. In terms of restorative and preven- mineral part of bone and teeth. Hydroxyapatite is al- tive dentistry, nano-hydroxyapatite has significant so an important source of calcium and phosphate, remineralizing effects on initial enamel lesions, cer- very important for the remineralization of demineral- tainly superior to conventional fluoride, and good ized enamel areas. The inorganic component of all results on the sensitivity of the teeth. The nano-HA the mineralized tissues of the human body is, in fact, IC has also been used as an additive material, in order made up of a large prevalence of calcium phos- to improve already existing and widely used dental phatesalts. Other inorganic materials such as calci- materials, in the restorative field (experimental ad- um carbonates and sulphates are present in smaller dition to conventional glass ionomer cements, that quantities too; in particular hydroxyapatite represents C has led to significant improvements in their me- 60-70% and 90% in weight of bone and enamel re- chanical properties). Because of its unique proper- spectively. The recently developed interest for nan- ties, such as the ability to chemically bond to bone, otechnology in many fields, is producing interesting to not induce toxicity or inflammation and to stimu- and imminent applications in dentistry for nano-hy- © late bone growth through a direct action on os- droxyapatite, which presents crystals ranging in size teoblasts, nano-HA has been widely used in peri- between 50 and 1000 nm. The nano-hydroxyapatite odontology and in oral and maxillofacial surgery. has a strong ability to bond with proteins, as well as Its use in oral implantology, however, is a widely with fragments of plaque and bacteria, when con- used practice established for years, as this sub- tained in toothpastes. This ability is due to the size of stance has excellent osteoinductive capacity and nanoparticles, which considerably increase the sur- improves bone-to-implant integration. face area to which proteins can bind. Besides, nano- 108 Annali di Stomatologia 2014; V (3): 108-114  Nano-hydroxyapatite and its applications in preventive, restorative and regenerative dentistry: a review of literature hydroxyapatite also acts as filler because it repairs many dental structures. In this study the attention small holes and depressions on enamel surface, a was paid to the search for materials to be added to function enhanced by the small size of the particles common glass ionomer cements available on the that compose it. The Japanese company Sangi Co. market, Fuji II GC, in order to improve its mechanical Ltd was the first to take an interest in hydroxyapatite, properties. i after purchasing the rights ifrom NASA (U.S. Nation- Nano-hydroxy and fluorapatite have been synthe- al al Aeronautics and Space Authority) in 1970. The as- sized using a sol-gel technique in an ethanol base. tronauts, in fact, lost minerals from the teeth and The results showed that after 1 and 7 days, the nano- bones in the absence of gravity, and NASA proposed HA/fluorapatite added to cements howed greater on a synthetic hydroxyapatite as a repairing material. hardness to compression (CS) 177-179 MPa, a high- The Sangi Co. Ltd had the idea in 1978 to launch er hardness to diametrical tension (DTS) 19-20 MPa toothpaste that could repair the tooth enamel, which and a higher hardness to biaxial flexibility (BFS) 26- contains for the first time nano-hydroxyapatite 28 MPa, compared to the control group (160 MPa in (Apadent). In 2006, the first toothpaste containing CS, 14 MPain DTS and 18 MPa in BFS) (Tab. 1). zi synthetic hydroxyapatite biomimetic as an alternative Therefore, glass ionomers containing nano-bioceram- to fluoride for the remineralization and repair of tooth ics are very promising restorative dental materials enamel appeared in Europe. The biomimetic hydrox- with improved mechanical properties and strong bind- na yapatite function is to protect the teeth with the cre- ing to dentin, and may very soon replace GIC current- ation of a new layer of synthetic enamel around the ly on the market. From these studies it seems to tooth, rather than hardening the existing layer with emerge, in fact, an unmistakable statistical datum: fluorine, that chemically changes into calcium modified GICs with the above listed substances pos- er halophosphate [Ca5(PO4)3F]. sess much higher capacity than traditional materials. In its granular form, hydroxyapatite is currently used in Moshaverina et al. (2008) (2), have extensively stud- clinical dental practice to reconstruct periodontal bone ied the effects of incorporating hydroxyapatite and defects, to the fill bone defects after cystectomy, after fluorapatite (FA) in a conventional glass ionomer ce- apicoectomy, after the loss of dental implants and to t ment (Fuji II GC). The addition of synthesized nano- increase of the thickness of atrophic alveolar ridges. Shaped blocks of hydroxyapatite are especially used In HA and FA in Fuji II improves the mechanical proper- ties (to compressive, diametral tensile and biaxial in maxillofacial surgery (bone defects after trauma, os- flexural forces) of the resulting cement and its bond- teotomies and reductive stabilization, reconstruction ing strength to dentin. These bioceramics are, there- of facial skeleton, replacement of parts of orbital and fore, considered promising additives for glass ni maxillary bone). Blocks, as well as granular powder, ionomer cements used as restorative materials. How- can also be used in pre-prosthetic surgery to increase ever, perhaps due to the low solubility value of FA, the thickness of the alveolar ridge. the FA-containing samples showed very high values, io Studies on biocompatibility have shown that hydroxy- after 7 and 30 days, in both mechanical properties apatite chemically binds to bone and induces no phe- and binding tests, as compared to compounds con- nomena of toxicity nor inflammatory, local or sys- taining HA and to GIC. temic. Some researches show that the hydroxyap- In recent years, attention has focused towards the iz atite, unlike tricalcium phosphate, doesn’t undergo re- synthesis of new compounds of nano-HA. This is the sorption. Other authors have instead found resorption case in the study on the remineralizing effects of zinc of hydroxyapatite. Thanks to its chemical and crystal- carbonate nano-HA (ZnCO₃/n-HAP) performed by Ed lographic affinity with inorganic components that con- Tschoppe et al. in 2011 (3). In the research, 35 stitute the bone, hydroxyapatite is able to establish bovine incisors were taken; from these teeth, 70 ex- chemical bonds and to ensure a more rapid integra- perimental blocks of enamel and 85 samples of tion of titanium implants to bone and surrounding tis- dentin were obtained. A quarter of all the samples sues. Numerous studies have highlighted the role of were coated with a special acid resistant paint, in or- hydroxyapatite in facilitating the process of osteointe- der to act as control group. Enamel lesions were ob- IC gration with or without other polymeric space. tained by dipping the blocks in a solution (5l) contain- ing 6 pM of MHDP, 3 mMCa Cl₂ dihydrate, 3 mM KH₂ PO₄ and 50 mM acetic acid, at a pH of 4.95, in an in- Analysis of the scientific literature (in restora- cubator (37° C, BR 6000; Heraeus Kulzer) for 14 C tive dentistry) days. The lesions in dentin were prepared by dipping The use of nano-hydroxyapatite as a material that Table 1. The synthesized nano-ceramic particles were in- could improve the properties of materials currently corporated in a powder of commercial glass ionomer (Fuji © used in restorative dentistry has been studied. II GIC). Moshaverina et al. in 2008 (1) have focused on the addition of N-vinylpyrrolidone containing acids, nano- Control Group Nano-HA/Fluoroapatite Group hydroxyapatite and fluorapatite to conventional glass ionomer cements (GIC). These cements have unique CS 160 MPa 177-179 MPa properties such as biocompatibility, anticariogenic ac- DTS 14 MPa 19-20 MPa BFS 18 MPa 26-28 MPa tion (due to the release of fluorides) and adhesion to Annali di Stomatologia 2014; V (3): 108-114 109  E. Pepla et al. the samples in a solution containing 0.0476 mMNaF, years old bulls were analyzed. The teeth, cut into 2.2 mMCaCl₂ dihydrate, 2.2mM KH₂PO₄, 50 mM blocks, were dipped in 8 ml of DS for 72 hours at 37° acetic acid and 10 mM KOH, at a pH of 5.0 (37° C) C. Finally, 70 teeth with a KHN (Knoop Hardness for five days. The pH value of the demineralizing so- Number) value between 171.6 and 204.3 were select- lutions was constantly monitored. Afterwards, half of ed. They were then divided into 10 groups exposed to i all demineralized surfaces were again covered with different pH values. Afterward, the blocks were longi- al paint (baseline control demineralization). The sam- tudinally sectioned in order to be studied by CSMH. ples were divided randomly into five groups (enamel The data were analyzed using SPSS 13.0 software. n=14, dentin n=17) and were placed separately in The remineralizing effect of nano-HA increased sig- on remineralizing solution for two and for five weeks. In nificantly when the pH was lower than 7.0. agreement with EN ISO 11609 standards, the respec- One of the most important variables present in the tive toothpastes were diluted in a 1:3 ratio in the rem- mouth is the variation of pH. The assessment of this ineralizing solution, in order to obtain a homogeneous variable is missing in this study. In another study by zi substance. Commercially available toothpastes con- Huang et al. of 2009 (5), they analyzed the mineraliz- taining ZnCO₃/n-HA or n-HA (all without fluorides) ing ability of nano-hydroxyapatite in cyclically variable were used while the toothpaste containing amino flu- pH conditions. na orides was used for the control group. Then, the sam- The high availability of calcium and phosphate in ples were manually brushed with a soft brush and these conditions, causes, according to the author, a with a minimum pressure; this procedure was per- positive effect on the remineralization of lesions. This formed every day for about 5 seconds and with a indicates that nano-HA is a better resource of free- contact time with the solutions of 115 seconds, a total Ca, and this is important for the defense from dental er time of 120 seconds. We must, however, emphasize caries and erosion. The largest increase in mineral- that this procedure has some significant limitations as ization was observed in the group with pH 4.0. The it is highly operator dependent and difficult to stan- group with pH 7.0, however, showed the lowest de- dardize and empirically assessable. After each brush- gree of mineralization. An accumulation of many min- ing, the samples were rinsed with deionized water for t erals in the lesions and a corresponding reduction of In 10 seconds. Every two days for each group, the solu- their depth were also observed. The effect of nano- tions were changed (250 ml). Finally, sections of 100 HA is better than the effect of micro-HA at pH 7.0 and mm were performed and analyzed by means of mi- at the same concentrations. The concentration of cal- croradiography and through an appropriate software cium in solutions containing nano-HA was greater (TMR for Windows 2.0.27.2; Inspektor Research Sys- than that detected in solutions containing micro-HA. ni tem, Amsterdam, The Netherlands). Thirty samples of The Ca concentration increase leads to a growth in enamel and two of dentin were lost during prepara- the saturation of oral fluids with HA, favoring the de- tion procedures. This complex in vitro study shows position of apatite minerals in the lesions and eventu- io that toothpastes containing different types of nano- ally promoting remineralization. hydroxyapatite have the same remineralizing capabil- In terms of dental erosion, it is important to empha- ities on enamel and dentin, and those containing fluo- size that its prevalence is increasing in young chil- iz ride have lower capacity than the first. We must, how- dren and adolescents in developed and in developing ever, take into account the limits of an in vitro study, countries. The main external cause of increased ero- as it is far from simulating the conditions present in sion is a higher consumption of acids in the diet and Ed the oral cavity. with drinks. In particular the use of sport drinks has In the study by Huang et al. of 2009 (4), the authors recently increased, and these may cause erosion ac- analyzed the remineralizing effect of nano-HA on cording to their acid content. With reference to this, is demineralized bovine enamel under cyclical condi- the interesting Min et al. in 2011 study (6), on nano- tions of pH, by the microhardness test, on cross-sec- hydroxyapatite as an addition to sports drinks. In this tions (CSMH) and on surfaces and through polarized study was examined the possible beneficial effects of IC light microscopy (PLM). Nano-HA and conventional additioning nano-hydroxyapatite to sports drinks. HA (crystals in the order of micrometers, from 0.5 to Powerade ® (PA) was taken as experimental solution 2 µm), were obtained by the National Incubation Base and citric acid was added as acid. They prepared dif- of Nano-Biomaterials Industrialization, Sichuan Uni- ferent solutions with the PA alone and with the addi- C versity. The demineralizing solution (DS) used to cre- tion of 0.05%, 0.10% and 0.25% nano-hydroxyap- ate lesions similar to caries had the following compo- atite. 20 bovine teeth per group, cut in 3.5 mm x 3.5 sition: acetic acid50 mM, Ca(NO₃)₂2.2 mM, KH₂PO₄ mm blocks, were treated for 20 minutes three times a 2.2 mM and NaF 5.3 μM. The pH value of the DS was day, with 2 h and 40 min of interval between each © adjusted to 4.5 by the addition of a solution of KOH. treatment. Once the treatment process was finished, The remineralizing solution (RS) used under condi- the samples were thoroughly rinsed with distilled wa- tions of cyclical pH contains instead: HEPES 20 mM, ter. Throughout the rest of the day, when not being CaCl₂ 1.5 mM, KH₂PO₄ 0.9 mM, KCl130 mM and treated, the teeth were immersed in a solution con- NaN₃ 1 mM. The pH value was adjusted to 7.0 with taining artificial saliva with the following composition: KOH. The dissolution of HA products was studied in gastric mucin 0.22%, KCl 14.93 mM, KH₂PO₄ 5.42 preliminary experiments. In the study, incisors of 4 mM NaCl 6.51 mM and CaCl₂ dihydrate 1.45 mM. 110 Annali di Stomatologia 2014; V (3): 108-114  Nano-hydroxyapatite and its applications in preventive, restorative and regenerative dentistry: a review of literature The cyclic pH process was repeated for 7 days. The provide rapid relief of dentin hypersensitivity (DH). Us- potential erosion was determined by changes in the ing a double-mask, randomized design, three denti- surface microhardness (SMH), and the teeth were an- frices: 1) containing 8% arginine and 1,450 ppm sodi- alyzed with the confocal laser scanning microscopy um monofluorophosphate; 2) containing 8% strontium (CLSM) and with the scanning electron microscope acetate and 1,040 ppm sodium fluoride; and 3) con- i (SEM). The prevention of dental erosions increased taining 30% microaggregation of zinc-carbonate hy- al with the concentration of n-HA, and sports drinks con- droxyapatite nanocrystals were compared after 3-day taining 0.25% of the substance have obtained the treatment. Participant’s DH was evaluated at baseline best results. and after 3 days using air-blast, tactile, cold water, and on The consumption of carbonic acid containing drinks is subjective tests. The final sample consisted of 85 indi- the main etiological factor for tooth erosion. An experi- viduals: 29 received the arginine-based dentifrice mental study on 18 permanent teeth dental erosion (group 1), 27 the strontium acetate-based dentifrice caused by beer was conducted by Hangoo et al. (11) (group 2), and 29 the dentifrice based on zinc-carbon- zi in 2011 (7). These elements were subsequently treat- ate hydroxyapatite (group 3). All dentifrices were most- ed with a remineralizing substance nano-hydroxyap- ly effective to reduce DH: the percentage of score re- atite based. In the study they primarily measured the duction from baseline to 3 days was >30% for all tests na microhardness of 18 permanent teeth (Fig. 1). Then (except for subjective test of group 2). The comparison they did second measurement of the teeth, after dip- among the three dentifrices showed that, after 3 days, ping them in a solution containing 40 ml of beer there was an improvement in air-blast (mean percent- (Behnoush Lemon Delester, Iran) for 5 minutes. The age of reduction, 39.2% in group 1, 42.0% in group 2, time was calculated according to actual studies on the and 39.2% in group 3), cold water (41.5, 51.8, and er permanence of beer in the mouth based on the 50%), tactile (50.3, 40.1, and 33.8%), and subjective amount drunk daily. The average microhardness pri- (33.1, 17.4, and 31.4%) test scores, with differences mary values – i.e. prior to any type of manipulation of being significant for cold water and subjective tests. the teeth –, of the 18 cases was 340.24 ± 25.4² For air-blast and tactile tests, there were no significant kgf/mm. This value reduced to 314.67 ± 33.89² (sec- t differences across groups at 3 days. Moreover, no sig- ond value of microhardness) after immersion in beer; In nificant differences at any test were observed in a sub- this is equivalent to 92.5% of the primary value of mi- set of patients that were followed up to 8 weeks: crohardness, and the “t” test analysis shows that this is all dentifrices were all highly efficacious. This study statistically significant (p=6.20). The value of sec- documents that the three tested dentifrices significantly ondary microhardness of the 9 cases in water was reduced DH after 3-day treatment, supporting their use ni 312.85 ± 36.79² kgf/mm; that reduces to 310.81 ± in clinical practice. To the best of the authors’ knowl- 31.44² (tertiary value of microhardness) after immer- edge, this is the first report documenting the rapid re- sion in drinkable water. This is equivalent to 99.3%, a lief from DH of a zinc-carbonate hydroxyapatite denti- io value that is not statistically significant (p=20.6). The frice. The study by Browing et al. of 2011 (9), finally fo- secondary value of microhardness of the 9 cases cused attention on the search for a material that could dipped in NHAP was 315.18 ± 30.65 kgf/mm. This in- reduce tooth sensitivity after bleaching. For this pur- iz creases to 320.99 ± 24.74² kgf/mm (tertiary value of pose, nano-hydroxyapatite was tested. It was noted microhardness) after immersion in a solution with that the teeth sensitivity after bleaching increased in NHAP. This value is equivalent to 98.2%, which is sta- the presence of enamel defects. Using a randomized Ed tistically significant (p=0.012). clinical trial, the efficacy of a paste containing n-HA in The results of this study demonstrate that there is a reducing this type of sensitivity was analyzed. A paste statistically significant increase in the microhardness containing n-HA (Renamel AfterBleach, Sangi Co. Ltd, of teeth demineralized by beer and then exposed to a Tokyo, Japan) and a placebo (zero-HA) were randomly solution of n-HA. assigned to 42 participants. A 7% hydrogen peroxide The aim of the study of Orsini et al. (8) is to evaluate gel was used for 14 days, in association with a desen- IC the relative abilities of three desensitizing dentifrices to sitizing paste used immediately for the 5 minutes after- wards. A diary was completed daily to note the effect of desensitization and the eventual sensitivity, on a VAS (Visual Analog Scale). Three aspects of the sen- C sitivity of the teeth were analyzed: percentage of par- ticipants, number of days and intensity level. Color change was evaluated. For zero-HA and n-HAgroups, respectively, 51 and 29% of participants reported dentinal sensitivity (p=0.06) (Tab. 2). The days of sen- © sitivity were 76 and 36 respectively (p=0.001). The changes in VAS score from baseline have an upward trend in the zero-HA group (p=0.16) (Tab. 3). The color change was equivalent for both groups. The conclu- Figure 1. Microhardness values after demineralization and sions showed that the group treated with n-HA had remineralization. lower sensitivity levels. Annali di Stomatologia 2014; V (3): 108-114 111  E. Pepla et al. Table 2. Number (percentage) of participants with sensitivity to any assessment. Number of assessments Group Participants Participants with sensitivity without sensitivity Baseline Zero-HA 3 (14%) 18 (86%) i First week whitening Zero-HA 14 (67%) 7 (33%) al Second week whitening Zero-HA 7 (33%) 13 (65%) First week after whitening Zero-HA 5 (25%) 15 (75%) Baseline n-HA 2 (10%) 19 (90%) on First week whitening n-HA 8 (38%) 13 (62%) Second week whitening n-HA 4 (19%) 17 (81%) First week after whitening n-HA 4 (19%) 17 (81%) n-HA=nano-sizedhydroxyapatite, zero-HA=placebo zi There is no significant difference between the groups during bleaching active phase (chi-square, p=0.06) Table 3. Percentage of days associated with sensitivity. na Number ofassessments Group Days with sensitivity Days without feeling Baseline Zero-HA 9 (6%) 138 (94%) First week whitening Zero-HA 50 (34%) 97 (66%) Second week whitening Zero-HA 26 (19%) 114 (81%) er First week after whitening Zero-HA 16 (11%) 124 (89%) Baseline n-HA 7 (5%) 140 (95%) First week whitening n-HA 20 (14%) 127 (86%) Second week whitening n-HA 16 (11%) 131 (89%) First week after whitening n-HA t 14 (10%) 133 (90%) n-HA=nano-sized hydroxyapatite, zero-HA=placebo In Participants in the group with n-HA experience significantly more days with sensitivity during the active phase of bleaching (chi-square, p=0.001) Analysis of the scientific literature (in oral microscope (SEM) (XL30; Philips, Eindhoven, The ni surgery) Netherlands) and by atomic force microscope (AFM) (SPM-9500J3; Shimadzu Corporation, Tokyo, Many researchers have focused on the use of nano- Japan). Male Sprague-Dawley rats, about eight io HA as a co-adjuvant material in oral surgery, espe- weeks old, were used for this study. The implant cially regarding the improvement of the dental implant sites were prepared at about 10 mm from the distal characteristics. In the work of Masahiro et al. of 2012 edge of the femur using a 0.8 mm round bur and iz (10), they analyze a new compound with nano-poly- widening by means of reamers (# ISO 090 and 100). morphic crystalline HA applied to microrough titanium A cylindrical implant that had been machined and surfaces through a combination of flame spray and sandblasted, or sandblasted and coated with HA was Ed calcination at a low temperature. It was then analyzed inserted into each hole prepared on the femur. The for the biological capacity to increase bone-implant muscles and skin were then sutured separately with integration. The sandblasted microrough titanium im- absorbable suture. The total number of animals used plants and the titanium implants linked to HA and was78 (54 animals for testing machined implants, sandblasted were analyzed via biomechanical histo- sandblasted, sandblasted and coated with HA; ana- morphometric methods in rats. lyzed at 2, 4 and 8 weeks; 24 animals for histological IC In the study the HA used as an addition to implants analysis for the groups of sandblasted and for sand- surface is 55% crystalline and causes an increase of blasted and coated with HA; analyzed at 2 and 4 the surface area by 70% when compared to uncoat- weeks). HA-coated implants showed an increased ed microrough surfaces. Furthermore, hydroxyapatite percentage of bone-implant contact and an increase C is free of impurities, with a calcium/phosphate ratio in bone volume within 50 μm close to the implant of 1.66, thus being equivalent to the stoichiometric surface. On the contrary, around implants coated value of HA. Titanium cylinders (1 mm in diameter with HA, the bone volume outside the boundary of 50 and 2 mm long) were obtained from Grade 5 titanium μm was low. In particular, this study demonstrated alloy (Ti-6Al-4V). In order to create the micro-rough- that nano-crystalline hydroxyapatite is indisputably © ness, titanium samples were sandblasted with alu- effective in increasing osteoconductivity and inhibit- minum oxidemicro-powder. The HA coating was ob- ing the infiltration of soft tissue around the implant, tained by flame spray on blasted surfaces. The flame but the effect is quite limited to the microenvironment was created by means of acetylene and oxygen, and around the implant. the air was used as a high-speed carrier. All exam- Ceramic nanoparticles represent an encouraging ined surfaces were inspected by scanning electron class of bone graft substitutes due to their improved 112 Annali di Stomatologia 2014; V (3): 108-114  Nano-hydroxyapatite and its applications in preventive, restorative and regenerative dentistry: a review of literature osteointegrative properties. Nano-crystalline hydrox- (Mv) 18 k Dawas used, derived from BASF (Lud- yapatite binds bone and stimulates bone healing en- wigshafen, Germany). The suspension of nano-hy- couraging osteoblastic activity. In the study conduct- droxyapatite used for the compound was prepared ed by Singh et al. in 2012 (11), the authors examine with a wet method and hydrothermal treatments. The the clinical and radiographic results obtained with proliferation of BMSCs culture on nHA/PA66 mem- i NCHA bone graft (Sybograf®) associated with colla- branes has been tested with the MTT method (MTT: al gen membranes (Periocol ® ), compared with OFD [3 - {4,5-dimethylthiazol-2YL}-2,5-diphenyl-2H-tetra- (Open Flap Debridement) in the treatment of intra- zoliumbromide]), and it was found to be higher than bony periodontal defects. the negative control group after 1 and 4 days of incu- on In the work on the comparison between NCHA asso- bation and, moreover, did not appear to have any ciated bone grafts with collagen membranes and tra- significant differences after 7 and 11 days of culture. ditional OFD technique, Singh et al. (11) designed a The results of the cell cycle suggest that the mem- controlled randomized clinical trial in parallel groups. brane has no negative influence on cell division. The zi Eighteen intrabony defects in 14 patients aged be- membrane has an asymmetric porous structure, in tween 25 and 65 years were randomly assigned to a which pores smaller than 10 microns are distributed test group and to a control group. The plaque index, on one side (microporous layer), while pores ranging na the gingival index, the PPD (probing pocket depth), between 30 and 200 μM are located on the opposite the clinical attachment level (CAL) and the gingival side (macroporous layer). The microporous layer of recession (REC) were recorded at baseline, and were the membrane prevents the migration of fibrous con- reassessed 6 months later (Tab. 4). Furthermore, nective tissue in bone defects, being also able to per- bone grafts were evaluated through digital software. meate sufficient nutrients for regenerating tissue. The er In the test sites they have placed NCHA bone graft results show that n-HA/PA66 membrane is a 3D with collagen membranes, while in control sites they porous structure with a dense microporous layer on performed only OFD. Recall appointments were set at one side and with a spongy microporous layer on the 7 days, 30 days, and then at 3 months and 6 months other side. In vitro experiments show that nHA/PA66 (Tab. 4). The association between resorbable mem- t membrane has a good affinity for attaching to BM- branes, derived from fish, and NCHA bone grafts is In SCs, and a non-negative effect on cells viability and particularly positive as concern to the improvement of proliferation. The results of in vitro and in vivo studies periodontal indices. This work has clearly shown that indicate that the nHA/PA66 membrane has an excel- the additional use of resorbable membranes derived lent biocompatibility and is indicated for use in guid- from fish in combination with NCHA bone grafts is ed tissue regeneration (GTR) or GBR. ni clinically, radiographically and statistically significant Recent studies suggest that nano-crystalline hydrox- compared to OFD alone, in terms of reduction of yapatite (nano-HA) paste represents a promising PPD, CAL gain and percentage of bone filling. class of grafting bone substitutes. The study of Kasai io In the study by Qu et al. in 2010 (12), the use of a et al. of 2008 (13) was conducted to investigate the bioactive and osteoconductive composite formed by proliferation of human periodontal ligament (PDL) in nano-hydroxyapatite and polyamide 66 (nHA/PA66) cell cultures, in the presence of a nano-HA paste, iz was tested, for the creation of a new asymmetric and to analyze cells’ associated signal paths. In this porous membrane to be used for guided bone regen- experimental research on the consequences of the eration (GBR). Regarding the membranes, they ana- application of nano-HA in cell culture with human pe- Ed lyzed the cytotoxicity of the material, the response of riodontal ligament (PDL), PDL cells were stimulated the surfaces to bone formation, the morphology, pro- with pastes of nano-HA and with an enamel matrix liferation and cell cycle progression of bone marrow derivative (EMD) in a soluble form. The proliferation stromal cells (BMSCs) in rat culture. The polygonal of PDL cells was determined by analyzing the incor- and fusiform shape of BMSCs was observed using a poration of bromodeoxyuridine (BrdU) in the DNA of scanning electron microscope (SEM). In the research proliferating cells. In order to understand the mecha- IC the PA66 with an average viscosity, molecular weight nism that underlies the increase in cell proliferation of PDL cells exposed to nano-HA, the phosphoryla- Table 4. The plaque index, the gingival index, the PPD tion of serine/threonine protein kinase Akt was ana- (probing pocket depth), the clinical attachment level (CAL) lyzed using phospho-specific antibodies. The nano- and the gingival recession (REC). C HA paste showed a potential for proliferation, two times lower than EMD, but both substrates signifi- Control group Test group cantly increased the proliferation rate (p<0.05) in PPD reduction 3.22 ± 1.09 mm 4.33 ± 0.5 mm comparison to the negative control group. In conclu- p = 0.007 p = 0.007 © sion, it seems that the growth and proliferation rate CAL gain 2.77 ± 1.09 mm 3.77 ± 0.66 mm of PDL cells in the presence of nano-HA paste is me- p = 0.006 p = 0.006 chanically connected to the activation of the receptor REC increase 0.55 ± 0.72 mm 0.49 ± 0.52 mm for the epidermal growth factor receptor (EGFR) and p = 0.025 p = 0.046 its downstream targets ERK1/2 and Akt. In conclu- Main gain in filled 2.07 ± 0.67 mm 0.91 ± 0.21 mm sion, these studies suggest that nano-HA paste is a radiografic defect p = 0.007 p = 0.008 potent stimulator of cell proliferation, which probably Annali di Stomatologia 2014; V (3): 108-114 113  E. Pepla et al. contributes to the fundamental process of periodon- this revolutionary substance and a growing number of tal tissue regeneration. scientific articles on the subject. Final remarks References i al The nano-hydroxyapatite is a revolutionary material 1. Moshaverina A, Ansari S, Moshaverina M, Roohpour N, Darr with a wide use in dentistry. With regard to restorative J. A, Rehman I. Effect of incorporation of hydroxyapatite and and preventive fields, nano-hydroxyapatite has re- fluoroapatitenanobioceramics into conventional glass ionomer on cements (GIC). Acta Biomaterialia. 2008;Volume 4, Issue 2, markable remineralizing effects on initial lesions of March:432-440. enamel, certainly higher than traditional fluorides used 2. Moshaverina A, Ansari S, Movasaghi Z, Billington RV, Darr until now for this purpose. Nano-hydroxyapatite is, in JA, Rehman IU. Modification of conventional glass-ionomer fact, a better source of free Ca, and this is a key ele- cements with N-vynilpyrrolidone containing polyacids, nano- ment as regards the remineralization, the protection zi hydroxy and fluoroapatite to improve mechanical properties. against caries and dental erosion. With regard to the Dent Mater. 2008 Oct;24(10): 1381-90. Epub 2008 Apr 22. latter point, of fundamental importance in dentistry, 3. Tschoppe P, Zandim DL, Martus P, Kielbassa AM. Enam- the road leading to the addition of small percentages el and dentin remineralization by nano-hydroxyapatite tooth- na of nano-HA (0.25%) in beverages such as mineral pastes. J Dent. 2011 Jun;39(6):430-7. Epub 2011 April 8. supplements for sports activities, in order to prevent 4. Huang S, Gao S, Cheng L, Yu H. Remineralization poten- tial of nano-hydroxyapatite on initial enamel lesion: an in vit- tooth erosion caused by those drinks, seems very ro study. Caries Res. 2011;45(5):460-8. Epub 2011 Sep 2. promising. Nano-HA has also been used as a supple- 5. Huang SB, Gao SS, Yu HY. Effect of nano-hydroxyapatite con- er mentary material, in order to improve the dental mate- centration on remineralization of initial enamel lesion in vitro. rials already existing and widely used. This is the case Biomed Master. 2009 Jun 4;(3):034104. Epub 2009 Jun 5. of the experimental addition to traditional GIC, a pro- 6. Min JH, Kwon HK, Kim BI. The addition of nano-sized hy- cedure that has led to significant improvements in the droxyapatite to a sport drink to inhibit dental erosion: in vit- mechanical properties of these substances. t ro study using bovine enamel. J Dent. 2011 Sep,39(9):629- In A continuing interest in the nano-crystalline structure of hydroxyapatite has prompted many researchers to 35. doi: 10.1016/j.dent.2011.07.001. Epub 2011 Jul 7. 7. Hangoo R, Abbasi F, Rezvani MB. Evaluation of the effect of nanohydroxyapatite on erosive lesions of the enamel of look for new combinations that could improve existing permanent teeth following exposure to soft beer in vitro. Sci- materials or create new ones that could meet their entific Research and assays. 2011;vol 6 (26):5933-5936. needs. This has led to new complex compounds, 8. Orsini G, Procaccini M, Manzoli L, Sparabombe S, Triduzzi ni such as nano-HA associated with zinc carbonate, P, Bambini F, Putignano A. A 3-day randomized clinical tri- which seems to be an excellent material for the rem- al to investigate the desensitizing properties of three denti- ineralization of initial lesions involving enamel and fricies. J Periodontal. 2013 Nov;84(11):e65-73. doi: io dentin, or as the nano-HA associated with the 10.1902/jop.2013.120697. Epub 2013 Mar 14; polyamide 66, used in order to create a new peri- 9. Browing WD, Sopanis DC, Deschepper EJ. Effect of nano- odontal membrane with improved properties. hydroxyapatite Paste on Bleaching-related Tooth Sensitiv- Noteworthy are the applications of nano-HA in fields ity. Journal of Esthetic and restorative Dentistry. 2011. iz 10. Masahiro Y, Takeshi U, Naoki T, Takayuki I, Kaori N, Norio other than strictly restorative or preventive. Because H, Takeo S, Takahiro O. Bone integration capability of of its unique properties, such as the ability to chemi- nanopoyimorphic crystalline hydroxyapatite coated on tita- cally bind to bone, without inducing toxicity or inflam- Ed nium implants. Int J Nanomedicine. 2012;7:859-873. mation and stimulating bone growth through a direct 11. Singh VP, Nayak DG, Shah D. Clinical and radiographic eval- action on osteoblasts, nano-HA has been widely used uation of Nano-crystalline hydroxyapatite bone graft (Sybo- in periodontology and in oral and maxillofacial graft) in combination with bioresorbable collagen membrane surgery. Collagen membranes associated with nano- (Periocol) in periodontal intrabony defects. Dent Res J (Is- HA are used to fill bone defects, since this substance fahan). 2012 Jan;9(1):60-7. leads to a clear improvement in periodontal indices. 12. Qu Y, Wang P, Man Y, Li Y, Zuo Y, Li J. Preliminary bio- IC compatible evaluation of nano-hydroxyapatite/polyamide 66 Its use in the field of implantology, instead, is a prac- composite porous membrane. Int J Nanomedicine. 2010 Aug tice widely used and has been consolidated in recent 9;5:429-35. years, since the nano-hydroxyapatite has excellent 13. Kasai A, Willershausen B, Reichert C, Rohring B, Smeets osteoinductive capacity and improves osteointegra- R, Schmidt M. Ability of nanocrystalline hydroxyapatite paste C tion in bone-implant interface. It is therefore natural to to promote human ligament cell proliferation. J Oral Sci. 2008 expect for the coming years an increased interest in Sep;50(3):279-85. © 114 Annali di Stomatologia 2014; V (3): 108-114 

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Original article Survival of post-treatment canine-to-canine lingual retainers with fiber-reinforced composite resin: a retrospective study i al on Davide Farronato, DDS, PhD1 ly understood, but relates to a number of factors, includ- Roberto Briguglio, MD, DDS2 ing periodontal and occlusal factors, soft tissue pres- Francesco Mangano, DDS1 sures and growth (1). This has led many orthodontists to Lorenzo Azzi, DDS3 conclude that permanent retention may be the only reli- Giovanni Battista Grossi, MD, DDS3 able way to keep ideal alignment after treatment (2-9). zi Francesco Briguglio, DDS, PhD2 Many appliance types have been used for the reten- tion of posttreatment tooth position, both fixed (10) and removable (11). In order for retainers to be ac- na 1 Department of Morphologic and Surgical Sciences, ceptable they must maintain the teeth in position Insubria University, Varese, Italy without compromising oral health. They must also be 2 Department of Experimental Sciences and Dentistry acceptable to patients and be reliable (12). Specialist Medical-Surgical, University of Messina, At the present, two types of fixed retainers are in use: Italy er a heavier wire bonded only on the canines and a 3 Department of Biomedical, Surgical and Dentistry lighter wire, usually multi-stranded, bonded to both Science, University of Milan, Italy the incisors and the canines (13-15). As an alternative to multistrand wire, the use of fiber-re- t inforced composite (FRC) retainers has been devel- Corresponding author: Francesco Briguglio In oped (16-20). These FRC are available in varying widths and forms, including braided polyethylene fibers Department of Experimental Sciences and Dentistry (Connect®, Kerr Inc, Orange, CA, USA), woven poly- Specialist Medical-Surgical, University of Messina ethylene fibers (Ribbond®, Ribbond Inc., Seattle WA, Viale Gazzi USA) as well as other fiber types and forms. The clini- ni 98100 Messina, Italy cians may use strips of reinforcing fiber bundles that al- E-mail: fra.briguglio@alice.it ready have been impregnated with resin in a prior con- trolled manufacturing process or may incorporate a low- io viscosity dental resin into the reinforcement at chair- Summary side. Whether the FRC is prepared by the dentist or purchased already impregnated, it is usually applied in The aim of the study is to evaluate the long term conjunction with a restorative composite in the fabrica- iz results of ribbond retainer after orthodontic treat- tion of a two component fixed splint. The FRC material ment. One hundred and thirty patients who were is used as a substructure to provide increased strength orthodontically treated satisfied the inclusion cri- and rigidity beneath an outer layer of particulate com- Ed teria of having received a semipermanent reten- posite, which provides an aesthetic appearance and tion were treated with FRC lingual retainers (Rib- better wear resistance (21). bond®). It was performed a follow up evaluation Several studies have assessed the effectiveness of dif- after 2 years average from the retainer application ferent types of bonded wire retainers (22-30), showing and any complication or failure was recorded. a large range in failure rates. Unfortunately, limited Data from 119 remaining patients that met the in- clinical information is available concerning the reliabili- IC clusion criteria were analyzed and no instances of ty of FRC retainers for long term retention of mandibu- loosening were observed. It may be concluded lar and maxillary anterior segment from canine-to-ca- that orthodontic canine-to-canine FRC retainers nine after orthodontic treatment (12, 31, 32). provide aneffective means of retaining realigned Therefore, the aims of this study were to retrospec- C anterior teeth for at least two years. tively evaluate the clinical survival rate of FRC lingual retainers by means of a historic cohort study, and to Key words: retention, ribbond, orthodontic treat- investigate the influence of gender, patient age and ment, FRC, movement of relapsing. retainer location on survival. © Introduction Materials and methods Retention is the phase of orthodontic treatment that at- Sample tempts to maintain teeth in their corrected positions after active tooth movement. The etiology of relapse is not ful- The records of individuals participating in this study Annali di Stomatologia 2014; V (3): 81-86 81  D. Farronato et al. were selected from a larger pool of patients treated at mined by closely adapting a piece of tinfoil to the lin- the practice of the first author (D.F.). gual festooning of the teeth (Fig. 2). The required One hundred and thirty patients who were orthodonti- length of Ribbond was cut with a special scissors cally treated satisfied the inclusion criteria of having (Ribbond fiber cutter, Ribbond Inc., Seattle WA, USA) received a semipermanent retention between January supplied by the manufacturer to prevent unraveling. i 2004 and July 2006. All identical type of FRC lingual The fiber ribbon was saturated with a few drops of al retainers (2 mm woven polyethylene ribbon-rein- bonding agent (Clearfil Se Bond, Kuraray America, forced; Ribbond ® , Ribbond Inc, Seattle WA, USA) Inc. New York, NY, USA) and embedded with flow (Fig. 1) were bonded from canine to canine in the (Enamel Plus HFO Flow, Micerium, Avegno GE Italy). on maxilla, mandible or in both arches, using the same Care was taken to keep the wet ribbon away from light procedures with the same materials, by a single oper- to prevent initial polymerization, which would interfere ator. Periodontally unhealthy teeth were excluded as with its manipulation. The wetted Ribbond was placed fmps and fmbs was not lower than 20% or if any tooth and the flosses were bent in an upward direction to was mobile or prosthetically restored. Composite position the FRC just above the interproximal areas. zi restorations were accepted in inclusion criteria but in The Ribbond was closely adapted into the interproxi- those cases sandblasting was performed under dam mal contacts against the teeth by the help of instru- to increase the retainer adhesion. ments and light cured for 40 seconds from lingual and na proximal directions. Then, flosses were removed and fibers were coated approximately 0,5 mm with another Application of retainers layer of light-cured composite (Enamel plus HFO, Micerium, Avegno GE Italy) and the embrasures were er Routine adhesive removal and polishing were per- shaped in order to facilitate good oral hygiene, paying formed (33) and instruction in oral hygiene were care- attention not to have any part of the fiber exposed fully carried out before FRC retainers were inserted. (Fig. 3). Excess resin was removed and a thin applica- The technique for placing the FRC retainer included tion of glycerin was placed on all the retainer to pre- t placement of the dental dam extending to the first pre- In molars bilaterally. Tooth surfaces from canine to ca- nine were etched with a 37% orthophosphoric acid gel for 30 seconds, then rinsed with an oil-free air-water spray for 40 seconds and left slightly moist for the wet bonding technique. An adhesive system (Clearfil Se ni Bond, Kuraray America, Inc. New York, NY, USA) was applied following the manufacturer’s instructions, us- ing a disposable brush and including the interproximal io surfaces and facial areas. The resin was not light cured at this time. Five 30-cm pieces of dental floss (Crest Glide, Procter & Gamble, Cincinnati, Ohio USA) were cut and tied all together at one end. Keep- iz ing the knot on the facial side, the free ends of the floss were threaded into inter-canine interproximal spaces and pulled lingually. A thin layer of flowable Ed composite (Enamel Plus HFO Flow, Micerium, Avegno Figure 2. Placing flosses into inter-canine interproximal GE Italy) was placed onto the lingual surface from ca- spaces and determination of the required length of ribbon nine-to-canine and light cured for 20 seconds. The by adapting a piece of tinfoil to the lingual surface of the dental arch length from canine to canine was deter- teeth. IC C © Figure 1. Two mm wide Ribbond® used as orthodontic lin- gual retainer. Figure 3. The lower FRC retainer in place. 82 Annali di Stomatologia 2014; V (3): 81-86  Survival of post-treatment canine-to-canine lingual retainers with fiber-reinforced composite resin: a retrospective study vent the formation of an oxygen-inhibiting layer on the Statistical analysis resin. The FRC retainer was subsequently polymer- ized from all aspects (e.g. facial, incisal, lingual, proxi- Statistical analysis was performed using the Statisti- mal) for 60 seconds, respectively. Finally, after re- cal Package for Social Sciences (version 18.0, SPSS moval of the rubber-dam, the occlusion was checked Inc., Chicago, Illinois, USA). Descriptive statistics and i with the use of a 32-µm articulation paper and adjust- Kaplan-Meier curves were calculated. al ed if necessary. Survival was defined at two levels: functional survival Every patient was clearly informed of the importance (endpoints: absolute failures) and overall survival of oral hygiene by giving more attention to plaque (endpoints: both absolute and relative failures). Ob- on control and was instructed to use dental floss for servations with no event in the respective analysis proper interproximal oral hygiene. were censored at the end of the individual observa- tion period. Kaplan-Meier survival analyses were done for the complete group of FRC retainers and Follow-up and definition of clinical events discriminated according to gender, age of the groups zi and retainer location. Average follow up was 39.9 months (median 40.7 months, IQR 14.9, months, SD 13.3 months). After na bonding, the patients were recalled for clinical ex- Results aminations every 6 months, or when the patients re- ported a failure. During the follow-up period all inter- Of 130 patients, eleven were not able or willing to be ventions were recorded, such as polishing and fin- clinically evaluated. Therefore, data from 119 remain- er ishing after chipping of small fragments of the resin ing patients that met the inclusion criteria were in- composite, repair of small delaminations with cluded in the analysis. Of these, 15 patients had FRC restorative resin composite, or rebonding of FRC re- retainers in both arches, so that a total of 134 FCR tainer after loosening. retainers were studied. If the FRC retainers debonded were lost during the t The maximum follow-up period was 61.4 months (me- follow-up period, they were registered as “absolute failure”. When less severe clinical events occurred, In dian 40.7 months, IQR 14.9, mean 39.9 months, SD 13.3). Most of the patients were adults, with a median such as fracture or delamination of the composite age of 32.5 years at the time of follow-up examination. without loosening of the bond between composite No instances of loosening were observed, therefore the and the teeth bonded, the FRC retainers were re- functional survival rate was 100%. Table 1 shows a ni paired and the event was registered as “relative fail- summary of the demographic characteristics of the pa- ure” (Fig. 4a, b). tient population and the effect of confounding factors on The wearing time was measured in months and was the overall survival rate. In total, relative failure (fracture io calculated as the time between bonding and any clini- or delamination of the composite) was recorded in 25 cal event recorded as failure. Only the first failures FRC retainers, corresponding to 18.7% of the 134 re- were counted and a reported failure in the maxilla or tainers bonded. Conversely, the present study shows in the mandible was counted as a separate incidence. that the FRC location exerted a significant influence on iz In addition, multiple failure sites in one retainer were the failure rate. In fact, the incidence of relative failures counted as one failure. All data were recorded by be- was remarkably lower for the mandibular than for the ing typed directly into an anonymized database. maxillary FRC retainers. Ed IC C a b © Figure 4. (a) FRC retainer’s relative failure at 60 months’ follow-up. (b) Higher magnification of the retainer, showing inter- proximal delamination and fracture of the composite (arrows). Is possible to notice plaque accumulation in correspondence to the gap, the interproximal wire can’t pass between teeth and demonstrate the fiber integrity. In this condition fiber keepon helding the fractured parts together avoiding teeth migration (Pekka K. Vallittu: Ultra-high-modulus polyethylene ribbon as reinforcement for denture polymethyl methacrylate: A short communication, Dent Mater 13:381-382, November,1997), but there could be high risk of infiltrating caries in the interproximal area and unaesthetic discoloration. Annali di Stomatologia 2014; V (3): 81-86 83  D. Farronato et al. Figure 5 shows that the cumulative overall survival passive at the time of bonding, the teeth may move. rate for the FRC retainers was 81.3%. Kaplan-Meier Another technique-related problem is frequent bond overall survival rates at 5 years were higher for failure, either in the wire/composite interface if too lit- mandibular retainers (86.3%) compared to maxillary tle composite is added, or in the adhesive/enamel in- retainers (65.6%). These differences in survival per- terface in situations with moisture contamination or i centages were statistically different (Fig. 6, log rank retainer movement during the bonding procedure al test, P=0.007). (34). In addition to bond failure, stress fracture of the interdental wire segments was reported (22). Some clinical studies have shown that there is a relatively on Discussion high failure rate ranging between 10.3 to 47%, de- pending on the technique used and follow-up obser- Orthodontic canine-to-canine retainers are frequently vation period (22, 27-29, 35). used to avoid relapse and secondary crowding of in- Recently, FRC materials have been introduced for cisors. Such retainers may either be fixed or remov- the fabrication of fixed dental prostheses, root posts zi able. Fixed lingual retainers were introduced in the and periodontal splints and much research is current- 1970s (10) and are often made of stainless steel ly being conducted for these clinical applications (36- wires. The major advantage of bonded canine-to-ca- 43). Conversely, very few studies have focused on na nine retainers relative to removable is that they are the use of FRCs as orthodontic retainers (31, 44, 45). compliance free. However, if the retainer wire is not A main advantage of a FRC retainer compared with the classic twist-flex retainer is its high transparency, result- ing in an almost invisible retainer (Fig. 7a-c). The re- er tainer can thus be placed close to incisal edge. This is an advantage from both biological and biomechanical points of view (44). One major disadvantage of the FRC retainer is that the placement procedure is time t consuming and technique sensitive. Moreover, it is In more expensive than other types of bonded retainers. To the best of our knowledge, this is the first large investigation to have analyzed the clinical survival rate of FRC lingual retainers for a long follow-up pe- riod. Of the 134 orthodontic retainers being followed ni none have exhibited debonding and the only kind of failure was fracture or delamination of the interproxi- mal composite (18.7%) without loosening of the bond io between composite and the 804 teeth bonded. Therefore, 100% of the retainers were still in place after 5 years. These results are substantially different from those iz obtained in the clinical trial by Rose et al. (36), in Figure 5. Kaplan-Meier survival curve showing a 81.3% which a total of 20 patients were assigned to receive success rate for the FRC retainers over a 61.4 month Ribbond® fiber or multistranded wire canine-to-canine Ed period. retainers. In terms of survival time, the results report- ed by Rose would suggest that the multistranded wire is significantly superior to the FRC retainer. It should, however, be noted that their sample size was only 10 for each group and no sample size calculation were reported. Moreover, the protocol described in the IC Rose’s article would be counter to the protocols used for the construction of any fiber-reinforced structure (44, 46-48). In fact, the authors polymerized the com- posite before applying the fiber and did not adapt the C fiber closely against the teeth. Conversely, in the cur- rent study the manufacturer’s instructions were fol- lowed (14). In order for fiber to work, the resin com- posite was not cured until after the fiber was closely © adapted against the tooth surface. In fact, placing the fiber against the surface minimizes the bond line thickness between the teeth and the fiber and, just like orthodontic brackets, the thinner the layer of bonding resin composite between the teeth and the laminate, the better the results. Whichever reinforce- Figure 6. Survival percentages. ment technique is used, it is critical that manufactur- 84 Annali di Stomatologia 2014; V (3): 81-86  Survival of post-treatment canine-to-canine lingual retainers with fiber-reinforced composite resin: a retrospective study explanation for this could be that all FRC retainers were applied by only one operator in our study, using the same materials and the same bonding techniques un- der rubber dam isolation. In fact, the bonding proce- dures are technique sensitive and factors such as i minute movements of the retainer during the setting al process of the adhesive or a lack of moisture control (49) could impair ideal adhesion. Dahl and Zachrisson’s (14, 15) reported the lower failure rates (9.8% of loos- on ening and wire fracture over a 38-month-observation period) with the use of the five-stranded spiral wire re- tainers (Penta-One), bonded by the same orthodontist. In a long-term clinical study where the retainers were a bonded by 15 different operators Foek et al. (23) re- zi ported a failure rate of 37.9%. Interestingly, however, they found that neither different operators nor experi- ence played a significant role in failure rate. na Finally, our data showed no significant differences in failure rates between genders and age, in agreement with the findings of previous studies (23, 24). More- over, in keeping with other studies (22, 24, 50, 51), er there is clear evidence that FRC retainers in the up- per arch are much more likely to fail than in the lower arch, and this may reflect the role of occlusal factors in the failure of these retainers (29). t b In Conclusions It may be concluded that orthodontic canine-to-canine FRC retainers provide an effective means of retaining ni realigned anterior teeth for at least five years. Careful preparation and adaptation of the Ribbond® fiber along with strict moisture control are the critical io steps for success in the FRC retainers. Nevertheless, there is a need for further controlled studies, both in vitro and in vivo, to validate the find- ings of this investigation. iz References Ed c Figure 7. (a) Mandibular FRC retainerat five-year follow-up 1. Melrose C, Millett DT. Toward a perspective on orthodontic showing (b,c) good aesthetics. retention? Am J Orthod Dentofacial Orthop. 1998;113:507-514. 2. Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Wor- thington HV. Orthodontic retention: a systematic review. J er’s instructions be followed. These reinforcement Orthod. 2006 Sep;33(3):205-12. materials are technique sensitive, meaning that the IC 3. Cerny R. The reliability of bonded lingual retainers. Aust Or- material does not perform well if its method of use is thod J. 2007;23:24-29. left to uninformed technical application or random 4. Durbin DD. Relapse and the need for permanent fixed re- chance (14). tention. J Clin Orthod. 2001; 35:723-727. The principal reason given by Rose et al. (31) for the 5. Salehi P, Zarif Najafi H, Roeinpeikar SM. Comparison of sur- C reduced reliability of the ribbon-reinforced retainers vival time between two types of orthodontic fixed retainer: was that FRC materials would possess greater yield a prospective randomized clinical trial. Prog Orthod. 2013 Sep strength than the wire, holding the teeth in a rigid 11;14:25. manner and resulting in more likely debonding. Foek 6. Lassaire J, Costi A, Charpentier E, Castro M. Post-orthodontic intra- and interarch changes at 1 year: a retrospective study © et al. (45) recently compared the bond strength of assessing the impact of anterior fixed retention. Int Orthod. various stainless orthodontic wires vs various FRC 2012 Jun;10(2):165-76. retainers and found no significant differences be- 7. Stability and relapse of dental arch alignment. Little RM. Br tween the wire groups and the Ribbond® retainers. J Orthod. 1990 Aug;17(3):235-41. Interestingly, the failure rates recorded in the present 8. Nanda RS, Nanda SK. Considerations of dentofacial growth investigation are also more favorable than those pub- in long-term retention and stability: is active retention need- lished previously for stainless steel wires (1, 35). One ed? Am J Orthod Dentofacial Orthop. 1992;101:297-302. Annali di Stomatologia 2014; V (3): 81-86 85  D. Farronato et al. 9. Parker WS. Retention—retainers may be forever. Am J Or- 32. Cordasco G, Farronato G, Festa F, Nucera R, Parazzoli E, thod Dentofacial Orthop. 1989;95:505-513. Grossi GB. In vitro evaluation of the frictional forces between 10. Butler J, Dowling P. Orthodontic bonded retainers. J Ir Dent brackets and archwire with three passive self-ligating brack- Assoc. 2005 Spring;51(1):29-32. ets. Eur J Orthod. 2009;31:643-6. 11. Hawley CA. A removable retainer. Int J Orthod. 1919;2:291- 33. Ardeshna AP. Clinical evaluation of fiber-reinforced-plastic i 298. bonded orthodontic retainers. Am J Orthod Dentofacial Or- al 12. Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Wor- thop. 2011 Jun;139(6):761-7. thington HV. Orthodontic retention: a systematic review. J 34. Patcas R, Pedroli G. A bonding technique for fixed maxillary Orthod. 2006;33:205-212. retainers. J Orthod. 2012 Dec;39(4):317-22. 13. Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Wor- 35. Lie Sam Foek DJ, Ozcan M, Verkerke GJ, Sandham A, Dijk- on thington HV. Retention procedures for stabilising tooth po- stra PU. Survival of flexible, braided, bonded stainless steel sition after treatment with orthodontic braces. Cochrane Data- lingual retainers: a historic cohort study. Eur J Orthod. base Syst Rev. 2006:CD002283. 2008;30:199-204. 14. Zachrisson BU. The bonded lingual retainer and multiple spac- 36. Deliperi S, Bardwell DN. Reconstruction of nonvital teeth us- ing of anterior teeth. Swed Dent J Suppl. 1982;15:247-255. ing direct fiber-reinforced composite resin: a pilot clinical study. zi 15. Zachrisson BU. Long-term experience with direct-bonded re- J Adhes Dent. 2009;11:71-78. tainers: update and clinical advice. J Clin Orthod. 2007;41:728- 37. Eminkahyagil N, Erkut S. An innovative approach to chair- 737;quiz 749. side provisional replacement of an extracted anterior tooth: na 16. Wu HM, Zhang JJ, Pan J, Chen D. Clinical evaluation of glass use of fiber-reinforced ribbon-composites and a natural tooth. fiber-reinforced composites for fixed orthodontic lingual re- J Prosthodont. 2006;15:316-320. tainers. Shanghai Kou Qiang Yi Xue. 2014 Feb;23(1):80-2. 38. Miller TE, Hakimzadeh F, Rudo DN. Immediate and indirect 17. Freudenthaler JW, Tischler GK, Burstone CJ. Bond strength woven polyethylene ribbon—reinforced periodontal-prosthetic of fiber-reinforced composite bars for orthodontic attachment. splint: a case report. 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Five-year sur- 21. Strassler HE, Serio CL. Esthetic considerations when splint- vival of 3-unit fiber-reinforced composite fixed partial dentures ing with fiber-reinforced composites. Dent Clin North Am. in the anterior area. Dent Mater. 2009;25:820-827. ni 2007;51:507-524; xi. 42. Van Wijlen P. A modified technique for direct, fibre-reinforced, 22. Andren A, Asplund J, Azarmidohkt E, Svensson R, Varde P, resin-bonded bridges: clinical case reports. J Can Dent As- Mohlin B. A clinical evaluation of long term retention with bond- soc. 2000;66:367-371. ed retainers made from multi-strand wires. Swed Dent J. 43. Wolff D, Schach C, Kraus T, Ding P, Pritsch M, Mente J, Jo- io 1998;22:123-131. erss D, Staehle HJ. Fiber-reinforced Composite Fixed Den- 23. Artun J, Spadafora AT, Shapiro PA. A 3-year follow-up study tal Prostheses: A Retrospective Clinical Examination. J Ad- of various types of orthodontic canine-to-canine retainers. hes Dent. 2010. iz Eur J Orthod. 1997;19:501-509. 44. 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Original article A multimedia oral health promoting project in primary schools in central Italy i al on Iole Vozza, DDS, PhD media educational approach has proved a valu- Fabrizio Guerra, MD, DDS able and updated tool to attract the attention of Massimiliano Marchionne, BSDH digital native children. Ercole Bove, MD, DDS Denise Corridore, DDS Key words: oral health, health promoting school, zi Livia Ottolenghi, DDS primary school. na Department of Oral and Maxillo Facial Sciences, “Sapien- Introduction za” University of Rome, Italy As children spend a considerable proportion of their lives in education, schools can play a significant role in promoting their oral health. Schools reach over 1 er Corresponding author: Iole Vozza billion children worldwide and are recognized as use- Department of Oral and Maxillo Facial Sciences, ful settings for health promotion (1). Oral health mes- “Sapienza” University of Rome sages can be reinforced during the school years, Via Caserta 6 t which are the most influential stages of children’s 00161 Rome, Italy E-mail: iole.vozza@uniroma1.it In lives. Health promoting schools (HPS) is increasingly adopted as an approach to guide supportive practices in promoting the development of healthy behaviors in the early years. Health promotion was codified by Ot- Summary tawa Charter for Health Promotion in the First Inter- ni national Conference on Health Promotion, on 1986. Aim. The purpose of the study Project was to test The European Network of Health-Promoting Schools the effectiveness of a multimedia game designed (ENHPS) started in 1992, followed by the establish- io in order to attract the attention of primary school ment of the WHO Global School Health Initiative in children to oral health basic concepts and use the 1995 (2). The Ottawa Charter for Health promotion instrument to assess students’ knowledge. was thereby transformed into practice. Encouraging Materials and methods. An originally designed children to adopt healthy lifestyle habits is a central iz multimedia game on oral health was administered objective, and health promotion at a community level, in the computer class rooms, before (T0) and after particularly through health promoting schools, may be (T1) an educational stage, to third (8-9 years) and an effective strategy. Thus, a Health Promoting Ed fifth graders (10-11 years) of primary schools in School should aim to: urban and rural areas of two provinces of medi- • Promote lifestyles conducive to good health um-small cities in Center Italy (Terni and Latina). • Provide an environment supporting healthy Considered variables were: age, gender, school lifestyles time schedule (only antemeridian, extended • Give students and staff the ability to take action schedule). The statistical test used was the non- for a healthier community and healthier living con- IC parametric Wilcox on signed-rank test. ditions (3). Results. Response rate was 90.6% (due to ab- The influence of childhood experiences on health sta- sence on the due date). 1,300 students were in- tus through HPS is well documented and implement- volved. Overall, the average of the correct an- ed worldwide (4-6). Different studies in Italy focused C swers was 40.7% before oral health lessons and the importance of oral health promotion at school (7, 59.2% after. An improving trend of correct an- 8); the Italian Ministry of Health published a volume swers was recorded from T0 to T1, significantly (p about “Promotion and protection of health in children < 0.05) among: fifth graders (+ 17.5%), extended and adolescents: criteria of clinical, technological and © school time schedulers (+18.1%) and females structural appropriateness” in 2012 to promote oral (+18.9%). The results, however, show poor global health among children and adolescents (9) following oral health knowledge, being total percentage of the criteria of the Regional Office for Europe of the correct answers below 60%. World Health Organization developed in the volume Conclusions. The results stress the importance of entitled “Gaining health” (10). Oral health education the school environment as access to health pro- can be taught as a specific subject or as part of motion for all socio-economic classes. The multi- health promotion integrated approaches with active Annali di Stomatologia 2014; V (3): 87-90 87  I. Vozza et al. participation aiming to sustainable changes in health- focused on toothbrush and its use. Once completed related behavior. The purpose of this study was to the questions the multimedia program processed the test the effectiveness of a multimedia game designed answers and the monitor displayed a picture of a in order to attract the attention of primary school chil- cartoon character who lost a couple of teeth for dren to oral health basic concepts and use the instru- each wrong answer. The first pair of teeth on the left i ment to assess students’ knowledge. of the image was associated to the first question al Multimedia approach has been chosen in order to en- and so forth in a sequential manner (Fig. 1). The counter digital natives’ interests and learning strategies. collected data were then statistically analyzed. Con- sidered variables were: age, gender, school time on schedule (antemeridian, extended). The statistical Materials and methods test used was the non-parametric Wilcox on signed- rank test. Third (8-9 years) and fifth graders (10-11 years) of elementary schools in two provinces of medium- zi small cities in Center Italy have been involved in the Results study. The schools were chosen including urban and rural areas of the two provinces. An originally de- The study included 1,300 third (8-9 years) and fifth na signed multimedia game on oral health was adminis- graders (10-11 years) of 14 elementary schools in tered in the computer class rooms, before (T0) and two provinces of medium-small cities in Center Italy after (T1) an educational stage, to the pupils. The (651 students of 6 schools in Terni and 649 students test was completely anonymous and there was no of 7 schools in Latina). The data are summarized in er need of ethical approval. A written informed parental Table 2. Response rate was 90.6% (due to absence consent was collected before the first administra- on the administration date). The results are described tion. The multimedia game consisted of five ques- in Figures 2-4. On 1,300 tested students the average tions on issues referring to the Health Promoting of the correct answers was 40.7% at T0 and 59.2% at Schools program. The study was divided into three t T1. On the whole there was an improving trend of separate phases. The first phase consisted in the administration of questions and data collection. The In correct answers after the educational phase, signifi- second phase was concentrated on oral health lessons in the selected schools. The lessons con- cerned basic knowledge of dental anatomy, meth- ni ods of brushing and proper nutrition. The third and final phase provided for the re-administration of the game, and the subsequent data collection, in order io to assess the learning level. The questions are re- ported in Table 1. The first question reflected, signif- icantly, as well as the knowledge of the role of the dentist, the socio-cultural situation of the family and iz therefore the knowledge of primary oral prevention transmitted to children. The second question was about the right technique of brushing and the third Ed question concerned caries and knowledge of sec- ondary prevention. The fourth question inquired about the importance of fluoride. The fifth question Figure 1. Results of the quiz by a cartoon. Table 1. Multimedia questions about oral health. IC Question 1 Question 2 Question 3 Question 4 Question 5 How often should How do you use What happens if the What is fluoride? How often should you you visit the dentist? your toothbrush? tooth has a cavity? change your toothbrush? C A) Every 2 years A) Fast horizontal A) Decay sooner or A) It protects teeth A) When bristles ruin B) When you need movements in order later goes away by itself from decay B) When it becomes C) Every 6 months to clean all teeth B) It’s possible to stop B) It cleans teeth black B) Gentle circular and small cavities and with the toothbrush C) Once a year short movements in save the tooth C) It freshens breath © order to clean one C) Decay always tooth at a time increases tooth size C) Horizontal and and you can lose vertical movements your tooth in order to clean everything quickly 88 Annali di Stomatologia 2014; V (3): 87-90  A multimedia oral health promoting project in primary schools in central Italy cantly (p < 0.05) in: fifth graders (+ 17.5%), extended school time schedulers (+18.1%) and females (+18.9%). No significant differences were found among schools in urban and rural areas of the two provinces. The results, however, show poor overall i oral health knowledge, being total percentage of cor- al rect answers below 60%. These data are even more worrying, given the simplicity of the administered questions. on Table 2. Sample distribution by variables. zi Latina Terni Total Figure 4. Improving trend of correct answers from T0 to T1 Females 297 311 608 among females. Males 352 340 692 na 3rd Grade 298 304 602 Discussion 5th Grade 351 347 698 Antemeridian schedule 77 92 169 Decay and gum disease are among the most diffused Extended schedule 572 559 1131 conditions in human populations, affecting over 80% Total 608 692 1300 er of school children in some countries (11). Many oral health problems are preventable and their early onset reversible. However, in several countries a consider- able number of children, their parents and teachers t have poor access to oral health care and limited In knowledge of oral health prevention. The problems are exacerbated by the consumption of sugary snacks and carbonated drinks which is high among children and adolescents (12-14). Encouraging children to adopt healthy lifestyle habits, and promoting oral ni health through Health Promoting Schools, may be an effective strategy. Many studies focused on the effect of oral health promoting schools in different countries io (15-20). In Italy this is an ongoing process particularly followed through the project “Guadagnare salute” in collaboration with the Ministry of Health (21). Provid- ing education on oral health in schools helps children iz to develop personal skills, provides knowledge about oral health and promotes positive attitudes and healthy behaviors. In this historical context, children Ed Figure 2. Improving trend of correct answers from T0 to T1 among fifth graders. show a continued interest to multimedia games. For this reason the quiz administered proved of great in- terest among students arousing curiosity and fun. From the analyzed results of this study it was found that 5 graders, as easily conceivable, showed greater knowledge in the field of oral health compared to 3 IC graders. A significant statistical difference was also found among males and females and among children who attended school with extended schedule time and those who attended antemeridian school time sched- C ule. The study revealed an improvement of oral health and prevention knowledge although this result can still be considered inadequate, being total percentage of correct answers below 60%. It’s fundamental improv- © ing knowledge about fluoride and white spot avoiding the onset of carious cavity and subsequent treatment with invasive mechanical aids (22, 23). To build a comprehensive oral health preventive program, three elements are essential that are oral health Figure 3. Improving trend of correct answers from T0 to T1 education/instruction, primary and secondary preven- among extended school time schedulers. tion measures (24). The school plays a crucial role, Annali di Stomatologia 2014; V (3): 87-90 89  I. Vozza et al. raising awareness both for students as parents to sup- siding in four North Italian communities. Oral Health Prev Dent. port a prevention protocol for oral health. In this study 2005;3(1):33-8. school proved to be a suitable environment for testing 9. Ministry of Health. Promotion and protection of health in chil- the multimedia project. In addition, the informed con- dren and adolescents: criteria of clinical, technological and structural appropriateness. 2012. Available from: sent required to parents for quiz administration of stu- i http://www.quadernidellasalute.it/download/download/16- dents, was able to promote parent knowledge and atti- al luglio-agosto-2012-quaderno.pdf tude towards oral health and prevention in order to af- 10. Regional Office for Europe of the World Health Organization. fect their children oral health behavior and status as Gaining health. 2006. Available from: http://www.euro. described in other studies (25, 26). Parents are con- who.int/__data/assets/pdf_file/0008/76526/E89306.pdf on sidered as the key factors for developing children and 11. Global Oral Health Data Bank. Geneva: World Health Or- shaping their healthy behaviors. However despite a ganization; 2004. growing body of research regarding the health-pro- 12. Pizzo G, Piscopo MR, Matranga D, Luparello M, Pizzo I, Giu- moting schools (HPS), research on measuring of the liana G. Prevalence and socio-behavioral determinants of den- HPS is limited and this could be the topic of future tal caries in Sicilian schoolchildren. Med Sci Monit. 2010 zi Oct;16(10):PH83-9. studies. 13. Zaborskis A, Milciuviene S, Narbutaite J, Bendoraitiene E, Kavaliauskiene A. Caries experience and oral health be- na haviour among 11-13-year-olds: an ecological study of data Conclusions from 27 European countries, Israel, Canada and USA. Com- munity Dent Health. 2010 Jun;27(2):102-8. The school has proved an ideal environment for oral 14. Krisdapong S, Prasertsom P, Rattanarangsima K, Sheiham health promotion project, both for the amount of A. Sociodemographic differences in oral health-related quality of life related to dental caries in thai school children. er catchment area, and for efficiency and speed of child population screening. The results stress the impor- Community Dent Health. 2013 Jun;30(2):112-8. 15. Lisboa CM, de Paula JS, Ambrosano GM, Pereira AC, tance of the school environment as where you can Meneghim Mde C, Cortellazzi KL, Vazquez FL, Mialhe FL. access to health services for all socio-economic Socioeconomic and family influences on dental treatment classes. Creating a game from the multimedia fea- t needs among Brazilian underprivileged schoolchildren par- tures, has proved a valuable tool to attract the atten- tion of digital native children. In ticipating in a dental health program. BMC Oral Health. 2013 Oct 19;13:56. 16. Iglesias Guerra JA, Fernández Calvo MT, Barrón Sinde J, Bartolomé Lozano M. Evolution of knowledge and oral hy- References giene habits in primary schoolchildren. Gac Sanit. 2013 Jul- ni Aug;27(4):362-4. 1. Kwan SY, Petersen PE, Pine CM, Borutta A. Health-promoting 17. Takeuchi R, Kawamura K, Kawamura S, Endoh M, Tomiki schools: an opportunity for oral health promotion. Bull S, Taguchi C, Kobayashi S. Effect of school-based fluoride World Health Organ. 2005 Sep;83(9):677-85. mouth-rinsing on dental caries incidence among schoolchildren io 2. Honkala S. World Health Organization approaches for sur- in the Kingdom of Tonga. J Oral Sci. 2012;54(4):343-7. veys of health behaviour among schoolchildren and for health- 18. Matulaitiene ZK, Zemaitiene M, Zemgulyte S, Milciuviene S. promoting schools. Med Princ Pract. 2014;23 Suppl 1:24-31. Changes in dental caries and oral hygiene among 7-8 year- iz 3. The status of school health. Report of the School Health Work- old schoolchildren in different regions of Lithuania 1983-2009. ing Group and the WHO Expert Committee on Compre- Stomatologia. 2012;14(2):53-9. hensive School Health Education and Promotion. Geneva: 19. Yekaninejad MS, Eshraghian MR, Nourijelyani K, Moham- World Health Organization. 1996. mad K, Foroushani AR, Zayeri F, Pakpour AH, Moscowchi Ed 4. Singh S. Evidence in oral health promotion-implications for A, Tarashi M. Effect of a school-based oral health-education oral health planning. Am J Public Health. 2012 program on Iranian children: results from a group random- Sep;102(9):e15-8. ized trial. Eur J Oral Sci. 2012 Oct;120(5):429-37. 5. Jürgensen N, Petersen PE. Promoting oral health of children 20. Pike J, Ioannou S. Evaluating school-community health in through schools—results from a WHO global survey 2012. Cyprus. Health Promot Int. 2013 Aug 8. [Epub ahead of print]. Community Dent Health. 2013 Dec;30(4):204-18. PubMed 21. Available from: http://www.guadagnaresalute.it/ 22. Brostek AM, Walsh LJ. Minimal intervention dentistry in gen- IC PMID: 24575523. 6. Langford R, Bonell CP, Jones HE, Pouliou T, Murphy SM, eral practice. Oral Health Dent Manag. 2014 Jun;13(2):285-94. Waters E, Komro KA, Gibbs LF, Magnus D, Campbell R. The 23. Maguire A. ADA clinical recommendations on topical fluo- WHO Health Promoting School framework for improving the ride for caries prevention. Evid Based Dent. 2014 health and well-being of students and their academic Jun;15(2):38-9. C achievement. Cochrane Database Syst Rev. 2014 Apr 24. Lam A. Elements in oral health programs. N Y State Dent 16;4:CD008958. J. 2014 Mar;80(2):26-30. 7. Panetta F, Dall’Oca S, Nofroni I, Quaranta A, Polimeni A, Ot- 25. Bozorgmehr E, Hajizamani A, Malek Mohammadi T. Oral tolenghi L. Early childhood caries. Oral health survey in kinder- health behavior of parents as a predictor of oral health sta- gartens of the 19th district in Rome. Minerva Stomatol. 2004 tus of their children. ISRN Dent. 2013 May 8;2013:741783. © Nov-Dec;53(11-12):669-78. 26. Garbin C, Garbin A, Dos Santos K, Lima D. Oral health ed- 8. Campus G, Senna A, Cagetti MG, Maida C, Strohmenger ucation in schools: promoting health agents. Int J Dent Hyg. L. Caries experience and status in school-age children re- 2009 Aug;7(3):212-6. 90 Annali di Stomatologia 2014; V (3): 87-90 

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Original article Root canal obturation: experimental study on the thermafil system related to different irrigation protocols i al on Guido Migliau, DDS1 Key words: smear layer, sodium hypochlorite, Afrah Ali Abdullah Sofan, PhD1 EDTA (Ethylene diaminetetraacetic acid), ther- Eshrak Ali Abdullah Sofan, PhD1 mafil, gutta-percha tags, dentinal tubules. Salvatore Cosma, MD2 Stefano Eramo, DDS2 zi Livio Gallottini, DDS1 Introduction Long-term seal of root canal system plays an impor- na 1 Department of Oral and Maxillo-Facial Sciences, tant role in supporting the healing of periapical tis- “Sapienza” University of Rome, Italy sues and prevents intracanal recontamination after 2 University of Perugia, Italy root canal treatment (1). Since a complete apical and coronal seal of the canal system are prerequisites for a successful nonsurgical root canal treatment, the er Corresponding author: comparison and evaluation of current obturation tech- Afrah Ali Abdullah Sofan niques are very important to determine the probability Department of Dental and Maxillo-Facial Sciences, of their efficacy in achieving this optimal goal (2). “Sapienza” University of Rome t Many studies have shown that microleakage adverse- Viale Regina Elena 287/a 00198 Rome, Italy In ly affects the success of root canal therapy (3, 4). Thus, the passage of microorganisms and their toxins E-mail: afrahy28@yahoo.it in the periradicular tissues can induce inflammation in the periradicular tissues (5, 6) and consequently re- duce the success rate of the root canal therapy. A ni three dimensional apical seal, however, that address- Summary es these ramifications will prevent leakage and the potential for reinfection of the root canal and of the io Aim. The aim of this study was to stress the abili- periradicular tissues. With the advent of the thermo- ty of a specific obturation technique (thermafil plasticized gutta-perch technique, new obturation technique) to seal root canal system in presence techniques have been introduced to achieve a three or absence of smear layer. dimensional obturation of the canal system. In 1978, iz Methodology. Sixteen monoradicular teeth, ex- WB Johnson (7) described a technique for the obtura- tracted for periodontal reasons, were collected for tion of root canals with thermoplasticised gutta-per- this study. All specimens were prepared with cha. A few years later, the thermafil device was intro- Ed nickel-titanium rotary files, and then divided into duced by Tulsa Dental. The “Thermafil” is a patented two groups: for each group was applied a differ- endodontic obturator consisting of flexible central car- ent kind of irrigation method, verifying the effec- rier made of stainless steel, titanium, or plastic uni- tiveness in removing the smear layer, thus ren- formly coated with a layer of α-phase gutta-percha dering the dentinal tubules more permeable for (8). When heated the gutta-percha becomes thermo- penetration of softened gutta-percha. Thermafil plasticized and adheres to the carrier. When inserted IC system was used to fill the root canals, and then into the prepared canal, carrier transports gutta-per- all the specimens were observed under scanning cha in the root canal and remains in the canal as part electron microscope (SEM). of obturation (9). Further development of the original Results. The results showed that the Group which technique led to the production of Thermafil Plus en- C followed irrigation only with sodium hypochlorite dodontic Obturators (Tulsa Dental Products, Tulsa, exhibited significantly less gutta-percha tags OK, USA) that presently use plastic carriers for the when compared to the second Group, which was delivery of softened gutta-percha (2). Thermoplasti- irrigated with sodium hypochlorite and EDTA. cized gutta-percha techniques have been demon- © Conclusion. The thermafil systems have a very strated to provide superior adaptation to canal walls good quality of compression and fluency that per- and filling of lateral canals compared with lateral mit to gain a good seal of endodontic space; fur- compaction (10, 11). During the use of all thermo- thermore it allows the penetration of gutta-percha plasticized gutta-percha techniques, the softened gut- with the formation of numerous of gutta-percha ta-percha can easily be moved into the canal irregu- tags inside the dentinal tubules above all when larities. Recently, the manufacturer of Thermafil smear layer is reduced or eliminated. (DENTSPLY Tulsa Dental Specialties, Tulsa, OK) has Annali di Stomatologia 2014; V (3): 91-97 91  G. Migliau et al. developed a carrier-based obturation that uses a pro- thick, extending a few micrometres into the dentinal prietary crosslinked gutta-percha core instead of us- tubules. Mader in 1984 (28) reported that the smear ing plastic carriers. According to the manufacturer, layer thickness was generally 1-2 μm. GuttaCore can be removed with greater ease than Mader described the smear material in two parts: other carrier-based systems; however, it is important first, superficial smear layer (Fig. 1) and second, the i to note that the core behaves unlike gutta-percha in material packed into the dentinal tubules. Packing of al that it does not readily dissolve with solvents and it is smear debris was present in the tubules to a depth of not as amenable to plasticizing with heat (12). Many 40 μm (24). authors have proposed that the smear layer that is The presence of the smear layer has been postulated on present following canal cleaning and shaping pre- to be an avenue for leakage and source of substrate vents the penetration and adaptation of the softened for bacterial growth and ingress (15, 23, 29, 30). root canal filling material into the dentinal tubules (13, Studies have shown that smear layer on the dentinal 14). Studies have shown that smear layer can serve walls of biomechanically instrumented root canals oc- as an avenue for leakage of microorganisms and as a cluded the dentinal tubules. Technically, the smear zi source for growth and activity of viable bacteria which layer may interfere with the penetration of gutta-per- remain entrapped in dentinal tubules (15-17). In the cha into the tubules and the adhesion and penetra- presence of the smear layer, apical leakage can be tion of root canal sealers into the dentinal tubules (14, na increased in canals obturated with gutta-percha (17). 19, 31, 32). By removing this layer, surface contact between the The most effective chemical method for removing the canal wall and the filling material can be increased, smear layer has been shown to be irrigated with 10 and thus apical seal may be improved (14, 18), there- mL 5.25% NaOCl followed by 10 mL 17% EDTA prior er by decreasing the occurrence of bacterial leakage to obturation (14, 22, 27). Many of the compounds (13,16, 19-21). The most effective chemical method used for irrigation have been chemically modified and for removing the smear layer has been shown to be several mechanical devices have been developed to irrigated with 10 mL 17% EDTA followed by 10 mL improve the penetration and effectiveness of irriga- 5.25% NaOCl prior to obturation (14, 22, 23). The t tion (33-35). sodium hypochlorite associated with EDTA to remove In purpose of this study was to evaluate the efficacy of Some irrigating solutions dissolve either organic or in- organic tissue in the root canal. In addition, several ir- the smear layer and to determine the percentage of rigating solutions have antimicrobial activity and ac- gutta-percha tags in the apical, middle and coronal tively kill bacteria and yeasts when introduced in di- thirds of root canals when filled with thermoplasti- rect contact with the microorganisms. In endodontic ni cized gutta-percha techniques (Thermafil System) us- the most commonly used irrigating solution is sodium ing scanning electron microscope (SEM). hypochlorite (NaOCl) (36-38). But sodium hypochlo- rite by itself is not sufficient for total cleaning of the io endodontic system (9). It has no effect on the smear The importance of irrigation in endodontic system layer and its high surface tension does not allow for its cleaning and disinfection of the root canal sys- The aim of irrigation in root canal treatment is to im- tem’s totality. For this reason, and according to the iz prove the cleaning and disinfection process within the different clinical situations, we will have to use other root canal system. Irrigation serves as a physical irrigants in combination with sodium hypochlorite. An- flush to remove debris as well as serves as an antimi- other irrigant that could be used in combination with Ed crobial agent, tissue solvent and lubricant. Root canal sodium hypochlorite, is EDTA (17%) (Ethylene di- irrigation plays a key role in the success of endodon- aminetetraacetic acid) (Smear Clear) (SybronEndo, tic treatment, because it helps in the progressive re- Orange, CA). moval of the smear layer and neutralizes the root Sodium hypochlorite is the most widely used as an canal microbial flora. endodontic irrigant in contemporary endodontic prac- The smear layer is a combination of organic and inor- IC ganic debris that is present on the root canal walls following instrumentation; it’s composed of dentinal shavings, tissue debris, odontoblastic processes, and microbial elements (24). The first researchers to de- C scribe the smear layer on the surface of instrumented root canals were McComb and Smith in 1975 (25). Identification of the smear layer was made possible using the electron microprobe with scanning electron © microscope (SEM) attachment, and first reported by Eick in 1970 (26). These workers showed that the smear layer was made of particles ranging in size from less than 0.5-15 μm. Scanning electron micro- scope studies of cavity preparations by Brännström and Johnson in 1974 (27) demonstrated a thin layer of grinding debris. They estimated it to be 2-5 μm Figure 1. Thermafil obturation of the specimens. 92 Annali di Stomatologia 2014; V (3): 91-97  Root canal obturation: experimental study on the thermafil system related to different irrigation protocols tice and is arguably still the preferred irrigating solu- present in the root canal system. A number of chemi- tion as it fulfills most of the criteria stipulated for an cal agents and/or physical methods have been inves- ideal irrigant. Sodium hypochlorite is non-specific and tigated to remove the debris and smear layer. Ethyl- is capable of killing a wide spectrum of microorgan- ene diaminetetraacetic acid (EDTA) is the most com- isms, ranging from bacteria to fungi and viruses. It is monly used solution. The EDTA is an aminopolycar- i considered the main root canal irrigant because of its boxylic acid and a colourless, water soluble solid. It is al broad-spectrum antimicrobial action and tissue dis- widely used to dissolve lime scale. The compound solving properties against most microorganisms (23, was first described in 1935 by Ferdin and Munz, who 39). It is an excellent irrigant in terms of its ability to prepared the compound from ethylenediamine and on function as a lubricant during biomechanical prepara- chloroactic acid. The combined action of NaOCl and tion of the root canals, and to dissolve pulpal necrotic EDTA, causing changes on collagen matrix and dem- tissues and the organic components of the smear lay- ineralization of root dentin with consequent exposure er. It is highly alkaline (pH 11-12.5) and is a strong of collagen, respectively results in a decrease of zi oxidizing agent of proteins. The mechanism through dentin microhardness as observed in many experi- which sodium hypochlorite exerts its bactericidal ef- mental studies. This effect probably contributes to in- fects is believed to be associated with the oxidative crease the incidence of fractures and/or cracks (42). na action of undissociated hypochlorous acid on the sul- The chelating action of EDTA solution induces an ad- phydryl groups of bacterial enzymes. The inhibition of verse softening potential on the calcified components these enzymes results in interference with metabolic of dentin and consequently a reduction in the micro- functions and ultimately death of the bacteria. Some hardness was expected. Also, the dissolving action of microscopic studies have shown that complete disso- NaOCl on the organic collagen components of dentin er lution of biofilms by sodium hypochlorite is possible explains how the alternated irrigation with these solu- using the direct contact test del Carpio-Perochena in tions affects the hardness of dentin. 2011 (40), incomplete dissolution and residual biofilm The combination of NaOCl and EDTA at a 1:1 ratio in- appears to be common under clinical conditions fol- creases the effect of the chelating agent. The combi- lowing full-strength NaOCl irrigation. Residual biofilm t nation of these solutions increases the pH, producing may contain viable bacteria and may decrease the in- In an alkaline environment in which EDTA has higher terfacial adaptation of root filling materials. Several affinity for calcium ions. Saleh and Ettman in 1999 models of biofilms are used in endodontic research, (43), reported similar results to those of the present and the efficacy of NaOCl depends on variables such study as they found that the use of 5% NaOCl alter- as the method of biofilm growth, NaOCl concentration nated with 17% EDTA reduced significantly root ni and exposure time. It could also be considered that dentin microhardness. However, it has also been re- oral mixed biofilms can be more resistant and have a ported that the combination of NaOCl and EDTA can greater adhesion to dentine in comparison with potentialize the erosion of the dentin walls when the io biofilms developed under laboratory conditions. smear layer is removed. Rajasingham in 2010 (44) Various concentrations of sodium Hypochlorite (NaO- verified that alternate irrigation with 5% NaOCl and Cl) have been used as root canal irrigants for many 17% EDTA resulted in increases of tooth surface iz decades. Zhang in 2010 (41) evaluated the effect of strain. Those authors explain that the alternate irriga- initial irrigation with 2 different NaOCl concentrations tion with 5% NaOCl and 17% EDTA probably allows (1.3 and 5.25%) on the erosion of radicular dentin the alternate depletion of organic and inorganic mater- Ed and concluded that 5.25% NaOCl increased dentinal ial, with a greater accumulative depth of effect on den- erosion compared with 1.3% NaOCl. The penetration tine and therefore tooth surface strain. They also em- of NaOCL into the dentin is limited. At high concen- phasize that the increase in strain, although signifi- trations it is toxic, whereas at low concentrations it is cant, does not yet indicate whether it is sufficient to ineffective against E. faecalis strains. The use of result in increased risk of tooth fracture due to fatigue. sodium hypochlorite is not without risk due to its cyto- IC toxicity and ability to cause necrosis, haemolysis and skin ulceration. Swelling, extra-oral ecchymosis and Materials and methods ulceration of the oral soft tissues have been reported following extrusion of sodium hypochlorite. The ef- Sixteen human single rooted teeth extracted for peri- C fects of sodium hypochlorite on necrotic tissue are odontal reasons, whereas the exclusion previous due to the hypertonicity of the solution. Although sev- root canal treatment. They were collected and eral chemical agents are available with different prop- cleaned of extraneous tissue, calculus and then erties, as far as cleaning of root canals is concerned, rinsed and stored in distilled water. Before instru- no currently available endodontic irrigant fulfills all mentation, the teeth were randomly divided into two © ideal physicochemical properties to covers all of the groups of 8 teeth each, according to the method and functions required from an irrigant, which act simulta- types of irrigation. Group 1, the root canals were irri- neously on the organic and inorganic components of gated only with sodium hypochlorite at 5% NaOCl smear layer. Therefore, interesting is the combination (Niclor – Ogna Laboratori Farmaceutici). Each tooth of different irrigation protocols to provide better clean- received an equal gross amount of time (30’) for irri- ing, antisepsis, and neutralization of toxic products gation and the same volume (10 ml) of sodium Annali di Stomatologia 2014; V (3): 91-97 93  G. Migliau et al. hypochlorite using 30 gauge open-ended needle (NaviTip ultradent, UT). Group 2, the root canals were irrigated with sodium hypochlorite 5% NaOCl alternated with 17% EDTA (Ogna Laboratori Farma- ceutici). Each tooth received an equal gross amount i of time (30’) for irrigation: 5 ml of sodium hypochlo- al rite and 5 ml of EDTA using, for each irrigant, a 30 gauge open-ended needle (NaviTip ultradent, UT). After access opening using a round diamond bur on mounted on a high-speed handpiece, the working length (WL) was determined by inserting a #10 K-file (Dentsply Maillefer, Ballaigues, Switzerland) into the canal until it was just visible at the apical foramen, zi then subtracting 1 mm. Apical patency was main- tained throughout instrumentation using a #15 K-file (Dentsply Maillefer). The canals were instrumented na using a crown-down technique with rotary ProTaper nickel-titanium files (Dentsply Maillefer) to a master apical file size of 0.25mm. The instruments were used with X-smart Device (Dentsply Maillefer) with 16:1 reduction rotary handpiece X-smart-contra-an- er gle (Dentsply Maillefer); the speed of rotation was maintained at 250 rpm with torque 52 Ncm. ProTa- per files were used according to the manufacture’s recommendation. Briefly, the pulp chamber was filled with 5% sodium hypochlorite (NaOCL) solution, t and S1 file was taken into the canal just short of In depth. Then the canal was irrigated, and the auxil- Figure 2. X-ray of a specimen. iary SX file was used to remove the coronal aspect of the canal away from furcal danger and to improve radical access. ni Shaping with the auxiliary SX was continued with brushing motion until two thirds of its cutting blades were below the orifice. The canal was irrigated, and io a size 10 K-file (Dentsply Maillefer) was used for re- capitulation. Preparation continued with S1, S2, F1 and F2 files to working length. At the end of instru- iz mentation (with F2 - size 25), the apical foramen gauging was performed by using NiTi K-files 0.2 ta- per, then, according to the size of the gauging, au- Ed thors finished preparation with NiTi rotary instru- ments of larger diameter than 25 (F3,F4,F5). Basing on this final diameter obtained and on master apical Figure 3. The teeth were immersed in hydrochloric acid file that were fitted to the working length, the correct 15% to obtain the dissolution of inorganic part. thermafil obturator was selected. The teeth were irri- gated after each change of instrument with only 5% IC sodium hypochlorite (NaOCI) for Group 1 and alter- Statistical analysis nation of 5% sodium hypochlorite (NaOCI) with ethyl- ene diaminetetraacetic acid (EDTA) at 17% for All specimens were observed in a series of 48 photos Group 2. All canals were dried with sterile paper with SEM (three photos for each specimen in the api- C points then they were filled with thermafil system cal, middle, and coronal third). The photos were used (Maillefer) without using endodontic cement (Figs. 1, to determine the statistical analysis by applying the 2). All teeth were anchored in gauge blocks of resin, Kruskall-Wallis test (is the one-way analysis of vari- then they were immersed in hydrochloric acid at 15% ance Anova); the analysis shows significant differ- for twelve hours in order to obtain the dissolution of ences (P<0.05) between the number of gutta-percha © enamel and dentin and expose the gutta-percha that tags within the obturation techniques as a function of present in canals (Fig. 3). The evaluation of the pres- defect location (apical, middle, and coronal third) on ence of gutta-percha tags in all samples was per- base of the two types of irrigation. formed using a scanning electron microscope (SEM), The presence or absence of gutta-percha tags were distinctly observing the coronal, middle and apical evaluated in the assessment criteria reported in third of root canals. Table 1. 94 Annali di Stomatologia 2014; V (3): 91-97  Root canal obturation: experimental study on the thermafil system related to different irrigation protocols Table 1. Scale that represents the percentage of gutta-per- cha surface with the presence of gutta-percha tags. Number Gutta-percha tags on the surface 0 No reproduction of tags i al 1 Gutta-percha tags < 25% 2 25% <Gutta-percha tags <50% 3 50% < Gutta-percha tags <57% on 4 Gutta-percha tags > 75% zi Figure 6. (SEM, 1000 x) Gutta-percha in apical third of canal (only Naocl). na Results and discussion The evaluation of the presence of gutta-percha tags er in all samples was performed using a scanning elec- tron microscope (SEM), distinctly observing the coro- nal, middle and apical third of root canals. The results showed that Group 1 (Figs. 4-6) followed t with irrigation only with sodium hypochlorite exhibited In significantly (P<0.05) less gutta-percha tags when Figure 4. (SEM, 1000 x) Gutta-percha in the coronal third compared to Group 2, which was irrigated with sodi- of canal (only Naocl). um hypochlorite in combination with EDTA. The obtained results were submitted for statistical analysis of GP tags were summarized in the Table 2. ni Final irrigation with 17% EDTA for 2 min has been recommended for removal of smear layer from root canal walls, especially at the cervical and middle io thirds. Therefore, it can be noticed from the internal analysis that excellent of gutta-percha penetration fundamentally from the coronal and the middle area of iz the root canal instead of the apical portion (Figs. 7, 8). The structure of apical dentin presents a decreased number of dentin tubules and the filling techniques Ed used may affect the adaptation and the penetration of the materials (Fig. 9). Shemesh in 2006 (45) postulat- ed that, because the dentinal tubule configuration is less dense in the apical portion than in the coronal portion of the root, this might compromise bonding in the apical region. As well, it is known that bonding is further compromised in sclerotic dentin, which is more IC Figure 5. (SEM, 1000 x) Gutta-percha in middle third of canal (only Naocl). common in the apical portions of adult teeth (46). Table 2. Number of specimens for the coronal, medium and apical third with different percentage of gutta-percha tags on the C surface (indicated as a numeric value in the scale reported in Table 1) in the two kind of irrigation protocol Groups. Irrigation Third coronal Third medium Third apical All protocols © Group 1 Percentage gutta-percha tags 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Hypochlorite (scale in Table 1) N. of specimens 7 1 0 0 8 0 0 0 8 0 0 0 23 1 0 0 Group 2 Percentage gutta-percha tags 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Hypochlorite (scale in Table 1) +EDTA N. of specimens 0 1 3 4 0 1 4 3 1 5 1 1 1 7 8 8 Annali di Stomatologia 2014; V (3): 91-97 95  G. Migliau et al. Tags in the dentinal tubules is complete and easy to apply. 2. It is evident the superiority of the irrigation with hypochlorite +EDTA compared to the single irriga- tion with hypochlorite to obtain the penetration of i gutta-percha in the dentinal tubules. al 3. The penetration of gutta-percha can be an indirect indicator of the ability of irrigants in the removal of endodontic smear layer. on 4. The thermafil system possesses a very good quality of compression and fluency that allows the penetra- tion of gutta-percha with the formation of numerous of gutta-percha tags inside the dentinal tubules and good seal of the endodontic space. zi Figure 7. (SEM, 1000 x) Gutta-percha in the coronal third References na of canal (Naocl+EDTA). 1. Stoll R, Betke K, Stachniss V. The influence of different fac- tors on the survival of root canal fillings: a 10-year retrospective study. J Endod. 2005;31:783-90. 2. Kytridou V, Gutmann JL, Nunn MH. Adaptation and seal abil- er ity of two contemporary obturation techniques in the absence of the dentinal smear layer. Int Endo J. 1999;32:464-474. 3. Naidorf IJ. Clinical microbiology in endodontics. Dent Clin North Am.1974;18:329-44. t 4. Saunders WP, Saunders EM. Influence of smear layer and In the coronal leakage of thermafil and laterally condensed gut- ta percha root fillings with a glass ionomer sealer. J Endod. 1994;20:155-8. 5. 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A comparison of thermoplastic obturation techniques: adaptation to the canal walls. J Endod. 1997;23:703-6. 11. Bowman CJ, Baumgartner JC. Gutta-percha obturation of IC lateral grooves and depressions. J Endod . 2002;28:220-3. 12. Beasley RT, Williamson AE, Justman BC. Time required to remove guttacore, thermfil plus, and thermoplasticized gut- ta-percha from moderately curved root canals with protaper C files. J Endod. 2013;39:125-8. 13. Gutmann JL. Adaptation of injected thermoplasticized gut- Figure 9. (SEM, 5000 x) Gutta-percha in the apical third of ta-percha in the absence of smear layer. Int Endod canal (Naocl +EDTA). J.1993;26:87-92. 14. Oksan T, Aktener BO, Sen BH, Tezel H. The penetration of © root canal sealers into dentinal tubules. A scanning electron Conclusions microscopic study. Int Endod J. 1993;26:301-5. 15. Pashley DH. Smear layer: physiological considerations. Oper According to the date of the present study it seems Dent Suppl. 1984;3:13-29. possible to reach the following conclusions: 16. White RR, Goldman M, Sun Lin PS. Influence of the smear 1. The evaluation method that we have proposed for layer upon dentinal tubule penetration by plastic filling ma- the measurement of the number of gutta-percha terials. J Endod. 1984;10:558-62. 96 Annali di Stomatologia 2014; V (3): 91-97  Root canal obturation: experimental study on the thermafil system related to different irrigation protocols 17. Kennedy WA, Walker WA 3rd , Gough RW. Smear layer re- 33. Philippe S, Fadl K. Sequence of Irrigation in Endodontics. moval effects on apical leakage. J Endod.1986;12:21-7. Oral Health. 2005;62-65. 18. Cergneux M, Ciucchi B, Dietschi JM, Holz J. The influence 34. Heling I, Chandler NP. Antimicrobial effect of irrigant com- of the smear layer on the sealing ability of canal obturation. binations within dentinal tubules. Int Endod J.1998;31:8-14. 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Int Endod J. 1996; 29:99-107. 38. Zamany A, Safavi K, Spangberg LS. The effect of chlorhex- 22. Goldman LB. The influence of several irrigating solutions for idine as an endodontic disinfectant. Oral Surg Oral Med Oral zi endodontics; A scanning electron microscopic study. Oral Pathol Oral Radiol Endod. 2003;96:578-81. Surg Oral Med Oral Pathol. 1981;52:197-204. 39. Yamada RS, Armas A, Goldman M, Lin PS. A scanning elec- 23. Baumgartner JC, Mader CL. A scanning electron microscopic tron microscopic comparison of a high volume final flush na evaluation of four root canal irrigation regimens. J Endod. with several irrigating solutions: part 3. J Endod.1983; 9:137- 1987;13:147-57. 42. 24. Violich DR, Chandler NP. The smear layer in endodontics 40. Del Carpio-Perochena AE, Bramante CM, Duarte MA et al. - a review. Int Endod J. 2010; 43:2-15. Biofilm dissolution and cleaning ability of different irrigant so- 25. McComb D, Smith DC. A preliminary scanning electron mi- lutions on intraorally infected dentin. J Endod. 2011; croscopic study of root canals after endodontic proce- 37:1134-8. er dures. J Endod.1975;1:238-42. 41. Zhang K, Tay FR, Kim YK, Mitchell JK, Kim JR, Carrilhof Ml. 26. Eick JD, Wilko RA, Anderson CH, Sorensen SE. Scanning The effect of initial irrigation with two different sodium electron microscopy of cut tooth surfaces and identification hypochlorite concentrations on the erosion of instrumented of debris by use of the electron microprobe. J Dent Res. radicular dentin. Dent Mater. 2010;26:514-23. 1970;49:1359-68. t 42. Torabinejad M, Handysiders R, Khademi AA, Bakland LK. 27. Brännström M, Johnson G. Effects of various conditioners and cleaning agents on prepared dentin surfaces: a scan- In Clinical implications of the smear layer in endodontics: A re- view. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. ning electron microscopic investigation. J Prosthet Dent. 2002;94:658-66. 1974;31:422-30. 43. Saleh AA, Ettman WM. Effect of endodontic irrigation solu- 28. Mader CL, Baumgartner JC, Peters DD. Scanning electron tions on microhardness of root canal dentine. J Dent. ni microscopic investigation of the smeared layer on root canal 1999;27:43-6. walls. J Endod.1984; 10:477-83. 44. Rajasingham R, Ng YL, Knowles JC, Gulabivala K. The ef- 29. Goldman M, Goldman LB, Cavaleri R, Bogis J, Lin PS .The fect of sodium hypochlorite and ethylene diamine tetraacetic efficacy of several endodontic irrigating solutions: a scanning acid irrigation, individually and in alternation, on tooth sur- io electron microscopic study: Part 2. J Endod.1982;8:487-92. face strain. Int Endod J. 2010;43:31-40. 30. Pitt Ford TR, Roberts GI .Tissue response to glass ionomer 45. Shemesh H, Wu MK, Wesselink PR. Leakage along apical retrograde root fillings. Int Endod J. 1990;23:233-8. root fillings with and without smear layer using two different iz 31. White RR, Goldman M, Sun Lin P. The influence of the smear leakage models: a two-month longitudinal ex vivo study. Int layer upon dentinal tubule penetration by plastic filling ma- Endod J. 2006;39:968-76. terials. J Endod.1984; 10:558-562. 46. Paquè F, Luder HU, Sener B, Zehnder M. Tubular sclero- 32. Gettlemen BH, Messer HH, ElDeeb ME. Adhesion of seal- sis rather than the smear layer impedes dye penetration into Ed er cements to dentine with and without the smear layer. J the dentine of endodontically instrumented root canals. Int Endod. 1991;17:15-20. Endod J. 2006;39:18-25. IC C © Annali di Stomatologia 2014; V (3): 91-97 97 

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Original article Atomic force microscopy study of enamel remineralization i al on Claudio Poggio, MD, DDS1 Key words: AFM, enamel, remineralization, SEM, Matteo Ceci, DMD, PhD1 soft drinks, surface roughness. Riccardo Beltrami, DMD, PhD2 Marco Lombardini, DMD, PhD1 Marco Colombo, DMD, PhD1 Introduction zi Dental erosion has been defined commonly as the 1 Department of Clinical, Surgical, Diagnostic and Pe- chemical dissolution of the hard tissues of teeth by na diatric Sciences, Section of Dentistry, University of acids of non-microbiological origin (1). Dental erosion Pavia, Italy is a common problem in modern societies, owing to 2 Department of Brain and Behavioural Sciences, the increased consumption of acid drinks such as Section of Statistics, University of Pavia, Italy soft drinks, sport drinks, fruit juices (2). The develop- ment of erosion involves a chemical process in which er the inorganic phase of the tooth is demineralized, Corresponding author: thereby reducing the hardness of the tooth sub- Claudio Poggio strates. Subsequent abrasive challenges through Department of Clinical, Surgical, Diagnostic t brushing increase the loss of the tooth substrates (3). and Pediatric Sciences, Section of Dentistry, University of Pavia In The early stages of dental erosion are characterized by a softening of the enamel surface to a depth of the Piazzale Golgi 3 order of 1-10 microns. Many studies have been car- 27100 Pavia, Italy ried out to understand the process of enamel dem- Phone: +39 0382 516257, +39 3398124925 ineralization at the early stages, but there are still lit- ni Fax: +39 0382 516224 tle known about if these early stages are reversible E-mail: claudio.poggio@unipv.it (4). Biological and chemical factors in the oral envi- ronment influence the progress of dental erosion. io Saliva provides protective effects by neutralizing and Summary clearing the acids; it is also a source of inorganic ions necessary for the remineralization process (5). Aim. The aim of the present in vitro study was the Enamel has no spontaneous capability to repair iz evaluation of two products: a CPP-ACP paste (GC when affected by specific dental pathologies such as Tooth Mousse, GC Corp.) and a desensitizing caries, abrasions or fractures because it contains no toothpaste (Colgate Sensitive Pro Relief, Colgate- cells (6). Therefore, when enamel is exposed to oral Ed Palmolive) on preventing enamel erosion pro- environment the only possibility to be reconstructed duced by a soft drink (Coca Cola) by using Atom- depends on the application of alloplastic materials. ic Force Microscopy (AFM). Toothpastes have been considered effective and ac- Methods. Thirty enamel specimens were assigned cessible vehicles to improve enamel resistance to to 6 groups of 5 specimens each. 1: intact enam- erosive attacks (7). The incorporation of protecting el, 2: enamel + soft drink, 3: intact enamel + Col- agents in toothpastes has become increasingly more IC gate Sensitive Pro Relief, 4: enamel + soft drink + common, because sensitivity is a common complaint Colgate Sensitive Pro Relief, 5: intact enamel + among patients. Many types of toothpaste recently GC Tooth Mousse, 6: enamel + soft drink + GC introduced are claimed to prevent erosion. Fluoride Tooth Mousse. The surface of each specimen was dentifrices have some protective effect on enamel C imaged by AFM. The root mean-square roughness eroded to brushing abrasion when immersed in vitro (Rrms) was obtained from the AFM images and the in a cola drink (8). Currently, conventional fluoride- differences in the averaged values among the containing toothpastes do not appear to be able to groups were analyzed by ANOVA test. protect efficiently against erosion (9). Colgate Sensi- © Results. Comparing groups 4 and 6 (soft drink + tive Pro Relief (Colgate-Palmolive, New York, NY, toothpastes) with group 2 (eroded enamel) a sta- USA) is based on arginine 8% (Pro-Argin™). Pro-Ar- tistical difference (P<0.05) was registered, sug- gin ™ technology contains arginine, an amino acid gesting effectiveness in protecting enamel naturally found in saliva, and a compound of insolu- against erosion of the products investigated. ble calcium in the form of calcium carbonate. Argi- Conclusions. The use of new formulation tooth- nine and calcium carbonate bind to the dentin-enam- pastes can prevent enamel demineralization. el negatively charged surface, creating a protective 98 Annali di Stomatologia 2014; V (3): 98-102  AFM study of enamel remineralization layer, resistant to acid stimuli, that covers the surface tion (19). The specimens were cut at the enamel- defects and occludes the exposed dentinal tubules dentin junction, with a high-speed diamond rotary bur with a consequently reduced sensitivity (10). GC with a water-air spray. The labial surfaces near the Tooth Mousse (GC Corp., Tokio, Japan) is based on enamel dentin junction were ground using silicon car- CPP-ACP. Casein phosphopeptides (CPP) contain- bide papers (grades 600 to 1200) under water irriga- i ing the cluster sequence – Ser(P)-Ser(P)- Ser(P)- tion to produce flat enamel surfaces. Samples were al Glu-Glu – have a remarkable ability to stabilize calci- placed into Teflon moulds measuring 10 x 8 x 2 mm, um phosphate (ACP) in metastable solution. Through embedded in flowable composite resin and polymer- the multiple phosphoseryl residues, the CPP binds to ized. The baseline root mean-square roughness, on forming nanoclusters of ACP, preventing their growth R rms , was measured for all the specimens before to the critical size required for nucleation and phase starting experimentation. No statistical difference in transformation (11). CPP-ACP has been demonstrat- R rms values (150±5) was recorded, suggesting that ed to have anticariogenic activity in laboratory, ani- the specimens may be comparable. mal and human in situ experiments (12). The CPP- zi ACP solutions have shown to significantly remineral- ize enamel subsurface lesions in vitro (13). CPP-ACP Demineralization and remineralization has been successfully incorporated into oral health na products such as a mouth rinses, chewing gums and A soft drink (Coca Cola, Coca Cola Company, Milano, sports drink to reduce enamel erosion (14). Changes Italy) was chosen for the demineralization process. in tooth structure due to extrinsic factors have been The pH at 20˚C, buffering capacity, concentration of widely investigated. Whereas the material losses (ab- calcium and phosphate of the beverage were mea- er solute erosions) have been carefully characterized, sured (20). Measurements were performed in tripli- only minor attention has been devoted to the investi- cate and average values calculated. Two remineral- gation of tooth surface change during erosion and izating agents were used: GC Tooth Mousse and, as demineralization (15). The kinetic roughening of a reference, Colgate Sensitive Pro Relief, a desensitiz- surface is the process that takes place when material t ing toothpaste. The samples were then assigned to 6 and experimental studies showed that this process In is removed from or added to the surface. Theoretical groups, each made of 5 teeth: - group 1: intact enamel might be often interpreted in terms of self-affinity - group 2: enamel + soft drink concepts and simple scaling laws. However, whereas - group 3: enamel + Colgate Sensitive Pro Relief many works have been devoted to the investigation - group 4: enamel + soft drink + Colgate Sensitive ni of film growth by chemical or physical vapor deposi- Pro Relief tion methods, less attention has been reserved to the - group 5: enamel + GC Tooth Mousse. inverse problem of surface etching, polishing, or ero- - group 6: enamel + soft drink + GC Tooth Mousse. io sion (16). Atomic Force Microscopy (AFM) is capable The control specimens (group 1) were taken on stor- of giving images with atomic resolution with minimal age for the whole experimentation and they did not sample preparation. This technique has been widely receive any treatment. The specimens of groups 2, 4 used to characterize the erosion of enamel and den- and 6 were immersed in 6mL of the soft drink for 2 iz tine (17). More recently, also AFM nanoindentation min at room temperature before rinsing with deion- has been applied to the study of enamel erosion (18). ized water. Four consecutive intervals of the immer- The aim of the present in vitro study was the evalua- sion procedure were carried out at 0, 8, 24 and 36 h Ed tion of a CPP-ACP paste and of a desensitizing for a total of 8 minutes (21). The toothpastes were toothpaste (Colgate Sensitive Pro Relief, Colgate- applied neat onto the surface of the specimens of Palmolive) on preventing enamel erosion produced groups 3, 4, 5 and 6 without brushing for 3 min at 0, by a soft drink (Coca Cola) by using Atomic Force 8, 24 and 36 h and then wiped off with distilled water Microscopy (AFM). washing. In groups 4 and 6 the toothpastes were ap- plied after demineralization with Coca Cola. IC Materials and methods Atomic Force Microscopy (AFM) observations Specimens’ preparation C After 24 hours from the last procedure of demineral- Specimens were prepared from 30 human incisors ization and remineralization (15), specimens were ob- free of caries and defects, extracted for periodontal served with an atomic force microscopy AutoProbe reasons. After the extraction, the teeth were cleansed CP 100 (Thermomicroscopes, Veeco, Plainview, NY, © of soft tissue debris and inspected for cracks, hy- USA), equipped with a piezoelectric scanner, which poplasia and white spot lesions; they were disinfected can cover an area of 100 x 100 μm2 with a range of 7 in 5.25% sodium hypochlorite solution for one hour μm in the z-direction. The most common topographi- and stored in artificial saliva (pH 7.0, 14.4 mM NaCl; cal parameters were determined, such as the surface 16.1 mM KCl; 0.3m mM Cl2.6H20; 2.9 mM K2HPO4; roughness (Rrms). Rrms is given by the standard devia- 1.0 mM CaCl2.2H2O; 0.10 g/100 ml sodium car- tion of the heights, obtained from the AFM images by boxymethylcellulose) during the whole experimenta- testing, for each sample, at least 10 different film ar- Annali di Stomatologia 2014; V (3): 98-102 99  C. Poggio et al. eas of 30 × 30 μm2 with a resolution of 256 x 256 pix- Discussion and conclusion els. From the analyses of the AFM height profiles, it was also possible to estimate the erosion cavities In the present in vitro study, AFM was used to verify depth of the enamel surface. The data were obtained the protective effect of a CPP-ACP paste on enamel by averaging on at least 20 selected lines of the im- exposed to the erosive action of a soft-drink. AFM i age. Measurements were performed on the treatment was used to study tooth surfaces in order to compare al specimens and on the matching controls. the pattern of particle distribution in the outermost layer of the tooth surfaces (19). It was found that AFM gives high-contrast, high-resolution images and on Statistical analysis is an important tool as a source of new structural in- formation: tapping mode AFM (TM-AFM) images are Differences in the averaged values among the groups able to show net differences between exposed and were analyzed by ANOVA test. Statistical difference unexposed enamel areas (4). There is a clear rela- was set at P<0.05. Post hoc Bonferroni test was per- tionship between erosion and temperature of the bev- zi formed to assess the differences between the differ- erages (2). In this study, the beverage was kept at a ent groups. constant temperature of 20° C. Although erosion pro- ceeds more slowly in vivo than in vitro owing to the na protective effect of saliva and acquired pellicle, the Results effect of temperature can be expected to be signifi- cant (22). In order to stress their demineralizing po- The surface roughness (Rrms) is an index of the sur- tential, the soft drink was replenished every 2 min to er face quality. The mean Rrms values recorded before ensure that it was carbonated and to reduce the experimentation was not statistically different when buffering effect from ions dissolved from the enamel compared with the mean Rrms value of group 1 (intact surface (21). Enamel surface is often aprismatic and enamel) after immersion in artificial saliva. Table 1 re- more highly mineralized than enamel subsurface. ports mean Rrms values with related standard devia- t This prismless enamel arises at the end of amelogen- tions obtained in the six groups. Comparing untreated specimens (group 1) with demineralized specimens In esis. Although this layer of enamel is more frequent on the surface of deciduous teeth, it can also be (group 2), a statistically significant difference found on the surface of permanent teeth. It is known (P<0.05) in R rms values was registered, with an in- that the prism-free enamel is gradually worn off dur- crease of surface roughness passing from intact ing mastication but it is retained in protected areas. ni enamel to enamel exposed to Coca Cola. A signifi- Flat and polished specimens were used in the pre- cant difference (P < 0.05) was registered when com- sent study in an attempt to standardize specimens paring the R rms values of group 3 (enamel treated and remove natural variations in surface enamel be- io with Colgate Sensitive Pro Relief) with intact enamel tween teeth and between different tooth sites and (group 1). Significant higher R rms values are regis- types, which may result in different responses to acid tered with GC Tooth Mousse (P < 0.05). Comparing dissolution (1). However, it should be noted that nat- the Rrms values of groups 4 and 6 (soft drink + tooth- iz ural tooth surfaces erode more slowly than polished pastes) with group 2 (enamel only demineralized) a surfaces (22). The specimens were cleaned with 5% statistical difference (P<0.05) was registered, sug- NaOCl for 1 hour, which could not alter enamel sur- gesting a protective effect of the toothpastes investi- face. The erosive potential of orange juice modified Ed gated against enamel demineralization. by food additives in enamel and dentine was evaluat- ed; it was concluded that only the combination of cal- cium lactate pentahydrate and sodium linear Table 1. Mean roughness values (Rrms) ± standard devia- polyphosphate reduced erosion (23). tion obtained in the six groups. Different superscript letters CPP-ACP clusters seem to be anticariogenic in labo- means significant differences between the groups (P < ratory animal in situ experiments (24) and on human IC 0.05). caries in vitro (13). A CPP-ACP crème was effective Groups Mean roughness in remineralizing early enamel lesions of the primary values (Rrms) teeth (25), while recently a CCP-ACP paste was found to be effective in promoting enamel remineral- 148 ± 19a C group 1: intact enamel ization (20). Finally CPP-ACP complex has been suc- group 2: enamel + soft drink 261 ± 28b cessfully added to chewing-gums: the efficacy of group 3: intact enamel + three commercially available sugar-free chewing Colgate Sensitive Pro Relief 59 ± 5c gums was compared, concluding that the superior © group 4: enamel + soft drink remineralization activity of the gum was attributed to + Colgate Sensitive Pro Relief 93 ± 7d the presence of casein phosphopeptide-amorphous group 5: intact enamel + calcium phosphate nanocomplexes (CCP-ACP) (26). GC Tooth Mousse 155 ± 14a Que et al., (27) study demonstrated that the new Pro- Argin formula toothpaste provided a significant reduc- group 6: enamel + soft drink + tion in dentin hypersensitivity. The reduced sensitivity GC Tooth Mousse 167 ± 12a recorded after a single application can be maintained 100 Annali di Stomatologia 2014; V (3): 98-102  AFM study of enamel remineralization over time with daily use of the product for a period of 24 weeks (28). In addition the desensitizing pastes based on argine and calcium carbonate have proven to be useful in reducing dentinal sensitivity if applied before a session of professional oral hygiene (29). i The Atomic Force Microscopy could analyze the topo- al graphical aspects of enamel samples and the effects of the demineralization/remineralization processes on the enamel morphology, in the presence of the studied on toothpastes. The most common topographical parame- ter was therefore determined, such as the surface roughness (Rrms), to quantitatively evaluate the surface aspect. After demineralization with an acidic substance such as Coca Cola, the surface should appear much zi rougher. The process of erosion causes, in fact, an in- crease of Rrms. The demineralizing process was inves- tigated by comparing the fraction of intact enamel (Fig. na 1) with the one treated with the soft drink (Fig. 2). After the demineralization process, cavities of diameter be- tween 4 and 7 microns were formed. This is reflected in the values of Rrms, which increased from 148 to 261 er nm. As regards the effect of the toothpastes in the process of enamel remineralization, several considera- tions can be made. Comparing the R rms values of groups 3 (enamel + Colgate Sensitive Pro Relief) with intact enamel (group 1) a statistical significant (P < t 0.05) decrease of surface roughness suggests a rem- ineralizating effect on intact enamel of the product In used. In groups 3, in fact, enamel shows the typical Figure 2. 2D and 3D AFM images: enamel exposed to soft aprismatic surface layer, on which it is possible to drink (A) and enamel demineralised and then reminer- alised with Colgate Sensitive Pro Relief (B) and with GC ni Tooth Mousse (C). identify the precipitated crystals of the remineralizating io agents (Fig. 1). Instead significant higher Rrms values are registered in group 5 (enamel + GC Tooth Mousse) (P < 0.05). However, in group 5, AFM images showed a random distribution along the surface of the protec- iz tive agent to form globular aggregates and/or precipi- tates of mineral substances, more or less abundant (as seen in the lighter areas of images). This may justify Ed roughness values, significantly higher than those recorded for the other product tested (Fig. 1). Compar- ing the Rrms values of groups 4 and 6 (enamel + soft drink + toothpastes) with group 2 (eroded enamel) a statistical difference (P<0.05) was registered, suggest- ing a remineralizing power on eroded enamel of the IC two products. In group 4 the prismatic structure of hy- droxyapatite, which typically becomes evident as a re- sult of erosion, was not observed. Therefore Colgate Sensitive Pro Relief seems to able to regenerate a ho- C mogeneous, very compact, thick and uniform surface layer (Fig. 2). As regards the effects of GC Tooth Mousse on eroded enamel (group 6), the prismatic structure is slightly evident but the cavities seems to © be well-filled. In this case the superficial layer of the remineralizing agent is probably constituted by a glob- ular arrangement of the mineral substances (Fig. 2). Under the limitations of the present in vitro study, the Figure 1. 2D and 3D AFM images: intact enamel (A) and application of the tested toothpastes can be consid- enamel treated with Colgate Sensitive Pro Relief (B) and ered effective on preventing enamel erosion pro- with GC Tooth Mousse (C). duced by a soft drink. Annali di Stomatologia 2014; V (3): 98-102 101  C. Poggio et al. Acknowledgments bleaching and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) treatment. J Dent. 2007;37:297-306. Nothing to declare. 15. Bertassoni LE, Habelitz S, Pugach M, et al. Evaluation of sur- face structural and mechanical changes following reminer- alization of dentin. Scanning. 2010;32:312-19. i 16. Barbour ME, Rees JS. The laboratory assessment of Conflict of interest statement al enamel erosion: a review. J Dent. 2004;32:591-602. 17. De-Deus G, Paciornik S, Pinho Mauricio MH, Prioli R. Real- The authors of this study have no conflict of interest time atomic force microscopy of root dentin during dem- to disclose. ineralization when subjected to chelating agents. Int Endod on J. 2000;39:683-92. 18. Lippert F, Parker DM, Jandt KD. In vitro demineralization/rem- References ineralization cycles at human tooth enamel surfaces inves- tigated by AFM and nanoindentation. J Colloid Interface Sci. 1. Hemingway CA, Parker DM, Addy M, Barbour ME. Erosion 2004;280;442-48. zi of enamel by non-carbonated soft drinks with and without 19. Farina M, Schemmel A, Weissmuller G, Cruz R, Kachar B, toothbrushing abrasion. Br Dent J. 2006;201:447-50. Bisch PM. Atomic force microscopy study of tooth sufaces. 2. Barbour ME, Finke M, Parker DM, Hughes JA, Allen GC, Addy J Struct Biol. 1999;125:39-49. na M. The relationship between enamel softening and erosion 20. Poggio C, Lombardini M, Vigorelli P, Ceci M. Analysis of caused by soft drinks at a range of temperatures. J Dent. Dentin/Enamel Remineralization by a CPP-ACP Paste: 2007;34:207-13. AFM and SEM Study. Scanning. 2013; in press. 3. Lippert F, Parker DM, Jandt KD. Toothbrush abrasion of sur- 21. Tantbirojin D, Huang A, Ericson MD, Poolthong S. Change face softened enamel studied with tapping mode AFM and in surface hardness of enamel by a cola drink and a CPP- er AFM nanoindentaion. Caries Res. 2004;38:464-72. ACP paste. J Dent. 2008;36:74-79. 4. Finke M, Jandt KM, Parker DM. The early stages of native 22. Ranjitkar S, Rodriguez JM, Kaidonis JA, Richards LC, enamel dissolution studied with atomic force microscopy. J Townsend GC, Bartlett DW. The effect of casein phospho- Colloid Interface Sci. 2000;232:156-64. peptide-amorphous calcium phosphate on erosive enamel and dentin wear by toothbrush abrasion. J Dent. 2009;37:250-54. t 5. Lussi A, Hellwig E, Zero D, Jaeggi T. Erosive tooth wear: di- agnosis, risk factors and prevention. Am J Dent. 2006;19:319- 23. Scaramucci T, Sobrai MA, Eckert GJ, et al. In situ evalua- 25. In tion of the erosive potential of orange juice modified by food 6. Oshiro M, Yamaguchi K, Takamizawa T, Inage H, et al. Ef- additives. Caries Res. 2012;46:55-61. fect of CPP-ACP paste on tooth mineralization: an FE-SEM 24. Santosh BP, Jethmalani P, Shashibushan KK, Subba VV. study. J Oral Sci. 2007;49:115-20. Effect of casein phosphopeptide amorphous calcium phos- 7. Kato MT, Lancia M, Sales-Peres SH, Buzalaf MA. Preven- phate containing chewing gum on salivary concentration of ni tive effect of commercial desensitizing toothpastes on calcium and phosphorus: an in vivo study. J Indian Soc Pe- bovine enamel erosion in vitro. Caries Res. 2010;44:85-9. dod Prev Dent. 2012;30:146-150. 8. Ganss C, Schulze K, Schlueter N. Toothpaste and erosion. 25. Zhang G, Zou J, Yang R, Zhou X. Remineralization effects of casein phosphopeptide-amorphous calcium phosphate io Monogr Oral Sci. 2013;23:88-99. 9. Moron BM, Miyazaki SS, Ito N, Wiegand A, Vilhena F, Buza- crème on artificial early enamel lesions of primary teeth. Int laf MA, Magalhães AC. Impact of different fluoride concen- J Paediatr Dent. 2011;21:374-81. trations and pH of dentifrices on tooth erosion/abrasion in vit- 26. Manton DJ, Walker GD, Fai C. Remineralization of enamel sub- iz ro. Aust Dent J. 2013;23:106-11. surface lesions in situ by the use of three commercially avail- 10. Cummins D. Dentin hypersensitivity: from diagnosis to a able sugar-free gums. Int J Paediatr Dent. 2008;18:284-90. breakthrough therapy for everyday sensitivity relief. J Clin 27. Que K, Fu Y, Hu D, et al. Dentin hypersensitivity reduction of a new toothpaste containing 8% arginine and 1450 ppm Ed Dent. 2009;22:Pro-Argin™ Special Issue. 11. Reynolds EC. Anticariogenic complexes of amorphous cal- fluoride an 8-week clinical study on Chinese adults. Am J cium phosphate stabilized by casein phosphopeptides: a re- Dent. 2010;23:28-35. view. Spec Care Dent. 1998;18:8-16. 28. Hamlin D, Mateo LR, Dibart S, Delgado E, Devizio W. Com- 12. Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC. Rem- parative efficacy of two treatment regimens combining in-of- ineralization of enamel subsurface lesions by sugar-free chew- fice and at-home programs for dentin hypersensitivity relief: ing gum containing casein phosphopeptide-amorphous cal- a 24-week clinical study. Am J Dent. 2012;25:146-152. IC cium phosphate. J Dent Res. 2001;80:2066-70. 29. Hamlin D, Phelan Williams K, Delgado E, Zhang YP, Devizio 13. Reynolds EC. Remineralization of enamel subsurface lesions W, Mateo LR. Clinical evaluation of the efficacy of a de- by casein phosphopeptide-stabilized calcium phosphate so- sensitizing paste containing 8% arginine and calcium car- lutions. J Dent Res. 1997;76,1587-95. bonate for the in-office relief of dentin hypersensitivity as- 14. Adebayo OA, Burrow MF, Tyas MJ. An SEM evaluation of sociated with dental prophylaxis. Am J Dent. 2009;22:Pro- C conditioned and bonded enamel following carbamide peroxide Argin™ Special Issue. © 102 Annali di Stomatologia 2014; V (3): 98-102 

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Original article Heavy metals and pain in the dysfunctional patient li na Carlo Di Paolo, MD, DDS idea that inflammation might be a pivotal factor in the Emanuela Serritella, DDS pathogenesis of such disorders. Other authors (5,6) io Fabrizio Panti, MD claim that the production of free radicals, pro-inflam- Giovanni Falisi, DDS, PhD matory and others neuropeptides, may lead to local- Fedele Manna, SSD ized inflammation, chronic tissue modifications, and to the development of neurogenic sensitization. az Toxins, free radicals and metals can caused inflam- Department of Oral and Maxillo-facial Sciences mation phenomena and cellular homeostasis modifi- Sapienza University of Rome, Italy cations, generating pathologies and sometimes even irreversible damages (7-13). Among these, heavy rn metals are particularly relevant. They can penetrate Corresponding author: the organism through numerous ways (food, medi- Emanuela Serritella cines, cosmetics), including materials routinely used Via Caserta, 6 in dentistry, leading to a deficiency in some vital func- te 00161 Rome, Italy tions (14-18). E-mail: emanuela.serritella@gmail.com An elevated concentration and accumulation of free radicals in biological tissues may cause oxidative Summary In stress (19-24). Among heavy metals, Mercury (Hg), deriving from alimentary, iatrogenic, cosmetic factors and mostly from amalgam dental fillings, can cause a Aims. The aim of this research is to verify the particularly relevant chronic intoxication (17,25). quality and quantity of heavy metals (HM) of den- The aim of this research is to quantify the quality and ni tal origin in TMD patients. Methods. A population quantity of heavy metals of dental origin in TMD pa- of 100 subject was studied and divided in two ho- tients. This comparison is based on the possible rela- mogeneous groups: Study Group (SG) and Con- tionship between these pathological conditions and trol Group (CG). Organism heavy metals were the inflammatory processes. This research project re- o tested by a spot sampling method in which the quires the comparison between three groups of ran- first urine of the day, through Inductively Coupled domly selected subjects: a group of dysfunctional pa- izi Plasma-Mass Spectrometry (ICP-MS), were ana- tients with metal manufacts in the oral cavity, a group lyzed. The results obtained were compared with of dysfunctional patients without any metals and a reference values (RV) of Italian people. Descrip- group of non-dysfunctional subjects, without any met- tive statistical analysis and student's t-test has als in the oral cavity. Ed been applied (statistical significance for p > 0.05). Results. The SG presented the absolute highest levels of HM compared to the CG (p=0.787). As re- Materials and methods gards the relation between pain and HM, the sub- jects that refer “severe/very severe” values of A consecutive series of patients has been selected, pain present the highest levels of HM in urines. all spontaneously joining the Service of Clinical C Conclusions. The obtained results seem to high- Gnathology of the Department of Odontostomatologi- light a possible direct proportionality between the cal and Maxillofacial Sciences of the University of CI level of pain the increase of the concentration of Rome “Sapienza”, from February 1 st to November heavy metals in all the examined groups and sub- 30th 2011, for a total of 200 patients. These were di- groups. vided into two groups: a Study Group (SG) and a Control Group (CG), according to the correspon- Key words: heavy metals, pain, TMD. dence to the following criteria: Inclusion criteria for the Study Group: 1. Presence of © TMD belonging to groups I, II, III of the Axis I, accord- Introduction ing to the RDC/TMD classification, or problems of ar- ticular dysfunction related to all phases of condylo- Temporomandibular Disorders (TMD) are a group of discal incoordination, from mandibular dislocation to pathologies determined by an interaction of structur- arthrosis, 2. Presence of one or more conservative or al, psycho-socio-environmental and genetic elements prosthetic metal manufacts, minimum 2 amalgam fill- (1,2). In the past some authors (3,4) developed the ings and/or 1 fixed-removable prosthesis. Annali di Stomatologia 2014; V (2): 41-51 41  C. Di Paolo et al. Inclusion criteria for the Control Groups: The study randomly, using a spot sampling according to Araki S.’ provides the composition of two control groups, 1 and method, and providing patients with a sterile 50cc con- 2. The first (CG1) is made up of TMD patients with tainer to collect early morning urines, which has been the above mentioned characteristics who do not pre- then returned to the Service of Clinical Gnathology. sent any conservative or prosthetic metal manufacts Urines analysis: urines have been analyzed by the li inside the oral cavity. The second (CG2) is made up Laboratory of Geochemistry of the Department of of healthy subjects without any conservative or pros- Earth Sciences of the University of Rome “Sapienza”. na thetic metal manufacts inside the oral cavity. Analytical data have been elaborated in cooperation Exclusion criteria for all the groups: 1. Positivity to the with the Department of Chemistry and Medicine Axis II of the classification RDC/TMD 2. Occurrence Technologies of the University of Rome “Sapienza”. of well-known local and/or systemic diseases that The assay of the heavy metals present in dental al- io may alter the inflammatory condition of the examined loys, named “ODmetals” (Tab. 3), has been per- subjects. 3. Presence of other metals in the body. 4. formed, as well as of other toxic metals, for a total Subjects who do not accept to be part of the survey. number of 22 metals examined (Tab. 4), also to test Suitable patients for the research are in the number of the subjects’ degree of intoxication. az 50 for the Study Group and 15 for the Control Group. A measurement of the relative density has been car- The scarce number of dysfunctions in this last group ried out through a refractometer, in order to correct indicates the difficulty in finding patients without any the results according to Araki S’method (26). The prosthetic or conservative reconstructions among the samples have then been analyzed through the ICP- rn subjects affected by TMD. Thus, in order to have an MS mass spectrometry (Inductively Coupled Plasma- equal number of participants in the two groups, 35 Mass Spectrometry). Data interpretation is possible subjects have been recruited in the Control Group by confrontating the results with the reference values te among the medical and the nursing staff of the Ser- (RV) for Italy (Tab. 5), elaborated by the National In- vice and students from the degree course in “Dental stitute for Health (ISS) of Rome, that measures the Sciences” at the University of Rome “Sapienza”. presence of metals in the Italian population between The total patient population is thus made up of 100 1990 and 2009 (27). male sex, 50 belonging to the Study Group (SG) and In subjects, of an average age of 41, mainly from the fe- These values have been compared with those resulting from the analysis of the collected samples, in order to 50 to the Control Group (CG). (Tab. 1-2) check if they were normal. The research on the possi- The SG is made up of TMD-affected patients, whose ble correlation between the presence of heavy metals level of heavy metals has been evaluated and com- ni pared with the intensity and typology of the dysfunc- tional pathology; the CG, 50 subjects without any Table 3. OD METALS. metals in the oral cavity, is made up of 15 dysfunc- tional patients (CG1) more 35 non-dysfunctional sub- Heavy metals of dental origin o jects (CG2). The CG1 has been compared with the Manganese (Mn) SG to evaluate the relationship between heavy met- Copper (Cu) izi als, intensity and dysfunctional typology. Zinc (Zn) All the subjects involved have been informed in ad- Molybdenum (Mo) vance about the study, its aims and the potential risks, Cobalt (Co) and have been given an informed consent paper. All Tin (Sn) Ed have undergone a health checkup, consisting of a gen- Nickell (Ni) eral medical examination performed by a specialist (an Mercury (Hg) anesthetist), and requiring basic hemato-chemical ex- Antimony (Sb) aminations in order to highlight the absence of any in- Indium (In) Titanium (Ti) progress inflammation. The study has been carried out C Table 1. Distribution of age in SG e CG. CI AGE SG CG Table 4. Heavy metals examined. Minimum 23 22 Maximum 75 62 • Aluminum (Al) • Colbalt (Co) Mean 47,92 28,59 • Iron (Fe) • Cadmium (Cd) Median 51,5 27,5 • Manganese (Mn) • Tin (Sn) • Copper (Cu) • Nickel (Ni) © • Arsenic (As) • Lead (Pb) • Cesium (Cs) • Mercury (Hg) Table 2. Distribution of gender in SG e CG. • Lithium (Li) • Antimony (Sb) • Rubidium (Rb) • Indium (In) GENDER SG CG • Zinc (Zn) • Titanium (Ti) Female 39 31 • Strontium (Sr) • Barium (Ba) Male 11 19 • Molybdenum (Mo) • Uranium (U) 42 Annali di Stomatologia 2014; V (2): 41-51  Heavy metals and pain in the dysfunctional patient Table 5. Concentration of metals in the urine for the Italian population from 1990 to 2009. Metal Reference value (RV) Other studies Urine (µg/L) Average ± ds Urine (µg/L) li 10,9±1,06 (AAS, ICP-AES 1990) Al 2,3-19,5 (1990) 5,36±3,76 (ICP-MS 2009) na As 2,3-31,1 (1990) 16,7±1,9 (AAS, ICP-AES, NAA 1990 ) 0,86±0,06 (AAS, ICP-AES 1990 Cd 0,38-1,34 (1990) 0,81±0,53 (ICP-MS 2009) 0,57±0,1 (AAS, ICP-AES, NAA 1990) Co 0,18-0,96 (1990) io 0,24±0,18 (ICP-MS 2009) 8,1±1,5 (NAA 1990) 0,1-17,5 (1990) Cs 4,52±2,24 (ICP-MS 2005) 2,00-6,82 (2005) az 12,9±8,3 (ICP-MS 2009) 23±6,9 (AAS, ICP-AES, NAA 1990) Cu 4,20-50 (1990) 12,9±7,0 (ICP-MS 2009) Fe 8,70±6,27 (ICP-MS 2009) rn 3,5±0,2 (AAS, ICP-AES, NAA 1990) Hg 0,1-6,9 (1990) 1,92±1,60 (ICP-MS 2009) Li 17,3±13,6 (ICP-MS 2009) 1,02±0,05 (AAS, ICP-AES 1990) te Mn 0,12-1,90 (1990) 0,22±0,10 (ICP-MS 2009) Mo 36,9±16,9 (ICP-MS 2009) 0,9±0,11 AAS, (ICP-AES 1990) Ni 0,06-1,74 (1990) In 0,87±0,50 (ICP-MS 2009) 17 ± 0,46 (AAS, ICP-AES 1990) Pb 12,0-27,0 (1990) 1,80 ± 1,40 (ICP-MS 2009) Rb 284-4.096 (1990) 2.190 ±203 (NAA 1990) Sn 0,90±0,64 (ICP-MS 2009) ni Sr 154±91 (ICP-MS 2009) 456±58 (AAS, ICP-AES, NAA 1990) Zn 266-846 (1990) 356±236 (ICP-MS 2009) o 2,7±0,5 (AAS, ICP-AES, NAA 1990) Ba 0,67-3,68 (2005) 1,77±1,30 (ICP-MS 2005) izi 1,24±0,78 (ICP-MS 2009) In < 0,15 (NAA 1990) 0,19-1,10 (1990) 0,79±0,07 (AAS, ICP-AES, NAA 1990) Sb Ed 0,02-0,12 (2005) 0,07±0,04 (ICP-MS 2005) 0,07-0,7 (1990) 0,42±0,09 (AAS 1990) Ti 0,02-0,17 (1994) 0,07±0,03 (ICP-MS 1994) U < 0,1 NAA (1990) C over the threshold levels and the algic symptomatology II. Main symptoms: TMJ pain (IIIa), and MUSCULAR in dysfunctional patients, has been focused mainly on pain (MM). CI the Study Group, where the totality of the patients is af- Pain has been measured with the subjective Verbal fected by TMD. Subsequently, the results have been Numeric Scale (VNS), according to an index of seri- confronted with the symptomatology of the CG1 pa- ousness subdivided in four categories: mild (<30); tients, representing 30% of the whole sample. moderate (30-50); severe (50-70); very severe (>70). The following pathological and symptomatic aspects III. Comorbidity: among the possible co-morbidities have been considered: with TMD, the most frequently considered are © I. Articular problems: according to the RDC/TMD headache and cervicalgia, anamnestically described classification, the pathologies I, IIa, IIb, and IIIc (Axis by patients, measured with the VNS scale and subdi- I) have been taken into account (1). These have been vided with reference to the above described index of considered either mild or severe according to the seriousness. presence or absence of pain, classified as below, and Heavy Metals analysis: evaluates the quantity and to the level of chronicity, through the relation between the typology of those metals presenting higher values onset time/clinical observation time. than the RV for the Italian population, paying particu- Annali di Stomatologia 2014; V (2): 41-51 43  C. Di Paolo et al. lar attention to the most frequent heavy metals in cant for the aims of this research have been reported. dental preparations, especially Mercury (Hg). Data have first been observed considering the pres- Dysfunctional problem analysis: correlates the dys- ence of heavy metals, and subsequently analyzed in functional characteristics, such as pathology and the different sample groups. pain, with the occurrence of heavy metals in urines, li in order to highlight a possible relation between the two. As regards the SG, in order to carry out a more Heavy metals analysis na significant check of the relation between the quantity of heavy metals and the seriousness of the symp- The whole studied population presents, for most of toms, subjects with a higher total level of heavy met- the metals which are taken into account, urine values als (Gr1) and metals present in dental preparations superior to the “reference values for Italian population io (Gr1OD) have been compared with patients present- (RV)” (27). Each subject, independently from the ing a minor level of total heavy metals (Gr3) and of group, presents levels which are over the threshold the most frequent metals in dental preparations for at least 4 of the 19 metals taken into account. (Gr3OD) (Tab.6, 7). (Figs. 1-2) az To verify the reliability, the data have been crossed Yet, the Study Group presents the absolute highest for metals and pathology/symptomatology, the vari- levels, compared to the whole Control Group. The ous metals have been quantified in the selected higher presence of metals in SG than in CG, in terms groups, and subsequently, the presence of metals in of variance entity from RV, is well highlighted from rn the different dysfunctional typologies has been also the results obtained by the Student’s t-test, which evaluated (Fig. 7-16 in the results paragraph). made the comparison possible among the variance Statistical analysis: the data obtained from urine means from RV (vmRV) of all metals: te analysis and those related to the pathological and Total metals (19): t = 0.2715; symptomatological aspects are not time-variant, that is, P (level of significancy) = 0.7876 we do not have any data referring to any 0 time and Another interesting result, in terms of variance entity subsequent phases; thus, a descriptive statistic analy- from RV, is obtained by the internal CG group com- sis has been carried out, in order to synthesize the available data through graphic instruments (his- In parison, that is, between the CG1 and CG2 sub- groups. The analysis of the vmRV, for all the exam- tograms), as well as indexes (the mean of variances ined metals and considering these two groups sepa- from RV) describing the most important aspects. In par- rately, has highlighted that CG1 presents a larger ticular, this kind of analysis has been of both qualitative number of heavy metals than CG2. ni (presence/absence of heavy metals in urines and of a Student’s t-test has actually proved significant: dysfunctional symptomatology) and quantitative (level Comparison GC1 – GC2: t = 0,1193; of heavy metals) nature. For the quantitative data, “Stu- P (level of significancy) = 0,9057 dent's t-test” has been applied (the difference between Another datum that has emerged analyzing metals in o the observed means is not significant for p<0,05). the different samples, concerns the so-called “OD metals” group (10 metals), namely those heavy met- izi als that can be found in dental alloys and in amal- Results gams, which are thus of specific interest for us. Six of these present a higher variance from the RV in A large quantity of data have emerged from the the SG patients (Tab. 8), while the remaining 4, with Ed analysis and the comparisons between the various levels over the threshold, are more frequent in the sample groups, consequently only the most signifi- CG patients (Tab. 9). The most frequently occurring elements in SG pa- tients, particularly Mercury (Hg), are by far the most Table 6. SG subdivision according to the number of total represented metals in dental materials. This datum metals. confirms and reinforce the sample division that has C been made in the research. Pt. N° % of SG Total heavy metals (19) The Student’s t-test is also significant: CI Gr1 6 12 % > 10metals OD Metals (10): t = 0.9735; Gr2 26 52% 5< metals ≤ 10 P (level of significancy) = 0.3448 Gr3 18 36% 1≤ metals ≤ 5 The results emerging from the statistic analysis and the descriptive analysis, which is expressed in percent- ages, confirm each other, thus resulting significant. “OD metals” are present with higher values than RV © Table 7. SG subdivision according to the number of OD also in patients who have prosthesis and/or orthodon- metals. tic appliances (16 patients: 32% of the SG). In these Pt. N° % of SG OD Metals (10) patients the most occurring elements are Molybde- num (Mo) in 50% of the sample (8 patients), Iron (Fe) Gr1OD 4 8% > 6 ODmetals and Mercury (Hg) in 62% (10 patients), Antimony Gr2OD 14 28% 3< ODmetals ≤ 6 (Sb) in 69% (11 patients), and Titanium (Ti) in 100% Gr3OD 32 64% 1≤ ODmetals ≤ 3 of the sample (16 patients) (Fig. 3). 44 Annali di Stomatologia 2014; V (2): 41-51  Heavy metals and pain in the dysfunctional patient Figure 1. Distribution of metals increased in SG (50 patients). 1≤ metals ≤ 5 li 5< metals ≤ 10 10< metals ≤ 15 na 15< metals ≤ 19 1≤ metals ≤ 5 5< metals ≤ 10 10< metals ≤ 15 15< metals ≤ 19 io Figure 2. Distribution of metals increased in CG az (50 patients). 1≤ metals ≤ 5 rn 5< metals ≤ 10 10< metals ≤ 15 15< metals ≤ 19 te 1≤ metals ≤ 5 5< metals ≤ 10 10< metals ≤ 15 15< metals ≤ 19 In Table 8. OD Metals more in SG. Table 9. OD Metals more in CG. Metal SG CG Metal SG CG ni N° Pt % N° Pt % N° Pt % N° Pt % Zinc (Zn) 12 24 5 10 Cobalt (Co) 7 14 31 62 Molybdenum (Mo) 19 38 8 16 Nickel (Ni) 12 24 35 70 o Mercury (Hg) 32 64 9 18 Indium (In) 0 0 3 6 Titanium (Ti) 30 60 11 22 Manganese (Mn) 12 24 35 70 Antimony (Sb) 38 76 17 34 izi Tin (Sn) 5 10 2 4 Ed Figure 3. Metals with significant percentage de- 100% Fe viancy in prosthetic/orthodontic patients. 90% Mn 80% Cd 70% 60% Zn Mo C 50% 40% Co 30% Sn CI 20% Ni 10% Hg 0% Sb Fe Mn Cd Zn Mo Co Sn Ni Hg Sb Ti © The most interesting result with Mercury (Hg) is that Dysfunctional problem analysis the variance from the reference value is proportional to the number of amalgam fillings in the single pa- The presence of heavy metals in the different dysfunc- tient’s oral cavity (Fig.4); therefore, it seems that tional pathologies has been evaluated, and in order to there might be a direct relation between the number proof the results, the data have been crossed contrari- of fillings and the increased release of metal ions in wise; that is, in the different dysfunctional/symptomato- the oral cavity. logical groups, metals have been quantified. To have a Annali di Stomatologia 2014; V (2): 41-51 45  C. Di Paolo et al. complete vision and a more specific comparison of the As regards the the IIa severe, in a total of 13 patients data, the different groups have been compared: dysfunc- Gr1occurs in 83% (19 patients) and Gr1OD in 100% tional subjects with metal preparations in the oral cavity (23 patients); Gr3 is present in 33% (7,59 patients), (SG: 50 patients, 100% of SG), the dysfunctional ones Gr3OD in 31% (7,13 patients), CG1in 27% (6,21 pa- without any metal preparations in the oral cavity (CG1: tients) and CG2 in 0% (0 patients). As regards the IIIc li 15 patients, 30% of the CG) and also those non-dysfunc- severe, in a total of 7 patients Gr1 present in 33% tional subjects without any metal preparations in the oral (2,31 patients), Gr1OD in 50% (3,50 patients), Gr3 in na cavity (CG2: 35 patients, 70% di CG). 17% (1,19 patients), Gr3OD in 12% (0,84 patients), Articular problems: the data related to the patholo- and CG1 and CG2 in 0% (Figs.5-6). gies belonging to the dysfunctional groups IIa (23 pa- Main algic symptomatology: TMJ pain (IIIa) and tients: 23% of the sample) and IIIc severe (7 patients: MM pain. io 7% of the sample) have resulted significant. Crossing TMJ pain is mainly referred to as severe/very severe: them with the quantitative subdivision of the metals, it in a total of 31 patients (48% of the sample) Gr1 oc- has resulted that in both pathologies the most fre- curs in 84% (26 patients), Gr1OD in 75% (23 pa- quent groups are Gr1 and Gr1OD. tients), Gr3 in 55% (17 patients), Gr3OD in 50% (15 az Figure 4. Hg amount in SG patients with amal- rn gam fillings. te In ni Figure 5. Metals – Articular problems. o izi Ed C Figure 6. Articular problems – Metals. CI © 46 Annali di Stomatologia 2014; V (2): 41-51  Heavy metals and pain in the dysfunctional patient patients), CG1 in 20% (6 patients) and CG2 in 0% (0 patients), CG1 in 27% (7 patients), CG2 in 0% (0 pa- patients). tients). In all the examined groups TMJ pain has been defined Muscular pain has been defined as mild by a lower mild/moderate by a minor percentage: in a total of 17 percentage in all the examined groups: in a total of 8 patients (26% of the sample) Gr1 is present in 17% (3 patients (12% of the sample) Gr1 and Gr1OD are li patients), Gr1OD in 25% (4 patients), Gr3 in 16% (3 present in 0% (0 patients), Gr3 in 8% (0,64 patients), patients), GrOD in 25% (4 patients), CG1 in 33% (6 Gr3OD in 19% (1,52 patients), CG1 in 7% (0,56 pa- na patients) and CG2 in 0% (0 patients) (Figs.7-8). tients) and CG2 in 0% (0 patients) (Figs. 9-10). Muscular pain has been mainly referred to as severe: Comorbidity: headache and cervicalgia. in a total of 27 patients (41% of the sample) Gr1 Is Headache is represented mainly as severe/very se- present in 83% (22 patients), Gr1OD in 75% (20 pa- vere in all the examined groups: in a total of 36 pa- io tients), Gr3 in 44% (12 patients), Gr3OD in 34% (9 tients (55% of the sample) Gr1 is present in 67% (24 az Figure 7. Metals – TMJ pain. rn te In ni Figure 8. TMJ pain – Metals. o izi Ed C Figure 9. Metals - MM pain. CI © Annali di Stomatologia 2014; V (2): 41-51 47  C. Di Paolo et al. patients), Gr1OD in 75% (27 patients), Gr3 in 66% the sample) Gr1 and Gr1OD are present in 50% (16 (24 patients), Gr3OD in 69% (25 patients), CG1 in patients), Gr3 in 67% (21 patients), Gr3OD in 63% 33% (12 patients) and CG2 in 0% (0 patients). (20 patients), CG1 in 26% (8 patients) and CG2 in Headache has been defined as mild/moderate, instead, 0% (0 patients). Cervicalgia has been defined instead by a lower percentage of patients: in a total of 12 patients as mild/moderate by a lower percentage of patients: li (18% of the sample) Gr1 and Gr1OD are present in 0% in a total of 19 patients (29% patients), Gr1 is present (0 patients), Gr3 in 1% (0,12), Gr3OD in 6% (0,72), CG1 in 33% (6,27 patients), Gr1OD in 25% (4,75 patients), na in 54% (6,48 patients) and CG2 in 0% (Fig. 11, 12). Gr3 in 17% (3,23 patients), Gr3OD in 15% (2, 85 pa- As regards Cervicalgia, this has also been defined as tients), CG1 in 47% (8,92 patients) and CG2 in 0% (0 severe/very severe: in a total of 32 patients (49% of patients) (Fig. 13, 14). io Figure 10. MM pain – Metals. az rn te In Figure 11. Metals – Headache. o ni izi Ed C Figure 12. Headache – Metals. CI © 48 Annali di Stomatologia 2014; V (2): 41-51  Heavy metals and pain in the dysfunctional patient Figure 13. Metals – Cervicalgia. li na io az Figure 14. Cervicalgia – Metals. rn te In ni Discussion due to the scarcity of the sample, rather than to typol- ogy of dysfunction. o The above reported results agree with those studies The SG patients with the more serious forms (IIa se- that underline how much environmental exposition vere and IIIc severe) present a higher percentage of izi factors such as air, water, and food are relevant total heavy metals (Gr1, 6 patients: 12% of the SG), sources of contamination for the whole population, and metals from dental preparations (Gr1OD, 4 pa- both healthy and affected by pathology (28,29). In tients: 8% di SG). The percentage deviancy of this fact, the CG1(dysfunctional subjects without dental above mentioned serious sample is significant if con- Ed preparations in the oral cavity) presents high concen- fronted with the deviancy of patients presenting a trations of metals that may make the dysfunction lower level of heavy metals, both total (Gr3, 18 pa- worse. Even if within the limits of this sample, this is tients: 36% of SG) and OD metals (Gr3OD, 32 pa- a presumable result because there is a directly pro- tients: 64% of SG). portional tendency between the concentration of met- Inside the control group (CG1+CG2) the IIa severe al ions and the exacerbation of the clinical sympto- represents the 26% (4 patients) of the CG1 (15 patients: C matology. 30% of the CG) and IIIc the 0% (no patients), while in The obtained results, moreover, seem to coincide the CG2 there is no pathology represented (Figs. 5-6). CI with those researches that show how dental materi- As regards the main algic symptomatology (TMJ als, especially those present in the amalgams, can pain, MM pain) in patients belonging to the SG, it is release metal ions in the organism (30) (Figs. 3-4). mainly severe or very severe, even if with different As regards the considered pathologies, the most percentages according to the groups (84-83% of Gr1; significant data are to be found in the severe forms 75% of Gr1OD; 55-44% of Gr3; 50-34% of Gr3OD). (for the presence of pain), and in particular in the Re- In CG the TMJ pain is defined mainly as mild (33% of © ducible disc displacement (IIa according to the CG), and MM pain, conversely, as severe (27% of RDC/TMD), and the TMJ arthrosis (IIIc according to CG). The most interesting evidence is that, in the the RDC/ TMD). Insignificant, and thus not reported, Gr1and Gr1OD groups, we find the highest percent- are the dysfunctional forms related to the group of the ages of TMJ and MM pain referred to as severe/very Irreducible disc displacement (IIb according to the severe (Figs. 7-10). RDC/TMD; 3 patients: 6 % in SG-1 patient: 2% in As regards comorbidity (headache and cervicalgia), CG). The scarce validity of the data for this groups is it also proved severe or very severe in the SG, al- Annali di Stomatologia 2014; V (2): 41-51 49  C. Di Paolo et al. though no pivotal percentage variances are found in 5. De Laat A. Temporomandibular Disorders as a source of oro- the various subgroups (67-50% of Gr1; 75-50% of facial pain. Acta neurol belg. 2011;101:26-31. Gr1OD; 66-67% of Gr3; 69-63% of Gr3OD). The pa- 6. Molina OF, Aquilino RN, Rank R, Santos ZC, Manzutti Eid tients of the CG, on the contrary, report lower values NL, Tavares PG. Is inflammation a mechanism in arthrogenic TMJ Otalgia? Rev Neurocienc. 2011;19(4)632-641. (mild for 54-47% of the sample) (Figs. 11-14). li 7. Alstergren P, Kopp S. Prostaglandin E2 in temporo- mandibular joint synovial fluid and its relation to pain and in- na flammatory disorders. J Oral Maxillofac Surg. 2000;58(2):180- Conclusions 6;discussion 186-8. 8. Alstergren P. Cytokines in temporomandibular joint arthritis. The obtained results seem to highlight a certain direct Oral Dis. 2000;6(6):331-4. proportionality between dysfunction and algic sympto- 9. Balkowiec-Iskra E. The role of immune system in inflammatory io matology seriousness and the increased concentra- pain pathophysiology. Pol Merkur Lekarski. 2010;29(174): tion of heavy metals in all the examined groups and 395-9. subgroups. 10. Haskin CL, Milam SB, Cameron IL. Pathogenesis of de- generative joint desease in the human temporomandibular az This data may be linked to some hypotheses found in joint. Crit Rev Oral Biol Med. 1995;6(3):248-277. the literature. Among these, we remember those by 11. Moalem G, Tracey D. Immune and inflammatory mechanisms De Bont and Stegenga (1997) (3,4) or Kacena at al. in neuropathic pain. Brain Res Rev. 2006;51(2):240-64. Epub (2001) (31) on the relation between inflammation and 2006 Jan 4. internal derangement and tissue degeneration phe- rn 12. Sommer C, Kress M. Recent findings on how proinflammatory nomena characterizing TMD, or Molina et al. (2011) cytokines cause pain: peripheral mechanisms in inflamma- (6), who link it to the appearance of articular and tory and neuropathic hyperalgesia. Neurosci Lett. 2004;361(1- muscular pain. Milam et al. (1998) (32) and De Laat 3):184-7. 13. Wang XD, Kou XX, Mao JJ, Gan YH, Zhou YH. Sustained te (2001) (5) find a correlation between the inflammation and the insurgence of an oxidative stress condition, inflammation induces degeneration of the temporomandibular joint. J Dent Res. 2002;91(5):499-505. Epub 2012. that may further amplify both the tissue inflammatory 14. Hogan MC. Heavy metal. Encyclopedia of Earth. National reaction and the sensitization phenomena at the level Council for Science and the Environment., Washington DC: of peripheral nervous system (33-36). In particular, this research has pointed out, for the In eds E.Monosson & C.Cleveland. 2010. 15. Manzon L, Grippaudo G. Fondamenti di materiali dentari. first time, how the accumulation of heavy metals re- Roma, Limiti, 2000. leased by dental preparations may be one of the fac- 16. Harben P. The Industrial Minerals Handbook, 3rd Edition, tors of the inflammation and/or of its progression. 1999. ni Some metals can also cause an oxidative stress in- 17. Nordberg G, Fowler B, Nordberg M, Friberg L. Handbook on crease, being able to catalyze the decomposition of the Toxicology of Metals. Elsevier, 2008. the hydrogen peroxide with the formation of oxydrilic 18. Duffus JH. Heavy metals a meaningless term? (IUPAC Tech- nical Report). Pure and Applied Chemistry. 2002:Vol. free radicals, promoting inflammatory and degenera- o 74:793-807. tive processes as well as the appearance of muscular 19. Rodríguez de Sotillo D, Velly A, Hadley M, Fricton J. Evidence and articular algic symptomatologies (32,37). izi of oxidative stress in temporomandibular disorders: a pilot The most relevant etiological hypothesis indicate that study. J Oral Rehabil. 2011;38(10):722-8. doi: 10.1111/j.1365- at the basis of dysfunctional pathologies there is a co- 2842.2011.02216.x. Epub 2011 Apr 4. occurrence of different factors, without measuring 20. Bray TM. Antioxidants and Oxidative Stress in Health and their effective role (1,38,39). This research points out Disease: Introduction. Proceedings of the Society for Ex- Ed the necessity that both clinicians and researchers perimental Biology and Medicine. 1999;vol.222:no.3. start taking into account the possible correlations be- 21. Forsberg L, deFaire U, Morgenstern R. Oxidative stress, hu- tween TMD and heavy metals in the oral cavity, also man genetic variation and disease. Archives of Biochemistry and Biophysics. 2001;389:84-93. considering the frequent occurrence of both cases in 22. Halliwell B, Cross C. Oxygen-derived species: their relation the population. In any case, it is necessary to confirm to human disease and environmental stress. Environ Health these results by developing wider and deeper studies. C Perspect. 1994;10:5-12. 23. Poli G, Parola M. Oxidative damage and fibrogenesis. Free Radical Biology and Medicine. 1997;22(1-2):287-305. CI References 24. Sies H. Oxidative stress: introductory remarks. Oxidative Stress, London, H.ed, 1985;1-9. 1. Cascone P, Di Paolo C. Patologia dell'articolazione tem- 25. Klinghardt D. [Online]. Available: http://www.klinghardta- poromandibolare. UTET scienze mediche, 2004. cademy.com/Articles/Heavy-Metals-and-Chronic-Dis- 2. Tanaka E, Detamore M, Mercuri L. Degenerative Disorders eases.html.2012. of the Temporomandibular Joint: Etiology, Diagnosis, and 26. Araki S. Effects of urinary volume on urinary concentrations © Treatment. J Dent Res. 2008;87(4):296-307. of lead, delta-aminolaevulinic acid, coproporphyrin, creati- 3. de Bont LG, Dijkgraaf LC, Stegenga B. Epidemiology and nine, and total solutes. British Journal of Industrial Medicine. natural progression of articular temporomandibular disorders. 1980;37(1):50-54. Oral Surgery Oral Medicine Oral Pathology. 1997;Vol 3, num- 27. Alimonti A, Bocca B, Mattei D, Pino A. Biomonitoraggio del- ber 81. la popolazione italiana per l'esposizione ai metalli:valori di 4. de Bont LG. Temporomandibular joint degenerative desease: riferimento 1990-2009, Istituto Superiore di Sanità (Rapporti pathogenesis. Management of Temporomandibular Joint De- ISTISAN 10/22), Roma, 2010. generative Diseases, Basel, Birkhäuser. 1996;3-11. 28. Araki S, Sata F, Murata K. Biological Monitoring o Exposure 50 Annali di Stomatologia 2014; V (2): 41-51  Heavy metals and pain in the dysfunctional patient to Industrial Chemicals. in (v. Fisherova- Bergerova, and M. 34. Sessle B. Peripheral and central mechanisms of orofacial in- Ogata, Eds.), Cincinnati, OH, ACIH, 1990;203-212. flammatory pain. Int Rev Neurobiol. 2011;97:179-206. 29. Nordberg G, Fowler B, Nordberg M, Friberg L. Handbook on 35. Lee S, YQ Z, Ribeiro-da-Silva A, Zhang J. Distinctive response the Toxicology of Metals. Elsevier, 2008. of CNS glial cells in oro-facial pain associated with injury, in- 30. Albi S. Amalgama e dintorni. Biocompatibilità dei materiali fection and inflammation. Mol Pain. 2010;6:79. li odontoiatrici: limiti e prospettive. Aldenia, 2009. 36. Merril R. Central mechanisms of orofacial pain. Dent Clin 31. Kacena MA, Merrel GA, Konda SR, Wilson KM, Xi Y, North Am. 2007;51(1):45-59. na Horowitz MC. Inflammation and Bony Changes at the Tem- 37. Spencer C, Gremilion H. Neuropathic orofacial pain: proposed poromandibular Joint. Cells Tissue Organs. 2001;169:257- mechanisms, diagnosis, and treatment considerations. 264. Dent Clin North Am. 2007;51(1):209-24. 32. Milam SB, Zaedaneta G, Schmitz JP. Oxidative Stress and 38. Luther F. TMD and occlusion part I. Damned if we do? Oc- Degenerative Temporomandibular Join Disease: A Proposed clusion: the interface of dentistry and orthodontics. British Den- io Hypothesis. J Oral Maxillofac Surg. 1998;56:214-223. tal Journal. 2007;202(1):E2; discussion 38-9. 33. Villa G, Ceruti S, Zanardelli M, Magni G, Jasmin L, Ohara 39. Luther F. TMD and occlusion part II. Damned if we don't? PT, Abbracchio MP. Temporomandibular joint inflammation Functional occlusal problems: TMD epidemiology in a wider activates glial and immune cells in both the trigeminal gan- context. British Dental Journal. 2007;202(1):E3; discussion az glia and in the spinal trigeminal nucleus. 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Original article Tooth wear among patients suffering from mental disorders li na Luca Piccoli, DDS, PhD needs for dental treatment were widespread Laith Konstantinos Besharat, DDS, PhD among psychiatric patients. io Michele Cassetta, MD, DDS, PhD Guido Migliau, MD, DDS, PhD Key words: tooth wear, psychiatric disorders, Stefano Di Carlo, MD, DDS, PhD bruxism. Giorgio Pompa, MD, DDS, PhD az Introduction Department of Oral and Maxillo-facial Sciences, Sapienza University of Rome, Italy Wear is described as the progressive loss of material rn from the contracting surfaces of a body, caused by relative motion at the surface (1, 2). Tooth wear is a Corresponding author: complex, multifactorial phenomenon with the interplay Lait Konstantinos Besharat of biological, mechanical, chemical and tribological te Department of Oral and Maxillo-facial Sciences factors (2). Over the last fifty years we have wit- Sapienza University of Rome nessed a general improvement of the oral hygiene, Viale Regina Elena, 287/A surely due to awareness campaigns, prevention and 00161 Rome, Italy E-mail: besharatlk84@yahoo.it In large scale access to dental services. In spite of all these measures that certainly improved the oral and dental health status; teeth because of their function undergo a slow but gradual wear due to normal aging Summary (3-5), so it may be considered a physiological ni process with an expected annual rate of wear of ap- Aim. Assess oral health, treatment needs and the proximately 11µm (6); in some cases, this wear is ac- correlation between tooth wear and medications centuated by diseases, disorders and administration in patients with psychiatric disease. of certain drugs through their side affects (dry mouth, o Methodology. 92 patients (40 male and 52 female) salivary gland hypofunction, muscle rigidity) could admitted in the Department of Neurology and Psy- lead to a significant friction between the occlusal sur- izi chiatry of the Umberto I Hospital of Rome under- faces of teeth resulting in increased wear. Therefore went an oral and dental clinical examination in ac- amount of tooth wear depends on factors such as cordance according to World Health Organization muscular forces, lubricants, patient diet habits and Basic Methods Criteria. One dentist performed all the type of the restorative material used (7). Specifi- Ed clinical examinations, training and calibration was cally erosion-related wear is increasing in the general carried out by an experienced clinical examiner. population (8, 9). The presence of teeth worn has be- To measure the degree of inter-examiner agree- come a common phenomenon in modern dentistry ment Kappa statistics was calculated. Level of especially in aging population (2, 10). This could be tooth wear was assessed using the tooth wear the result of the increased interested in retaining classification of Johansson et al. Exact psychi- teeth as opposed to having them extracted (11). C atric pathology and medications of each patient However tooth wear is a clinical finding in all age were registrated. The Statistical Package for the groups (12-14). The terms attrition, abrasion, erosion CI Social Sciences (SPSS Inc., Chicago, Ill.) was and abfraction all have been used to describe the used to analyze the data. A value of P < 0.05 was loss of tooth structure (2), but they only describe clini- considered statistically significant. cal manifestations of a number of events without in- Results. 34.78% of the sample regarding tooth cluding the causative factor (15). Attrition which is de- wear demonstrated score 2. Men demonstrated fined as a gradual loss of hard tooth substance from 30% score 2, and 20% score 3 and 4 whereas fe- occlusal contacts with an opposing dentition or © male patients 38.46% score 2, 7.69% score 3 and restoration, is related to aging but may be accelerat- none score 4. ed by extrinsic factors such as parafunctional habits Conclusions. Chronic exposure to neuroleptic of bruxism, traumatic occlusion in the partially eden- drugs can cause phenomena of bruxism. There is tulous dentition and malocclusion (16, 17). Clinically a direct correlation between tooth wear, psychi- occlusal wear attributable to attrition will produce atric disorders and administration of certain equal and matching wear facets on opposing teeth drugs. Poor oral hygiene and extensive unmet (18, 19). 52 Annali di Stomatologia 2014; V (2): 52-60  Tooth wear among patients suffering from mental disorders Abrasion is the loss of tooth substance through me- bating sleep bruxism (51-53); about 69% related chanical means, independent of occlusal contact (20). their sleep bruxism or its aggravation to stress or The most common cause of dental abrasion is tooth anxiety (54). brushing (16, 21). Abfraction describes loss of tissue in the cervical region as a result of crack formation li during tooth flexure (10, 19). Mastication and maloc- Materials and methods clusion play a major role in abfraction lesions (22). na Dental erosion is defined as loss of tooth structure by A sample of: 92 patients (40 male and 52 female) a non bacterial chemical process (18, 20). The with average age of 40 years were submitted to our source of acid can be endogenous, such as from investigation. All subjects gave their consent to par- gastric reflux, or exogenous from acidic foods and ticipate in this study. The patient selection was made io drinks (23); the distribution and wear pattern of ero- randomly among the patients at the Day Hospital of sion is specifically associated with origin of the acid the Department of Psychiatry at the Sapienza Univer- and the posture of the head when the acid is present sity of Rome. All patients were medically balanced; az (24, 25). Patients with bulimia or gastric reflux pre- none was under a psychotic attack and were all capa- sent the lingual surfaces of their maxillary anterior ble of understanding the supplied information. The teeth severely affected while their mandibular teeth fact that the screening was completely free of charge are protected from the erosive effect by the tongue guaranteed a heterogeneous sample in terms of so- rn and saliva (24). To determine if tooth wear is a result cio-economic status and oral health. Indeed, the ex- of abfraction, erosion, abrasion or erosion is really aminations, not necessarily conducted in the pres- difficult since these factors could act together with ence of pain, involved both dentally healthy subjects other ones masking in this way the true nature of and subjects affected by different dental diseases. te tooth wear (18). Clinical examination was conducted by the same cali- According to literature, tooth wear is more likely to be brated operator registrating: associated with bruxism than with temporomandibular i) oral hygiene status, utilizing the Green and Ver- joint disorders (TMJD). Although an association be- millon Semplified Oral Hygyen Index (OHI-S) (55) tween tooth wear and TMJD has been reported (26, In ii) degree of tooth wear using a method derived from 27), most studies indicate that TMJD is not a risk fac- the criteria set by Johansson et al. (56) tor for tooth wear (28-34). Bruxism on the other hand iii) the type of psychiatric diagnosis and drug thera- has been consistently implicated in tooth wear etiolo- pies in place. gy (28, 35-37). For each individual were made four three intra-oral ni Bruxism is defined as the oral activity characterized photographs and a facial profile. The purpose and by grinding or clenching of teeth without the pres- procedures of the study were explained to the partici- ence of food (38). The symptoms that confirm the pants and informed consent was obtained. Informa- o presence of this disease are: grinding noise, pain in tion on diagnosis and treatments was collected from jaw muscles, pain in the temporomandibular joint the patient’s medical charts and files. Moreover dur- izi (TMJ), headaches and neck pain. Clinically patients ing the phases of the anamnesis a series of ques- who suffer from bruxism present: tooth wear, sucking tions have been carried out based on a table formu- the cheeks, tongue jagged, tooth fracture, ankylosis, lated by the working group. Interviews typically began failure of dental prosthesis or dental restoration due with a standard questionnaire. It consisted of so- Ed to wear temporomandibular joint disorders and diffi- ciodemographic information, sleep/wake schedule, culty in prosthetic rehabilitation. However, it is appro- physical health queries, and questions related to priate to differentiate two types of bruxism: awake sleep and mental disease symptoms. All questions bruxism and sleep bruxism. Bruxism is a very com- required were made for entire diagnostic descriptions mon condition, most people it is estimated around according to the International Classification of Sleep 80-90% at least once in their lifetime had symptoms Disorders (ICSD) (57) and the Diagnostic and Statisti- C of grinding (39), the prevalence of the phenomenon cal Manual of Mental Disorders, fourth edition (DSM- is estimated between 5-8% in general population ac- IV) classifications (58). The duration of interviews CI cording to the majority of the authors (40-46). Sleep ranged from 20 to 60 min and were all completed in bruxism is an oral habit characterized by a rhythmic one session. The ICSD (57) suggests the following as activity of the temporomandibular muscles that caus- minimal criteria for sleep bruxism: (I) the presence of es a forced contact between dental surfaces during teeth grinding during sleep; and (II) at least one of the sleep. It is accompanied by tooth clenching or grind- following associated features: abnormal tooth wear, ing that can be loud enough to be heard by the bed muscular discomfort, or sound associated with the © partner. A Canadian study reported an 8% preva- tooth grinding. lence of tooth grinding during sleep (47). A Finnish twin cohort study, reported tooth grinding at least once a week in 3.7% of the women and 3.8% of the Classification of tooth wear men (48). Another 2 international studies found a rate of 10% of sleep tooth grinding (49, 50). Anxiety Various systems for classifying and evaluating the disorders and stress are known factors for exacer- wear of the teeth exist. Tooth wear indices are the Annali di Stomatologia 2014; V (2): 52-60 53  L. Piccoli et al. most popular method of quantifying wear over a long Data reliability period of time as they are readily available and do not require special equipment (59). Many of these use a In order to check intra-examiner and inter-examiner five-point scale based on severity of dental wear. In- levels of data consistency: tra-examiner reliability are of key importance for the - Both examiners received a 6 month training in as- li usefulness of these methods, and reliability of these sessing these measures and indices. approaches has been confirmed in many studies, but - Kappa statistics were calculated regarding tooth na no method is universally accepted (60). Measure- wear, oral and hygiene status; inter-examiner val- ments can also be recorded by the use of laser pro- ue for the first examiner respectively was 0.86, filometry (61) or stereomicroscopy images and com- 0.84, and 0.88, 0.86, for the second one. puterized image fitting (62). 3D laser scanning can be - Each examiner was calibrated separately against io used to scan the surface of a replica to construct a the experienced supervisor. 3D image for quantifying the wear more accurately - Recalibration sessions were conducted periodically (63). In addition to traditional rating systems there through data collection; every 15 patients a random az have been recently introduced sophisticated and sample of three patients were re-examined sepa- complex wear simulators, but a clear correlation be- rately by both investigators in order to ensure data tween in vitro and clinical data has not been estab- reliability. During the cross-checking sessions each lished (26). Moreover clinical performance of dental examiner was blinded to previous data collected and biomaterials cannot be precisely predicted and oral rn to information regarding the patient’s anamnesis. environment cannot be simulated simply because - Upon reexamination no significant differences in standard oral conditions doesn’t exist (64). However, scores were noticed. the usefulness of all these innovative diagnostic tools - Data were entered in two different personal com- te in a clinical setting is questionable despite improved puters by the two examiners, the two data files accuracy and reliability they have a high cost and re- were compared in order to detect entry errors. quire specialized hardware and software restricting The two files resulted identical. their use in everyday dental practice (65). In The degree of tooth wear for each tooth was classified according to a method that is derived from the criteria Results set out by Johansson et al. (48). The dental wear evaluation procedure was performed with the patient The sample was composed of 92 patients; 56.52% sitting upright in a dental chair, wiping the surfaces of were women and 44.48% were men (Fig. 1): ni teeth with a jet of air and cotton wool. Degree of wear - 5% of male patients and 8% of female patients was estimated by direct vision or by using a mirror ac- showed values between 0.3 and 0.6, as evidence cording to five criteria: of a satisfactory state of oral hygiene (Fig. 2). • Score 0: no visible facet in the enamel. Morpholo- o - 13% of male patients and 13% of female ones gy of the occlusal/incisal intact. showed values between 0.7 and 1.8 as evidence • Score 1: marked wear facets in enamel. Morphol- izi of a medium degree of oral hygiene (Fig. 2). ogy of the occlusal/incisal altered. - 83% of male patients and 79% of female ones re- • Score 2: wear into the dentin. The dentin is ex- ported values between 1.9 and 3.0 corresponding posed occlusal/engraved or on an adjacent tooth to a poor oral hygiene (Fig. 2). surface. The morphology of the occlusal/incisal Ed The mental disorders registrated during the examina- has changed in shape with a reduction in height tion of the sample are: of the crown. 1) paranoid schizophrenia • Score 3: extensive wear into dentin. Dentine area 2) disorders of language larger (> 2 mm square) exposed to occlusal/in- cisal. The morphology of the occlusal/incisal total- 3) dysthymia ly lost locally or generally. Substantial loss of 4) schizophrenia C height of the crown. 5) residual psychosis • Score 4: wear in the secondary dentin. 6) mental retardation CI 7) schizophrenia undifferentiated 8) psychoneurosis Statistical analysis 9) personality disorders 10) depressive disorders Statistical analysis was performed using SPSS Inc, 11) psychosis 12) adjustment disorders © ver. 13.0, Chicago, IL, USA. Chi-squared test was used for statistical evaluation of proportions. Students 13) disorders of power T-test for 2 independent means was applied. In cases 14) moderate depression with more than 2 independent means we used the 15) anxious depressive syndrome ANOVA test. Moreover wherever necessary a linear 16) affective syndrome dipolar regression analysis was performed. A p-value of less 17) affective disorders of the personalities than 0.05 was considered significant. A 95% CI was 18) bipolar disorder grade II used in all analysis. 19) alcoholism. 54 Annali di Stomatologia 2014; V (2): 52-60  Tooth wear among patients suffering from mental disorders Side effects of the various medications received from grade 0 19.57%, grade 3 13.04% and grade 4 8.70% the patients are reported in Table 1. (Fig. 3). Grade 2 tooth wear was registrated in 34.78% of the By comparing the degree of tooth wear in the two sex- patients whereas grade 1 in 23.19% of the patients, es separately we observed a greater degree of wear fe- li Figure 1. Percentages of male and female pa- na tients of the sample. io az rn te Figure 2. Oral hygiene of sample. In o ni izi Table 1. Side effects of medications adminestered to the sample. Ed Drug SIDE EFFECTS SEROQUEL: drowsiness, dyspepsia, constipation, dry mouth, asthenia, rhinitis, tachycardia. TRANQUIRIT: drowsiness, dyspepsia, constipation, dry mouth, asthenia, rhinitis, tachycardia. DEPAKIN CHRON: gastric irritation, nausea, hyperammonemia, weight gain, transient loss of hair, aggression, hyperactivity, behavioral problems, ataxia, tremors, lethargy, drowsiness, hallucinations, anemia, C skin rash. LEPONEX: constipation, hypersalivation, dry mouth, nausea, vomiting, anorexia, tachycardia, hypertension, CI tremors, rigidity, seizures, sweating, arrhythmias, myocarditis, delirium, respiratory depression, hyperlipidemia, skin reactions. AKINETON: constipation, dry mouth, nausea, vomiting , tachycardia, dizziness, confusion, euphoria, hallucinations, memory impairment, anxiety. TAVOR: drowsiness confusion, ataxia, amnesia, dependence, aggression, muscle weakness, dry mouth, © gastrointestinal and visual disturbances. CYMBALTA: dry mouth, gastrointestinal disturbances, constipation, eye dryness, difficulty of urination, headache, arrhythmias. RIVOTRIL: drowsiness, fatigue, dizziness, muscle hypotonia, coordination disturbances, restlessness, confusion, amnesia, dependence, hypersalivation, pruritic, visual disturbances. FELISON: drowsiness, confusion, ataxia, dependence. Annali di Stomatologia 2014; V (2): 52-60 55  L. Piccoli et al. males; about 38% of females showed the grade 2 com- Regarding medications was found that about half of pared with 30% of males (Figs. 4, 5). Similarly 38% of female patients taking the Depakine chon compared the females showed grade 1 tooth wear while the per- to 20% of male patients (Fig. 6). Moreover 20% of centage for males ranged around 20% (Figs. 4, 5). males receive Seroquel while 23% of female patients It is important however to note that while the degree receive Tranquirit (Fig. 6). Figure 6 lists all drug ther- li of wear 4 reaches 20% in males, females have not apies lists of the sample comparing the various rates presented a single case (Figs. 4, 5). between the sexe na Figure 3. Tooth wear of patients. io az rn te In Figure 4. Degree of tooth wear on male patients. o ni izi Ed Figure 5. Degree of tooth wear on female pa- tients. C CI © 56 Annali di Stomatologia 2014; V (2): 52-60  Tooth wear among patients suffering from mental disorders Figure 6. Medications administered to the entire sample. li na io az rn te In o ni Discussion suffering from xerostomia leading to gingivitis, peri- izi odontitis, stomatitis and increased risk of caries; Psychiatric patients are turning to the dentist much therefore oral hygiene is of great importance for more rarely than the general population (66). Taking these patients (66, 75, 76). In some subjects we not- into account that the 2 main reasons that the general ed the presence of old incongruous dental prosthesis Ed population avoids going to the dentist are dental care associated with a very poor hygiene. Males in our anxiety and the cost of care it is natural that those fac- study in concordance with international literature (66) tors generally are accentuated in the population of pa- showed a lower index of oral hygiene than females tients suffering from mental disorders. Another reason and that value resulted statistically significant at the that influences the low affluence of psychiatric patients χ2 test. The majority of the patients are not self-suffi- to the dentist is pain insensitivity that mental disorders cient with regard to oral hygiene and in terms of ac- C patients demonstrate and could be a result of the cess to dental care. pathology itself or a side effect of the medications that In our study we registrated a high prevalence of tooth CI they receive. Insensitive to pain associated with illness wear in our sample (80%) whereas in international lit- and injury, has been reported frequently in this popula- erature in studies that involve general population of tion (67-73). It is important to underline that even if se- all ages this percentage doesn’t exceed 20% (30,77). vere tooth wear has an impact on oral pain levels (74), Wear at the majority of the patients involved sites of in the population studied none of the patients exam- occlusal contact only a small part (7%)of the female ined referred oral or tooth pain. Pain insensitivity could population examined showed tooth surface loss with © lead to a delay in diagnosis and treatment. characteristics of erosion in noncontact areas and On examination it was found a general and wide- around contact areas typical of acid regurgitation re- spread neglect of oral hygiene. During the clinical ex- sulting from gastroesophageal reflux disease aminations we registrated cases of gingival hyperpla- (GERD). Interviewing this part of the sample didn’t sia and in some cases dental abscesses that persist- occur that they consume highly acidic carbonated ed for a long time. Patients suffering from long term beverages or fruit juices. Habitual sucking of lemons psychiatric illness are on medication for long periods other fruits or tomatoes weren’t referred. Annali di Stomatologia 2014; V (2): 52-60 57  L. Piccoli et al. On the basis of the presence of both clinical and vary flow. Special precautions must be taken when anamnestical indicators authors retain that the major- performing surgery and when prescribing or adminis- ity (93%) of the registrated wear at the sites of oc- tering analgesics, antibiotics or sedative agents that clusal contact derives from either awake bruxism are likely to have an adverse interaction with psychi- (60%) or sleep bruxism (40%). atric medications. Preventive dental education use of li Authors retain that there is an association between saliva substitutes and anticaries agents are indicate. bruxism psychiatric disorders and their medications An improved understanding of the factors associated na that can cause phenomena such as: dry mouth, mus- of tooth wear may lead to more effective interven- cle stiffness, hypofunction of salivary glands. Given the tions. Tooth wear is a public health problem and the nature of our study we cannot claim that surely med- multitude of indices and flaws in existing indices ications and not the pathologies themself cause brux- make published data difficult to elaborate, analyze io ism but international literature support the correlation and interpret. between medications and bruxism. It is worthnoting that a psychological stress component may play a role, but not all tooth grinders have emotional problems az References (78). Another international study highlighted the use of the Naranjo Adverse Drug Reactions Probability Scale, 1. Ramalho A, Miranda J. The relationship between wear and which indicated a highly probable relationship between dissipated energy in sliding systems. Wear. 2006;260:361- the bruxism and long-term exposure of neuroleptic 367. rn therapy (79). Moreover various cases of antidopamin- 2. Mair L, Stolarski T, Vowles R, Lloyd C. Wear: mechanisms, ergic related bruxism have been reported (80). Fur- manifestations and measurement. Report of a workshop. J thermore suggested involvement of adrenergic, sero- Dent. 1996;24:141-148. 3. Pergamalian A, Rudy TE, Zaki HS, Greco CM. The associ- te tonergic, and dopaminergic systems in the pathogene- ation between wear facets, bruxism, and severity of facial pain sis of bruxism, as the side effects were relieved after in patients with temporomandibular disorders. J Pros Dent. propranolol was added to ongoing antipsychotic treat- 2003;90:194-200. ment (81). It has been postulated that disturbances in 4. Tsiggos N, Tortopidis D, Hatzikyriakos A, Menexes G. As- In the central dopaminergic system, especially within the mesocortical tract, are linked to bruxism (82, 83) and sociation between self-reported bruxism activity and occur- rence of dental attrition, abfraction, and occlusal pits on nat- selective serotonin reuptake inhibitors (SSRIs) induced ural teeth. J Prosthet Dent. 2008;100:41-6. bruxism (84, 85). SSRI-induced bruxism is considered 5. Pigno MA, Hatch JP, Rodrigues-Garcia RC, Sakai S, Rugh to be a consequence of serotonergically mediated inhi- JD. Severity, distribution, and correlates of occlusal tooth wear ni bition of the dopaminergic system. in a sample of Mexican-American and European-American Absence of tooth wear of grade 4 in our study in the adults. Int J Prosthodont. 2001;14:65-70. 6. Goho C, Jones HL. Association between primary dentition female population and a 20% prevalence in the male wear and clinical temporomandibular dys-function signs. Pe- one is probably reflecting the higher bite force of o diatr Dent. 1991;13:263-6. males compared to females (36). 7. Hugoson A, Bergendal T, Ekfeldt A, Helkimo M. Prevalence It is worth noting underline the fact that authors faced and severity of incisal and occlusal tooth wear in an adult izi an unexpected collaboration and will from the majori- Swedish population. Acta Odontol Scand. 1988;46:255-65. ty of the psychiatric patients to undergo a clinical ex- 8. Barlett DW. Retrospective long term monitoring of tooth wear amination, phenomenon that other authors in other using study models. Br Dent J. 2003;194:211-3. studies have noted too (86). 9. Kononen M, Klemetti E, Waltimo A, Ahlberg J, Evalahti M, Ed Kleemola-Kuhala E, et al. Tooth wear in maxillary anterior teeth from 14 to 23 years of age. Acta Odontol Scand. Conclusions 2006;64:55-8. 10. Pintado MR, Anderson GC, DeLong R, Douglas WH. Vari- ation in tooth wear in young adults over a two-year period. Our study in accordance with the international litera- J Prosthet Dent. 1997;77:313-20. ture showed a high frequency of psychiatric patients C 11. Mahalick J, Knap F, Weiter E. Occlusal wear in prostho- who suffered from tooth wear. Many drugs adminis- dontics. J Am Dent Assoc. 1971;82:154-159. tered during psychiatric therapy often act as an en- 12. Bartlett DW. The role of erosion in tooth wear: aetiology, pre- CI docrine disruptor with a marked decrease in saliva, in vention and management. Int Dent J. 2005;55:277-284. other cases with stiffness muscle factors that will 13. Arnadottir IB, Holbrook WP, Eggertsson H, Gudmundsdot- surely accentuate the level of wear of the teeth no tir H, Jonsson SH, Gudlaugsson JO, et al. Prevalence of den- longer lubricated by saliva. From the results shown tal erosion in children: a national survey. 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Original article Influence of vision on masticatory muscles function: surface electromyographic evaluation li na Domenico Ciavarella, DDS, PhD1 masseters close test in the two groups. The exact Antonio Palazzo, MD1 causes of MMp are still unknown. The role how oc- io Alfredo De Lillo, DDS1 ular disorders (OD) may play an important role in Lucio Lo Russo, DDS, PhD1 pathogenesis of MMp is still a controversal issue. Sergio Paduano, DDS3 Ocular arc reflexes (OAR) may involve changes in Luigi Laino, DDS, PhD1 head and neck posture and generate modifications az Claudio Chimenti, DDS2 of contraction resulting in muscle contraction and Federica Frezza, DDS1 finally weakness. Lorenzo Lo Muzio, DDS,PhD1 Key words: surface electromyography, masticato- rn ry muscles pain, ocular disorders. 1 Department of Clinical and Experimental Medicine, Faculty of Medicine, School of Dentistry, University of Foggia, Italy Introduction te 2 Department of Surgical Sciences, Faculty of Medi- cine, School of Dentistry, University of L’Aquila, Italy Masticatory muscles (MM) function is influenced by 3 Department of the Health, University “Magna Grae- many factors such as postural problems, traumas, cia” Catanzaro, Italy In psycho-physiological issues and occlusal alterations. Masticatory muscles pain (MMp) is a condition en- countred in temporo-mandibular joint disorder (TMD) Corresponding author: and in head/neck facial pain. Its pathogenesis is still Domenico Ciavarella unclear (Fig. 1) (1,2). Several studies have de- ni Department of Clinical and Experimental Medicine, scribed how the level of electromyographic activity Faculty of Medicine, School of Dentistry, (EMG) in the pericranial muscle is higher in patients University of Foggia with MMp than in healthy controls in rest position (3- Via Rovelli 6). The interaction between muscle pain and muscle o 71100 Foggia, Italy activity at rest is still unclear because the EMG activ- Phone: +39 347 6131225 ity in muscle pain patients has been shown to be izi Fax: +39 0881 588080 higher as compared to control subjects (7,8). The E-mail: drdomenicociavarella2@yahoo.it maximal voluntary contraction (MVC) in painful mus- cles is decreased in patients with temporomandibular disorder (7,8). Ed Summary Other symptoms related to MMp are often acoustic alterations, vertigo, nausea, salivary disturbance, The role of the ocular disorders (OD) in pathogene- sis of MMp is still a controversal issue. Ocular arc reflexes (OAR) may involve changes in head and neck posture and generate modifications of con- C traction resulting in muscle contraction and finally weakness. sEMG tests were performed on 28 pa- CI tients (13 with masticatory muscles pain and my- opia/15 healthy) in rest position with eyes open and eyes closed. Patients group control (healthy pa- tients) showed no significance difference in sEMG record in open/close test. In non healthy patients there were great differences between the sEMG © recordings with eyes closed and open. Temporalis and masseters showed a statistical difference of means activation in two tests (temporalis p = 0.0010; masseters = 0.0006). Great difference there was in means muscles activation between open eyes healthy test and non healthy. No difference in close eyes test was evaluated in temporalis and Figure 1. Possible pathogenesis of MMs. Annali di Stomatologia 2014; V (2): 61-65 61  D. Ciavarella et al. disfagy and sometimes language alterations (9). The tion on the functional status of the craniomandibular muscular stress is often treated with an oral appli- neuromuscular system and was useful in determining ance such as resin splint which helps reduce clench- the proper cranio-mandibular relationship. ing (10-12). To position the electrodes, subjects were requested The role how ocular disorders (OD) may play an im- to close their mouths and clench (Fig. 2) (15,16). To li portant role in pathogenesis of MMp is still a contro- reduce electrode impedance, the skin was carefully versal issue. Ocular arc reflexes (OAR) may involve cleaned prior to electrode positioning, and recordings na changes in head and neck posture and generate were performed 5-6 min later, allowing the conductive modifications of contraction resulting in muscle con- paste to adequately moisten the skin surface (17). traction and finally weakness. The aim of this study is The analogue sEMG signal was amplified, digitised, to evaluate the influence of OD in MM contractions, in and digitally filtered. The instrument was directly in- io patients with masticatory muscles pain and in healthy terfaced with a computer, which presented the data subjects, using surface Electromyography (sEMG). graphically. The signals were averaged over 25 ms, with muscle activity of the four tested muscles espressed in microvolts (μV). az Materials and methods The sEMG test was performed on each patient in resting (i.e. no voluntary muscle contraction and no In this study, sEMG tests were performed on 28 pa- dental contact) conditions and in different ocular tients (10 males and 18 females, ages 16 to 48) at states (i.e. eyes open and eyes closed). In particular, rn School of Dentistry, University of Foggia. The partici- the sEMG test was performed in patients sitting, with pants and their parents provided written informed their ocular plane parallel to the floor, after measur- consent to be involved in the study. The EMG activity ing their body temperature, and with a room temper- te at rest and clench in the temporal and masseter mus- ature of 26° C. No other interferences were present cles was recorded in two groups of patients with dif- in the room. ferent conditions: myopic patients and masticatory An eight channel surface Electromyograph was muscles pain; asymptomatic subjects was used as a used on 4 groups of muscles: temporalis and mas- control. On each patient the RDC questionnaire was submitted (13). In seters (masticatory muscles) and the digastrics and sternocleidmastoids (neck muscles). On sEMG test Patients’ criteria selection was as follows: Angle’s muscle contractions were represented on 5 window Class I Molar (i.e. normal intermaxillary dental rela- displays and were calculated in microvolts (μV). On tionships), good symmetry of dental arches, no re- view displays it is possible to see the activity level of ni fractive errors, patients’ anamnesis of temporo- each monitored muscle. Each column of numbers mandibular disease (TMD) or facial pain history ab- represents the average muscle activity (μV) sence, absence of neuromuscular pathology, and no throughout a marked region and the time for the history of neuromuscular pathology, absence of neu- muscle to exceed the activity level. This is mea- o ropathic or myofascial pain, absence of any anterior sured in milliseconds. or posterior/lateral cross-bite; no signs or symptoms izi of TMD (according to the RDC questionnaire) (13). Subjects taking drugs other than nonsteroid inflam- matory drugs, paracetamol or minor opioid anal- gesics were excluded, as well as subjects presenting Ed with systemic pathologies such as diabetes, and subjects suffering from generalised diffuse muscle and/or articular pain. The non-healthy group (13 pa- tients; mean age 26,5 ± 6.9) suffering from either masticatory muscles pain (MMp) and myopia was enrolled in the study. Examinations were performed C using a standardized form in which the following were listed: history of the diseases, palpation at rest, CI in maximal voluntary contraction and during mandibular motions of the masticatory and neck muscles, palpation of temporo-mandibular joint (TMJ), assessment of spontaneous and triggered pain using a visual analogue scale (VAS), mandibu- lar motions recorded by an electrognathograph as © suggested by Okeson (14). Surface electromyography evaluation The tests, performed by means of Biopack elec- Figure 2. Patient with surface electromyography elec- tromyography. This diagnostic test provided informa- trodes. 62 Annali di Stomatologia 2014; V (2): 61-65  Influence of vision on masticatory muscles function: surface electromyographic evaluation Electromyography gives the operator the effective activation in two tests. In open eyes test mean of acti- RMS (Root Mean Squared) value. RMS is calculated vation was 23.85 μV. This value was greater than as the square root of the medium power in a date mean in close eyes 3.538 μV. The medians differ sig- time interval (X RMS = √1/T t0∫x2 (t) dt). The Averaged nificantly (P-Value < 0.0001) (Tab. 1). EMG display shows a rectified average of the muscle Masseters changed their activity in close eyes test in li signals which are contained within the zoom cursor. respect to open eyes test. Non-healthy subjects The height of the graph (“mountain peaks”) repre- showed a mean of activation in open eyes (24.46 μV) na sents the activity of the muscle averaged every 25 greater than close eyes test (4.923 μV). The medians milliseconds. The numbers below represent the aver- differ significantly (P-Value < 0.0001). age firing strength of each muscle (μV). All tests were Authors evaluated open eyes means of each muscle performed for 10 seconds duration. between healthy and non-healthy subjects. There io was a great difference in masseters means between open eyes healthy test and non-healthy test. Healthy Statistical analysis showed masseters mean of activation of 3.200 μV while non-healthy subjects 24.46 μV. The medians az A statistical analysis of data with open and close differ significantly (P-Value < 0.0001). eyes in healthy and non healthy were done. Data In close eyes test of masseters non-healthy subjects were evaluated on statistical “GraphPad” software presented no difference with healthy subjects (mean performing a Paired t-test. Statistical significance was non-healthy 4,923 μV, healthy 2,600 μV). The medi- rn set at 0.05. ans do not differ significantly (p=0.1987). In open eyes temporalis presented a substantial dif- ference of activation as well (healthy 4.067 μV, non- Results te healthy 23.85 μV). The medians differ significantly (P-Value < 0.0001). Control group showed no significant difference in In close eyes test there was no difference between sEMG records in open/close tests. Temporalis activa- the two groups of patients. No statistical difference tion (right and left mean) in two tests had the same In range of activation. The medians do not differ signifi- was evaluated (p=0,7605) (Tab. 2). Authors observed a significant variation in switching cantly (P-Value = 0.3976) . from eyes closed to eyes open in all non-healthy pa- Masseters activation (right and left mean) in healthy tients. subjects, in open/close tests had no significant An Electromyographic test in open and close eyes ni change in activation (open 3.200 μV; close 2.600 and in rest jaw position was conducted. During the μV). Values of 2.0/3.0 μV when recorded with the test an error occurred because some patients closed mandible at rest are generally accepted as indicating their eyes. Authors observed how 4 subjects during muscle posturing. The medians do not differ signifi- physiologic open/close eyes produced an electromyo- o cantly (P-Value = 0.3274) (Tab. 1). graphic image that was unusually. Every open/close In patients with muscles suffering (non-healthy) there movement induced a great increase of electromyo- izi were differences between the sEMG recordings with graphic trace. Authors did not include this data in sta- close eyes and open. MM increased their work by vi- tistical analysis because only a small sample present- sion. Temporalis showed great difference of means ed this phenomena. Ed Table 1. Results of sEMG test in healthy and non-healthy subjects. Mean SEM Median Min Max 95 % CI p-Value C (pairing means Test) Temporalis open 4.067 0.82 2.000 1.000 24.000 2.374-5.759 0.3976 CI activation (μV) close 3.567 0.7485 2.000 1.000 21.000 2.036-5.097 healthy Masseter open 3.200 2.511 2.000 1.000 12.000 2.263-4.137 0.3274 activation (μV) close 2.600 2.298 2.000 0.000 11.000 1.742-3.458 healthy © Temporalis open 23.85 6.807 10.00 1.000 128.0 9.823-37.869 <0.0001 activation (μV) close 3.538 0.7590 2.000 0.0 17.00 1.975-5.102 non healthy Masseter open 24.46 5.708 15.00 2.000 100.0 12.703-36.22 <0.0001 activation (μV) close 4.923 1.105 2.000 0.0 21.00 2.647-7.199 non healthy SEM: Standard error of means; CI: Confidence Interval; Significance level: p < 0.05 Annali di Stomatologia 2014; V (2): 61-65 63  D. Ciavarella et al. Table 2. Results of sEMG open/close test between healthy and non-healthy subjects. Mean SEM Median Min Max 95 % CI p-Value (pairing means Test) Temporalis Healthy 4.067 0.82 2.000 1.000 24.000 2.374-5.759 li <0,0001 activation (μV) Non healthy 23.85 6.807 10.00 1.000 128.0 9.823-37.869 open na Temporalis Healthy 3.567 0.7485 2.000 1.000 21.000 2.036-5.097 0,7605 activation (μV) Non healthy 3.538 0.7590 2.000 0.0 17.00 1.975-5.102 close Masseter Healthy 3.200 2.511 2.000 1.000 12.000 2.263-4.137 io <0,0001 activation (μV) Non healthy 24.46 5.708 15.00 2.000 100.0 12.71-36.22 open Masseter Healthy 2.600 2.298 2.000 0.000 11.000 1.742-3.458 az 0,1987 activation (μV) Non healthy 4.923 1.105 2.000 0.0 21.00 2.647-7.199 close SEM: Standard error of means; CI: Confidence Interval; Significance level: p < 0.05 rn Discussion known that when the ocular globes stir, all ocular te muscles are stimulated. At the same time there is a The purpose of the authors was to evaluate if ocular neurologic reflex that induces all the neck muscles to disorders (OD) may influence MM activity and pro- change position for a better view of the object in inter- duce masticatory muscles pain (MMp). The MMp est. Some fibres coming from the macula do not pathogenesis is still unclear. Its association with OD In is an actually item of discussion in literature research. reach the visual cortex of the brain but directly influ- ence postural mechanisms of the body (23,24). The association of upper activation of the muscles in Anatomical researches show how the Optic Nerve rest position and the OD was observed (18). It was starts from the retinal photoreceptors and stretches to evaluated a modification of EMG activity at rest with corpus genicolatum laterale and then continues to ni closed eyes in patients with cranio-cervical disfunc- parts 17/18/19 of Brodmann’s area of lobus occipitalis tion (19) and in patients with OD (20). No significant (25). Some optic nerve fibres don’t follow the same difference of EMG over the anterior temporalis area route through corpus genicolatum laterale but instead at mandible rest position comparing eyes closed with o eyes open condition in young healthy people with normocclusion and without visual defects (21). izi Authors evaluated MM contraction in healthy and non healthy (i.e. patients suffering of facial pain) subjects by use of sEMG. In the present paper authors observed no difference in healthy patients without OD in both condi- Ed tions open/close eyes and in patients with ocular disor- ders as myopia the modifications in open eyes are statis- tically significative when paired in close condition both for temporalis and masseters rest evaluation. The activation of the masticatory muscles in open eyes was greater in patients with OD than healthy subjects; no difference C was observed in close eyes test in two evaluated groups. It is well known that ocular vision (OV) has an impor- CI tant role in controlling body equilibrium and move- ments. Vestibulo-ocular reflex and ocular reflex through substantia reticularis influences masticatory and postural muscles. In recent years, some authors have tried to discover if OV plays a role in MMp pathogenesis. Neuro-physiologicical sources show © how there is a strong connection between the various Figure 3. Possible neurologic connection. Corpus genicola- parts of the nervous system for some types of invol- tum lateralis CGL; nucleus centralis (NC); nucleus rubrum untary reflexes. Control of conscious and subcon- (NR); substantia reticularis (SR); nucleus motorius nervi scious movements and some functions are modified trigemini (N mo V); ganglius trigemini (GT); apparatus sen- by neurologic sensitive afferent reflexes (22). sitivus nervi trigemini (ASV). [modified from Francis Hart- OV may influence many types of muscular activity by mann, Gerard Cucchi. Le disfunzioni cranio-mandibolari activating neurologic sensitive reflexes. It is well (SADAM). Ed. Springer, 1997] 64 Annali di Stomatologia 2014; V (2): 61-65  Influence of vision on masticatory muscles function: surface electromyographic evaluation go to the superior colliculi via the brachium of colli- 9. Hartmann F, Cucchi G. Stress and the problem of pain in my- culi. From the superior colliculi, fibres project to sub- ofascial pain dysfunction syndrome (M.P.D.S.). Prog Odon- stantia reticularis and the reflex ends in nucleus mo- toiatr. 1991;4(10):8-10. torius nervi trigemini (Fig. 3) (26). It is probable that 10. Coy RE, Flocken JE, Adib F. Musculoskeletal etiology and therapy of craniomandibular pain and dysfunction. Cranio Clin this type of arc reflex in patients, with OD, unevaluat- li Int. 1991;1(2):163-73. ed is overexpressed to generate a strong MM con- 11. Kidder GM, Solow RA. Precision occlusal splints and the di- traction that may result finally in pain. na agnosis of occlusal problems in myogenous orofacial pain patients. Gen Dent. 2014;62(2):24-31. 12. Koralakunte PR. Prosthetic management of a masticatory Conclusion muscle disorder with customized occlusal splint. J Clin Di- agn Res. 2014;8(3):259-61. io sEMG evaluation showed how no modifications in 13. Dworkin SF, LeResche L. Research diagnostic criteria for tem- open/close tests was presented in healthy subjects. poromandibular disorders: review, criteria, examinations and Non-healthy subjects presented great modification in specifications, critique. Craniomandib Disord. 1992;6 (4): 301-55. open/close tests. These findings were of great interest in az 14. Okeson J. Oro-facial pain: guideless for assessment, diag- patients with unexplainable masticatory muscles pain. nosis, and management. Chicago, IL: Quintessence Pub- The exact causes of MMp are still unknown; peripheral lishing Co, Inc. 1996. myofascial mechanisms and central dysregulation of 15. Castroflorio T, Farina D, Bottin A, Piancino MG, Bracco P, pain processing structures play a role in MMp patho- rn Merletti R. Surface EMG of jaw elevator muscles: effect of genesis but their relative weight both with the frequency electrode location and interelectrode distance. J Oral Rehabil. of pain and among patients is still a controversial issue. 2005;32(6):411-7. 16. De Oliveira RH, Hallak JE, Siessere S, De Sousa LG, Sem- prini M, De Sena MF, et al. Electromyographic analysis of te Conflicts of Interest/Role of the Funding masseter and temporal muscles, bite force, masticatory ef- ficiency in medicated individuals with schizophrenia and mood Source disorders compared with healthy controls. J Oral Rehabil. 2014;41(6):399-408. All authors disclose any financial and personal rela- tionships with other people or organizations that In 17. Tartaglia GM, Testori T, Pallavera A, Marelli B, Sforza C. Elec- tromyographic analysis of masticatory and neck muscles in could inappropriately influence (bias) their work. subjects with natural dentition, teeth-supported and implant- supporte prothesis. Clin Oral Implants Res. 2008;19:1081-1088. 18. Veiersted KB, Westgaard RH, Andersen P. Electromyographic ni References evaluation of muscular work pattern as a predictor of trapezius myalgia. Scand J Environ Health. 1993;19:284-290. 1. Svenson J, Cowen D, Rogers A. Headache in the emergency 19. Miralles R, Velenzuela S, Ramirez P, Santander H, Palazzi department: importance of history in identifying secondary C, Ormeno G, et al. Visual imput effect on EMG activity of o etiologies. J Emerg Med. 1997;15(5):617-21. sternocleidomastoid and masseter muscles in healthy sub- 2. Silveira A, Armijo-Olivo S, Gadotti IC, Magee D. Masticatory jects and in patients with myogenic cranio-cervico-mandibu- izi and cervical muscle tenderness and pain sensivity in a remote lar disfunction. Cranio. 1998;16(3):168-84. area in subjects with a temporomandibular disorder and neck 20. Monaco A, Cattaneo R, Spadaro A, Giannoni M, Di Marti- disability. J Oral Facial Pain Headache. 2014;28(2):128-37. no S, Gatto R. Visual input effect on EMG activity of masti- 3. Schoenen J, Gerard P, De Pasqua V, Sianard-Gainko J. Mul- catory and postural muscles in healthy and in myopic chil- dren. Eur J Paediatr Dent. 2006;7(1):18-22. Ed tiple clinical and paraclinical analyses of chronic tension-type headache associated or unassociated with disorder of per- 21. Spadaro A, Monaco A, Cattaneo R, Masci C, Gatto R. Ef- icranial muscles. Cephalalgia. 1991;11:135-39. fect on anterior temporalis surface EMG of eyes open-closed 4. Ashina M, Bendtsen L, Jensen R, Sakai F, Olesen J. Muscle condition. European Juournal Of Paediatric Dentistry. hardness in patients with chronic tension-type headache: re- 2010;11:210-212. lation to actual headache state. Pain. 1999; 79(2-3):201-5. 22. Pierrot-Deseilligny C. Central oculomotor circuits. Rev Neu- 5. Jensen R, Rasmussen BK. Muscular disorders in tension- rol (Paris). 1985;141(5):349-70. C type headache. Cephalalgia. 1996; 16:97-103. 23. Horton JC. Ocular integration in the human visual cortex. Can 6. Jensen R, Bendtsen L, Olesen J. Muscular factors are of im- J Ophthalmol. 2006; 41(5):584-93. portance in tension-type headache. Headache. 1998;38:10-17. 24. Tzelepi A, Lutz A, Kapoula Z. EEG activity related to CI 7. Burdette BH, Gale EN. The effects of treatment on masticatory preparation and suppression of eye movements in three-di- muscle activity and mandibular posture in myofascial pain- mensional space. Exp Brain Res. 2004;155(4):439-49. dysfunction patients. J Dent Res. 1988;67:1126-30. 25. Kuhl S, Haug H, Schliesser W. Morphometry of cortical neu- 8. Raphael KG, Janal MN, Sirois DA, Dubrovsky B, Wigren PE, rons. The best estimation of perikaryon volume from the pro- Klausner JJ, et al. Masticatory muscle sleep background elec- jection area. Microsc Acta. 1982;86(4):315-22. tromyographic activity is elevated in myofascial temporo- 26. Lewis RF, Zee DS. Abnormal spatial localization with trigem- © mandibular disorder patients. J Oral Rehabil. 2013. inal-oculomotor synkinesis. Evidence for a proprioceptive ef- 40(12):883-91. fect. Brain. 1993;116 ( Pt 5):1105-18. Annali di Stomatologia 2014; V (2): 61-65 65 

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Original article Effect of PDGF, IGF-1 and PRP on the implant osseointegration. An histological and immunohistochemical study in rabbits li na Emanuela Ortolani, MD1 tissues. In fact, platelets play an important role in Massimiliano Guerriero, MD2 many processes by releasing many factors, such as io Antonella Coli, MD3 platelet-derived growth factor (PDGF), insulin-like Amalia Di Giannuario, BD4 growth factor-1 (IGF-1), transforming growth factor Gianluca Minniti, DDS5 (TFG) and vascular endothelial growth factor (VEGF), Antonella Polimeni, MD, DDS6 that control cell proliferation, differentiation, chemo- az taxis and tissue morphogenesis. The clinical use of platelet-rich plasma (PRP) has been shown to en- 1 General Dentistry and Emergency Care Unit George hance soft and bone tissue healing and PRP has Eastman Dental Hospital, Rome, Italy been used in implantology to supply growth factors to rn 2 Laboratory of Pathology, A. Cardarelli Hospital, sites of surgery, in order to increase the rate of bone Campobasso, Italy deposition and quality of bone regeneration (1,2). 3 Institute of Pathology, Sacro Cuore Cattolica Uni- Once it is released from platelets, PDGF can improve versity, Rome, Italy new bone deposition by promoting collagen synthesis te 4 Istituto Superiore di Sanità (ISS), Rome, Italy and increasing the deposition of bone matrix (3,4). It 5 Private practice, Rome, Italy has been shown that PDGF, which binds to specific 6 Department of Oral and Maxillo-facial Sciences, Pe- surface receptors, has important functions in many In diatric Dentistry Unit, Sapienza University of Rome, Italy physiological processes including wound healing and angiogenesis, also playing a synergistic role with oth- er factors, such as IGF-1 (5,6). In the present work we carried out a study in an experimental animal Corresponding author: model to evaluate the effect of PDGF, IGF-1 and ni Emanuela Ortolani PRP on the integration of bone implants placed in the General Dentistry and Emergency femurs of rabbits. The influence of the treatment on Care Unit George Eastman Dental Hospital, Rome the process of implant osseointegration was evaluat- Viale Regina Elena, 287/B ed by histological and immunohistochemical exami- o 00161 Rome, Italy nation performed on bone samples taken at different E-mail: emanuelaortolani@tiscali.it time after implantation. izi Summary Materials and methods Ed The ability of platelet-derived growth factor All procedures were in accord with the Italian laws (PDGF), insulin-like growth factor-1 (IGF-1) and (DL 27/1/92 n.116) and the directives of the Council platelet-rich plasma (PRP) to increase the rate of of European Communities (886/609 CE). The study osseointegration of endosseous implants and to was performed on eight healthy male breeding rab- improve the quality of bone remodeling on the bits “Fauve de Bourgogne”, weighing 2.5 to 3 Kg. Ex- surface of titanium, has been investigated in an perimental subjects were randomly assigned to 2 C experimental intraosseous defect model by an groups for evaluating osseointegration and bone re- histological and immunohistochemical evalua- generation capability around dental implants: one CI tion. The results from this study demonstrate that group treated with PDGF/IGF-1, and the other one rabbits treated with the combination PDGF/IGF-1 treated with PRP. The animals were anesthetized showed a higher positive effect on bone regener- with an intravenous injection of penthobarbital (30 ation than PRP-treated or controls. mg/kg). Anesthesia was maintained, when needed, with additional penthobarbital. Additionally, a local Key words: PDGF, IGF-1, PRP, growth factors, anesthetic (lidocaine 0.5 ml/adrenaline) was applied © bone formation, dental implants. subcutaneously. After the incision of the skin and the subcutaneous tissues, planes were dissected in order to expose the femur. Then, using a low speed drill Introduction with continuous irrigation, bone defects were per- formed. Before implantation, bone defects were filled The release of growth factors by platelets can con- with PDGF/IGF-1 combination or with PRP. In each tribute to cell proliferation and healing of damaged animal one intraosseous defect performed in the con- 66 Annali di Stomatologia 2014; V (2): 66-68  Effect of PDGF, IGF-1 and PRP on the implant osseointegration. An histological and immunohistochemical study in rabbits trolateral femur was simultaneously filled with methyl- sites showed only a focal and discontinuous deposi- cellulose gel vehicle to serve as control. tion of fibroblasts around the implants. The combination of PDGF and IGF-1 (both supplied This fibrous tissue was composed of spindle cells by Sigma Chemicals, Milan, Italy, and diluted at a with elongated or oval nuclei and numerous mitotic concentration of 4 μg/μL) was added immediately be- figures (indicating high proliferative activity) (Fig. 1a). li fore use to 30 μl of vehicle, which consisted of a 2% In this phase, the first deposition of bone was ob- methylcellulose gel solution (Methocel, Fluka, Milan, served below the cortical bone in proximity of the na Italy). To obtain PRP, an average 5 mL autologous neck of the hole, consisting of osteoid matrix trabecu- blood sample was retrieved, and 3,8 % sodium citrate lae, bordered by osteoblasts. These trabeculae of os- was immediately added to blood as anticoagulant. teoid appear not yet joined neither to the cortical Then, the whole blood was centrifuged for 15 minutes bone adjacent neither to the implant. io at 100 g. The supernatant was carefully removed and 30 μl of PRP (containing an average of 50000-70000 platelets) were added to 20 μl of methylcellulose gel 7th to 12th day vehicle (Methocel). az A total volume of 50 μl of methylcellulose gel contain- All histological samples taken from the animals treat- ing PDGF-IGF1 or PRP was applied in the hole, and ed with PDGF/IGF-1 exhibited significant bone regen- the implant placement followed. The dental implants, eration in the neck hole adherent to the cortical bone, measuring 3.3 mm in diameter and 8 mm in length, through a process of endosteal bone formation. On rn were positioned in each femoral metaphysis. After the other hand, bone formation appeared uneven in this procedure, the muscle planes and the superficial tissues were sutured. For preventing infection, and te antibiotic therapy (rocefin, 20 mg/kg) was adminis- tered via intramuscular injection after surgery. After 4, 7 and 12 days from implant insertion, the rab- bits were euthanized by an intravenous injection of In penthobarbital solution. Their femurs were dissected, and a segment of metaphysis about 1.5 cm in length comprising the implant was obtained for histological and immunohistochemical study. After 24 hours of fixation in buffered formalin and ad- ni ditional 36 hours of decalcification with a commercial EDTA-hydrochloric acid mixture (Surgipath Decalcifi- er II, Leica Biosystem, USA) the implant was “gently” removed and the bone segment was cut longitudinal- o ly with a plane passing through the hole. The bone fragments were embedded in paraffin and 4 µm con- izi secutive sections were cut and numbered. a For conventional histology staining with hematoxylin- b eosin or Van Gieson to assess the morphological de- tail of osseointegration was performed. For immuno- Ed histochemistry, deparaffinized sections were incubat- ed for 10 minutes with methanol containing 10% H2O2 to block the activity of endogenous peroxidases. The sections were then incubated with polyclonal rabbit anti-PDGFR-α and monoclonal mouse anti PDGFR-β antibodies (Santa Cruz Biotechnology, at cat. sc-338 C and sc-6252 dilution of 1:200), anti-VEGF and anti- VEGFR antibodies. CI After washing, the sections were incubated with streptavidin-biotin detection system (LSAB, Dako). Fi- nally, the reaction was developed with diaminobenzi- dine solution. Figure 1. Histological analysis of the implant site treated © with PDGF and IGF-1. 1a) At 4th day, the implant sites Results treated with PRP or PDGF/IGF1 showed abundant cap-like deposition of fibroblastic tissue around the implants; this fi- 4th day brous tissue was composed of spindle cells with elongated or oval nuclei and numerous mitotic figures. 1b) At the 12th The implant sites treated with PRP or PDGF/IGF1 day, a substantial amount of well formed, significantly more showed abundant cap-like deposition of fibroblastic abundant woven bone in subjects treated with PDGF/IGF1 tissue around the implants. In contrast, the control than in animals treated with PRP and controls, was found. Annali di Stomatologia 2014; V (2): 66-68 67  E. Ortolani et al. animals PRP-treated. Scarce bone deposition was observed in control sites. In the animals treated with PDGF/IGF1 numerous islands of cartilage leading to endochondral ossification were observed around im- plants, and by the 12th day, in the same group of ani- li mals, a substantial amount of well formed, woven bone significantly more abundant than in animals na treated with PRP and controls, was found (Fig. 1b). Immunohistochemistry io After immunohistochemistry with antibodies against PDGFR-β, presence of scattered positive blast-like cells was observed in both treated and untreated ani- az mals (Fig. 2). Also megakaryocytes appeared to be Figure 2. Near the implant site at 4th day from surgery, im- labelled, but lymphocytes were generally negative. In munohistochemical staining for PDGFR-b showed scat- addition, a fraction of chondroblasts and osteoblasts tered cells in the reparative tissue rich in fibroblast. in osteoid matrix were also positive. rn After immunohistochemistry with antibodies against PDGFR-α, no significative results were seen. ing and bone formation, expressed receptors for A significant expression of VEGF and VEGFR-2 in PDGF-β. Therefore, from our data, showing presence animals sacrificed at 4th and 7th day was observed, te of cells expressing PDGF receptors in foci of osteoin- with a strong expression present in the cytoplasm of tegration, add further evidence for usefulness of osteoblasts bordering the osteoid matrix. Then, the growth factors addition in site of implant surgery. expression rapidly decreased in the animals sacri- In ficed at 12th day. A widespread, although weaker pos- itivity was observed in the cytoplasm of fibroblast-like References cells forming the fibrous callus. A similar, although more discrete positivity, was observed after immuno- 1. Torres J, Tamimi F, Alkhraisat MH, et al. Platelet-rich plas- histochemistry with anti-VEGFR2 antibody. ma may prevent titanium-mesh exposure in alveolar ridge ni augmentation with anorganic bovine bone. J Clin Periodontol. 2010;37:943-951. 2. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin Discussion and Conclusions (PRF): A second-generation platelet concentrate. Part I: Tech- o nological concepts and evolution. Oral Surg Oral Med Oral Recent studies have suggested that a number of Pathol Oral Radiol Endod. 2006;101:E37-44. growth factors, including PDGF, promote tissue repair 3. Chang PC, Seol YJ, Cirelli JA, et al. PDGF-B gene therapy izi and regeneration, including bone formation; more- accelerates bone engineering and oral iplant osseointegra- over, the efficacy of growth factor therapies in peri- tion. Gene Ther. 2010;17:95-104. odontology and implantology has been well charac- 4. Hollinger JO, Hart CE, Hirsch SN, Lynch S, Friedlaender GE. terized in a variety of in vitro and in vivo studies (7,8). Recombinant human platelet-derived growthfactor: Biology Ed The present study, focused on the histological char- and clinical applications. J Bone Joint Surg Am. 2008;90 (sup- pl 1):48-54. acteristics of the early osseointegration of implants, 5. Lynch SE, Nixon JC, Colvin RB, Antoniades HN. Role of with or without addition of PRP and PDGF/IGF-1 in platelet-derived growth factor in wound healing: Synergis- combination, in an animal model, demonstrate a high- tic effects with other growth factors: Proc Natl Acad Sci U er bone regeneration rate in growth factors-treated S A. 1987; 84:7696-7700. group than in PRP or control group. Our results show C 6. Tokunaga A, Oya T, Ishii Y, et al. PDGF receptor beta is a a greater new bone deposition in animals in which potent regulator of mesenchymal stromal cell function. J Bone PDGF/IGF-1 was added to bone defect, when com- Miner Res. 2008;23:1519-1528. CI pared to animals treated with PRP or controls. 7. Yun JH, Han SH, Choi SH, et al. Effects of bone marrow- Interestingly, our immunohistochemical demonstra- derived mesenchymal stem cells and platelet-rich plasma on bone regeneration for osseointegration of dental implants: tion that various types of cells present in reparative Preliminary study in canine three-wall intrabony defects. J foci express receptors for these molecules, in particu- Biomed Mater Res B Appl Biomater. 2013 Dec 5. doi: lar PDGFR-β, support the experimental evidence of 10.1002/jbm.b.33084. positive therapeutic effects of PDGF on osseointegra- © 8. Kaigler D, Avila G, Wisner-Lynch L, et al. Platelet-derived tion. In normal bone marrow around the implant, growth factor applications in periodontal and peri-implant bone many blast cells, also including osteoprogenitors, regeneration. Expert Opin Biol Ther. 2011;11:375-85. doi: chondrocytes and osteoblasts involved in tissue heal- 10.1517/14712598.2011.554814. 68 Annali di Stomatologia 2014; V (2): 66-68 

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Original article Biocompatibility of a new pulp capping cement li na Claudio Poggio, MD, DDS1, Introduction Matteo Ceci, DMD, PhD1, io Riccardo Beltrami, DMD, PhD2, Direct pulp capping involves the application of a den- Alberto Dagna, DMD, PhD, tal material to seal communications between the ex- Marco Colombo, DMD, PhD1, posed pulp and the oral cavity (mechanical and cari- Marco Chiesa, DMD, PhD1 az ous pulp exposures) in an attempt to act as a barrier, protect the dental pulp complex and preserve its vital- ity (1). Inducing hard tissue formation by pulp cells as 1 Department of Clinical, Surgical, Diagnostic an ultimate goal of capping material use is widely ac- and Pediatric Sciences, Section of Dentistry, rn cepted (2). University of Pavia, Italy Several materials such as calcium hydroxide-based 2 Department of Brain and Behavioural Sciences, materials and more recently mineral trioxide aggre- University of Pavia, Italy gate (MTA) are commonly used for this purpose (3,4). te Calcium hydroxide is the most popular agent for di- rect and indirect pulp capping and maintaining pulp Corresponding author: vitality, given its ability to release hydroxyl (OH) and Claudio Poggio calcium (Ca) ions upon dissolution (5,6). Both clini- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences In cally and histologically it has been found to produce satisfactory results in indirect and direct pulp capping, Section of Dentistry, Policlinico “San Matteo”, because it is capable of stimulating the formation of University of Pavia tertiary dentin by the pulp. This is documented by ba- Piazzale Golgi 3, sic research and clinical studies with reported suc- ni 27100 Pavia, Italy cess rates in excess of 80% for direct pulp capping Phone: +39 0382 516257, +39 3398124925 (7,8). Currently, calcium hydroxide products are the Fax: +39 0382 516224 best documented and most reliable materials for di- E-mail: claudio.poggio@unipv.it o rect pulp capping and serve as the “gold standard” against which new materials have to be tested (9). izi Nevertheless, calcium hydroxide has some draw- Summary backs. Poor bonding to dentin, material reabsorption, high solubility and mechanical instability are among Aim. The aim of the present study was to evaluate them. In addition, the formation of reparative dentine Ed the biocompatibility of a new pulp capping materi- may not be due to the bioinductive capacity of the al (Biodentine, Septodont) compared with refer- material but due to a defense mechanism by the pulp ence pulp capping materials: Dycal (Dentsply), induced by the irritant nature of calcium hydroxide ProRoot MTA (Dentsply) and MTA-Angelus (An- (10, 11); the high pH (12.5) of calcium hydroxide sus- gelus) by using murine odontoblast cell line and pensions causes liquefaction necrosis at the surface Alamar blue and MTT cytotoxicity tests. of the pulp tissue with the formation of a necrotic lay- C Methods. The citocompatibility of murine odonto- er at the material-pulp interface (7). blasts cells (MDPC-23) were evaluated at different Dycal (Dentsply) is a self-setting radiopaque calcium CI times using a 24 Transwell culture plate by Ala- hydroxide-based material used both as a pulp cap- mar blue test and MTT assay. ping agent and as a liner under restorations, cements Results. The results were significantly different and other base materials. Its toxicity to pulp cells is among the pulp capping materials tested. Bio- well documented (12, 13). compatibility was significant different among ma- Portland cements, commonly named mineral trioxide terials with different composition. aggregate (MTA) cements (such as ProRoot MTA, © Conclusions. Biodentine and MTA-based prod- MTA-Angelus, Tech Biosealer and others), are thera- ucts show lower cytotoxicity varying from calci- peutic, endodontic repair calcium silicate materials in- um hydroxide-based material which present high- troduced at first as a grey cement (14). These materi- er citotoxicity. als promote the proliferation/differentiation of human dental pulp cells (15-17) and show calcified tissue- Key words: biocompatibility, MTT test, murine conductive activity with the ability to encourage new odontoblast, pulp capping materials. hard tissue formation in terms of dentine bridge devel- Annali di Stomatologia 2014; V (2): 69-76 69  C. Poggio et al. opment over the exposed pulp (18,19). Compared to of catalyst paste and base paste. ProRoot MTA and calcium hydroxide materials, MTA has an enhanced MTA-Angelus, composed of white Portland cement interaction with dental pulp tissue (15) with less pulp and bismuth oxide (31, 32), were prepared following inflammation and limited pulp tissue necrosis (18, 20). the manufacturer’s instructions. Biodentine consists Several new calcium silicate-based materials have re- of a powder in a capsule and liquid in a pipette. The li cently been developed (21-23), aiming to improve powder was mixed with the liquid in a capsule in the some MTA drawbacks such as its difficult handling triturator for 30 seconds. Once mixed, Biodentine na property (24) and long setting time (14). Biodentine sets in about 12 minutes. During the setting of the ce- (Septodont) is among these materials and it is claimed ment calcium hydroxide was formed. to be used as a dentine restorative material in addition to endodontic indications similar to those of MTA. This io agent is characterized by the release of calcium hy- Odontoblast cell line culture condition droxide in solution (25, 26), which when in contact with tissue fluids forms hydroxyapatite (27-29). The mouse odontoblast cell line (MDPC-23) was As pulp capping materials will be in direct contact kindly provided from Dr Jacques Eduardo (Dept. Cari- az with pulp tissue for long periods of time, their biocom- ology, Restorative Sciences, Endodontics; University patibility is of particular importance. Several methods of Michigan School of Dentistry). Odontoblast-like cell for the determination of biocompatibility of dental ma- line (MDPC-23) is recommended for application to in terials have been recommended, but the analysis of vitro studies concerning the biocompatibility of dental rn in vitro cellular reactions are generally considered to materials. Mac Dougall (33), reported that the immor- be the initial approach (30). This allows for the basic talized mouse odontoblast cell line is positioned in biological characterization of a material and for analy- the periphery of the pulp and are the first cells affect- te sis of the underlying cellular mechanisms. ed by dental materials. The aim of the present study is to evaluate the bio- MDPC-23 cells were cultured in DMEM medium compatibility of a new pulp capping material (Bioden- (Biowhittaker, Italy) supplemented with 10% fetal tine, Septodont) compared with reference pulp cap- bovine serum (FBS), 2% glutamine, 2% sodium pyru- ping materials: Dycal (Dentsply), ProRoot MTA (Dentsply) and MTA-Angelus (Angelus) by using In vate, 1% amphotericin and 2% (w/v) streptomycin/ penicillin at 37 °C in 5% CO2 atmosphere (34). The murine odontoblast cell line and Alamar blue and cells were routinely detached using a trypsin-EDTA MTT test. solution for 2 minutes at 37°C, and resuspended in DMEM medium. ni For the cytotoxicity tests, MDPC cells were deposited Materials and methods in the lower chamber of the 24 well culture plate and left for 4 hours at 37°C before any experiment. The following materials were used: Dycal, ProRoot o MTA, MTA-Angelus and Biodentine. The components of each material and its manufacturer are reported in Cytotoxicity tests izi Table 1. Dycal, a two-paste system made of a base paste and Cytotoxicity tests were performed with the Transwell a catalyst paste (13), was prepared following the insert (Sigma-Aldrich, St. Louis, MO) methodology manufacturer’s instructions by mixing equal amounts and the immortalized mouse odontoblast cell line MD- Ed Table 1. Characteristics of tested materials. Material Components LOT Manufacturer Dycal Base paste: (1,3-butylene glycol disalicylate, zinc 120717 Dentsply Tulsa Dental, C oxide, calcium phosphate, calcium tungstate, iron Johnson City, TN, USA oxide pigments). CI Catalyst paste: (calcium hydroxide, N-ethyl-o/p-toluene sulphonamide, zinc oxide, titanium oxide, zinc stearate, iron oxide pigments). ProRoot MTA Powder: calcium phosphate, calcium oxide, silica, bismuth oxide. 12001879 Dentsply Tulsa Dental, Liquid: distilled water Johnson City, TN, USA © MTA-Angelus Powder: potassium oxide, aluminum oxide, sodium oxide, iron 24120 Angelus, Londrina, oxide, sulfur trioxide, calcium oxide, bismuth oxide, magnesium PR, Brazil oxide, potassium sulfate, sodium sulfate, silica. Liquid: distilled water Biodentine Powder: tricalcium silicate, dicalcium silicate, calcium carbonate, B06562 Septodont, Saint- calcium oxide, iron oxide, zirconium oxide. Maur-des-Fosses, Liquid: calcium chloride, hydro soluble polymer. France 70 Annali di Stomatologia 2014; V (2): 69-76  Biocompatibility of pulp capping material PC-23. The advantage of using a non direct contact ostasis. The loss of plasma membrane asymmetry is test for the evaluation of the dental material citotoxici- an early event in apoptosis, independent of cell type, ty is related to the fact that cells and materials are resulting in the exposure of phosphatidylserine (PS) usually separated (35). residues at the outer plasma membrane leaflet (36). Cytotoxicity of the four pulp-capping materials was as- PSVue reagents are a family of fluorescent probes li sessed with MDPC-23 cells grown in the lower cham- containing a bis(zinc 2+ dipicolylamine) group (Zn- ber of a 24-mm diameter Transwell plate with a 0,3 DPA), a motif that has been found to bind with high na mm pore size polycarbonate membrane (Sigma) (35). affinity to surfaces enriched with anionic phospho- In order to standardize the samples, for the various lipids, especially phosphatidylserine (PS) exposed on analyzes and evaluations, the materials were placed cell membranes. The plate was kept under gentle agi- on sterile paper disks of 0.5 cm in diameter. All test tation for 2 hours at room temperature. After 2 hours, io materials were prepared and mixed under sterile hood the solution of PSVue has been eliminated and the following preparation methods recommended by the washing of the plate has been carried out with abun- manufacturer. The excess material was removed us- dant Buffer-TES. The next step involved the addition ing sterile spatula. Dycal, ProRoot MTA, MTA-Angelus az of the dye Hoechst 33342, affine to DNA for viable and Biodentine were mixed on special glass plates cells. After 15 minutes the images were acquired us- and later will be placed with sterile carrier on paper ing confocal laser scanning microscope (CLSM) (37). disks. The Transwell membrane of the inner chamber, filled with the paper disks, was then placed into the rn lower chamber of the 24 well culture plate each con- Results taining at the bottom 5x104 cells and incubated at 37 °C in 5% CO2 atmosphere for 24 h, 48 h and 72 h, re- Cytotoxicity tests te spectively. In order to improve the search, the per- centage of vitality of the cells was evaluated in three Figure 1 shows the results obtained with the Alamar time intervals: 24, 48 and 72 hours. Some wells were blue test at 24, 48 and 72 hours. incubated with only tissue culture media (negative The results obtained to 24 hours show that the higher control) whereas others with a 10% dilution of 30% In H2O2 (positive control). The vitality was assessed by percentage of cell vitality is found in Biodentine (106%), which shows an average of even greater Alamar blue test. For a further control, the percentage compared to the negative control cells, while Dycal of vitality of murine odontoblasts, at 72 hours, was al- (8.6%) is the material that presents the lowest values, so assessed with the MTT assay (bromide 3-(4,5-di- so as to become the minimum value of the range of ni methylthiazol-2-yl)-2, 5-diphenyltetrazolium). The vi- vitality of the pulp-capping materials tested in re- tality test to Alamar blue reagent acts as an indicator search. ProRoot MTA and MTA-Angelus both show of cell health, determining the reducing power in order good percentage of vitality, which amounted to 95% to measure quantitatively the proliferative capacity; o and 93.6% respectively. the reagent was added in a ratio of 1:10 to the cell In the assessment performed at 48 hours, dissimilar culture and then the cells were kept in the incubator izi for 3-4 hours at 37º C. The degree of fluorescence results emerge between the various materials. Some and the relative values of absorbance were then ac- of them show an improvement of the percentage of quired by reading in a spectrophotometer at a wave- vitality; MTA-Angelus equals the number of cells of length of 595 nm. The MTT test is a standard colori- the negative control and Biodentine presents a cell vi- Ed metric assay for measuring the activity of enzymes tality greater than 13% compared to control. Contrari- that reduce the MTT to formazan (a salt blue) in the wise Dycal and ProRoot MTA show a deterioration of mitochondria, giving the substance a blue/purple col- the data. or. This reaction is assessed and measured by the In the assessment at 72 hours, the analysis of the spectrophotometric reading of the sample, at a wave- samples show a worst general behavior of the materi- length of 570 nm. Five replicates for each pulp cup- als which leads to a decrease in the percentage of vi- C ping material were used for each experiment per- tality and in the average number of cells. The only ex- formed in duplicate. ceptions are Biodentine and Dycal. Biodentine is the CI material with the best percentage compared to the negative control, thus demonstrating a marked bio- Confocal Laser Scanning Microscope (CLSM) compatibility. The average number of cells remains stable compared to the previous assessment made at Once performed the cytotoxicity test of the different 48 hours with a percentage which stabilizes at 114%. materials, the Transwell inserts was removed and the Dycal demonstrates a slight increase in the number © land was eliminated from the culture plate. After of cells (6%), with a substantially cytotoxic behavior. washing the slides with the buffer Buffer-TES, 250 ml ProRoot MTA and MTA-Angelus prove to have a of 10 mM solution of the fluorescent dye PSVue slight negative trend, but with good percentage of vi- TM480 were added per well, in order to detect the tality that are stabilized on 71% for both materials. presence of apoptotic cells present in the culture. Figure 2 shows the results of the vitality tests per- Apoptosis is defined as programmed, physiological formed with the MTT assay at 72 hours. The MTT test cell death and plays an important role in tissue home- confirmed the percentage ratios between the various Annali di Stomatologia 2014; V (2): 69-76 71  C. Poggio et al. after incubation with different pulp capping materials confirmed the cytotoxicity tests results: a few cells were observed in the presence of Dycal, indicating an high level of citotoxicity (Fig. 5) whereas ProRoot MTA (Fig. 6), MTA-Angelus (Fig. 7) and Biodentine li (Fig. 8) did not seem to be cytotoxic. na Statistical analysis As reported in Table 2, after 24 hours the amount of io cells present in contact with MTA-Angelus is not sta- az Figure 1. Alamar blue test results at 24, 48 and 72 hours. rn te In Figure 2. Results of the vitality test performed with the MTT ni assay at 72 hours. materials and between the materials and the posi- o tive/negative controls determined with the Alamar Figure 3. CLSM images of apoptosis assay in the transwell blue test.. MTA Angelus shows the best percentage wells prepared with a 30% solution of hydrogen peroxide izi of vitality at all. In general even if the relationships (positive control). between the various materials are similar, there was a slight increase in the mean number of cells. Ed Confocal Laser Scanning Microscope (CLSM) images After staining with PSVueTM480 and Hoechst 33342 dyes, the morphological structure of the cells in cul- C ture was observed with CLSM. The use of fluorescent dye PSVueTM480 shows the presence of apoptotic CI cells. The Hoechst 33342 dye acts by binding to the DNA of viable cells and coloring the nucleus in blue. Figure 3 shows the negative control observations (preparation containing only the culture medium) while Figure 4 shows the positive control observa- tions (prepared with hydrogen peroxide added to the © culture medium). As clearly shown, H2O2 is very cyto- toxic and the cells stained with PSVue480™ reagent are completely fluorescent in green (Fig. 3). In ab- sence of any type of materials, the cells were not green fluorescent (Fig. 4) but we could see the nuclei stained with Hoechst. Figures 5 - 8 show the images Figure 4. CLSM images of apoptosis assay in presence of acquired for each material. These images obtained culture medium only (negative control). 72 Annali di Stomatologia 2014; V (2): 69-76  Biocompatibility of pulp capping material li na io az rn Figure 5. CLSM images of apoptosis assay in the transwell Figure 7. CLSM images of apoptosis assay in the transwell wells prepared with Dycal. wells prepared with MTA-Angelus. te In o ni izi Ed Figure 6. CLSM images of apoptosis assay in the transwell Figure 8. CLSM images of apoptosis assay in the transwell C wells prepared with ProRoot MTA. wells prepared with Biodentine. CI Table 2. Mean ± standard deviation of Bonferroni post-hoc test of the different values of cell viability. Different superscript letters indicate a statistically significant difference (P <0.001). The same superscript letter indicates a not statistically signifi- cant difference (P> 0.001). © Materials 24 h 48 h 72 h Negative control 500000 ± 0a 522000 ± 0d 466000 ± 0g Positive control (H2O2) 37000 ± 2738b 25000 ± 1850e 18000 ± 1332i Dycal 43000 ± 2326c 22000 ± 5740e 30000 ± 1868l ProRoot MTA 475000 ± 53675a 465000 ± 55629d 333000 ± 33157h MTA-Angelus 468000 ± 72158a 522000 ± 56089d 333000 ± 59216h Biodentine 533000 ± 60897a 592000 ± 20182d 533000 ± 42179f Annali di Stomatologia 2014; V (2): 69-76 73  C. Poggio et al. tistically different from the amount of cells present in conclusions of others Authors (39, 40) on the non- contact with Biodentine, ProRoot MTA and the nega- complete biocompatibility of calcium hydroxide-based tive control (P> 0001). The lowest values after 24 h is materials: the protective effect of these materials to- provided by Dycal and the positive control. wards the pulp is not complete. Calcium hydroxide After 48 hours no statistically significant difference is has an important action in protecting the pulp from li demonstrated between MTA-Angelus, Biodentine, thermal, mechanical and microbiological stimuli (5, 6) ProRoot MTA and the negative control (P> 0.001). No because of its antibacterial action and its property of na statistically significant difference is also present be- stimulating sclerotic an reparative dentin formation. In tween Dycal and the positive control (P> 0.001), clinical practice, the presence of hard tissue barrier af- where the number of live cells is significantly lower ter capping can be considered an asset, since it pro- compared to the samples of the remaining materials vides natural protection against the infiltration of bac- io (P <0.001). teria and chemical products. However, the importance After 72 hours Biodentine shows a significantly of calcified hard tissue barrier formation after capping greater number of viable cells compared to all other has been challenged by other studies, which have materials tested (P <0.001), MTA-Angelus and Pro- shown multiple tunnel defects and cell inclusions in az Root MTA show values not significantly different be- bridges following pulp capping with calcium hydroxide tween them (P> 0.001) and the negative control has (41). This may lead to leakage and bacteria penetra- retained intermediate values. Finally in the positive tion into pulp tissue unlike the permanent seal pro- control samples the lower number of cells was found duced by bonding agents. Furthermore it is equally rn (P <0.001). demonstrated that, due to the alkalinity of its pH, calci- Table 3 shows the values obtained with the MTT test. um hydroxide induces cytotoxicity, causing the forma- There are no statistically significant differences tion of a layer of coagulation necrosis, when it is in di- te among ProRoot MTA, MTA-Angelus, Biodentine and rect contact with the dental pulp (7). For both these the negative control (P>0.001). Dycal shows signifi- reasons calcium hydroxide do not seem the eligible cant lower values (P<0.001). material to be used in case of exposed pulp tissue. Very different results were obtained from the analysis Discussion and conclusion In of the MTA-based materials (ProRoot MTA and MTA- Angelus). Both materials to the evaluation of the 72 hours, with Alamar blue test and MTT assay, have re- Pulp capping materials should act as a barrier which ported excellent percentage of vitality, detected in a protects the vitality of the entire pulp tissue by cover- range that goes from 71% to 95% of vitality and in ni ing the minimal exposed tissue and by preventing some samples the results were even assimilated to from further endodontic treatments. Due to this fact the negative control. This significant difference be- the material used should provide an appropriate host tween the values of vitality of calcium hydroxide and response; this means that tissues that come into con- MTA is clearly due to the structural difference of the o tact with the materials do not show any toxic, irritat- two basic components and due to the various physio- ing, inflammatory, allergic, genotoxic, or carcinogenic logical and biochemical reactions induced on tissues. izi action (38). It has been demonstrated that MTA has the ability to In the present study Dycal demonstrates the lower induce the formation of a bridge of hard tissue of rates of vitality and a strong cytotoxic capability. Dycal greater thickness compared to the bridge established has shown the lowest mean number of cells in the col- in presence of calcium hydroxide, also managing to Ed orimetric assay performed with Alamar blue, with as- cause less inflammation in the adjacent tissues (18, sessments at 24, 48 and 72 hours, and in the MTT as- 20). The dental pulp also contains progenitor cells say at 72 hours. The low percentage of vitality of Dy- and stem cells, which can proliferate and differentiate cal occurs already in the first 24 hours, manifesting into odontoblasts forming dentin; Guven and Cehreli small variations of 1-2 percentage points to the vari- (42) reported that, probably, MTA is able to facilitate ous measurement intervals. These results confirm the these cellular changes by inducing the secretion of C morphogenetic proteins and growth factors such as BMP-2 and TGF-β1. CI In the present study Biodentine proved to be the Table 3. Mean ± standard deviation of Bonferroni post-hoc more biocompatible material. Biodentine, in measure- test of the different values of cell viability. Different super- ments made at 24, 48 and 72 hours, reported per- script letters indicate a statistically significant difference (P centage of vitality above the negative control. After <0.001). The same superscript letter indicates a not statis- 24 hours it recorded values equal to 106%, rose to tically significant difference (P> 0.001). 113% and 114% in the two subsequent analysis. Bio- © dentine is a new bioactive cement based on calcium Materials MTT silicate for pulp capping, derivation of bioengineering, Negative control 124074 ± 0a with anti-inflammatory behavior (43), different from Dycal 45741 ± 5040b the classic materials based on calcium silicate, such ProRoot MTA 140741 ± 30098a as Portland cement. The technology behind the man- MTA-Angelus 179444 ± 99142a ufacturing process of the active bio-silicate, the main Biodentine 166481 ± 59317a constituent of Biodentine, removes the metallic impu- 74 Annali di Stomatologia 2014; V (2): 69-76  Biocompatibility of pulp capping material rities which are present in other cements (44). The 8. Duda S, Dammaschke T. Die direkte Überkappung – Vo- setting reaction involves the hydration of tricalcium raussetzungen für klinische Behandlungserfolge. Endodontie. silicate, the production of a calcium silicate-based gel 2009;18:21-31. and calcium hydroxide, which in contact with phos- 9. 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Journal of Endodontics. 2010; growth factor b1 and bone morphogenetic protein produc- 36:16-27. tion by human fibroblasts in vitro. Journal of Endododontics. 32. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a com- 2007;33:447-450. prehensive literature review-Part III: clinical applications, draw- 43. About I, Laurent P, Tecles O. Bioactivity of biodentine: a te backs, and mechanism of action. Journal of Endodontics. Ca3SiO5-based dentin substitute. Journal of Dental Research. 2010;36:400-13. 2010;89:165. 33. Mac Dougall M, Selden JK, Nydegger JR and Carnes DL. 44. Grech L, Mallia B, Camilleri J. Characterization of set In- Immortalized mouse odontoblast cell line M06-G3 applica- termediate Restorative Material, Biodentine, Bioaggregate Dentistry. 1998;10:11-6. In tion for in vitro biocompatibility testing. American Journal of and a prototype calcium silicate cement for use as root-end filling materials. International Endodontic Journal. 34. de Souza Costa CA, Vaerten MA, Edwards CA and Hanks 2013;46:632-41. CT. Cytotoxic effects of current dental adhesive systems on 45. Atmeh AR, Chong EZ, Richard G, Festy F, Watson TF. immortalized odontoblast cell line MDPC-23. Dental Mate- Dentin-cement interfacial interaction: calcium silicates and rials. 1999;15:434-41. polyalkenoates. Journal of Dental Research. 2012; 91:454- ni 35. Babich H, Sinensky MC. Indirect cytotoxicity of dental ma- 9. terials: a study with Transwell inserts and the neutral red up- 46. Colon P, Bronnec F, Grosgogeat B, Pradelle-Plasse N. In- take assay. Alternative to Laboratory Animals. 2001;29(1): teraction between a calcium silicate cement (Biodentine) and o 9-13. its environment. Journal of Dental Research. 2010;89:401. 36. van Engeland M, Nieland LJW, Ramaekers FCS, Schutte B, 47. About I. Dentin regeneration in vitro: the pivotal role of sup- Reutelingsperger CPM. Annexin v-affinity assay: a review portive cells. Advanced Dental Research. 2011;23:320-324. izi Ed C CI © 76 Annali di Stomatologia 2014; V (2): 69-76 

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Case report Oral proliferative verrucous leukoplakia treated with the photodynamic therapy: a case report li na Umberto Romeo, DDS1,2 but more clinical trials, with prolonged follow-up Nicola Russo, DDS1 controls, are necessary to evaluate its effective- io Gaspare Palaia, DDS, PhD1,2 ness in the mid and long time period. Gianluca Tenore, DDS, PhD1,2 Alessandro Del Vecchio, DDS, PhD1,2 Key words: photodynamic therapy, oral leuko- plakia, oral cancer, 5-aminolevulinic acid, poten- az tially malignant disorders. 1 Department of Oral and Maxillo-facial Sciences, Sapienza University of Rome, Italy 2 Master EMDOLA (European Master Degree On Introduction rn Laser Applications), Sapienza University of Rome, Italy Oral squamous cell carcinoma (OSCC) is the fifth common cancer in the world with an annual world- wide incidence exceeding 300,000 cases (1). The te Corresponding author: disease is an important cause of death and morbidity, Gaspare Palaia with a 5-year survival less than 50% (2). These poor Department of Oral and Maxillofacial Sciences, data are mainly due to the frequent great diagnostic Sapienza University of Rome Via Caserta, 6 In delay that characterizes the early phases of OSCC cases. So the prevention of OSCC is the most impor- 00161 Rome, Italy tant approach to minimize its incidence and to pro- Phone: +39 3394522515 vide a better quality of life of patients. In particular, E-mail: gaspare.palaia@uniroma1.it the secondary prevention is based on the early diag- ni nosis and management of the so-called Potentially Malignant Disorders (PMDs), a series of pathologies Summary characterized by the risk of neoplastic degeneration (2). Among the PMDs of the oral mucosa the most o Aims. About 60% of the oral cancer arise on a frequent is the Oral Leukoplakia (OL) (2). Clinically, pre-existent potentially malignant disorder of oral OLs can be classified in two different groups: homo- izi mucosa like the oral proliferative verrucous geneous and non-homogeneous lesions. Moreover, leukoplakia. The treatment with the photodynamic another type of OL characterized by a multifocal lo- therapy of these lesions represents, in the last calization and a very high risk of malignant transfor- years, an innovative, non-invasive and effective mation (about 70%) is the oral proliferative verrucous Ed therapeutic possibility to achieve the secondary leukoplakia (OPVL) (3,4). The OPVL is more common prevention of oral cancer. In the last decade, case in middle-aged women and the female-to-male ratio reports have described patients with similar treat- is 4:1 (5); is of uncertain etiology and is not strongly ed through a photochemical reaction induced by associated with tobacco use or alcohol with the HPV laser light. The aim of this study is to evaluate the infection that may play an important role in these le- effectiveness of the topical 5-ALA photodynamic sions (5). Multiple oral sites may be involved and be- C therapy in the treatment of a case of Oral prolifer- fore malignant transformations can pass many years ative verrucous leukoplakia. up to even some decades (4). CI Case report. A female patient of 80 years old af- In the last decades many treatments were used in the fected by white verrucous plaques on the right treatment of PMDs: traditional surgery (6), electro- buccal mucosa was recruited for our case report. surgery, cryosurgery, laser surgery and the adminis- The right side lesion was treated with the photo- tration of drugs (e.g. carotenoids, exc.) (7). Recently dynamic therapy with topical administered 5- the progresses in the knowledge suggested the pos- aminolevulinic acid using the 635 nm laser light sibilities of a non invasive treatment of OL with the © to activate the photosensitizer. laser (8). Generally the laser interaction on oral mu- Results. The lesion showed complete response cosa is based on the phototermic effect, that means after 4 sessions of photodynamic therapy and no to have the possibility to cut the tissue to perform a recurrence was noticed after 12 months. biopsy (9,10). Another effect of laser on soft tissue is Conclusions. The photodynamic therapy can be a photochemical effect, the so called photodynamic considered an effective treatment in the manage- therapy (PDT) that is based upon a photochemical ment of oral verrucous proliferative leukoplakia, laser light induced reaction, strictly directed on patho- Annali di Stomatologia 2014; V (2): 77-80 77  U. Romeo et al. logic cells, permitting a safe and complete removal of cided to treat the lesion with a minimal invasive tech- the lesion without sacrifice of healthy tissue (11). The nique: the topical 5-ALA-PDT. The consensus for the PDT involves three components: light, a photosensi- treatment from the patient was required before the tizer and oxygen. A photosensitizer, or its metabolic start of the therapy. precursor, is locally applied upon the lesion. The acti- The formulation of 20% gel of 5-ALA used in our li vation of the photosensitizer with a low level laser study was prepared using 25% of Lutrol F127 (Basf light, determines the transition of the agent from a Chemtrade GmbH, Burgbernheim, Deutschland) and na low energy ground state to an excited singlet state. 1% of Carbopol 971P (Lubrizol, Cleveland-Ohio The singlet state can react with endogenous oxygen State, USA). Double concentrated gels of Lutrol F127 to produce singlet oxygen and other reactive oxigen and Carbopol 971P in water were separately pre- species (ROS), causing a rapid and selective de- pared prior to mixing. After refrigerating at 4° C, the io struction of the target tissue (Fig. 1). solution of Lutrol F127 was mixed with equal volume These photochemical induced reactions lead in many of the Carbopol 971P gel and the mixture was stored ways to the destruction of neoplastic tissues; as a at 4° C. Prior to use, 800 mg of gel was mixed with first, ROS kill directly tumor cells; in other cases, PDT 200 mg of 5-ALA (Fagron GmbH, Barsbuttel, az damages the tumor associated vascular tissues, Deutschland). The formulation was used within 3 leading to thrombus formation and subsequent tumor hours after the preparation. A thin layer of gel was infarction. Moreover PDT can also elicit an immune applied topically on the lesion using a microbrush response against tumor cells (12). The advantages of (Fig. 2). For the first 10 minutes after the application rn the PDT in the treatment of OL were confirmed in of the gel, three cotton rolls were placed onto the ori- many studies in literature (8, 12-14). On the other fices of majors salivary glands to avoid the dilution of hand, PDT in several cases, requires multiple ses- gel by the saliva. In addition, during this period, the te sions of irradiation to achieve complete regression of doctor controlled the salivary flow by intermittent suc- the lesion and the costs of the laser and of the photo- tion. The gel was left 1.5 hours over the lesion to per- sensitizers are high. mits its gathering into target cells. During this period, A lot of natural and synthetic agents have photosensi- a gauze was placed over the lesion to avoid the re- In tizing potential, but the 5-aminolevulinic acid (5-ALA) is one of the most important photosensitizer in the moval of gel. For the activation of the photosensitizer management of OL. For the treatment of pre-malig- nant and malignant lesions in the oral cavity has been used PDT with topical administered 5-ALA. Due to ni the limited depth of topical 5-ALA administration, and the limited light penetration of 635 nm laser light, the use of 5-ALA is restricted to superficial lesions (1-2 mm) such as homogeneous flat leukoplakia, ery- o troleukoplakia and verrucous leukoplakia (15). 5-ALA is rapidly cleared from the tissue and the body within izi 48 hours and skin photosensitivity lasts less than 24 hours (15). The aim of this study is to report the man- agement of a clinical case of OVPL trough the PDT obtained with the locally administration of a 20% gel Ed of 5-ALA. Figure 1. Clinical aspect of the lesion before 5-ALA-PDT Case report treatment. A female patient of 80 years was recruited for the C study; history and general physical investigation re- vealed no relevant findings and no tobacco-chewing CI or smoking habit was reported from the patient. The clinical examination of the mouth revealed painless white verrucous plaque lesion with multiple peaks on the buccal mucosa bilaterally (Fig. 1). A clinical provi- sional diagnosis of OVPL was made considering the multifocal, verrucous aspect of the lesion (16) and, © subsequently, this diagnosis was confirmed by inci- sional biopsy of the diseased mucosa. The histologi- cal examination revealed proliferative corrugated hy- perkeratosis, acanthosis, mitoses, broad rete ridges and inflammatory cell infiltrated on the connective tis- sue. The lesion was photographed for further evalua- tion. Considering the dimension of the lesion, we de- Figure 2. Application of 20% 5-ALA gel on the lesion. 78 Annali di Stomatologia 2014; V (2): 77-80  Oral proliferative verrucous leukoplakia treated with the photodynamic therapy: a case report was used a diode laser of 635nm (Doctor Smile-Den- tal Laser, Vicenza, Italy) (Fig. 3). Each application consisted of five 3 mins and one 100s irradiations with five 3-minutes breaks for a total of 1000s (flu- ence rate: 100mW/cm2, total energy dose 100J/cm2) li using the fractionated protocol of irradiation de- scribed by Chen et al. (14). With this irradiation proto- na col, the lesional epithelial cells have the possibility to regenerate new PpIX and obtain new oxygen during multiple 3-minutes resting period. The laser has been set at a very low power (100mW), to take advantage io only of the photochemical effect of the laser, without the overheating of the targeted tissues. The treatment was performed twice a week until the clinical resolu- tion of the lesion. At the end of the therapy, the pa- Figure 5. Clinical aspect after 12 months of follow-up. az tient was arranged for a follow-up schedule once a month and clinical photographs were taken at each patient’s visit to evaluate the clinical outcome of PDT. The lesion showed complete response after 4 treat- Discussion rn ments of PDT (Fig. 4). The treatment was painless and the patient did not require either local anesthesia In our case the results are encouraging. The suc- during the irradiation or analgesics drugs after the cessful clinical outcome could be due to the gel te treatment. The examination at 6 months after the last preparation, the fractionated protocol of irradiation session of PDT showed that the OPVL disappeared used, and the characteristics morphological, histolog- completely with a good healing of the mucosa. The ic and biological features of the lesion. The 20% 5- patient was satisfactory for the treatment and the fol- ALA gel was adherent to oral mucosa and partially re- low-up at 12 months showed no recurrence (Fig. 5). In sistant to the dilution of saliva. This aspect is very im- portant because the gel form helped the absorption of 5-ALA from the mucosal surface. The fractionated protocol of irradiation allows the regeneration of new PpIX by the lesional epithelial cells and the obtaining ni of new oxygen during multiple 3-minutes rests. So re- sults in a more successful clinical outcome for the therapy of OVPL. Moreover the verrucous appear- ance of this lesion provided a large area of retention o for the gel, resulting in a difficult removal of 5-ALA from salivary flow. izi One of the main limitation of the 5-ALA-PDT is the low depth of penetration of the topical photosensitiz- er. For this reason, this therapy is restricted to super- ficial lesions of 1-2 mm of thickness. Ed Previous study demonstrated the effectiveness of this therapy in the management of OL. Fan et al. Figure 3. Irradiation with 635 nm diode laser. (13) treated 12 patients with oral dysplastic lesions using orally administered ALA. All 12 patients showed regression of the lesion of the lesions to normal or less dysplastic. Kübler et al. (13) treated C 12 patients affected by leukoplakia of the oral mu- cosa for several years. 20% ALA cream was applied CI to the lesion for 2 hours. Five patients showed com- plete response, four patients showed a partial reso- ponse, and in three patients treatment showed no response. Sieron et al. (14) treated 12 patients with lesions that affected a variety of intraoral sites using 10% ALA cream. Irradiation was performed in 6-8 © sessions of therapy. A complete response was ob- tained in 10 patients, with one recurrence during 6 months. The potential advantages of the PDT for treating the OPVL are: moderate side-effects, possi- bility to give repeated doses without cumulative tox- Figure 4. Clinical resolution after 4 treatments of 5-ALA- ic effects, excellent aesthetic results with healing PDT. process characterized by little or no scars and re- Annali di Stomatologia 2014; V (2): 77-80 79  U. Romeo et al. duction of pain during the treatment. The poor side References effects and the lack of invasiveness permit the repe- tition of the treatment in case of recurrences even in 1. Lingen M, Sturgis EM, Kies MS. Squamous cell carcinoma the short period. The disadvantages of the PDT con- of the head and neck in nonsmokers: Clinical and biologic sist mainly in its high costs and the longer duration, characteristics and implication for management. Curr Opin li up to five weeks. Oncol. 2001;13:176-182. 2. Warnakulasuriya S, Johnson NW, van der Waal I. Nomen- na clature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med. 2007;36:575-80. Conclusions 3. Van der Wall J, Reichart PA. Oral proliferative verrucous leukoplakia revisited. Oral Oncol. 2008;44:719-21. In this case report, 5-ALA-PDT has been an effective 4. Hansen LS, Olson JA, Silverman S Jr. Proliferative verrucous io and non-invasive treatment for the management of leukoplakia. A long term study of thirthy patients. Oral Surg the OVPL. It has been easily accepted by the pa- Oral Med Oral Pathol. 1985;60:285-298. tient. The main problem of this therapy is the difficul- 5. Bagan J, Scully C, Jimenez Y, Martorell M. Proliferative verrucous leukoplakia: a coincise update. Oral Disease 2010;16:328-332. az ty to avoid the removal of gel by salivary flow. The 6. Kuribayashi Y, Tsushima F, Sato M, Morita KI, Omura K. Re- development of gel or other vehicles more adhesive currence patterns of oral leukoplakia after curative surgical to oral mucosa may enhance the absorption of the resection: important factors that predict the risk of recurrence photosensitizer increasing the success of clinical and malignancy. J Oral Pathol Med 2012;41:682-8. rn outcome of PDT. In spite of the encouraging results 7. Ribeiro AS, Salles PR, Da Silva TA, Mesquita RA. A of our study, more clinical trials with prolonged fol- rewiew of the nonsurgical treatment of oral leukoplakia. Int low-up controls are necessary to evaluate the real J of Dent. 2010;18:601-8. absolute effectiveness of this therapy in the mid and 8. Kübler A, Haase T, Rheinwald M, Barth T, Muhling J. Treat- te long time. ment of oral leukoplakia by topical application of 5-aminole- vulinic acid. J Int Oral Maxillofac Surg. 1998;27:466-469. 9. Romeo U, Libotte F, Palaia G, Del Vecchio A, Tenore G, Vis- ca P, et al. Histological in vitro evaluation of the effects of List of abbreviations In Er:YAG laser on oral soft tissues. Lasers Med Sci. 2012;27:749-53. OSCC, Oral squamous cell carcinoma; PMD, Po- 10. Romeo U, Palaia G, Del Vecchio A, Tenore G, Gambarini tentially Malignant Disorder; OL, Oral leukoplakia; G, Gutknecht N, et al. Effects of KTP laser on oral soft tis- OPVL, Oral proliferative verrucous leukoplakia; sues. An in vitro study. Lasers Med Sci 2010;25:539-43. PDT, Photodynamic therapy; 5-ALA, 5-aminole- 11. Konopka K, Goslinki T. Photodynamic therapy in dentistry. ni vulinic acid; PpIX, Protoporphyrin IX; OVH, Oral J Dent Res. 2007;86:694-707. verrucous hyperplasia; OEL, Oral eythroleuko- 12. Hopper C. The role of photodynamic therapy in the man- agement oral cancer and precancer. Eur J Cancer B Oral On- plakia. col. 1996;32:71-72. o 13. Fan KF, Hopper C, Speight PM, Buonaccorsi G, MacRobert AJ Bown SG. Photodynamic therapy using 5-aminolevulin- Consent izi ic acid for premalignant and malignant lesions of the oral cav- ity. Cancer. 1996;78:1374-1383. Written informed consent was obtained from the pa- 14. Sieron A, Adamek M, Kawczyk-Krupka A, Mazur S, Ilewicz tient for publication of this case report and any ac- L. Photodynamic therapy (PDT) using topically applied delta aminolevulinic acid (ALA) for the treatment of oral leukoplakia. Ed companying images. The study has been conducted in accordance with the Declaration of Helsinki. J Oral Pathol Med. 2003;32:330-336. 15. Chen HM, Yu CH, Tu PC, Yeh CY, Tsai T, Chiang CP. Suc- cessful treatment of oral verrucous hyperplasia and oral leuko- plakia with topical 5-aminolevulinic acid-mediated photody- Conflicts of interest namic therapy. Lasers Surg Med. 2005;37:114-22. 16. Zakrzewska JM, Lopes V, Speight P, Hopper C. Prolifera- C The authors declare that they have no competing in- tive verrucous leukoplakia: a report of ten cases. Oral Surg terests. Oral Med Oral Pathol Oral Radiol Endod. 1996;82:396-401. CI © 80 Annali di Stomatologia 2014; V (2): 77-80 

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Original article Salivary glucose concentration and daily variation in the oral fluid of healthy patients li na Antonella Polimeni, MD, DDS1 Results. The average rate of un-stimulated sali- Marco Tremolati, DDS, MS, PhDC2 vary flow was 0,53±0,21 ml/min. There were no io Luigi Falciola, MD, PhD3 significant differences between salivary glucose Valentina Pifferi, MD3 values and salivary flow in female and male pa- Gaetano Ierardo, DDS1 tients. However, we observed a typical trend Giampietro Farronato, MD, DDS2 which recurred for each patient and resembled a az “pseudo-glycemic curve”. 1 Department of Oral and Maxillo-facial Sciences, Conclusions. The collected data suggests that “Sapienza” University of Rome, Italy glucose concentration results did not show sta- 2 Department of Biomedical, Surgical and Dental tistically significant differences (p>0,078) which rn Sciences, University of Milan, Italy could however be due to the little number of pa- 3 Department of Chemistry, University of Milan and tients assessed, nonetheless there is a trend, re- Sensors Group of the Italian Chemical Society, Italy calling a “pseudo-glycemic curve” not referable to changes in flow rates, probably due to glucose te catabolism and shunt. Corresponding author: Giampietro Farronato Key words: salivary glucose, saliva, oral hygiene, In Department of Biomedical, Surgical and Dental Sci- ences, University of Milan oral fluid, spectrophotometry. Via Commenda, 10 20122 Milano, Italy Introduction E-mail: giampietro.farronato@unimi.it ni Oral fluid is an organic fluid, easy to collect and to preserve, which may give us plenty of information Summary about the presence of systemic and local diseases via non-invasive sampling methods. It is constituted o Aim. The aim of this study was to determine the by a complex chemical milieu of teeth and oral soft concentration and the variations of salivary glu- tissues, consisting mainly on water, essential elec- izi cose in healthy patients who were sampled at five trolytes, glycoproteins, antimicrobial enzymes and nu- different intervals during the day. merous other important constituents like glucose (1, Materials and methods. Samples of un-stimulated 2). In the last decade the concentration of many bio- saliva have been collected from 21 healthy patients markers present in saliva has acquired increasing im- Ed using the drooling technique and they were divid- portance possibly showing the presence of systemic ed into two categories. In the first category, pa- illness and reflecting the metabolic, nutritional, im- tients were asked not to toothbrush their teeth in munological, hormonal, emotional and neurological the 8 hours prior to collection of the salivary sam- state of the patient (3-5). ple. Patients in the second category were instead Many articles have been written regarding the role asked to toothbrush 90 minutes before the collec- and presence of glucose in oral fluids such as saliva C tion of the first sample of saliva. The glucose con- and gingival crevicular fluid (GCF) in diabetic pa- centration was measured in all patients via an en- tients. However, little efforts have been made to as- CI zymatic spectrophotometry. Patients have been se- sess healthy patients. Above all, there are no articles lected following a strict inclusion criteria, which in- that describe repeated sample taking at different in- cluded <5% of plaque presence e according to the tervals of the day (10-14). plaque Index and a total absence of oral disease Glucose is a small molecule (180 DA) that diffuses that could possibly interfere with sample taking or through blood vessel membranes and passes through oral fluid analysis. The average age of patients was blood serum into GCF and salivary ducts to finally © 22,4±2,6 years old of which 45% were female and reach the oral cavity (15). Several studies assert that 55% were male. Samples were collected five times salivary glucose levels are not related to glycaemia, between 8 am and 12 pm, before and after break- even if the oral fluid of diabetic patients presents higher fast. Data was statistically analyzed using the levels of glucose than those in healthy controls (14-17). Skewness/Kurtosis Test, Shapiro-Wilk Test, Sampling oral fluid is easy, non-invasive for patients Kruskal Wallis Test and Linear Regression Model, and safe for clinicians, However, several authors do considering values of p<0,05 to be significant. not agree on the results obtained from such analyses, Annali di Stomatologia 2014; V (1): 1-6 1  A. Polimeni et al. due to the different available protocols in sampling them their toothbrush and toothpaste in order to procedures and the different analytical techniques. demonstrate and explain to them the correct oral hy- Ramsaier et al. and Kinney et al. report using one of giene techniques. the most repeatable and simple procedures to sam- Salivary samples were always collected between 8 ple oral fluid: the drooling technique (2, 18). am and 12 pm. Un-stimulated whole saliva from each li Many authors sampled oral fluid in a specific range of participant was collected at each study visit via pas- time and patients were instructed not to brush their sive drooling into a sterile plastic tube. na teeth, eat, drink or smoke 2-3 hours before the time of The first sample was taken after 8 hours from tooth saliva sample collection, but none of them have as- brushing (from 8:00 am to 8:30 am) or after 90 minutes sessed a plaque index score and/or oral health evalua- (following two different Protocols). After the first oral flu- tion. This is essential as plaque residuals may play an id sample collection, patients were asked to eat a stan- io important role in salivary glucose concentration (19-21). dardized breakfast (selected by us). After breakfast, pa- Based on these premises, the goal of the present study tients were asked to brush their teeth as they would is to evaluate the presence and therefore compare sali- normally. One hour after tooth brushing the second oral az vary glucose concentration in healthy young individuals fluid sample was collected. Other three samples were with excellent oral care. We also intend to analyze un- taken respectively after 90, 120 and 180 minutes. stimulated oral fluid samples taken at different times One hundred and twenty five total samples were col- before and after a standardized breakfast, comparing lected and statistically normalized using the Skew- rn two different protocols; with tooth brushing (90 min be- ness/Kurtosis and Shapiro-Wilk Normality Tests, and fore first sample taking) and without tooth brushing (8 then analyzed with the Kruskal Wallis Test and Linear hours from the last domiciliary oral hygiene care). Regression Model. Values where p<0,05 were con- sidered to be significant. te Materials and methods Reagents and solutions Thirty-seven patients who mantained all permanent In teeth and had no salivary dysfunctions were included Glucose oxidase/peroxidase, o-dianisidine dihy- in the study. Patients were trained for 6 months on drochloride and sodium fluoride were purchased by how to carry out effective oral domiciliary hygiene Aldrich; Sodium azide, D(+)-glucose monohydrate care. They were monitored until they reached a and sulphuric acid (95-97%) were Merck reagents. Plaque Index score, which was less than 5% accord- Artificial saliva was prepared, according to the litera- ni ing to the Silness and Loe index. Of the thirty-seven ture (22) by dissolving in water the following patients assessed, only twenty-one of them have reagents: 0.9 gL -1 KCl (Aldrich), 0.66 gL -1 KH 2PO 4 managed to reach a 5% plaque level within the 6 (Baker), 0.08 gL-1 MgCl2 6H2O (Carlo Erba), 0.49 gL-1 o months. Hence, these patients have been included in KHCO3 (Merck), 0.37 gL-1 NaNO3 (Merck), 0.12 gL-1 the study only one diabetic patient was included in CaCO3 (Merck), 0.64 gL-1 NH4Cl (Merck), 0.20 gL-1 izi the study under his specific request. Urea (Merck), 2.00 gL-1 Mucin (Aldrich). All the solu- The patients selected were between 20 to 25 years tions were prepared with Millipore Milli-Q ultrapure old (average 22,4 ± 2,6 years). Of these, 45% were water (resistivity > 18 MΩ cm-1). female and 55% were males. All patients were in Standard solutions of D(+)-glucose monohydrate Ed good systemic and periodontal health, as assessed were prepared for the calibration plot, diluting a 100 from both their medical history and oral and periodon- ppm solution. tal examination. 5 mg of o-dianisidine dihydrochloride were dissolved in Exclusion criteria for the study were: familiarity with or 1 mL of water and 0.8 mL of this solution were added to suspected diabetes, presence of metabolic diseases, a Glucose oxidase/peroxidase solution, prepared dis- use of pharmacological drugs during the month prior to solving the content of a capsule in 39.2 mL of water. C sample collection, presence of gingivitis or periodontal Solutions of 0.01 M NaF and 0.01 M NaN3 were used disease, incorrect or unusual nutritional habits, pres- as glycostatic and bacteriostatic agents respectively, CI ence of xerostomia or reduced salivary flow. and a 12 N H2SO4 solution was used to stop the en- A single clinician (M.T.) evaluated all patients, using zymatic reaction. a recent medical history and clinical findings. M.T was also responsible for instructing the patients on correct oral hygiene care and collecting repeated Determination method samples. The information recorded was: age, gender, © number of teeth and the plaque Index score accord- The method used for the determination of glucose in ing to Silness and Loe. saliva samples is an optimization of the GAGO-20 After an additional evaluation, patients received de- Sigma Aldrich Technical Bulletin. It is a spectrophoto- tailed information about the study procedures. All pa- metric enzymatic technique based on the transforma- tients have been asked not to brush their teeth, drink tion of glucose to gluconic acid mediated by glucose or eat within 8 hours prior to the first sample collec- oxidase and the consequent production of H2O2. Hy- tion (at 8 am). They were also asked to take with drogen peroxide reacts with o-dianisidine in the pres- 2 Annali di Stomatologia 2014; V (1): 1-6  Salivary glucose concentration and daily variation in the oral fluid of healthy patients ence of peroxidase, producing a colored product, For both protocols the standardized breakfast con- whose absorbance, proportional to glucose concen- sisted in a sweetened coffee or tea (with 2 tea- tration, is measured at 427 nm. spoons of sugar corresponding to 8,4 g) and an 2 mL of the solution containing glucose oxidase/per- empty croissant. oxidase and o-dianisidine were added to each sam- The collection procedure of saliva involved taking li ple to be analyzed; after 30 min at 37° C in a thermo- two samples of 0.5 mL to which 0.25 mL of 0.01 M stating bath and 2 mL of 12 N H2SO4 were used to NaF and 0.25 mL of 0.01 M NaN 3 were added as na stop the enzymatic reaction. The absorbance spec- glycostatic and bacteriostatic agents. The first sam- trum was measured in the range 380-800 nm, mea- ple was mixed with 2 mL of the solution containing suring the maximum at 427 nm. glucose oxidase/peroxidase and o-dianisidine whilst the second sample was mixed with 2 mL of water io (blank). Both samples were treated as described in Calibration plot the method section. The measurements of glucose concentration in the samples were obtained sub- The calibration plot was obtained using calibration tracting the blank absorbance and using the calibra- az solutions gathered by mixing 0.25 mL of 0.01 M NaF, tion plot. The blank subtraction is essential to par- 0.25 mL of 0.01 M NaN3, 0.25 mL of artificial saliva tially eliminate the contribution to the absorbance and 0.25 mL of standard glucose solutions in the con- caused by the different opacity of the saliva sam- centration range of 0 to 40 ppm. Each of these sam- ples, which comes from different patients. In such rn ples was treated with the procedure explained before, way, the measurement can only be referred to the measuring and correcting the absorbance with the glucose content. blank value. te Results Protocols This study involved 21 non-diabetic patients; 11 Two protocols were established to evaluate the glu- cose measurements and behavior in human saliva: In (52,4%) male and 10 (47,6%) female patients aged between 20 to 25 years. The average age was 22,4 ± • Protocol 1 (12 healthy patients): the first sample 2,6 years. For the whole oral fluid sample the aver- was collected after 8 hours from tooth brushing, age flow rate was 0,53 ± 0,21 ml/min. A statistically before breakfast (shown by the red continuous significant correlation between salivary glucose and ni vertical line in Fig. 1) and subsequent morning un-stimulated salivary flow rate was found (P=0,001). tooth brushing (shown by the green dashed verti- cal line in Fig. 1). Saliva was then collected at 60, 90, 120, 180 minutes from breakfast and morning Calibration plot o tooth brushing. • Protocol 2 (9 healthy patients + 1 diabetic pa- The calibration plot (Fig. 2) of the analytical method- izi tient): the first sample was collected in the mor- ology chosen for this study was obtained in the range ning after 8 hours from tooth brushing, (shown by of 0-4 mg dL-1 with a positive correlation. The limit of the green dashed vertical line in Fig. 2). The pa- detection was calculated at 0.011 mg dL-1 of glucose tients were then asked to have breakfast (shown and the limit of quantification at 0.0325 mg dL -1 of Ed by the red continuous vertical line in Fig. 2). Sali- glucose. These results show that the method used is va was then collected at 60, 90, 120, 180 minutes applicable to analyze the glucose content in human from breakfast. saliva. C Figure 1. General glucose concentration trend (“pseudo-glycemic curve”) for the two Protocols (two examples for each protocol: continuous lines CI from data in bold in Tables 1 and 2). The dashed line represents the trend of the diabetic patient. © Annali di Stomatologia 2014; V (1): 1-6 3  A. Polimeni et al. Discussion Nevertheless, a particular trend, showing a maximum value around 90 min from breakfast has been ob- Many authors have proved the efficiency and impor- served. Figure 1 shows two examples for each proto- tance of saliva as diagnostic fluid. Salivary tests to col (continuous lines, data in bold in Tab. 1 and 2) detect both periodontal and systemic illnesses are representing this trend. This data suggests a correla- li now an established possibility. In fact, in literature tion between food intake and salivary glucose. How- there are plenty of articles available which discuss ever, such correlation has to be further assessed due na the applicability of oral fluid sample analyses (from to the small number of samples analyzed. the simplest one to the most complex) as the integrat- The difference between the two Protocols is particu- ed microfluidic platform for oral diagnostics, usually larly evident in the first collected samples. known as Point-of-care (POC) salivary tests (23-26). Protocol 1, in which the first sample is collected in the io Several studies evaluate the concentration of glucose morning before tooth brushing (8 hours after the last in the saliva of diabetic patients. However, only a mi- tooth brushing), demonstrates that during the night, nority of them focuses on healthy patients assessed when the salivary flow rate is reduced, the levels of glucose in oral fluids increases and probably accumu- az at different times during the day with the purpose of investigating whether their glucose levels vary ac- lates on oral hard and soft tissues. cording to several factors such as tooth-brushing and Protocol 2, which involves tooth brushing before the nutritional habits. first sample collection (precisely 90 minutes before), demonstrates the importance of effective oral hygiene rn Table 1 and Table 2 show the results of the glucose determination according to both Protocols. care which reduces the level of glucose in the oral The data collected varies significantly form patient to cavity (compared to Protocol 1) up to a measurement patient (as expected), probably due to the different of 0 in half of the cases. Moreover, salivary flux acti- te metabolism of each individual. vation in these patients, due to tooth brushing, proba- In Figure 2. Calibration plot for glu- cose determination via enzymatic spectrophotometric method. o ni izi Ed Table 1. Glucose concentration data for all the samples collected in Protocol 1. P C CI Table 2. Glucose concentration data for all the samples collected in Protocol 2; a diabetic patient has also been recorded. © P 4 Annali di Stomatologia 2014; V (1): 1-6  Salivary glucose concentration and daily variation in the oral fluid of healthy patients bly plays a role in the salivary glucose concentration Paludetti G, Scarano E. Potential applications of human sali- observed. va as diagnostic fluid. Acta Otorhinolaryngol Ital. The dashed line in Figure 2 - Protocol 2, shows the 2011;31:347-357. 2. Kinney JS, Morelli T, Braun T, Ramseier CA, Herr AE, Sug- behavior of glucose in the diabetic patient. The trend ai JV, Shelburne CE, Rayburn LA, Singh AK, Giannobile WV. of the “pseudo-glycemic curve” is the same already li Saliva/pathogen biomarker signatures and periodontal dis- discussed, but shifted at higher values, demonstrat- ease progression. J Dent Res. 2011; 90:752-758. ing how it may be possible to use salivary glucose na 3. Pohjamo L, Knuuttila M, Tervonen T, Haukipuro K. Caries concentration in the monitoring of diabetic patients. prevalence related to the control of diabetes. Proc Finn Dent Regarding the concentration of salivary glucose, the Soc. 1988;84:247-52. average collected from all patients involved in this 4. Arcella D, Ottolenghi L, Polimeni A, Leclercq C. The rela- study was lower than the measurement obtained by tionship between frequency of carbohydrates intake and den- io Soares et al. (27), which was 5,94 mg/dL and Di Gioia tal caries: a cross-sectional study in Italian teenagers. et al. (28) which was 5,57 mg/dL. Agha-hosseini et al. Public Health Nutr. 2002;5(4):553-60. 5. Farronato G. Odontostomatologia per l’Igienista Dentale, Basi observed an average salivary glucose measurement of anatomo-cliniche e protocolli operativi. Piccin-Nuova Libraria az 13,6 mg/dL. As proposed by Soares et al. (27), one 2007. possible explanation of salivary glucose differences ob- 6. Farronato G, Regaldo G, Mascardi A. Azione enzimatica tained in these studies may be the various study de- dell’Alfa-Amilasi sulla placca batterica. Dent Cadm. signs as well as the diversity of the methods used and 1987;7:59-63. rn selection criteria of the sample collection (13, 29). This 7. Farronato G, Venerando B, de Colle C, Tonon M. Azione di data suggests that domiciliary oral hygiene techniques una destranasi sulla placca batterica in soggetti sottoposti of each patient should always be assessed before oral a chirutgia ortognatodontica. Prevenzione e Assistenza Den- fluid sample taking or, if possible, previously set. tale 1992: 5. 8. Farronato G, Venerando B, Biagi R, De Colle C, Passuello te In accordance to the results obtained from this study, the F, Tonon M. Azione di una destranasi sulla placca batteri- majority of authors observe a statistically significant cor- ca in soggetti handicappati: sperimentazione clinica. Pre- relation between flow rate and salivary glucose concen- venzione e Assistenza Dentale. 1992:3. tration. These suggest a pivotal role of flow rate, not only 9. Polimeni A., Gallottini L., Dolci M. La secrezione salivare e for the assessment of glucose concentration but also for In le sue alterazioni. Roma. Euroma, Editrice Univ. La Goliardica the identification of biomarkers levels in the diagnosis or 1995. screening of systemic and local diseases (27-29). 10. Twetman S, Johansson I, Birkhed D, Nederfors T. Caries in- cidence in young type 1 diabetes mellitus patients in rela- tion to metabolic control and caries-associated risk factors. ni Conclusions Caries Res. 2002;36:31-5. 11. Karjalainen KM, Knuuttila ML, Käär ML. Salivary factors in children and adolescents with insulin-dependent diabetes mel- Based on the results obtained from the samples stud- litus. Pediatr Dent. 1996;18:306-11. o ied, it is possible to determine that salivary glucose is 12. Ben-Aryeh H, Serouya R, Kanter Y, Szargel R, Laufer D. Oral present even when plaque levels and oral health sta- health and salivary composition in diabetic patients. J Dia- tus are strictly controlled. However, further studies izi betes Complicat. 1993;7:57-62. are required to prove a correlation between glucose 13. Moore PA, Guggenheimer J, Etzel KR, Weyant RJ, Orchard intake and salivary glucose as the number of patients T. Type 1 diabetes mellitus, xerostomia, and salivary flow and samples collected in our study were limited. rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92:281-91. Ed Moreover, an alternative, complementary, more rapid, 14. Jurysta C, Bulur N, Oguzhan B, Satman I, Yilmaz TM, precise and accurate analytical methodology (capa- Malaisse WJ, Sener A. Salivary glucose concentration and ble of following glucose concentration in saliva possi- excretion in normal and diabetic subjects. J Biomed bly on-site), is to be designed. In this context, electro Biotechnol 2009; Article ID 430426, 6 pages. analytical techniques, capable of monitoring small doi:10.1155/2009/430426 quantities of organic compounds in situ (30-31), could 15. Ben-Aryeh H, Cohen M, Kanter Y, Szargel R, Laufer D. Sali- C be an interesting alternative. vary composition in diabetic patients. J Diabetes Complicat. 1988; 2: 96-99. 16. Amer S, Yousuf M, Siddqiui PQ, Alam J. Salivary glucose CI Acknowledgements concentrations in patients with diabetes mellitus-a minimally invasive technique for monitoring blood glucose levels. Pak J Pharm Sci. 2001;14:33-37. Authors thank Colgate-Palmolive Company for finan- 17. Chávez EM, Borrell LN, Taylor GW, Ship JA. A longitudinal cially supporting the study. analysis of salivary flow in control subjects and older adults with type 2 diabetes. Oral Surg Oral Med Oral Pathol Oral © Radiol Endod. 2001 Feb;91(2):166-73. 18. Ramseier CA, Kinney JS, Herr AE, Braun T, Sugai J, Shel- burne CA, Rayburn LA, Tran HM, Singh AK, Giannobile WV. Identification of Pathogen and Host-Response Markers References Correlated With Periodontal Disease. J Periodontol. 2009;80:436-446. 1. Castagnola M, Picciotti PM, Messana I, Fanali C, Fiorita A, 19. Mandel ID, Wotman S. The salivary secretions in health and Cabras T, Calò L, Pisano E, Passali GC, Iavarone F, disease. Oral Sci Rev. 1976;8:25-47. Annali di Stomatologia 2014; V (1): 1-6 5  A. Polimeni et al. 20. Loe H, Silness J. Periodontal disease in pregnancy. I. 27. Soares MSM, Batista-Filho MMV, Pimentel MJ, Passos IA, Chi- Prevalence and severity. Acta Odontol Scand. 1963;21:533- menos-Küstner E. Determination of salivary glucose in healthy 551. adults. Med Oral Patol Oral Cir Bucal. 2009;14:510-3. 21. Silness J, Loe H. Periodontal disease in pregnancy. II. Cor- 28. Di Gioia ML, Leggio A, Le Pera A, Liguori A, Napoli A, Si- relation between oral hygiene and periodontal condition. Acta ciliano C, et al. Quantitative analysis of human salivary glu- li Odontol Scand. 1964; 22:121-135. cose by gas chromatography-mass spectrometry. J Chro- 22. Roger P, Delettre J, Bouix M, Béal C. Characterization of matogr B Analyt Technol Biomed Life Sci. 2004;801: na Streptococcus salivarius growth and maintenance in artifi- 355-8. cial saliva. J Appl Microbiol. 2011 Sep;111(3):631-41. 29. Carda C, Mosquera-Lloreda N, Salom L, Gomez de Ferraris 23. Giannobile WV. Salivary diagnostics for periodontal diseases. ME, Peydró A. Structural and functional salivary disorders J Am Dent Assoc. 2012;143:6-11. in type 2 diabetic patients. Med Oral Patol Oral Cir Bucal. 24. Herr AE, Hatch AV, Giannobile WV, Throckmorton DJ, Tran 2006;11:E309-14. io HM, Brennan JS, Singh AK. Integrated microfluidic platform 30. Falciola L, Pifferi V, Mascheroni E. Platinum-Based and Car- for oral diagnostics. Ann N Y Acad Sci. 2007;1098:362-74. bon-Based Screen Printed Electrodes for the Determination 25. Kinney JS, Ramseier CA, Giannobile WV. Oral fluid-based of Benzidine by Differential Pulse Voltammetry. Electro- biomarkers of alveolar bone loss in periodontitis. Ann N Y analysis. 2012; 24-4:767-75. az Acad Sci. 2007;1098:230-51. 31. Falciola L, Pifferi V, Possenti ML, Carrara V. Square Wave 26. Taba M Jr, Kinney J, Kim AS, Giannobile WV. Diagnostic bio- Voltammetric detection of furan on platinum and platinum- markers for oral and periodontal diseases. Dent Clin North based Screen Printed Electrodes. J Electroanal Chem. 2012; Am. 2005;49:551-71. 664:100-4. rn te In o ni izi Ed C CI © 6 Annali di Stomatologia 2014; V (1): 1-6 

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Original article Effects of dentin surface treatments on shear bond strength of glass-ionomer cements li na Claudio Poggio, MD, DDS1 values of RMGIC and lowered the shear bond Riccardo Beltrami, DMD, PhD2 strength values of GIC significantly. io Andrea Scribante, DMD, PhD2 Marco Colombo, DMD, PhD1 Key words: conventional glass-ionomer cement, Marco Lombardini, DMD, PhD1 resin-modified glass-ionomer cement, dentin pre- treatment, phosphoric acid, polyacrylic acid, self- az etch adhesives, shear bond strength test. 1 Department of Clinical-Surgical, Diagnostic and Paediatric Science, University of Pavia, Italy 2 Department of Brain and Behavioural Sciences, Introduction rn Section of Statistics, University of Pavia, Italy Glass-ionomer cements (GICs) were developed and first presented by Wilson and Kent (1) in 1972: the Corresponding author: goal was finding an ideal restorative material with te Claudio Poggio physical properties similar to tooth structure, with ad- Department of Clinical-Surgical, Diagnostic and Pae- hesion to dentine/enamel, with resistance to degrada- diatric Science, University of Pavia, Italy tion in the oral cavity (2) and with ability to release Piazzale Golgi, 1 27100 Pavia, Italy In fluoride (3). GICs are able to bond chemically to enamel, dentin, plastics, and non-precious metals (4, E-mail: c.poggio@unipv.it 5); other potential advantages of GICs are adhesion in a wet substrate and the release of fluoride ions over long periods (6). Previous studies showed that ni Summary enamel adjacent to glass-ionomer cements was less deeply and less frequently demineralised compared Aim. The aim of this in vitro study was to evaluate with that adjacent to non fluoridated materials (7, 8). the effect of different surface treatments on shear Moreover, glass-ionomer cements were shown to re- o bond strength of a conventional glass-ionomer lease fluoride longer and at higher levels than fluo- cement (GIC) and a resin-modified glass-ionomer ride-containing composites (9). The concept that izi cement (RMGIC) to dentin. glass-ionomers can act as rechargeable fluoride re- Materials and methods. 80 bovine permanent in- lease devices has been proposed (10). Studies re- cisors were used. 40 cylindrical specimens of a ported that the regular use of fluoride toothpastes can GIC (Fuji IX GP Extra) and 40 cylindrical speci- result in the absorption of fluoride into the glass- Ed mens of a RMGIC (Fuji II LC) were attached to the ionomer and that this fluoride can subsequently be dentin. The teeth were then randomly assigned to released into the adjacent tooth structure (11, 12). 8 groups of equal size (n=10), 4 for every type of Initial formulation of GICs underwent several modifi- glass-ionomer cement, corresponding to type of cations with the intent to improve handling and physi- dentin surface treatments. Group 1: GC Cavity cal properties. A remarkable improvement of this Conditioner; Group 2: 37% phosphoric acid gel; class of material occurred with the introduction of the C Group 3: Clearfil SE Bond; Group 4: no dentin resin-modified glass-ionomer cement (RMGIC). This conditioning (control). The specimens were material is characterised by the addition of photo-acti- CI placed in a universal testing machine (Model vated metacrilate, and a small amount of resin, such 3343, Instron Corp., Canton, Mass., USA) and as 2-HEMA or Bis-GMA, to the conventional glass- subsequently tested for shear bond strength ionomer cement (GIC) (13, 14). Over the years many (MPa). studies have been carried out to demonstrate that Results. ANOVA showed the presence of signifi- GICs and RMGICs bond naturally to the tooth surface cant differences among the various groups. Post (15, 16). Bond strengths are lower than composite © hoc Tukey test showed different values of shear resins bonded with appropriate bonding agents, but bond strength for Fuji IX GP Extra and for Fuji II the durability of the bond appears greater (17). This LC. The different conditioners variably influence may be attributed to the bioactive nature of the inter- the adhesion of the glass-ionomer cements test- face between the cement and the tooth (15, 18), ed. Conclusions. RMGIC shear bond to dentin which leads over time to a strong, durable bond was higher than GIC. The use of a Self-etch adhe- formed by an ion-diffusion process (19). Many condi- sive system improved the shear bond strength tioning solutions, such as polyacrylic acid and phos- Annali di Stomatologia 2014; V (1): 15-22 15  C. Poggio et al. phoric acid in different concentrations have been in- placed on the cut surface of the tooth, and packing vestigated as a pre-treatment to GICs and RMGICs, them until they were full. In GIC specimens, there in order to improve their adhesion to the dentin sur- was a 6-min interval from the start of mixing to com- face (20-23). Dentin conditioning can act differently plete curing of the cement, but in RMGIC the speci- on GICs and RMGICs due to the presence of resin mens were immediately cured using a LED curing li components that can infiltrate into the demineralised light in softstart-polymerisation mode (Celalux 2 High- dentin and after polymerisation result in microme- Power LED curing-light, Voco GmbH, Cuxhaven, Ger- na chanical retention (24). many) for 10 seconds at a light intensity of 1000 The purpose of the present in vitro study was to eval- mW/cm2. The tip of the light-curing unit was placed uate the effect of different surface treatments on 1 mm above the surface of the cement. The teeth shear bond strength of a conventional glass-ionomer were then randomly assigned to 8 groups of equal io cement and a resin-modified glass-ionomer cement size (n=10) corresponding to the type of dentin sur- to dentin. face treatments and to the cylindrical specimen at- tached. Group 1: GC Cavity Conditioner (20% poly- az acrylic acid and 3% aluminum chloride hexahydrate) Materials and methods for 20 seconds, rinsed and gently air-dried plus Fuji IX GP Extra. Group 2: 37% phosphoric acid gel (Total In the present in vitro study, 80 bovine mandibular in- Etch; Ivoclar Vivadent AG, Schaan, Liechtenstein) for rn cisor were collected and randomly divided into 8 15 seconds, rinsed and gently air-dried plus Fuji IX groups (n=10). Tissue remnants and debris were re- GP Extra. Group 3: Clearfil SE Bond (Kuraray) ap- moved with periodontal curettes. The teeth were plied according the Instruction for use plus Fuji IX GP stored in 0.5% chloramine solution for one week and Extra. Group 4: no dentin conditioning (control) plus te later in distilled water at 4º C. The teeth were embed- Fuji IX GP Extra. Group 5: GC Cavity Conditioner ded in self-cured acrylic resin, obtaining 2.0 cm large (20% polyacrylic acid and 3% aluminum chloride x 2.0 cm thick specimens. The teeth were randomly hexahydrate) for 20 seconds, rinsed and gently air- assigned to 8 groups (n=10) according to the dentin dried plus Fuji II LC. Group 6: 37% phosphoric acid treatment received. The vestibular enamel was re- In gel (Total Etch; Ivoclar Vivadent AG, Schaan, Liecht- moved to obtain a flat surface of dentin. In all groups, enstein) for 15 seconds, rinsed and gently air-dried a high-speed turbine attached to a device was used plus Fuji II LC. Group 7: Clearfil SE Bond (Kuraray) for standardised dentin preparation. The lingual plus Fuji II LC. Group 8: no dentin conditioning (con- dentin surface was exposed using a high-speed car- trol) plus Fuji II LC. Details of materials employed are ni bide rotary instrument (# H21L.314.014; Komet, Ger- presented in Table 1 and in Table 2. many) under copious water irrigation. The surface was rinsed with water and gently air dried. Different o types of surface treatments were employed: GC Cavi- Shear Bond Strength Testing ty Conditioner, 37% phosphoric acid gel, Clearfil SE izi Bond, no dentin conditioning. 40 cylindrical speci- Specimens were stored in a solution of 0,1% mens (4 mm diameter × 4 mm height) of a conven- (weight/volume) thymol for 24 hours and then were tional glass-ionomer cement (Fuji IX GP Extra) and placed in a universal testing machine (Model 3343, 40 cylindrical specimens (4 mm diameter × 4 mm Instron Corporation, Norwood, MA, USA) (Fig. 1). Ed height) of resin-modified glass-ionomer cement (Fuji Specimens were secured in the lower jaw of the ma- II LC) were attached to the dentin. The capsules of chine so that the bonded cylinder base was parallel to glass-ionomer cements were activated and mixed ac- the shear force direction (Fig. 2). The shear bond cording to the manufacturer’s instructions. The pre- strength was performed at 0.5 mm/minute until the pared mixture was packed into a cylindrical plastic sample ruptured. Specimens were stressed in an oc- moulds (a diameter of 4 mm and a height of 4 mm) cluso-gingival direction at a crosshead speed of 1 C CI Table 1. Glass-ionomer cements employed in the study. Material Type Composition Manufacturer Batch Number Fuji IX GP Extra GIC Polyacrylic acid, GC Corporation, Tokyo, Japan 1102214 in caps Fluoro-alumino-silicate glass, © Distilled water Fuji II LC in caps RMGIC 2-hydroxyethyl GC Corporation, Tokyo, Japan 1103127 methacrylate (HEMA), Urethane Dimethacrylate (UDMA), Polyacrylic acid, Fluoro alumino-silicate glass, Distilled water 16 Annali di Stomatologia 2014; V (1): 15-22  Effects of dentin surface treatments on shear bond strength of glass-ionomer cements Table 2. Conditioners employed in the study. Material Composition Manufacturer Batch Number GC Cavity 20% polyacrylic acid, 3% aluminum GC Corporation, Tokyo, Japan 1102171 Conditioner chloride hexahydrate,distilled water li Total Etch phosphoric acid (37 % in H2O), Ivoclar Vivadent AG, Schaan, P35844 na thickeners and pigments Liechtenstein Clearfil SE Bond Primer: 10-MDP, HEMA, Kuraray Medical, Sakazu, Primer: 01040AA Hydrophilic dimethacrylate, CQ, Okayama, Japan N,N-Diethanol-p-toluidine, water. Bond: 10-MDP, Bis-GMA, Bond: 01556AA io Hydrophilic dimethacrylate, HEMA, CQ, N,N-Diethanol-p-toluidine, silanated colloidal silica. az rn te In o ni izi Ed C Figure 1. Universal testing machine Model 3343, Istrom Figure 2. Universal testing machine Model 3343, Istrom (Universal testing machine, Model 3343, Instron Corpora- (Universal testing machine, Model 3343, Instron Corpora- CI tion, Norwood, MA, USA). tion, Norwood, MA, USA). The bonded cylinder base was parallel to the shear force direction. mm/min (16-18). The maximum load necessary to within the tooth (19). The adhesive remnant index debond was recorded in Newton (N) and calculated in (ARI) was used to assess the amount of adhesive left © MPa as a ratio of Newton to surface area of the cylin- on the enamel surface (20). This scale ranges from 0 der. After the testing procedure, the fractured sur- to 3. A score of 0 indicates no adhesive remaining on faces were examined with an optical microscope the tooth in the bonding area; 1 indicates mixed fail- (Stereomicroscope SR, Zeiss, Oberkochen, Ger- ure with less than half of the adhesive remaining on many) at a magnification of 10x to determine failure the tooth; 2 indicates mixed failure with more than modes and classified as adhesive failures, cohesive half of the adhesive remaining on the tooth; and 3 in- failures within the composite, or cohesive failures dicates all adhesive remaining on the tooth. The ARI Annali di Stomatologia 2014; V (1): 15-22 17  C. Poggio et al. scores were used as a more complex method of of variance (ANOVA) was applied to determine defining bond failure site among the enamel, the ad- whether significant differences in debond values ex- hesive, and the composite (25). Samples were ther- isted among the groups. The Tukey test was used as mocycled and debonded using a shear force with a post-hoc. The chi-squared test was used to deter- crosshead speed of 0.5 mm/min. Shear bond mine significant differences in the ARI scores among li strengths were determined using a Hounsfield Uni- the different groups. Significance for all statistical versal Testing machine, at a loading rate of tests was predetermined at P<0.05. na 1 mm/min, using a knife edge placed 1 mm away from the interface. Loads at failure were converted to bond strengths by dividing by the contact areas of the Results cylinders. After mechanical failure, the fracture io modes in all the specimens were evaluated under a Descriptive statistics of the shear bond strength stereomicroscope (Nikon; Japan) at ×20. (MPa) of the different groups are illustrated in Table 3 and in Figure. 3. ANOVA showed the presence of sig- az nificant differences among the various groups Statistical analysis (P<0.0001). Post hoc Tukey test showed that when testing Fuji IX GP Extra the application of cavity con- Statistical analysis was performed with Stata 9.0 soft- ditioner (Group 1) showed significantly higher shear rn ware (Stata, College Station, Tex). Descriptive statis- bond strength than all other surface treatments tics, including the mean, standard deviation, median, (P<0.05). Moreover phosphoric acid gel application and minimum and maximum values were calculated (Group 2) showed no significant difference in shear for all groups. Kolmogorov and Smirnov test was ap- strength values than no conditioning control group te plied to assess normality of distributions. An analysis (Group 4). Lowest values were reported when Clearfil Table 3. Descriptive statistics of the different groups tested. In Groups Material Enamel pre-treatment Mean SD Min Mdn Max Tukey * 1 Fuji IX GP Extra Cavity Conditioner 3.51 1.22 1.51 3.34 5.34 A 2 Fuji IX GP Extra Ortophosphoric acid 1.86 1.10 0.18 1.11 5.02 B ni 3 Fuji IX GP Extra Clearfil SE Bond 0.00 0.00 0.00 0.00 0.00 C 4 Fuji IX GP Extra No conditioning 1.94 0.96 0.84 1.92 3.36 B o 5 Fuji II LC Cavity Conditioner 10.24 2.20 5.10 11.09 14.28 D 6 Fuji II LC Ortophosphoric acid 6.53 1.90 2.08 6.30 11.23 E izi 7 Fuji II LC Clearfil SE Bond 15.88 4.40 7.03 15.69 26.29 F 8 Fuji II LC No conditioning 5.72 2.82 2.46 5.17 11.66 E *: Tukey post hoc: Means with the same letters are not significantly different. Ed Figure 3. Mean shear bond strength and standard deviation of the different groups tested. C CI © 18 Annali di Stomatologia 2014; V (1): 15-22  Effects of dentin surface treatments on shear bond strength of glass-ionomer cements SE Bond was applied (Group 3). On the other hand, as higher than that of conventional GICs (32). Howev- when testing Fuji II LC the highest shear bond er, the exact mechanism of adhesion of this material strength values (P<0.001) were reported when is not completely established. Some SEM studies re- Clearfil SE Bond was applied (Group 7). Significantly vealed the formation of tags at the dentin-cement in- lower (P<0.05) values were reported when Cavity terface resultant from the RMGIC polymer penetration li conditioner was applied (Group 5). Lowest shear into the dentinal tubules (21, 28, 33). strength values (P<0.01) were reported both when The application of surface-altering solutions to dentin na enamel was pretreated with phosphoric acid gel prior to bonding with glass-ionomer cements has a (Group 6) and when no conditioner was applied long history (34, 35). The purpose of applying these (Group 8). Overall, Fuji II LC showed significantly solutions has been to increase the strength of the higher shear bond strength values than Fuji IX GP bond formed between the dentin surface and cement. io Extra (P<0.0001). When comparing ARI Score results For chemically-cured glass-ionomer cements, one of of the different groups, no statistical difference was these first solutions used for this purpose was citric found in frequency distribution among various groups, acid (36). Although 50% citric acid was commonly az that all showed a significant prevalence of ARI Score used as a dentin conditioning agent, it fell out of of “0” (Fig. 4). favour because it lacked biocompatibility (37), opened dentin tubules (38), and produced either no increase or decrease in bond strength (38, 39). Polyacrylic acid rn Discussion in various concentrations has also been suggested as a dentin conditioner prior to placement of chemically The adhesion of dental materials to dentin has been set glass-ionomer cement because Powis et al. (38) extensively investigated in the last decades in order to believed that it increases wettability of dentin surface te make it effective and durable, but due to dentin com- and improves ion exchange with the cement. Al- plexity this is an arduous procedure (26). Unlike though researchers have recommended its use in an enamel, dentin is a live, dynamic tissue that contains attempt to maximise bond strength, suggested con- greater portion of water and organic material. It is con- centrations and application times have varied. Berry In nected to the pulp through the dentinal tubules, which et al. (40) used SEM to evaluate dentin surfaces treat- extend from the pulp to the dentin-enamel junction. ed with number of conditioning solutions and conclud- These tubules contain dentinal fluid that is responsible ed that a 5 second application of 40% polyacrylic acid for the intrinsic humidity of this structure (26, 27). Dif- produced the most ideal surface for bonding. Howev- ferent mechanical tests have been proposed to as- er, Long et al. (41) found that a 30 second treatment ni sess the bonding performance of restorative materi- with either 30% or 35% polyacrylic acid produced als. Although it suffers criticism, shear testing has bond strengths that were significantly higher than been widely used to evaluate the bonding ability of ad- those produced using 15%, 20%, 25% and 40% solu- o hesive materials to dental structure (22, 28). Particu- tions. Although differences in opinion remain concern- larly regarding GICs, which present low bond strength, ing application times and concentrations for poly- izi other tests may be difficult to apply (29). Previous acrylic acid, researchers continue to recommend its studies have shown that typical shear bond strengths use as a dentin pre-treatment with chemically set of glass-ionomer cements to dentine lie in the range glass-ionomer products. Polyacrylic acid is the most 1–3 MPa, and rarely exceed 5 MPa (30, 31). The commonly used conditioner for conventional GICs be- Ed bond strength RMGICs to dentin have been reported cause it is capable of cleansing the dentin surface Figure 4. ARI Scores percentages of the different groups tested. C CI © Annali di Stomatologia 2014; V (1): 15-22 19  C. Poggio et al. without completely unplugging the dentinal tubules. dentin treatment with polyacrylic acid is recommend- The increase in bonding efficiency resulting from con- ed by the manufacturer of Fuji II LC considering the ditioning can be attributed to: a cleansing effect which fact that the liquid of Fuji II LC contains approximately removes loose cutting debris following cavity prepara- 35% hydroxyethyl methacrylate (HEMA) (manufactur- tion, a partial demineralisation effect which increases er’s data). li the surface area and creates microporosities and a Previous studies demonstrated a significant improve- chemical interaction of the polyalkenoic acid with ment in the bond strength of Fuji II LC after condition- na residual hydroxyapatite. The auto-adhesion of glass- ing with polyacrylic acid (43-45). Pereira et al. (28) ionomer cements to tooth tissue has recently been observed resin tag formation in dentin specimens elucidated to be two-fold in nature. Micromechanical pretreated with polyacrylic acid and restored with Fuji interlocking is achieved by shallow hybridisation of II LC. Fuji II LC contains HEMA which can facilitate io the micro-porous, hydroxyapatite-coated collagen net- an improvement in the wetting ability as well as suit- work . In this respect, glass-ionomer cements can be able bonding (46). A hybrid-like layer was reported to considered as adhering to tooth tissue through a kind form at the Fuji II LC/dentin interface when condition- az of self-etch approach. As the second part of self-ad- ing was carried out prior to application of this cement hesion mechanism, true primary chemical bonding oc- (44). According to many Authors phosphoric acid curs through the formation of ionic bonds between the conditioning prior to RMGIC application was able to carboxyl groups of the polyalkenoic acid and calcium improve adhesion to dentin. The effective removal of rn of hydroxyapatite that remained around the exposed the smear layer, exposure of collagen and opening of surface collagen. The polyacrylic acid pre-treatment is dentinal tubules promoted a better resin monomer much milder than a traditional phosphoric acid treat- (HEMA) penetration within the underlying dentin, thus ment, and the exposed collagen fibrils are not com- creating a hybrid layer. Hybrid layer increases the te pletely denuded of hydroxyapatite. The phosphoric surface energy and contributes to provide a better acid treatment demineralised superficial dentin to a moisture of the dentin surface creating an interdiffu- variable thickness of the order of several microns (de- sion zone between the cement and dentin matrix, pending on time of application) and the hydroxyap- which contributes to micromechanical retention, in In atite removal prevented formation of ion exchange in addition to chemical adhesion to dentin (21, 22, 48). which the carboxyl groups of the cement interacted According to the previous research this study demon- with calcium ions and phosphate from hydroxyapatite. strated the dentin bond strength of Fuji II LC using Our research shows that the use of polyacrylic acid Clearfil SE Bond (contain hydrophilic monomers) was on dentin increases shear strength value of GIC statistically higher than other treatments or no treat- ni whilst the use of another system for pre-treatment, ments (in the present study unconditioned specimens phosphoric acid, shows no significant difference in showed significantly lower bond strength results than shear strength values. all conditioned specimens). The better bonding per- o Dentin surface treatment remains a topic of research formance of RMGICs compared to conventional GICs as new, resin-containing glass-ionomer products like could be due to their expected dual mechanism of ad- izi visible light activated liners/ bases are introduced to hesion (32). Resin cements are composites of a resin the market. Prati et al. (23) evaluated the effects of matrix, such as Bis-GMA or urethane dimethacrylate, nine different dentin surface treatments on the shear and fine inorganic particles as filler (48). HEMA is an bond strength of Vitrabond to human dentin. They example of a hydrophilic primer, used to improve the Ed found that although many of the treatments signifi- infiltration of adhesive monomers into demineralised cantly altered the dentin as observed using scanning dentin by wetting the surface of collagen fibres and electron microscopy, only neutral and acidic oxalate maintaining the collagen network in an expanded solutions significantly increased the bond strength. state by stiffening the collagen fibres (49, 50). In ad- This finding implies that glass-ionomer products dition, the increase in the bond strength can be attrib- which contain resin may require dentin treatments uted to the polymerisation of HEMA leaving of a film C that differ from those used with traditional glass- of polymerised material on the dentin surface (51, ionomer cements. It should not be surprising then 52). Also, HEMA increases the infusion and impreg- CI that the dentin treatment used with recently devel- nation of resin monomers into demineralised dentinal oped visible light activated glass-ionomer restorative matrix. Thus, the interfacial hybrid zone formed by materials differs from those recommended for use polymerized resins, including HEMA must have with chemically set glass-ionomers forms. This is played an important role in enhancing the bonding of probably due to the liquid component that contains resin materials (53). acrylic monomers: dentin treatment with dentin bond- © ing primers rather than polyacrylic acid may be effec- tive in maximising bond strengths. Prisma Universal Conclusions Bond (30% hydroxyethyl methacrylate, 6% phospho- nated penta-acrylate ester in ethanol) and similar Within the limitations of this study and according to primers that contain hydrophilic monomers facilitate the methodology used in our study and the statistical wetting of dentin and enhance bonding between analysis obtained, the following conclusions can be dentin and resin-containing materials (42). However, drawn: 20 Annali di Stomatologia 2014; V (1): 15-22  Effects of dentin surface treatments on shear bond strength of glass-ionomer cements · RMGIC showed significantly higher shear bond 19. Ngo H, Mount GJ, Peters MC. A study of glass-ionomer ce- strength to dentin than GIC; this can be attributed ment and its interface with enamel and dentin using a low- to action of HEMA that can have played an impor- temperature, high-resolution scanning electron microscop- ic technique. Quintessence Int. 1997 Jan;28(1):63-69. tant role in enhancing the bonding of RMGIC; 20. Erickson RL, Glasspole EA. Bonding to tooth structure: a com- · the use of adhesive system, as Clearfil SE Bond, li parison of glass-ionomer and composite resin systems. J Es- improved shear bond strength of RMGIC to dentin thet Dent. 1994;6(5):227-244. because it contains hydrophilic monomers that na 21. Nakanuma K, Hayakawa T, Tomita T, Yamazaki M. Effect enhance bonding between dentin and RMGIC; of the application of dentin bonding agent on the adhesion · the application of adhesive system, as Clearfil SE between the resin-modified glass-ionomer cement and Bond, significantly lowered shear strength of GIC: dentin. Dent Mater. 1998;14(4):281-286. therefore adhesive application is not recommend- 22. Pereira PNR, Yamada T, Inokoshi S, Burrow MF, Sano H, io ed when using conventional glass-ionomer ce- Tagami J. Adhesion of resin-modified glass-ionomer cements ments. using resin bonding systems. J Dent. 1998;26(5-6):478-485. 23. Prati C, Montanari G, Biagin G, Fava F, Pashley DH. Effects of dentin surface treatments on shear bond strength of Vi- az trabond. Dent Mater. 1992;8(1):21-26. References 24. Burrow MF, Nopnakeepong U, Phrukkanon S. A compari- son of microtensile bond strengths of several dentin bond- 1. Wilson AD, Kent BE. A new translucent cement for dentistry: ing systems to primary and permanent dentin. Dent Mater. the glass-ionomer cement. Br Dent J. 1972;15(4):133-135. rn 2002;18(3):239-245. 2. Walls AWG. Glass polyalkenoate (glass-ionomer) cements: 25. Zanata RL, Navarro MF, Ishikiriama A, da Silva e Souza Ju- a review. J Dent. 1986;14(6):231-246. nior MH, Delazari RC. Bond strength between resin composite 3. Forsten L. Fluoride release and uptake by glass-ionomers and etched and non-etched glass-ionomer. Braz Dent J. and related materials and its clinical effect. Biomaterials. 1997;8:73-78. te 1998;19(6):503-508. 26. Swift Junior EJ, Pawlus MA, Vargas, MA. Shear bond strength 4. Kent BE, Lewis GG, Wilson AD. The properties of a glass- of resin-modified glass-ionomer restorative materials. Oper ionomer cement. Br Dent J. 1973; 135:322-326. Dent. 1995;20(4):138-143. 5. Hotz P, McClean JW, Sced I, Wilson AD. The bonding of 27. Garberoglio R, Brännström M. Scanning electron microscopic In glass-ionomer cements to metal and tooth substrates. Br Dent investigation of human dental tubules. Arch Oral Biol. J. 1977;142:41-47. 1976;21(6):355-362. 6. Cook PA, Youngson CC. An in vitro study of the bond strength 28. Pereira PNR, Yamada T, Tei R, Tagami J. Bond strength and of a glass-ionomer cement in the direct bonding of orthodontic interface micromorphology of an improved resin-modified brackets. Br J Orthod. 1988;15:247-253. glass-ionomer cement. Am J Dent. 1997;10(3):128-132. ni 7. Dijkman GEHM, Arends J. Secondary caries in situ around 29. Wang L, Sakai VT, Kawai ES, Buzalaf MAR, Atta MT. Effect fluoride-releasing light-curing composites: a quantitative mod- of adhesive systems associated with resin-modified glass- el investigation on four materials, with a fluoride content be- ionomer cements. J Oral Rehabil. 2006; 33(2):110-116. tween 0 and 26% vol. Caries Res. 1992;26:351-257. 30. Burke FM, Lynch E. Glass polyalkenoate bond strength to o 8. Kindelan J D. In vitro measurement of enamel demineral- dentine after chemomechanical caries removal. J Dent. ization in the assessment of fluoride-leaching orthodontic 1994;22(5):283-91. bonding agents. Br J Orthod. 1996;23:343-349. izi 31. Berry EA 3rd, Powers JM. Bond strength of glass-ionomers to 9. Chadwick SM, Gordon PH. An investigation into the fluoride coronal and radicular dentin. Oper Dent. 1994;19(4):122-6. release of a variety of orthodontic bonding agents. Br J Or- 32. Almuammar MF, Schulman A, Salama F. Shear bond thod. 1995;22:29-33. strength of six restorative materials. J Clin Pediatr Dent. 10. Forsten L. Fluoride release and uptake by glass-ionomers. 2001;25(3):221-225. Ed Scand Dent J Res. 1991;99:241-245. 33. Abdalla AI. Morphological interface between hybrid ionomers 11. Hatibovic-Kofman S, Koch G. Fluoride release from glass- and dentin with or without smear-layer removal. J Oral Re- ionomer cement in vivo and in vitro. Swed Dent J. habil. 2000;27(9):808-814. 1991;15:253-258. 34. Causton BE, Samara-Vickrama DY, Johnson NW. Effect of 12. Seppä L, Forss H, Ögaard B. The effect of fluoride application calcifying fluid on the bonding of cements and composites on fluoride release and the antibacterial action of glass- to dentin, in vitro. Br Dent J. 1976;140:339-442. C ionomers. J Dent Res. 1993;72:1310-1314. 35. Shalabi HS, AsmusseN E, Jorgensen KD. Increased of a 13. Mathis R, Ferracane JL. Properties of a glass-ionomer/resin- glass-ionomer cement to dentin by means of FeCl3. Scand composite hybrid material. Dent Mater. 1989;5(5):355-358. J Dent Res. 1981;89:348-353. CI 14. Di Nicolo R, Shintome LK, Myaki SI, Nagayassu MP. Bond 36. Prodger TE, Symonds M. ASPA adhesion study. Br Dent J. strength of resin modified glass-ionomer cement to prima- 1977;143:266-270. ry dentin after cutting with different bur types and dentin con- 37. Aboush YE, Jenkins CB. The effect of poly(acrylic acid) ditioning. J Appl Oral Sci. 2007;15(5):459-464. cleanser on the adhesion of a glass polyalkenoate cement 15. Mount G.J. Colour atlas of glass-ionomer cements, 3rd edn to enamel and dentin. J Dent. 1987;15:147-152. 2002, (Martin Dunitz: London) 38. Powis DR, Folleras T, Merson SA, Wilson AD. Improved ad- © 16. Wilson AD, Kent BE. A new translucent cement for dentistry. hesion of a glass-ionomer cement to dentin and enamel. J The glass-ionomer cement. Br Dent J. 1972 Feb Dent Res. 1982; 61:1416-1422. 15;132(4):133-135. 39. Aboush YE, Jenkins CB. An evaluation of the bonding of 17. Tyas MJ. 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Original article Characterizing scientific production of Italian Oral Surgery professionals through evaluation of bibliometric indices li na Stefano Tetè, MD, DDS1† ues increased more regularly as the career length Vincenzo Luca Zizzari, DDS1 progressed than the hc-index values, even if the io Alessandro De Carlo, DDS1 last seemed to be less variable. h- and hc-indices Felice Lorusso, DDS 1 are both stable bibliometric parameters, but as Marta Di Nicola, MD2 the hc-index values are related not only to the Adriano Piattelli, MD 1 number of citation but also to their age, it seems az Enrico Gherlone, MD, DDS3 to be less influenced by the authors’ career Antonella Polimeni, MD, DDS4 length. Bibliometric analysis of the scientific pro- duction in dentistry may facilitate the recognition of factors that may further enhance research ac- rn 1 Department of Medical, Oral and Biotechnological tivity and clinical performance and be useful for a Sciences, “G. D’Annunzio” University, Chieti comparative assessment of authors or research Pescara, Italy groups in terms of quality and quantity of the sci- 2 Department of Biomedical Sciences,“G. D’Annun- entific production. te zio” University, Chieti Pescara, Italy 3 Department of Oral Science, “Vita-Salute San Raf- Key words: career length, contemporary h-index, faele” University, Milan, Italy h-index, oral surgery, scientific production. In 4 Department of Oral and Maxillo-facial Sciences, Sapienza University of Rome, Italy Introduction Corresponding author: Recently, scientific research in dentistry gained great ni Stefano Tetè importance due to the technological innovation in ma- Department of Medical, Oral and Biotechnological terials and techniques, which were also introduced in Sciences, “G. D’Annunzio” University this field, and not less important, in order to improve Via dei Vestini, 31 the quality of dental care. Nowadays, even more den- o 66100 Chieti, Italy tal professionals are involved in dental research, not E-mail: tete@unich.it only researchers with a University position. The diffu- izi sion also of national and international scientific soci- eties improved the interest of the clinicians in dental Summary research, both in an indirect way by showing their in- terest in meetings participation and in staying up to Ed The aim of this study was to characterize the sci- date on innovations, and both directly, by conducting entific production of Italian Oral Surgery profes- primary or clinical research. In order to evaluate the sionals by evaluating different bibliometric in- quality and the impact on society of this scientific ac- dices. The bibliometric evaluation was conducted tivity, many different bibliometric indices were intro- on the Scopus Database upon all the Active Mem- duced (1). The bibliometric analysis conducted on a bers joining three important Italian scientific soci- group of authors is important because it allows to C eties in Oral Surgery (SIdCO, SIO, and SICOI). The monitor the scientific development in that specific re- scientific production was analysed by consider- search field, to permit an efficient allocation of re- CI ing the number of total publications, number of search funds, to improve the research activity in a de- total citations, h-index, and hc-index. Moreover, termined field, to reward structures that host “high the overall sample was divided into two groups quality” researchers, and to verify the presence of in- (Academics and Not Academics), according to the efficiencies (2). fact the professionals had or not a university po- Characterizing the scientific production of a single au- sition, and then into sub-groups according to the thor or of a group of professionals involved in scientific © different career lengths. Statistical analyses were and clinical research is currently a complex process, performed to compare the scientific productivity which is not based on a standardized methodology, amongst groups. For all the considered parame- and that often uses criteria not entirely satisfactory for ters a lack of homogeneity between groups was both the researchers and institutions (3). reported, and significantly greater mean values Nowadays, the bibliometric evaluation in the medical were recorded for the Academics compared to the field is possible by consulting numerous databases Not Academics Group. Moreover, the h-index val- on the World Wide Web, each offering search facili- Annali di Stomatologia 2014; V (1): 23-29 23  S. Tetè et al. ties on a particular subject. The scientific research lished a long time ago and brilliant young scientists posed many questions about what tools and which who produced a large number of significant publica- database is best to use and what are their features, tions but that nowadays have a small number of im- even if a common idea has yet to be achieved (4). portant papers due to the time constraint, and the age Evaluation of different bibliometric indices is one of of the cites that would allow to identify scientists li the best known methods for analyzing the entire sci- whose contributions are still influential even if they entific production of an author or group of authors in were published a long time ago. na order to detect the historical development, the quanti- In fact, the h-index does not decline with the passing tative amount and the qualitative impact of scientific of time, and likely an author may maintain unchanged studies. This method turns out to be at the same time its h-index value even though he may not have any also the most criticized, because of the many vari- published scientific articles in recent (12, 13). Differ- io ables that may be included in this evaluation (5). ently, the contemporary h-index, by assigning a dif- For example, the evaluation of the absolute number ferent weight to the most recent publications com- of publications or citations often does not allow to pared to older ones, favors the authors with a sub- az evaluate in a proper way the entire research activity stantial recent scientific production respect to not of an author, and often it is not useful to compare two more “scientifically active” researchers (1, 14, 15). authors. Therefore, many other indicators were intro- The aim of this study was to characterize the scientif- duced and are currently used in order to perform ic production of Italian Oral Surgery professionals by rn these evaluations (6). evaluating different bibliometric indices, and to com- One of the most popular and useful index for the pare the performance of h-index and hc-index in mir- evaluation of an author’s scientific production is the roring the scientific production distribution among re- h-index, suggested by Hirsch J., and its variables. searchers with different career lengths. te The h-index is defined as the highest number of pa- pers of a scientist that have been cited h or more Materials and methods times (7). The h-index is simple to calculate and allows in a Experimental parameters In synthetic way to determine both the quantity and the quality of an author’s scientific production, based on All data were found and recorded from January 7 to both the number of publications and the number of ci- January 19, 2013. For each author were considered tations each publication received. The total number of publications and related citations indexed in Sci- publications give back, by scientific insight, the pro- Verse® Scopus database until 31 December 2012; on ni duction of a specific author, while the number of cita- the other hand, were excluded from the calculation at tions made from the scientific community, give the the time of data acquisition, articles published from opportunity to verify the best researchers, works and January 1, 2013 and 2013 citations of articles pub- o institutions, as well as the most common areas of re- lished until December 2012. search or interest, based on the assumption that the izi most interesting scientific contributions are also those that are most frequently cited (6). From its introduc- Selection of the study population tion, the h-index was already applied to several disci- plines, such as Physics, Biology, Biomedicine, The list of Italian professionals involved in Oral Ed Healthcare, etc. (6). Surgery was obtained by selecting the Active Mem- Many researchers pointed out some drawbacks of the bers of the 3 most important Italian scientific societies h-index, related to several different variables which in Oral Surgery, SIdCO (Italian Society of Oral influence the assessment of scientific output of a re- Surgery, SIO (Italian Society of Osseointegration), searcher. Moreover once a paper has reached the and SICOI (Italian Society of Oral Surgery and Im- number of citations which qualifies it for the core set, plantology), downloadable online (http://www.sidcoin- C then further citations are irrelevant (7, 8). forma.it/, http://www.sicoi.it/, http://www.osteointe- An other criticism could be that no other kind of pro- grazione.it/, respectively). All researchers names CI duction such as books, chapter in books or proceed- were included in a Microsoft Excel file created ad ings are being considered, neither publications in hoc. The overall population was firstly divided into journals that are not part of the database used for the two different groups, depending on the member be- author’s search, no matter how many times they are longing to a university setting or not, named Acade- cited (9, 10). mics and Not Academics, respectively. The overall Many authors consider the h-index roughly influenced sample was then further divided into sub-groups ac- © by the career length, as its value is likely to increase cording to the different career length, where the defi- linearly with time. A time related index was proposed nition of career length of a researcher was used to by Sidiropoulos et al., the contemporary h-index (11). identify the period since his first publication to 31 De- These authors investigated how this index could be cember 2012. The sub-groups were obtained by di- adapted to take into account the age of the papers, viding the Academics Group into tertiles according to thus differentiating between senior scientists that their career length, and the Not Academics Group in- have received many of their cites due to papers pub- to quartiles (Tab. 1). 24 Annali di Stomatologia 2014; V (1): 23-29  Scientific production of Italian Oral Surgeons Data collection searcher’s topics of interest, the scientific production of the author and the time period in which it was pro- The database chosen for the collection of data biblio- duced, in order to enclose in the most faithful way as metric was SciVerse ® Scopus (www.scopus.com). possible the scientific production of the same author. The bibliometric data collection was performed by Total number of publications were calculated regard- li three operators with experience in the field of litera- less of the type of all indexed publications on Scopus ture search. In accordance with the site instructions na (at example: proceddings, review, article, letters). to search for author, for each name in the “Author Search”, (http://www.scopus.com/search/form.url?dis- play=authorLookup&clear=t&origin=searchbasic&txGi Data recording and characterization d=4GSgDGaqqvp9pwfgYXjS7W8%3a3) the following of the scientific production io data have entered: surname, first names, and in sub- section “Subject Areas” have been checked items For each researcher, the following parameters were “Life Science” and “Health Science”. It was decided to derived from the authors Scopus data: total number az include only the initials of the name to prevent possi- of publications, total number of citations, and h-index. ble loss of data due to the fact that some publica- The corresponding hc-index was calculated using the tions, not showing the name of the author, cannot be ABILITANVUR v0.9, 2012-11-15© software (Vincen- traced by the system. After viewing the search re- zo Della Mea, University of Udine http://mitel.dimi.uni- rn sults, it was proceeded to click on the “Show Profile ud.it/varia/abilitanvur/), through the achievement of a Matches with One Document”, where present, to in- file ad hoc (.csv) where every single publication from clude in the calculation of the total profiles with a sin- each author were reported including the data of publi- gle publication that were not shown in the first in- cation and the number of citation in the format te stance. (year,citation). All this parameters were inserted into In cases of same name and surname or mismatch of spreadsheet Office Excel 2007 (Microsoft Corpora- affiliations among the results, profiles that were not tion. Redmont, Washington State) containing the au- attributable to the contact examined were excluded at the discretion of operators according to the re- In thors and each numeric value was formatted to three decimal fraction (Tab. 2). Table 1. Groups definition and numerosity. (x = career length is defined as the number of years since each professional’s ni first publication to December 31st 2012.) Groups Definitions Sample size o Total sample Active Members having at least one scientific publication indexed on Scopus n=214 Academics Active Members of the Italian scientific societies analyzed n=58 izi belonging to a university setting 10≤x≤23 Authors career length comprised between 10 and 23 yrs n=19 24≤x≤29 Authors career length comprised between 24 and 29 yrs n=22 30≤x≤43 Authors career length comprised between 30 and 43 yrs n=17 Ed Not Academic Active Members of the Italian scientific societies analyzed n=156 not belonging to a university setting 1≤x≤7 Authors career length comprised between 1 and 7 yrs n=40 8≤x≤16 Authors career length comprised between 8 and 16 yrs n=44 17≤x≤28 Authors career length comprised between 17 and 28 yrs n=38 29≤x≤50 Authors career length comprised between 29 and 50 yrs n=34 C CI Table 2. Indicators formulae used in the study Indicator Description Formula Total Publication Total number of pubblication for each author Doc1 + doc2 +…..docn found on Scopus until December 31st 2012 © Total Citations Total number of citation for each author found on Cit1 + cit2 +…. citn Sopus database until December 31st 2012 h-index Hirsh-index resulted from the author’s account Index h: h of his Np have h citations each of Scopus database and the other (Np - h) papers have ≤ hc hc-index Contemporary H index variable of Hirsh-index S(I,t)=4/(t-t1+1) * C(I,T), t >=t1 calculated from the Abilitanvur online software Annali di Stomatologia 2014; V (1): 23-29 25  S. Tetè et al. Statistical analysis Academics. Data regarding the different sub-groups were reported in Tables 4 and 5. In particular, it could Researchers showing 0 publication were excluded be noted that the h- and hc-index did not have a con- from the statistical analysis. All the analysis were con- tinuous increase along with the progression of an au- ducted on the total population sample and for each thor career, as with the increasing number of total li group considered. Data were processed to calculate publications and citations. As for the median h-index median, interquartile range (IR), coefficient of varia- in the Academics group, it was found to remain stable na tion, and range (R) of the following: the number of to- when considering the researchers with a career tal publications, number of total citations, h-index, and length of more than 24 years, while a peak of hc-in- hc-index. Kurtosis test was performed in order to as- dex could be recorded for the subgroup with a career sess data distribution. Data were then analysed by the length between 24 and 29 years. As for the Not Acad- io Wilcoxon test, in order to check whether there was emics group, a slight gradual increase of the h-index statistically significant difference between the groups, median values was observed, while the highest hc-in- using the add-in for Microsoft Excel, PHStat2 (Pren- dex median value was recorded for the researchers az tice Hall, Inc., Pearson Education). Each statistic test with a long career. was considered true when the probability value (p-val- ue), compared with the desired significance level of our test (p < 0.05), was smaller. Discussion rn Approaching a bibliometric analysis, the crucial initial Results point is the choice of the best database where finding data with minor risks to have bias or mistakes for au- te Characterization and impact thors’ scientific production. Among the more known of scientific production databases for bibliometric evaluation, we considered SciVerse ® Scopus was used for this study. In the In this study, a total of 260 Active Members belonging opinion of the authors, Scopus appeared to be the In to the three main Italian scientific societies involved most complete database with the largest bibliography in Oral Surgery, SIdCO, SIO, and SICOI, were select- of abstracts and citations in the scientific literature. ed. Between all the Active Members considered, Scopus indexes nearly 18,000 journal titles (mostly 83,4% of them (n=214) had at least one scientific peer-reviewed journals) in the scientific, medical, publication indexed on Scopus database, and were technical, humanities and social sciences, published ni considered for the bibliometric analysis. from more than 5,000 publishers, and is regularly up- The overall data, related to the total population, dated (16). Among the most important features, Sco- proved the scientific production distribution of those pus citation can easily derive the h-Index of the au- o professionals to be rather uneven, by considering the thors allowing to make the citation analysis of authors median value of 11 (IR: 3 - 34). Also according the and publications (through the Citation Tracker) and to izi number of citations per researcher, a median of 4 (IR: carry out the analysis of the profile of the authors and 9 - 191.75) was recorded, revealing a high variability affiliations. However, it has the considerable limit that between the overall sample. Similarly, the median h- it calculates the h-index without taking into considera- index was 4 (IR: 1-7), while the median hc-index was tion papers published prior to 1996; in this way au- Ed 3 (IR: 1 - 6). thors with a scientific production more limited in time By considering the overall population, the scientific have an advantage (2). production in the last ten years represented about Other databases were also evaluated before using 68.95% compared to the total scientific publications SciVerse® Scopus for this study. With regard to ISI of the samples (data not shown). All the Active Mem- Web of Science, although easy to use because it in- bers were divided between the Academics and Not corporates the calculation function h-index, it pos- C Academics Groups, as previously described. Among sesses several “weak points”. First, the database in- the Active Members of the scientific society consid- cludes only the journals that are listed in the Thom- CI ered, the Not Academics (n=156) were more numer- son Reuters (17). Consequently, the scientific pro- ous than the Academics (n=58). duction of an author may be severely underestimated In particular, the Academics showed a median value for because of the absence of some publications. In ad- total number of publications significantly higher (36.5; dition for the reasons set out above, in calculating the IR: 22.25 - 66.5) than Not Academics (6; IR: 2 - 20.25). h-index of an author, all citations made in journals not As regards the other parameters considered, i.e. the indexed in ISI Thomson Reuters database are ex- © number of citations, the h-index and hc-index, it was cluded, whereby the result does not respond to a pre- possible to notice a lack of homogeneity between the cise mathematical calculation. Finally, from the cita- Academics and the Not Academics Groups, as de- tions report are excluded all references showing even scribed in Table 3. small errors in the formatting or writing. Furthermore, the distribution of the overall scientific Also the databases which can be accessed for free, production among researchers with different career as Medline and Google Scholar, have some limita- length was evaluated both for the Academics and Not tions. Even if, Medline was found to be the database 26 Annali di Stomatologia 2014; V (1): 23-29  © Table 3. Characterization of the overall scientific production of the Active Members and comparison between the Academics and Not Academics Groups. Total publications Total citations h-index hc-index Group Total Academics Not Total Academics Not Total Academics Not Total Academics Not CI Sample C Academics Sample Academics Sample Academics Sample Academics Median 11 36.5 6 59 196 31 4 7 2 3 6 2 Interquartile 3-34 22.25-66.5 2 – 20.25 9-191,75 70-541.75 4-112.75 1-7 4 – 11.75 1–5 1-6 4 - 10 1–4 range Coefficient 1,78 1,351 0,694 2,66 2,029 1,921 1,11 0,812 1,1 0,96 0,654 1,004 of variation Ed Range 1-584 9 - 584 1 - 106 0-7187 2 - 7187 0 - 1487 0-41 1 - 41 0 - 22 0-23 1 - 23 0 - 15 Annali di Stomatologia 2014; V (1): 23-29 Table 4. Characterization of the Active Members with a University setting divided into tertiles according to their career length. Scientific production of Italian Oral Surgeons Academics izi Total publications Citations h-index hc-Index Group 10 ≤ x ≤ 23 24 ≤ x ≤ 29 30 ≤ x ≤ 43 o 10 ≤ x ≤ 23 24 ≤ x ≤ 29 30 ≤ x ≤ 43 10 ≤ x ≤ 23 24 ≤ x ≤ 29 30 ≤ x ≤ 43 10 ≤ x ≤ 23 24 ≤ x ≤ 29 30 ≤ x ≤ 43 Median 21 39 59 122 199 225 6 8 8 6 7 6 Interquartile 14-41,5 25,5-62,5 36-105 42-303,5 80-703,5 80-590 4-8,5 6-14,5 5-12 4-8,5 4-12 4-10 ni range Coefficient 1,139 0,752 1,31 1,992 1,273 2,184 0,873 0,696 0,867 0,667 0,596 0,68 of variation Range 10-191 10-156 23-584 7-3179 56-2121 31-7187 In 2-31 3-27 2-41 2-18 2-19 2-23 Table 5. Characterization of the Active Members without a University setting divided into quartiles according to their career length. te Not Academics Total publications Citations h-index hc-Index Group 1 ≤ x ≤ 7 8 ≤ x ≤ 16 17 ≤ x ≤ 28 29 ≤ x ≤ 50 1 ≤ x ≤ 7 8 ≤ x ≤ 16 17 ≤ x ≤ 28 29 ≤ x ≤ 50 1 ≤ x ≤ 7 8 ≤ x ≤ 16 17 ≤ x ≤ 28 29 ≤ x ≤ 50 1 ≤ x ≤ 7 8 ≤ x ≤ 16 17 ≤ x ≤ 28 29 ≤ x ≤ 50 rn Median 2 6 7 32 5 54 42 108,5 1 2,5 3 4 1 2,5 2 3 Interquartile 1-3 2,25-17,5 3-19 9,25-55 1-11,5 22-145 7-109 11,75-263,75 1-1,5 1-5,75 2-6 2-7,75 1-1 1-5 1-5 1-6 range az Coefficient 1,72 1,491 1,427 0,791 1,847 1,136 1,947 1,355 0,901 0,792 1,135 0,855 0,852 0,761 1,052 0,835 of variation Range 1,35 1-106 2-105 1-90 0-101 1-415 0-1487 0-1113 0-5 1-11 0-22 0-17 0-4 1-10 0-15 0-11 io 27 na li  S. Tetè et al. which is updated with the greatest regularity and thus a. The h-index is represented by a natural number, able to provide an overview of the most current scien- usually belonging to a small set, which then has, tific production of an author, it dids not have a report as they say in mathematical jargon, a low resolu- or a function that can take into account the citations of tion, which is determined by a flattening of the each publication and therefore cannot allow the calcu- values of h-index of researchers, which penalizes li lation of the h-index and other indices for the assess- those that have a high number of citations com- ment of the appreciation of a given publication (18). pared to those who have less, making the gap be- na As well as other databases, Publish or Perish on tween them less noticeable. Google Scholar is not able to trace the entire scientif- b. While some databases penalize “old” researchers, ic output of an author, even if studies showed that it the h-index penalizes “young” researchers, as the is accurate enough to evaluate properly the scientific more recently published papers are less likely to io productivity of an author. Indeed, this database be cited in other articles just because they did not seemed to have a higher coverage than the other have enough time to accumulate citations. with regard to citations to articles on book chapters c. The h-index is a realistic way to assess the scien- az and conference proceedings, as well as journals in tific value of an author if its production is spread languages other than English, and seemed to have over 10 years. On the contrary, the h-index could good coverage for very dated publications. Publish or be an advantage for those who have published Perish contains functions able to perform an analysis extensively in the past but whose scientific pro- rn of the scientific production of the author, including duction in recent years has been reduced or even even the automatic calculation of various indices, in- stopped because the older articles have had more cluding the h-index, the m-index, the g-index, the e- time to be cited by others despite the interest of index, but it seemed to be less accurate than Scopus the scientific production is expected to be very te in discriminating researchers with similar surnames low considering the scientific progress occurred at and names (1, 12). the same time. In the present study, by considering the overall popu- d. In the computation-index there could also be a lation of Active Members joining the three most im- massive loss of information, since by definition In portant Italian scientific societies in Oral Surgery, a the h-index equals the number (N) of articles that very heterogeneous sample could be recorded, as have received a number of citations greater than shown by the Kurtosis test and the coefficient of vari- or equal to N. Items that have received a substan- ation. tial number of citations did not affect the h-index. Considering the total number of scientific publica- To give an example, if an author has an h-index ni tions, the data showed that more than half of the pub- of 5, it means that 5 of its articles have been cited lications have been produced in the last ten years. each a number of times equal to 5 or more. In this This result confirms the validity of the Italian scientific calculation the total number of citations is not o research in the field of oral surgery and how this re- considered, therefore if one or more of these arti- search has been increasing in recent years. cles has a very high number of citations, the final izi As expected, the bibliometric analysis showed a sig- value of the h-index does not change, and it may nificant difference in scientific production between the be equal to the h-index of an author with a small- Not Academics group and the Academics Group of er number of citations. professionals belonging to the main scientific soci- e. One of the most criticized aspects of h- index is the Ed eties of surgical specialties in dentistry, both in quali- possible influence of self-citations. Self-citations do tative and quantitative terms. In fact, by analyzing the have a great impact on the h-index, especially in distribution of all the analysed parameters, signifi- the case of young scientists with a low h-index. cantly higher values could be detected in the Acade- The hc-index is based on the normalization of cita- mics Group. In the Not Academics group, more than tions based on the elapsed number of years since the 20% of the researchers evaluated did not have any paper has been published. It takes into consideration C scientific publication indexed in Scopus. This finding the age of an article (19). A scientist, for example, can be explained by considering that a professional, has a number of significant articles that produced a CI unlike a university professor, have more difficulties in large h-index, but recently he became rather inactive being engaged in scientific research. or was retired. Therefore, senior scientists, who still The h-index and hc-index values recorded suggest keep their contributions, or brilliant young scientists, that the Italian scientific production in Oral Surgery who are expected to contribute a large number of sig- presents points of excellence, although the median nificant papers in the near future but now have only a values indicate the presence of few researchers with small number of important articles due to the time © scientific production quantitatively valid and continu- elapsed, are not distinguished by the original h-index. ous in time. Both indices could have a high value, because they The h-index can detect the actual influence of an au- showed a low coefficient of variation in an indepen- thor on the scientific community, irrespective of the dent way from the groups considered. fact that he may have published individual articles of The comparison between h-index and hc-index con- great success or many articles with low number of ci- firmed how this variable reduced discrepancies in tations (4). evaluating the scientific production of a group of au- 28 Annali di Stomatologia 2014; V (1): 23-29  Scientific production of Italian Oral Surgeons thor. Moreover, the h-index was found to gradually in- 5. Falagas ME, Pitsouni EI, Malietzis GA, Pappas G. Com- crease along with the number of publications and ci- parison of PubMed, Scopus, Web of Science, and Google tation in each group and to remain stable when con- Scholar: strengths and weaknesses. FASEB J 2008;22:338- 342. sidering the researchers with longer career length. 6. Alonso S, Cabrerizo FJ, Herrera-Viedma E, Herrera F. h-in- Otherwise, hc-index, for its nature, tends to vary less li dex: A Review Focused in its Variants,Computation and Stan- significantly as the professionals career gets longer, dardization for Different Scientic Fields. J Informetrics thus allowing to compare in a more equal way the sci- na 2009;3:273-289. entific production of researchers with a different ca- 7. Hirsch J. An index to quantify an individual’s scientifc research reer length (2). out-put. Proceedings of the National Academy of Sciences 2005;102:16569-16572. 8. Patel VM, Ashrafian H, Ahmed K, Arora S, Jiwan S, Nichol- io Conclusions son JK, et al. How has healthcare research performance been assessed?: a systematic review. J R Soc Med 2011;104:251- 261. It should be reported that the results of a bibliometric 9. Schreiber M. Twenty Hirsch index variants and other indi- az analysis conducted on the basis of these indices, cators giving more or less preference to highly cited papers. though providing synthetic measurements, can not be Phys 2010;522:536-554. immediately translated into absolute qualitative as- 10. Kellner AW, Ponciano LC. H-index in the Brazilian Acade- sessments. In fact, the citation analysis, besides spe- my of Sciences: comments and concerns. An Acad Bras cific considerations regarding reliability, availability rn Cienc 2008;80:771-781. and solidity of the data, was not able to fully assess 11. Sidiropoulos A, Katsaros D, Manolopoulos Y, Generalized the applied research, or career path a researcher in hirsch hindex for disclosing latent facts in citation networks. its entirety, but it can be used for an assessment for Scientometrics 2007;72:253-280. 12. Bakkalbasi N, Bauer K, Glover J, Wang L. Three options for te the comparative evaluation of different authors or re- citation tracking: Google Scholar, Scopus and Web of Sci- search groups. ence. Biomed Digit Libr 2006;29:3-7. 13. Thompson DF, Callen EC, Nahata MC. Publication metrics and record of pharmacy practice chairs. Ann Pharma- References In cother 2009;43:268-275. 14. Ugolini D, Parodi S, Santi L. Analysis of publication quality 1. Khan NR, Thompson CJ, Taylor DR, Gabrick KS, Choudhri in a cancer research institute. Scientometrics 1997;38:263- AF, Boop FR, et al. Part II: Should the h-index be modified? 274. An analysis of the m-quotient, contemporary h-index, au- 15. Chacín-Bonilla L. H-index: a new bibliometric indicator of the thorship value, and impact factor. World Neurosurg academic activity. Invest Clin 2012;53:219-222. ni 2013;doi:pii: S1878-8750(13)00825-5. 10.1016/j.wneu.2013. 16. Bakkalbasi N, Bauer K, Glover J, Wang L. Three options for 07.011. citation tracking: Google Scholar, Scopus and Web of Sci- 2. Ball P. Index aims for fair ranking of scientists. Nature ence. Biomed Digit Libr 2006;3:7. o 2005;436:900. 17. Kelly CD, Jennions MD. The h-index and career assessment 3. Jazayeri SB, Alavi A, Rahimi-Movaghar V. Situation of med- by numbers. Trends Ecol Evol 2006;21:167-170. ical sciences in 50 top countries from 1996 to 2010—based 18. Cabezas-Clavijo A, Delgado-López-Cózar E. Google Schol- izi on quality and quantity of publications. Acta Med Iran ar and the h-index in biomedicine: The popularization of bib- 2012;50:273-278. liometric assessment. Med Intensiva 2013;37:343-354. 4. Han WD, Yu Q, Wang YL. Comparative analysis between 19. Cronin B, Meho L. Using the h-index to Rank influential In- impact factor and h-index for reproduction biology journals. formation Scientists. J Am Soc Inf Sci Tec 2006;57:1275- Ed J Anim Vet Adv 2010;9:1552-1555. 1278. C CI © Annali di Stomatologia 2014; V (1): 23-29 29 

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Original article Onlay bone grafting simultaneous with facial soft tissue augmentation in a hemifacial microsomia patient using de-epithelialized orthograde li submental flap: a technical note na Amin Rahpeyma1 As for providing a good foundation for soft tissue aug- Saeedeh Khajehahmadi2 mentation, osteodistraction, bone grafting, and or- io thognathic surgery have been indicated to precede soft tissue surgery (6-8). 1 Oral and Maxillofacial Diseases Research Center, In this paper, a case of de-epithelialized orthograde Faculty of Dentistry, Mashhad University of Medical submental flap, simultaneous with bone grafting of az Sciences, Iran the mandibular ramus, is presented for the correction 2 Dental Research Center, Faculty of Dentistry, of mandibular angle hypoplasia. This simple and easy Mashhad University of Medical Sciences, Iran procedure is emphasized with some technical notes that help us handle such complicated cases. rn Corresponding author: Patient presentation: a 27-year-old male patient Saeedeh Khajehahmadi presented to the Maxillofacial Surgery Department Dental Research Center, Faculty of Dentistry, with congenital HFM. Right mandibular angle defi- te Mashhad University of Medical Sciences ciency involving hard and soft tissues was noticed. Vakilabad Blvd Although the right auditory meatus was blocked, the 91735 Mashhad, Iran external ear was small and deformed (microtia). The E-mail: khajehahmadis@mums.ac.ir In pinna was positioned inferiorly compared to the left side. A pre-auricular skin tag was present on the right side. As far as the orbits were concerned, their posi- Summary tion and shape were normal. The masseter muscle and parotid gland on the right side were absent and ni Soft tissue augmentation in hemifacial microso- the temporal muscle was hypoplastic. Moreover, the mia patients is a challenging procedure. Free mi- right mandibular ramus was short and abnormally crovascular flap transfer is considered usually as shaped, whereas the condyle and coronoid process- the most accepted choice. On the other hand, es were almost normal. Regarding his dentition, he o bone grafting, simultaneous with facial soft tissue had only eight remaining teeth in his mouth. Further- augmentation using de-epithelialized orthograde more, the right corner of the mouth was slanted pos- izi submental flap, is a suggested procedure. More- teriorly (slight macrosomia) (Fig. 1). The severity of over, preoperative evaluation of facial artery and his deformity according to the OMENS (orbital defor- anterior belly of the digastric muscle are essential mity, mandibular hypoplasia, ear deformity, nerve in- steps for success in such flaps. Furthermore, volvement and soft tissue deficiency) classification Ed bone suture technique helps achieve more pre- was O0M2BE2N0S2 (Fig. 2). dictable results and reduces the need for postop- erative bulky dressing. Surgical procedure: a decision was made to use de- epithelialized orthograde submental flap simultaneous Key Words: hemifacial microsomia, submental with on lay bone grafting of the mandibular ramus. Em- flap, bone graft. ploying color Doppler sonography, the facial artery was C identified and the presence of the right digastric mus- cle (anterior belly) was confirmed. Moreover, the pinch CI Introduction test showed minimal skin laxity and the thyro-mental distance was just two fingers. As a matter of fact, a de- Hemifacial microsomia (HFM) is the second most cision was made to use de-epithelialized flap design prevalent congenital facial anomaly after cleft before flap elevation from the submental area (Fig. 3). lip/palate (1), with an incidence rate of 1:5000 to Regarding the flap’s pedicles, subcutaneous tissues 1:5600 of live births (2). The etiology of this anomaly and the platysma muscle were included in the non- © is defective structures derived from the first and sec- pedicle side, where a son the pedicle side, subcuta- ond branchial arches which are hypoplastic (3). More- neous tissues, platysma muscle, anterior belly of di- over, the severity of this anomaly varies from mild to gastric muscle and mylohyoid muscle were included severe forms (4). Many surgical procedures for soft (Fig. 4). tissue augmentation of the face have been suggested Consequently, a supraperiosteal tunnel was created in such patients, where microvascular flap transfer is at the right mandibular angle region, extending supe- said to be the most accepted procedure (5). riorly to the zygomatic arch. Subsequently, a free cor- 30 Annali di Stomatologia 2014; V (1): 30-33  Onlay bone grafting simultaneous with facial soft tissue augmentation in a hemifacial microsomia patient using de-epithe- lialized orthograde submental flap: a technical note Figure 1. a: Clinical picture of hemifacial microsomia patient. b: Histopathological view of the skin tag. li na a b io az rn te In Figure 2. Post-operative pantomogram view: mandibular ramus in the right is short and abnormally shaped. o ni Figure 4. De-epithelialized orthograde submental flap. izi Ed Figure 3. De-epitelialization procedure begins before flap elevation. C CI tico-cancellous bone graft from the right anterior iliac crest was obtained. Two bone holes were made at the superior border of the bone graft and sutured to the distal part of the soft tissue flap using 2-0 vicryl suture (Fig. 5). © The bone graft was onlay-grafted on the lateral sur- face of the right mandibular ramus and internally fixed with two miniscrews. Then the sutures that passed through the bone holes were tightened. Ac- cordingly, the flap covered the bone graft and filled Figure 5. Two bone holes in the distal part of free bone the subcutaneous tunnel (Fig. 6). Treatment results graft and two sutures that passed through these holes and three month after operation are shown in Figure 7. engaged with soft tissue on the non-pedicle side. Annali di Stomatologia 2014; V (1): 30-33 31  A. Rahpeyma et al. flap was first reported in 1997 (14). This flap was em- ployed for soft tissue augmentation in two HFM pa- tients for the first time by Tan in 2007 (15). As far as this article is concerned, new suggestions were made: a, Simultaneous bone grafting of the ra- li mus; b, Bone suturing of the soft tissue flap, omitting tension induced on sutures after operation and mak- na ing the result more predictable; c, preoperative evalu- ation of facial artery and anterior belly of digastric muscle. Moreover, this is an important step since muscle agenesis and absence of the facial artery can io be seen in 40% of HFM patients (16, 17). These two variables can greatly affect the volume and perfusion of the flap obtained. Furthermore, osteomuscular sub- az mental flap is not indicated in these patients because of limited and insufficient bone below the inferior mandibular canal. Generally, soft tissue augmentation in HFM can be achieved by several methods. These methods include rn vascularized free tissue transfer (free groin and parascapular flaps), pedicled flaps (superficial tempo- Figure 6. On lay bone grafting and simultaneous soft tissue ral fascia), and vascularized bone grafts. Moreover, te augmentation of the defect. non-vascularized dermis fat graft and lipo-filling are the simplest methods mentioned in literature for the treatment of such deformities (18-21). Free flaps are difficult procedures and have considerable complica- In tions. Obviously, lipo-filling is much simpler but with great resorption rates and the need for procedure repetition. ni Conclusion De-epithelialized orthograde submental flap accom- o panied with on lay ramus bone grafting is a useful technique for soft tissue augmentation in carefully se- lected HFM patients. izi References Ed 1. Monahan R, Seder K, Patel P, Alder M, Grud S, O’Gara M. Hemifacialmicrosomia: Etiology, diagnosis and treatment. Am Dent Assoc. 2001;132:1402-8. 2. Naikmasur VG, Mantur RS, Guttal KS. Hemifacialmicrosomia. Figure 7. Result of the procedure three months postopera- A report of two cases. N Y State Dent J. 2009;75:38-43. tively. 3. Kane AA, Lo LJ, Christensen GE, Vannier MW, Marsh JL. C Relationship between bone and muscles of mastication in hemifacialmicrosomia. Plast Reconstr Surg 1997;99:990-7. 4. Huisinga-Fischer CE, Zonneveld FW, Vaandrager JM, Discussion CI Prahl-Andersen B. Relationship in hypoplasia between the masticatory muscles and the craniofacial skeleton in hemi- Submental flap, introduced by Martin in 1993, is con- facialmicrosomia, as determined by 3-D CT imaging. J Cran- sidered a useful technique in facial reconstruction (9). iofac Surg. 2001;12:31-40. Based on the composition of the flap, it can be used 5. La Rossa D, Whitaker L, Dabb R, Mellissinos E. The use of as a myocutaneous, faciocutaneous and osteomus- microvascular free flaps for soft tissue augmentation of the © cular flap (10). Moreover, based on its blood supply it face in children with hemifacialmicrosomia. Cleft Palate J. can be categorized into orthograde or reverse flow 1980; 17:138-43. 6. Dhillon M, Mohan RP, Suma GN, Raju SM, Tomar D. Hemi- (11). The advantages of this flap are large skin pad- facialmicrosomia: a clinicoradiological report of three cases. dle, axial blood supply and appropriate tissue bulk J Oral Sci. 2010;52:319-24. (12, 13). On the other hand, the hairy nature of this 7. Myung Y, Lee YH, Chang H. Surgical correction of progressive flap makes it less appropriate for reconstruction of hemifacial atrophy with on lay bone graft combined with soft the oral cavity in males. De-epithelialized submental tissue augmentation. J Craniofac Surg. 2012;23:1841-4. 32 Annali di Stomatologia 2014; V (1): 30-33  Onlay bone grafting simultaneous with facial soft tissue augmentation in a hemifacial microsomia patient using de-epithe- lialized orthograde submental flap: a technical note 8. Kim S, Seo YJ, Choi TH, Baek SH. New approach for the 15. Tan O, Atik B, Parmaksizoglu D. Soft-tissue augmentation surgico-orthodontic treatment of hemifacialmicrosomia. J of the middle and lower face using the deepithelialized sub- Craniofac Surg 2012;23:957-63. mental flap. Plast Reconstr Surg. 2007;119:873-9. 9. Martin D, Pascal JF, Baudet J, Mondie JM, Farhat JB, Athoum 16. MacQuillan A, Biarda FU, Grobbelaar A. The incidence of A, et al. The submental island flap: a new donor site. Anato- anterior belly of digastric agenesis in patients with hemifa- li my and clinical applications as a free or pedicled flap. Plast cialmicrosomia. Plast Reconstr Surg 2010;126:1285-90. Reconstr Surg. 1993;92:867-73. 17. Huntsman WT, Lineaweaver W, Ousterhout DK, Buncke HJ, na 10. Amin AA, Sakkary MA, Khalil AA, Rifaat MA, Zayed SB. The Alpert BS. Recipient vessels for microvascular transplants submental flap for oral cavity reconstruction: extended in- in patients with hemifacialmicrosomia. Craniofac Surg. dications and technical refinements. Head Neck Oncol; 1992;3:187-9. 2011;3:51. 18. Cobb AR, Koudstaal MJ, Bulstrode NW, Lloyd TW, Dunaway 11. Chen WL, Zhou M, Ye JT, Yang ZH, Zhang DM. Maxillary DJ. Free groin flap in hemifacial volume reconstruction.Br J io functional reconstruction using a reverse facial artery-sub- Oral Maxillofac Surg. 2013;51:301-6. mental artery mandibular osteomuscular flap with dental im- 19. Zhang Y, Jin R, Shi Y, Sun B, Zhang Y, Qian Y. Pedicled su- plants. J Oral Maxillofac Surg. 2011;69:2909-14. perficial temporal fascia sandwich flap for reconstruction of 12. Rahpeyma A, Khajehahmadi S, Nakhaei M. Submental Artery severe facial depression. J Craniofac Surg. 2009;20:505-8. az Island Flap in Reconstruction of Hard Palate after wide Sur- 20. Choung PH, Nam IW, Kim KS. Vascularized cranial bone gical Resection of Verruccous Carcinoma, Two Case Reports. grafts for mandibular and maxillary reconstruction. The pari- Iran J Otorhinolaryngol.2013;25:177-81. etal osteofascial flap. J Craniomaxillofac Surg. 1991;19:235- 13. Rahpeyma A, Khajehahmadi S. Oral reconstruction with sub- 42. rn mental flap. Ann Maxillofac Surg. 2013;3:144-7. 21. Tanna N, Broer PN, Roostaeian J, Bradley JP, Levine JP, 14. Yilmaz M, Menderes A, Barutçu A. Submental artery island Saadeh PB. Soft tissue correction of craniofacial microso- flap for reconstruction of the lower and mid face. Ann Plast mia and progressive hemifacialatrophy. J Craniofac Surg. Surg. 1997;39:30-5. 2012;23:2024-7. te In o ni izi Ed C CI © Annali di Stomatologia 2014; V (1): 30-33 33 

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Case report Resolution of endodontic issues linked to complex anatomy li na Guido Migliau, PhD, DDS techniques that favour the resolution of even complex Erlind Pepla, MD cases are now becoming routine in the specialist prac- io Laith Kostantinos Besharat, MD tice (1). As regards the tools used for root canal thera- Livio Gallottini, PhD, DDS py, the use of manual files in conjunction with me- chanical drills (e.g., Gates-Glidden and Largo drills) to remove interference in the pulp chamber and the az Department of Oral and Maxillo-facial Sciences, coronal portion of the canal has all but been super- Sapienza University of Rome, Italy seded. Nowadays, mechanical files mounted on hand- pieces equipped with speed reducers and purpose- designed engines are prevalent in endodontic applica- rn Corresponding author: tions. These devices also benefit from the favourable Erlind Pepla properties of nickel-titanium alloy (used to make them) Department of Oral and Maxillo-facial Sciences, and increased taper. Moreover, the latest generation Sapienza University of Rome of nickel-titanium (NiTi) instruments are very flexible te Viale Regina Elena 287/a and are better able to adapt to even the most accentu- 00198 Rome, Italy ated curvatures. Thanks to their more enhanced cut- E-mail: kledion2004@libero.it ting tips, they also consent more flared, more tapered In and more predictable preparations to be made in con- siderably shorter time-frames than those required to Summary perform similar procedures using manual stainless steel files. First and foremost among the technological Anatomical abnormalities of the root canal sys- aids at the endodontist’s disposal nowadays is without ni tem are frequently seen in specialist endodontic doubt the electronic apex locator, which has become practice, and represent a challenge to be faced much more reliable and performs far better than in the with skill and thoroughness, beginning with an past. Indeed, it allows such precise location of the accurate diagnostic phase and devising the most apex and determination of the working length (2) that o appropriate treatment plan. Fortunately, much many specialist endodontists now refrain from per- progress has been made in endodontic research forming x-rays during surgery altogether. Neverthe- izi thanks to technological advances and the evolu- less, in cases of anomalous endodontic anatomy, tion of higher performance instruments, which there is a high risk of morphological features compli- now consent even very complex cases to be re- cating the correct measurement of the working length, solved with relative ease. Below are described the so particular care needs to be taken in these cases Ed salient features of recent progress in endodon- (3). Thankfully, however, with the aid of magnification tics, along with a description of several clinical devices such as Galilean or prism loupes and espe- cases in which the operator has encountered nu- cially the operating microscope, endodontists are able merous difficulties due to peculiar tooth morphol- to observe the operating field up close, and are there- ogy, overcome successfully thanks to the appli- fore better equipped to deal with such troublesome cation of modern tools and consolidated clinical anatomy (4). Thus, the specialist endodontist now has C experience in the field. a range of simplified and more rapid techniques at his disposal. That being said, it is not the instruments that CI Key words: complex endodontic therapy, en- must perform the therapy, so the specialist endodon- dodontic anatomy, endodontic diagnosis, nickel- tist should also be equipped with a complementary titanium instrumentation, tooth morphology. degree of experience, skill and know-how, particularly in the use of this array of instruments (manual and mechanical) and devices (radiological and diagnostic). Introduction With this combination, even the most complex clinical © situations can be resolved successfully (5). Since the 1990s, great strides have been made in en- The endodontist is likely to have a better idea of the dodontics, consenting the achievement of ever more root canal system anatomy in question before begin- predictable and long-lasting outcomes. The introduc- ning treatment, although he must be ready to deal tion of new instruments and technological aids have with surprises, as it turns out to be far more compli- led to the development of a completely different ap- cated than initially foreseen in a high percentage of proach to root canal treatment, and have advanced cases (Fig. 1). The operating microscope is invalu- 34 Annali di Stomatologia 2014; V (1): 34-40  Resolution of endodontic issues linked to complex anatomy C-shaped configuration of the lower second molars in a Chinese population. The anatomy of the secondary components (sec- ondary canals, apical deltas, anastomoses, isthmis, curves) of the root canal presents extreme variability, li even though its primary components (main canal, pulp chamber, foramina and apices) generally conform to na standardized models based on the probability of a cer- tain configuration. The teeth, which generally present the greatest anatomical complexity, are without doubt the upper molars, especially the first, in which four io canals distributed among three roots are very common indeed (62%). The mesiobuccal root of these teeth usually presents two canals in one of various configu- Figure 1. Post-operative x-ray with correct endodontic filling. az rations: 37% being Weine type II (2 coronal orifices and 1 apical foramen) and 25% Weine type III (2 dis- tinct canals). Other teeth that are rather complex to able in such cases, and as well as applications in en- treat due to their anatomy are the lower incisors, as rn dodontic surgery that have by now become routine, is these present 2 buccal-orally distributed canals in 42% ever more commonly used in orthograde endodontics of cases. The lower premolars are also prone to anom- in specialist practice, especially in retreatment and aly, and in 26% of cases feature a configuration with difficult cases (8). Indeed, magnification of the oper- two canals (Weine type II or III) (14). On the whole, the te ating field is fundamental for observing complex fea- anatomy of the other teeth is far less variable, although tures of the endodontic anatomy and identifying any some exceptions are seen (see reported cases). The misrecognized, accessory or lateral canal, foramina curvature of the root can also be problematic, in that and particular anatomical conformations (e.g., c- abnormalities are common and not easily detected by shapes, isthmuses, anastomoses). In retreatment, In radiographical means. The root curvatures most worth this device is extremely useful in aiding the removal of note are the double distal-palatine curve of the up- of posts or fragments of files broken off inside the per lateral incisors and the curved buccal side of the canal (9). Furthermore, it may be the only means able palatine root of the upper molars; these can easily de- to confirm a diagnosis of probable fracture, consent- ceive the endodontist in that their apices are difficult to ni ing an otherwise invisible crack to be discerned. Ra- see properly on x-ray, and it is therefore easy to make diological examination is also very important, and is an inappropriate choice of tools. This in turn can lead generally performed using digital support nowadays: to perforation or false paths, which are difficult to re- o both orthopantomography and periapical-endoral x- dress after the fact. One anomalous morphological ray data can be processed using purpose-designed characteristic that can be observed with some frequen- izi software and image optimization that can reveal cy in the lower molars (although cases have been re- pathologies and varying degrees of anatomical com- ported in the upper molars and lower first premolars) is plexity that are undetectable by clinical examination a C-shaped pulp chamber. C-shaped mandibular mo- alone. Furthermore, the recent introduction of cone- lars are so called due to the cross-sectional shape of Ed beam computed tomography (CBCT) now consents their root and canals; instead of having several differ- observation in three-dimensional space with a very ent orifices, the pulp chamber of this type of tooth dis- low biological cost (they emit a considerably reduced plays a single cestoid orifice with an arc of 180° (or quantity of radiation with respect to conventional CT). more), which begins at the angle with the mesiolingual CBCT also has a sub-millimetricresolution and is line and extends buccally or lingually in a circular fash- therefore useful for examining fine detail with extreme ion, ending in the vicinity of the distal wall. Below the C precision (10). Its major application is in implant orifice of the C-shaped molar, a wide variety of surgery, but it is also very useful in orthograde, and anatomical variations in the structure of the canal sys- CI especially retrograde, endodontics, helping to identify tem are possible. These variants can be classified into and locate apex lesions, anatomical variants and re- two groups: (a) those featuring a single cestoid C- lationships with adjacent anatomical structures (max- shaped canal extending from the orifice to the apex; illary sinus, inferior alveolar nerve). Moreover, it con- and (b) those featuring three distinct canals below the sents visualization of external and internal resorption, C-shaped orifice. The latter type is far more common as well as root canal perforations and fractures, ac- than the former, which represent the exception rather © cessory canals and lateral apices (11). In fact, a re- than the rule (15).The prevalence of C-shaped molars cent study by Patel and Horner (12) highlighted the is strongly influenced by racial factors. In fact, this fact that CBCT can be used to diagnose almost 100% anatomical variant is far more common in Asian popu- of apex lesions, as compared to 28% using conven- lations with respect to Caucasians (16). Developmen- tional endoral x-ray. Zhang et al. (13) also used tal dental defects can also cause procedural difficulties CBCT to highlight the frequency of triradicular lower in endodontic treatment. These anomalies can be clas- first molars (43% even featured four canals) and the sified as follows: Annali di Stomatologia 2014; V (1): 34-40 35  G. Migliau et al. - Fusion: fusion of two adjoining teeth due to close there is a risk of underestimating the problem. This contact between tooth buds; this can involve the can lead to failure, not only of the root canal therapy entire teeth or only the crowns; itself, but also of the subsequent direct or indirect - Gemination (twinning): incomplete division of the restoration. Indeed, this was the case in a patient tooth bud resulting in an otherwise normal tooth who presented caries pathology with pulpal inflamma- li joined to its supernumerary offshoot; tion at the 3.3, which needed to be used as anchor- - Concrescence: fusion of the cementum of two age for a mobile prosthesis and was accordingly re- na adjoining teeth, generally due to trauma; stored by means of a glass-fibre intracanal post and a - Dens in dente (dens invaginatus): the develop- ceramic-fused-to-gold crown. Upon completion of ment of part of a tooth inside another; the defect treatment, which lasted roughly six months, the pa- is termed coronal, radicular or corono-radicular, tient continued to complain of discomfort at the ca- io depending on the portion of the tooth it occupies. nine while chewing. This was initially attributed to a Weinstein et al. reported a clinical case of geminated problem of occlusion, but digital magnification of the upper second molar that, despite the anatomy-related periapical-endoral x-ray showed that the tooth fea- az difficulty, they managed to treat with the aid of an op- tured a further oral root that had previously escaped erating microscope and ultrasonic tips. Likewise Zey- notice and had therefore not been treated (Fig. 2). labi et al. (17) successfully treated a lower third molar Once the problem had been identified, the case was fused with a supernumerary disto-molar. Aguiar et al., simple to resolve, and the symptoms disappeared up- rn on the other hand, described complex endodontic on treatment of the painful root (Fig. 3). A similar clin- treatment of a lower premolar with two roots and ical case was that of an upper premolar that present- three canals. Other authors (18) have presented a ed three roots, two buccal and one palatal, a tooth case of dens in dente of an upper canine, treated sat- that had previously been treated and restored with a te isfactorily despite the complexity of the internal mor- single crown (Fig. 4). Also in this case, close exami- phology of the canal system. nation of the x-rays brought to light the unexpected anatomical variant and retreatment resolved the pain (Fig. 5). Both cases, despite their diagnostic com- Clinical series In plexity, were not particularly difficult to treat. However certain cases of shape anomaly are more trouble- In complex clinical situations it is necessary to per- some, especially during the operative phase (17). form careful evaluation of the case beforehand and This was the case in a patient who reported algic establish an appropriate treatment plan, otherwise symptoms in the left lower sector. Scrutiny of the or- o ni izi Ed C CI © Figure 2. X-ray of a left mandibular canine with two roots and two canals (one untreated). Figure 3. Post-operative x-ray. 36 Annali di Stomatologia 2014; V (1): 34-40  Resolution of endodontic issues linked to complex anatomy li na io az rn te In ni Figure 4. X-ray of a right upper premolar that presented three roots, two buccal and one palatal. o thopantomograph (OPT) (Fig. 6) revealed a deep ob- izi turation troubled by caries relapse on the mesial sur- face of the left lower second molar, which was fused Figure 5. Post-operative x-ray. to the adjacent third molar (Fig. 7). Root canal treat- ment was hampered by the peculiar anatomy, espe- Ed cially in the pulp chamber shaping phase and the identification of the canal orifices. In particular, four canals were present: larger mesial and distal (Fig. 8) and two smaller intermediate (Fig. 9); the mesial canal was housed in the mesial root, while the other three were all found in the distal (Fig. 10). Accentuat- C ed curves can also cause some difficulty during root canal therapy (Fig. 11). In the past these would have CI been treated using pre-curved stainless steel files, an operation that took considerable time, and one that would have led to canal straightening. Today, howev- Figure 6. Orthopantomograph that revealed a deep obtura- er, thanks to modern NiTi files and the use of a mixed tion with secondary caries on the mesial surface of the left technique (stainless steel – NiTi) more flared prepa- lower second molar. rations can be accomplished and the original curva- © ture maintained without undue time being necessary. This was the case in a patient presenting to our at- tention with considerable pain in the fourth quadrant. 12). The patient did not wish to undergo osseointe- Clinical examination and OPT revealed a, by then, in- grated implant surgery and so the only option, without congruent bridge spanning four tooth positions (from resorting to a mobile prosthesis, was treatment and 4.5 to 4.8), whose posterior supporting tooth had be- restoration of the 4.8. The anatomy of the third molar come affected by secondary caries and pulpitis (Fig. is known for its complexity and abnormality, and this Annali di Stomatologia 2014; V (1): 34-40 37  G. Migliau et al. li na io az Figure10. Post-operative x-ray. Figure 7. Left lower second molar fused to the adjacent third molar. rn te In ni Figure11. Post-operative x-ray with correct endodontic filling. o Figure 8. Intra-operative x-rays for working length. izi Ed C Figure 12. Orthopantomograph that revealed incongruent bridge spanning four tooth positions (from 4.5 to 4.8), CI whose posterior supporting tooth had become affected by secondary caries. Figure 9. Intra-operative x-rays for working length. ing manual stainless steel and rotary NiTi files; the © tooth was then restored via the insertion of two glass- fibre posts and prepared as a posterior support for case was no exception; it was mesiodistally elongat- the fixed prosthesis of 5 teeth, thereby rehabilitating ed, buccolingually narrow and featured two roots with the patient’s fourth quadrant (Fig. 13). Another com- two canals of accentuated distal curvature. In spite of plex case to treat is the so-called “MB2,” or fourth the considerable challenges presented by the case, it canal (two in the mesiobuccal root), of the upper mo- was resolved successfully by a mixed technique us- lars. It is mandatory to look out for this defect as it is 38 Annali di Stomatologia 2014; V (1): 34-40  Resolution of endodontic issues linked to complex anatomy present in a high percentage of patients. In such cas- es, (Fig. 14) the canal is often very narrow and curved, and needs to sought in the mesiobuccal root (Fig. 15) displaced palatally and slightly mesial to the main mesiobuccal canal (Fig. 16). li na io az Figure 15. Post-operative x-rays with correct endodontic filling and evidence of the “MB2” canal. rn te Figure 13. Post-operative x-ray with correct endodontic fill- ing and build up with two glass-fibre posts. In o ni Figure 16. Post-operative x-rays with correct endodontic izi filling and evidence of the “MB2” canal. Ed preparation, disinfection and sealing of the root canal system (7). Nowadays, however, when plan- ning treatment, the endodontist can rely on far greater safety and precision in diagnostic tools with Figure 14. Pre-operative x-ray of left first maxillary molar. respect to the past. C Conclusions CI Discussion Endodontics is an extremely important branch of den- Diagnosis is one of the fundamental steps in medi- cine and dentistry in general, and for endodontics in tistry whose aim is the recovery of severely compro- particular. Indeed, an appropriate treatment plan mised teeth. This can be accomplished with varying cannot be defined without accurate diagnosis and a degrees of difficulty, depending on the complexity of © thorough preliminary study of the clinical case; only the clinical case in question. As we have seen, partic- in this way will it be possible to deal with unexpected ularly complex cases need to be managed with par- occurrences in the best possible fashion (6). The en- ticular care in both the diagnostic and intervention dodontic anatomy is particularly challenging and for phases, both of which can be greatly aided by the ad- the clinician, so an optimal diagnostic approach, vanced technologies, instruments and innovative ma- suitable access techniques and highly professional terials at our disposal. These not only serve to simpli- skill are indispensable for the successful location, fy techniques, but also confer results with greater out- Annali di Stomatologia 2014; V (1): 34-40 39  G. Migliau et al. come predictability and long-term success rates with 7. Pablo OV, Estevez R, Hellborn C, Cohenca N. Root anato- respect to the past, even in extremely difficult cases my and canal configuration of the permanent mandibular first (19). It is therefore vital that an endodontist is highly molar: Clinical implications and recommendations. Quin- tessence Int. 2012; 43(1):15-27. skilled, a specialist able to deal with even the most 8. Weinstein T, Rosano G, Del Fabbro M, Taschieri S. En- complex clinical situations, in both orthograde treat- li dodontic treatment of geminated maxillary second molar us- ment and retrograde surgery. Furthermore, the mod- ing an endoscope as magnification device. Int. Endod J. 2010; ern-day endodontist needs to be proficient in post-en- na 43(5):4543-50. dodontic restoration, managing adhesive reconstruc- 9. Aguiar C, Mendes D, Camara A., Figueiredo J. Endodontic tion techniques and endocanal posts, in order to ob- treatment of mandibular second premolar with three root tain a tight seal at both the crown and the apex, both canals. J Contemp Dent Pract. 2010; 11(2):78-84. necessary to ensure the success of treatment. In line 10. Patel S, Mannocci F, Shemesh H, Wu MK, Wesselink P, Lam- io brechts P. Radiographs and CBCT – time for a reassess- with international trends, the philosophy of our school ment? IntEndod J. 2011; 44(10):887-8. is that the endodontist should be able to complete 11. Zheng Q, Zhang L, Zhou X, Wang Q, Wang Y, Tang L, Song and resolve the case of a severely compromised F, Huang D. C-shaped root canal system in mandibular sec- az tooth from beginning to end, including, as a last re- ond molars in Chinese population evacuate by cone-beam sort (when it cannot be saved) its extraction and re- computed tomography. Int Endod J. 2011; 44(9):857-62. placement with an osseointegrated implant (20). 12. Patel S, Horner K. The use of cone beam computed to- mography in endodontics. Int Endod J. 2009; 42(9):755-6. rn 13. Zhang R, Wang H, Tian YY, Yu X, Hu T, Dummer PM. Use of cone beam computed tomography to evaluate root and References canal morphology of mandibular molars in Chinese individ- uals. Int Endod J. 2011; 44 (11):990-9. 1. Mortman RE. Technologic advances in endodontics. Dent 14. Laurichesse JM, Maestroni F, Breillat J. Endodonzia Clini- te Clin North Am. 2011; 55(3): 461-80. ca. 2ndedn. Masson Editrice 1990. 2. Piasecki L, Carneiro E, Fariniuk LF, Westphalen VP, Florentin 15. Cooke HG, Cox FL. C-shaped canal configurations in MA, da Silva UX. Accuracy of Root ZX II in locating foramen mandibular molars. J Am Dent Assoc. 1979;99:836-9. in teeth with apical periodontitis: an in vivo study. J Endod. 16. Seo MS, Park DS. C-shaped root canals of mandibular sec- 2011;37(9):1213-6. 3. Tang L, Sun TQ, Gao XJ, Zhou XD, Huang DM. Tooth anato- In ond molars in a Korean population: clinical observation and in vitro analysis. Int Endod J. 2004; 37:139-144. my risk factors influencing root canal working length ac- 17. Zeylabi A, Shirani F, Heidari F, Farhad AR. Endodontic man- cessibility. Int J Oral Sci. 2011; 3(3): 135-40. agement of a fused mandibular third molar and disto molar: 4. Del Fabbro M, Taschieri S. Endodontic therapy using mag- a case report. Aust Endod J. 2010; 36(1):29-31. nification devices: a systematic review. J Dent. 2010; 38(4): 18. Kusgoz A, Yilidirim T, Kayipmaz S, Saricaoglu S. Nonsur- ni 269-75. gical endodontic treatment of type III dens invaginatus in max- 5. Mounce RE. Discussion of a complex endodontic case: when illary canine: an 18-month follow-up. Oral Surg Oral Med Oral to refer. Dent Today 2009; 28(9):108, 110-1. Pathol Oral Radiol Endod. 2009; 107(3):103-6. o 6. Newton CW, Hoen MM, Goodis HE, Johnson BR, Mc- 19. Barnes JJ. Patel S. Contemporary endodontics – part 1. Br Clanahan SB. Identify and determine the metrics, hierarchy Dent J. 2011; 25; 211(10): 463-8. and predictive value of all the parameters and/or methods 20. Bateman G, Barclay CW, Sauders WP. Dental dilemmas: En- izi used during endodontic diagnosis. J Endod. 2009; dodontics or dental implants? Dent Update. 2010; 37(9):579- 35(12):1635-44. 82, 585-6, 589-90. Ed C CI © 40 Annali di Stomatologia 2014; V (1): 34-40 

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2-Pippi 4b_Riv Annali 1 2014 19/03/14 09:13 Pagina 7 Original article Evaluation capability of surgical difficulty in the extraction of impacted mandibular third molars: a retrospective study from a post-graduate institution li na Roberto Pippi, MD, DDS erative evaluation although their judgement differed from that given by the tutor and did not correlate io with the operative time. Lower third molar extrac- Department of Oral and Maxillo-facial Sciences, tion difficulty seems to be influenced by some “Sapienza” University of Rome, Italy topographic factors such as tooth position, im- paction depth and relationship between inferior az alveolar nerve and impacted tooth. Corresponding Author: Roberto Pippi Key words: dental anatomy, student, statistics. Department of Oral and Maxillo-facial Sciences rn “Sapienza” University of Rome, Italy Via Caserta, 6 Introduction 00161 Rome, Italy Phone: +390649976651 Establishment of the degree of surgical difficulty in te Fax: +390644230811 mandibular third molar extraction is extremely important E-mail: roberto.pippi@uniroma1.it. for correct management in order to reduce the risk of accidents and complications. A careful analysis of clini- Summary In cal and radiographic features of each case is therefore mandatory to program surgery. Several studies (1-7) have been carried out during the last decades in order Introduction. The first aim of the present study to find a method as objective as possible to preopera- was to analyze if any correlation exists between tively establish the degree of surgical difficulty in ni the post-graduate’s and the tutor’s difficulty eval- mandibular third molar surgery. uation of the same tooth to be extracted. Second- In 1988 Pederson (1) proposed a difficulty index based ly, the study aimed to verify whether, and possibly on anatomical and radiographic features of the tooth to which, anatomical/topographic characteristics of be extracted. Yuasa et al. (5) re-examined anatomical o the impacted lower third molar influence the post- and radiographic parameters while Renton et al. (4) al- graduate’s difficulty evaluation. Thirdly, patient’s so took into consideration patient-related factors such izi age and gender were studied for any influence ei- as age, race, gender, weight and height. In 2005 a ther on the post-graduate’s and tutor’s extraction Spanish study by Diniz-Freitas et al. (8) showed that difficulty evaluation or on surgical time. Lastly, the Pederson index was not enough to define the real the possible effect of the post-graduate’s difficulty extraction difficulty since it did not consider clinical fac- Ed evaluation on the incidence of surgical accidents tors, such as mouth opening, age and cheek flexibility, was also studied. to be relevant. Materials and methods. Eighty-four impacted In a recent study Gbotolorun et al. (9) proposed a new mandibular third molars have been retrospectively index in which they considered both clinical (patient’s reviewed. For each molar, pre- and operative infor- age and body mass index) and radiologic variables mation have been collected. The Pearson’s Product (depth of inclusion and root curvature) (10). Susarla C Moment Correlation, the general linear model with and Dodson (7, 11) outlined the surgeon’s difficulty backward stepwise procedure, the variance analy- evaluation related to his/her own clinical and practical CI sis and the logistic regression were used for infer- experience. Other studies have been carried out on this ential statistics. topic (12-14) and a specific test has been elaborated, Main results. Correlation between the post-gradu- that is “the Objective Structured Assessment of Techni- ate’s and tutor’s difficulty evaluation of each lower cal Skill for surgical residents” (OSATS), with the first third molar to be extracted as well as between diffi- aim being to evaluate the surgeon’s knowledge about culty evaluation and operative time were statistical- surgical phases and how they plan and carry out the © ly significant. Tooth position, impaction depth and surgery and with the final aim of critically analyzing and relationship with the inferior alveolar nerve influ- eventually modifying teaching criteria. enced operative times. Pre-surgical difficult degree The first aim of the present study was to verify if any had a positive significant effect on accident occur- correlation exists between the post-graduate’s difficulty rence. evaluation of each lower third molar to be extracted and, Conclusions. The pre-operative post-graduates' dif- respectively: 1) the post-operative difficulty evaluation ficulty evaluation did not differ from their post-op- by the same post-graduate; 2) the tutor’s difficulty evalu- Annali di Stomatologia 2014; V (1): 7-14 7 2-Pippi 4b_Riv Annali 1 2014 19/03/14 09:13 Pagina 8 R. Pippi ation of the same tooth to be extracted; 3) the operative distance between the anterior margin of the mandibular time for the same surgery. Secondly, the study aimed to rhamus and the distal surface of the second molar verify if and possibly which anatomical/topographic crown is at least equal to the mesio-distal diameter of characteristics of the impacted lower third molar influ- the third molar crown; in the second class the same dis- ence the post-graduate difficulty evaluation. Thirdly pa- tance is smaller than the mesio-distal diameter of the li tient’s age and gender were studied for any influence ei- third molar crown; in the third class that distance is very ther on the post-graduate’s and tutor’s difficulty evalua- close, or less than, zero. na tion of extraction or on surgical time. Lastly, the possible Relationships between inferior alveolar nerve (i.a.n.) effect of the post-graduate’s difficulty evaluation on the and third molar roots were classified as absence, conti- incidence of surgical accidents was also studied. guity on the horizontal plane and imbrications, with the help of computerized tomographic studies performed io when the nerve was superimposed by the tooth on the Materials and methods panoramic radiograph. For each surgery the operative time was measured Eighty-four impacted mandibular third molars extracted az chronometrically by an outside assistant, from soft from March 1, 2011 until June 30, 2011 have been ret- tissue incision until the end of the procedure without rospectively reviewed for this study. Surgical extrac- the suture. tions were performed by ten graduates in dentistry at- A score from 1 to 3 was attributed by the tutor to each tending their second (5) and third (5) year of training rn of the following variables: position, depth, Pell and Gre- during their 3-year post-graduate course in Oral gory’s classification, root morphology, relationship with Surgery at the “Sapienza” University of Rome. the inferior alveolar nerve and degree of mouth open- Third molar assignment to the post-graduates had been ing. A total 6-18 score was therefore obtained for each te previously and randomly decided by a tutor since they of the 84 selected teeth. usually work in shifts. For each molar, a clinical chart At the moment of their difficulty evaluation, post-gradu- was drawn up by the assigned post-graduate. Inclusion ates did not know, what difficulty method of assess- criteria for the study were the complete record of epi- ment the tutor would have used. The present study was In demiological, clinical and radiographic information in- cluding pre-operative data, dental and operative vari- approved by the local Ethical Committee with the proto- col number 724/12. Ethical Principles for medical re- ables, pre- and post-operative post-graduate’s evalua- search stated by Helsinki Declaration have been fol- tion of the degree of surgical difficulty in a 1-10 score lowed. and data concerning the performed surgical technique, ni follow-up examinations as well as any accidents or complications. Pre-operative data included dental variables, local clini- Statistical design cal signs and symptoms as well as the extent of mouth o opening, meaning the greatest distance between the Pearson’s correlation (r) was initially used to assess the edge of upper and lower incisors. relationship between the post-graduate’s difficulty eval- izi Dental variables included axis inclination, impaction uation (both pre- and post-operative) of each lower depth, Pell and Gregory’s classification, root morpholo- third molar to be extracted, the tutor’s difficulty evalua- gy and relationship with the inferior alveolar nerve. tion of the same tooth, and the operative time for that Operative variables included flap design, ostectomy surgery. Ed width, tooth sectioning, operative time excluding suture To assess if, and possibly which, anatomical/topo- time, intra-operative accidents, suture time, residual graphic characteristics of the impacted lower third mo- cavity revision, wound irrigation, drainage, suture mate- lar influenced the post-graduate’s difficulty evaluation, a rials and modalities, cold dressing and post-operative general linear model (GLM) was then developed using medical treatment (2, 3, 10, 15). “post-graduate’s pre-operative evaluation” as depen- Inclination of tooth axis was evaluated on the orthopan- dent variable and the following factors as predictor vari- C tomography and was classified as vertical, horizontal, ables: tooth position (vertical, horizontal, mesioangular mesial or distal. and distoangular); Pell and Gregory class for the CI As for the impaction depth, Winter’s classification (16) amount of space distally to the second molar (I, II and was modified by dividing Group C into two subgroups, III); impaction depth (AB, C1 and C2); root morphology C1 and C2; in the first one, the most coronal portion of (a, b and c); relationship with the i.a.n. (1 and 2); post- the third molar was located at the level of the coronal graduate training year (second and third); degree of half of the second molar root and in the second one, it mouth opening (in mm). All predictor variables, exclud- was located in the apical half of the second molar ing the degree of mouth opening, were entered in the © root. Groups A and B remained unmodified: in Group model as qualitative variables. A backward stepwise A the most coronal part of the third molar was located procedure was then applied to build the model by in- above the occlusal plane of the second molar while in cluding only those predictor variables that had a signifi- Group B it was located at the level of the crown of the cant effect (p < 0.05) on the “difficulty evaluation”. second molar. Since the correlation between “post-graduate pre-oper- As for Pell and Gregory’s classification, it consists of ative difficulty evaluation” and “operative time” resulted three orthopantomographic classes: in the first one the moderate (see results below), a second GLM was de- 8 Annali di Stomatologia 2014; V (1): 7-14 2-Pippi 4b_Riv Annali 1 2014 19/03/14 09:13 Pagina 9 Third molar difficulty evaluation veloped entering the “operative time” as dependent ty evaluation (coefficient ± standard error = -1.04 ± variable and the above-mentioned predictor variables 0.36, t = -2.92, P = 0.0046) (Fig. 4), i.e. post-graduates to study if any tooth characteristics could affect the op- perceived a less difficult extraction if the tooth to be ex- erative time although they were not specifically consid- tracted was vertical. ered in the evaluation of extraction difficulty degree by The GLM for “operative time” was highly significant (R li post-graduates. = 0.65, F 6,77 = 9.21, P < 0.0001) and it showed that Moreover, to rule out the possibility that the tutor had not only the position, but also the impaction depth and na unconsciously assigned the most difficult cases to the the relationship with the i.a.n. influenced the operative third year post-graduates, the one-way analysis of vari- time. In particular, the shortest operative times were as- ance (ANOVA) was used to test the effect of “post- sociated with vertical position (coefficient ± standard er- graduate training year” on “tutor’s difficulty evaluation”. ror = -9.56 ± 2.78, t = -3.44, P < 0.001) (Fig. 5), AB (co- io The influence of patient’s age and gender on both “ex- efficient ± standard error = -15.15 ± 4.07, t = -3.72, P < traction difficulty evaluation” and “operative time” was 0.0004) (Fig.6) and C1 depth of impaction (coefficient ± tested separately, using Pearson correlation and one- standard error = -9.34 ± 4.11, t = -2.27, P < 0.026) (Fig. az way ANOVA respectively, because these variables 6), and the absence of relationship between tooth and were not explicitly considered by the tutor in the as- i.a.n. (coefficient ± standard error = -4.00 ± 1.77, t = - sessment of surgical difficulty. 2.26, P = 0.026) (Fig. 7). Second-year post-graduates Finally, to verify whether the post-graduate’s preopera- tended to have longer durations than third-year post- rn tive difficulty evaluation could predict the occurrence of graduates, although this tendency was not statistically surgical accidents, a simple logistic regression model significant (factor not included in the model: t = 1.87; P was developed, using “accident occurrence/non occur- = 0.065) (Fig. 8). Note that the latter results cannot be rence” as dependent variable and “pre-operative diffi- due to the tutor assigning unconsciously the most diffi- te culty evaluation” as predictor variable. cult cases to the most experienced post-graduates, giv- Model residuals and variables used in parametric sig- en that there was no significant relationship between nificance tests were tested for normality using the Kol- tutor evaluation and post-graduate training year (F 1,82 mogorov-Smirnov test. All statistical analyses were car- = 0.55, p=0.459). In ried out with STATISTICA Release 8, Statsoft Inc., Tul- Moreover, it was found that neither the age of patients sa, OK, USA. (Tab. 2), nor their gender (Tab. 3) were related to the lenght of surgery or to the difficulty evaluation degree assigned either by the tutor or by the post-graduates. Results Finally, the post-graduate’s pre-surgical difficulty evalu- ni ation degree was significantly related to the probability Table 1 reports the distribution of cases (absolute and of accident occurrence (χ² = 5.84, p = 0.0156; Fig. 10) percent frequencies) for the qualitative variables, and in that surgical accidents happened more frequently o the mean values ± standard error for the continuous when post-graduates evaluated extractions as more dif- variables. ficult and less frequently when extractions were consid- izi There was a high positive correlation between the post- ered easy. graduate’s pre-operative difficulty evaluation and the post-graduate’s postoperative difficulty evaluation (r = 0.88, n = 84, P < 0.0001), meaning that post-graduates Discussion Ed did not substantially modify their evaluation after the surgical event. Conversely, the correlation between Many factors have been investigated over time as pos- post-graduate’s preoperative difficulty evaluation and sible causes of difficulty in lower third molar extraction operative time was moderate (r = 0.44, n = 84, P < since the correct establishment of the overall surgical 0.0001) and the correlation between post-graduate pre- difficulty degree is essential in decision making. Actual- operative difficulty evaluation and tutor’s difficulty eval- ly, it allows the surgeon to decide whether he/she is ca- C uation was low, although statistically significant (r = pable of performing the procedure or whether he/she 0.22, n = 84, P = 0.04). These results suggest that the has to refer the case, comparing its difficulty with CI operation was sometimes either more difficult or easier his/her technical skills derived from his/her surgical than post-graduates expected, and also that post-grad- training. Adequate technical ability is also required for uates evaluation of operation difficulty was substantially the second operator as well as for the dental assistant different from that made by the tutor (Figs. 1-3). who help the surgeon in extracting mandibular third The GLM developed for “post-graduate’s pre-operative molars and therefore they should be carefully chosen difficulty evaluation” was statistically significant, al- by the surgeon. Moreover, the establishment of correct © though it allowed to explain a relatively small portion of surgical difficulty degree is important in daily work the variability in the post-graduate’s assessment of sur- scheduling in that each extraction should be introduced gical difficulty (R = 0.33, F 3,80 = 3.27, P = 0.025). This in the dentist’s/oral surgeon’s daily activity considering was because only tooth position, among the considered the sequence and type of all other dental treatments to predictor variables, had a significant effect on post- be carried out during the day, the estimated time for its graduate difficulty evaluation. Specifically, the vertical completion and the unavoidable decrease of concentra- position had a negative effect on post-graduate difficul- tion which occurs with the increase of working hours. Annali di Stomatologia 2014; V (1): 7-14 9 2-Pippi 4b_Riv Annali 1 2014 19/03/14 09:13 Pagina 10 R. Pippi Table 1. Third molars by patient, dental, and operative variables. Patient variables gender M 26 (31,0%) F 58 (69,0%) age 27,36 ± 11,21 li (K-S: d = 0,20; p < 0,01) Dental variables inclination mesial 29 (34,5%) na vertical 29 (34,5%) horizontal 18 (21,4%) distal 28 (9,5%) Pell & Gregory’s class I 26 (31,0%) io II 53 (63,1%) III 5 (6,0%) impaction depth A/B 59 (70,2%) C1 23 (27,4%) az C2 22 (2,4%) root morphology a 73 (86,9%) b 24 (4,8%) c 27 (8,3%) rn relationship with the 1 39 (46,4%) inferior alveolar nerve 2 45 (53,6%) 3 20 (0,0%) te Operative variables postgraduate’s training year II° 43 (51,2%) III° 41 (48,8%) surgical time (min.) 30,65 ± 1,97 In (K-S: d = 0,82; p < 0,20) mouth opening (mm) 45,90 ± 0,75 (K-S: d = 0,15; p < 0,10) surgical accidents yes 14 (16,7%) no 70 (83,3%) ni post-graduate’s pre-operative 4,60 ± 0,22 difficulty evaluation (1-10 scale) (K-S: d = 0,10; p < 0,05) o post-graduate‘s post-operative 4,60 ± 0,25 difficulty evaluation (1-10 scale) (K-S: d = 0,10; p < 0,05) izi tutor’s difficulty evaluation (6-18 scale) 8,26 ± 0,18 (K-S: d = 1,52; p< 0,05) Ed C CI © Figure 1. Post-graduate’s post-operative difficulty evalua- Figure 2. Surgical time in relation to post-graduate’s pre- tion in relation to post-graduate’s pre-operative difficulty operative difficulty evaluation. evaluation. Other factors which should be considered are the direct given surgical skill, to the required operative time as proportionality existing between the difficulty degree well as to the amount and quality of materials and in- and the treatment costs which are closely related, for a struments needed. Lastly, the correct difficulty evalua- 10 Annali di Stomatologia 2014; V (1): 7-14 2-Pippi 4b_Riv Annali 1 2014 19/03/14 09:13 Pagina 11 Third molar difficulty evaluation li na io az Figure 3. Tutor’s difficulty evaluation in relation to post- Figure 6. Effect of impaction depth on post-graduate’s pre- graduate’s pre-operative difficulty evaluation. operative difficulty evaluation. Boxes AB depht of impaction show the mean values and the standard error range; rn whiskers indicate the range of values found within two stan- dard errors plus or minus the mean. te In o ni Figure 4. Effect of third molar’s inclination on post-gradu- ate’s pre-operative difficulty evaluation. Boxes show the izi mean values and the standard error range; whiskers indi- Figure 7. Effect of impaction depth on surgical time. Boxes cate the range of values found within two standard errors C1 Impaction depth show the mean values and the stan- plus or minus the mean. V = vertical; H = horizontal; M = dard error range; whiskers indicate the range of values mesial; D = distal. found within two standard errors plus or minus the mean. Ed C CI © Figure 5. Effect of third molar’s inclination on surgical time. Figure 8. Effect of the third molar’s relationship with the in- Boxes show the mean values and the standard error range; ferior alveolar nerve (IAN) on surgical time. Boxes show whiskers indicate the range of values found within two stan- the mean values and the standard error range; whiskers in- dard errors plus or minus the mean. V = vertical; H = hori- dicate the range of values found within two standard errors zontal; M = mesial; D = distal. plus or minus the mean. Annali di Stomatologia 2014; V (1): 7-14 11 2-Pippi 4b_Riv Annali 1 2014 19/03/14 09:13 Pagina 12 R. Pippi Table 2. Relationship between age and difficulty variables. tion increases the satisfaction of patients as far as the treatment received is concerned, especially if the ex- Difficulty variables p pected surgical time is observed. All factors that char- Surgical time 0.65 acterize mandibular third molar surgery and how each Post-graduates’ pre-operative evaluation 0.12 factor affects the degree of difficulty must be therefore li Post-graduates’ post-operative evaluation 0.17 provided and extensively explained to the post-gradu- Tutor’s evaluation 0.81 ates, although some authors believe that the correct na definition of the degree of difficulty can be reached only intra-operatively (15). The main aim of the present study was, therefore, to Table 3. Relationship between gender and difficulty vari- evaluate to what extent post-graduates in oral surgery io ables. were able to correctly establish the difficulty degree of lower third molar surgical extraction and possibly Difficulty variables F 1, 82 p whether and which factor they considered to be more important. Since the length of surgery has already been az Surgical time 0.068 0.80 Post-graduates’ pre-operative evaluation 0.23 0.63 considered as an objective difficulty index by many au- Post-graduates’ post-operative evaluation 0.03 0.86 thors, (2, 4, 5, 7, 9, 11, 17) any other factor which may Tutor’s evaluation 1.54 0.22 have influenced the operative time was finally investi- gated as a possible determinant of surgical difficulty al- rn though surgical experience influences the length of surgery as well. As for the descriptive results, the findings that few molars te (5/84) were in Pell and Gregory’s third class, only 2/84 were in the C2 class of impaction depth, none had imbri- cations with the inferior alveolar nerve and the majority of them (73/84) had a simple root morphology (Tab. 1) In clearly explain the low of mean post-graduate (4.60 ± 0.2) and tutor (8.28 ± 0.18) judgements of technical diffi- culty. The sample is therefore biased toward easier cas- es as previous samples by other authors were (7). As for the first aim, the highly statistical significance ni (p<0,05) of all variables of interest, either those of post- graduates (pre- and post-operative) or those of the tu- tor, and those of the operative time, is certainly due to the high sample size (N=84). Moreover, some observa- o tions are worthy of note. A very high correlation (r=0,88) exists between pre- and post-operative post- izi Figure 9. Effect of the post-graduate’s training year on sur- graduate difficulty evaluations, that is, post-graduates gical time. Boxes show the mean values and the standard did not modify their judgement concerning the extrac- error range; whiskers indicate the range of values found tion difficulty after they performed surgery, although in within two standard errors plus or minus the mean. many cases surgery was easier or more difficult than Ed the post-graduates had expected, as shown by the moderate correlation between the pre-operative difficul- ty evaluation and the operative time (r = 0,44), consid- ering that the operative time of each surgery is certainly proportional to the objective surgical difficulty in addi- tion to the surgeon’s technical skill. Two possible rea- C sons can explain this. First, post-graduates might have assumed that longer operative times were due to their CI technical inability rather than to the actual difficulty of surgery. Second, they might have not wanted to reveal their wrong assessment of the case. If longer operative times were really due to a lower post-graduate techni- cal ability, the high correlation between pre- and post- operative difficulty evaluation might suggest that a © careful preliminary analysis of all parameters can be highly predictive of surgical difficulty, although Barreiro- Torres et al. (18) found little correspondence between Figure 10. Observed probability of surgical accidents ver- pre- and post-surgical difficulty evaluations for maxillo- sus the post-graduate’s pre-operative difficulty evaluation. facial surgeons (38,7%), for oral surgeons (45,1%), or Points indicate mean values; whiskers indicate standard for primary care dentists (31,9%). Moreover, first there errors. is not a universal scale for grading surgeon’s experi- 12 Annali di Stomatologia 2014; V (1): 7-14 2-Pippi 4b_Riv Annali 1 2014 19/03/14 09:13 Pagina 13 Third molar difficulty evaluation ence, although an assumption may be based on senior- important in difficulty extraction of lower third molars ity ranking (11, 19), and secondly, Susarla and Dodson since surgical difficulty usually attributed to this para- (11) found that surgeons had a good ability to estimate meter is related to the more complex access and in- the relative importance of third molar variables in deter- strumentation and to the lower illumination and visibil- mining surgical difficulty regardless their experience. ity due to the space reduction between second molar li Low correlation (r = 0,22), although statistically signifi- and mandibular rhamus. This classification, however, cant (p< 0,042), existed between post-graduate and tu- is difficult to apply when the impacted third molar is na tor evaluations, that is, post-graduates evaluated surgi- not vertical due to the lack of datum-lines corre- cal difficulty in a substantially different manner than the sponding to mesial and distal crown surfaces. Incor- tutor regardless their training year. It appears very rect positioning of the patient’s head during orthopan- strange that the ability to correctly judge the difficulty de- tomographic examination can also modify the rela- io gree did not increase from the second to the third train- tionship between second molar and mandibular ing year. However, higher surgical times were associat- rhamus so that more than one factor can justify that ed with surgeries performed by second training year data concerning Pell and Gregory’s classification are az post-graduates (Fig. 5), although, just by little, this was not significant. Further studies are therefore neces- not statistically significant (p=0.065). Although it is intu- sary to exactly verify whether or not Pell and Grego- itive that increasing surgical skill decreases operative ry’s classification is a reliable factor in predicting sur- time, it is possible that senior post-graduates intentional- gical difficulty. rn ly wanted to overestimate surgical difficulty to demon- Root morphology resulted not to be an important factor strate their increased ability with shorter surgical times. in influencing surgical difficulty evaluation of mandibular However, statistical significant inverse correlation be- third molar extraction since it was not related to the pre- tween surgical experience and operative time was first operative difficulty degree (a: p=0.77; b: p=0.34) or with te speculated and then found by Susarla and Dodson (7, the actual surgical difficulty degree, since it was also 11). Given the low correlation between post-graduate not related to the operative time (a: p=0.46; b: p=0.91). and tutor evaluations, it appears necessary that post- This is in contrast with previous reported data (2-6, 9, graduates be correctly instructed to and how to assign a 17, 19) which showed this parameter was a very impor- In difficulty value to each anatomical and topographic fac- tant factor in determining surgical difficulty. However, in tor in third molar surgery so that they can be able to cor- the majority of cases (73/84 = 86,9%) of the present rectly define the overall difficulty degree of each study, third molar roots were fused or separated but not surgery. Despite different difficulty scales were frequent- divergent (“a”) so that the present sample can be bi- ly used in the past for third molar extraction (1, 2, 4, 5. ased toward a simple root morphology. ni 7-9, 11, 17, 18), none took into account all factors The relationship between third molar and the inferior which, over time, have been found to influence third mo- alveolar nerve did not influence post-graduate’s pre-op- lar surgical difficulty to varying degrees. Further studies, erative difficulty judgment as well, while a good correla- o aimed to validate a difficulty scale which can be accord- tion exists, with a high significativity (p=0.026), between ingly adopted for clinical and didactical proposals, are the absence of any kind of relationship and the opera- izi therefore highly recommended in the future. tive time, to show that when the tooth did not have rela- As for the second aim, a high correlation existed be- tionship with the alveolar nerve the extraction was tween tooth position and pre-operative difficulty evalua- much less difficult, as already shown by Susarla and tion since post-graduates perceived surgical extractions Dodson (7) and Benediksdottir et al. (6), although this Ed as simple when third molars were vertical (p=0.0046). was not confirmed by Santamaria and Arteagoitia (2). Vertical position was also highly related to the operative Since the extent of mouth opening did not influence ei- time (p=0.00096), being associated with the shortest ther the pre-operative difficulty evaluation nor the oper- operative time. Tooth position was already found to be ative time, this variable seems to be unrelated to the a reliable parameter in the expectation of extraction dif- difficulty degree of surgery, as already shown in all the ficulty in many previous studies (2-7, 9). previous studies in which it has been evaluated (1, 4, 5, C As for the impaction depth, although it was not related 7). However, since the reduction of mouth opening lim- to the post-graduates’ difficulty evaluation, it was highly its access, instrumentation, illumination and visibility in CI related to the operative time since the shorter the oper- third molar region, it appears reasonable that this vari- ative time the less deep the third molar was (A/B: p= able should be considered an actual predictive factor of 0.00037; C1: p=0.026) (Fig. 4). Impaction depth result- surgical difficulty. Actually, the mean value of mouth ed to be the most important indicator of surgical difficul- opening in the present study was 45,90 ± 0,75 mm, ty in many previous studies (2-6, 9, 19). with 30,00 mm as the lowest value which is sufficient to Pell and Gregory’s classification, on the contrary, did allow a good surgical approach in the posterior region © not influence either the post-graduate’s pre-operative of the mouth. Wider or selected samples for this para- difficulty evaluation nor the operative time, so that it meter are therefore necessary for its better evaluation. seems unreliable in determining surgical difficulty, as As for the third aim, the effect of the patient’s age and already reported by Garçia et al. (3), but only in rela- gender was separately tested in the present study for tion to vertical third molars, yet in contrast with re- two different reasons. First, they were not considered in sults reported by Yuasa et al. (5). It appears rather the tutor difficulty evaluation. Secondly, it was intended strange that Pell and Gregory’s classification is not to limit the number of variables included in the models Annali di Stomatologia 2014; V (1): 7-14 13 2-Pippi 4b_Riv Annali 1 2014 19/03/14 09:13 Pagina 14 R. Pippi to avoid the over-fitting that is the possible false results References due to the presence of too many variables in relation to the number of statistical units. The present results 1. Pederson GW. Oral Surgery. Philadelphia, Saunders, 1988. Cit- showed that patient’s age and gender did not exert a ed in: Koerner KR. The removal of impacted third molars-prin- significant effect either on operative times, nor on post- ciples and procedures. Dent Clin North Am 1994; 38: 255-78. li graduates difficulty evaluations. 2. Santamaria J, Arteagoitia I. Radiologic variables of clinical significance in the extraction of impacted mandibular third As for the age of patients, these results do not confirm na molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod those of previous studies (4, 6, 9), in which this variable 1997; 84: 469-73. has shown to influence the difficulty of surgery although 3. Garçia GA, Sampedro FG, Rey GJ, Vila PG, Martin MS. Pell- the limit of age in those study samples was variable from Gregory classification in unreliable as a predictor of difficulty 23 (6) to 34 years (9). Results from the study of Carvalho in extracting impacted lower third molars. Br J Oral Maxillofac io et al. (17) seemed to agree with the present ones but the Surg 2000; 38: 585-7. mean age of that study population was very low (21.8 ± 4. Renton T, Smeeton N, McGurk M. Factors predictive of difficulty 2,4) compared to the present (27.36 ± 11.21). of mandibular third molar surgery. Br Dent J 2001; 190: 607-9. As for the gender, the present data confirm those of 5. Yuasa H, Kawai T, Sugiura M. Classification of surgical dif- az previous studies (6, 7, 9, 11, 17) in which gender was ficulty in extracting impacted third molars. Br J Oral Maxillofac Surg 2002; 40: 26-31. not an important factor in determining surgical difficulty. 6. Benediksdottir IS, Wenzel A, Peterson JK et al. Mandibular However, the Body Mass Index (BMI) (9) - that is, the third molar removal: risk factors for extended operative time, individual’s weight divided by the square of his/her rn pain and complications. Oral Surg Oral Med Oral Pathol Oral height - and the weight of patients (4) have been re- Radiol Endod 2004; 97: 438-46. ported to be significantly related to surgical difficulty in- 7. Susarla SM, Dodson TB. Risk factors for third molar extraction dependently from the gender, although no possible ex- difficulty. J Oral Maxillofac Surg 2004; 62: 1363-71. te planations have been given for this correlation. Since 8. Diniz- Freitas M, Lago-Méndez L, Gude-Sampedro F, Somoza- BMI is a measure of body fatness, its correlation with Martin JM, Gàndara-Rey JM, Garcìa-Garcìa A. Pederson scale the extraction difficulty appears rather unexplainable. fails to predict how difficult it will be to extract lower third mo- Moreover BMI has been found to differ in relation to the lars. Br J Oral Maxillofac Surg 2007; 45: 23-7. gender (20), so a correlation between gender and ex- traction difficulty would be expectable. In 9. Gbotolorun MO, Arotiba GT, Ladeinde AL. Assessment of factors associated with surgical difficulty in impacted mandibular third molar extraction. J Oral Maxillofac Surg 2007; As for the last aim, it is worthy of note that despite the 65: 1977-83. greater care required when surgeries were judged as 10. Blaeser BF, August MA, Donoff RB, et al. Panoramic radi- difficult, accidents, such as root and alveolar wall frac- ographic risk factors for inferior alveolar nerve injury after third ni ture or flap tearing, occurred anyways, regardless of molar extraction. J Oral Maxillofac Surg 2003; 61: 417-21. the post-graduate’s training year. 11. Susarla SM, Dodson TB. How well do clinicians estimate third mo- lar extraction difficulty? J Oral Maxillofac Surg 2005; 63: 191-9. 12. Faulkner H, Regehr G, Martin J, Reznick R. Validation of an o Objective Structured Assesment of Technical Skill for Sur- Conclusion gical Residents. Academic Med 1996; 71(12): 1363-5. izi 13. Winkel C, Reznick R, Cohen R, Taylor B. Reliability and con- In conclusion, the pre-operative post-graduates' difficul- struct validity of a structured technical skills assessment form. ty evaluation did not differ from their post-operative Am J Surg 1994; 167: 423-7. evaluation although their judgement differed from that 14. Martin J A, Regehr G, Reznick R, Macrae H, Murnaghan given by the tutor and did not correlate with the opera- J, Hutchinson C, Brown M. Objective structured assessment Ed tive time. Moreover, it seems that post-graduates did of technical skill (OSATS) for surgical residents. Br J Surg not consider the impaction depth in their difficulty evalu- 1997; 84: 273-8. ation although this parameter resulted highly related to 15. Chandler LP, Laskin DM. Accuracy of radiographs in clas- the operative time. Finally, from the present data it sification of impacted third molar teeth. J Oral Maxillofac Surg 1988; 46: 656-60. seems that lower third molar extraction difficulty was in- 16. Winter GB. Principles of exodontia as applied to the impacted fluenced by some topographic factors such as tooth po- C third molar. American Medical Books, St. Louis, MO, 1926. sition, impaction depth and relationship between inferi- 17. Carvalho RWF, do Egito Vasvoncelos BC. Assessment of or alveolar nerve and impacted tooth, whereas demo- factors associated with surgical difficulty during removal of CI graphic variables, such as patient’s age and gender, impacted lower third molars. J Oral Maxillofac Surg 2011;69: were not important in predicting surgical difficulty. 2714-21. 18. Barreiro-Torres J, Diniz-Freitas M, Lago-Méndez L, Gude- Disclosures: there are no funding sources for the pre- Sampedro F, Gándara-Rey J-M, García-García A. Evalua- sent work. There are no commercial associations, cur- tion of the surgical difficulty in lower third molar extraction. Med Oral Patol Oral Cir Bucal 2010; 15(6): e869-74. rently and within the past five years, that might pose a © 19. Akadiri OA, Obiechina AE. Assessment of difficulty in third potential, perceived, or real conflict of interest, including molar surgery- a systematic review. J Oral Maxillofac Surg grants, patent licensing arrangements, consultancies, 2009; 67:771-4. stock or other equity ownership, advisory board mem- 20. Deurenberg P, Weststrate JA, and Seidell JC. Body mass berships, or payment for conducting or publicizing the index as a measure of body fatness: age- and sex-specific present study. prediction formulas. Brit J Nutrition 1991; 65(02): 105-14. 14 Annali di Stomatologia 2014; V (1): 7-14 

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1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 218 Original article Effectiveness of a personalized device in the evaluation of mandibular second molar periodontal healing after surgical extraction of adjacent li third molar na Roberto Pippi, MD, DDS mate of second molar periodontal healing after ad- jacent third molar surgical extraction. No patient- io or tooth-related factors seem to be able to affect Department of Oral and Maxillo-facial Sciences, either second molar periodontal healing or probing “Sapienza” University of Rome, Italy depth measures obtained with or without the per- sonalized device in individuals younger than 25 az years old. It can be therefore recommended that Corresponding author: lower third molar surgical extraction be performed Roberto Pippi in young adults. Department of Oral and Maxillo-facial Sciences rn “Sapienza” University of Rome Key words: periodontal healing, periodontal probing, Via Caserta, 6 radiographic measurements, smoking, statistics. 00161 Rome, Italy Phone: +390649976651 te Fax: +390644230811 Introduction E-mail: roberto.pippi@uniroma1.it Many studies have been performed over the years to Summary In verify periodontal modifications of the lower second molar distal surface after adjacent third molar surgical extraction (1-14) with regard to several risk factors, Aim. The primary aim of the present study was to such as flap design, the infra-bony pre-operative pocket validate the effectiveness of a personalized device on the second molar distal surface, the patient’s age, ni able to guide periodontal probing in evaluation of the width of the contact area between second and third second molar periodontal healing after adjacent molar and the mesial width of third molar follicular third molar surgical extraction. Secondarily, the space. However, clinical evaluation of periodontal de- study analyzed if any patient and tooth related fac- fects on the distal surface of the lower second molar o tors affected the second molar periodontal healing can be affected by non-repeatability of the measure- as well as if they were able to affect the periodontal ments due to unavoidable variation in the probing site, izi probing depth performed with or without the per- as well as of the insertion axis of the periodontal probe. sonalized device. The use of a device to guide periodontal probing theo- Materials and methods. Thirty-five lower second retically minimizes inter- and intra-examiner variability, molars were evaluated after extraction of the adja- making the measurements obtained at different times Ed cent third molar. Pre-operative as well as 3 and 12 comparable. The primary aim of the present study was month post-operative probing depths of the distal to validate the effectiveness of a personalized device surface of the second molar were evaluated. All built to guide periodontal probing in the clinical evalua- measurements were taken by two different meth- tion of lower second molar periodontal healing after ad- ods: standard two-point and four-point probing us- jacent third molar surgical extraction, in comparison ing a personalized onlay-type guide. Periapical radi- with the conventional periodontal probing technique, C ographs were also evaluated. The Pearson product using the radiographic assessment of bone healing as moment and the general linear model with back- an objective reference. Second, this study analyzed CI ward stepwise procedure were used for inferential whether any patient- or tooth-related factors were able statistics. to affect second molar periodontal healing, as well as Results. The mean 12-month post-operative prob- periodontal probing depth performed with or without the ing depth/mean pre-operative probing depth ratio personalized device. obtained with the guided probing method showed a highly significant effect on the 12-month radi- © ographic post-operative/pre-operative radiographic Materials and methods measure ratio. None of the examined patient- or tooth-related factors showed a significant effect on Sampling pre-operative/12-month post-operative radiographic measure ratio. The examined sample included 35 second molars that Conclusions. The use of the proposed personal- were clinically and radiographically evaluated before ized device seems to provide a more reliable esti- and after extraction of the adjacent third molar, from 30 218 Annali di Stomatologia 2013; IV (3-4): 218-229 1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 219 Healing after third molar surgery subjects among the patients treated with the same com- mon protocol by the same operator over a 2-year period at the Oral Surgery Unit of the Department of Oral and Maxillo Facial Sciences at the “Sapienza” University of Rome. The inclusion criteria included the following: at li least one lower extracted third molar; vertical, mesio-an- gular or horizontal third molar class B-depth impaction; na the presence of the first two molars and the second pre- molar on the extraction side, to assure stent stability during measurements; and the patient’s consent to use the clinical data for statistical evaluation. The exclusion io criteria included the following: any systemic disease and local or generalized periodontitis; pregnancy or lacta- tion; any medication in the last 6 months that could influ- ence wound healing after surgery; any type of recon- Figure 1. The personalized acrylic stent used for the study az struction on the distal surface of the second molar, as with the probe positioned in one of the four 6 mm high well as a second molar prosthetic crown on the extrac- grooves. tion side; caries on the occlusal and inter-proximal sur- faces of the first two molars, as well as on the second rn premolar; a history of root planing performed immediate- stent at the level of the four points chosen for probing, ly after surgical extraction; a history of problems in stent using a probe similar to that used for the measure- seating at the 3- and 12-month probing follow-ups; miss- ments. Each stent was approximately 2 mm thick, in- te ing or incomplete periodontal data or radiographs; any volved three teeth from the second molar to the second type of conservative or prosthetic rehabilitation per- premolar and extended for 4-5 mm from the occlusal formed on the molars or second premolar on the extrac- surface on the distal face of the second molar, ending tion side before the 12-month follow-up; and a history of approximately 4 mm coronally from the gingival margin, professional calculus or plaque removal after surgery In before the 12-month follow-up. All of the clinical and ra- so the grooves were at least 6 mm in height. A slight overlap (approximately 1 mm) of the stent on the lateral diographic measurements were obtained under magnifi- surfaces of all of the teeth involved was allowed to as- cation using a Head-Worn Loupe KS (Carl Zeiss, Ger- sure retention and stability. many) with the following technical features: magnifica- All of the probing measurements were obtained to the ni tion ratio: 4x; working distance: 300 mm; free distance nearest millimeter from the free gingival margin to the to object: 220 mm; field of view: 50 mm; and length of bottom of the pocket, using the same probe. To im- optical system: 51.5 mm. prove visibility, the measurements were obtained in an All of the following examinations and treatments were indirect manner, using a #5 mouth mirror (Kerr Co. o performed by the same investigator. USA) positioned distally to the second molar. izi Periodontal examinations and measurements Radiographic examinations and measurements - WHO periodontal screening and recording (PSR), with - Periapical radiographs were performed pre-operative- Ed a PCP 11 5B probe (Hu-Friedy, USA), and furcation ly, as well as at 3 and 12 months post-operatively (Fig. probing of first and second molars, with a #2 Nybers 2), with a Castellini radiographic machine (70 KVp – 8 probe (PQ2N6 - Hu-Friedy, USA), were performed to mA – 0.38 kW tube type Cox 70G8CEI), using the par- exclude generalized periodontitis or localized periodon- allel technique, with a long cone and a precision device titis on the extraction side. (Rinn® XCP Instruments Kit, Dentsply, Elgin, IL, USA) - Periodontal probing depth (PD) of the distal surface of and a focal object distance of approximately 20 cm. Be- C the lower second molar was always performed with the fore the film-holder was positioned in the mouth, for same straight, tapered, 15 mm probe (42-746-02 2A each radiograph, a millimetric adhesive grid (Phil x-Ray CI Martin, Germany) pre-operatively, as well as at 3 and Grid - Pat. Pending) was applied on the film side facing 12 months post-operatively, on the extraction side by the teeth. The radiographs were examined on a di- two different methods: aphanoscope (230 V, ~ 50-60 Hz, 85 W - Titanox, A - standard (stand) two-point probing, disto-buccal Italy). Study measurements were obtained with a milli- (DB) and disto-lingual (DL); and metric ruler, from the cement-enamel junction (CEJ) to B - four-point probing (dev), buccal (B), disto-buccal the bottom of the radiographically detectable bone de- © (DB), centro-distal (CD) and disto-lingual (DL), using a fect just near the distal surface of the second molar. personalized onlay-type guide or stent (Fig. 1), directly For each radiograph, the definitive unknown measure- made in the patient’s mouth during a preliminary ses- ment was calculated by applying a mathematical pro- sion using auto-polymerizing acrylic resin (Jet Kit, Lang portion, in which the known terms were the actual milli- Dental MFG Co. Inc. Wheeling, IL, USA) and then com- metric length of ten vertically contiguous squares of the pleted in the laboratory. During resin polymerization, 4 grid and the millimetric value of the defect, both ob- vertical grooves were made on the distal side of the tained from the radiographs. Each value obtained in Annali di Stomatologia 2013; IV (3-4): 218-229 219 1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 220 R. Pippi li na io Figure 2. The complete three-radiograph set of one of the studied second molars. Pre-operative x-ray (left); 3-month post- operative x-ray (middle); 12-month post-operative x-ray (right). az this manner was then approximated to the nearest milli- trend index, the standard error (SE), as the variability metric unit. All of the radiographic measurements were index, and the Kolmogorov-Smirnov test (K-S), as the performed by the examiner at the end of the study. distribution normality test, were used for descriptive sta- - The following data resulting from pre-operative tistics of quantitative variables. Absolute and percent- rn panoramic radiographs of all of the patients were also age frequencies were used for qualitative variables. considered: contact area width between the third and Pearson’s product moment (r) and the general linear second molar (≤ 3 mm / ≥ 4 mm); and third molar incli- model (GLM) with the backward stepwise procedure te nation (0-29°/30-59°/60-90°). (BSP) were used for inferential statistics. The study was conducted with the approval of the local Ethical Committee, with protocol number 725/12. Ethi- Surgical technique cal principles for medical research, as stated by the Third molar extraction was performed according to the In Helsinki Declaration, were followed. Informed consent/assent was obtained from all of the study par- following standard protocol: pre-operative oral antibiotic ticipants. prophylaxis with amoxicillin plus clavulanic acid (2 g) 1 hour before the procedure; 3% mepivacaine anesthesia ni of the inferior alveolar nerve, plus 2% mepivacaine infil- Study design trative anesthesia with adrenaline in the buccal mucosa of the third molar region; angular flap; tooth removal af- For each of the proposed aims, a different study design ter ostectomy and/or tooth sectioning, if needed; re- was planned. o moval of follicular remnants and inflammatory tissue The first aim was to verify the degree of correspon- from the residual cavity; final cleaning with sterile saline dence between the periodontal healing evaluation per- izi irrigation; 3-0 silk sutures with a taper-cut needle; and formed by radiographic measurements and the probing granular nimesulide 100 mg immediately after surgery depths measured with and without the personalized de- and further doses, if needed, every 12 hours following vice as a guide. suture removal at 1 week post-operatively. No root As a first step, to evaluate the possible improve- Ed planing of the distal surface of the second molar was ment/worsening over time of the second molar peri- performed before, during or after surgery. No specific odontal status, the mean pre-operative PD/post-oper- instructions on oral hygiene were provided to the pa- ative mean PD at 3 and 12 months, as a ratio mea- tients after surgery. Surgical extractions in the same sured with (dev3/pre and dev12/pre) and without patient were performed at different times. (stand3/pre and stand12/pre) the personalized device, were calculated, in which 1 indicated stableness, val- C ues < 1 indicated improvement, and values > 1 indi- Other clinical features cated worsening. Moreover, the ratios of measure- CI ments obtained from pre-operative radiographs (xrpre) The following data were also collected as binary vari- to those obtained from 3- (xr3) and 12- (xr12) month ables (yes/no): pre-operative inflammatory signs or post-operative radiographs were calculated (xr3/pre symptoms; third molar communication with the oral en- and xr12/pre, respectively) as an objective control. vironment; visible plaque presence on the distal surface The postulate was that if the probing depth measure- of the second molar at least in one of the follow-up ex- ments obtained with the personalized device provided © aminations; and the patient’s smoking habits. an effective measurement of the second molar peri- odontal improvement/worsening, then a statistically sig- nificant correlation would exist between those measure- Statistical methods ments and the radiographic measurements. In other words, it should be possible to predict the radiographic Each lower second molar was considered an indepen- outcome from the probing depth measurements ob- dent statistical unit. The mean value, as the central tained using the personalized device. Moreover, if the 220 Annali di Stomatologia 2013; IV (3-4): 218-229 1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 221 Healing after third molar surgery latter were more reliable than the results obtained with observed values of the dependent variable (xr12/pre) the standard probing method, one might expect that the and the predicted values on the basis of the explanato- correlation between the measurements obtained with ry variables (dev12/pre or stand12/pre). The postulate the personalized device and the radiographic measure- was therefore that, if a variable positively or negatively ments would be stronger than the correlation between influenced the correlation between xr12/pre and li measurements obtained with the classic probing dev12/pre or stand12/pre, that variable should also method and the radiographic measurements. Because positively or negatively influence the deviation values of na a very strong correlation was found between dev12/pre the two xr12/pre models, respectively developed with and dev3/pre (r = 0.91), as well as between dev12/pre (xrdev12/preRES) and stand12/pre (xr- stand12/pre and stand3/pre (r = 0.81), meaning that the stand12/preRES) as explanatory variables. Two differ- second molars, the periodontal status of which im- ent GLMs with BSP were used to test, respectively the io proved after 12 months, were basically the same as effects on xrdev12RES and xrstand12RES of the those found to have improved periodontally after 3 above-mentioned variables: patient’s age, sex, and months, only the ratios calculated at 12 months were smoking habits (yes/no); visible plaque presence at fol- used (dev12/pre; stand12/pre; xr12/pre) to shorten and low-up examinations (yes/no); contact area between az simplify the subsequent analysis. third and second molars (≤3 mm/≥4 mm); third molar in- Two GLMs were therefore developed: the first one clination relative to the second molar axis (≤30°/>30°); used xr12/pre as a dependent variable and dev12/pre pre-operative local signs and/or symptoms of infection as an explanatory variable; the second one, in which (yes/no); and pre-operative third molar communication rn xr12/pre was used as a dependent variable and with oral environments (yes/no). stand12/pre as an explanatory variable, was then de- veloped. Results te To investigate more closely the comparison between the standard and guided probing methods, the previous analysis was repeated using the PD measurements ob- Descriptive results tained in the only comparable point of the two methods, dard method, instead of the mean measurements ob- In named “B” in the guided method and “DB” in the stan- All of the surgical procedures were uneventful. The age of the patients at the time of surgery ranged from 16 to tained with each of the two methods. Hence, the ratios 46 years old, with a mean age of 24.37 ± 0.93 years between the 12-month post-operative PD and the pre- old. Nineteen of the 35 third molar extractions were operative PD, respectively obtained with and without performed in female patients (54.29%) and 16 in male ni the stent (B12/pre and DB12/pre), were used. Two fur- patients (45.71%). Pre-operative symptoms, as well as ther GLMs were therefore developed, using xr12/pre, communication with the oral environment, were present as a dependent variable and, respectively, B12/pre and in 19 of 35 cases (54.29%). In 18 of 35 cases DB12/pre as explanatory variables. (51.43%), third molar inclination was less than 30°, and o The second aim was to verify whether and which pa- in 23 cases (65.71%), the contact area between the tient-related and third molar-related variables influ- second and third molar was ≥ 4 mm. Twenty-three ex- izi enced periodontal second molar healing. tractions were performed in smokers (65.71%), and in Radiographic measurements after 12 months (xr12/pre) 24 of 35 cases (80%), visible plaque was detectable on have been used as objective measurements of second the distal surface of the second molar in at least one of molar periodontal healing. A GLM with the BSP (p > the follow-up examinations. Ed 0.05) has been used to analyze the effects of the fol- The mean probing depths detected pre-operatively lowing explanatory variables on xr12/pre: patient’s age, (pre), as well as at three (3) and twelve (12) months sex, and smoking habits (yes/no); visible plaque pres- post-operatively with (dev) and without (stand) the per- ence at follow-up examinations (yes/no); contact area sonalized device, were the following: devpre=3.10 ± between the third and second molars (≤3 mm/≥4 mm); 0.16; dev3=3.08 ± 0.10; dev12=2.75 ± 0.11; stand- pre-operative local signs and/or symptoms of infection pre=5.50 ± 0.27; stand3=4.94 ± 0.25; and C (yes/no); pre-operative third molar communication with stand12=4.00 ± 0.16. oral environments (yes/no); and third molar inclination The mean radiographic measurements of bone defects CI relative to the second molar axis (≤30°/>30°). For con- were the following: pre-operative (xrpre)=6 ± 0.38; 3 venience, third molar inclination was also considered a months post-operatively (xr3)=4.94 ± 0.40; and 12 binary variable because only 5 third molars were found months post-operatively (xr12)=3.68 ± 0.32. to have inclinations between 30° and 60°. The third aim was to verify whether and which patient- related and third molar-related factors influenced the Inferential analysis results © correlation between guided probing depths (dev12/pre) and radiographic measurements (xr12/pre) and to de- First aim termine whether any correlation existed between stan- dard probing depths and radiographic measurements. The results obtained with the first GLM (Fig. 3) (coeffi- For this type of analysis, the residuals of the two gener- cient ± SE=0.52 ± 0.15; t=3.56; p=0.0011) showed that al linear models, developed to accomplish the first aim, dev12/pre had a highly significant effect on xr12/pr (F1, were used. Residuals are the deviations between the 33=12.68; p=0.0011), although the correlation between Annali di Stomatologia 2013; IV (3-4): 218-229 221 1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 222 R. Pippi li na io az Figure 3. Ratio of the 12-month post-operative radiograph- Figure 4. Ratio of the 12-month post-operative radiograph- ic measures to the pre-operative radiographic measures ic measures to the pre-operative radiographic measures versus ratio of the mean 12-month guided probing depths versus ratio of the mean 12-month standard probing rn to the mean pre-operative guided probing depths. depths to the mean pre-operative standard probing depths. the observed xr12/pre values and the predicted values, te on the basis of dev12/pre, was moderate (R=0.53), in- dicating that dev12/pre variability explained a moderate portion of xr12/pre variability. Finally, the residuals (the differences between the observed xr12/pre values and In the predicted values on the basis of dev12/pre) showed an almost normal distribution (K-S: d=0.11; p>0.20). This finding confirms the estimate of the standard error regression coefficient. In other words, a statistically sig- nificant, although moderate, correspondence existed ni between radiographic measurements and periodontal probing depth obtained with the personalized device. Results from the second GLM (Fig. 4) (coefficient ± SE=0.65 ± 0.25; t=2.63; p=0.01) were generally similar o to those obtained with the previous GLM (F1, 33=6.92; p=0.0128), although stand12/pre had a less significant Figure 5. Ratio of the 12-month post-operative radiograph- izi effect on xr12/pre than dev12/pre (higher p value), and ic measures to the pre-operative radiographic measures it explained a smaller portion of xr12/pre than versus ratio of the 12-month guided probing depths in the dev12/pre (lower R value). In other words, this corre- B point to the pre-operative guided probing depths at the spondence was lower than that between radiographic same point. Ed measurements and measurements obtained with the guided probing technique. The use of the personalized device therefore seemed to provide a more reliable es- timate of second molar periodontal healing. The results from the last two GLMs (Fig. 5: F 1, 33=12,79; p=0.0011; Fig. 6: F1, 33=7.72; p=0.0089) con- C firmed those obtained with the two previous GLMs (Figs. 3, 4), in that the guided method produced find- CI ings were slightly more correlated with the radiographic findings (coefficient ± SE=0.42 ± 0.19; t=3.58; p=0.001) than those obtained with the standard method (coeffi- cient ± SE=0.50 ± 0.18; t=2.79; p=0.009). © Second aim Because no models were developed by the BSP, none Figure 6. Ratio of the 12-month post-operative radiograph- of the examined patient-and tooth-related factors had ic measures to the pre-operative radiographic measures significant effects (Tab. 1) (p-values < 0.05 with the T- versus ratio of the 12-month guided probing depths in the test) on the ratio between pre-operative and 12-month DB point to the pre-operative guided probing depths at the post-operative radiographic measurements (xr12/pre). same point. Annali di stomatologia 2013; IV (3-4): 0-0 Annali di Stomatologia 2013; IV (3-4): 218-229 1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 223 Healing after third molar surgery Table 1. Partial correlations (PC) between the explanatory ferent times. The use of each lower second molar of variables not included in the general linear model and the same patient as a single statistical unit has already xr12/pre (dependent variable). been reported in previous studies (5-7) because, from the analysis of variance concerning probing depths and Explanatory variables PC T p intra-bony defects, it seemed there was no dependence li Gender -0.084 -0.486 0.630 between two operations performed in the same patient, Smoking habits -0.022 -0.129 0.898 even if performed at different times. na Plaque 0.109 0.630 0.533 The mean age of the patients in the present study Contact area -0.194 -1.135 0.264 (24,30 ± 0,98) was younger than that in previous stud- Symptoms 0.085 0.490 0.627 ies (27,2 ± 6,35 (3); 27 ± 7 (10); 30, 37 ± 2,32) (14). If Inclination -0.192 -1.125 0.269 the only patient older than 30 years old (46 years old) io Communication with oral cavity 0.000 0.002 0.998 was excluded, the mean age of the patients (23,63 ± Age 0.137 0.797 0.431 0,73) was similar to that in Montero and Mazzaglia’s study (13). In the studies of Cetinkaya et al. (11) and Faria et al. (14) the mean age (18,53 ± 1,60 (11); 21,03 az Table 2. Partial correlations (PC) between the explanatory ± 4,38) (14) was younger than in the present study. variables not included in the general linear model and Only two previous studies (5, 10) have evaluated the xrdev12/preRES (dependent variable). periodontal condition of any other tooth, to assess whether second molar periodontal involvement was a rn Explanatory variables PC T p local problem due to third molar impaction or peri- Gender 0.155 0.902 0.373 odontitis. Specifically, Kuegelberg (5) examined the Smoking habits 0.093 0.540 0.592 first mandibular molar, while Kan et al. (10) examined te Plaque 0.057 0.326 0.747 the entire dentition. To avoid any influence that local Contact area -0.077 -0.446 0.658 or generalized periodontitis might have on post-surgi- Symptoms 0.012 0.069 0.945 cal second molar periodontal healing, the present Inclination -0.225 -1.326 0.194 study analyzed patients in whom the WHO PSR, Communication with oral cavity 0.000 Age 0.191 0.002 1.118 In 0.998 0.272 which was previously applied, excluded any type of periodontal involvement (not including the second mo- lar distal surface). With the same purpose, to avoid any positive or nega- Table 3. Partial correlations (PC) between the explanatory tive influence on the healing process, in the present ni variables not included in the general linear model and xr study, patients with systemic conditions that might stand12/pre RES (dependent variable). have an effect on bone growth and periodontal heal- ing, such as uncontrolled diabetes mellitus or im- Explanatory variables PC T p munosuppressive treatments, and participants who o Gender -0.236 -1.397 0.171 were subjected to professional plaque and calculus Smoking habits -0.075 -0.432 0.668 removal after surgery, before the 12-month follow-up, izi Plaque 0.120 0.694 0.492 or to root planing immediately after surgical extraction Contact area -0.212 -1.246 0.222 were excluded from this study. As a routine measure, Symptoms 0.119 0.688 0.496 calculus removal was gently performed only intra-op- Inclination -0.178 -1.039 0.306 eratively, if present. Actually, root planing of the sec- Ed Communication with oral cavity 0.057 0.331 0.743 ond molar distal surface has been found to improve Age 0.103 0.597 0.554 healing in the presence of pre-existing periodontal im- pairment (PD > 4 mm); however, it can determine pe- riodontal deterioration if performed for any indication, Third aim for example, in subjects with healthy preoperative sec- ond molar periodontal status (16). Osborne et al. (17) C Because no models were developed with the BSP, previously found minimal benefits by root planing and none of the examined patient- or tooth-related factors curetting the second molar in individuals younger than CI had significant effects (Tab. 2) (p-values < 0.05 with the 25 years old at the time of third molar removal. t-test) on the ratio between pre-operative and 12-month Accuracy is especially needed in clinical studies aimed post-operative radiographic measurements (xr12/pre) to verify differences in the effectiveness of different di- or on the deviations between the observed value of agnostic or therapeutic procedures, to avoid any possi- xr12/pre and the values predicted on the basis of each ble sources of error. All of the steps of each procedure considered factor (Tab. 3) (dev12/pre or stand12/pre). are subject to the risk of error. Inter-examiner and intra- © examiner variability is also a clear source of error in clinical studies. Discussion Many attempts have been undertaken in the past to standardize clinical and radiographic methods in In the present study, 35 second molars were examined studies aimed to evaluate periodontal healing after after adjacent third molar extraction in 30 patients. In 5 different therapeutic procedures. Methodological patients, both lower third molars were extracted at dif- standardization certainly limits the intra- and inter-ex- Annali di Stomatologia 2013; IV (3-4): 218-229 223 1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 224 R. Pippi aminer variability. Furthermore, inter-examiner vari- whereas the loupe was used to magnify the image. ability is clearly avoided if the measurements are ob- Much better reading was therefore guaranteed. tained by the same examiner. As for probing force, it is usually thought that measure- In the present study, all of the procedures were per- ments obtained by the same expert investigator are formed by the same expert surgeon, and much effort comparable to each other or at least that the existing li was undertaken to apply reproducible methods of in- differences are diluted among all measurements. Has- vestigation and treatment to limit any possible causes sel et al. (21) found poor correlation between PD mea- na of error. Details were provided for all of the steps of the surements and the probing force applied, so they con- research, although simple, partly self-made and easily cluded that probing force had only a moderate influ- available methods were used because they are com- ence on PD measurements and that the probing tech- monly used in daily practice, they do not require exten- nique was more critical in PD measurement than the io sive training for use, and they are not uncomfortable for pressure applied to the probe. Inter and inter-examiner the patients. The only disadvantage was the direct variability in PD measurements of a same defect is chair-side making of the stent, which was fairly time- therefore more related to different areas of the defect consuming and which develops heat and an unpleasant being measured at different times than to the probing az taste. An indirect technique could otherwise be used, force applied in different measurements. so the guide could be made on a plaster cast, obtained Because probe tip diameter and calibration have also from a previous alginate impression, although in this been considered as further variables able to influence case, direct adaptation in the patient’s mouth was periodontal probing and because these characteristics rn sometimes necessary nevertheless before its use. have been found to change from one probe type to an- Although both clinical and radiographic examinations other, as well as in the same batch of instruments (22), have limitations in measurement accuracy, and many in the present study, the same probe was always used te attempts have been undertaken in the past to eliminate for all of the probing measurements, to improve accura- every source of error and to reduce inter- and intra-ex- cy and reproducibility. aminer variability, they are commonly used in clinical As for positional error, in the present study, a personal- practice, as well as in research studies. ized device was used to guide the probe during mea- In the present study, probing depth was the only prob- ing parameter considered. Clinical attachment level In surements. The use of a personalized guide or stent for periodontal probing depth has already been de- (CAL) was not evaluated because the cemento-enamel scribed in the literature, (1, 2, 18-20, 23, 24) as well as junction (CEJ) was sometimes not visible on the distal to evaluate lower second molar periodontal healing af- aspect of the second molar due to its sub-gingival loca- ter adjacent third molar removal (11). However, Watts ni tion, and therefore it could not be used as a clinical ref- (18) reported that, despite the use of the stent to guide erence point. Moreover, the main aim of the present periodontal probing, the greater source of error in his study was not to obtain a real measurement of the peri- study was just the position at which the probe was odontal (bone and soft tissue) level but to verify the dif- placed. Nevertheless, in Watts’s study (18), the guide- o ferent ability of the two diagnostic clinical methods ap- lines were marked on the stent with a heated burnish- plied in evaluating periodontal healing under standard- er, but no information was provided about the diameter izi ized conditions. or the depth of the grooves or their height. Cetinkaya The landmarks for radiographic measures were the et al. (11) reported no information about the stent at CEJ and the bottom of the bone defect on the distal all. In the present study, the grooves were furrowed surface of the second molar. during resin hardening, using a probe similar to that Ed used for the measurements, and the groove height was at least 6 mm to guide the probe properly each Probing measurements time into the same position and with the same inclina- tion, despite possibly aberrant pocket anatomy (25), There are three possible main sources of error related scanty visibility and limited patient cooperation due to to probing measurements in the second molar region discomfort or pain caused by gingival inflammation. C (18-20): visual, tactile and positional. The first is related Moreover, to exclude any interference in the correct to the difficulty in visual perception of the probing depth choice of the axis of probe insertion during groove fur- CI on the distal surface of the second molar with the stent rowing, no cases with reconstructions or prosthetic in place. The second is mainly related to the presence crowns on second molars were included in the present of a third molar crown or calculus, which can somewhat study because imperfect distal surfaces might have al- affect the pre-operative probing depth, as well as prob- tered the anatomic relationship between the distal ing force and probe-tip diameter and calibration. The tooth surface and the periodontium, giving rise to diffi- third, which the use of the stent was intended to re- culties in probe insertion and therefore possibly alter- © duce, is related to the different probing point and incli- ing probing depth measurements, which could indicate nation from one measurement to another. a false periodontal condition. A mirror and a 4x loupe were used in the present study Despite the use of the personalized device, some de- to improve visibility during probing measurements. The gree of error is however to be expected. Watts (18) mirror was used not only to look at the reflected image, previously suggested that changes in probing depth because direct reading was obstructed by the stent, but over a period of time are merely due to localized ex- also to reflect the light, thus increasing illumination, aminer error. Because the variation in horizontal 224 Annali di Stomatologia 2013; IV (3-4): 218-229 1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 225 Healing after third molar surgery probing position seems to have been an important er- Another possible cause of probing error and low repro- ror in all of the studies in which individual sites were ducibility of measurements was previously found to be analyzed over time (19), the depth and the height of the depth of sites (19, 25), most likely because the the grooves seemed to be important features to mini- deeper the pocket was, the higher the risk of positional mize positional differences, making subsequent mea- changes of the tip of the probe during its penetration li sures comparable. In the present study, the grooves was, although the use of the stent theoretically mini- were furrowed during resin hardening, using a probe mized this type of possible error as well. na similar to that used in periodontal probing, so they Finally, the state of periodontal tissues can influence were almost perfectly aligned with the site that was to PD measurements as well due to different resistance to be probed. If they were furrowed afterward with a penetration between variously inflamed and healthy tis- cylindrical burr, they could have incorrectly guided sues, as well as the different responses of patients to io the probe into the gingival sulcus due to a wrong in- probe penetration at various degrees of inflammation. clination. Moreover, the grooves ended approximately The use of the stent also avoids that the probe insertion 4 mm coronally to the gingival margin, so the probe axis having to be modified relative to the lower compli- was clearly visible during insertion. Nevertheless, ance of the patient due to possible tissue inflammation. az slight inclination of the probe is possible despite the height of the grooves, which was approximately 6 mm, as well as their depth, which was slightly greater Radiographic measurements than the probe diameter, especially in subsequent rn measurements, because the tapered morphology of The choice to use the radiographic measurements of the probe does not allow the probe diameter to fit the bone defects as objective references might be ques- groove diameter in cases of PD less than the pre-sur- tionable; however, it is a safe and universally recog- te gical PD, so attention was always paid to assure that nized method to obtain subsequent comparable mea- the probe was in the groove for the entire 6 mm tract surements of the bone height in a standardized man- during the measurement. A parallel-sided probe could ner, without surgical re-entry or traumatic periodontal therefore be more adequate in guided probing than a probing (4). However, many sources of technical radi- In tapered one, although this type of probe is less fre- quently used in clinical practice because it is less ographic errors exist, including vertical or/and horizon- tal changes in projection geometry due to different an- able to penetrate periodontal tissues. gulations between the central beam and the film or the Moreover, because it was possible that the stent be- teeth and different distances between the teeth and came unfit over time and could not be used either due the film or the tube (4, 26-29). Because intra-oral radi- ni to slight tooth movements caused by occlusal forces, ographic exams provide two-dimensional representa- orthodontics, tooth extraction or periodontal disease or tions of a three-dimensional condition, in which it can due to conservative or prosthetic tooth rehabilitation be difficult to distinguish between technical artifacts possibly performed during the study period, patient ex- and real anatomic changes, a highly standardized o clusion from the present study was undertaken for method is necessary to limit inter-exam variability and these reasons. Furthermore, the same stent would to improve the interpretation of the radiographic izi most likely be unfit after many years in the case of fur- anatomy. Actually, a horizontal, abnormal central ther measurements to analyze second molar periodon- beam angulation can determine superimposition be- tal modification better after adjacent third molar extrac- tween the tooth root and the bony defect, which can tion over a long period of time, as performed by some otherwise be obscured by the root (29). Similarly, ab- Ed authors (5, 10). normal vertical angulations can determine false dou- Because bone regeneration is certainly greater where ble bone levels, with the lingual more or less apical the infra-bony defect is deeper, which is more often in than the buccal and the bottom of the defect more or the middle of the second molar distal surface due to less close to the alveolar crest (29). third molar crown impaction, the choice to consider In the present study, the reproducibility of radiographic four-point measurements with the guided probing images was always achieved using the long cone par- C method, instead of the two line-angle measurements allel technique, with a precision device and a constant with the standard method, could explain the greater focal object distance of approximately 20 cm. To make CI reliability of the guided method because it might be the subsequent measurements comparable, patients in able to evaluate the healing process, that is, a site- whom prosthetic crowns, fillings or inlays/onlays were specific process, in greater detail than the usual performed on the second molar before the 12-month method. However, because the statistical analysis follow-up, with possible alteration of the second molar was performed using the mean of the measurements crown distal surface, were excluded from the study. obtained with each method, the possible greater sen- Moreover, a millimetric grid was used to measure radi- © sitivity of the guided method, due to the more detailed ographic bone defects and to verify the reproducibility evaluation of the infra-bony defects on the distal sur- of geometric projection. The use of the grid, applied on face of the second molar, could have been diluted. the film before the radiograph was obtained, is a simple Furthermore, slightly greater reliability of the guided and cost-effective method from a biological, as well as method was demonstrated, although measurements an economic, point of view, to minimize errors possibly performed with the two methods only at similar line- caused by radiographic distortion and enlargement angle points were considered. caused by slight differences in film position and/or focal Annali di Stomatologia 2013; IV (3-4): 218-229 225 1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 226 R. Pippi object distance. However, to the best of the author’s can also explain both the inter- and intra-examiner vari- knowledge, there have been no studies on periodontal ability of the method, the guided method compels the healing of the lower second molar distal surface after probe to penetrate each time at the same point and adjacent third molar extraction but only a report on with the same inclination. In fact, the probe is an inves- healing after periodontal treatment in which the grid has tigation instrument, which should be used to freely li been used (30), and this report showed high accuracy search the contour of the bone defect and to detect and in bone defect assessment. For radiation hygiene rea- measure its deepest point. The personalized device na sons, no second radiographs were obtained at the used in the present study, as well as some other de- same time to test the image reproducibility of the ap- vices already proposed in the past, seems to be more plied method. In contrast, because the first radiographs reliable for comparative research studies, in which the were always of good quality, second radiographs were definition of the real anatomy of the defect is not an io never necessary. The reproducibility of radiographic im- aim, while the free probing method should be prefer- ages has been verified in that the millimetric length of ably used in clinical practice. ten contiguous squares of the grid, measured on each The second aspect is the difference between the mean radiograph of the same tooth, was never 0,5 mm radiographic measurements and both the guided and az greater or less than 10 mm, that is, within the approxi- free probing mean measurements. The present results mation range of periodontal PD measurements. In fact, are difficult to explain and disagree with those of low levels of variability have already been shown in the Kuegelberg et al., (4) who found a mean infra-bony in- past in the lower molar region, especially if the parallel crease of approximately 0.6 mm for every millimeter of rn technique with the long cone was used (4, 26-28, 31, increased PD, starting from 3 mm of PD and 1 mm of 32), regardless of the use of a personalized film-holder, infra-bony defect and who suggested that the presence applied by means of acrylic resin or impression material of pseudo-pockets on the distal surface of second mo- te (28, 32), to reproduce the same position of the film lars explained the discrepancy. each time relative to the teeth and therefore to obtain Some considerations can help in understanding the super-imposable subsequent dental radiographs. present results. Probing depth is a linear measurement, Another source of error in bone defect depth measure- which employs the free gingival margin as a superficial because of interference from anatomic structures due In ment is difficulty in radiographic CEJ location (31, 32) reference point and the deepest point of the bone de- fect as a deep reference point. Periodontal probes cer- to horizontal and/or vertical angulation of the central X- tainly never reach the latter point, except in intra-opera- ray beam, although the use of the long cone parallel tive probing or probing at surgical re-entry, although technique seems to result in no significant differences probing to bone, under local anesthetics, has been pro- ni in locating the correct CEJ position when applied in the posed as a more precise method for obtaining more re- lower molar region. To improve the examiner’s ability to alistic measurements (33). Some anatomic variables locate the radiographic reference points, in the present can influence PD measurement: gingival tissue thick- study, measurements were obtained under a 4x magni- ness; bone defect topography; the presence of obsta- o fication view. Higher magnifications have already been cles to probe penetration, such as calculus; and differ- reported to be useless (4). ent consistency and thickness of connective attach- izi The removal of decimals from the definitive radiograph- ment, which are also relevant with regard to different ic measurements for statistical analysis, with approxi- degrees of inflammation. mation to the nearest unit, has already been applied by The mean pre-surgical measurements found in the pre- Kuegelberg et al., (4) and it can be justified by the limit- sent study (xrpre: 6 ± 0.38; devpre 3.10 ± 0.16; stand- Ed ed influence that decimals have on final data. More- pre 5.50 ± 0.27) can be mainly explained by the inter- over, if clinical measurements are related to radi- ference with probe penetration, possibly due to the third ographic measures, it is plausible that the two types of molar crown and sometimes due to the calculus, espe- measurements fall in the same range of approximation. cially in the guided method because it more extensively The possible, although minimal, residual variability of studied the distal surface of the second molar, and ow- radiographic measurements in the present study, ing to the stent, it did not allow the probe to avoid ob- C caused by all of the above-mentioned sources of error, stacles during penetration. As for the 3-month mea- was not very important in the present investigation in surements (xr3 = 4.94 ± 0.40; dev3 = 3.08 ± 0.10; CI that each radiographic measurements, used as objec- stand3 = 4.94 ± 0.25), they can be explained by the re- tive reference of periodontal healing, was related to the sistance to probe penetration offered by the last 1-3 mean PD found at the same time with the two different mm connective attachment fibers because healing had probing methods applied. occurred by then, and the gingival margin was near fi- nal maturation. Finally, increased gingival tissue, as Kuegelberg et al. (4) already suggested, can explain © Descriptive results the results found in the present study regarding the 12- month measurements (xr12: 3,68 ± 0,32; dev12: 2,75 ± The first aspect to be analyzed is the difference found 0,11; stand12: 4,00 ± 0,16). between the mean PD measured with the stent and the The third aspect to be considered is the progression, mean standard PD. One possible explanation for this over time, of periodontal healing on the distal surface of difference is that, while with the free probing method, the lower second molar after adjacent third molar ex- the deepest defect point is sought, and this technique traction. The present results seem to demonstrate pro- 226 Annali di Stomatologia 2013; IV (3-4): 218-229 1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 227 Healing after third molar surgery gressive improvement of soft and hard tissue healing taken in patients with periodontal disease, in which after surgery. This finding is supported by the results healing could be impaired either by the older age of pa- reported by the Critically Appraised Topic of Richard- tients or by the presence of the disease. son and Dodson (16), based on 8 articles they re- The results of the present study, which did not find cor- viewed, in which PD measurements were found, on av- relations between any study variable and the healing li erage, to be unchanged or to have improved 6 to 12 process on the distal surface of the second molar, are months after third molar extraction, although the pre- in line with those of Kuegelberg et al., (5) who showed na sent results refer to 3- and 12-month post-operative that patient sex and age at the time of surgery, the measurements. presence of visible plaque, bleeding on probing, prob- ing depths ≥ 7 mm on the distal surface of the second molar and a widened third molar follicle did not affect io Inferential results the healing process in individuals younger than 20 years of age, although the present results are not sup- The results from the comparison between periodontal ported by those of other studies, which found correla- probing measurements with and without the personal- tions between one or more variables and the healing az ized device with regard to radiographic measures should process. Montero and Mazzaglia (13) found that third be considered with some caution because the differ- molar depth was strongly correlated with both baseline ences between the two models are small, and they could periodontal PD and post-surgical changes. In the study also have been due to random fluctuations. Replication by Kan et al., (10) detectable plaque at the distal sur- rn of this study will therefore be needed to confirm the ap- face of the second molar, mesio-angular third molar im- parent greater reliability of the guided probing depth. paction and the presence of a crestal radiolucency api- Because a low correlation between dev 12/pre and cal to the third molar were found to be related to peri- te stand 12/pre (r = 0.15) was found, it is also possible odontal probing depth in the regression model in indi- that the two methods provide complementary and not viduals just older than 25 years old (27 ± 7). Although it redundant information on second molar periodontal is plausible that the presence of plaque on the distal healing. Actually, because the healing process occurs surface of the lower second molar could influence peri- in a progressive but quantitatively non-homogeneous In manner, probing depth at different points could detect odontal healing after adjacent third molar removal, and because the distal surface of the second molar has different quantitative aspects of the same process. been previously found to show a higher plaque score It is also important to emphasize that the results obtained than other surfaces, this surface could be a locus mi- by the two probing methods were only moderately corre- noris resistentiae for the development of local periodon- ni lated with the results obtained by radiographic measure- titis, as well as for deterioration of the healing process ments, as already found by Kuegelberg et al. (4). This (3). However, despite only a few patients have previ- finding is true either if the mean PD obtained from each ously been found to be plaque-free on this surface, of the two probing techniques was used for statistical plaque was not found to be related to second molar pe- o analysis or if the measurements obtained with the two riodontal healing in patients younger than 20 years old techniques at their only similar point (B and DB) were (6). To verify whether the presence of plaque did or did izi used. This low correlation can be explained by consider- not have an impact on second molar periodontal heal- ing that probing depth and radiographic bone level are ing, no cases were included in the present study in two aspects of the same periodontal picture, which are which the patient’s oral hygiene following extraction only partially related to each other. Hausmann et al. (34) was supervised or enhanced, although it is possible Ed reported that probing attachment level and radiographic that the two scheduled follow-up examinations never- bone level were different features of periodontitis and theless positively influenced patient oral health. Howev- that the weak correlation between their respective er, Kuegelberg et al. (6) already showed that enhanced changes could the result of a number of causes, which plaque control during the initial phase of healing did not range from no relationship to a time lag, which could ob- affect the prevalence of intra-bony defects. scure any relationship. No other authors, with the exclusion of Kuegelberg (5), C A very weak correlation between probing attachment who found post-surgical healing impairment due only to changes and radiographic changes over a 2-year peri- smoking in individuals older than 30 years old, have in- CI od was reported by Pilgram et al., (35) who suggested vestigated the correlation between smoking habits and that although there were some physio-pathologic rea- lower second molar periodontal healing after adjacent sons to believe that a relationship existed between at- third molar extraction. The present results seem to dis- tachment level and bone height, this relationship agree with those of the systematic review by Patel et seemed to be weak, complex and/or not time-related. al., (38) who found that smoking had a negative effect Another likely reason for the low correlation between on bone regeneration. However, these authors ana- © clinical and radiographic measurements is that the lyzed bone regeneration after regenerative therapies in changes over the 1-year study period were within the periodontally compromised patients, while in the pre- range of errors with the measuring techniques used, as sent study, bone regeneration was spontaneous, and already suggested by others (36). the patients were younger and were free from peri- Other previous studies (33, 34, 36, 37) have investigat- odontal disease. ed the correlation between clinical and radiographic as- Because the non-significant effect of each of the pa- sessments of periodontal healing, but they were under- tient- or tooth-related examined variables could also Annali di Stomatologia 2013; IV (3-4): 218-229 227 1_Pippi2_Riv Annali 3-4 2013 13/02/14 10:52 Pagina 228 R. Pippi have been due to the qualitative nature of some of the lar 6-36 months after impacted third molar extraction. A ret- variables (e.g., smoking, plaque, etc.), further studies rospective cross-sectional study of young adults. J Clin Pe- are needed, in which only quantitative measurements, riodontol 2002; 29(11):1004-1011. 11. Cetinkaya BO, Sumer M, Tutkun F, Sandikci EO, and Misir such as the number of cigarettes smoked, the plaque F. Influence of different suturing techniques on periodontal amount and the degree of pre-operative infection, li health of the adjacent second molars after extraction of im- and/or an increased sample size should be evaluated pacted mandibular third molars. Oral Surg Oral Med Oral to investigate whether one or more of the study vari- na Pathol Oral Endod 2009; 108(2):156-161. ables have significant effects on second molar peri- 12. Ana F-I, Mercedes G-T. A modified device for intra-oral ra- odontal healing. diography to assess the distal osseous defects of mandibu- lar second molar after impacted third molar surgery. Imag- ing Sci Dent 2011; 41:115-121. io Conclusions 13. Montero J, Mazzaglia G. Effect of removing an impacted mandibular third molar on the periodontal status of the mandibular second molar. J Oral Maxillofac Surg 2011; In conclusion, within the limits of the present study, a 69:2691-2697. az personalized device seems to provide a more reliable 14. Faria AI, Gallas-Torreira, López-Ratón M. Mandibular second estimate than the standard probing method of peri- molar periodontal healing after impacted third molar extraction odontal healing on the distal surface of the lower sec- in young adults. J Oral Maxillofac Surg 2012; 70:2732- 2741. ond molar after adjacent third molar extraction. 15. Krausz AA, Machtei EE, Peled M. Effects of lower third mo- rn Because all of the examined patient- and tooth-related lar extraction on attachment level and alveolar bone height factors seemed to not be able to affect either second of the adjacent second molar. Int J Oral Maxillofac Surg 2005; molar periodontal healing or probing depth measure- 34(7):756-760. ments obtained with or without the proposed personal- 16. Richardson DT, Dodson TB. Risk of periodontal defects af- ter third molar surgery: an exercise in evidence-based clin- te ized device in individuals younger than 25 years old, it ical decision-making. Oral Surg Oral Med Oral Pathol Oral can be recommended that lower third molar surgical ex- Radiol Endod 2005; 100(2):133-137. traction be performed in young adults. 17. Osborne WH, Snyder AJ, Tempel TR. Attachment levels and crevicular depths at the distal of mandibular second molars In following remval of adjacent third molars. J Periodontol 1982; References 53(2):93-95. 18. Watts T. Constant force probing with and without a stent in 1. Stephens RJ, App GR, Foreman DW. 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2_Pavoni_Riv Annali 3-4 2013 13/02/14 10:23 Pagina 230 Original article Gnathological features in growing subjects li na Fabiana Ballanti, DDS, MS1 of 16,6% of TMDs while males one of 10,8% Salvatore Ranieri, DDS1 (?2=0.556;; p=0.456). According to angle malocclu- io Alberto Baldini, DDS, PhD1 sion, the prevalence was 14% in subjects with Class Chiara Pavoni, DDS, MS1 I malocclusion, 15% in sample with Class II and 9% Patrizio Bollero, DDS, MS2 in patients with Class III (?2=0.540;; p=0.763). Ac- Paola Cozza, MD, DDS, MS1 cording to presence or absence of crossbite, preva- az lence of TMD signs and symptoms was 13,8% among subjects without crossbite and 14,3% among 1 Department of Orthodontics, “Tor Vergata” University subjects with crossbite, with no significant differ- of Rome, Italy ence between the two subgroups (?2= 0,047619;; rn 2 Department of Dental and Oral Pathology, “Tor Ver- p=0.050). In relation of midline deviation, prevalence gata” University of Rome, Italy of TMDs was 15% in subjects without deviation, 15,8% in functional deviation subjects and 4,7% in anatomic deviation ones (?2=1.555;; p=0.05). Preva- te Corresponding author: lence of TMDs was 12,6% in subjects with bilateral Chiara Pavoni chewing and 28% in unilateral chewing. Conclu- Department of Orthodontics, sions. TMDs seem to be not associated to age, to “Tor Vergata” University of Rome viale Oxford, 81 In gender, Angle Class, cross-bite and chewing side. 00133 Rome, Italy Key words: epidemiological study, temporo- E-mail: chiarapavoni@libero.it mandibular disorders, dental malocclusions, skele- tal discrepancy. ni Summary Introduction Aim. Aim of this study was to evaluate the preva- o lence of temporomandibular disorders (TMD) in a Temporomandibular disorders (TMD), a sub-classification sample of consecutive subjects. Materials and of musculoskeletal disorders, has been defined as a col- izi methods. TMDs were recorded in a sample of 580 lective term embracing a number of clinical problems that subjects (279 M, 301 F; mean age: 13.4y). For each involve the masticatory musculature, the temporomandibu- subject a case history was compiled to evaluate the lar joints and associated structures or both of them (1). social and demographic parameters. An extraoral The aetiology and the pathophysiology of TMD are poorly Ed exam was effected to point out the face proportions, understood. It is generally accepted that the aetiology is and an intraoral exam was performed to analyze multifactorial, involving a large number of direct and indi- dental occlusion, mandibular deviation during open- rect causal factors. Among such factors, occlusion is fre- ing, presence of cross-bites, overjet and overbite. A quently cited as one of the major aetiological factors functional exam was carried out to evaluate causing TMD (2). Other aetiological factors are: unstable mandibular movements and to find joint sounds and occlusion, stress and other psychologic factors, trauma, C myofascial pain. The sample was divided into 6 individual predisposition, and structural conditions (3). groups according to the: gender, age (ages 6y- 11y In the past, TMD were considered like a typical degen- CI and 12y-16y), Angle Dental Class, cross-bite, mid- erative disease of the adult and so many epidemiologi- line deviation and chewing side. For this investiga- cal studies were performed in adult population. Fre- tion latex gloves, a millimeter calipers (precision quencies of TMD signs and symptoms were between 0,01 mm) and a phonendoscope were used. The per- 12% to 57% (4-13). centages of signs and symptoms were compared Since the end of the 1970s, several epidemiological using the ?2-test with Yates correction to determine studies of signs and symptoms of TMD in children and © the differences among the groups for the rates of adolescents have been performed. In these studies, the TMDs, reduced opening/lateral/protrusive move- prevalence varies from 5,9% to 66% (14-28). ments, and myofascial pain. Results. The preva- There are several reasons for the diverging results in lence of TMDs in the total sample was 13,9%. previous epidemiological studies. Differences in the Among 6y-11y subjects the percentage of TMD was composition of the material, the examination methods 7,3% while it was 16,1% among 12y-16y subjects and the definitions and criteria for the chosen variables (?2=1.634;; p=0.201). Females showed a percentage are some of the reasons. 230 Annali di Stomatologia 2013; IV (3-4): 230-238 2_Pavoni_Riv Annali 3-4 2013 13/02/14 10:23 Pagina 231 Gnathological features in growing subjects The inevitable inter and intra-individual variations be- the buccal groove of the mandibular first molar. In tween examiners are other explanations. Another im- Class I, the mesiobuccal cusp of the maxillary first portant, yet frequently overlooked reason, is that ex- molar is aligned with the buccal groove of the amination methods designed for adults have been mandibular first molar. In Class II, the molar relation- used for children, without proper consideration of the ship shows the buccal groove of the mandibular first li difficulties and limitations that exist in the examination molar distally positioned when in occlusion with the of children (29). mesiobuccal cusp of the maxillary first molar. In Class na The reasons for interest about these diseases in chil- III, the molar relationship shows the buccal groove of dren stems from the need for early identification the the mandibular first molar mesially positioned to the conditions responsible for the TMD symptoms because mesiobuccal cusp of the maxillary first molar when the they might lead to serious injury to stomatognathic. teeth are in occlusion. io Therefore, the aim of this investigation was to evaluate The sample were then divided into two groups based the prevalence of TMD signs and symptoms in a sam- on the existence of cross bite: 1) absence of cross-bite ple of Caucasian young subjects. (unilateral or bilateral; anterior or posterior) (533 sub- az jects), 2) presence of crossbites (47 subjects). After these classifications, the TMD signs and symp- Materials and methods toms were evaluated using the Research Diagnostic Criteria for Temporomandibular Disorders. rn In the period from October 2011 to November 2012, a re- searcher has proposed to newly arrived 800 subjects to participate in this investigation, but only 580 (279 males Palpation of muscles and TMJ and 301 females, mean age was 13.4 years) acceded to it. te Inclusion criteria were: It was necessary to find myofascial pain and arthralgia. • Caucasian subjects (age range: 6-16 years) Palpation was accomplished mainly by fingertips of the • Newly arrived patients index and third fingers or the spade-like pad of the dis- • No history of orthodontic treatments tal phalanx of the index finger only with standardized In • No history of acute traumatic injury or motor vehicle pressure, as follows: palpation will be done with 2 lbs of accidents pressure for extraoral muscles, 1 lb of pressure on the • No cranio-facial syndromes, metabolic diseases, joint and intraoral muscles. During palpation of one side neurological disorders, neoplasia muscles, it was used the opposite hand to brace the • No social or demographic differences. head to provide stability. ni The social and demographic information, TMD signs Myofascial Pain: pain of muscle origin, including a com- and symptoms, and occlusal features were recorded by plaint of pain as well as pain associated with localized a well–trained clinical researcher on the case history areas of tenderness of palpation in muscles. o based on the standardized Research Diagnostic Crite- It was report pain or ache in the jaws, temples, face, ria for Temporomandibular Disorders (30). preauricolar area or inside the ear at rest or during izi Case history consists in a history questionnaire (Fig.1) function and pain reported by the subject in response to filled in by young subjects with the help of own parents palpation of three or more of following of 20 muscles and in a second part called examination form filled in by sites: posterior temporalis, middle temporalis, anterior a researcher with records coming from clinical evalua- temporalis, origin of masseter, body of masseter, inser- Ed tion (Fig. 2). tion of masseter, posterior mandibular region, sub- The subjects were divided into 6 groups according to mandibular region, lateral pterygoid area, and tendon of gender, age, angle dental class, presence of cross- temporalis. bite; midline deviation; chewing side in Caucasian Arthralgia: pain or tenderness in the joint capsule population. and/or the synovial lining of the TMJ. The sample was first classified into two groups accord- 1) Pain in one or both joint sites (lateral pole and /or C ing to their age: 1) 6-11 years (185 subjects), 2) 12-16 posterior attachment) during palpation; years (395 subjects) and according to their gender, 2) one or more of the following self-reports of pain: CI which included 279 males and 301 females. pain in the region of the joint, pain in the joint during The subjects were then divided according to Angle maximum unassisted opening, pain in the joint during Dental Class into four groups: lateral excursion; Class I: Molar and canine bilateral Class I (311 sub- 3) for a diagnosis of sample artralgia, coarse crepitus jects) must be absent. Class II: Molar and canine bilateral Class II (192 sub- © jects) Class III: molar and canine bilateral Class III (77 sub- Auscultation of TMJ jects) Subdivision Class: different classes in the two sides (0 Using a stethoscope, it was possible to find TMJ subjects). sounds. These sounds may occur as a single click, or The classifications are based on the relationship of may consist of multiple sounds or crepitus. the mesiobuccal cusp of the maxillary first molar and Clicking consists of a single joint sound of short dura- Annali di Stomatologia 2013; IV (3-4): 230-238 231 2_Pavoni_Riv Annali 3-4 2013 13/02/14 10:23 Pagina 232 F. Ballanti et al. NAME PLACE OF BIRTH SURNAME GENDER ADDRESS JOB li DATE OF BIRTH RACE na Please read each question and respond accordingly. For each of the questions below, circle only one response. 1. Would you say your health in general? Excellent Very good io Good Fair Poor az 2. Would you say your oral health in general? Excellent Very good rn Good Fair Poor 3. Have you got? te Genetic disease Metabolic disease Psychiatric disease Anxiety Rheumatoid arthritis In Lupus Systemica arthritic disease Headache Noises or ringing in your ears ni 4. Have you ever had acute traumatic injury or motor vehicle accidents? YES o NO 5. Have you ever had othodontic treatment? izi YES NO 6. Have you had pain in the face, jaw temple, in front of ear or in the ear in the past mouth? Ed YES NO If yes, how many months ago did your facial pain begin for the first time? months _________ 7. Does your jaw click or pop when you open or close your mouth or when chewing? C YES NO CI 8. Have you ever had your jaw lock or catch so that it won’t open all the way? YES NO 9. Have you ever told, or do you notice, that you grind, your teeth or clench your jaw while sleeping at night? YES © NO 10. Have you a favourite chewing side? YES NO If yes, what? Figure 1. History questionnaire. 232 Annali di Stomatologia 2013; IV (3-4): 230-238 2_Pavoni_Riv Annali 3-4 2013 13/02/14 10:23 Pagina 233 Gnathological features in growing subjects Opening patterns Straight Right Lateral Deviation (Uncorrected) li Right Corrected (S) Deviation na Left Lateral Deviation (Uncorrected) Left Corrected (S) Deviation Functional Deviation Anatomic Deviation io Vertical range of motion mm az Unassisted opening without pain Maximun unassisted opening Maximun assisted opening rn Vertical incisal overlap Joint sounds a) Opening Right Left te None Click In Crepitus b) Closing Right Left None Click ni Crepitus Exursions mm o Right lateral excursion Left lateral excursion izi Protrution Joint sounds on excursions Ed Right Sounds None Click Crepitus Excursion right Excursion left C Protrusion CI Left sounds None Click Crepitus Excursion right Excursion left © Protrusion Figure 2. Examination form. tion. It is loud and may be referred to as a pop. Mandibular excursive moviments Crepitation is a multiple rough gravel-like sound de- scribed as grating. It was used a millimeter calipers (precision 0,01 mm) Annali di Stomatologia 2013; IV (3-4): 230-238 233 2_Pavoni_Riv Annali 3-4 2013 13/02/14 10:23 Pagina 234 F. Ballanti et al. Extraoral muscle pain with palpation 0= No Pain 1= Mild Pain 2= Moderate Pain 3= Severe Pain Right Left Temporalis (posterior) Back of temple 0123 0123 li Temporalis (middle) Middle of temple 0123 0123 Temporalis (anterior) front of temple 0123 0123 na Masseter (origin) cheek/under cheejbone 0123 0123 Masseter (body) cheek/side of face 0123 0123 Masseter (insertion) cheek/jawline 0123 0123 Posterior mandibular region (stylohyoid/posterior digastric region) 0123 0123 io Submandibular region (medial pterigoyd/suprahyoid/anterior digastric region) 0123 0123 Joint pain with palpation az Right Left Lateral pole outside 0123 0123 Posterior attachment 0123 0123 rn Intraoral muscle pain with palpation Right Left Lateral pterigoyd area (behind upper molars) 0123 0123 te Tendon of temporalis 0123 0123 Figure 2. (cont.) Examination form. In for measuring mandibular excursive moviments: right These calculations were performed for each of the six lateral excursion, left lateral excursion, protrusive and categories of the groups using Sigma Stat 3.5, midline deviation. Systat Software Inc, Point Richmond, California, USA. ni It was necessary for evalueting reduced opening, later- al and protrusive movements. A restrictive mandibular opening is considered to be of Results any distance < 40 mm. o The lateral movements were noted when they were <8 In this study, the prevalence of signs and symptoms of mm and the protrusive movements were also evaluated TMD was 13,9%. TMD were represented by TMJ izi in a similar manner. sounds. It was not found others like muscle and/or TMJ The sample was then divided into three groups accord- pain or limitation of mandibular moviments. ing to midline deviation that can be classified in: 1) absence of deviation when midline is aligned both in Ed closed mouth and in open mouth (446 subjects); Gender and age range 2) functional deviation when midline is deviated in closed mouth but aligned in open mouth (64 subjects); Prevalence of TMD signs and symptoms within the 3) anatomic deviation when midline is deviated both in sample classified on the basis of gender was 16,6% closed mouth and in open mouth (70 subjects). among females and 10,8% among males, with no sig- Finally it was divided in two groups according to chew- nificant difference with respect to gender distribution C ing side: 1) unilateral chewing (47 subjects) and 2) bi- (χ²=0.556; p=0.456). lateral chewing (533 subjects). Prevalence of TMD signs and symptoms within the CI sample classified on the basis of age was 7,3% among subjects who were 6-11 years old and 16,1% among Statistical analysis those who were 12-16 years old, with no significant dif- ference between the two subgroups (χ²=1.634; The data regarding the prevalence of signs and symp- p=0.201). toms in the groups were analyzed considering the six © categories of groups before described. For each category of groups, the prevalence (ex- Angle Dental Class pressed in percentage with respect to the number of subjects included in each group) of each TMD sign The prevalence of TMD signs and symptoms in sub- or symptom and the percentages among the differ- jects classified according to the Angle Dental Class ent groups were compared using the Chi-square was 14% among subjects who had class I, 15% among analysis. subjects who had Class II and 9% among subjects who 234 Annali di Stomatologia 2013; IV (3-4): 230-238 2_Pavoni_Riv Annali 3-4 2013 13/02/14 10:23 Pagina 235 Gnathological features in growing subjects Figure 3. CLINICAL EXAMINA- TION a) TMJ Palpation; b) Open- ing Patterns; c,d,e,f) TMJ Auscul- tation li na io az a b rn te In ni c d o izi Ed C e f CI had Class III. In this analysis, there were no observed subjects without crossbite and 14,3% among subjects significant differences in the prevalence of any of the with crossbite, with no significant difference between considered TMD signs and symptoms among the differ- the two subgroups (χ²= 0,047619; p=0.050). © ent groups (χ²=0.540; p=0.763). Midline deviation Crossbite According to midline deviation, prevalence of TMD was According to presence or absence of crossbite, preva- 15% among subjects who had no midline deviation, lence of TMD signs and symptoms was 13,8% among 15,8% among subjects who had a functional deviation Annali di Stomatologia 2013; IV (3-4): 230-238 235 2_Pavoni_Riv Annali 3-4 2013 13/02/14 10:23 Pagina 236 F. Ballanti et al. and 4,7% among subjects who had anatomic deviation Other authors instead consider some Angle dental (χ²= 1.555556; p=0.050). classes like risk factors predisposing to TMD. Szentpte- teri et al., in 1986; Selaimen in 2007 consider Class II malocclusions as an important risk factor (13, 35). Chewing Selaimen has analyzed a group of 72 subjects with TMD, li myofascial pain, with or without restriction in the opening According to chewing side, prevalence of TMD was and artalgia comparing with a control group. His analysis na 12,6% among subjects who had a bilanced chewing showed that the absence of a canine in lateral excursions and 28% among subjects who had unilateral chewing (crude OR = 3.9, CI = 1.6 to 9.7) and the Class II maloc- (χ²=2,18181; p=0.050). clusion (crude OR = 8.0, confidence interval [CI] = 2.2 to 29.3) can be considered as potential risk factors (35). io Many authors consider class III malocclusion, especial- Discussion ly those characterized by the presence of scissor-bite and open bite, a condition of potential risk both in chil- az TMD distribution according to gender and age dren and in adult because frequently associated with In this epidemiological investigation we found no signifi- occlusal interferences. cant differences between the DTM and gender and age Among occlusal variables, cross-bite, especially the group. According to gender, our result is similar to unilateral one, has a significant role in the development rn those of some authors (18, 22, 26). Motegi et al. exam- of the TMD. ined 7337 Japanese subjects (3219 F and 4118 M) In support of this thesis, there are in fact several au- aged between 6 and 18 years and found an incidence thors (9, 28, 34, 36). Myers et al. found that in children of DTM, consisting mainly of joint sounds (97.2%), with functional posterior cross-bite, the condyle can be te 12.2%. The incidence of DTM is 11% for males and displaced upwardly from the side of the cross-bite and 13% for females without a statistically significant differ- bottom side without cross-bite (36). ence (18). Motegi has instead showed a higher correlation be- If we consider pain symptoms, the situation changes. tween TMD with crowding (24.9%) and excessive over- In According Walhund K, 2003; Hirsch et al. 2006, Nilsson jet (20.1%). Instead, the correlation with other occlusal IM et al., 2007, females are more severely affected by variables was lower: deep bite (6.8%), bite the head-to- the pain symptoms than males and this can be ex- head (6.3%), anterior cross-bite (5.4%) and posterior plained by considering the different hormonal functions cross-bite (3.8%) (18). (23, 27, 31, 32). Walhund K analysed 864 adolescents People with an excessive overjet, tend to protrude the ni and found a higher prevalence of pain symptoms in fe- mandible (37). This tends to cause a double closure males than in males (23). Hirsch has reached the same (dual bite), which over time could affect the function of conclusion, analysing a sample of 1011 subjects aged the masticatory muscles, increase muscle tension and o 10-18 years (31). In our sample, the pain does not ap- overload the TMJ (38). Occlusal crowd tends to cause pear statistically significant (0 subjects) probably be- occlusal interference and seems to be a critical factor in cause of the young age of the subjects (mean age 13.4 the genesis of TMD. izi years) due to a prepuberal growth stage. Other authors believe that to contribute to the onset of In relation to age, our study showed no significant dif- DTM, it is not malocclusion conceived as a static oc- ferences between the DTM and age in contrast to other clusal relationship but conceived by the functional point studies in which the prevalence of DTM increases with Ed of view. Therefore, any alteration of the occlusal func- increasing age (22, 26, 33, 34). tion as parafunction, habits, premature, interference, Magnusson T, in a prospective study, followed 402 sub- unilateral chewing, may result in TMD (39, 40). jects 7, 11 and 15 years randomly selected for a period of The cross-sectional study conducted by Casanova- 20 years. The author has observed that the prevalence of Rosado on a sample of 506 Mexicans aged 14-25 DTM increases from childhood to adolescence (34). years actually showed as significant risk factors gender Studying 101 adolescents (aged 11-17) with a cross- C (Female Odds Ratio (OR) = 1.7), bruxism (OR = 1.5) sectional study, Le Resche has concluded that the and unilateral chewing (OR = 1.5) (40). prevalence of TMD is linked more to pubertal develop- CI ment rather than to age (33). Our hypothesys because, in relation to age, our study Conclusions showed no significant differences could be the mean age of 12y-16y sample near to 13 years and so due to The results in the current study, in a Caucasian sample a preadolescent stage. of 6-16 years old (580 subjects), indicate that there is © not any association among TMD signs and symptoms and the analysed features. TMD distribution according to occlusal factors In our analysis significant differences between the DTM and the different Angle dental classes were not found. References In accordance with this conclusion there is the study carried out by Tecco et al., in 2011, who analyzed a 1. American Academy of Orofacial Pain. Differential diagno- sample of 1134 subjects (5-15 years) (28). sis and management considerations of temporomandibu- 236 Annali di Stomatologia 2013; IV (3-4): 230-238 2_Pavoni_Riv Annali 3-4 2013 13/02/14 10:23 Pagina 237 Gnathological features in growing subjects lar disorders; in Okeson JP (ed): Orofacial Pain: Guidelines 20. Egermark I, Carlsson GE, Magnusson T. A 20-year lon- for Assessment, Diagnosis, and Management. Quintessence gitudinal study of subjective symptoms of temporo- Publishing Co Inc 1996; 113-184. mandibular disorders from childhood to adulthood. Acta 2. de Leeuw R. 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3_Sale_Riv Annali 3-4 2013 13/02/14 10:39 Pagina 239 Original article Validation of the Italian version of the Oral Health Impact Profile-14 (IOHIP-14) li na Denise Corridore, DDS, PhD1 IOHIP-14 demonstrates an acceptable method to Guglielmo Campus, DDS, PhD2 assess the impact of oral health on the quality of io Fabrizio Guerra, DDS, PhD1 life, with evidence of reliability and validity, mak- Francesca Ripari, DDS, PhD1 ing it a promising instrument for assessing IOHIP Silvana Sale, DDS, PhD2 in an adult population. Livia Ottolenghi, DDS, PhD1 az Key words: oral health, quality of life, IOHIP-14. 1 Department of Oral and Maxillo-facial Sciences, “Sapienza” University of Rome Introduction rn 2 Dental School, University of Sassari Very few valid tools existed to assess functional and psychological outcomes of oral disorders until recently. Corresponding author: te The impact of health on an individual’s quality of life Silvana Sale has been defined as ‘health-related quality of life’ (1). Dental School, University of Sassari Oral health-related quality of life (OHRQoL) come out Viale San Pietro, 43/C I of the development of socio-dental indicators, in order 07100 Sassari, Italy E-mail: si.sale@tiscali.it In to find out non-clinical aspects of oral health, broaden- ing the focus of oral epidemiological research (2). Self-reported health measures have been demon- strated to reflect a pervasive mood disposition of neg- Summary ative affectivity (3). OHRQoL measures should also ni correspond to decision-making criteria (like treatment Objective. The original english version of Oral needs, timing etc). Health Impact Profile (IOHIP) was translated in The original 49-item IOHIP (Oral Health Impact Pro- Italian language, and then validated among a con- o file) was developed by Locker and Slade (2-4) and secutive sample of patients attending in the den- based on Locker’s conceptual model of oral health tal ward at the Dental Institute of the “Sapienza” izi (5). It includes seven domains namely: functional limi- University of Rome, Italy. tation, physical pain, psychological discomfort, physi- Research design. The original english version of cal disability, psychological disability, social disability IOHIP-14 was translated into the Italian language and handicap. The validity and reliability of a short by a professional translator and subsequently Ed version of the questionnaire, the IOHIP-14, has been back-translated into English by an independent documented in several different clinical conditions person and then validated. Participants: 852 per- like oral surgery, elderly, etc (6-7). son, 342 males (40.1%) and 510 females (59.9%) Three different scoring methods of the IOHIP-14 have participated to this survey. Results. The Cronbach’s alpha of the scale was been reported: 1- a simple summary of the recorded 0.90. No correlation was negative and the correla- score (which is expressed as the sum of the seven C tion coefficients extended form 0.27 (the correla- raw sub-scale scores on a scale from 0 to 4 where a tion between “pain“ “irritable”) to 0.69 (the corre- high score signifies worse OHRQoL); 2- a weighted and standardized summary score (where weights are CI lation between “totally unable to function” and “difficult to do jobs”). The coefficients ranged attributed to every question within the domain); 3- the from 0.42 to 0.74 with no value above the drop-out total number of problems reported (i.e. occasionally, value of 0.20 recommended for included an item often, or very often with a possible range of 0–14 in a 15 points scale. A highly significant relation- problems) (8-10). The IOHIP scale originally devel- ship between the IOHIP scores and the perceived oped in English has been recently translated into dif- © oral health status was observed. The subjects ferent languages (10-12) and the various versions of who perceived their oral health status to be poor this scale have shown to be valid and reliable instru- had a higher IOHIP score than those thought their ments to assess oral health-related quality of life in oral health status was good or fair. Similarly there the different populations. was a significant relationship between the IOHIP The aims of the study were to assess the validity and scores and the perceived need for dental care. reliability of the Italian version of the Oral Health Im- Conclusions. The translated Italian version of pact Profile-14 (IOHIP-14). Annali di Stomatologia 2013; IV (3-4): 239-243 239 3_Sale_Riv Annali 3-4 2013 13/02/14 10:39 Pagina 240 D. Corridore et al. Materials and methods 5-point Likert type scale: 0=never, 1=hardly ever, 2=oc- casionally, 3=fairly often and 4=very often. The study protocol received en ethical approval from the Ethics Committee of the “Sapienza” University of Rome n° 507/ 2007. Data analysis li The unweighted Italian IOHIP-14 score was calculat- na Study design ed by summing the scores of the responses to the 14 items while the unweighted IOHIP subscale scores In 2005 a small pilot study (13) was carried out, in were calculated by summing the scores of the re- which the original 49-IOHIP was translated and then sponses to items corresponding to the subscales. Ac- io pre-validated. The results of this pilot study showed cordingly the IOHIP score could therefore range from good reliability of the index, however an excessively 0 to 14 for an individual. Instrument reliability was time-consuming was noted. Since the IOHIP-49 is a measured by assessing internal consistency and test–retest reliability. Internal consistency was as- az long questionnaire and time-consuming to administer, the same research group decided to translate and vali- sessed using Cronbach’s α (which measures the cor- date the shorter and self-administrate IOHIP-14 scale relation between items, i.e. questions), for each of the in a larger sample population. seven health domains, and for all 14 items. To as- sess test–retest reliability, the intraclass correlation rn coefficient (ICC) was calculated based on the repeat- Translation procedure ed subministration of the questionnaire to 25% of the sample after 60 days. Cronbach’s α values and test– te In order to ensure a correct procedure for cross-cultur- retest ICCs above 0.5-0.7 (14-16) are generally con- al adaptation and linguistic validation, the Authors fol- sidered to indicate sufficient reliability for an instru- lowed a translation/back-translation procedure. The ment or scale to be used to make group compar- IOHIP-14 scale was forward translated into Italian by isons; instruments or scales with coefficients above In two translators who are native Italian, are fluent in 0.85 are considered reliable enough for individual pa- tient comparisons. With regard to internal consisten- English and have experience of the issue; then a con- sensus version was identified and subsequently back- cy, inter-item and corrected item- total correlation co- translated into English by an independent person who efficients for the different IOHIP scale items were al- was not involved in the study to guarantee accuracy so calculated (Paerson’s coefficient). The homogene- ni and comparability of the translation. ity of the scale was evaluated on the basis of the cor- rected item-total correlation coefficients computing the correlation between each individual item in the Selection of the sample scale and the rest of the scale with the item of inter- o est eliminated. Construct validity of the scale was as- A consecutive sample of patients attending the Den- sessed examining the association between perceived izi tal Department of the “Sapienza” University of Rome, oral health status, perceived need for treatment, type Italy was invited to take part in this cross-sectional of visit (first examination or recall visit) and the IOHIP study during the first three weeks of the month of scores using Kruskal Wallis test. The acceptability of June 2007. All the subjects were recruited by the clin- the instrument was evaluated by calculating the num- Ed ical staff, trained in the study protocol and procedures ber of missing items (non-responses). All data entry by the investigator team. The clinical staff explained and analyses were conducted with the STATA SE 9.0 the aim of the research and the procedures involved statistical analysis software from STATA Inc. (USA). and asking the participation and to sign a consent Unless stated otherwise, the criterion for statistical form. Participants completed the questionnaire in the significance was set at α=0.05. waiting room. C Cognitive disparity and communication problems among the participants may hamper the use of an in- Results CI strument and seriously affect the results of scoring sys- tems, so subjects with more than 5 missing answers Of the 852 individuals included in the survey, more were excluded from further analysis. than a quarter of the sample (30.99%) was aged During the study period 1045 person attended to the more than 50 years and more than half of them Dental Department of the “Sapienza” University of (69.01%) were between 20-49 years (Tab. 1). Table 2 Rome. All of them were asked to participated, 878 (ac- displays the correlation matrix for the 14 items of the © ceptance rate 84.0%) accepted but the questionnaire IOHIP-14 scale. No correlation was negative and the was completed by 852 person, 342 males (40.1%) and correlation coefficients extended form 0.27 (the corre- 510 females (59.9%) that were enrolled for this survey. lation between “pain“ “irritable”) to 0.69 (the correla- The IOHIP-14 scale consists of 14 questions or items tion between “totally unable to function” and “difficult about impacts that could arise as a result of problems to do jobs”). The reliability was evaluated on the ba- in teeth, mouth or dentures and are grouped into seven sis of the corrected item-total correlation coefficients dimensions or domains. The responses are made on a (Tab. 3). The coefficients ranged from 0.42 (difficult 240 Annali di Stomatologia 2013; IV (3-4): 239-243 3_Sale_Riv Annali 3-4 2013 13/02/14 10:39 Pagina 241 Validation of the Italian version of the Oral Health Impact Profile-14 (IOHIP-14) to relax) to 0.74 (interrupted meals) with no value Discussion above the drop-out value of 0.20 recommended to in- clude an item in a 15 points scale. The Cronbach’s al- The measurement of the oral health-related quality of pha of the scale was 0.90. The results of the assess- life is, ideally, a culturally sensitive instrument, but this ment of construct validity are shown in Table 4. A procedure is a costly and time-consuming work; an al- li highly significant relationship between the IOHIP ternative method would be to translate an existing in- scores and the perceived oral health status was ob- strument and adapt it in an other language i.e. Italian. na served. The subjects who perceived their oral health The present study therefore attempted at validating an status to be poor had a higher IOHIP score than Italian translation of the IOHIP-14 and to adapt the orig- those who thought their oral health status to be good inal English IOHIP version to the Italian cultural envi- or fair. Similarly there was a significant relationship ronment and to investigate its psychometric properties. io between the IOHIP scores and the perceived need The topic of the cross-cultural adaption of health-relat- for dental care. These results support the construct ed self-reported measure have been debated in several validity of the translated IOHIP-14 scale. reports (4, 17). The adopted instruments must be cul- Intraclass correlation coefficients for patients be- az turally and socially appropriate and reliable for the local tween baseline and second administration of the population demonstrating also good psychometric prop- questionnaire (n= 219 subjects 25.70% of the total erties. Therefore a rigorous translation and validation sample examined) were 0.74, and 0.72 using the total process is fundamental before an instrument build up IOHIP-14, weighted and number of problems scoring rn for one culture could be used in another population methods, respectively (data not in table). group with a different culture. All subjects answered to all 14 items of the IOHIP The results of this study were considered sufficient for questionnaire and there were no missing values. 7 the instrument’s use to discriminate subjects with differ- te items (8, 9, 18, 26, 30, 39, 44) lead to impact on less ent levels of perceived oral health and to evaluate than 5% of the participants. At a closer examination, changes in the OHRQoL in a typical target population these items showed a connection to severe oral of the questionnaire survey. The reliability of the instru- health related impacts such as eating/digestion im- ment, assessed using Cronbach’s alpha, was higher pairment and the use of prostheses, which can be ex- pected to be rather infrequent among young people. In the standard criteria deemed (18); furthermore the val- ue achieved in our paper was higher than those report- ed in the original English version (19). Since its devel- opment, the IOHIP-14 has been preferred to the IOHIP- 49 by a number of researchers due to its practicality Table 1. Gender and age distribution of the sample. ni (10, 19). A considerable scientific evidence now exists on the validity and reliability of the IOHIP-14 (20). Age in years Males Females Total The main reason for using the short form was to make 18-29 52 76 128 available an efficient way of data collection based on o 30-39 70 134 204 the premise that a long questionnaire cannot be used in 40-49 94 162 256 some research settings and clinical practices even izi 50-59 48 62 110 though it provides more comprehensive data. A mea- 60-69 38 42 80 sure that takes a long time to be filled in may be not >69 40 34 74 useful in a clinical setting (like a Dental Clinic) due to Total 342 510 852 the burden placed on patients and clinicians (4, 20). Ed Table 2. Internal consistency: IOHIP inter-item correlation, correlation coefficients. IOHIP 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. C 1. Difficult pronounce words — 2. Worsened taste 0.53 — 3. Pain 0.38 0.41 — CI 4. Uncomfortable to eat 0.42 0.45 0.58 — 5. Self-conscious 0.48 0.49 0.58 0.65 — 6. Feel tensed 0.45 0.45 0.53 0.54 0.62 — 7. Diet unsatisfactory 0.43 0.44 0.35 0.52 0.48 0.49 — 8. Interrupted meals 0.47 0.50 0.48 0.54 0.56 0.52 0.58 — © 9. Difficult to relax 0.40 0.47 0.52 0.49 0.55 0.64 0.44 0.61 — 10. Embarrassed 0.39 0.43 0.42 0.49 0.63 0.58 0.47 0.55 0.56 — 11. Irritable 0.39 0.38 0.27 0.33 0.39 0.39 0.42 0.43 0.38 0.47 — 12. Difficult to do jobs 0.41 0.39 0.36 0.35 0.39 0.40 0.49 0.52 0.53 0.43 0.49 — 13. Life less satisfying 0.45 0.46 0.38 0.45 0.50 0.51 0.50 0.54 0.55 0.50 0.50 0.61 — 14. Totally unable to function 0.43 0.44 0.37 0.43 0.42 0.44 0.48 0.58 0.51 0.42 0.45 0.69 0.68 — Pearson coefficient Annali di Stomatologia 2013; IV (3-4): 239-243 241 3_Sale_Riv Annali 3-4 2013 13/02/14 10:39 Pagina 242 D. Corridore et al. Table 3. Reliability analysis: corrected item-total correlation and Cronbach’s alpha. IOHIP Item-total Average total-item alpha correlation covariance 1. Difficult pronounce words 0.58 0.65 0.90 li 2. Worsened taste 0.60 0.65 0.90 3. Pain 0.59 0.64 0.90 na 4. Uncomfortable to eat 0.66 0.62 0.90 5. Self-conscious 0.72 0.61 0.89 6. Feel tensed 0.69 0.62 0.89 7. Diet unsatisfactory 0.64 0.64 0.90 io 8. Interrupted meals 0.74 0.62 0.89 9. Difficult to relax 0.42 0.61 0.92 10. Embarrassed 0.67 0.63 0.90 11. Irritable 0.55 0.66 0.90 az 12. Difficult to do jobs 0.64 0.64 0.90 13. Life less satisfying 0.70 0.63 0.89 14. Totally unable to function 0.67 0.64 0.90 rn Table 4. Association between type of visit, perceived oral health status, perceived need for dental care and IOHIP-14 scores. te Variable IOHIP-14 scores Self perceived oral health Self perceived oral health status on first examination status on recall examination n (%) In n (%) Poor 190 (50.2) 251 (53.2) Fair 132 (35.2) 172 (36.4) Good 55 (14.6) 52 (10.4) P=0.02 Variable IOHIP-14 scores Self perceived need for dental Self perceived need for dental ni care on first examination care on recall examination n (%) n (%) Yes 211 (55.8) 189 (39.9) o No 133 (35.2) 243 (51.3) Don’t know 34 (9.0) 42 (8.9) P=0.001 izi Kruskal-Wallis test was used to test the differences between groups. Ed The high alpha value (0.90) indicates that the 14 study, but the response rate was high and the results items of translated IOHIP scale measures the same permitted to draw conclusions about the validity of the construct. The fit of a specific item to the scale was Italian version of IOHIP-14 in a wider general practice considered deleting the item and examining the population of patients. change in the alpha value of the scale. It was evident No general consensus exists about which method from the results that the omission of any of the 14 should be used to assess reliability, validity and re- C items did not raise the Cronbach’s alpha score of the sponsiveness (10, 21). However, the α coefficients and scale. If an item is well fitted to its scale, the value of test-restest coefficients observed seemed indicate the CI alpha would decrease when the particular item is Italian IOHIP-14 as a reliable method. deleted from the scale. This provides further evidence However, a limitation in this study is that only subjective for the very satisfactory internal consistency of the outcomes were used. Clinical data could reduce per- translated scale. sonal beliefs’ influences on answers in a quality of life- The significant associations between the IOHIP-14 and related questionnaire. subscales scores and the self-rated oral health status Therefore, further studies of the properties of the Ital- © and subject’s perceived treatment need supported the ian IOHIP-14 should be carried out including clinical construct validity of the Italian version of IOHIP. All assessment and testing of the questionnaire in popu- these results were able to suggest that the Italian ver- lations with a higher disease burden/disease variation sion of IOHIP demonstrated good validity and reliability. i.e. diabetic patients or older groups. Other aspects of The inclusion in this sample of irregular attenders – i.e. the questionnaire should be checked as the respon- patients who only register when attending for an imme- siveness of Italian IOHIP-14 to changes in oral health diate problem may be considered a limitation of the conditions. 242 Annali di Stomatologia 2013; IV (3-4): 239-243 3_Sale_Riv Annali 3-4 2013 13/02/14 10:39 Pagina 243 Validation of the Italian version of the Oral Health Impact Profile-14 (IOHIP-14) Conclusions in Sri Lanka. J Oral Rehabil 2004; 31:831-836. 10. Fernandes MJ, Ruta DA, Ogden GR, Pitts NB, Ogston SA. Assessing oral health related quality of life in general den- In conclusion, the translated Italian version of IOHIP tal practice in Scotland: validation of the OHIP-14. Community was valid and reliable as the original English version of Dent Oral Epidemiol 2006; 34: 53-62. IOHIP and then it could be considered a valuable in- li 11. Lopez R, Baelum V. Spanish version of the Oral Health Im- strument for measuring oral health-related quality of life pact Profile (OHIP-Sp). BMC Oral Health 2006; 6:11. na for the Italian population. 12. Wong MCM, Lo ECM, McMillan AS. Validation of a Chinese version of the Oral Health Impact Profile (OHIP). Commu- nity Dent Oral Epidemiol 2002; 30:423-430. 13. Sacco G, Dall’Oca S, Campus G, Ottolenghi L. Quality of life References and oral health. Validation of the Italian version of OHIP-49. io Proceeding Italian Congress of Dentistry 2007; 1:111. 1. Chen MS. Hunter P. Oral health and quality of life in New 14. McDowell I, Newell C. Measuring health. A guide to rating Zealand: a social perspective. Soc Sci Med 1996; 43:1213-1222. scales and questionnaires. Oxford: Oxford University Press 2. Locker D, Slade G. Association between clinical and sub- 1996: p137. az jective indicators of oral health status in an older adult pop- 15. Bland JM, Altman DG. Statistics notes: Cronbach's alpha. ulation. Gerodontology 1994; 11:108-114. Br Med J 1997; 314:572-4. 3. Locker D, Slade G. Oral Health and quality of life among old- 16. Bowling A. Measuring health. A review of quality of life mea- er adults: The Oral Health Impact Profile. J Can Dent Assoc surement scales. Milton Keynes: The Open University 1993; 59:830-833. rn Press 1997: p112. 4. Locker D, Allen PF. Developing short-form measures of oral 17. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guide- health-related quality of life. J Public Health Dent 2002; 62:13- lines for the process of cross-cultural adaptation of self-re- 20. port measures. Spine 2000; 25:3186-91. 5. Locker D. Measuring oral health: a conceptual frame work. 18. Slade GD. Derivation and validation of a short-form oral health te Community Dent Health 1988; 5:3-18. impact profile. Community Dent Oral Epidemiol 1997; 6. Allen PF, Locker D. Do weights really matter? An assess- 25:284-290. ment using the oral health impact profile? Community Den- 19. Locker D, Matear D, Stephens M, Lawrence H, Payne B. tal Health 1997; 14:133-138. Comparison of the GOHAI and the OHIP-14 as measures 7. Hegarty AM, McGrath C, Hodgston TA, Porter SR. Patient- centred outcome measures in oral medicine: are they valid In of the oral health-related quality of life of the elderly. Com- munity Dent Oral Epidemiol 2001; 29:373-81. and reliable? Int J Oral Maxillofac Surg 2002; 31:670-674. 20. Saub R, Locker D, Allison P. Derivation and validation of the 8. Robinson PG, Gibson B, Khan FA, Birnbaum W. Validity of short version of the Malaysian Oral Health Impact Profile. two oral health-related quality of life measures. Communi- Community Dent Oral Epidemiol 2005; 33:378-83. ty Dent Oral Epidemiol 2003; 31:90-99. 21. John MT, Patrick DL, Slade GD. The German version of the ni 9. Ekanayake L, Perera I. The association between clinical oral Oral Health Impact Profile – translation and psychometric health status and oral impacts experienced by older individuals properties. Eur J Oral Sci 2002; 110:425-433. o izi Ed C CI © Annali di Stomatologia 2013; IV (3-4): 239-243 243 

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4_Tetè_Riv Annali 3-4 2013 13/02/14 10:45 Pagina 244 Original article SEM evaluation of human gingival fibroblasts growth onto CAD/CAM zirconia and veneering ceramic for zirconia li na Vincenzo Zizzari, DDS1 to the surface and showed a flattened profile. The Bruna Borelli, DDS2 disc surface covered by HGFs resulted to be wider io Marianna De Colli, PhD1 in Group A than in Group B samples. At SEM obser- Margherita Tumedei, DDS3 vation, after 24h and 72h, differences in cell attach- Donato Di Iorio, DDS3 ment were slightly noticeable between the groups, Susi Zara, PhD1 with an evident flattening of HGFs on both surfaces. az Roberto Sorrentino, DDS, MSc, PhD2 All differences between Group A and group B be- Amelia Cataldi, MD1 came less significant after 7 days of culture in vitro. Enrico Felice Gherlone4 Conclusions. SEM analysis of HGFs showed differ- Fernando Zarone, MD, DDS2 ences in terms of cell adhesion and proliferation, rn Stefano Tetè, DDS3 especially in the early hours of culture. Results showed a better adhesion and cell growth in Group A than in Group B, especially up to 72h in vitro. Dif- 1 Department of Pharmacy, “G. D’Annunzio” University ferences decreased after 7 days, probably because te of Chieti-Pescara, Italy of the rougher surface of CAD/CAM zirconia, pro- 2 Department of Neurosciences and Reproductive and moting better cell adhesion, compared to the Odontostomatological Sciences, “Federico II” Univer- smoother surface of veneering ceramic. sity of Naples, Italy 3 Department of Medical, Oral, and Biotechnological In Key words: CAD/CAM zirconia, veneering ceramic, Sciences, University “G. D’Annunzio” University of human gingival fibroblasts, scanning electron mi- Chieti-Pescara, Italy croscope, zirconia cell attachment, ceramic cell at- 4 Department of Dentistry, “Vita Salute S. Raffaele” Uni- tachment. ni versity, Milan, Italy Introduction Corresponding author: o Stefano Tetè In the last decades, the introduction of metal-free Department of Medical, Oral, restorations has led to the development of innovative izi and Biotechnological Sciences ceramic materials showing excellent optical properties “G. D’Annunzio” University and better mechanical characteristics compared to the Via dei Vestini, 31 early dental ceramics; besides, the introduction of 66100 Chieti, Italy Computer Aided Design/Computer Aided Manufactur- Ed Phone: +39 0871 3554095 ing (CAD/CAM) technologies has allowed high preci- E-mail: tete@unich.it sion and predictability of the restorative results. The most noticeable advantages of the metal-free materials are: translucency, esthetic natural appearance, chro- Summary matic stability, low plaque retention and fluids absorp- tion, high hardness, wear resistance, low thermal con- C Aim. To evaluate the growth of Human Gingival Fi- ductivity and chemical inertness (1). broblasts (HGFs) cultured onto sample discs of Many in vitro and clinical studies reported optimum bio- CI CAD/CAM zirconia and veneering ceramic for zirco- compatibility for high strength polycristalline ceramics nia by means of Scanning Electron Microscope (e.g. alumina, zirconia), showing favorable biological (SEM) analysis at different experimental times. responses in soft tissues. In particular, the use of zirco- Methods. A total of 26 experimental discs, divided in- nia has become more and more widespread in the clini- to 2 groups, were used: Group A) CAD/CAM zirconia cal practice, for the fabrication of single crowns, fixed (3Y-TZP) discs (n=13); Group B) veneering ceramic dental prostheses and implant abutments (2-5). © for zirconia discs (n=13). HGFs were obtained from Prolonged contact between these prostheses and oral human gingival biopsies, isolated and placed in cul- soft tissues makes the biocompatibility and the integra- ture plates. Subsequently, cells were seeded on ex- tion of these materials critical for long-term success (6, perimental discs at 7,5x103/cm2 concentration and 7). Several all-ceramic materials and surface modifica- cultured for a total of 7 days. Discs were processed tion methods were proposed in order to improve bio- for SEM observation at 3h, 24h, 72h and 7 days. compatibility and soft tissue integration of fixed dental Results. In Group A, after 3h, HGFs were adherent restorations (1, 3). 244 Annali di Stomatologia 2013; IV (3-4): 244-249 4_Tetè_Riv Annali 3-4 2013 13/02/14 10:45 Pagina 245 SEM evaluation of human gingival fibroblasts growth onto CAD/CAM zirconia and veneering ceramic for zirconia Some in vitro and in vivo studies on animal models severe illness, unstable diabetes, drug abuse, history of showed that the interaction between gingival fibroblast head and neck irradiation, chemotherapy. Moreover, cells and zirconia surface depends on a number of vari- each subject was pretreated for 1 week with professional ables related to the surface microtopography, the dental hygiene and antibiotic therapy was administered chemical composition and the cell phenotype charac- pre-operatively (amoxicillin/clavulanic acid, 2 g 1 hour li teristics (8). It was shown that the surface roughness before extraction). The tissue fragments were immedi- might alter cellular activity in vitro (9). This could be ac- ately placed in Dulbecco’s modified Eagle’s medium na counted not only for the chemical and biological proper- (DMEM) for at least 1 h, rinsed 3 times in phosphate- ties but also for the structure of the surface, as it is buffered saline solution (PBS), minced into small tissue known that fibroblasts show greater affinity for smooth pieces and cultured in DMEM containing 10% foetal or finely grooved surfaces than for rough ones (10, 11). bovine serum (FBS), 10% penicillin and streptomycin io The aim of the present investigation was to evaluate and 1% fungizone. Cells were maintained at 37°C in a the growth and cell attachment of Human Gingival Fi- humidified atmosphere of 5% (v/v) CO2. Cultured HGFs broblasts (HGFs) onto samples of CAD/CAM zirconia with DMEM containing 10% FBS, 1% penicillin and and veneering ceramic for zirconia at different experi- streptomycin and following 4-8 passages were used. az mental times by means of Scanning Electron Micro- Subsequently, each experimental disc was placed in a scope (SEM) morphologic and qualitative analysis. 12-well plate and HGFs were seeded in each well at 7,5×103/cm2 concentration and cultured for a total of 7 days. HGFs at same concentration were also seeded in rn Methods an empty well as control. A qualitative analysis was performed under SEM for all A total of 26 experimental discs were prepared for this the discs at different experimental times. After 3 h, 24 te in vitro study. Thirteen discs of CAD/CAM yttria-stabi- h, 72 h and 7 days in vitro, test discs were fixed in glu- lized tetragonal zirconia (3Y-TZP) (IPS e.max Zir CAD, taraldehyde 2% in 0.1 M phosphate buffer pH 7.2, Ivoclar Vivadent AG, Liechtenstein, ISO standard rinsed with phosphate buffer 0,15 M, dehydrated in an 13356. 1997) were fabricated in a milling center without increasing ethanol series and finally dried in hexam- receiving any surface treatment (Group A), while other 13 discs of veneering ceramic for zirconia were ob- In ethyldisilazane. The samples were then metallized with gold in a sputtering device and observed by SEM at tained by die-casting in a laboratory and then polished 100x, 800x and 1600x magnification. Cell morphology and glazed (Group B). All the samples had a mean sur- was assessed on micrographs randomly taken indiffer- face of 2,8 cm2. The discs were cleaned and disinfect- ent areas of each experimental discs. The trial was ni ed by ultrasonic treatment in Alconox®-water solution conducted in triplicate for each experimental point. for 5 min; then, they were rinsed with sterile purified water (cell-culture grade) and ultrasonically treated again for 5 min in isopropyl alcohol. The samples for Results o HGFs culture were then transferred aseptically to sterile 12-well cell-culture trays and submerged in isopropyl al- SEM observation of CAD/CAM zirconia discs showed a izi cohol for 20 min, rinsed twice with sterile purified water surface with regular roughness related to the milling and dried for a minimum of 8 h at 60° C under aseptic procedure of manufacturing, while discs of veneering conditions. These procedures of disinfection were con- ceramic showed a smooth surface with only little de- gruent with previously published techniques for testing fects, probably due to the glazing treatment (Figs. 1-3). Ed ceramic materials (12). SEM analysis of HGFs on the different experimental One disc per group was randomly selected and ana- surfaces showed differences in terms of cell adhesion lyzed by Scanning Electron Microscope (SEM Zeiss and growth. EVO-50, Cambridge, UK) for surface morphology ob- Group A revealed HGFs almost completely adherent to servation. the surface with a flattened profile and rather elongated HGFs were obtained from fragments of healthy margin- morphology, already after 3 h in vitro (Fig. 4). More- C al gingival tissue from the retromolar area taken during over, at the same time, the area covered by HGFs re- surgical extraction of impacted third molars in adult sulted higher in Group A than in Group B. HGFs in CI subjects (aged 18 to 60). Each patient gave written in- Group B discs appeared round shaped, flattened on the formed consent for participating in this study as donor surface with round nuclei. After 24 h of culture, both of HGFs in accordance with the Local Ethics Commit- Group A and Group B samples showed HGFs with de- tee, in compliance with Italian legislation and the code finitive morphology, long cytoplasmic elongations, even of Ethical Principles for Medical Research involving Hu- if a reduced area was covered by HGFs in Group B man Subjects of the World Medical Association (Decla- discs (Fig. 5). © ration of Helsinki). After 72 h in vitro culture, SEM observation showed an Before gingival tissue withdrawal, each subject under- evident flattening of HGFs on both surfaces and differ- went complete medical anamnesis for systemic and oral ences in surface coverage could be not noticed be- infections or diseases. All the selected patients had tween the groups at that experimental time (Fig. 6). Af- healthy systemic conditions, including the absence of ter 7 days of culture, both surfaces appeared entirely any diseases that would contraindicate oral surgery. The covered by HGFs and no differences between the exclusion criteria were: uncontrolled periodontal disease, groups could be evidenced (Fig. 7). Annali di Stomatologia 2013; IV (3-4): 244-249 245 4_Tetè_Riv Annali 3-4 2013 13/02/14 10:45 Pagina 246 V. Zizzari et al. A B li na io az C D rn te In ni Figure 1. Scanning electron micrographs analysis of CAD/CAM zirconia disc sample: A) 100x magnification; B) 800x magni- fication; C) 1.60Kx magnification; D) Graphic representation of the surface roughness. o A B izi Ed C C D CI © Figure 2. Scanning electron micrographs analysis of veneering ceramic for zirconia disc sample: A) 100x magnification; B) 800x magnification; C) 1.60Kx magnification; D) Graphic representation of the surface roughness. 246 Annali di Stomatologia 2013; IV (3-4): 244-249 4_Tetè_Riv Annali 3-4 2013 13/02/14 10:45 Pagina 247 SEM evaluation of human gingival fibroblasts growth onto CAD/CAM zirconia and veneering ceramic for zirconia li na io Figure 3. Graphic 3D reconstruction of the surface morphology: A) CAD/CAM zirconia disc sample; B) veneering ceramic for zirconia disc sample. az rn te In o ni Figure 4. Scanning electron micrographs of HGFs cultured for 3 h on the different experimental discs at 100x, 800x, and izi 1600x magnification: A) CAD/CAM zirconia disc sample; B) veneering ceramic for zirconia disc sample. Ed C CI © Figure 5. Scanning electron micrographs of HGFs cultured for 24 h on the different experimental discs at 100x, 800x, and 1600x magnification: A) CAD/CAM zirconia disc sample; B) veneering ceramic for zirconia disc sample. Annali di Stomatologia 2013; IV (3-4): 244-249 247 4_Tetè_Riv Annali 3-4 2013 13/02/14 10:45 Pagina 248 V. Zizzari et al. li na io az rn Figure 6. Scanning electron micrographs of HGFs cultured for 72 h on the different experimental discs at 100x, 800x, and te 1600x magnification: A) CAD/CAM zirconia disc sample; B) veneering ceramic for zirconia disc sample. In o ni izi Ed C Figure 7. Scanning electron micrographs of HGFs cultured for 7 days on the different experimental discs at 100x, 800x, and 1600x magnification: A) CAD/CAM zirconia disc sample; B) veneering ceramic for zirconia disc sample. CI Discussion and conclusion Zirconia has been used in the last years as an excellent biomaterial for orthopedic and oral applications. The Despite the complexity of cells and dental ceramic in- addition of yttria as an allotropic transformation catha- teraction in vivo, which is governed by a number of lytic stabilizer was also investigated, resulting in a stabi- © chemical and physical processes, in vitro studies may lized zirconia ceramic (3Y-TZP), exhibiting well demon- be very useful for a comprehensive material selection strated medium/long term mechanical performances to achieve optimal soft tissue integration. Among the when used for the fabrication of crown/bridge frame- variables related to the structure and composition of works (4, 5, 13-15). Due to a fairly high incidence of biomaterials, one of the main topics is surface topogra- mechanical complications, like the veneer ceramic chip- phy, as it reflects in vitro cell behavior in term of cell ping (16), in the last years the dental research has morphology, proliferation and adhesion. been increasingly focused on the possibility of using 248 Annali di Stomatologia 2013; IV (3-4): 244-249 4_Tetè_Riv Annali 3-4 2013 13/02/14 10:45 Pagina 249 SEM evaluation of human gingival fibroblasts growth onto CAD/CAM zirconia and veneering ceramic for zirconia zirconia as a monolithic material, for anatomically- J Dent 2007; 35:819-826. shaped restorations, without the less fracture-resistant 3. Denry I, Kelly JR. State of the art of zirconia for dental ap- feldspathic veneering ceramic. plications. Dent Mater 2008; 24:299-307. 4. Sorrentino R, Galasso L, Tetè S, De Simone G, Zarone F. The CAD/CAM zirconia discs appeared to be rougher Clinical evaluation of 209 all-ceramic single crowns cemented than the veneering ceramic ones. The evidenced fewer li on natrural and implant-supported abutments with different and slower HGFs attachment to veneering ceramic, luting agents: a 6-year retrospective study. Clin Implant Dent compared to that to zirconia surface, could be ex- na Relat Res 2012; 14:184-197. plained considering that a rough surface could favor fi- 5. Sorrentino R, De Simone G, Tetè S, Russo S, Zarone F. Five- broblasts adhesion and induce more rapidly the typical year prospective clinical study of posterior three-unit zirco- flattened phenotype. In fact, HGFs showed a better ad- nia-based fixed dental prostheses. Clin Oral Investig 2012; hesion and growth on CAD/CAM zirconia rather than 16:977-985. io on ceramic veneer discs surface up to 24 h of in vitro 6. Messer RL, Lockwood PE, Wataha JC, Lewis JB, Norris S, Bouillaguet S. In vitro cytotoxicity of traditional versus con- culture. These findings suggested that a different sur- temporary dental ceramics. J Prosthet Dent 2003; 90:452- face roughness can affect HGFs adhesion and growth 458. az onto the different samples. After 24 h of culture, differ- 7. Li J, Liu Y, Hermansson L, Söremark R. Evaluation of bio- ences in cell attachment between Group A and Group compatibility of various ceramic powders with human fi- B discs became less evident, thus suggesting that, af- broblasts in vitro. Clin Mater 1993; 12:197-201. ter an initial phase of adaptation, HGFs proliferated sig- 8. Piconi C, Maccauro G. Zirconia as a ceramic biomaterial. Bio- rn nificantly faster on the smooth veneering ceramic re- materials 1999; 20:1-225. spect to the rougher surface of CAD/CAM zirconia, as 9. Brunette DM. The effect of implant surface topography on reported by Yamano et al. (17). the behavior of cells. Int J Oral Maxillofac Implants 1988; 3:231-246. For successful tissue integration to prosthetic ceramic 10. Chehroudi B, Gould TR, Brunette DM. A light and electron te materials, cells have to uniformly colonize the surface. microscopic study of the effects of surface topography on the Since after 24h of culture both CAD/CAM zirconia and behavior of cells attached to titanium-coated percutaneous veneering ceramic materials favored an effective HGFs implants. J Biomed Mater Res 1991; 25:387-405. proliferation process, the results of the present in vitro 11. Könönen M, Hormia M, Kivilahti J, Hautaniemi J, Thesleff I. investigation allowed to hypothesize that both the test- In Effect of surface processing on the attachment, orientation, and proliferation of human gingival fibroblasts on titanium. ed surfaces could be suitable to support in vivo soft tis- sue integration. Further in vitro and clinical studies will J Biomed Mater Res 1992; 26:1325-1341. be needed to support the present findings. 12. Messer RL, Lockwood PE, Wataha JC, Lewis JB, Norris S, Bouillaguet S. In vitro cytotoxicity of traditional versus con- temporary dental ceramics. J Prosthet Dent 2003; 90:452- ni 458. Acknowledgements 13. Luthardt RG, Holzhüter M, Sandkuhl O, Herold V, Schnapp JD, Kuhlisch E, et al. Reliability and properties of ground Y- o The authors wish to thank FIRB-Accordi di Program- TZP-zirconia ceramics. J Dent Res 2002; 81:487-491. ma 2010, “Processi degenerativi dei tessuti mineraliz- 14. Ambré MJ, Aschan F, von Steyern PV. Fracture strength of zati del cavo orale, impiego di biomateriali e controllo yttria-stabilized zirconium-dioxide (Y-TZP) fixed dental pros- izi delle interazioni con i microrganismi dell’ambiente”, theses (FDPs) with different abutment core thicknesses and for the fellowship attributed to Dr. V.L. Zizzari and Dr. connector dimensions. J Prosthodont 2013 Jan 4. doi: 10.1111/jopr.12003. [Epub ahead of print]. M. De Colli; dental technician Mr. Attilio Sommella and 15. Takaba M, Tanaka S, Ishiura Y, Baba K. Implant-support- Ed IVOCLAR Vivadent for providing the sample disks. ed fixed dental prostheses with CAD/CAM-fabricated porce- lain crown and zirconia-based framework. J Prosthodont 2013 Jan 4. doi: 10.1111/jopr.12001. References 16. Kimmich M, Stappert CF. Intraoral treatment of veneering porcelain chipping of fixed dental restorations: a review and 1. Zarone F, Russo S, Sorrentino R. From porcelain-fused-to- clinical application. J Am Dent Assoc 2013; 144:31-44. 17. Yamano S, Ma AK, Shanti RM, Kim SW, Wada K, Sukotjo C metal to zirconia: clinical and experimental considerations. Dent Mater 2011; 27:83-96. C. The influence of different implant materials on human gin- 2. Manicone PF, Rossi Iommetti P, Raffaelli L. An overview of gival fibroblast morphology, proliferation, and gene expres- CI zirconia ceramics: basic properties and clinical applications. sion. Int J Oral Maxillofac Implants 2011; 26:1247-1255. © Annali di Stomatologia 2013; IV (3-4): 244-249 249 

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5_Pacifici_Riv Annali 3-4 2013 13/02/14 10:54 Pagina 250 Original article Surface roughness of glass ionomer cements indicated for uncooperative patients according to surface protection treatment li na Edoardo Pacifici, PhD1 VFG) were sectioned perpendicular to the restora- Maurizio Bossù, DDS, PhD1 tion surface and processed for SEM evaluation. io Agostino Giovannetti, DDS, PhD2 Results. No statistical differences in roughness Giuseppe La Torre, MD3 could be noticed between groups or factors. Fol- Fabrizio Guerra, MD, DDS4 lowing microscopic observation, interfaces be- Antonella Polimeni, MD, DDS1 tween restoration material and coating were better az for group IXC than for group VFG. Conclusions. When specimens are obtained simu- 1 Department of Oral and Maxillo-facial Sciences, Pedi- lating normal clinical procedures, the presence of atric Dentistry Unit, “Sapienza” University of Rome, surface protection does not significantly improve rn Italy the surface roughness of GICs. 2 Department of Oral and Maxillo-facial Sciences, Prosthodontics Unit, “Sapienza” University of Rome, Key words: GIC, roughness, coating. Italy te 3 Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Italy Introduction 4 Department of Oral and Maxillo-facial Sciences, Oral In Diagnosis Unit, “Sapienza” University of Rome, Italy Glass ionomer cements (GIC) were introduced by Wil- son and Kent in 1972 (1). These materials are used in restorative dentistry for a variety of qualities such as Corresponding author: adhesion to enamel and dentin in humid conditions, Edoardo Pacifici less volumetric contraction (2), preservation of the pulp, ni Department of Oral and Maxillo-facial Sciences coefficient of thermal expansion similar to dentin, low Pediatric Dentistry Unit solubility in the oral environment and release of fluo- “Sapienza” University of Rome ride, that can aid the affected dentin remineralization Via Caserta, 6 process (3). Nevertheless, their sensitivity to moisture, o 00185 Rome, Italy low mechanical strength and low wear resistance make Phone: +39 06 49976612 glass ionomer restorations usually less durable (4). izi E-mail: edoardo.pacifici@uniroma1.it Because of the abovementioned qualities this cement finds a broader application in pediatric dentistry. In par- ticular, it can become the material of excellence in all Summary cases where it is not possible either to isolate properly Ed the operative field from saliva (with a rubber dam) or to Background. Even today, use of Glass Ionomer Ce- perform all the steps of adhesion and stratification re- ments (GIC) as restorative material is indicated for quired by the composites. In young patients with a low uncooperative patients. level of cooperation the possibility of using a high quali- Aim. The study aimed at estimating the surface ty material that can be quickly applied in non-optimal roughness of different GICs using or not their pro- conditions is extremely important. C prietary surface coatings and at observing the in- In the past decade several studies were conducted to terfaces between cement and coating through SEM. improve the characteristics of GICs. CI Materials and methods. Forty specimens have been Resin-modified glass ionomer cements (RMGIC) and obtained and divided into 4 groups: Fuji IX (IX), Fuji highly-viscous glass ionomer cements (HVGIC) were IX/G-Coat Plus (IXC), Vitremer (V), Vitremer/Finish- developed to overcome the poor mechanical strength ing Gloss (VFG). Samples were obtained using sili- associated to conventional GICs, thus maintaining their cone moulds to simulate class I restorations. All clinical advantages (4). specimens were processed for profilometric evalu- RMGICs, introduced by Mitra in 1991, are made with © ation. The statistical differences of surface rough- the addition of light-cured resin hydrophilic (4). HV- ness between groups were assessed using One- GICs were designed as an alternative to amalgam for Way Analysis of Variance (One-Way ANOVA) posterior preventive restoration (4), where access/isola- (p<0.05). The Two-Way Analysis of Variance (Two- tion are compromised and aesthetics is of secondary Way ANOVA) was used to evaluate the influence of importance, particularly for the Atraumatic Restorative two factors: restoration material and presence of Technique (ART) introduced by the World Health Orga- coating. Coated restoration specimens (IXC and nization for use in developing countries (2). 250 Annali di Stomatologia 2013; IV (3-4): 250-258 5_Pacifici_Riv Annali 3-4 2013 13/02/14 10:54 Pagina 251 Surface roughness of glass ionomer cements indicated for uncooperative patients according to surface protection treatment Hardening of RMGICs occurs both through the tradi- water, the result will be a loss of calcium and aluminum tional acid-base reaction of GICs and through light-cur- ions, surface erosion and loss of the translucency (12). ing polymerization (4). However, acid-base reaction is Surface protection for GICs was assessed by some still the dominant one, while photo polymerization can studies (13). Protecting RMGICs with resin coating be considered as an auxiliary one (4). Photo-polymer- helps HEMA (highly hydrophilic) not to absorb water, li ization only acts on the resin component. The acid- and consequently increases the quality of the cement, base reaction used to harden and reinforce the matrix in particular reducing dimensional variations (11). A na is relatively immature, just after using the lamp. This re- clinical study has shown that GIC protection can im- action is delayed in RMGICs because of the presence prove esthetics, counteracting the color change due to of water inside the mixture of powder and liquid (5), contamination during acid-base reaction (14). which is partially replaced with a water-soluble Therefore, the aim of this study was to assess the inter- io monomer (4). The structure of the resin reduces water action and the influence on topography as well as the spreading within the material (4). GICs come to com- changes in average roughness provided for by different plete polymerization after 1 week, even though the ma- GICs and surface coatings in dental restorations when az trix reaches a sufficient level of acid-base reaction (4) finishing/polishing procedures cannot be implemented. after only five minutes. Surface roughness will be assessed with profilometric In restoration procedures, a surface character, such as measurements and the interface between materials will roughness, can determine the quality and the clinical be examined with SEM analysis. rn behavior of the restoration material (6). Consequently, The tested null hypotheses showed that a statistically great relevance has been given to studies on the similar surface roughness is achieved using or not us- roughness of filling materials and of glass ionomer ce- ing coating on GICs surface and that similar interfaces ments in particular. are achieved using different GICs in combination with te Smooth surfaces can influence the wear of material (2), the proprietary coating. the aesthetic aspect of restorative materials, the onset of spots and can also increase the risk of secondary caries (7). On the other hand, rough surfaces can help Materials and methods In retention, survival and proliferation of many caries-in- Forty specimens were obtained and divided into 4 ducing microorganisms (Streptococcus mutans and groups (n=10): Lactobacillus spp.) in the oral cavity and also favor peri- Group A (IX): Fuji IX GP Fast Capsule (GC Corp., odontal diseases (Porphyromonas gingivalis and Acti- Tokyo, Japan); nobacillosis actinomicetemcomitans) (8); they also fa- ni Group B (IXC): Fuji IX GP Fast Capsule (GC Corp., vor plaque retention causing gingival irritation. Although Tokyo, Japan)/G-Coat Plus (GC corporation, Tokyo surface free energy can play a role in bacterial adhe- Japan); sion and retention, surface roughness overrules the in- o Group C (V): Vitremer (3M ESPE, Seefeld, Germany); fluence of surface free energy (9). Group D (VFG): Vitremer (3M ESPE, Seefeld, Ger- In addition, smoother reconstructions are also easier to many)/Finishing Gloss (3M ESPE, Seefeld, Germany). izi maintain (9) and therefore more durable (8). Specimens were obtained following manufacturers’ in- There are many roughness parameters in use, but structions and at controlled temperature of 23±2°C. arithmetic mean roughness is by far the most common To create a standardized first-class cavity, silicone one. Each roughness parameter is calculated using a molds were prepared with putty impression material, to Ed formula to describe the surface. Arithmetic mean rough- obtain 4 mm wide and 5 mm long samples with a height ness (Ra) is the arithmetic average of all frames of the of about 2.5 mm (Fig. 1). profile filtered by measuring the length from the line of In Groups A and B, after vibrating the capsule for 10s the reference profile. with TAC 400/M (4200 rpm; Linea TAC s.r.l. - Monte- The threshold value of Ra below which no plaque forma- tion is observed (supra-and subgingival) is 0.2 μm (9). C No further reduction in bacterial accumulation is expect- ed below this threshold value. Any increase in surface CI roughness, above 0.2 μm, results in a simultaneous in- crease in plaque accumulation with subsequent increase of the risk of caries and periodontal inflammation (9). GICs are usually hydrolytically unstable during the initial stages of setting (2); in particular, the resin-modified ones, appear susceptible to dehydration (10). RMGICs © water absorption appeared to be dependent on hy- drophilic resin HEMA (2-hydroxyethyl methacrylate) con- tent (11). Drying of these materials leads to a large loss of water, and consequently to irreversible changes in shape, loss of the interface in few minutes and formation of trines and cracks, caused by the material being ex- posed to air (4). In the event of premature contact with Figure 1. First-class cavity replacement silicone molds. Annali di Stomatologia 2013; IV (3-4): 250-258 251 5_Pacifici_Riv Annali 3-4 2013 13/02/14 10:54 Pagina 252 E. Pacifici et al. grosso d’Asti, AT, Italy), the material was dispensed For each specimen, images of the surface were ac- through the capsule tip to bulk fill the mould. quired at 350 magnifications and were then recon- In Groups C and D cement was manually mixed using structed with 3D geometry. Scan area measured ap- a cement spatula and following the manufacturer’s in- proximately 886×670 μm. For each specimen, acquisi- structions, in a ratio of two scoops of powder for two tions ranged from one to five. li drops of liquid. Afterwards, the cement was placed into An excel file containing the coordinates of points in the silicone mould. space was obtained from the 3D geometry of the surface na In all groups, restoration surface was modeled with a profile of the sample. RA values, profile analysis and its Heidemann spatula to obtain a surface as flat as possi- regression line were obtained for each acquisition. Ra ble, however, simulating clinical procedures. field parameter and formula are shown in Table 2. In Groups C and D, GIC was light cured for 30s with a The excel file obtained from the acquisition that de- io conventional quartz-tungsten-halogen light (Polylight 3 scribes the cloud of points on the 3D surface is a matrix Steril; Castellini, Castel Maggiore, BO, Italy; power con- of 1200 rows by 1600 columns. Each column appeared sumption 52 W, wavelength (range) 400-515 nm). to contain from 10 to 200 data due to spurious values. Group B surfaces were covered with coating G-Coat az The values described above were filtered removing Plus using a disposable brush followed by light cure for those data showing three orders of magnitude higher 30 seconds. than the average. The elimination of erroneous data Group D surfaces were varnished with Finishing Gloss, makes surface roughness more evident. included in the manufacturer packaging, using a dis- rn Data always show a gradient, either due to imperfect posable brush and light cure for 30 seconds. All proce- flatness of the surface or to imperfect positioning of the dures were carried out by a single researcher. sample under the microscope. This affects the determi- Glass Ionomer Cements used in the study, their manu- nation of the reference line. To overcome this problem te facturers, batch numbers and compositions are report- the regression line was calculated and roughness mea- ed in Table 1. Coating and their relevant information surements were made with respect to this. are also reported in Table 1. For each acquisition excel cannot filter more than 1200 Before final testing, all specimens were stored for 1 values per column, (1200x1600 = 1920000 values); week at 37°C to complete the self-curing reaction. In due to this amount of data, for each sample, data were collected from 9 different points of the surface. Of these, the surface profile has been viewed. For the Profilometric analysis samples with fewer irregularities the regression line and the values of roughness were assessed. ni Profilometric analysis was carried out according to ISO For each sample, in addition to numerical data, two 3D 4287: 1997 (and 4288: 1996). As to the roughness scans of the area type were carried out and were defined analysis, a HIROX 3D digital microscope (distributed in reticulated axonometric and continues axonometric. Italy by Simitecno Srl for Hirox - USA Inc., River Edge A simulation picture, that is a two-dimensional recon- o (NJ) USA) was used. struction of the surface, was also made. izi Table 1. Composition, batch numbers and the application modes of the materials used in the study. Ed Table 1 The Glass Ionomer Cements Investigated Material Classification Manufacturer Components Batch Average particle size (μm) Fuji IX GP Fast Highly viscous GC Corporation, Powder: # 0603204 7 C Glass Ionomer Tokyo, Japan Alumino silicate Cement glass, pigments Liquid: CI Polyacrylic acid, distilled water Vitremer Resin Modified 3M, St Paul, MN, Powder: # N186025 6.25 Glass Ionomer USA Aluminum fluoride Powder and Cement silicate glass # N190949 © Liquid: Liquid Polymethacrylic acid, hydroxyethylmethacrylate GC Coat Plus Surface coating GC Corporation, #0708031 Tokyo, Japan Finishing Gloss 3M, St Paul, MN, Bis-GMA, # N190764 USA Triethyleneglycoldimethacrylate 252 Annali di Stomatologia 2013; IV (3-4): 250-258 5_Pacifici_Riv Annali 3-4 2013 13/02/14 10:54 Pagina 253 Surface roughness of glass ionomer cements indicated for uncooperative patients according to surface protection treatment Table 2. Ra surface roughness parameter informations. phosphate buffer (pH 7.4) for 24 h and then washed under running water for 30 min. Parameter Field Parameter Formula Later they were post-fixed in osmium tetroxide (OsO4) Ra Amplitude for 2 h, at air temperature. Afterwards, they were washed in a phosphate buffer for li 30 min with 3 changes. The samples were dehydrated with ethyl alcohol at increasing concentrations for a to- na tal of 2 h at air temperature. For maximum drying, specimens were subjected to Statistical analysis “critical point drying” through carbon dioxide (CO2) fluid. The samples were mounted on stubs with silver adhe- io Data obtained following the above mentioned proce- sive conductor (“Silver dag”) and metallized with gold dures were tabulated and statistically analyzed using by sputter coat S150 (Edwards, London, UK). SigmaPlot for Windows 11,0. Mean (standard devia- The samples were examined and observed under field az tion) and median values of rugosity were calculated for emission SEM Hitachi S 4000 (Hitachi Ltd. Tokyo, each group. For each variable, boxplots and whiskers Japan) operating at magnifications ranging from x40 to were plotted for all groups. 2000 and at an accelerating voltage of 8-10 kV. Group’s roughness data distribution was evaluated rn with the Kolmogorov-Smirnov test. As their distribu- tion was abnormal, the use of One-Way Analysis of Results Variance (One-Way ANOVA) for groups was preclud- ed. Data were tested resorting to Kruskal-Wallis Profilometric analysis te Analysis of Variance (ANOVA) that was applied to as- sess the statistical significance of between-group dif- No significant differences were detected between ferences. groups for profilometric value (p>0.05). Results and Roughness data were also assessed with Two-Way statistics regarding Ra values for each tested group are Analysis of Variance (Two-Way ANOVA). The two fac- In shown in Table 3. tors taken into account were restoration material (Fuji Neither material nor surface coating turned out to be IX and Vitremer) and presence of surface coating. a significant factor for profilometric analysis to GICs For all the analyses the level of significance was set at (p>0.05). In addition there was not a statistically sig- α = 0,05. nificant interaction between material and type ni (p>0.05). Table 4 and 5 show the results and statis- tics regarding the comparison between coated and SEM analysis not-coated GICs. o The digital microscope also reported three types of digi- Group B and D specimens, after profilometer testing, tal images: continues axonometric (Fig. 2); reticulated were sectioned perpendicular to the restoration sur- axonometrics (Fig. 3); 2D reconstructions also called izi face, with sections parallel to long axis of the surface, simulation picture (Fig. 4). up to 0.5 mm from the interface between GIC and var- nish. This procedure was performed using a low-speed diamond blade (Isomet 1000, Buehler, Lake Bluff, IL, SEM analysis Ed USA) under water-cooling. The cut samples were frozen in liquid nitrogen and fractured with microtome Microscopic observation has shown differences regard- (Reichert-Jung, Cambridge Instruments GmbH, Nuss- ing the interfaces between the material and the coating loch, Germany) resulting in 3 slices for every specimen. in the various groups. G-Coat Plus shows a continuous Slices were partially incorporated into composite resin, interface with Fuji IX for its entire surface (Fig. 5). No air leaving the interface area free. bubbles were found between the two materials even at a C For both group B and group D, 30 specimens were ob- 1000x magnification. Vitremer and Finishing Gloss show tained that can be analyzed microscopically. a good interdigitation but some bubbles are present CI Specimens were first fixed in 2.5% glutaraldehyde along the interface. Bubbles begin to appear at magnifi- Table 3. Results of Roughness test and statistical significance between Groups. Ra values © Group N Mean sd Median 25%-75% Fuji IX 16 4,69 (6,81) 2.57 0.22-6.28 Fuji IX / G-Coat Plus 13 2,00 (2,94) 0.95 0.62-1.61 Vitremer 15 1,71 (1,23) 1.38 0.68-2.54 Vitremer / Finishing Gloss 10 0,87 (0,66) 0.64 0.39-1.29 Annali di Stomatologia 2013; IV (3-4): 250-258 253 5_Pacifici_Riv Annali 3-4 2013 13/02/14 10:54 Pagina 254 E. Pacifici et al. Table 4. Results of Roughness test and statistical significance between coated and not-coated restorations. Ra values Coated/Not-Coated N Mean sd Median 25%-75% li Coated 23 1,57 (2,38) 0.84 0.49-1.56 Not-Coated 31 3,16 (4,98) 1.52 0.53-3.30 na Table 5. Results of Roughness test and statistical significance between materials. Ra values io Material N Mean Std Dev Median 25%-75% Fuji IX 29 3,488 5,516 1,18 0,386-3,41 az Vitremer 25 1,439 1,141 0,962 0,554-2,149 Figure 2. Continues axonometric: (A) rn IX; (B) IXC; (C) V; and (D) VFG. te In o ni izi Ed Figure 3. Reticulated axonometric: (A) IX; (B) IXC; (C) V; and (D) VFG. C CI © 254 Annali di Stomatologia 2013; IV (3-4): 250-258 5_Pacifici_Riv Annali 3-4 2013 13/02/14 10:54 Pagina 255 Surface roughness of glass ionomer cements indicated for uncooperative patients according to surface protection treatment Figure 4. 2D reconstructions: (A) IX; (B) IXC; (C) V; and (D) VFG. li na io az rn te In o ni izi Ed C Figure 5. Fuji IX - GC Coat Plus interface photomicrographs at different magnification: (A) 40x; (B) 70x; (C) 100x; (D) 400x; (E) 700x; and (F) 1000x. CI cations of 400x (Fig. 6). No debris were found between The two restorative materials commonly used for the GIC and varnish, enabling a more intimate linking. restoration of primary teeth did not differ in terms of sur- face roughness. In literature, surface roughness of GICs was assessed after completion of the polishing Discussion steps (15, 16) and after the application of the material © against a matrix (9). In this study, we tried to measure The formulated null hypothesis has to be accepted, GICs surface roughness after teeth restoration clinical since profilometric analysis has shown that coated procedures in uncooperative patients. GICs are not significantly different compared to not- Surface roughness was always higher than 0.2 μm, coated GICs in. As to SEM analysis, the articulated null that is the threshold value of Ra below which there is hypothesis has to be rejected, since HVGIC proved to no plaque formation (supra- and sub gingival) (9). be different from RMGIC. Most of the papers in literature did not show Ra values Annali di Stomatologia 2013; IV (3-4): 250-258 255 5_Pacifici_Riv Annali 3-4 2013 13/02/14 10:54 Pagina 256 E. Pacifici et al. Figure 6. Vitremer - Finishing Gloss interface photomicrographs at differ- ent magnification: (A) 200x; (B) 500x; (C) 1000x; and (D) 2000x. li na io az rn te lower than 0.2 μm apart from the areas resulting from these steps were performed after the complete harden- compressing GIC against a matrix, which represent the In surfaces as smooth as possible (9). Other clinically ir- ing of the matrix (19). The value of roughness obtained, however, did not reach the limit of 0.2 microns. Per- relevant studies have obtained a surface smoother than forming finishing and polishing after 7 days also de- 0.2 μm but the GIC samples were produced placing a creased bacterial microleakage (20). This phenomenon glass plate on the surface (2, 9). was attributed to moisture contamination and dehydra- ni After application of GICs in the cavity, it is often clinical- tion caused by the procedures of finishing and polishing ly necessary to remove excess material or recontouring during the initial acid-base reaction (21). the restoration (16), although this was achieved with a Another cause of material roughness is partly the incor- matrix. After using a matrix and finishing the surface poration of air bubbles during manual mixing of powder o with an abrasive strip, a rougher surface (6) can be of- and liquid. With encapsulated materials, too mechani- ten obtained. Ending the restoration with the matrix ob- cal vibrations may include air during mixing (9, 18). izi tained, the result is a polymer-rich and relatively unsta- Moreover viscosity can add a higher level of porosity to ble GIC (4). For some materials Van Meerbeek B et al. GICs thus increasing roughness of HVGIC in this study. (17) have found a surface roughness lower than 0.2 μm The particle size difference of GICs influence physical but only after polishing with 4000 grit silicone carbide properties such as fracture toughness, compressive Ed paper. However, often times in uncooperative patients strength, abrasion resistance and surface microhard- polishing and finishing cannot be performed during ness (22). Also the surface roughness of GICs is depen- teeth restoration; this is particularly true in patients with dent partly on their particle size range (16). In this study, “special needs” where the pediatric dentist has a short materials with bigger average particle size (Fuji IX GP period to perform the necessary procedures. Fast) have shown a higher surface roughness median In this study, he resulting values were also higher than value. The mean particle size of Vitremer is 6.25 μm, C 0.5 microns (18) that represent the tongue limit of while that of Fuji IX GP Fast is approximately 7 μm. The roughness distinction. Only RM-GIC used in combina- mean particle size of regular Fuji IX GP is much larger CI tion with its proper coating reached roughness values (13.5 μm). Vitremer show a more homogeneous distrib- close to this discomfort threshold. ution between small and large particles (17). Ra values of 1-1.5 μm were shown in surfaces obtained According to Gladys and van Meerbeek (17), conven- with various steps of finishing, performed immediately tional GICs presented larger mean particle sizes. More- after light curing (9, 15, 16). Finishing and polishing over, these cements are more sensitive to water (7) steps are complicated by the heterogeneity of these ma- and have longer setting time (17). © terials (15, 16). During these steps, it is easier to abrade Although high surface roughness values were obtained the soft matrix, leaving the hard glass particles protrud- by GICs, microbiological tests did not show any ing from the surface (16). Compared to conventional changes in comparison to healthy teeth. This is due to ones, because of their higher hardness, RMGICs show the antibacterial activity of the fluoride content in these a lower reduction of surface roughness after polishing. materials (7). The release of fluoride has a specific bac- Reduced values of roughness were obtained when fin- tericidal effect on Streptococcus Mutans, but only for a ishing and polishing were made after a week, since relatively short period of time (23). 256 Annali di Stomatologia 2013; IV (3-4): 250-258 5_Pacifici_Riv Annali 3-4 2013 13/02/14 10:54 Pagina 257 Surface roughness of glass ionomer cements indicated for uncooperative patients according to surface protection treatment The system used to simulate filling procedures could A bonding failure between GIC and the coating could produce a large spread of values, also among the dif- create a high-roughness area and a gap. Moreover, all ferent areas of the same restoration. Using filling in- those benefits given by coating like fluoride release struments only - without any finishing procedure - it is (28) and microleakage resistance (29) would be lost. impossible to get a homogeneous surface. This lack Additionally, the bond strength of glass ionomer ce- li of homogeneity is also due to the nature of the materi- ments has not been negatively influenced by early ac- al that changes and hardens during the placement for cess to water (30), therefore contrary to the instructions na the self-curing reaction. Surface heterogeneity has issued by most manufacturers, there is no need for a been highlighted by a statistical analysis that did not resin coating. show statistical difference. Statistical analysis also in- The problem of coatings with uncooperative patients dicates that some areas present outlying values. Even is that two additional steps are required for position- io if some areas have shown a low degree of roughness, ing: coating brushing on surface and light curing. it is almost impossible not to find a part of the restora- These procedures are not always possible with this tion with a high value of roughness. This spread of da- type of patients, for which glass ionomer cements are az ta is the main cause of the absence of statistical sig- more indicated. nificance in this study, even if groups present different For future developments, our research shall be focused mean values of roughness. Other studies show more on samples with a wider bearing surface and parallel to homogeneous and smoother surfaces obtained on the planar surface that will be evaluated. rn specimens following polishing procedures that cannot Further studies are necessary in order to clarify the in- always be applicable. fluence of the type of mixing on surface roughness, re- In this study, no statistically significant differences were sistance of coating under continuous masticatory loads observed among the surfaces regardless of the pres- and clinical outcomes of GICs protection. te ence of the coating. Data obtained with this study disagree with those ob- tained by Salama et al. (24) that show a statistically sig- Conclusions nificant difference in the use of coating. However, in this study GIC specimens were prepared pressing the In Within the limitation of this in vitro study, coated surface material against glass slabs. of glass ionomer cements showed a surface roughness Surface protection was further discussed by many stud- similar to uncoated ones. ies. Early found that an improvement of the hydration- Vice versa, better performances were detected for mar- dehydration problem was obtained after the application ginal sealing ability. However, a better interaction with ni of varnish (25). More recent and deeper studies have proper coating was detected with highly viscous glass strongly recommended protecting the surface of GICs ionomer cements compared to resin modified glass to preserve water balance in the system (26). ionomer cements. Results of study show that the use of coating reduces o surface roughness of GICs either for HVGICs than for RMGICs, even though this reduction is not statistically References izi significant. SEM analysis shows that there are differences in the 1. Wilson AD, Kent BE. A new translucent cement for dentistry. relationships between GIC and his specific coating. Fuji The glass ionomer cement. Br Dent J 1972; 132:133-135. IX and GC-Coat show a close interdigitation for the en- Ed 2. da Silva RC, Zuanon ACC. Surface Roughness of Glass tire interface whereas Vitremer and Finishing Gloss Ionomer Cements Indicated for Atraumatic Restorative present areas of weaknesses where there isn’t a close Treatment (ART). Braz Dent J 2006; 17:106-109. connection between the two materials. 3. Brito CR, Velasco LG, Bonini GA, Imparato JC, Raggio DP. Lower viscosity means a low contact angle between the Glass ionomer cement hardness after different materials for surface protection. J Biomed Mater Res A 2010; 93: 243-246. resin and the surface of the restoration, which provides 4. Sidhu SK. Glass-ionomer cement restorative materials: a for the best protection (26), and favors the presence of C sticky subject? Aust Dent J 2011 Jun; 56 Suppl 1:23-30. gaps in the interface between the two materials. 5. Wan AC, Yap AUJ, Hastings GW. Acid-base complex re- There is a theoretical relation between contact angle actions in resin-modified and conventional glass ionomer ce- CI and roughness expressed in the Wenzel equation. But ments. J Biomed Mater Res 1999; 48:700-704. to ensure this relationship an ideal solid and homoge- 6. Bagheri R, Burrow MF, Tyas MJ. Surface characteristics of neous surface is necessary (27). GIC surfaces are het- aesthetic restorative materials - an SEM study. J Oral Re- erogeneous and thus the Wenzel equation cannot ex- habil 2007; 34:68-76. plain any influence of roughness on contact angle. In- 7. Rios D, Honório HM, Araújo PA, Machado MA. Wear and su- fluence of roughness on the contact angle of this non- perficial roughness of glass ionomer cements used as © sealants, after simulated tooth brushing. Pesqui Odontol Bras ideal surface cannot be assumed (27). 2002; 16:343-348. These gaps are not directly correlated with surface 8. Quirynen M, Bollen CM. The influence of surface roughness roughness, but they could represent areas of lower re- and surface-free energy on supra- and subgingival plaque sistance. A problem of the coatings is their resistance formation in man. A review of the literature. J Clin Periodontol under masticatory loads. Where there isn’t a close rela- 1995; 22:1-14. tion between GIC and coating, it is easier to find a 9. Bollen CM, Lambrechts P, Quirynen M. Comparison of sur- break between the two materials. face roughness of oral hard materials to the threshold sur- Annali di Stomatologia 2013; IV (3-4): 250-258 257 5_Pacifici_Riv Annali 3-4 2013 13/02/14 10:54 Pagina 258 E. Pacifici et al. face roughness for bacterial plaque retention: a review of the modified resin composite. J Oral Rehabil 1999; 26: 48-52. literature. Dent Mater 1997; 13:258-269. 21. Mount GJ, Makinson OF. Glass-ionomer restorative cements: 10. Sidhu SK, Sheriff M, Watson TF. In vivo changes in rough- clinical implications of the setting reaction. Oper Dent 1982; ness of resin-modified glass ionomer materials. Dent Mater 7:134-141. 1997; 13:208-213. 22. Yli-Urpo H, Lassila LV, Närhi T, Vallittu PK. Compressive li 11. Cattani-Lorente MA, Dupuis V, Payan J, Moya F, Meyer JM. strength and surface characterization of glass ionomer ce- Effect of water on the physical properties of resin-modified ments modified by particles of bioactive glass. Dent Mater na glass ionomer cements. Dent Mater 1999; 15:71-78. 2005; 21:201-209. 12. Sidhu SK, Sherriff M, Watson TF. The effects of maturity and 23. Forss H, Jokinen J, Spets-Happonen S, Seppä L, Luoma H. dehydration shrinkage on Resin-modified glass-ionomer Fluoride and mutans streptococci in plaque grown on glass restoration. J Dent Res 1997; 76:1495-1501. ionomer and composite. Caries Res 1991; 25:454-458. 13. Shintome LK, Nagayassu MP, Di Nicoló R, Myaki SI. Mi- 24. Salama FS, Schulte KM, Iseman MF, Reinhardt JW. Effects io crohardness of glass ionomer cements indicated for the ART of repeated fluoride varnish application on different restora- technique according to surface protection treatment and stor- tive surfaces. J Contemp Dent Pract 2006; 7:54-61. age time. Braz Oral Res 2009; 23:439-445. 25. Mount GJ. Clinical placement of modern glass-ionomer ce- 14. van Dijken JW. 3-year clinical evaluation of a compomer, a ments. Quintessence Int 1993; 24: 99-107. az resin-modified glass ionomer and a resin composite in Class 26. Karaoğlanoğlu S, Akgül N, Ozdabak HN, Akgül HM. Effec- III restorations. Am J Dent 1996; 9:195-198. tiveness of surface protection for glass-ionomer, resin-mod- 15. Yap AU, Ng JJ, Yap SH, Teo CK. Surface finish of resin-mod- ified glass-ionomer and polyacid-modified composite resins. ified and highly viscous glass ionomer cements produced by Dent Mater J 2009; 28:96-101. rn new one-step systems. Oper Dent 2004; 29:87-91. 27. Aguilar-Mendoza JA, Rosales-Leal JI, Rodríguez-Valverde 16. Yap AU, Tan WS, Yeo JC, Yap WY, Ong SB. Surface tex- MA, González-López S, Cabrerizo-Vílchez MA. Wettability ture of resin-modified glass ionomer cements: effects of fin- and bonding of self-etching dental adhesives. Influence of ishing/polishing systems. Oper Dent 2002; 27:381-386. the smear layer. Dent Mater 2008; 24:994-1000. 17. Gladys S, Van Meerbeek B, Braem M, Lambrechts P, Van- 28. Kotsanos N, Dionysopoulos P. Lack of effect of fluoride re- te herle G. Comparative physico-mechanical characterization leasing resin modified glass ionomer restorations on the con- of new hybrid restorative materials with conventional glass- tacting surface of adjacent primary molars. a clinical ionomer and resin composite restorative materials. J Dent prospective study. Eur J Paediatr Dent 2004; 5:136-142. Res 1997; 76:883-894. 29. Magni E, Zhang L, Hickel R, Bossù M, Polimeni A, Ferrari 18. In Jones CS, Billington RW, Pearson GJ. The in vivo percep- tion of roughness of restorations. Br Dent J 2004; 196:42-45. M. SEM and microleakage evaluation of the marginal integrity of two types of class V restorations with or without the use 19. Yap AU, Ong SB, Yap WY, Tan WS, Yeo JC. Surface tex- of a light-curable coating material and of polishing. J Dent ture of resin-modified glass ionomer cements: effects of fin- 2008; 36:885-891. ishing/polishing time. Oper Dent 2002; 27:462-467. 30. Wang XY, Yap AU, Ngo HC. Effect of early water exposure 20. Lim CC, Neo J, Yap A. The influence of finishing time on the on the strength of glass ionomer restoratives. Oper Dent 2006; ni marginal seal of a resin-modified glass-ionomer and polyacid- 31:584-589. o izi Ed C CI © 258 Annali di Stomatologia 2013; IV (3-4): 250-258 

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Original article Mechanical resistance of carbon and stainless steel hand instruments used in a reciprocating handpiece li na Lucila Piasecki, DDS, MSc1 canal; the time to fracture was recorded for each Dina Al-Sudani, DDS, MSc2 file and data were statistically analyzed (ANOVA). io Alessio Giansiracusa Rubini, DDS, MSc3 Results. Mean values (and SD) were 527 (± 89) sec- Giampaolo Sannino, DDS3 onds for the CS instruments and 548 (± 104) sec- Maurizio Bossù, DDS3 onds for the SS files. No significant differences Luca Testarelli, DDS, MSc3 were observed between groups (p=0,062). az Roberto Di Giorgio, DDS3 Conclusions. According to the results, both carbon Ulisses Xavier da Silva-Neto, DDS, MSc, PhD1 and stainless steel instruments presented similar Christian Giampietro Brandão, DDS, MSc, PhD4 fatigue resistance when used with M4 reciprocating Gianluca Gambarini, MD, DDS, PhD3 handpiece in double curved canals. rn Key words: cyclic fatigue, endodontic instruments, 1 School of Health and Biosciences, PUCPR, carbon steel, stainless steel, reciprocating hand- Curitiba, Brazil piece. te 2 KSU, Riyadh, Saudi Arabia, Arabia 3 Department of Oral and Maxillo-Facial Sciences, “Sapienza” University of Rome, Italy Introduction In 4 State University of West Paraná, Cascavel, Brazil Despite nickel-titanium (NiTi) rotary or reciprocating in- struments have gained popularity among practitioners Corresponding author: and endodontic specialists, the stainless steel (SS) Lucila Piasecki manual files are still widely used for initial canal negoti- ni School of Health and Biosciences, PUCPR ation, to establish an endodontic glide path, to deter- Rua Imaculada Conceicao, 1155 mine working length either radiographically or with the 80215-901 Curitiba, Brazil aid of electronic apex locators and to verify patency. E-mail:lucilapiasecki@hotmail.com Canal negotiation is easier due to the fact the manual o SS files usually have a cutting tip: however, this tip and the inherent rigidity of the alloy are theoretically not ide- izi Summary al for instrumentation of curved canals (1,2). Therefore, the tendency nowadays is to use SS instruments only Aim. The manual files are still widely used for ini- in small sizes (generally smaller than ISO #20) and pre- tial canal negotiation prior the use of nickel-titani- curve the instrument when canal curvatures are ob- Ed um shaping instruments, to determine working served. length and to verify patency. A mechanical glide Motion and methods of use are also very important in path can be performed using manual files with making negotiation easier while preventing iatrogenic handpieces, such as M4 Handpiece (SybronEndo, errors. It has been shown (3) that when a filing or ream- USA) that allows a 30°/30° reciprocating motion. ing motion are applied to an instrument inside a curved The Pathfinders (SybronEndo, USA) are hand files canal, the greatest amount of cutting occurs at the in- C designed to negotiate complex canals, made from ner curve and apex because of the action of a lever stainless steel (SS) or carbon steel (CS) alloys. arm and fulcrum (4). Intending to overcome the curva- CI The aim of this in vitro study was to compare ture influence, the balanced force technique was pro- cyclic fatigue resistance of these two different posed, resulting in better cleaning and less apical types of manual Pathfinder instruments used in a transportation compared to hand filing motion (5-7). M4 reciprocating handpiece in double curved arti- The concept of balanced-forced technique was intro- ficial canals. duced for manual hand filing, but it can be also be Materials and methods. Manual instruments de- mechanized. The M4 Safety Handpiece (Sybron Endo, © signed for glide path (size #9 ISO .02 taper) made Glendora, CA, USA), was developed for mechanical from different alloys were selected: Group SS - preparation of root canals, using manual endodontic in- stainless steel Pathfinders (Sybron Endo) and struments in a 30°/30° reciprocating motion, that can be Group CS - carbon steel Pathfinders size K2 considered the mechanical expression of the balanced (Sybron Endo). Ten instruments of each group were force motion. This M4 handpiece, which can be used tested for resistance to cyclic fatigue with a recip- with electric endodontic motors or be directly connected rocating M4 handpiece inside an artificial S-shaped to the dental unit, features a 4:1 gear reduction, and os- Annali di Stomatologia 2013; IV (3-4): 259-262 259  L. Piasecki et al. cillates 30 degrees in both clockwise/counterclockwise so can be made by using a stiffer alloy, carbon steel directions. It can be used with most of commercially (an alloy that cannot be autoclaved) to allow better ne- available SS or nickel-titanium (NiTi) manual files, not gotiation in complex canals since they can be consider only for preparation but also for enhancing final irriga- single use instruments that easily deform and need to tion or for gutta-percha removal (8). be discarded after one use. li Notwithstanding these interesting properties, a very few Therefore, the aim of this in vitro study was to compare number of studies had been published in the last na two different types of Pathfinder handfiles (size #9 ta- decades about the M4 handpiece (9,10). On the other per .02) made by stainless steel or carbon steel, used hand, many studies demonstrated that SS K-files in a M4 reciprocating handpiece for the negotiation of mounted in a Giromatic (MicroMega, Besancon, France) S-shaped artificial canals, to evaluate if different alloys 90°-90° reciprocating handpiece, were able to negotiate could be more or less beneficial in terms of resistance io narrow canals and maintain the original path, when to cyclic fatigue. used up to a size 25 (11-13). The M4 Handpiece pre- sents smaller reciprocation angles than Giromatic (re- spectively 30°/30° vs 90°/90°), which theoretically az Materials and methods should result in a safer movement, because torsional stress and bending stress are lower when angles are Two different types of size #9 .02 taper manual instru- smaller. Such a constant and predictable 1/12 turn mo- ments were selected: tion can be consider an improved hand filing, being rn Group SS - stainless steel handfiles, Pathfinders; more precise and reproducible than what can be manu- Group CS - carbon steel handfiles, Pathfinders CS, ally achieved (usually 1/4 or 1/8 turn). Therefore, the M4 size K2. handpiece could be used as an alternative for both initial All the instruments (Fig. 1) were produced by the same te negotiation and creation of an endodontic glide path. manufacturer (Sybron Endo,Glendora,Ca,USA), pre- Initial negotiation is the most delicate part of manual senting the same features, to eliminate all variables re- hand filing especially in thin, narrow, calcified and lated to design or manufacturing process; they were vi- curved canals. Clinicians often start by using very small In instruments (ISO sizes #6 to #8) that are meant to find the path towards the apex in complex and challenging sually examined under a stereomicroscope to discard any defective instruments. The device used to test the situations. Therefore, these instruments need a lot of instrument resistance to cyclic fatigue in double shaped different mechanical properties, which often contradict artificial canal have been previously used and de- among themselves: excellent cutting ability, and a cut- scribed in a peer-reviewed scientific article (14). The device (Fig. 2) consists of a mainframe to which a ni ting tip to progress easily through dentin, but only to a certain amount, due to the risk of apical blockage; flexi- mobile plastic support for the electric handpiece is con- bility to follow canal anatomy and prevent transporta- nected, and a stainless steel block containing the artifi- tion, but some inherent rigidity is needed to make pos- cial canals. The electric handpiece was mounted on a o sible to progress a small instrument through the canal, mobile device to allow the precise and reproducible especially when calcified or constricted. Intending to placement of each instrument inside the artificial canal. izi provide these requirements, special instruments have This placement ensured three-dimensional alignment been manufactured and commercialized for the cre- and the positioning of the instruments to the same ation of glide path, such as the Pathfinders (Sybron En- depth. The artificial canal was manufactured by repro- do, Glendora, CA, USA). ducing an instrument’s size and taper, thus providing Ed The manual Pathfinder instruments present a different the instrument with a suitable trajectory. A simulated design from traditional K-files or Reamers, and they al- root canal with a double curvature was constructed: the Figure 1. The two types of tested in- struments: a. Stainless steel Pathfin- der; b. Carbon steel Pathfinder CS C K2. CI © 260 Annali di Stomatologia 2013; IV (3-4): 259-262  Mechanical resistance of carbon and stainless steel hand instruments used in a reciprocating handpiece files. No significant differences were noted between groups (p=0,062). Discussion li Many dentists fear that manual instruments could easily na break when used in an M4 handpiece, especially when working in thin, narrow, constricted or calcified canals. They have read or heard that SS instruments present a high risk of intracanal separation when rotated inside a io curved canal (15). This statement is correct, but in clini- cal practice we need to fully understand how different motions influence performance and safety of endodon- tic instruments. A recent study from Gambarini et al. az (16) showed that SS ISO instruments used in a M4 rec- iprocating handpiece were significantly more resistant that .02 tapered NiTi rotary instruments designed for glide path. These results can be easily explained due to rn the fact that M4 handpiece allows only an oscillating movement inside a canal, not a full rotation: conse- quently, reciprocating SS instruments are very resistant te to cyclic fatigue, significantly more than NiTi rotary in- struments. In fact, even if the NiTi alloy presents a su- perior resistance to fatigue, rotation creates much more instrumentation stresses compared to reciprocation and In as a consequence failure may occur earlier (17). Many studies have been published recently showing Figure 2. The testing apparatus for cyclic fatigue with dou- ble curvature (S-shaped artificial canal). that reciprocating motions reduce both torsional stress and cyclic fatigue of NiTi, regardless of the different manufacturing process (18-22). Interestingly, no stud- ni first coronal curve has 60o angle of curvature with a ra- ies have evaluated the differences between a recipro- dius of 5 mm, located 8mm from the tip of the instru- cating movement and the M4 one. ment, and the second is apical, with 70o angle and a ra- Moreover, in the past many studies have demonstrated dius of curvature of 2 mm, whose center was placed at that resistance to fracture is dependent on the size, de- o 2 mm, from the tip. sign and manufacturing differences of the SS instru- Ten instruments of each group were activated inside ments (24,25). More recently, Gambarini et al. con- izi the double curved artificial canal with a M4 handpiece firmed these data (article in press), showing that file de- (4:1 reduction, 30°/30° reciprocation), mounted in an sign and manufacturing processes play a significant endodontic motor (ASEPTICO, Woodinville, WA), until role in determining resistance to fatigue of SS instru- fracture occurred. ments also when used with a reciprocating handpiece. Ed For each instrument, the time to fracture in seconds (s) The K-files and Reamers with flutes created by a twist- was recorded by the same operator with a chronometer ing process showed greater fatigue resistance, while to an accuracy of 0.1s. After positioning the instrument Hedström files manufactured by a grinding process, into the artificial canal, as soon as the reciprocation were weaker. It has been demonstrated also for NiTi started, timing was initiated and it was stopped when that grinding process is likely to create defects and mi- instrument breakage occurred. Since the instruments crocracks on the external surface of the instruments, C are not fully rotated inside the canal, the actual speed thus reducing resistance to metal fatigue (24). cannot be properly measured. Therefore, time to failure On the contrary, the present study demonstrated that in CI was selected as the most precise way to describe resis- vitro resistance to fracture of manual instruments used tance to breakage. in a M4 Handpiece produced with different alloys (car- Mean values and standard deviation (SD) were then bon vs stainless steel) was not significantly dependent calculated for each group. Cyclic fatigue data were an- on the different characteristics of alloys. Data showed alyzed by one-way ANOVA test to determine any statis- no statistically significant difference between the two tical difference between groups; the significance was tested instruments. © determined at the 95% confidence level. Conclusion Results Carbon steel is a slightly harder and more rigid alloy Mean time to fracture was 527 (± 89) seconds for the than SS, and it is being used for Pathfinder instruments CS instruments and 548 (± 104) seconds for the SS because improved cutting efficiency and a slightly high- Annali di Stomatologia 2013; IV (3-4): 259-262 261  L. Piasecki et al. er stiffness can be beneficial properties for a small in- 11. Weine FS, Kelly RF, Bray KE. Effect of preparation with en- strument, which is meant to negotiate and pre-enlarge dodontic handpieces on original canal shape. J Endod thin, narrow and curved canals. However, in cases of 1976;2:298-303. 12. Klayman SM, Brilliant JD. A comparison of the efficacy of se- complex anatomy such as double curvature canals, rial preparation versus Giromatic preparation. J Endod flexibility and resistance to fracture are more important li 1975;1:334-7. parameters, reducing the risk of iatrogenic errors and 13. Hülsmann M, Stryga F. Comparison of root canal prepara- intracanal separation. na tion using different automated devices and hand instru- Hence we may conclude that tested different alloys did- mentation. J Endod 1993;19(3):141-5. n’t play a significant role in determining fatigue resis- 14. Al-Sudani D, Grande NM, Plotino G, Pompa G, Di Carlo S, tance of the tested instruments. These results support Testarelli L, et al. Cyclic fatigue of nickel-titanium rotary in- the clinical use of both SS and CS Pathfinder instru- struments in a double (S-shaped) simulated curvature. J En- io ments with the reciprocating M4 Handpiece for the cre- dod 2012;38:987-9. 15. Lopes HP, Elias CN, Siqueira JF, Soares RG, Souza LC, ation of an endodontic glide path in the most complex Oliveira JCM, et al. Mechanical behavior of pathfinding en- curvatures, when safety is a concern. dodontic instruments. J Endod 2012;38:1417-21. az 16. Gambarini G, Plotino G, Sannino G, Grande NM, Giansira- cusa A, Piasecki L, et al. Cyclic Fatigue of Instruments for References Endodontic Glide Path. Odontology 2013;in press. 17. Gambarini G, Rubini AG, Al Sudani D, Gergi R, Culla A, De 1. Walia HM, Brantley W, Gerstein H. An initial investigation of rn Angelis F, et al. Influence of different angles of reciprocation the bending and torsional properties of Nitinol root canal files. on the cyclic fatigue of nickel-titanium endodontic instruments. J Endod 1988;14:346-51. J Endod 2012;38:1408-11. 2. Berutti E, Negro AR, Lendini M, Pasqualini D. Influence of 18. Kim H-C, Kwak S-W, Cheung GS-P, Ko D-H, Chung S-M, manual preflaring and torque on the failure rate of ProTa- Lee W. Cyclic fatigue and torsional resistance of two new nick- te perrotary instruments. J Endod 2004;30:228-30. el-titanium instruments used in reciprocation motion: Reci- 3. Weine FS, Kelly RF, Lio PJ. The effect of preparation pro- proc versus Wave One. J Endod 2012;38:541-4. cedures on original canal shape and on apical foramen shape. 19. Plotino G, Grande NM, Testarelli L, Gambarini G. Cyclic fa- JEndod1975;1:255-62. tigue of Reciproc and Wave One reciprocating instruments. 4. Wildey WL, Senia ES. A new root canal instrument and in- In strumentation technique: a preliminary report. Oral Surg Oral Int Endod J 2012;45:614-8. 20. Yared G. Canal preparation using only one Ni-Ti rotary in- Med Oral Pathol 1989;67:198-207. strument: preliminary observations. Int Endod J 2008;41:339- 5. Roane JB, Sabala CL, Duncanson MG. The “ Balanced Force 44. ” Concept for Instrumentation of Curved Canals. J Endod 21. Gambarini G, Gergi R, Naaman A, Osta N, Al-Sudani D. 1985;11:203-11. Cyclic fatigue analysis of twisted file rotary NiTi instruments ni 6. Wu MK, Wesselink PR. Efficacy of three techniques in clean- used in reciprocating motion. Int Endod J 2012;45:802-6. ing the apical portion of curved root canals. Oral Surg Oral 22. Pedullà E, Grande NM, Plotino G, Gambarini G, Rapisarda Med Oral Pathol Oral Radiol Endod 1995;79:492-6. E. Influence of continuous or reciprocating motion on cyclic o 7. Southard DW, Oswald RJ, Natkin E. Instrumentation of curved fatigue resistance of 4 different nickel-titanium rotary in- molar root canals with the Roane technique. J Endod struments. J Endod 2013;39:258-61. 1987;13:479-89. 23. Rubini AG, Sannino G, Pongione G, Testarelli L, Al-Sudani izi 8. Masiero AV, Barletta FB. Effectiveness of different techniques D, Jantarat J, Luca M, Gambarini G. Influence of file motion for removing gutta-percha during retreatment. Int Endod J on cyclic fatigue of new nickel titanium instruments. Ann Stom- 2005;38:2-7. atol 2013; 4:149-151. 9. Lloyd A, Jaunberzins A, Dhopatikar A, Bryant S, Dummer PMH. 24. Haikel Y, Gasser P, Allemann C. Dynamic fracture of hybrid Ed Shaping ability of the M4 handpiece and Safety Hedstrom Files endodontic hand instruments compared with traditional in simulated root canals. Int Endod J 1997;30:16-24. files. J Endod 1991;17:217-20. 10. Kosa D, Marshall G, Baumgartner JC. An analysis of canal 25. Roth WC, Gough RW, Grandich R, Walker W. A study of the centering using mechanical instrumentation techniques. J En- strength of endodontic files: potential for torsional breakage dod 1999;25:441-5. and relative flexibility. J Endod 1983;9:228-32. C CI © 262 Annali di Stomatologia 2013; IV (3-4): 259-262 

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7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 263 Case report A case report of a TPS dental implant rigidly connected to a natural tooth: 19-year follow-up li na Alessandro Quaranta, DDS, PhD1 Conclusions. The present case report showed the Ottavia Poli, MD, DDS2 complete functionality and stability of a tooth to im- io Iole Vozza, DDS, PhD2 plant rigidly connected FPD over a period of 19 years. 1 School of Dentistry, “Politecnica delle Marche” Univer- Key words: dental implants, natural tooth, rigid az sity, Ancona, Italy connection, follow-up. 2 Department of Oral and Maxillo-facial Sciences, “Sapienza” University of Rome, Italy Introduction rn Corresponding Author: The incorporation of natural teeth as abutments in im- Alessandro Quaranta plant-supported restorations is sometimes necessary to School of Dentistry reach chewing comfort. However, the survival rates of te Politecnica delle Marche University both implants and reconstructions in combined tooth- Via Tronto 10, implant supported fixed partial dentures (FPDs) are 60020 Ancona, Italy lower than those reported for solely implant supported E-mail: alessandro.quaranta@univpm.it In FPDs (1). In addition, the convenience of connecting tooth to implant is a very discussed issue since an im- plant does not feature the same anatomical and physio- Summary logical aspects of a tooth. In fact, while the tooth is pro- vided with periodontal ligament that functions as an hy- ni Aim. A partial edentulous area was restored with a draulic system, a dental implant does not feature any tooth to implant fixed partial denture and a rigid periodontal ligament and is directly connected with the connection between the two elements. Maintenance surrounding bone. Teeth with healthy periodontal liga- recalls were performed over a 19-year period of ob- ment show mobility of 50-200 μm upon displacement of o servation on a yearly basis. the crown with a force of 01. N (2, 3) while dental im- Methods. The following parameters were collect- plants demonstrate values less than 10 μm (4). More- izi ed during each examination over the entire period over, tactile perception of natural tooth abutments was of observation: PD around the implant and natural shown to be significantly higher than that demonstrated tooth abutment, gingival index, modified gingival for implant abutments. Sensory feedback due to peri- index, plaque index, modified plaque index, oc- odontal mechanoreceptors located in the periodontal Ed clusal assessment, marginal bone loss. Radi- ligament are extremely sensitive to external stimuli. ographic assessment of peri-implant bone remod- These receptors have thresholds of about 20 μm of eling was performed in a retrospective way. The thickness in between antagonistic teeth and 1-2 g upon following reference points were assessed on each tooth loading. After extraction of teeth the periodontal image: fixture-abutment junction, threads, first ligament and its receptors disappear. contact of the crestal bone with the implant on Following the placement of dental implants detection C both mesial and distal side. This made possible, thresholds are increased to at least 50-100 μm of with the known values for implant diameter and thickness and 50-100 g upon tooth loading. The un- CI length, to make linear measurements of remain- derlying mechanism of the so-called ‘bone-percep- ing peri-implant bone measured from the mesial tion’ phenomenon remains a matter of debate, but it and distal marginal bone levels and the fixture- is assumed that mechanoreceptors in the 4 peri-im- abutment junction. The amount of bone change plant bone and neighbouring periosteum may be acti- over the baseline to a 19 years follow-up observa- vated by implant loading (5). In order to compensate tion time was calculated for both the implant and the different intrusion behaviours of teeth and im- © the natural tooth. plants in a tooth to implant FPD, a stress disposer Results. Clinical parameters showed healthy values has been suggested (6). In this experimental study it over the entire period of observation with slight iso- was noted that the value of resorption around the im- lated positive bleeding on probing. Bone remodel- plant rigidly attached with the natural tooth did not ing values were constant over the entire period with jeopardize implant integration. Additionally it was ob- slight higher values around the tooth. Peri-apical ra- served that the rigid connection is more favourable diographs did not show any intrusion of the tooth. than the connection with disposer because it is able Annali di Stomatologia 2013; IV (3-4): 263-268 263 7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 264 A. Quaranta et al. to attenuate the intrusion of natural tooth. Finally, in this study it was recommended to design pontic as short as possible to prevent the phenomenon of intru- sion and more straight as possible to prevent lateral displacement of the natural abutment. Other re- li searchers have evaluated the biomechanical stress of perimplant bone in tooth to implant FPDs (7). Spe- na cific factors that positively reduced the stress were the rigid connection, the number of splinted teeth and the direction of the prosthetic loading. This in vitro re- search was performed using 3-D finite element analy- io sis. The three variables were compared to the value of the stress on the bone and mobility of teeth in- volved. The results showed that load direction and tooth mobility were the main elements affecting stress az Figure 1. Baseline X-ray showing the absence of 2.8, 2.9 value on bone tissue. The occlusal stress as cause of natural teeth. teeth lateral movement in FPDs has been investigat- ed in another study (8). This experiment was carried out with the non-linear finite element analysis and thetic elements. A gold ceramic crown was also rn computed tomography. One-piece and two-piece im- planned on tooth # 30. The patient adopted an antimi- plants splinted to natural teeth were used and the crobial prophylaxis with a mouthwash of 0.12% chlorex- quality of periodontal support was varied. The analyti- idine (Dentosan 0.12%, Pfiezer, New Brunswick, NJ, te cal results showed as oblique load caused greater USA) rinsing for 1 minute prior to surgery and three stress on the bone tissue than axial stresses. One- times a day for the following 10 days. Systemic antibi- piece implant absorbed occlusal forces better than otics were prescribed (Zimox ® 1gr, Pfiezer, New two-piece one while the degree of periodontal support Brunswick, NJ, USA; 3 gr for day; amoxicillin for 6 days and the number of splinted teeth according to these In authors slightly affected the transmission of stress on starting 1 hour before surgery). Local anesthesia was induced by infiltration with articaine/epinephrine (Eco- the bone around FPDs (9). The purpose of the pre- cain® 20 mg/ml, Molteni Dental, Italy). A full thickness, sent study was to evaluate on a long follow-up time crestal incision was made and the bone site exposed. (19 years) the peri-implant bone remodeling, the peri- The implant placement was performed following the in- ni odontal and peri-implant health and the success rate structions of the implant manufacturer under abundant of a combined tooth to implant FPD supported by a saline solution irrigation. A TPS cylindrical hollow-bas- plasma sprayed (TPS) implant rigidly splinted to a ket design implant was inserted (ITI Bonefit®, Strau- natural tooth abutment. mann, Switzerland) (4.1 mm diameter x 12 mm length) o (Fig. 2). The patient was instructed to maintain a liquid or semiliquid diet for the first three days and then grad- izi Materials and methods ually return to a normal diet. Painkiller medications (Aulin®, nimesulide 100 mg, Roche, Italy) were pre- Treatment plan, implant surgery scribed and adopted by patient when needed. A two- and prosthetic restoration stages surgery was adopted and the implant healed Ed completely covered and uneventfully. The surgical un- On January 1994 a 53 years old, healthy patient covering of the implant was performed 4 months later (G.L.R.), was visited in the Unit of Prosthodontics and and an healing abutment was connected to the implant. Implant Dentistry, School of Dentistry, “Sapienza” Uni- Fifteen days after the suture removal an impression versity of Rome. The patient reported as his chief com- was taken and a temporary methacrylate resin FPD plaint the need to restore a distal edentulous area in connecting the implant and the tooth # 29 was deliv- C the left lower jaw. The patient also reported severe hy- ered. Five months following the implant placement a persensitivity on tooth # 28. The clinical assessment pick-up impression with polivinylsiloxane material (Op- CI confirmed that teeth # 30 and 31 were missing and a tosil ® and Xantopren ® , Bayer, Germany) was per- deep gingival recession was observed on the buccal formed. A single casting with a proper design to aspect of tooth # 2.89 (A.D.A. Classification). No addi- achieve a reduced occlusal surface and avoid exces- tional dental treatments were required. Peri-apical radi- sive deflecting stress was made. In order to prevent ographs and clinical examination revealed optimal peri- premature contacts on the implant occlusal surface and odontal status on teeth # 28 and 29 and sufficient bone consequent excessive stress to the abutment natural © to place standard dental implants in the area of teeth # tooth a “group” occlusal model was made. In this type 30 and 31 (Fig. 1) Several treatment modalities were of occlusal model, the residual teeth had the first oc- proposed to the patient and because of financial rea- clusal contact. A gold-ceramic FPD was finally deliv- sons he opted for a tooth to implant FPD with the ered and cemented. Although the patient was thor- placement of a dental implant in position 31 while in- oughly informed about the need of a strict periodontal volving tooth 29 as mesial abutment. The FPD was and implant maintenance therapy, he did not show up planned with a rigid connection between the two pros- at the first control visit that was planned 6 months after 264 Annali di Stomatologia 2013; IV (3-4): 263-268 7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 265 A case report of a TPS dental implant rigidly connected to a natural tooth: 19-year follow-up li na io az Figure 2. Periapical X-ray performed following implant placement. Figure 3. The fixed partial is rigidly connected between the natural tooth and the dental implant. the prosthetic loading. The first supportive visit was car- rn ried out after one year; when the temporary crown on tooth # 28 was removed and a definitive gold alloy and ceramic crown was fixed (Figs. 3, 4). After wards, a te supportive therapy program was performed on a regu- lar basis (every 4 to 6 months). The final clinical and ra- diographic assessment was made on March 2012. In Clinical evaluation Over the entire period of observation, the following pa- rameters were collected during each examination: ni a. PD around the implant and natural tooth abutment; b. gingival index (GI) and modified gingival index (mGI) Figure 4. Periapical X-ray performed after fixed partial den- (10, 11); ture and single crown delivery. c. plaque index (PI) and modified plaque index (mPI) o (12, 13); d. occlusal assessment; veloper under standardized conditions. The radi- izi e. marginal bone loss. ographs, set on a cephalometric unit in a dark room, Probing depth was recorded at four aspects for both were acquired and converted in digital images with a the implant and the natural tooth (mesio and disto buc- camera, and saved into a computer memory in TIFF cal, buccal, lingual). Plaque and gingival indices for the format. Later each image was processed with specific Ed natural tooth and modified plaque index (mPI) and gin- software (Scion Image Beta 4.03 for Windows XP, gival index (mGI) for the implant respectively were Scion LTD USA) and displayed on a high resolution used. The patient was instructed about proper daily oral monitor. A computer assisted calibration was made on hygiene procedures to perform 3 times a day through mesial and distal side of each implant measuring the the use of medium hardness dental brush, interdental known distance between 2 threads. This calibration al- brushes, and mouth washes. lowed a correct measurement even if there was a C slight deviation of the central beam and a consequent magnification of the image. The following reference CI Radiographic assessment points were assessed on each image: fixture-abut- ment junction, threads, first contact of the crestal bone Radiographic assessment of peri-implant bone remod- with the implant on both mesial and distal side. This eling was performed in a retrospective way according made possible, with the known values for implant di- to two previously published papers (14, 15). Briefly, ameter and length, to make linear measurements of standardized peri-apical radiographs were taken using remaining peri-implant bone measured from the © a Rinn XCP Ring positioner (Dentsply, Constanz, Ger- mesial and distal marginal bone levels and the fixture- many) and a beam guiding rod to allow parallelization abutment junction. The linear measurements were between the x-ray tube and the film and standardize made by a trackball driven cursor on a 10 times mag- all the radiographs. The radiographs were performed nified digitized image of the implant on the monitor. with a dental x-ray machine (Dentsply, Constanz, Ger- The amount of bone change over the baseline to a 19 many) equipped with a long tube that operated at years follow-up observation time was calculated for 70Kw/7.5mA and were developed in an automatic de- both the implant and the natural tooth. Annali di Stomatologia 2013; IV (3-4): 263-268 265 7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 266 A. Quaranta et al. Results of the bridge. This may subject the entire framework to flexion and significantly dislocate the tooth in the All the clinical and radiographic parameters collected apical direction. It is important to emphasize that, al- over the entire period of follow-up are reported in though in a different way, dental implants allow mod- Table 1. The values of GI and PI for natural tooth and ulation of functional occlusal loads similarly to teeth. li mGI and mPI for the implant showed a minimal in- To better understand the behavior of perimplant crease over time with a slight increase around the bone, which is able of activating a continuous dynam- na natural tooth during the seventeenth year when the ic remodeling in order to adapt to the variations of oc- presence of bleeding on probing and calculus was clusal loads, it has been introduced the concept of observed. No peri-implant and periodontal pockets "bone-perception" (17). Some researchers published were observed during all the follow-up period. No recommendations that should be considered during io prosthetic complications as discementation, abutment the treatment planning of a tooth to implant rehabilita- loosening, ceramic or metallic fracture were ob- tion. Firstly, it is essential to assess the morphology served. Peri-apical radiographs did not show any in- of the natural abutment roots and it is better to use curved or oval-section roots. Secondly, the connec- az trusion, even minimal, of the tooth abutment (Fig. 5). Bone remodeling around the two abutments is tion between anterior teeth and implants should be showed in Table 2. Constant values over the time avoided because anterior teeth have a greater hori- with slight higher values around the tooth were ob- zontal clinical mobility (90-108 μm) compared to im- plants (18). From the clinical point of view, in order to rn served. ensure predictability of the tooth and implant support- ed restoration, it is appropriate not to splint periodon- Discussion and conclusion tally compromised dental elements with high mobility te since this causes a cantilever with excessive stress Tooth to implant FPDs are characterized by the pres- on implants with massive loss of peri-implant bone ence of supporting elements (teeth and implants) that tissue as final result. Some Authors suggested the feature a different viscoelastic deformation. This may use of rigid connection to avoid the intrusion of teeth In determine tooth intrusion and the possibility of lateral in tooth to implant FPDS (19). Other Authors re- viewed the incidence of intrusion in tooth-implant movement followed by a fast viscoelastic return. Im- plants have very reduced movements compared to connection and concluded that rigid connections natural teeth. For these reasons, tooth to implant seem to produce the greatest stress on the natural FPDs should be planned and made after a very care- tooth, periodontal ligament and perimplant bone tis- ni ful evaluation. In order to correctly select the natural sue while the non-rigid connections reduce stress on abutment the following parameters should be consid- the bone while increasing it on the prosthetic restora- ered: periodontal status and bone support around the tion. These Authors observed that FPDs with rigid natural tooth. Teeth with clinical mobility should not connection had an higher success rate than non-rigid o be used as prosthetic abutments (16). The tooth to one (20). Another study carried out on 876 implants implant distance is another key factor. An increased in 244 partially edentulous patients rehabilitated with izi tooth to implant distance may increase shock and fixed prostheses anchored on implants rigidly con- cause peri-implant bone remodeling (17). Moreover, nected to the natural elements showed as after 15 the presence of a long intermediate pontic between years of functioning just one single implant failed the implant and the tooth and any axial force applied while all the remaining implants did not show any Ed to the restoration may determine a bending moment functional or stability loss (21). Similar results were Table I. Clinical parameters during 19-years follow-up. Follow-up IPD IPD IPD IPD mPI mGI TPD TPD TPD TPD PI GI C period mesio facial disto lingual mesio facial disto lingual facial facial facial facial CI Baseline NA NA NA NA NA NA NA NA NA NA NA NA 1 year 2.5 2.0 2.5 2.5 0 0 2.0 1.5 2.0 2.0 0 0 3 years 2.5 2.0 2.0 2.5 0 0 2.0 1.5 2.0 2.0 0 0 5 years 3.0 2.0 2.5 3.0 0 0 2.0 2.0 2.5 2.0 0 0 7 years 3.0 2.0 2.5 3.0 1 0 2.0 2.0 2.5 2.0 0 0 9 years 3.5 3.0 3.0 3.0 1 1 2.5 2.0 2.5 2.5 1 1 © 11 years 3.5 3.0 3.0 3.0 1 1 2.5 2.0 3.0 2.5 1 1 13 years 3.5 3.0 3.5 3.0 1 1 2.5 2.5 3.0 3.0 1 1 15 years 3.5 3.0 3.5 3.5 1 1 2.5 2.5 3.0 3.0 1 2 17 years 4 3.0 4.0 3.5 2 1 3.0 2.5 3.0 3.0 2 2 19 years 4 3.0 4.0 4.0 2 2 3.0 2.5 3.5 4.0 2 2 Mean 3.3 2.6 3.05 3.01 0.9 0.7 2.4 2.1 2.7 2.6 0.8 0.9 NA: Not Assessed 266 Annali di Stomatologia 2013; IV (3-4): 263-268 7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 267 A case report of a TPS dental implant rigidly connected to a natural tooth: 19-year follow-up Figure 5. Periapical X-rays made dur- ing the maintenance therapy per- formed on a two year basis. li na io az rn te In o ni izi Ed published in a review in which a total of 25 papers limits of the present case-report and we do think that were included. The Authors concluded that the use of longitudinal studies about the success and survival rigid connectors produce clinical results more favor- rates of tooth to implant restorations are urgently able compared to interlock or to heat sinks of the oc- needed. However, in the present case report it was clusal load with evident predictability in the long term possible to observe the complete functionality and C and reducing severe biological and prosthetic compli- stability of a tooth to implant rigidly connected FPD cations as intrusion of natural tooth abutment (22). over a period of 19 years. This paper described the The TPS screw is a commercially pure titanium im- case of a fixed tooth to implant partial denture that CI plant with a plasma-sprayed surface that was origi- has been observed for 19 years. Although a case re- nally described by Ledermann (23). In recent years port manuscript does not feature the highest level of most of dental implant manufacturers do not produce scientific evidence, the present paper describes the TPS implants anymore. As a matter of fact, these sur- successful restoration of an edentulous area with a faces were replaced by sandblasted and etched ones fixed tooth to implant rehabilitation. The long term © (SLA) because it has been shown that medium rough success of this case was possible because a very surfaces may increase the bone-implant contact careful treatment planning has been developed. In (BIC) in both the early (3 months from healing) and fact, evaluation of the root morphology of the natural late (12 months) stages of osseointegration process tooth abutment, the adoption of a rigid connection (24). However, different studies did not register any and the design of the pontic are the main key factors differences in bone covering between the TPS and for the long term successful restoration of this type of SLA surfaces (25). We are, of course, aware of the implant prosthetic rehabilitation. Annali di stomatologia 2013; IV (3-4): 0-0 267 7_Quaranta_Riv Annali 3-4 2013 13/02/14 10:49 Pagina 268 A. Quaranta et al. Table II. Peri-implant bone remodeling during 19-years follow-up. Follow-up BIO-OS- TPS IMPLANT NATURAL TOOTH Baseline 0 0 1st Year following Prosthetic Loading 0.29 0.40 li 3rd Year following Prosthetic Loading 0.31 0.41 na 5th Year following Prosthetic Loading 0.21 0.45 7th Year following Prosthetic Loading 0.18 0.47 9th Year following Prosthetic Loading 0.29 0.48 11th Year following Prosthetic Loading 0.31 0.46 io 13th Year following Prosthetic Loading 0.30 0.49 15th Year following Prosthetic Loading 0.21 0.47 az 17th Year following Prosthetic Loading 0.30 0.48 19th Year following Prosthetic Loading 0.20 0.45 Total mm 2.6 3.10 rn References 13. Danza M, Tortora P, Quaranta A, et al. Randomised study for the 1-year crestal bone maintenance around modified di- te 1. Lang NP, Pjetursson BE, Tan K, Brägger U, Egger M, Zwahlen ameter implants with different loading protocols: a radiographic M. A systematic review of the survival and complication rates evaluation. Clin Oral Investig 2010; 14:417-26. of fixed partial dentures (FPDs) after an observation period 14. Quaranta A, Cicconetti A, Battaglia L, Piemontese M., Pom- pa G, Vozza I. Crestal bone remodeling around platform of at least 5 years. II. Combined tooth--implant-supported FPDs. Clin Oral Implants Res 2004; 15:643-53. 2. Muhleman HR. Die physiologische und pathologische Zahn- In switched immediately loaded implants placed in sites of pre- vious failures. Eur J Infl 2012; 10:115-122. 15. Lulic M, Brägger U, Lang NP, et al. Ante's (1926) law revisit- beweglichkeit. Schweizer Monatsschrift fu¨r Zahnheilkunde ed: a systematic review on survival rates and complications of 1951:1-71. fixed dental prostheses (FDPs) on severely reduced periodontal 3. Muhleman HR. Periodontometry, a method for measuring tissue support. Clin Oral Implants Res 2007; 18:63-72. tooth mobility. Oral Surgery 1951; 4:1220-1223. ni 16. Baron M, Haas R, Baron W, et al. Peri-implant bone loss as 4. Cohen SR, Orenstein JH. The use of attachments in com- a function of tooth-implant distance. Int J Prosthodont bination implant and natural tooth fixed partial dentures: a tech- 2005; 18:427-33. nical report. Int J Oral Maxillofac Implants 1994; 9:230-234. 17. Klineberg I, Murray G. Osseoperception: sensory function o 5. Jacobs R. Periodontal tactile perception and Peri-implant Os- and proprioception. Adv Dent Res 1999; 13:120-9. seoperception. In Lindhe J. Clinical Periodontology and Im- 18. Misch CE, Bidez MW. Implant-protected occlusion: a bio- plant Dentistry. Blackwell Munksagaard 2008:122-23. izi mechanical rationale. Compendium 1994; 15:1330, 1332, 6. Naert IE, Duyck JA, Hosny MM, et al. Freestanding and tooth- 1334 passim; quiz 1344. implant connected prostheses in the treatment of partially 19. Sheets CG, Earthman JC. Tooth intrusion in implant-assisted edentulous patients. Part I: An up to 15-years clinical eval- prostheses. J Prosthet Dent 1997; 77:39-45. uation. Clin Oral Implants Res 2001; 12:237-44. Ed 20. Hita-Carrillo C, Hernández-Aliaga M, Calvo-Guirado JL. Tooth- 7. Lin CL, Wang JC, Chang WJ. Biomechanical interactions in implant connection: a bibliographic review. Med Oral Patol tooth-implant-supported fixed partial dentures with variations Oral Cir Bucal 2010 Mar 1; 15(2):e387-94. in the number of splinted teeth and connector type: a finite 21. Jemt T, Lekholm U, Adell R. Osseointegrated implants in the element analysis. Clin Oral Implants Res 2008; 19:107-17. treatment of partially edentulous patients: a preliminary study 8. Lin CL, Wang JC, Chang SH, et al. Evaluation of stress in- on 876 consecutively placed fixtures. Int J Oral Maxillofac duced by implant type, number of splinted teeth, and vari- Implants 1989; 4(3):211-7. C ations in periodontal support in tooth-implant-supported fixed 22. Hoffmann O, Zafiropoulos GG. Tooth-implant connection: a partial dentures: a non-linear finite element analysis. J Pe- review. J Oral Implantol 2012; 38(2):194-200. riodontol 2010; 81:121-30. 23. Ledermann Ph. Vollprotetische Versorgung des Zahnlosen CI 9. Silness J, Loe H. Periodontal disease in pregnancy II. Cor- Problemunterkiefers mit Hilfe von 4 titan-plasmabeschichteten relation between oral hygiene and periodontal condition. Acta PDL-schraubenimplantaten. Schweiz Mschr Zahnheilk; Odontol Scand 1964; 22: 121-135. 1979; 89:137-145. 10. Loe H, Silness I. Periodontal disease in pregnancy I. Preva- 24. Albrektsson T, Wennerberg A. Oral implant surfaces: Part lence and severity. Acta Odontol Scand 1963; 21:533-551. 2--review focusing on clinical knowledge of different surfaces. 11. Mombelli A, van Oosten MA, Schurch E Jr, Land NP. The mi- Int J Prosthodont 2004; 17(5):544-64. © crobiota associated with successful or failing osseointegrat- 25. Cochran DL, Schenk RK, Lussi A, et al. Bone response to ed titanium implants. Oral Microbiol Immunol 1987; 2:145-51. unloaded and loaded titanium implants with a sandblasted 12. Mombelli A, Lang NP. The diagnosis and treatment of peri- and acid-etched surface: a histometric study in the canine implantitis. Periodontol 2000 1998; 17:63-76. mandible. J Biomed Mater Res 1998; 40(1):1-11. 268 Annali di Stomatologia 2013; IV (3-4): 263-268 

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8_Vellone 5b_Riv Annali 3-4 2013 24/02/14 12:49 Pagina 269 Case report Diagnosis and treatment of synovial chondromatosis of the TMJ: a clinical case li na Valentino Valentini, MD, PhD Introduction Paolo Arangio, MD, PhD io Sara Egidi, MD Synovial chondromatosis is a rare, benign, chronic, Marco Capriotti, MD progressive and proliferative lesion that usually af- Valentino Vellone, MD fects large joints (1). This disease is characterized by Marco Castrechini, MD az the development of cartilaginous nodules within the Giulio Bosco, MD space of synovial joints, tendon sheaths or cases; the Piero Cascone, MD nodules subsequently degrade, detach and form free- floating, calcified bodies within the joint space. In rn 1933, Axhausen (2) described the first case of syn- Maxillo-facial Surgery Unit ovial chondromatosis affecting the temporomandibu- “Sapienza” University of Rome, Italy lar joint. The aetiology still remains unknown, but a history of trauma and inflammation is often found (3, te 4). Clinical symptoms of chondromatosis affecting the Corresponding author: TMJ are often characterized by swelling, pain, Valentino Vellone headache, crepitation, malocclusion and joint dys- Maxillo-facial Surgery Unit function. The big challenge concerning synovial chon- “Sapienza” University of Rome Viale del Policlinico, 155 In dromatosis is to suspect and establish a correct diag- nosis. These nonspecific initial signs and symptoms 00161 Rome, Italy may mimic other nonspecific TMJ’s diseases and can E-mail: valentino.vellone@gmail.com easily lead to a delay in diagnosis or a misdiagnosis. Here we present a case of synovial chondromatosis ni of the TMJ and the appropriate diagnostic and treat- ment performed. Summary o Synovial chondromatosis is a rare, benign, chron- ic, progressive and proliferative lesion that usual- Case report izi ly affects large joints. This disease is character- ized by the development of cartilaginous nodules A 60 year-old Caucasian woman referred to our De- within the space of synovial joints, tendon partment of Maxillofacial surgery, swelling in the left sheaths or cases; the nodules subsequently de- pretragic preauricular region (Fig. 1). Ed grade, detach and form free-floating, calcified Her medical history revealed, nonspecific pain, maloc- bodies within the joint space. In 1933, Axhausen clusion and headaches. She didn’t receive any specific described the first case of synovial chondromato- diagnosis during the years and she was subjected to sis affecting the temporomandibular joint. The ae- many orthpanoramic x-ray (Fig. 2) and orthodontic tiology still remains unknown, but a history of treatment for many years without any improvement be- trauma and inflammation is often found. Clinical fore admission in our department. C symptoms of chondromatosis affecting the TMJ She was subjected to a MRI of the TMJ, which reported are often characterized by swelling, pain, on the left side a huge serous effusion involving the su- CI headache, crepitation, malocclusion and joint perior compartment, above ligaments of the retrodiscal dysfunction. The big challenge concerning syn- tissue. The liquid component of the spillage was even ovial chondromatosis is to suspect and establish studied through dynamic acquisitions showing its mobil- a correct diagnosis. These nonspecific initial ity and its morphological changes resulting from condy- signs and symptoms may mimic other nonspecif- lar and meniscal movements. ic TMJ’s diseases and can easily lead to a delay The patient referred us that she performed arthrocente- © in diagnosis or a misdiagnosis. Here we present a sis (5) and anti-inflammatory therapy yet in another case of synovial chondromatosis of the TMJ and medical structure without any benefits. After a year of the appropriate diagnostic and treatment per- worsening symptoms, the patient performed CT scan, formed. which showed the presence of reactive tissue, fluid content in the joint capsule and fragmentation of the Key words: temporomandibular joint, chondrocalci- cortical bone (Fig. 3). nosis, TMJ surgery. According to the patient’s history we decided then to Annali di Stomatologia 2013; IV (3-4): 269-272 269 8_Vellone 5b_Riv Annali 3-4 2013 24/02/14 12:49 Pagina 270 V. Valentini et al. li na io az rn Figure 3. CT scan image. te In Figure 1. Patient with left pretragic preauricular swelling. o ni izi Ed Figure 2. Orthopanoramic x-ray. treat her with TMJ open surgery (6). The patient’s left Figure 4. White, gritty and parenchymatous mass removed. TMJ was explored through a preauricular approach; the joint capsule was opened to expose the upper C joint space. A white, gritty and parenchymatous mass Discussion was removed from the anteromedial aspect of the up- CI per joint space to the condyle head (Fig. 4). This ma- Synovial chondromatosis is a rare, benign process that terial was sent for histologic and citologic examina- typically affects large joints of young adults. Although it tion together with portion of articular capsule. Minimal more commonly involves the knee, elbow, and hip, it remodeling of the glenoid fossa was performed. may occur in the temporomandibular joint (TMJ). This No recurrence was apparent six months after the op- disease is characterized by the development of carti- eration. laginous nodules within the synovial space from the © Histologic examination of the material composed of synovial connective tissue matrix (8); the nodules sub- fibrocartilage showed a focal cluster of hematoxylin sequently degradated, detached and become fluctuat- crystalline deposition in proximity to neoangyogene- ing intrarticular bodies tending to calcify in the joint sis area and little chronic inflammation cells (7). This space. The involved joint space may also become suggested a nonspecific chondrocalcinosis. widened, and articular erosions may occur, eventually The patient showed good functional recovery after leading to secondary osteoarthritis. In 1933, Axhausen surgery and a complications free follow-up (Figs. 5, 6). described the first case of synovial chondromatosis af- 270 Annali di Stomatologia 2013; IV (3-4): 269-272 8_Vellone 5b_Riv Annali 3-4 2013 24/02/14 12:49 Pagina 271 Diagnosis and treatment of synovial chondromatosis of the TMJ: a clinical case cal signs, the development of nonspecific pain and headaches can lead to a delay in diagnosis or to a mis- diagnosis of other more common causes of headaches. However, CT is now being used with great success to evaluate TMJ disorders. li Progress in imaging with computed tomography and magnetic resonance have improved the ability to delin- na eate temporomandibular disease markedly, particularly with use of sagittal and coronal section imaging. It is important a complete evaluation, particularly with the use of diagnostic imaging for a correct evaluation of io TMJ intra-articular disease, which can appear to be a cause of nonspecific headaches. Proper treatment of synovial chondromatosis depends az on accurate diagnosis. Although clinical diagnosis of chondromatosis is possible but difficult using arthroscopy, a definitive diagnosis can be made only by histological examination. Many author suggest the role rn of arthroscopy in diagnosis and treatment of chondro- matosis (9-12). With larger masses, an open joint pro- cedure with disc preservation may be indicated. Differ- ential diagnosis is also very important. Intra-articular te temporomandibular pain most commonly is due to de- generative osteoarthritis, which is typically a progres- Figure 5. Patient 6 month after operation. sive disease, late stage of meniscal perforation; os- teosarcoma and chondrosarcoma (the most frequent) In are malignant disease processes that can arise within the TMJ while benign tumors tend to occur with less frequency than malignant disease (13). ni Conclusion Synovial chondromatosis is a rare, benign pathological o entity that should be included in the differential diagno- sis for patients with a preauricular, radiographically het- erogeneous mass that seems to affect the TMJ. Clinical izi symptoms overlap those of other TMJ diseases. These often are characterized by joint swelling, pain and joint dysfunction. However, its radiological identification is Ed extremely important, and nowadays, CT scan has be- come a very important tool in TMJ imaging in associa- tion with MRI and arthroscopy for the differential diag- nosis of TMJ pathology. Conservative surgical excision is needed for resolution. Figure 6. Patient with a good mouth opening recovery. C fecting the temporomandibular joint. The aetiology re- Consent section: Signed publication consent was ob- tained from the patient. A copy of the written consent is CI mains unknown, but a history (2) of trauma and recur- rent inflammations is often found. One of the most chal- available for review by the Editor of this journal. lenging features of synovial chondromatosis is to sus- Competing interests: None declared. pect and establish a correct diagnosis. Patients with synovial chondromatosis affecting other major joints are predominantly male, but most patients with TMJ in- References © volvement are female (F:M:4:1) (3) as is the case with 1. Cascone P, Rivaroli A, Arangio P, Giovannetti F. Chondro- other forms of TMJ disease. In most cases, a specific calcinosis: rare localization in the temporomandibular joint. cause often is elusive. Clinical symptoms and signs J Craniofac Surg 2006 Nov;17(6):1189-92. overlap those of other TMJ diseases. These often are 2. Axhausen G. Pathologie und therapie des kiefergelenkes. nonspecific, including joint swelling, joint dysfunction, Fortschr Zahneil 1933;9:171-86. anterior TMJ disc displacement, pain, crepitation, mal- 3. Kademani D, Bevin C. A mass in the temporomandibular joint. occlusion and facial swelling. In the absence of physi- J Am Dent Assoc 2008 Mar;139(3):301-3. Annali di Stomatologia 2013; IV (3-4): 269-272 271 8_Vellone 5b_Riv Annali 3-4 2013 24/02/14 12:49 Pagina 272 V. Valentini et al. 4. Miller AS, Harwick RD, Daley DJ. Temporomandibular joint chondromatosis of the temporomandibular joint. J Oral Surg synovial chondromatosis: report of a case. J Oral Surg 1973; 31(9):691-3. 1978;36(6):467-8. 10. McCain JP, de la Rua H. Arthroscopic observation and treat- 5. Spallaccia F, Rivaroli A, Cascone P. Temporomandibular joint ment of synovial chondromatosis of the temporomandibu- arthrocentesis: long-term results. Bull Group Int Rech Sci lar joint: report of a case and review of the literature. Int J li Stomatol Odontol 2000 Jan-Apr; 42(1):31-7. Oral Maxillofac Surg 1989; 18(4):233-6. 6. Cascone P, De Biase A, De Ponte F, Saltarel A. Therapeutic 11. Miyamoto H, Sakashita H, Miyata M, Kurita K. Arthroscop- na planning in synovial chondromatosis of the temporo- ic diagnosis and treatment of temporomandibular joint syn- mandibular joint. J Craniofac Surg 1996 Sep; 7(5):352-7. ovial chondromatosis: report of a case. J Oral Maxillofac Surg 7. Cascone P, Rinna C, Ungari C, Poladas G, Filiaci F. Pig- 1996; 54(5):629-31. mented villonodular synovitis of the temporomandibular joint. 12. Wise DP, Ruskin JD. Arthroscopic diagnosis and treatment J Craniofac Surg 2005 Jul;16(4):712-6. of temporomandibular joint synovial chondromatosis: report io 8. Cascone P, Vetrano S, Nicolai G, Fabiani F. Temporo- of a case. J Oral Maxillofac Surg 1994; 52(1):90-3. mandibular joint biomechanical restrictions: the fluid and syn- 13. Carls FR, von Hochstetter A, Engelke W, Sailer HF. Loose ovial membrane. J Craniofac Surg 1999 Jul;10(4):301-7. bodies in the temporomandibular joint: the advantages of 9. Alling SC, Rawson DW, Staats J, Middleton RA. Synovial arthroscopy. J Craniomaxillofac Surg 1995; 23(4):215-21. az rn te In o ni izi Ed C CI © 272 Annali di Stomatologia 2013; IV (3-4): 269-272 

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Case report Immediate denture fabrication: a clinical report li na Sergio Caputi, MD, DDS ture show numerous advantages as preservation of fa- Giovanna Murmura, MD, DDS, PhD cial appearance and height, muscular tone, phonetic io Laura Ricci, DDS and reduction of post-extraction pain (3). Giuseppe Varvara, DDS, PhD Several procedures have been described in the literature Bruna Sinjari, DDS, PhD in order to construct an intermediate or transitional pros- thesis, to reduce the time required for its fabrication and az to provide a fast and economical service (4-7). Khan et Department of Medical, Oral al. (1992) fabricated an immediate transitional complete and Biotecnological Sciences, denture in one appointment using self polymerizing, "Gabriele d'Annunzio" University of Chieti-Pescara, Italy tooth-colored acrylic, and visible light-cured resins (8); rn however, multiple extractions performed in the same ap- pointment may be traumatic, complicating the adaptation Corresponding author: of the patient to the newly fabricated denture (1). In a re- Sergio Caputi port, a speedy economical interim immediate denture us- te Department of Medical, Oral ing a vacuum-forming machine without conventional lab- and Biotecnological Sciences, oratory procedures was also reported (9). A less traumat- "Gabriele d'Annunzio" University ic immediate complete denture placement was evaluated Via dei Vestini, 31 66100 Chieti, Italy In in another clinical study, where the remaining teeth were cut off the gingival margins instead of extracting them at E-mail: scaputi@unichi.it the time of prosthesis insertion, performing the placement procedures in a clean, blood-free environment, whereas the roots were extracted at a later time (10). ni Summary The treatment outcome is not always predictable as the prostheses cannot be completely assessed before The aim of the present clinical report was to de- achievement (11). One of the most important issues to be scribe the use of a patient’s extensive fixed pros- considered in immediate denture fabrication may be the o thesis, where the supporting teeth were hopeless, difficulty to assess the occlusal vertical dimension (OVD) for fabricating an interim immediate complete den- and centric relation after extraction of the posterior teeth. izi ture. The present procedure was used to replicate Indeed in a clinical report, Gilboa et al (2009) per- the vertical dimension, phonetic and aesthetic of formed a procedure to fabricate an immediate complete the existing fixed prostheses as part of an immedi- overdenture using several teeth retained an interim pro- ate denture and a final complete denture. visional fixed partial denture until the complete denture Ed was finished. In this procedure the posterior occlusion Key words: immediate complete denture, dental was maintained during the healing period and the trau- prosthesis, vertical dimension. ma of multiple extractions at one visit was avoided (12). Recently, Gooya et al. (2013) described the use of a patient’s fixed prosthesis for fabricating, in one appoint- Introduction ment, an interim immediate partial denture, where three C remaining teeth were maintained to preserve OVD and The immediate denture is a dental prosthesis construct- retentive clasps were used to improve temporary pros- CI ed to replace the lost dentition, associated structures of thesis retention. The Authors concluded that in this pro- the maxillae and mandible and inserted immediately cedure the occlusion, OVD, and facial support was following removal of the remaining teeth. Generally, two maintained during the healing period (1). types of immediate dentures are described in the litera- The purpose of this report was to describe a technique for ture: conventional immediate dentures and interim im- fabrication of an interim immediate denture using patient’s mediate dentures (1). In the traditional type, the interim current fixed partial denture, preserving patient original in- © prosthesis is fabricated to immediately place after the formation: phonetic, esthetic, facial height and OVD. extraction of natural teeth and can be used as the de- finitive or long-term prosthesis. The interim type is used for a short time after tooth extraction. After the achieve- Clinical report ment of healing period, the immediate denture may be relined or replaced with the newly fabricated final den- A 67-year-old woman with a fixed partial maxillary pros- ture (2). It was reported that the interim immediate den- thesis extended from the upper second right premolar Annali di Stomatologia 2013; IV (3-4): 273-277 273  S. Caputi et al. and first left molar was evaluated for the treatment. The patient presented no significant medical history but was a heavy smoker and no occlusal or temporo-mandibu- lar disease. Clinical examination and radiographic as- sessment (Figs. 1, 2) revealed an unrestored mouth li with generalized severe chronic periodontitis of the teeth supporting fixed prosthesis, that were considered na hopeless. Therefore, the operator decided to use the patient’s current prosthesis for the fabrication of an in- terim immediate denture. The patient, who signed the informed consent, accepted a treatment plan for an im- io mediate maxillary denture. It was proceeded to register the face bow, record rim to duplicate the patient original maxilla-mandibular rela- Figure 1. Initial clinical examination of the patient with a az tionship, and take an irreversible hydrocolloid impres- fixed denture from the second upper right premolar to first sion (Kromopan, LASCOD S.p.A, Siesto Fiorentino, left molar. Italy). Stone casts were poured and mounted on a rn te In o ni izi Ed C CI © Figure 2. Radiographic evaluation of the residual teeth. 274 Annali di Stomatologia 2013; IV (3-4): 273-277  Immediate denture fabrication: a clinical report medium value articulator (Sam 2P, SAM, Präzision- original one taken before. The pressure areas were de- stechnik GmbH, Fussbergstrasse, Gauting, Germany). tected and occlusion adjusted. When the occlusal over- The wax up anatomic corrections were made to give a load was present, it was proceed in empting it further. pleasant tooth arrangement. Then, a hard denture reline material (Tokuso Rebase, The casts were then duplicated with an alginate im- J. Morita, USA, Inc, Irvine, California, USA) was used to li pression material (Kromopan, LASCOD S.p.A, Siesto rebase the prostheses, inviting the patient to close in Fiorentino, Italy). Self polymerizing resin (Palavit 55, maximum occlusion obtaining the same level of the na Kulzer GMBH & co, Wehrheim, Germany), was pre- OVD tattoo. Thus, the prosthesis was slightly emptied pared in a shade that matches the patient dentition and in correspondence of the post extractive sites and re- poured into maxillary dental arch impression (8) (Fig. lined with a sofreliner material (Sofreliner Tough, J. 3), polymerized, polished and then finished. The acrylic Morita USA, Inc, Irvine, California, USA) to obtain more io resin arch was reseated in the impression, and the stability and durability during tissue healing. After 15 maxillary cast poured in dental stone. The resin plaque days, the material was eliminated and replaced with a was build up applying to the entire maxillary cast a pink new one. The alveolar resorption was periodically mon- itored and the prostheses relined after an adequate az self-ploymerizing resin (Paladur, Kulzer, Wehrheim, Germany) and its monomer was alternatively added to healing period. have the entire denture base. The maxillary denture After one month, this prostheses was used as a cus- was separated from the cast, finished and polished, ob- tomized individual tray to make the border moulding taining so the provisional total denture (Fig. 4). and take the final impression with a polyvinyl siloxane rn The OVD was performed doing the vertical measure- material (Dimension Penta H Quick Tray, ESPE Ameri- ment of the face between any two arbitrary selected points that are conventionally located one above and te one below the oral cavity in the midline with a black pen. Then, the teeth were extracted leaving in situ only the roots of the left and right canines which would help to prevent the bone resorption and to offer more reten- tion to the prostheses. The prosthesis was emptied a In little and tried in the patient’s mouth to observe the oc- clusal contacts and if the OVD was equivalent to the o ni Figure 5. Provisional immediate denture used as a cus- izi tomized individual tray. Ed Figure 3. Maxillary acrylic resin arch powered in dental stone. C CI © Figure 6. Registrations of the face bow and the record rim Figure 4. Provisional immediate denture. using the actual immediate denture. Annali di Stomatologia 2013; IV (3-4): 273-277 275  S. Caputi et al. vation of the original occlusal relationships and OVD. When a procedure for fabricating conventional immedi- ate denture was performed, careful evaluation of the vertical dimension of occlusion, centric relation and the placement of the teeth are essential factors for the suc- li cess of the treatment (14). In the present report, the OVD is not modified but it is na preserved the original one. It is almost well known that the maintenance of the origi- nal OVD and centric relation is fundamental for the suc- cess total removable prosthesis. Gooya et al. (2013) io suggested in a recent report to carefully select artificial teeth with the same cuspal inclination which, helps to match cuspal inclination with anterior and posterior guid- Figure 7. Final total denture. az ance and make an acceptable occlusal scheme (1). Whilst, in the present report anatomic wax up correc- tions were made to give a pleasant tooth arrangement ca, Norristown, Pennsylvania, USA) (Fig. 5). The regis- and maintain their height and dimensions in order to do trations of the face bow and the record rim were per- rn not change the patient’s appearance and function. formed using the actual immediate denture (Fig. 6). In addition, the immediate denture made following the The impression was poured in dental cast and mounted described technique could be easily used to transfer on the articulator with the prosthesis. The permanent the record rim, face bow and take the final impression total denture was fabricated using the classical tech- te (since it could be used as custom made impression nique but using patient’s original OVD, occlusion, pho- tray), for the final denture construction reducing time, netic and esthetic. At subsequent appointments, the visits and costs. Also to verify the integrity of the oc- teeth trial-in was directly performed and the final total clusal relationship the casts are not hand articulated in prostheses was delivered (Fig.7). In maximum intercuspal position as described recently (15), but mounted in a medium value articulator. The contraindications to this treatment procedure include Discussion the presence of symptomatic teeth or acute root infec- tions and in case of complete edentulous patients. The conventional immediate denture treatment requires ni The present clinical report presents a treatment proce- a series of appointments to perform the standard pro- dure that makes immediate denture placement more pre- cedures; indeed, after the extraction of remaining teeth dictable and less stressful. The delivery of the prosthesis and the any necessary adjunct surgery, the denture is o is less traumatic because extractions are deferred. It pro- placed, tested for areas of excessive pressure, and ad- vides greater control over the prosthodontic aspects, and justed (12). Actually, when a conventional complete the convenience of performing the placement procedure izi denture is fabricated, there is generally a period from in a clean, blood-free environment. several weeks to months of edentulism for healing after The procedure described, replicating the vertical di- teeth extraction (13). mension, phonetic and aesthetic of the existing fixed There is diminished predictability in a combined surgical Ed prostheses of patient, can be used to fabricated the in- and prosthodontic visit: surgery is performed, and difficul- terim immediate denture and a final complete denture. ties with extractions, bleeding, and /or pain control may be In addition, the complete removable prostheses ob- encountered; moreover, the appointments can become tained with this procedure can be used as a custom prolonged and stressful for both patients and dentist. tray for the final denture fabrication. In addition, the interim immediate denture is used in or- However, considering the introduction and successful der to preserve the esthetic, mastication, and the oc- C outcome of dental implants, further clinical studies clusal support (1). The procedure performed in this clin- could be needed to evaluate the use of present tech- ical report described an immediate denture fabrication nique to fabricate a removable implant supported provi- CI technique, preserving much information as possible sional prostheses. A fixed or removable implant-re- from the patient’s original situation. Furthermore, reduc- tained denture should be favored as the final treatment ing the number of traditional technique visits, a com- of edentulous patients. plete denture was delivered after the extraction of teeth and the patient received the final new denture without the additional trauma of the surgery. © During the mounting on the articulator in maximum inter- References occlusion position, the patient has to wait to have his 1. Gooya A, Ejlali M, Adli AR. Fabricating an interim immedi- prostheses. In the initial period that the denture is worn, ate partial denture in one appointment (modified jiffy denture). it will not reset on extraction sites or surgical wounds. A clinical report. J Prosthodont.2013; 22:330-3. The functional advantages included the possibility to 2. Zarb GA, Bolender CL. Prosthodontic treatment for edentulous perform the denture adjustments, the use of pressure– patients. 12th Ed. St.Louis:The C.V. Mosby Co. 2004; 8: 123- indicating materials in a blood-free field and the preser- 159. 276 Annali di Stomatologia 2013; IV (3-4): 273-277  Immediate denture fabrication: a clinical report 3. Seals RR, Kuebker WA, Stewart KI: Immediate complete den- 1992; 67:747-748. tures. Dent Clin North Am 1996; 40:151-167. 10. Woloch MM. Non traumatic immediate complete denture place- 4. Racka TA, Esposito SJ. The “Jiffy” denture: a simple solu- ment: a clinical report. J Prosthet Dent 1998; 80:391-3. tion to a sometimes difficult problem. Compend Contin Educ 11. Wyatt CCL. Immediate dentures. In MacEntee MI, ed. The 1995; 16:914-6. complete denture: a clinical pathway. Chicago, IL: Quin- li 5. Soni A. Trial anterior artificial tooth arrangement for an im- tessence Publishing 1999; 99-107. mediate denture patient: a clinical report. J Prosthet Dent 12. Gilboa I, Cardash HS. An alternative approach to the im- na 2000; 84:260-3. mediate overdenture. J Prosthodont 2009; 18:71-5. 6. Cardash HS, Kaufman C, Helft M. An interim denture tech- 13. Bouma LO, Mansueto MA, Koeppen RG. A nontradition- nique. Quint Dent Tech 1983; 7:89-91. al technique for obtaining optimal esthetics for an imme- 7. Swoope CA, Wisman LJ, Wands DH. Interim dentures. J diate denture: a clinical report. J Prosthodont 2001; Prosthet Dent 1984; 32:604-12. 10:97-101. io 8. Khan X, Haeberle CB. One appointment construction of an 14. Passamonti G, Kottrajarus P, Gheewala RK, Clark RE, immediate transitional complete denture using visible light- Maness WL. The effect of immediate denture on maxillo- cured resin. J Prosthet Dent 1992; 68:500-2. mandibular relations. J Prosthet Dent 1981; 45:122-6. 9. Joffe EH: Simplified fabrication of the interim denture using 15. Gotlieb AS, Askinas SW. An atypical chairside immediate den- az a vacuum forming machine: a clinical report. J Prosthet Dent ture: a clinical report. J Prosthet Dent 2001; 86:241-3. rn te In o ni izi Ed C CI © Annali di Stomatologia 2013; IV (3-4): 273-277 277 

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1-Lauritano_- 19/06/13 10:32 Pagina 170 Original article Oral microflora and periodontal disease: new technology for diagnosis in dentistry li na Francesco Carinci1 Introduction Luca Scapoli2 io Ambra Girardi2 Periodontitis represents a destructive chronic inflamma- Francesca Cura2 tory disease with a bacterial infection resulting from the Dorina Lauritano4 complex actions of a small subset of periodontal Gianna Maria Nardi3 pathogens (1). az Annalisa Palmieri2 From a pathological point of view, periodontitis can be defined as the presence of gingival inflammation at sites where there has been a pathological detachment 1 Department of Morphology, Surgery and Experimental of collagen fibres from the cementum and the junctional rn Medicine, University of Ferrara, Italy epithelium has migrated apically (2). The inflammatory 2 Department of Specialist Diagnostic and Sperimental response of the periodontal tissues to infection is influ- Medicine, University of Bologna, Italy enced by environmental factors as well as by genetic te 3 Department of Stomatologic and Maxillo-Facial factors (3). The primary microbial factor contributing to Sciences, University “Sapienza”, Rome, Italy periodontitis is a shift in the content of the oral microflo- 4 Department of Interdisciplinary Medicine and Surgery, ra, while the primary immunological factor is the de- University of Milan-Bicocca, Milan, Italy structive host inflammatory response (4). In The microbiota associated with periodontal health and disease has been intensely studied for well over a cen- Corresponding author: tury by several generations of skilled scientists and clini- Dorina Lauritano cians (5, 6). Oral microbiota is an enormously complex Department of Interdisciplinary Medicine and Surgery and dynamic entity that is profoundly affected by perpet- ni University of Milan-Bicocca ually changing local environments and host-mediated Via Cadore, 48 selective pressures (7). The presence of a commensal 20052 Monza, Italy microbiota, including potential pathogens, is essential for the proper development of mucosal immunity (8). o Phone: +39 3356790163 E-mail: dorina.lauritano@unimib.it The normal oral flora is hence in a balance between pathogens and commensals that requires regular izi cleaning to be maintained. A decrease in oral hygiene Summary is quickly followed by the build-up of oral biofilms on tooth surfaces and, if left untreated, will progress to gin- gival inflammation and possibly periodontitis, alveolar Ed Periodontitis is a disease that affects and destroys the tissues that support teeth. Tissues damage re- bone loss and loss of teeth. It is likely that differences sults from a prolonged inflammatory response to in host-defence mechanisms, including antimicrobial protein profiles, determine whether bacterial coloniza- an ecological shift in the composition of subgingi- tion progresses to overt disease (9). val biofilms. Three bacterial species that constitute Recent data estimate that the oral cavity may contain the red complex group, Porphyromonas gingivalis, up to 19000 bacterial phylo-types (10), but each individ- C Tannerella forsythia, and Treponema denticola, are ual will only have a rate of the total numbers of considered the main pathogens involved in peri- pathogens. Indeed, there is a substantial diversity in odontitis. CI the content of the microflora between individuals (11) In the present study a real-time PCR based assay and between different oral sites within the same individ- was designed to detect and quantify red complex ual (12, 13). Research has indicated that dietary species, then used to investigate 146 periodontal changes combined with poor hygiene can cause a shift pocket samples from 66 periodontitis patients in the composition of the oral bacteria (13, 14). More- and 80 controls. Results demonstrated a signifi- over, some evidence in recent studies suggests that © cant higher prevalence of red complex species the oral microbiome changes as humans age and the and increased amount of P. gingivalis and T. den- dysbiosis in the oral cavity can lead to periodontitis (4). ticola in periodontal pocket of periodontitis pa- Several methods have been used for microbiological tients. testing in periodontitis (15). However, many techniques have not been fully accepted due to low sensitivity or Key words: tooth, ligament, periodontal, diseases, in- specificity, moreover sometimes they are slow, expen- flammation, bone, resorption. sive and laborious. In our laboratory (LAB srl, Ferrara, 170 Annali di Stomatologia 2013; IV (2): 170-173 1-Lauritano_- 19/06/13 10:32 Pagina 171 Oral microflora and periodontal disease: new technology for diagnosis in dentistry Italy), we developed a rapid and sensitive test to detect highly conservated sequence of the 16S ribosomal RNA and quantify the three bacterial species more involved gene. The second reaction detected and quantified the in periodontitis that constituted the red complex group: three red complex bacteria, i.e. P. gingivalis, T. forsythia Porphyromonas gingivalis, Tannerella forsythia, and and T. denticola, in a multiplex PCR. This reaction includ- Treponema denticola. Both P. gingivalis and T. dentico- ed a total of six primers and three probes that were highly li la occur concomitantly with the clinical signs of peri- specific for each specie. Oligonucleotide concentrations odontal destruction. They appear closely ‘linked’ topo- and PCR conditions were optimized to ensure sensitivity, na logically in the developing biofilm, shown an in vitro specificity and no inhibitions in case of unbalanced target ability to produce a number of outer membrane-associ- amounts. Absolute quantification assays were performed ated proteinases and are considered the first using the Applied Biosystems 7500 Sequence Detection pathogens involved in the clinical destruction of peri- System. The amplification profile was initiated by a 10 min io odontal tissues. Moreover both them and T. forsythia, incubation period at 95°C to activate polymerase, fol- show an higher prevalence in disease than in health lowed by a two-step amplification of 15 s at 95°C and 60 s suggesting that these bacterial are associated with the at 57°C for 40 cycles. All these experiments were per- az local development of periodontitis (16). formed including nontemplate controls to exclude The presence and the level of these pathogens can be reagents contamination. effectively revealed by real time polymerase chain reac- Plasmids containing synthetic DNA target sequences tion analysis using bacterial species-specific primers (Eurofin MWG Operon, Ebersberg Germany) were and probes. used as standard for the quantitative analysis. Stan- rn Our findings support the hypothesis that detection and dard curves for each target were constructed in a quantification of red complex bacteria in crevicular fluid triplex reaction, by using a mix of the same amount of could be an appropriate tool for diagnosis and progno- plasmids, in serial dilutions ranging from 101 to 107 te sis of periodontitis. copies. There was a linear relationship between the threshold cycle values plotted against the log of the copy number over the entire range of dilutions (data not Material and methods shown). The copy numbers for individual plasmid In A total of 146 individuals participated to the study, 66 preparations were estimated using the Thermo Nan- oDrop spectrophotometer. were affected by chronic periodontitis, while 80 consti- The absolute quantification of total bacterial genome tuted the control group. Controls include 46 healthy indi- copies in samples allowed for the calculation of relative viduals and 34 affected by a moderate gingivitis. Table 1 amount of red complex species. To prevent samples ni summarizes principal characteristics of the groups. and polymerase chain reaction contamination, plasmid A sample of the periodontal pocket microbiota was ob- purification and handling was performed in a separate tained from a single site by a paper probe. DNA was laboratory with dedicated pipettes. extracted and purified using standard protocols that in- o clude two consecutive incubation with lysozyme and proteinase K, followed by spin-column purification. Statistical analysis izi Descriptive statistics was performed using Microsoft Real-Time Polymerase Chain Reaction Excel spreadsheets. The Freeman-Halton extension of Fisher's exact test to compute the (two-tailed) probabili- Ed Primers and probes oligonucleotides were designed bas- ty of obtaining a distribution of values in a 2x3 contin- ing on 16S rRNA gene sequences of the Human Oral Mi- gency table, given the number of observations in each crobiome Database (HOMD 16S rRNA RefSeq Version cell. Odds ratio calculation was performed online at the 10.1) counting 845 entries. All the sequences were OpenEpi web site (www.openepi.com). aligned in order to find either consensus sequence or less Absolute bacteria amount were normalized against the conservate spots. Two real-time polymerase chain reac- total bacterial load, obtaining the relative bacteria C tion (PCR) runs were performed for each sample. The amount (RBA). The one-way analysis of variance first reaction quantified the total amount of bacteria using (ANOVA) was used to determine whether there was CI two degenerate primers and a single probe matching an any significant differences between the mean RBA val- Table 1. Principal characteristics of the groups. Total Healthy Gingivitis Periodontitis © Subjects 146 46 34 66 Males 63 12 14 37 Females 83 34 20 29 Age (means years ± SD) 39.8±18.9 31.6±18.6 34.3±15.4 48.9±18.2 Sampling depht (mm±SD) 3.9±1.7 2.6±0.6 3.2±1.0 5.0±1.7 Annali di Stomatologia 2013; IV (2): 170-173 171 1-Lauritano_- 19/06/13 10:32 Pagina 172 F. Carinci et al. ue of three patients group, i.e. healthy, gingivitis and of these three species among groups of patients with periodontitis. different diagnosis - regardless of different clinical as- pects that may describe severity of the disease – in or- der to understand whether the presence of the red Results complex species and their relative amount may be con- li sidered predictive factors of periodontitis. Occurrence and amount of red complex bacteria from Prevalence of the three investigated species among health, na crevicular fluid were evaluated in 146 individuals. A sin- gingivitis and periodontitis patients was shown in Table 2. gle specimen from each patient was analyzed by quan- Each specie was common among healthy patients, howev- titative real time PCR (LAB test LAB® s.r.l, Ferrara, er the prevalence was roughly double in periodontitis Italy) (Figs. 1, 2), obtaining measures of total bacteria group. Intermediate values, but closer to healthy individuals io load and of three species involved in periodontitis, i.e. were observes among patients affected by gingivitis. P. gingivalis, T. forsythia, and T. denticola. Here we re- The Freeman-Halton extension of Fisher's exact test in- port a preliminary study focused mainly on prevalence dicated that the prevalence of each red complex specie az is different among groups of patients with high degree of statistical significance, P. gingivalis P value = 2x10-8, T. forsythia P value = 1x10-8, and T. denticola P value = 2x10-4. The higher level of association with periodontitis was observed for T. forsythia, indeed the observed rn odds ratio was 6.1 (95% C.I. 3.1-11.9) when healthy in- dividuals were compared to periodontitis patients, and 4.6 (95% C.I. 2.6-7.9) when healthy and gingivitis te groups where combined and compared to periodontitis patients. Results of quantitative data indicated that the normal- ized amount of P. gingivalis significantly differs among In patient groups F(2, 304) = 7.77, P value = 0.001; as well as for T. denticola F(2, 304) = 7.47, P value = 0.001. On the contrary did not vary for T. forsythia F (2, 304) = 1.41, P value = 0.25. The calculated mean val- Figure 1. LAB®-test kit. ues were plotted in Figure 3. ni Discussion o The polymerase chain reaction (PCR) is the most sen- sitive and rapid method to detect microbial pathogens izi in clinical specimens. In particular, the diagnostic value of PCR is significantly higher when specific pathogens that are difficult to culture in vitro or require a long culti- vation period such as for anaerobic bacteria species in- Ed volved in periodontitis onset. A recent improvement of this technique is the real-time PCR that allow for quan- titatation of DNA target using fluorogenic probes in a close setup. Beside the opportunity to quantify target, the advantage to perform the assay is a closed system, in which the reaction tube is never opened after amplifi- C cation, is of great value to prevent laboratory contami- Figures 2 Method of sampling bacterial DNA. nation and false positive results. In addition the need of CI Table 2. Association analysis between red complex bacteria and periodontitis. OR (95% C.I.) Healthy [1] Gingivitis [2] Periodontitis [3] [1] vs. [3] [1]+[2] vs. [3] © P. gingivalis negative 32 48 32 5.1(1.8-4.3) 4.2(2.6-6.8) positive 38 32 34 T. forsythia negative 49 31 22 6.1(3.1-11.9) 4.6(2.6-7.9) positive 21 39 44 T. denticola negative 42 38 43 3.4(1.8-6.4) 2.4(1.5-3.9) positive 24 46 23 172 Annali di Stomatologia 2013; IV (2): 170-173 1-Lauritano_- 19/06/13 10:32 Pagina 173 Oral microflora and periodontal disease: new technology for diagnosis in dentistry li na io Figure 3. Plots representing the relative amount of each red complex bacterial specie in the different groups of patients. az a probe in addition to the two PCR primers, further in- review of definitions of periodontitis and methods that have crease the specificity of the reaction. been used to identify this disease. J Clin Periodontol 2009; In the present investigation we designed and tested the 36:458-467. rn performance of a real-time PCR based assay to detect 3. Kinane DF, Peterson M, Stathopoulou PG. Environmental and other modifying factors of the periodontal diseases. Pe- and quantify the red complex bacteria involved in peri- riodontology 2000 2006; 40:107-119. odontal disease. In particular we found that P. gingivalis, 4. Berezow AB, Darveau RP. Microbial shift and periodontitis. T. forsythia, and T. denticola were strongly related to pe- Periodontology 2000 2011; 55:36-347. te riodontitis because their prevalence was higher among 5. Tanner ACR IJ. Tannerella forsythia, a periodontal pathogen periodontitis patient. The presence of these bacterial entering the genomic era. Periodontology 2000 2006; species can significantly increase the risk to develop pe- 42:88-113. riodontitis, being the OR comprised between 6.1 (T. for- 6. Teles RP, Haffajee AD, Socransky SS. Microbial goals of pe- In sythia) and 3.4 (T. denticola). The results of quantitative 7. riodontal therapy. Periodontol 2000 2006; 42:180-218. Armitage GC. Comparison of the microbiological features of data analysis indicated that the relative amount of P. gin- chronic and aggressive periodontitis. Periodontol 2000 givalis and T. denticola in periodontal pocket was sensi- 2010; 53:70-88. bly higher in affected patients. This indicated that both 8. Davey ME, O'Toole GA. Microbial biofilms: from ecology to the presence and relative amount of red complex bacte- ni molecular genetics. Microbiol Mol Biol Rev 2000; 64:847-867. ria is relevant data in periodontal disease diagnosis. 9. Gorr SU, Abdolhosseini M. Antimicrobial peptides and pe- riodontal disease. J Clin Periodontol 38 Suppl 11:126-141. 10. Slots J. Update on Actinobacillus Actinomycetemcomitans o Conclusion and Porphyromonas gingivalis in human periodontal disease. J Int Acad Periodontol 1999; 1:121-126. 11. Nasidze I, Li J, Quinque D, Tang K, Stoneking M. Global di- izi Molecular analysis of periodontal pocket microflora by real-time PCR represent an effective inexpensive versity in the human salivary microbiome. Genome Res 2009; 19:636-643. method to rapidly detect and quantify red complex bac- 12. Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defin- terial species. This test was performed in a large patient ing the normal bacterial flora of the oral cavity. J Clin Microbiol Ed sample and results demonstrated that the test is a valu- 2005; 43:5721-5732. able tool to improve diagnosis of periodontal disease. 13. Avila M, Ojcius DM, Yilmaz O. The oral microbiota: living with a permanent guest. DNA Cell Biol 2009; 28:405-411. 14. Al-Ahmad A, Roth D, Wolkewitz M, Wiedmann-Al-Ahmad M, Acknowledgenment Follo M, Ratka-Kruger P, et al. Change in diet and oral hy- giene over an 8-week period: effects on oral health and oral C This work was supported by LAB® s.r.l, Ferrara, Italy. biofilm. Clin Oral Investig 14: 391-396. 15. Loomer PM. Microbiological diagnostic testing in the treat- ment of periodontal diseases. Periodontology 2000 2004; CI 34:49-56. References 16. Mineoka T, Awano S, Rikimaru T, Kurata H, Yoshida A, An- sai T, et al. Site-specific development of periodontal dis- 1. Kuboniwa M, Inaba H, Amano A. Genotyping to distinguish ease is associated with increased levels of Porphy- microbial pathogenicity in periodontitis. Periodontology romonas gingivalis, Treponema denticola, and Tannerel- 2000 2010; 54:136-159. la forsythia in subgingival plaque. J Periodontol 2008; © 2. Savage A, Eaton KA, Moles DR, Needleman I. A systematic 79:670-676. Annali di Stomatologia 2013; IV (2): 170-173 173 

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3-Pusinanti_- 19/06/13 10:35 Pagina 184 Original article A simplified post preparation technique after Thermafil obturation: evaluation of apical microleakage and presence of voids using li methylene blue dye penetration na Luca Pusinanti voids was always found in the last millimetre of the Riccardo Rubini1 canal obturation. This study proposes a post prepa- io Agnese Pellati2 ration technique which provides for complete carri- Nicoletta Zerman1 er removal using pliers, hand compaction of resid- ual gutta-percha with a manual plugger and en- az largement of the root canal, using appropriate post 1 Restorative Department, Dental School, space burs, free of any interference from the carri- University of Ferrara, Italy er. Operating time is reduced, as is the risk of creat- 2 Department of Morphology and Embriology, ing ledges or iatrogenic perforations. rn University of Ferrara, Italy Key words: thermafil, post space, apical micro leakage. Corresponding author: te Luca Pusinanti Introduction Via Migliari, 15 44123 Ferrara, Italy The Thermafil (Dentsply Maillefer – Switzerland) obtura- Phone: +39 3334700102 E-mail: lucapuso@gmail.com In tion technique derives from an idea of Dr. W. Ben John- son (1), who first described a technique in which gutta- percha moulded on a file was softened in a flame and in- serted into the root canal with the file. The coronal portion Summary of the file was then sectioned and removed and the api- ni cal portion left behind as a part of the root filling (2, 3). Aim. To evaluate the apical microleakage of Ther- Marketed at the beginning of the 1990s, Thermafil en- mafil obturations after three different post space dodontic obturators have since been completely modified preparation techniques. and now form an integral part of a complete and sophis- o Materials and methods. 33 root canals of mono- ticated system of root canal obturation that, when used radiculated extracted teeth were prepared with M correctly, can give optimal results (4). izi two and then obturated with Thermafil. Teeth so The wedge effect that occurs during carrier insertion, to- treated were then divided into three groups and gether with the very fine and homogeneous reticular the post space to middle root was prepared using structure of the gutta-percha, favours the penetration of three different techniques. In samples in group A the obturating materials into the lateral canals and denti- Ed the housing for the post was created using a Tor- nal tubules (5, 6) as in the vertical condensation technique pan bur, and the carrier was partially removed on- and System-B (Sybron Endo – USA), but with an efficacy ly in the coronal portion. In samples in group B which is significantly superior to that of the lateral con- the carrier was completely removed and gutta-per- densation, warm lateral condensation and Obtura (7, 8) cha was hand compacted, before canal prepara- (Obtura Spartan Endodontics – USA) techniques. The tion using a Torpan bur. In samples in group C the Thermafil technique shows a capacity to completely adapt C carrier was completely removed, without gutta- to the canal walls which is comparable to that of other percha compaction, before canal preparation us- methods like vertical and lateral condensation (9-20). As CI ing a Torpan bur. The roots were immersed for 72 for the capacity to hermetically seal the apical third, where hours in methylene blue dye solution and sec- more than 90% of all endodontic anatomical complexities tioned transversely at 1-3-5 mm from the apex for are found, what emerges from the literature is that Ther- evaluation of dye penetration using a stereomicro- mafil obturations demonstrate better hermetic seal than scope. The data collected were processed using is obtainable using the lateral condensation, Obtura or Ul- Win CAD software and subjected to statistical trafil (Coltène/Whaledent - Switzerland) techniques, and © analysis using the Student t test for p<0.05. equally good hermetic seal compared to warm vertical Results. There were no significant differences be- condensation or System-B (21-40). tween the three groups, except for the presence of The excellent results obtainable using the modern Ther- voids in the intermediate section of teeth in groups mafil obturation technique are largely due to standard- B and C. ization of the technique, regarding both the operative Conclusions. Post space preparation did not influ- steps and the most recent techniques of root canal shap- ence the apical seal, and gutta-percha without ing using rotary instruments in NiTi, which allow the high- 184 Annali di Stomatologia 2013; IV (2): 184-190 3-Pusinanti_- 19/06/13 10:35 Pagina 185 A simplified post preparation technique after Thermafil obturation: evaluation of apical microleakage and presence of voids using methylene blue dye penetration est quality and the most homogeneous canal preparation. The Thermafil system is the best solution available today for the obturation of curved canals because the carrier is very flexible and easily adapts even to tight curves and limited canal diameters, making it possible to drastically li reduce the time necessary for conservative preparation and obturation to working length, even in those canals na which do not allow precise cone fitting. The difficulty for post space preparation in cases where Thermafil has been used is due to the presence of the plas- tic carrier: the risks of inadvertently making ledges or lateral io root perforations limit the use of carrier-based techniques. Many techniques for cutting down the carriers are de- scribed in the literature. The classic method is with a az heat source using Touch’n Heat (Sybron Endo – USA) or Figure 1. 33 extracted teeth. System-B tips, or using appropriate burs like Post Space Burs, Calibrated burs, Torpan burs or Peeso reamers pas- per incisors, 1 canine, 3 premolars, 3 lower incisors; sively, without forcing, between carrier and gutta-percha. group B (study group 1): 4 upper incisors; 2 canines, 3 rn The rationale for these burs is to remove the carrier to the premolars and 2 lower incisors and group C (study desired depth through the frictional heat generated dur- group 2): 5 upper incisors, 2 canines, 3 premolars and ing rotation. Even though there is no evidence for the risk 1 lower incisor (Fig. 1). of apical seal loss following immediate post space prepa- The root canals of all the teeth were prepared according te ration, it is common practice to delay post placement to to the following protocol: access to the pulp chamber a second appointment, to permit complete setting of the was gained using a cylindrical diamond bur mounted on sealer and stabilization of the whole obturation (41-47). a high-speed handpiece and later expanded using a In order to make the entire procedure for placing posts af- ter Thermafil obturations safer, easier and quicker, the In round bur mounted on a contrangle. Endodontic access was sounded with an EXDG-16 probe (Hu - friedy - USA), aim of this study was firstly to evaluate the apical seal and and the working length was visually determined using a the presence of voids, using dye penetration into root K-file (Dentsply Maillefer - Switzerland) # 0.10. The root canals obturated using the Thermafil technique after two canals were shaped with Mtwo (Sweden & Martina - different post preparations which both involved complete ni Italy) rotary NiTi instruments # 10/.04 – # 15/.05 – # removal of the plastic carrier, and secondly to compare 20/.06 mounted on an X-smart (Dentsply Maillefer - the results obtained with those of conventional post space Switzerland) endodontic handpiece, used with delicate preparation. brushing movements to maintain a conservative prepa- o Because the capacity to hermetically seal the apical third ration, alternated with thorough washing with 5% sodium is the most important criterion for evaluating endodontic hypochlorite (Ogna - Italy). After shaping of root canals, izi procedures and techniques, it has been the subject of re- the preparation was checked with a Thermafil naked car- search projects using a great variety of methods (5-47), rier and wiped dry with fine and medium paper points including infiltration of liquids and dyes, electrochemical (Mynol Chemical Co. - USA). An x-fine paper point Pulp methods, and infiltration with resin and radio-isotopes. Canal Sealer (Kerrdental - USA) was placed above the Ed The infiltration of colorants is a common technique in- canal walls and the root canals were obturated with the volving the immersion of the root in dyes like methylene Thermafil technique, using caliber 20, 30 and 35 obtura- blue, Prussian blue, eosin and India ink. Normally only the tors to working length, choosing the obturator best suit- apical third comes into contact with the dye while the rest able to the single root canal anatomy according to the root of the tooth is isolated using silicone or varnish. The infil- canal conformation and to the canal apex diameter. Thirty tration can be either passive, obtained by simple immer- minutes after canal obturation, the carrier was sectioned C sion in the dye at atmospheric pressure or in a vacuum, with a Thermacut bur (Dentsply Maillefer - Switzerland) or else active, forcing the dye into the root under pressure and post space preparations were carried out. CI or by centrifugation. The root is then sectioned vertically The samples in group A were then subjected to prepa- or even diaphanized for measurement of the microleakage ration of the endodontic space for application of fiber using an optical microscope. Passive methylene blue dye post as far as the middle root with a Torpan bur, used penetration is probably the technique most commonly passively between the carrier and the gutta-percha, to used to evaluate the apical seal, and was chosen for this enlarge the root canal correctly and to separate the study because of its simplicity and limited cost. most coronal portion of the Thermafil obturator, but © without removing the apical portion. The samples in group B were subjected to preparation Materials and methods of the endodontic space for application of fiber post as far as the middle root with a Torpan bur, after complete This study involved 33 single-rooted extracted teeth, removal of the Thermafil carrier, which was pulled out stored in saline solution and subsequently divided into with tweezers. Prior to the preparation of post space, three groups as follows: group A (control group): 4 up- gutta-percha was manually compacted using Schilder’s Annali di Stomatologia 2013; IV (2): 184-190 185 3-Pusinanti_- 19/06/13 10:35 Pagina 186 L. Pusinanti et al. li na io az Figure 3. Sectioned sample without dentinal leakage. rn te In Figure 2. Tooth embedded in resin. ni plugger (Dentsply Maillefer - Switzerland) # 8 and # 9. The samples in group C were subjected to preparation of the endodontic space for application of fiber post as o far as the middle root with a Torpan bur, after complete removal of the Thermafil carrier, which was pulled out Figure 4. Sectioned sample with dentinal leakage 2. izi with tweezers. In this group no compaction of gutta-per- cha was carried out before using the Torpan bur. The access to the pulp chamber was sealed with com- posite resin. Subsequently, the samples were immersed Ed and stored for seven days in saline solution at 37 de- grees before applying a homogeneous layer of nail pol- ish on the root surface up to 1 mm from the apical fora- men. When the insulating layer had dried, the teeth were fully immersed for 72 hours in methylene blue dye. After three days the samples were cleaned thoroughly in C water and embedded in acrylic resin (Figure 2). Subsequently for each of the 33 teeth three sections CI were made using Micromet Automatica (Remet - Italy) cutting system at 1 mm (level “a”), 3 mm (level “b”), and 5 mm (level “c”) from the apex, making a total of 99 thin sections. The sections thus obtained were then ana- lyzed using an optical microscope and processed using Win CAD software, to calculate the area of dentin col- © Figure 5. Sectioned sample with void. ored by methylene blue in relation to the total dentinal area. The aim was to evaluate the degree of infiltration of root fillings at three distances from the apex (Figs. 3, Results 4). Optical magnification also made it possible to as- sess the presence of voids in the endodontic material In group A (the control group) the area which was infil- (Fig. 5). Findings were subjected to statistical analysis trated averaged 25.89% at 1 mm from the apex (sec- using Student T Test for p<0.05. tion 1), 14.83% at 3 mm from the apex (section 2) and 186 Annali di Stomatologia 2013; IV (2): 184-190 3-Pusinanti_- 19/06/13 10:35 Pagina 187 A simplified post preparation technique after Thermafil obturation: evaluation of apical microleakage and presence of voids using methylene blue dye penetration Table 1. Section at 1 mm from apex. Group A % Dentin Voids Group B % Dentin Voids Group C % Dentin Voids showing showing showing leakage leakage leakage li A1 a 0.61 No B1 a 19.40 No C1 a 4 No na A2 a 52.96 No B2 a 0 No C2 a 0 No A3 a 1.55 No B3 a 0 No C3 a 35.67 No A4 a 35.43 No B4 a 3 No C4 a 7,91 No A5 a 27 No B5 a 22 No C5 a 82 No io A6 a 14.52 No B6 a 22 No C6 a 3 Yes A7 a 41.21 No B7 a 11.62 No C7 a 4.70 No az A8 a 12.05 No B8 a 7.44 No C8 a 2.94 No A9 a 44.80 No B9 a 12.50 No C9 a 43.40 No A10 a 53.97 No B10 a 44.76 No C10 a 3.46 No rn A11 a 0.66 No B11 a 35.84 No C11 a 26.73 No Mean 25.89 Mean 16.26 Mean 19.39 Standard 20.96 Standard 14.47 Standard 25.66 te Deviation Deviation Deviation Table 2. Section at 3 mm from apex. In Group A % Dentin Voids Group B % Dentin Voids Group C % Dentin Voids showing showing showing leakage leakage leakage ni A1 b 0 No B1 b 22.81 No C1 b 2 No A2 b 53.07 No B2 b 0 No C2 b 0 No A3 b 0.42 No B3 b 0 No C3 b 48.78 Yes o A4 b 7.67 No B4 b 2.28 No C4 b 7.14 No izi A5 b 0.93 No B5 b 24.34 Yes C5 b 91 Yes A6 b 3.41 No B6 b 40.51 Yes C6 b 9.34 Yes A7 b 9.18 No B7 b 23.80 Yes C7 b 7.14 Yes Ed A8 b 7.60 No B8 b 10.13 No C8 b 6.36 No A9 b 37.02 No B9 b 2.31 No C9 b 81.03 Yes A10 b 39.83 No B10 b 54.67 No C10 b 4.55 No A11 b 4.02 No B11 b 88 No C11 b 40.21 Yes Mean 14.83 Mean 24.44 Mean 27.05 C Standard 18.92 Standard 27.55 Standard 33.23 Deviation Deviation Deviation CI 19.88% at 5 mm from the apex (section 3). No voids apex (section 2) with 6 voids found, and 37.37% at 5 were found in the endodontic obturating material. mm from the apex (section 3) with 7 voids found In group B (study group 1) the area which was infiltrat- (Tabs. 1, 2 and 3). © ed averaged 16.26% at 1 mm from the apex (section What emerges from the statistical analysis is that there 1), 24.44% at 3 mm from the apex (section 2), with 3 were no statistically significant differences with regard voids found, and 30.7% at 5 mm from the apex (section to infiltration of endodontic obturation by methylene 3) with 3 voids found. blue between the three groups of data, distributed by In group C (study group 2) the area which was infil- level and distance from the apex of the sections. trated averaged 13.39% at 1 mm from the apex (sec- There were also no statistically significant differences tion 1) with 1 void found, 27.05% at 3 mm from the between the groups regarding the presence of voids in Annali di Stomatologia 2013; IV (2): 184-190 187 3-Pusinanti_- 19/06/13 10:35 Pagina 188 L. Pusinanti et al. Table 3. Section at 5 mm from apex. Group A % Dentin Voids Group B % Dentin Voids Group C % Dentin Voids showing showing showing leakage leakage leakage li A1 c 0 No B1 c 47.39 Yes C1 c 4 No na A2 c 37.25 No B2 c 0 No C2 c 0 No A3 c 0 No B3 c 0 No C3 c 100 Yes A4 c 24.31 No B4 c 22.86 No C4 c 12.58 No A5 c 0.53 No B5 c 8.98 No C5 c 65,43 Yes io A6 c 20.75 No B6 c 60.44 Yes C6 c 10.44 Yes A7 c 35.87 No B7 c 35.54 Yes C7 c 29.84 Yes az A8 c 0.86 No B8 c 14.92 No C8 c 30.29 Yes A9 c 39.64 No B9 c 18.25 No C9 c 85.78 Yes A10 c 52.19 No B10 c 44.32 No C10 c 0 No rn A11 c 7.27 No B11 c 85 No C11 c 72.79 Yes Mean 19.88 Mean 30.70 Mean 37.37 Standard 19.22 Standard 26.72 Standard 36.96 te Deviation Deviation Deviation the root canal obturating material in the sections at 1 which observed three times more infiltration in canals and 3 mm from the apex. In filled with Thermafil which had a plastic carrier than in Statistically significant differences were seen between those obturated with Thermafil using a metallic carrier, groups B and C, and between groups A and C, regarding or using the lateral technique of compactation (44). The the presence of voids in sections 5 mm from the apex. timing of the post space preparation does not seem to influence microleakage, as can be deduced from the lit- ni erature: statistically significant differences were not Discussion found between microleakage from samples in which post space was prepared immediately after obturation o It has been widely demonstrated in the literature that and microleakage from samples in which post space the Thermafil system gives excellent results in en- was prepared 7 days after obturation (45). Significant izi dodontic fillings (21-40), whereas this technique consti- differences in the quality of apex seal were not seen in tutes an obstacle and is difficult to use when preparing root canals filled with Thermafil before or after post the lodging for a retention intraradicular pivot. In the lit- space preparation (46, 47). Our results show, more- erature several methods for post-space preparation in over, that the standard deviation of the mean percent- Ed root canals filled with Thermafil are described, but they ages of infiltrated surface is relatively high, which could seem complicated. With a view to simplifying the proce- indicate insufficient predictability regarding the possibili- dure, in the present study we evaluated the effect on ty of apical microleakage; this may be due to the high the quality of endodontic seals of a method which in- morphologic endodontic variability of radicular apexes. volves removal of the Thermafil carrier, possibly fol- Our results suggest that canal filling seal obtained us- lowed by the recompaction of gutta-percha while it is ing the Thermafil technique does not depend on, and is C still warm. not modified by, the technique used for post-space The first important point which emerged from the study preparation, even without waiting 24 hours for full set- CI was the presence of possible infiltration in all the ting of the gutta-percha. Another important result which groups, including samples in which the integrity of emerged during our evaluation of the precision of the Thermafil obturators was not altered before or during endodontic filling in the apical third, was the observa- the phase of post-space preparation. We suppose that tion under the optical microscope of the presence or mechanical and thermal stresses generated during absence of gutta-percha well adapted to the dentinal post-space preparation can have a negative influence canal walls in the three sections investigated (at 1, 3 © on sealing precision which can compromise the correct and 5 millimeters from the apex). It was also important adaptation of gutta-percha to the canal walls, as to find endodontic filling material without voids in the claimed by Gopikrishna & Parameswaren in 2006 (43). apical millimiter of the root canal, in the presence or ab- It is also true that microleakage between gutta-percha sence of the Thermafil carrier, while a statistically sig- and canalar dentin could occur in root canals complete- nificant difference in the occurrence of voids in the ly filled with Thermafil before, or else in the absence of canal filling material was found only between group C any post space preparation. There are studies, in fact, and groups A and B. 188 Annali di Stomatologia 2013; IV (2): 184-190 3-Pusinanti_- 19/06/13 10:35 Pagina 189 A simplified post preparation technique after Thermafil obturation: evaluation of apical microleakage and presence of voids using methylene blue dye penetration At this point we can assert that this research has pro- 16. Anbu R, Nandini S, Velmurugan N. Volumetric analysis of posed a technique which simplifies the procedure for root filling using spiral computed tomography: an in vitro study. post space preparation of root canals filled using the Int Endod J 2010; 43(1):64-68. 17. Gutmann JL, Saunders WP, Saunders EM, Nguyen L. A as- Thermafil technique. Even if further studies will be nec- sessment of the plastic Thermafil obturation technique. Part essary, we can say that it is possible to completely re- li 1. Radiographic evaluation of adaptation and placement. Int move the Thermafil carrier using tweezers, and to com- End J 1993; 26(3):173-178. pact gutta-percha inside the root canal using manual na 18. Juhlin JJ, Walton RE, Dovgan JS. Adaptation of Thermafil pluggers, to limit the formation of voids inside the en- components to canal walls. J Endod 1993; 19(3):130-135. dodontic filling materials that could alter canal seal in 19. Johnson B, Lasater D. Adaptation of Thermafil components the long term. Using a common bur for post space to canal walls. J Endod 1993; 19(6):266. preparation, the canal lumen can easily be enlarged 20. Lee CQ, Cobb CM, Robinson SJ, LaMartina T, Vo T. In vit- io since the coronal portion of the root canal is free from ro evaluation of the thermafil technique with and without gut- interference. Operating times are considerably short- ta-percha coating. Gen Dent 1998; 46(4):378-381. 21. Pathomvanich S, Edmunds DH. The sealing ability of Ther- ened and the risk of creating iatrogenic perforations is mafil obturators assessed by four different microleakage tech- az notably reduced. niques. Int Endod J 1996; 29(5):327-334. 22. Haїkel Y, Freymann M, Fanti V, Claisse A, Poumier F, Wat- son M. Apical microleakage of radiolabeled lysozime over References time in three techniques of root canal obturation. J Endod rn 2000; 26(3):148-152. 1. Johnson WB. A new gutta-percha technique. J Endod 23. Xu Q, Ling J, Cheung GS, Hu Y. A quantitative evaluation 1978; 4:184. of sealing ability of 4 obturation techniques by using a glu- 2. Becker TA, Donnelly JC. Thermafil obturation: a literature re- cose leakage test. Oral Surg Oral Med Oral Pathol Oral Ra- view. Gen Dent 1997; 45(1):46-55. diol Endod 2007; 104(4):e109-113. te 3. Gulabivala K, Leung SF. Review of a new root canal obtu- 24. Karagenç B, Gençoğlu N, Ersoy M, Canserver G, Külekçi G. ration technique. Dent Update 1994; 21(2):73-78,80-83. A comparison of four different microleakage tests for as- 4. Buchanan S. Common misconceptions about carrier-based sessment of leakage of root canal fillings. Oral Surg Oral Med obturation. Endod Pract 2009 Nov; 7-11. Oral Pathol Oral Radiol Endod 2006; 102(1):110-113. In 5. Blum JY, Machtou P, Micallef JP. Analysis of forces devel- 25. Kontakiotis E, Chanotis A, Georgopoulou M. Evaluation of oped during obturations. Wedging effect: Part II. J Endod 3 obturation techniques. Quintessence Int 2007; 38(4):e195- 1998; 24(4):223-228. 200. 6. Weis MV, Parashos P, Messer HH. Effect of obturation tech- 26. Kytridou V, Gutmann Jl, Nunn MH. Adaptation and sealability nique on sealer cement thickness and dentinal tubule pen- of two contemporary obturation techniques in the absence ni etration. Int Endod J 2004; 37(10):653-663. of the dentinal smear layer. Int Endod J 1999; 32(6):464-474. 7. Clinton K, Van Himel T. Comparison of a warm gutta-per- 27. Pommel L, Camps J. In vitro apical leakage of System B com- cha obturation technique and lateral condensation. J Endod pared with other filling techniques. J Endod 2001; 27(7):449- 2001; 27(11):692-695. 451. o 8. Goldberg F, Artaza LP, De Silvio A. Effectiveness of differ- 28. Gençoğlu N, Samani S, Günday M. Evaluation of sealing ent obturation techniques in the filling of simulated lateral properties of Thermafil and Ultrafil techniques in the absence izi canals. J Endod 2001; 27(5):362-364. or presence of smear layer. J Endod 1993; 19(12):599-603. 9. Weller RN, Kimbrough WF, Anderson RW. A comparison of 29. McMurtrey LG, Krell KV, Wilcox LR. A comparison between thermoplastic obturation techniques: adaptation to the canal Thermafil and lateral condensation in highly curved canals. walls. J Endod 1997; 23(11):703-706. J Endod 1992; 18(2):68-71. 10. Somma F, Cretella G, Carotenuto M, Pecci R, Bedini R, De 30. Scott AC, Vire DE, Swanson R. An evaluation of the Ther- Ed Biasi M, Angerame D. Quality of thermoplasticized and sin- mafil endodontic obturation technique. J Endod 1992; gle point root fillings assesed by micro-computed tomogra- 18(7):340-343. phy. Int End J 2011; 44(4):362-369. 31. Fabra-Campos H. Experimental apical sealing with a new 11. Marciano MA, Ordinola-Zapata R, Cunha TV, Duarte MA, canal obturation system. J Endod 1993; 19(2):71-75. Cavengao BC, Garcia RB, Bramante CM, Bernardineli N, 32. Bhambhani SM, Sprechman K. Microleakage comparison of Moraes IG. Analysis of four gutta-percha techniques used Thermafil versus vertical condensation using two different C to fill mesial root canals of mandibular molars. Int End J 2011; sealers. Oral Surg Oral Med Oral Pathol 1994; 78(1):105- 44(4):321-329. 108. 12. Jarrett IS, Marx D, Covey D, Karmazin M, Lavin M, Gound 33. Dummer PM, Lyle L, Rawle J, Kennedy JK. A laboratory study CI T. Percentage of canals filled in apical cross-sections - an of root fillings in teeth obturated by lateral condensation of in vitro study of seven obturation techniques. Int Endod J gutta-percha or Thermafil obturators. Int Endod J 1994; 2004; 37(6):392-398. 27(1):32-38. 13. Gençoğlu N, Samani S, Günday M. Dentinal wall adaptation 34. Hata G, Kawazoe S, Toda T, weine FS. Sealing ability of ther- of thermoplasticized gutta-percha in the absence or presence moplasticized gutta-percha fill techniques as assessed by of smear layer: a scanning electron microscopic study. J En- a new method of determining apical leakage. J Endod 1995; © dod 1993; 19(11):558-562. 21(4):167-172. 14. De-Deus G, Gurgel-Filho ED, Magalhães KM, Coutinho-Fil- 35. Abarca AM, Bustos A, Navia M. A comparison of apical seal- ho T. A laboratory analysis of gutta-percha filled area obtained ing and extrusion between Thermafil and lateral condensa- using Thermafil, System B and lateral condensation. Int En- tion techniques. J Endod 2001; 27(11):670-672. dod J 2006; 39(5):378-383. 36. Punia SK, Nadig P, Punia V. An in vitro assessment of api- 15. Schäfer E, Olthoff G. Effect of three different sealers on the cal microleakage in root canals obturated with gutta-flow, Re- sealing ability of both Thermafil obturators and cold lateral- silon, Thermafil and lateral condensation. A stereomicroscopic ly compacted gutta-percha. J Endod 2002; 28(9):638-642. study. J Conserv Dent 2011; 14(2):173-177. Annali di Stomatologia 2013; IV (2): 184-190 189 3-Pusinanti_- 19/06/13 10:35 Pagina 190 L. Pusinanti et al. 37. Gulabivala K, Holt R, Long B. An in vitro comparison of ther- apical filling materials after post space preparation. Oral Surg moplasticized gutta-percha obturation techniques with cold Oral Med Oral Pathol 1992; 74(5):644-647. lateral condensation. Endod Dent Traumatol 1998; 14(6):262. 43. Gopikrishna V, Parameswaren A. Coronal sealing ability of 38. Gençoğlu N, Oruçoğlu H, Helvacioğlu D. Apical leakage of three sectional obturation techniques – SimpliFill, Thermafil different gutta-percha techniqyues: Thermafil, Js Quick-Fill, and warm vertical compaction – compared with cold later- li Soft Core, Microseal, System B and lateral condensation with al condensation and post space preparation. Aust Endod J a computerized fluid filtration meter. Eur J Dent 2007; 1(2):97- 2006; 32(3):95-100. na 103. 44. Ricci ER, Kessler JR. Apical seal of teeth obturated by the 39. Dalat DM, Spångberg LS. Comparison of apical leakage in laterally condensed gutta-percha, the Thermafil plastic and root canals obturated with various gutta-percha techniques Thermafil metal obturator techniques after post space using a dye vacuum tracing method. J Endod 1994; preparation. J Endod 1994; 20(3):123-126. 20(7):315-319. 45. Saunders WP, Saunders EM, Gutmann JL, Gutmann ML. An io 40. Inan U, Aydemir H, Taşdemir T. Leakage evaluation of three assessment of the plastic Thermafil obturation technique. Part different root canal obturation techniques using electro- 3. The effect of post space preparation on the apical seal. chemical evaluation and dye penetration evaluation meth- Int Endod J 1993; 26(3):184-189. ods. Aust Endod J 2007; 33(1):18-22. 46. Dalat DM, Spångberg LS. Effect of post preparation on the az 41. Gutmann JL, Saunders WP, Saunders EM, Nguyen L. A as- apical seal of teeth obturated with plastic Thermafil obtura- sessment of the plastic Thermafil obturation technique. Part tors. Oral Surg Oral Med Oral Pathol 1993; 76(6):760-765. 3. The effect of post space preparation on the apical seal. 47. Rybicki R, Zillich R. Apical sealing ability of Thermafil following Int End J 1993; 26(3):184-189. immediate and delayed post space preparations. J Endod rn 42. Ravanshad S, Torabinejad M. Coronal dye penetration of the 1994; 20(2):64-66. te In o ni izi Ed C CI © 190 Annali di Stomatologia 2013; IV (2): 184-190 

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4-Baldini_- 19/06/13 10:47 Pagina 191 Original article Association between periodontal disease and Interleukin-1β +3953 and vitamin D receptor Taq1 genetic polymorphisms in an Italian caucasian li population na Alberto Baldini, PhD, DDS1 41% controls (p<0.01). Alessandro Nota, DDS1 Conclusion. The results of this case control study at- io Elena Fanti, BSc2 test that the T allele of VDR Taq1 is strongly associ- Francesco Saverio Martelli, DMD, IRF3 ated with periodontal disease, whereas the t allele of Cosimo Ottomano, MD4 the IL-1β +3953 confers a slightly protection against Giuseppe Lippi, MD4 the risk of periodontitis. az Key words: periodontal diseases, periodontitis, ge- 1 Department of Orthodontics, netics, interleukins, gene expression. University of Rome “Tor Vergata”, Italy rn 2 Biomolecular Diagnostic, Firenze, Italy 3 IRF Microdentistry, Firenze, Italy Introduction 4 U.O. Ematochimica Diagnostics, te University Hospital of Parma, Italy Periodontal diseases encompass a variety of conditions affecting the periodontium. A simple classification of this condition has been agreed upon in 1999, during the Inter- Corresponding author: national Workshop for a Classification of Periodontal Dis- Alberto Baldini, PhD, DDS Centro Medico Polispecialistico Baldini Srl In eases and Conditions, and is now widely used by clini- cians and research scientists worldwide (1). Via S. Orsola, 5 Basically, this classification ranks periodontal disease and 24048 Bergamo, Italy conditions into eight leading categories, that are gingival Phone: +39 035 271935 diseases (including dental plaque-induced gingival dis- ni E-mail: studiomedicobaldini@gmail.com eases, non-plaque-induced gingival lesions), chronic peri- odontitis (either localized or generalized), aggressive peri- odontitis (either localized or generalized), periodontitis as Summary a manifestation of systemic diseases (i.e., associated with o hematological disorders, genetic disorders, or not other- Aim. Periodontal diseases entail a variety of condi- wise specified), necrotizing periodontal diseases (which izi tions affecting the periodontium. The pathogenesis can be either necrotizing ulcerative gingivitis or necrotiz- results from a complex interaction of genetic and ing ulcerative periodontitis), abscesses of the periodon- environmental factors. Although there are evi- tium, periodontitis associated with endodontic lesions, as dences to confirm a role of genetic determinants, well as developmental or acquired deformities and condi- Ed the outcome of the available studies is controver- tions (1, 2). sial and the largest part of the research has been According to the Research, Science and Therapy Com- carried out in Asian populations. mittee of the American Academy of Periodontology, the Methods. We investigated two polymorphisms in prevalence of severe generalized periodontitis is com- the genes encoding Interelukin-1β (IL-1β +3953 prised between 5% and 15% of the general population, C>T; rs1143634) and vitamin D receptor (VDR Taq1; although moderate disease may affect a majority of C rs731236) in 42 Caucasian patients with chronic pe- adults (2). Accordingly, the prevalence of gingivitis riodontal disease and 39 Caucasian subjects, among school children in the US ranges from 40% to CI matched for age and gender. 60%, whereas 47% of males and 39% of females aged Results. The IL-1β C allele was present in 100% of 18 to 64 exhibit at least one site which bled on probing cases and 92% of controls (p=0.07), the T allele was (BOP). Although reliable data attests that relatively few present in 19% of cases and in 44% controls sites with gingivitis progress to develop manifest peri- (p=0.017). The prevalence of the VDR Taq1 tt geno- odontitis, a genetically determined response has been type was lower in patients as compared with con- hypothesized, with non-smoking or former smoking, in- © trols (i.e., 10 versus 59%; p<0.01), whereas the tT terleukin (IL)-1 genotype-positive individuals having and TT genotypes were disproportionally higher in greater risk of BOP than non-smoking and former patients than in cases (i.e., 62 versus 33% for tT smoking IL-1 negatives (3). and 29% versus 8% for TT; p<0.01). As specifically regards the pathogenesis, the old view The t allele was present in 71% of cases and 92% of of periodontitis as the outcome of infection is now over- controls (p=0.016), whereas the T allele was present come by the new concept that the disease would in 90% of patients with periodontal disease and in emerge from a complex interaction of several genetic Annali di Stomatologia 2013; IV (2): 191-195 191 4-Baldini_- 19/06/13 10:47 Pagina 192 A. Baldini et al. and environmental factors (4-6), including bacterial in- Table 1. Leading characteristics of the study population. fection, host response and inflammation, with tobacco Values are shown as mean ± standard deviation. smoking, ageing, male gender and low socioeconomic PPD, probing pocket depth; BOP, bleeding on probing. status being considered other important risk factors (7, 8). The host response mediated by several cytokines is Chronic Healthy li now regarded as a leading aspect in the clinical expres- periodontal controls sion of periodontitis, and several inflammatory biomark- disease na ers have been consistently associated with periodontal n 42 39 disease, especially prostaglandin E2 (PGE2), tumor Age (yrs) 60±9 55±15 necrosis factor-alpha (TNF-α), Interleukin-1 alpha (IL- 1α), and Interleukin-1 beta (IL-1β) (9, 10). Interestingly, Gender, females (%) 27 (64%) 30 (77%) io only 20% of periodontal diseases is now attributed to PPD (mm) 4,17 1,34 bacterial variance, 20% to tobacco use, whereas 50% Presence of PUS (%) 58 0 of disease expression has been attributed to genetic BOP (%) 99 26 az variance at several loci, including specific polymor- phisms at the loci encoding for some cytokines (i.e., IL- 1α, IL-1β, IL-6, TNF-α) (9), as well as for the vitamin D receptor (VDR) gene (10). Hilden, Germany). Allelic analysis was performed using Although some studies (11) and meta-analyses (12, 13) rn Taq Man1 SNP Genotyping Assays rs731236 and are now available to attribute a certain the role to these rs1143634 (Applied Biosystems, Forster City, CA, USA), genetic determinants in the pathogenesis of periodontal which are based on a predesigned mix of unlabeled disease, the outcome is often controversial. As such, polymerase chain reaction (PCR) primers and the Taq te the aim of this article was to investigate whether two Man® minor groove binding group (MGB) probe (FAM™ polymorphisms in the genes encoding IL-1β (i.e., IL-1β and VIC® dye-labeled), on the instrument Step One (Ap- +3953 C>T; rs1143634) and VDR (i.e., VDR Taq1; rs plied Biosystems). Thermocycler conditions were an ini- 731236) are associated with periodontal disease in a tial 35 s denaturation at 95° C, followed by 40 cycles of Caucasian population. In 95° C for 10 s and 60° C for 45 s. The significance of differences between cases and controls was evaluated with Chi-Square test using Analyse-it for Microsoft Ex- Materials and methods cel (Analyse-it Software Ltd, Leeds, UK). ni The study population consisted in 42 Caucasian pa- tients (27 females and 12 males, mean age of 60±9 years) with chronic periodontal disease diagnosed ac- Results cording to the well-established criteria of the Interna- o tional Workshop for a Classification of Periodontal Dis- The results of IL-1β +3953 are shown in Figure 1. A sig- eases and Conditions (1). nificant difference was observed in the overall distribution izi Accordingly, each of the 42 patients with chronic periodon- of C/T polymorphisms (Pearson Chi-Square = 7.106; tal disease had severe and generalized form of periodon- DF=2; p=0.029), in that patients with periodontal disease tal disease, showing at least 5 sites with probing pocket exhibited a higher prevalence of the CC genotype (81 depth (PPD) >6 mm located in different teeth and distrib- versus 56%), whereas the TT genotype was present in Ed uted among the four quadrants, BOP and pus. The control 8% of controls but in none of the cases (Fig. 1). The het- group consisted in 39 Caucasian subjects matched for erozygous allele CT was present in 19% of cases versus age and gender (30 females and 9 males, mean age 36% of controls. Globally, the C allele was present in 56±15 years) not affected by periodontal disease, i.e., with 100% of cases and 92% of controls (Pearson Chi- no history of periodontal disease, without periodontal Square = 3.36; DF=1; p=0.07), whereas the T allele was pockets >3 mm and radiographic evidence of bone loss present in 19% of patients with periodontal disease and C (Tab. 1). in 44% without (Pearson Chi-Square = 5.71; DF=1; All the subjects were enrolled in the study after signing p=0.017). CI an inform consent form, and the experimental protocol An even more statistically significant associations was was accepted by the ethical committee. however found for the VDR Taq1 polymorphism (Fig. 2) No case or control subject was affected by systemic (Pearson Chi-Square = 23.024; DF = 2; p<0.01), in that diseases that are known to influence development or pro- the prevalence of the tt genotype very low in patients gression of periodontal disease (e.g., diabetes), or was with periodontal disease as compared with controls (i.e., pregnant, currently smoking or using anti-inflammatory 10 versus 59%), whereas the tT and TT genotypes were © drugs. Each patient signed the informed consent to be disproportionally higher in patient than in cases (i.e., 62 included in the study, which was carried out in accor- versus 33% for tT and 29% versus 8% for TT). Overall, dance with the Declaration of Helsinki, and under the the prevalence of the t allele was present in 71% of cas- terms of all relevant local legislation. Genomic testing es and 92% of controls (Pearson Chi-Square = 5.84; was carried out after collecting material with a sterile DF=1; p=0.016), whereas the T allele was present in foam tipped applicator. The DNA was extracted with a 90% of patients with periodontal disease and in 41% commercial kit purchased from Qiagen (Qiagen GmbH, controls (Pearson Chi-Square = 22.25; DF=1; p<0.01). 192 Annali di Stomatologia 2013; IV (2): 191-195 192 4-Baldini_- 19/06/13 10:47 Pagina 193 Association between periodontal disease and Interleukin-1β +3953 and vitamin D receptor Taq1 genetic polymorphisms in an Italian caucasian population Figure 1. Results for IL-1β +3953. li na io az rn te Figure 2. Results for VDR Taq1. In o ni izi Ed Discussion and conclusion Asian populations did not allow to draw definitive con- clusions on this topic. C Periodontal disease is a public health problem afflicting The results of our investigation, which were limited to the vast majority of adults in mild to moderate forms the two genetic polymorphisms for which more solid ev- CI and being associated with important clinical implica- idence are available (i.e., IL-1β +3953 and VDR Taq1), tions not only for dental medicine, but also for its causal attest that patients who are more prone to develop relationship with a variety of other important disorders, chronic periodontitis may have an important genetic namely cardiovascular disease (13, 14). Recent and re- predisposition. markable advances in our understanding of the patho- This finding may have important clinical implications in genesis of periodontal disease have led to a radical ap- terms of genotype-based risk assessment, early pre- © proach for prevention and treatment, which now deeply vention of predisposed individuals (e.g., smoking and involve the assessment of personal susceptibility. The genetic interactions are important contributory factor in outcome of several epidemiological investigations have severity of periodontitis), and more aggressive treat- allowed to identify a variety of genetic polymorphisms ment of patients at greater risk. that may be associated with periodontal disease (7, The two genotypes that have been assessed in this 15), but the heterogeneity of the studies, the different study exert different but synergic role in the pathogene- diagnostic criteria as well as the prevalent enrolment of sis of periodontal disease. The pivotal role of the IL-1 Annali di Stomatologia 2013; IV (2): 191-195 193 4-Baldini_- 19/06/13 10:47 Pagina 194 A. Baldini et al. family of interleukins as mediators of inflammatory re- odontal disease, so that mediators of bone metabolism actions has been well established. Both IL-1α and IL- like the VDR and its genetic polymorphisms may play a 1β exert similar proinflammatory activities, whereas IL- role in the pathogenesis (19). Unfortunately, the poten- 1 receptor antagonist (IL-1Ra) is an anti-inflammatory tial mechanism/s linking VDR and its gene polymor- cytokine that counteract the former interleukins by bind- phisms with periodontal disease are still largely ob- li ing to the IL-1 receptor (16). scure. Some hypothesis were postulated, including Although some similarities exist between IL-1α and IL- negative influences on bone mineral density, turnover, na 1β, the latter is a different molecular form, which is also and bone loss (10, 20). In 2011 Deng et al. carried out known as catabolin. IL-1β exerts a kaleidoscope of bio- a database search retrieving 15 studies involving 1338 logical functions; it is an important mediator of the in- cases and 1302 controls, and found that that chronic flammatory response and actively involved in several periodontitis cases had a weak significantly higher fre- io cellular activities such as cell proliferation, differentia- quency of TT genotype of VDR Taq1 (OR = 1.86, 95% tion, and apoptosis. In a seminal article by Liu et al., the CI, 1.00, 3.46; p = 0.049) in Asians (10). These results severity of periodontal disease (in terms of gingival in- are globally in agreement with those obtained in our az dex, probing depth and gingival crevicular fluid flow) case control study in a Caucasian population, since we was first associated with IL-1β activity (17). Hou et al. observed that the prevalence of the T allele was more also reported that the tissue concentration of IL-1β de- than twice in with patients with periodontal disease as termined from diseased gingivae were remarkably high- compared with healthy controls (i.e., 90 versus 41% P er than those of controls from both healthy sites of peri- < 0.01). rn odontitis and non-periodontitis subjects (18), thereby Taken together, the results of this case control study at- confirming that IL-1β plays a significant role in the path- test that the T allele of VDR Taq1 are strongly associat- ogenic mechanisms of periodontal tissue destruction ed with periodontal disease, whereas the t allele of the te and that its assessment in periodontal tissue might be a IL-1β +3953 confers a slightly protection against the valuable aid and useful diagnostic marker of disease. risk of periodontitis. The important role played by IL-1β on periodontal dis- ease has been attributed to the potency of inducing References bone resorption and connective tissue destruction, paving the way to further studies assessing whether In 1. Armitage GC. Development of a classification system for pe- genetic polymorphisms in the IL-1β gene might induce riodontal diseases and conditions. Ann Periodontol 1999; variations of cytokine levels in the periodontal tissue 4:1-6. and thereby predispose to periodontitis. Nevertheless, 2. Baldini A, Tecco S, Cioffi D, Rinaldi A, Longoni S. Gnatho- ni conflicting results recently reviewed by Laine et al. logical postural treatment in an air force pilot. Aviat Space were published, so that this polymorphism cannot be Environ Med. 2012; 83:522-526. considered as yet a definitive risk factor for susceptibili- 3. Burt B. Research, Science and Therapy Committee of the ty to chronic periodontitis for the worldwide population American Academy of Periodontology. Position paper: epi- o (15). In a recent meta-analysis of 53 studies including demiology of periodontal diseases. J Periodontol 2005; 4178 cases and 4590 controls, Nikolopoulos et al. 76:1406-1419. izi 4. Gemmell E, Seymour GJ. Immunoregulatory control of found a significant association of IL-1β +3953 C>T Th1/Th2 cytokine profiles in periodontal disease. Peri- polymorphism and chronic periodontal disease (9). In odontol 2000, 2004; 35:21-41. particular, the carriage of the T allele conferred a 45% 5. Stabholz A, Soskolne WA, Shapira L. Genetic and envi- relative increase in the risk for chronic periodontitis Ed ronmental risk factors for chronic periodontitis and aggres- (Odds Ratio [OR]: 1.45, 95% CI: 1.13, 1.85) and more sive periodontitis. Periodontol 2000, 2010; 53:138-153. than doubled the hazard in populations of Asian origin 6. Baldini A, Nota A, Tripodi D, Longoni S, Cozza P. Evalua- (OR: 2.18, 95% CI: 1.22, 3.92). Both TT versus CT+CC tion of the correlation between dental occlusion and posture and TT+CT versus CC contrasts showed evidence of using a force platform. Clinics 2013; 68:45-49. an association between the IL-1β 3953 C>T polymor- 7. Kinane DF, Mark Bartold P. Clinical relevance of the host re- sponses of periodontitis. Periodontol 2000, 2007; 43:278-293. phism and chronic periodontal disease (OR: 1.60, 95% C 8. Armitage GC, Cullinan MP, Seymour GJ. Comparative bi- CI: 1.11, 2.311, and OR: 1.50, 95% CI: 1.16, 1.93, re- ology of chronic and aggressive periodontitis: introduction. spectively). An even stronger association was observed Periodontol 2000, 2010; 53:7-11. CI comparing carriers of TT or CT genotype with the CC 9. Nikolopoulos GK, Dimou NL, Hamodrakas SJ, Bagos PG. homozygotes in Asian populations (OR: 2.42, 95% CI: Cytokine gene polymorphisms in periodontal disease: a meta- 1.49, 3.94). A statistically significant heterogeneity was analysis of 53 studies including 4178 cases and 4590 con- however found in these analyses, which hence de- trols. J Clin Periodontol 2008; 35:754-767. creased the overall statistical significance of the associ- 10. Deng H, Liu F, Pan Y, Jin X, Wang H, Cao J. BsmI, TaqI, ations. ApaI, and FokI polymorphisms in the vitamin D receptor gene © Overall the data of Nikolopoulos et al. in Asian popula- and periodontitis: a meta-analysis of 15 studies including 1338 cases and 1302 controls. J Clin Periodontol 2011; 38:199- tions is in disagreement with our findings in Cau- 207. casians, whereby the T allele was two times more 11. Scapoli C, Mamolini E, Carrieri A, Guarnelli ME, Annunzia- prevalent in controls than in patients with periodontal ta M, Guida L, Romano F, Aimetti M, Trombelli L. Gene--gene disease (i.e., 19 versus 44%; P = 0.017). interaction among cytokine polymorphisms influence sus- Vitamin D plays a key role in bone metabolism. Alveolar ceptibility to aggressive periodontitis. Genes Immun. 2011; bone is now considered a major characteristic of peri- 12(6):473-480. 194 Annali di Stomatologia 2013; IV (2): 191-195 4-Baldini_- 19/06/13 10:47 Pagina 195 Association between periodontal disease and Interleukin-1β +3953 and vitamin D receptor Taq1 genetic polymorphisms in an Italian caucasian population 12. Laine M. L. , Crielaard W., Bruno G. L. Genetic susceptibil- logic findings of gingival tissue in periodontitis patients. Cy- ity to periodontitis. Periodontology 2000, 2012, 58:37-68. tokine 1996; 8:161-167. 13. Yoshie H, Kobayashi T, Tai H, Galicia JC. The role of ge- 18. Hou LT, Liu CM, Liu BY, Lin SJ, Liao CS, Rossomando netic polymorphisms in periodontitis. Periodontol 2000 EF. Interleukin-1beta, clinical parameters and matched cel- 2007; 43: 102-132. lular-histopathologic changes of biopsied gingival tissue li 14. Marchetti E, Monaco A, Procaccini L, Mummolo S, Gatto R, from periodontitis patients. J Periodontal Res 2003; Tetè S, Baldini A, Tecco S, Marzo G: Periodontal disease: 38:247-254. na the influence of metabolic syndrome. Nutr Metab (Lond). 2012 19. Uitterlinden AG, Ralston SH, Brandi ML, Carey AH, Grin- 25; 9:88. berg D, Langdahl BL, et al; The association between com- 15. Laine ML, Loos BG, Crielaard W. Gene polymorphisms in mon vitamin D receptor gene variations and osteoporosis: chronic periodontitis. Int J Dent 2010; 2010:324719. a participant-level meta-analysis. Ann Intern Med 2006; 16. Dinarello CA. Biologic basis for interleukin-1 in disease. Blood 145:255-264. io 1996; 87:2095-2147. 20. Baldini A, Zaffe D, Nicolini G. Bone-defects healing by high- 17. Liu CM, Hou LT, Wong MY, Rossomando EF. Relationships molecular hyaluronic acid: preliminary results. Ann Stoma- between clinical parameters, Interleukin 1B and histopatho- tol (Roma). 2010; 1:2-7. az rn te In o ni izi Ed C CI © Annali di Stomatologia 2013; IV (2): 191-195 195 

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6-Cantarella_- 19/06/13 10:37 Pagina 204 Original article The dynforce archwire li na Daniele Cantarella Orthodontic archwires are made of different alloys, like Luca Lombardo stainless steel, nichel-titanium, beta-titanium, and oth- io Giuseppe Siciliani ers. The physical features of orthodontic archwires are expressed in the stress-strain or load-deflection dia- Postgraduate School of Orthodontics, gram (1, 2) as shown in Figure 2. Ferrara University, Italy Orthodontic archwires have an elastic behavior. When az the wire is deflected, it gives back a force of response (Figs. 1, 2). Linear deflection is expressed by “d” in Corresponding author: Figure 1. The force of response depends on the rigidi- Daniele Cantarella ty of the archwire, represented by the slope of the rn Postgraduate School of Orthodontics curve represented in Figure 2. Archwires with higher Ferrara University rigidity have a more vertical slope. Archwires with low- Via Montebello 31 er rigidity (higher flexibility) have a more horizontal slope. te 44121 Ferrara, Italy Phone: (+39) 0532-202528 The diagram (Fig. 2) is also useful to understand the E-mail: danielecant@hotmail.com resilience of the archwires. The resilience is defined as the area under the load-deflection curve out to the pro- Summary In portional limit. It represents the energy storage capacity of the wire (1). In other words it is the energy that a wire This article is a presentation of a clinical methodology aimed at minimizing binding in fixed orthodontic ap- ni pliances. The dynforce archwire is explained. The dynforce archwire has a full size anterior segment (e.g. .021x.025) and undersized posterior segments with rectangular cross-section (e.g. .018x.025 or o .018x.022), and is used in the orthodontic phase of space closure with or without TAD miniscrews. Two izi clinical cases are presented. Key words: archwire, binding, friction, incisor, torque, sliding, retraction, miniscrew, TAD, skeletal Ed anchorage, ceramic brackets. Figure 1. Deflection (d) of a beam of orthodontic wire of Introduction length L, redrawn from Proffit and Fields (1). It is the Authors’ view that low forces in orthodontics can C minimize archwire to bracket binding and resistance to sliding in fixed appliances. Orthodontic archwires, when CI deflected (Fig. 1), give a force of response. The force of response produces binding of the archwires at the edges of the bracket slots. Wires with lower force of response can minimize binding during the orthodontic treatment. This model will be explained in the article. © Materials and methods and discussion Orthodontic archwires can be seen like beams supported on one or two ends (1). It is of fundamental importance to know the behavior of orthodontic archwires in order to understand binding. Figure 2. Load-deflection diagram. 204 Annali di Stomatologia 2013; IV (2): 204-211 6-Cantarella_- 19/06/13 10:37 Pagina 205 The dynforce archwire is able to absorb in the elastic range and is able to give ets. These systems generate a force that is perpendic- back during the alignment of teeth. ular to the direction of movement of the archwire Wires with higher proportional limit have higher re- through the bracket slot. silience. They can be bent at greater angles before Classical Friction depends on the law traditionally de- they undergo plastic deformation. Infact the proportion- scribed in friction: classical friction= μ x Fn where: li al limit is the point at which plastic (permanent) defor- μ= coefficient of friction, mation starts to occur (1, 2). It is desirable that ortho- Fn= force perpendicular to the opposing surfaces slid- na dontic archwires have high resilience so that they can ing on each other. give back the energy they absorb during the deflection The coefficient of friction (μ) is an intrinsic property of phase and efficiently align teeth. Other important para- the wire-bracket couple and it depends on the surface meters to know are the yield strength, represented by features of the material. io the point at which 0,1% of permanent deformation is Classical friction has been reported (5, 13) to be: measured, and the ultimate strength at which the wire ➢ almost zero for self-ligating brackets, breaks (1), as shown in Figure 2. ➢ 10 to 29 grams for steel-ligatures, az The flexural rigidity of an archwire is defined as “E” mul- ➢ 106 to 138 grams for elastomeric ligatures. tiplied by ”I” (3). “E” is the Modulus of Elasticity of the wire, Under a clinical standpoint tighter steel ligatures gener- and it depends on the alloy of the wire (stainless steel, ate higher levels of classical friction because the steel nichel-titanium, beta-titanium or others). ligature produces a force that is perpendicular (Fn in rn “I” is the second moment of inertia. The second moment the above formula) to the direction of sliding of the wire of inertia is used in structural engineering and it ex- through the bracket slot. On the other hand, loose steel presses the resistance to deflection of a beam. ligatures can be made if low levels of classical friction For orthodontic archwires with rectangular cross-section are clinically desirable. te “I” is equal to h3w /12 (where “h” is the height and “w” is Elastomeric ligatures show higher levels of classical the width of the rectangular cross-section). friction than steel ligatures. However, the polymers of For orthodontic archwires with round cross-section “I” is the elastomeric ligatures undergo degradation and equal to π r4/64 (where “r” is the radium of the cross-sec- plastic deformation (19) and lose 70% of their force 48 tion). Under a practical stand-point we can think the second mo- In hours after placement in the oral environment (6). Hence it can be expected that 2 days after placement ment of inertia like the cross-section area of the wires. in the mouth elastomeric ligatures generate 40-50 Wires with larger cross-section area have a higher sec- grams of force (20). ond moment of inertia and therefore are more rigid. When the archwire is parallel to the bracket slot only ni If we want to have a more flexible wire (less rigid) we classical friction contributes to resistance to sliding. can choose a wire with a lower modulus of elasticity (for This situation in which the wire does not contact the example choosing nichel-titanium instead of stainless edges of the bracket slot is called “passive configura- o steel) or a wire with a smaller cross-section area. tion” (4) and it is rarely encountered in clinical settings. With angulation between the wire and the bracket slot, Following is a discussion on the factors that affect re- izi the wire starts to contact the edges of the bracket slot sistance to sliding (RS) in orthodontic fixed appliances. (“critical contact angle for binding”) and binding phe- For the sake of simplicity the discussion will be divided nomena start to occur (5), as shown in Figure 3. This is in four points. called the “active configuration”. In binding the archwire Ed is elastically deformed, and due to its elastic properties it tends to return to its original shape, generating bind- Point 1 - the Force of Response of the deflected ing of the wire at the opposing corners of the bracket wires (1, 3) slot, as shown in Figure 3 (15, 16). Resistance to slid- The Force of Response of the deflected archwire is ing due to binding has been reported to reach levels as equal to 3 x E x I x d ÷ L3 where : high as 826 grams (10). C E = Modulus of Elasticity of the wire, At greater angulations the archwire can no longer with- I = Second Moment of Inertia of the wire stand the forces of the slot walls and it begins to per- CI d = linear deflection of the wire (as shown in Fig. 1), manently deform (notching) (5), as shown in Figure 3. L= length of the beam of wire (as shown in Fig. 1), Wires with higher force of response generate higher Higher force of response increases the resistance to levels of binding. sliding (7-10, 12). This concept will be further explained We saw in point 1 that the force of response of the de- in point 2. flected wire is equal to 3 x E x I x d ÷ L3. This formula can explain most of the factors that affect © binding, as summarized in the following discussion. Point 2 - Resistance to sliding is the sum of classi- a. A small inter-bracket distance increases the resi- cal friction, binding, permanent deformation (4). stance to sliding (7). In fact a longer beam of wire (“L” in the above formula) reduces the force of re- Classical friction is generated by the systems that se- sponse of the wire by the third power of the length. cure the archwires into the bracket slots: elastomeric b. A greater angulation between archwire and bracket ties, steel ligatures, clips or slides of self-ligating brack- slot increases the resistance to sliding (8, 10). In Annali di Stomatologia 2013; IV (2): 204-211 205 6-Cantarella_- 19/06/13 10:37 Pagina 206 D. Cantarella et al. li na io az rn Figure 3. Resistance to sliding in orthodontic fixed appliances is the sum of Classical Friction, Binding, Permanent Deforma- tion (notching). fact greater deflection (“d” in the above formula) in- nichel-titanium wire is 60 grams (12x5). In other words, te creases the force of response of the wire. at 5 degrees of wire-bracket angulation the resistance c. Stainless Steel wires have coefficients of binding to sliding of the .019x.025 stainless steel wire (more much higher than nichel-titanium or beta-titanium rigid, hence with higher force of response) is 270 grams wires (7, 9, 12). In fact greater Modulus of Elasticity higher than the resistance to sliding of the .016x.022 sponse of the deflected wire. In (“E” in the above formula) increases the force of re- nichel-titanium wire. Some strategies can be adopted in order to minimize d. A larger cross-section area of the archwire increa- the force of response of the deflected wires and binding ses the resistance to sliding (8, 10). In fact greater in clinical orthodontics: second moment of inertia (“I” in the above formula) a. Use of larger inter-bracket distances, for example ni increases the force of response of the deflected wi- using single wing brackets (14), re. Particularly, Moore et al. (8) found that a b. Reduction of the angulation between archwire and .021x.025 stainless steel wire has a coefficient of bracket slots during space closure in sliding mecha- binding three times larger than the coefficient of nics, for example by means of power arms or by o binding of a .019x.025 stainless steel wire. completely leveling the curve of spee before the Smaller inter-bracket distances, greater angulations phase of space closure, izi between wire and slot, higher modulus of elasticity and c. Use of archwires with lower modulus of elasticity, larger cross-section areas of wire increase the force of d. Use of archwires with smaller cross-section area. response of the deflected wire and increase binding of All above mentioned methods reduce the force of re- the wire against the bracket slot, slowing down tooth sponse of the deflected wires and reduce resistance to Ed movement. sliding in orthodontic treatments. It is important also to review the meaning of the Coeffi- Finally, resistance to sliding is also affected by notch- cient of Binding. ing. Notching (plastic or permanent deformation) hap- Resistance to sliding due to binding is equal to Coeffi- pens when the wire is deflected beyond the elastic cient of Binding multiplied by wire-bracket angulation (proportional) limit (1), as shown in Figure 2 and Figure beyond critical contact angle (4). 3. When the wire is permanently deformed, it does not C Studies (7, 8, 10, 11, 13) have been done where the return to its original shape. Notching causes all motion wire slides through the bracket slot when the bracket of the archwire through the bracket to cease (5). Clini- CI has different angulations in relation to the archwire. A cally this is particularly important in extraction space diagram is produced where the horizontal axis repre- closure. The long span of wire running along the ex- sents the wire-bracket relative angulation and the verti- traction area can be distorted by the food during masti- cal axis represents the resistance to sliding. The slope cation. Wires with permanent deformation stop any slid- of the curve represents the coefficient of binding. ing of the wire through the brackets of posterior teeth if The coefficient of binding for the .019x.025 stainless space closure is performed with sliding mechanics. © steel wire has been reported to be 66 grams/degree of A method to increase the proportional limit of stainless wire-bracket angulation (13) and coefficient of binding steel archwires is heat treatment (2). Wires are heated for the .016x.022 nichel-titanium wire 12 grams/degree at low temperatures (370 to 480° C) for few minutes af- of wire-bracket angulation (13). For example at 5 de- ter archwires have been given the archform. Heat treat- grees of wire-bracket angulation resistance to sliding ment relieves the internal stress generated during the for the .019x.025 stainless steel wire is 330 grams shaping of the archform (cold working). After heat treat- (66x5), while the resistance to sliding of the .016x.022 ment wires exhibit a higher resilience, in other words 206 Annali di Stomatologia 2013; IV (2): 204-211 6-Cantarella_- 19/06/13 10:37 Pagina 207 The dynforce archwire they can be bent at greater angles before they undergo plastic deformation. The measured increase in elastic strength may be as great as 50% (2). Heat treated wires also show a slightly higher (by 10%) modulus of elasticity (2). The advantage of these wires is that they li maintain their shape during clinical use, improving slid- ing mechanics. na Point 3 - Archwires with low coefficient of binding are of critical importance to minimize resistance to io sliding when ceramic brackets are used. Bagby and Ngan (9) studied the coefficient of binding az for the .019x.025 stainless steel wire and for the .019x.025 nichel-titanium wire inserted in different ce- ramic brackets. They found that at 5,9° of wire bracket angulation the rn .019x.025 stainless steel wire has 180-400 grams of re- sistance to sliding, while the .019x.025 nichel-titanium wire has 5-20 grams of resistance to sliding. Figure 4. Tooth movement in sliding mechanics is a multi- Stainless steel wires have lower coefficient of friction te step tipping-uprighting mechanism. than nichel-titanium wires (2), due to the smoother sur- face of stainless steel. However, nichel-titanium has a of binding. Wires with higher resilience are more effec- lower modulus of elasticity than stainless steel, hence tive in the uprighting phase. Orthodontic archwires when it is deflected it has a lower force of response thus minimizing binding. In have a dynamic behavior. The work and the resilience of the archwires are of critical importance in this According to the findings of this study, when ceramic process. brackets are used in orthodontic treatments, archwires Heat treatment of stainless steel increases the propor- with low coefficients of binding should be utilized in or- tional (elastic) limit of the wire, improving the uprighting der to minimize resistance to sliding. ni phase of tooth movement. Heat treated wires are rec- ommended by the authors during space closure with sliding mechanics. Point 4 - Binding is present in orthodontics in most o clinical situations. The four points explained above are the basis of a pro- tocol aimed at minimize binding in clinical orthodontics. izi We will analyze the alignment phase and the space clo- The protocol is characterized by the use of small diam- sure phase. eter nichel-titanium wires (size .010 or .012) during the During alignment, most of the time teeth are crowded orthodontic alignment phase and by the use of the dyn- so that the wire exceeds the critical contact angle and force archwire (18) during the phase of space closure. Ed binding phenomena are present. Small diameter nichel- Some clinical examples are presented. titanium archwires, with low force of response and low During the orthodontic alignment phase the use of coefficient of binding are recommended by the authors small diameter nichel-titanium archwires has several in this phase. advantages. Thinner wires generate lower force when Space closure is performed after the alignment phase deflected, so it is easier to ligate teeth that are severely is finished. In sliding mechanics the Class I force need- crowded. Lower forces also minimize the patient dis- C ed to close the spaces is generated by elastic chains or comfort during the first days of orthodontic treatment. coils attached to the brackets. Since brackets are far Thinner wires with lower force of response also have CI from the center of resistance of the tooth, the tooth tips lower coefficient of binding (13). This is particularly im- until the wire contacts the edges of the bracket slot and portant during the alignment of highly positioned ca- binding phenomena start to occur (15, 16). The deflect- nines (Fig. 5). ed wire then tends to return to the original (non-deflect- Infact, in the presence of high resistance to sliding, the ed) shape and generates a moment of a couple that wire cannot slide through the brackets of canine, pre- uprights the root of the tooth (17), as shown in Figure 4. molars, molars. As a consequence spaces may open © Tipping and uprighting repeat many times until the between canine and lateral incisor or between canine tooth reaches the final position desired by the ortho- and first premolar, like shown in Figure 6. Wire to dontist. Orthodontic tooth movement in sliding mechan- bracket binding would create spacing during the align- ics is not a continuous process; rather it is a multi-step ment phase and buccal flaring of incisors. “tipping and uprighting” or “binding and releasing” The use of thin nichel-titanium wires with low force of mechanism. Wires with higher flexibility are more effi- response and low coefficient of binding allows the wire cient in the tipping phase due to their lower coefficient to slide through the brackets of canine, premolars and Annali di Stomatologia 2013; IV (2): 204-211 207 6-Cantarella_- 19/06/13 10:37 Pagina 208 D. Cantarella et al. Figure 5. Start of alignment of a highly positioned canine. li na io az rn te Figure 6. In the pres- ence of high resistance In to sliding, opening of spaces and buccal flar- ing of incisors may oc- cur during the align- ment phase. o ni izi Ed molars, without opening of spaces and without buccal 016x022 nichel-titanium and 019x025 beta-titanium C flaring of incisors as shown in Figure 7. It is typical to wires to finish the leveling/alignment phase. observe the wire coming out distally to the bracket of During space closure the dynforce archwire (18) is the molar during the alignment phase (Fig 7). used. The dynforce (Fig. 12) is made of heat-treated CI In Figures 8 and 9 we can see the bonding of a patient stainless steel and has an anterior segment with size with highly positioned canine. A .012 nichel-titanium .021x.025 occupying the incisor brackets, and posterior wire is inserted the day of the bonding. segments with size .018x.025 occupying the brackets Figures 10 and 11 show the patient after 40 days. The of canines, premolars, molars. canine has been aligned without opening of spaces and The dynforce low friction (L. F.) has anterior segment © without buccal flaring of incisors. with size .021x.025 and posterior segments with size The .012 nichel-titanium wire has a low force of re- .018x.022. The material is heat-treated stainless steel sponse and low coefficient of binding, allowing the in order to reduce indentations (notching) during the wire to slide through the ceramic brackets with mini- clinical use and improve sliding mechanics. Posterior mum friction and to come out distally to the bracket of segments (either .018x.025 or .018x.022 in size) are the molar. more flexible and hence have lower coefficient of bind- After the .012 Ni-Ti, the authors recommend the use of ing than the conventional .019x.025 stainless steel 208 Annali di Stomatologia 2013; IV (2): 204-211 6-Cantarella_- 19/06/13 10:37 Pagina 209 The dynforce archwire Figure 7. In the presence of low resistance to sliding, alignment is performed with- out opening of spaces and without buccal flaring of in- li cisors. The archwire comes out distally to the molar na bracket. io az rn te In o ni Figures 8 and 9. Frontal and lateral view of start of alignment of a patient with highly positioned canine. Use of .012 nichel-ti- tanium archwire. izi Ed C CI Figures 10 and 11. Frontal and lateral view of the patient after 40 days. Alignment of teeth occurred without opening of spaces and without buccal flaring of incisors. Low forces generate low binding. Also, low forces are more easily contrasted by the pressure of the lips (lip bumper effect). © archwires traditionally used for the retraction of anterior The anterior segment (size .021x.025) has higher rigidi- teeth. The aim is to minimize binding and notching dur- ty, in order to maximize the control of incisor tip and ing the phase of space closure. Further, posterior seg- torque. Higher rigidity also helps to prevent canting of ments (either .018x.025 or .018x.022) have rectangular the incisal plane when asymmetrical forces are used, cross-section and not round cross-section, because the for example during midline shift correction. rectangular shape offers a better control of the arch- Hooks 6,5 mm long are used when the Dynforce arch- form during space closure mechanics. wire is utilized with TAD miniscrews. Annali di Stomatologia 2013; IV (2): 204-211 209 6-Cantarella_- 19/06/13 10:37 Pagina 210 D. Cantarella et al. Figure 12. Dynfor- ce Archwire li na io az rn te In o ni izi Figure 13. Dynforce Archwire with miniscrews placed 7-8 mm above the archwire. Ed As shown in Figure 13 the dynforce can be used in as- sociation with miniscrews positioned between second premolar and first molar 7-8 mm above the archwire. The retracting force is generated by elastic chain run- ning from the miniscrews to the hooks of the archwire. C The retracting force passes close to the center of resis- tance of the dental arch in order to produce a bodily CI movement of front teeth. In this configuration binding is minimized for two rea- sons: a) Posterior segments of the Dynforce are undersized, hence with lower coefficient of binding, b) Hooks 6,5 mm long work like power arms: the point © of application of the retracting force is close to the center of resistance of the dental arch, hence the Figure 14. Start of en-masse retraction performed with the Dynforce archwire and miniscrews. angulation of the wire relative to the brackets and the deflection of the wire are minimized during the retraction phase. archwire low friction (L.F.), with anterior segment with size A clinical case is presented. Figure 14 shows the start of .021x.025 and posterior segments with size .018x.022. en-masse retraction of anterior teeth with the dynforce After three months of retraction (Fig. 15) incisors and 210 Annali di Stomatologia 2013; IV (2): 204-211 6-Cantarella_- 19/06/13 10:37 Pagina 211 The dynforce archwire retracting forces. Also, ceramic brackets can be rou- tinely used without compromising treatment time. References li 1. Proffit WR, Fields HW. Contemporary Orthodontics, Second na ed. Mosby 1993; pag.289-302. 2. Philips RW. Skinner’s Science of Dental Materials 1991; W.B. Saunders Company pag. 18-19; pag. 537-551. 3. Kalpakijan S, Schmid SR. Tecnologia meccanica. Ed Pearson 2008. io 4. Kusy RP. Ongoing Innovations in biomechanics and materials for the new millennium. Angle Orthodontist 2000; Vol 70, No 5. Figure 15. After Canine Class I is achieved, retraction is 5. Thorstenson GA, Kusy RP. Effect of archwire size and materi- continued with the Dynforce archwire with reciprocal an- az al on the resistance to sliding of self-ligating brackets with sec- chorage. ond-order angulation in the dry state; Am J Orthod Dentofacial Orthop 2002; 122: 295-305 6. Oshagh M, Ajami S. A comparison of force decay: elastic chain or tie-back method?. World J Orthod 2010 Winter; 11(4):e45-51. rn 7. Kusy, Whitley. Resistance to sliding of orthodontic appliances in dry and wet states: influence of archwire alloy, interbracket distance, and bracket engagement. J Biomed mater Res. 2000 Dec 15; 52(4):797-811. te 8. Moore, Harrington, Rock. Factors affecting friction in the pre- adjusted appliance. European Journal of Orthodontics 2004; 26(6):579-583. 9. Bagby, Ngan. Frictional Resistance of ceramic brackets when In subjected to variable tipping moments. The Orthodontic Cy- berJournal September 2004. 10. Frank CA, Nikolai RJ. A comparative study of frictional resis- tances between orthodontic brackets and arch wires. Am J Or- thod 1980; 78:593-609. 11. Thorstenson GA, Kusy RP. Effects of ligation type and method ni Figure 16. Extraction space completely closed. on the resistance to sliding of novel orthodontic brackets with second order angulation in the dry and wet states. Angle Or- thodontist 2003; 7 (4):418-430. 12. Articolo LC, Kusy RP. Influence of angulation on the resistance o canines moved backwards. Canine class I relationship to sliding in fixed appliances. Am J Orthod Dentofacial Orthop is achieved and miniscrews are removed. The hooks of 1999 Jan; 115(1):39-51. the dynforce wire are bent with a three prong plier and izi 13. Thorstenson GA, Kusy RP. Comparison of resistance to slid- converted into short hooks. Space closure is then fin- ing between different self-ligating brackets with second order ished with reciprocal anchorage with elastic chain run- angulation in the dry and saliva states. Am J Orthod Dentofa- ning from the hook of the archwire to the hook of the cial Orthop 2002; 121:472-482. Ed molar bracket. Figure 16 shows spaces closed four 14. Wick Alexander RG. The 20 principles of the Alexander Disci- months after the start of retraction. The settling phase pline. Quintessence Pub 2008. is then performed with conventional methods. 15. Burrow SJ: Friction and resistance to sliding in orthodontics: A critical review. American journal of Orthodontics and Dentofa- Efficient sliding mechanics was performed thanks to cial Orthopedics. 2009, April, Vol 135, Number 4. low wire-bracket binding and proper point of application 16. JCO Interviews, Dr. William Proffit on the present and future of of the retracting force. orthodontics. Journal of Clinical Orthodontics, 2008 Dec, Vol- C ume 42, Number 12. 17. Nanda R. Biomechanics in Clinical Orthodontics, WB Saun- Conclusions ders 1997. CI 18. Cantarella D, Moon HB. Efficient sliding mechanics using Dy- Archwire to bracket binding plays a significant role in namica Archwire with Anchorplus Mini-Implant Screws sliding mechanics in clinical orthodontics. Binding can (TADs). American Association of Orthodontics, Boston, may be minimized by appropriate strategies. Particularly, the 1-5 2009, Table Clinics. 19. Taloumis LJ, Smith TM, Hondrum SO, Lorton L. Force decay use of low force nichel-titanium archwires (size .010 or and deformation of orthodontic elastomeric ligatures. Am J Or- © .012) during the alignment phase, and the use of the thod Dentofac Orthop 1997; 111:1-11. dynforce archwire during the phase of closure of 20. Melting TR, Odegaard J, Holte K, Segner D. The effect of fric- spaces are advocated by the authors. tion on the bending stiffness of orthodontic beams: a theoreti- The advantages of using archwires and mechanics that cal and in vitro study. Am J Orthod Dentofac Orthop 1999; minimize binding are the possibility to use lower Class I 116:336-345. Annali di Stomatologia 2013; IV (2): 204-211 211 

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2-Laganà_- 21/06/13 10:36 Pagina 174 Case report Post-traumatic impaction of maxillary incisors: diagnosis and treatment li na Valeria Paoloni, DDS1 Introduction Chiara Pavoni, DDS1 io Manuela Mucedero, DDS1 Trauma to oral and facial structures is a significant Patrizio Bollero, DDS, PhD2 problem that may have serious medical, esthetic and Giuseppina Laganà, DDS1 psychologic consequences on both children and their Paola Cozza, MD, DDS, MS1 parents. Studies have shown that approximately 30% az of all children under the age of 7 years experience in- juries to ≥ 1 of their primary incisors and that most seri- 1 Department of Orthodontics, University of Rome “Tor ous injuries to primary teeth occur between the ages of Vergata”, Italy 1 and 3 years (1). rn 2 Department of Oral Pathology, University of Rome This high incidence is related to the passage to the up- “Tor Vergata”, Italy right posture, the early stages of walking, a lack of mo- tor coordination and the unconsciousness of the child. te The majority of the trauma occurs as a result of fall ac- Corresponding author: cidents at home or during sporting activities (1, 2). Giuseppina Laganà According to gender, boys were injured more frequently Department of Orthodontics, in all age than girls (2) and owing to their exposed posi- University of Rome “Tor Vergata” In tion in the dental arch, the upper central incisors are the teeth most commonly affected by traumatic injury in Via G. Baglivi, 5/E 00161 Rome, Italy both primary and permanent dentition (1). Phone: +39 06 44232321 In primary dentition intrusions are the most common E-mail: giuseppinalagana@libero.it type of trauma. These are luxation injuries which usual- ni ly results from an axially directed impact, displacing the incisor deeper into the alveolar socket. The primary in- Summary cisors is driven deeply into the alveolar bone invading the follicle of permanent germ which lies palatally in o Aim. To provide clinicians with useful information close proximity to its root. In fact there is a close for immediate diagnosis and management of im- anatomic relationship between the apices of the prima- izi ry incisors and the germs of the succeeding teeth: the pacted maxillary incisors due to trauma. hard tissue barrier between them has a thickness of Methods. We present a case of post-traumatic im- less than 3 mm and it might simply consist of connec- paction of a central right maxillary incisor in a tive fibrous tissue (3). Ed young patient. The treatment plan consisted in the This close relationship explains why injuries to primary interceptive management (surgical and orthodon- teeth are easily transmitted to the permanent dentition tic), the valuation of the necessary space to move (4). the impacted tooth in the normal position and the The displacement results in compression of and dam- biomechanical approach for anchorage, avoiding age to the periodontal ligament, contusion to the socket prosthetic/implants replacement. walls and injury to the pulp of the intruded incisor. The C Results. The therapy of an impacted maxillary in- reported prevalence of intrusion injuries affecting pri- cisor due to trauma requires a multidisciplinary ap- mary incisors varies among different studies and proach: orthodontic, surgical, endodontic and peri- CI ranges from 4.4% to 22% (3). This high incidence is be- odontal considerations are essential for successful cause of the pliability of the facial skeleton and of the treatment. periodontal ligament, the large volume of teeth in rela- Conclusions. Surgical exposure and orthodontic tion to the bone in primary and mixed dentition and fi- traction is the treatment most often used in case nally the shorter roots of primary teeth (5). of posttraumatic impacted incisor: this technique Therefore traumas to primary dentition may interfere © in fact can lead to suitable results at the peri- with further odontogenesis of permanent teeth and ac- odontal, occlusal and esthetics levels at an early cording to site and extension of the injury, different mal- stage and more definitively than with other treat- formations may occur ranging from a slight disturbance ment options. in the mineralization of enamel to a sequestration of the entire tooth germ (4). They may lead to abnormality in Key words: eruption disturbances, impacted incisor, the path of eruption of permanent series which may re- oral trauma, orthodontic traction, early diagnosis. sult in impaction or ectopic eruption (6). The percent- 174 Annali di Stomatologia 2013; IV (2): 174-183 2-Laganà_- 21/06/13 10:36 Pagina 175 Post-traumatic impaction of maxillary incisors: diagnosis and treatment age of developmental disturbances of the permanent Diagnosis incisors that could be attributed to injuries of their pre- decessors ranges from 12% to 74% (3). Early diagno- The impaction of maxillary permanent incisor is often sis is very important to monitor and prevent complica- clinically and radiologically diagnosed in early ages be- tions (6). cause the non-eruption of the anterior tooth causes li concern to parents during early mixed dentition phase (8). na Sequelae Clinical signs of an impacted tooth include asymmetric eruption of more than 6 months in relation to its homo- The effects of trauma on the permanent tooth germ be- logue, change of the sequence and chronology of nor- come clinically manifest only after the normal exfoliation mal eruption, retention of the primary tooth, midline de- io period is over. It is possible, however, that in an earlier viation, space closure and elevation of the soft tissue of stage a malformation may be discovered radiographi- the palatal or labial mucosa (8, 9). cally (7). Diagnosis of impacted tooth is verified and its location az The age of the child at the time of injury (germs of the determined through radiographic evaluation. Panoramic permanent teeth are particularly sensitive in the early radiograph is considered the standard radiographic stages of their development, which occurs between the first-step examination for treatment planning of impact- ages of 4 months and 4 years), the developmental ed teeth because (10, 11) it is unique in that it will show phase of the permanent tooth germ, the direction and rn the entire dentition as a whole (12) and it may reveal severity of the trauma, the type of injury sustained and the existence of an impacted tooth. Unfortunately, le- the presence of alveolar bone fracture are important sions of permanent teeth resulting from previous trau- variable influencing the effect on the developing perma- ma to the deciduous dentition are not always clearly te nent germ (1, 3, 4, 7). observable on panoramic radiograph because the de- The consequences for permanent dentition after a trau- ciduous teeth are projected onto the permanent teeth ma to primary dentition may affect the coronal or root and the direction of projection is unfavorable in regard region or the whole of the permanent tooth germ (5). to the root curvature (7). Many sequelae can be found in the coronal region: 1) In white or yellow-brown discoloration of enamel; 2) white Due to the highly detailed three-dimension information obtained, computerized tomography is the method of or yellow-brown discoloration of enamel and circular choice for accurately defining the position of an enamel hypoplasia, that represented the borderline be- unerupted tooth and identifying any root resorption of tween hard tissue formed before and after injury; 3) adjacent teeth not detectable by other methods (12). ni crown dilaceration, that is described as an acute devia- The highly detailed information and the excellent tissue tion in the long axis of the crown originating from a non- contrast without blurring and overlapping of adjacent axial displacement of already formed hard tissue in re- structures outweighs the high radiation dose, limited lation to the developing noncalcified tissue (crown di- o availability, and high cost (13, 14). laceration can result from an intrusion of the primary in- Three-dimensional imagery enables analysis of the pre- cisor when a child is around that age of 2 years, when izi half the crown would be formed) (3-5). cise location and orientation of impacted teeth, their sit- Sequelae affecting the root region include: 1) root dupli- uation relative to obstacles to eruption, their external cation; 2) root dilaceration, these lesions appeared as a and internal anatomy, the labial and palatal bone thick- marked curvature confined to the root portion and may ness; any resorption of the adjacent teeth or pathologi- Ed result from intrusion of a primary incisor after comple- cal bone loss; the presence or absence of a continuous tion of permanent crown formation between the ages of radiolucent line between the root and the bone (possi- 2 and 5 years; 3) partial or complete arrest of root for- ble ankylosis) (15). mation, rare sequelae resulting from injury to primary Recently cone beam CT (CBCT) has been introduced incisors between the ages of 4 and 7 years (3-5). as a technique dedicated to the imaging of dental and When the entire permanent tooth germ is affected, al- maxillofacial structures. It has one-sixth of the radiation C terations to the process of eruption of the permanent of computed tomography, is more time efficient, more tooth may be noted: 1) delayed eruption due to early cost effective, is still able to provide three dimensional CI loss of a primary incisor and formation of thick, fibrous images, excellent bone differentiation and an unlimited gingival tissue; 2) accelerated eruption, when the pri- number of views (11, 12). Its disadvantages include mary incisor is lost after the child is aged 5 years espe- spatial resolution of subtle structures that is slightly in- cially in the presence of alveolar bone resorption fol- ferior to that of CT and limited representation of soft tis- lowing an infection of the injured tooth; 3) ectopic erup- sues (due to the lower radiation dose) (11). tion or (4) impaction that can be explained by the phys- © ical displacement of the permanent germ with or with- out dilaceration at the time of the injury, the lack of Treatment eruption guidance from prematurely lost primary in- cisor, ankylosis or alterations of root resorption; 5) mal- The therapy of an impacted maxillary incisor due to formation of the permanent germ giving the appear- trauma requires a multidisciplinary approach: orthodon- ance of an odontoma; 6) sequestration of the perma- tic, surgical, endodontic and periodontal considerations nent tooth germ (3-5). are essential for successful treatment (16). Careful Annali di Stomatologia 2013; IV (2): 174-183 175 2-Laganà_- 21/06/13 10:36 Pagina 176 V. Paoloni et al. planning is required especially because these are often tioned flap and orthodontic traction into proper align- dilacerated incisors (17). ment (18). If there is a retained, necrotic, ankylosed primary in- The most commonly solution is surgical extraction of cisor it must be surgically removed because it repre- the impacted incisor (19) followed by an orthodontic sents an obstacle to spontaneous eruption of the per- treatment either to close the space or to keep it open li manent one. Sometimes after primary tooth’s removal, until the patient reaches an age when definitive na the permanent incisor erupts without any further treat- prosthodontic treatments may be used. ment. When the displacement is severe and prevents Both methods have associated problems: orthodontic the spontaneous eruption, an orthodontic treatment is space closure substituting the lateral incisor for the necessary. central one with subsequent resin restoration is seldom Depending on the localization of the tooth and the de- indicated nor aesthetically satisfactory, while removable io gree of dilacerations different treatment options have prosthetic replacement during childhood and adoles- been suggested in literature (8): surgical excision of the cence may be unsatisfactory for psychological reasons impacted incisor and subsequent restoration with a (18). Moreover early loss of a maxillary incisor may re- az bridge or implant after orthodontic space opening when sult in loss of alveolar height in the anterior region of growth had stabilized; surgical excision of the impacted the maxilla (20). In some cases extraction of the tooth incisor, orthodontic space closure and prosthodontics is unavoidable because of the severity of the inversion restoration of the left lateral incisor as the central in- of the tooth (8). rn cisor at a later stage; orthodontic space opening, un- The surgical-orthodontic approach is the solution most covering the impacted tooth using the apical reposi- widely adopted to save an impacted incisor (20) and it Figures 1 a-d. Pretreatment extraoral te photographs. In o ni izi Ed a b C CI © c d 176 Annali di Stomatologia 2013; IV (2): 174-183 2-Laganà_- 21/06/13 10:36 Pagina 177 Post-traumatic impaction of maxillary incisors: diagnosis and treatment would yield satisfactory results with carefully planned Aim of this report was to show the interceptive manage- procedures (18). ment (surgical and orthodontic) of a case with an im- This technique is commonly directed to surgical expo- pacted central maxillary incisor caused by trauma in a sure of the crown and to apply an orthodontic traction. young patient, avoiding prosthetic/implants replace- The strategy adopted for the surgical exposure is mini- ment. li mal bone removal and closed eruption after placing an attachment on the unerupted incisor. This is considered na a good surgical choice considering the long-term es- Case report thetic-periodontal status (9). The degree and level of dilacerations, tooth’s vertical po- A 9-year-old Caucasian girl was referred by his general sition, tooth’s maturity, flap design and orthodontic trac- dentist to the Department of Orthodontics of the Univer- io tion are factors determining the success rate of orthodon- sity of Rome “Tor Vergata” for an orthodontic evalua- tic-surgical management of impacted incisors (18). tion. The chief complaint was concern about an erup- The chances of failure could be due to ankylosis, exter- tion disturbance, which had resulted in an unaesthetic az nal root resorption, root exposure after orthodontic trac- appearance. The child was in excellent physical health tion, loss of attachment (17, 21). and had no history of disease, but there was a history Autotransplantation with premolars or supernumerary of anterior dental trauma at age 4 to its primary in- teeth and surgical repositioning of impacted incisor has cisors. This trauma induced the necrosis and ankylosis of the maxillary primary right central incisor. rn been reported in dental literature (20). te In ni a b o izi Ed C c d CI © e Figures 2 a-e. Pretreatment intraoral photographs. Annali di Stomatologia 2013; IV (2): 174-183 177 2-Laganà_- 21/06/13 10:36 Pagina 178 V. Paoloni et al. Diagnosis Panoramic radiograph showed the complete set of per- manent teeth in different stage of formation and the im- The patient had balanced facial pattern with a good paction of the upper permanent right central incisor which profile, and an asymmetric ugly smile. Intraoral clinical showed a severe intraosseous displacement (Fig. 3). The vertical position of the delayed permanent incisor li examination showed a mixed dentition, an altered se- quence of eruption, the absence of the maxillary per- in relation to the contralaterally erupted central incisor was in sector v3 (22) (Pict. 1), while its angulation to na manent right central incisor and the ankylosis and the mid-sagittal plane was 90° (23) (Pict. 2). necrosis of the maxillary primary right central incisor CT-Dentascan evaluation defined exactly the place of (Figs. 1a-1d). the impacted incisor: the tooth was positioned horizon- Occlusal analysis revealed a molar Class I relationship. tally and its crown was close to the anterior nasal spine There was not significant dental crowding in both arch- io and across the midline, while the root was displaced es. The maxillary right central incisor was absent while palatally (6) (Figs. 4a, 4b). the maxillary right lateral incisor was erupting. Overbite Cephalometric analysis revealed a skeletal Class I mal- was reduced (Figs. 2a-2e). az occlusion (ANB T1: 3°) and a normofacial pattern (FMA Radiological examinations were performed to complete T1: 26°). Lower incisor showed good inclination on clinical evaluation. mandibular plane (IMPA T1: 89°) (Figs. 5a, 5b). rn Figure 3. Pretreatment panoramic radiograph. te In ni Picture 1. Smailiene et al. measurement (22). o izi Ed C Picture 2. Bryan et al. measurement (23). CI © 178 Annali di Stomatologia 2013; IV (2): 174-183 2-Laganà_- 21/06/13 10:36 Pagina 179 Post-traumatic impaction of maxillary incisors: diagnosis and treatment li na io az a b Figures 4 a-b. Pretreatment CT-Dentascan. rn te In o ni izi Ed a b Figures 5 a-b. Pretreatment cephalometric radiographs. C Treatment objectives Treatment progress CI The purpose of this treatment was to guide the im- The multidisciplinary approach involved a combined pacted incisor into proper alignment with the adja- surgical/orthodontic treatment. After evaluating the ad- cent teeth, without root damage, and to re-create a vantages and disadvantages of the therapeutic options, complete anterior dentition and a stable functional the following treatment steps were established: 1) sur- © occlusion. The treatment aimed also to extrude the gical removal of the ankylosed and necrotic maxillary incisor with all its supporting tissues (alveolar bone primary right central incisor which represented an ob- and attached gingiva), to investigate the effects that stacle to permanent incisor’s eruption, 2) monitoring for surgical exposure, orthodontic movements and final spontaneous eruption, 3) orthodontic traction, 4) fixed tooth position would have had on them and to eval- appliance to obtain the proper alignment. uate the long-term gingival and periodontal condi- First of all the primary incisor was surgically removed. tions (19). After 6 months the maxillary right incisor erupted in an Annali di Stomatologia 2013; IV (2): 174-183 179 2-Laganà_- 21/06/13 10:36 Pagina 180 V. Paoloni et al. ectopic position parallel to the occlusal plane, near to the labial fornix (Fig. 6). A modified Quad Helix with a TMA arm and a terminal loop was applied to the upper arch as anchorage. A button was bonded on vestibular surface of tooth and li an elastomeric module was connected from the but- ton to the loop of the TMA arm. The elastic module na generated a constant light force of no more than 30- 50 g (24-26). The force was activated monthly creat- ing a physiological direction of tooth eruption (27-29) (Figs. 7a-7b). io Once the impacted tooth moved close to its place in den- tal arch, brackets were placed on the upper arch and it a az rn te b In Figures 8 a-b. Incisor’s derotation. Figure 6. Spontaneous eruption after surgical removal of the ankylosed and necrotic primary incisor. ni was tied to an archwire (0.016 x 0.022-in multibraid stainless steel). Thanks to a lingual button and elastic chain the incisor was derotated. Interim radiographs were requested to verify the root positioning. Active treat- o ment with fixed appliance took 10 months (Figs. 8a-8b). When the impacted incisor was in its position in upper izi arch, brackets were debonded and the patient began wearing essix retainers. Ed Treatment result The patient showed a good smile arch and balanced profile (Figs. 9a-9d). a The impacted maxillary right central incisor was suc- cessfully brought into proper position. The final appear- C ance of the tooth was esthetically pleasing, with gingi- val margins at the same level with similar clinical CI crowns sizes. The tooth responded well to vitality and did not show abnormalities in crown shape. No pulp pathology or color change was found. From a periodon- tal point of view a band of labial keratinized gingival measuring 4 mm was present, and pocket depth ranged from 1 to 2 mm (Figs. 10a-10e). © Final radiographs indicated intact roots, proper root alignment, and no root disease. A skeletal class I (ANB 3°) was mantained. An ideal b overbite and overjet were established and a Class I molar and canine relationship was presented. Upper Figures 7 a-b. Modified Quad Helix with a TMA arm and a and lower incisors showed good inclination (IMPA 89°; terminal loop. U1^FH 110°) (Figs. 11a-11c). 180 Annali di Stomatologia 2013; IV (2): 174-183 2-Laganà_- 21/06/13 10:36 Pagina 181 Post-traumatic impaction of maxillary incisors: diagnosis and treatment Figures 9 a-d. Post-treatment extraoral photographs. li na io az a b rn te In o ni izi c d Ed C CI a b c © d e Figures 10 a-e. Post-treatment intrao- ral photographs. Annali di Stomatologia 2013; IV (2): 174-183 181 2-Laganà_- 21/06/13 10:36 Pagina 182 V. Paoloni et al. Figures 11 a-c. Radiograph- ic records: two months be- fore debonding. li na io az a rn te In o ni b c izi Conclusions 2. Kargul B, Caglar E, Tanboga I. Dental trauma in Turkish chil- dren, Istanbul. Dent Traumatol 2003; 19:72-75. 3. Diab M, elBadrawy HE. Intrusion injuries of primary incisors. A traumatic injury in early age can realize a delay of erup- Ed Part III: Effects on the permanent successors. Quintessence tion and eventually an impacted tooth. Upper incisors are Int 2000; 31(6):377-384. the most frequent impacted teeth due to trauma (6). 4. Andreasen JO, Sundström B, Ravn JJ. The effect of trau- Surgical exposure and orthodontic traction is the treat- matic injuries to primary teeth on their permanent succes- ment most often used: this technique in fact can lead to sors. I. A clinical and histologic study of 117 injured permanent suitable results at the periodontal, occlusal and esthet- teeth. Scand J Dent Res 1971; 79(4):219-83. ics levels at an early stage and more definitively than 5. Arenas M, Barberia E, Lucavechi T, Maroto M. Severe trau- C ma in the primary dentition - diagnosis and treatment of se- with other treatment options. quelae in permanent dentition. Dent Traumat 2006; 22(4):226- Sometimes the surgical removal of the retained trauma- 230. CI tized primary incisor alone can lead to spontaneous 6. Cozza P, Mucedero M, Ballanti F, De Toffol L. A case of an eruption of the permanent tooth. unerupted maxillary central incisor for indirect trauma localized However long-term monitoring of the stability and peri- horizontally on the anterior nasal spine. J Clin Pediatr Dent odontal health of the impacted incisor is very important 2005; 29(3):201-203. after orthodontic traction (30). 7. von Gool AV. Injury to the permanent tooth germ after trau- ma to the deciduous predecessor. Oral Surg Oral Med Oral © Pathol 1973; 35(1):2-12. 8. Kuvvetli SS, Seymen F, Gencay K. Management of an References unerupted dilacerated maxillary central incisor: a case report. Dent Traumatol 2007; 23(4):257-261. 1. Altun C, Cehreli ZC, Güven G, Acikel C. Traumatic intrusion 9. Valladares Neto J, de Pinho Costa S, Estrela C. Orthodon- of primary teeth and its effects on the permanent successors: tic-surgical-endodontic management of unerupted maxillary a clinical follow-up study. Oral Surg Oral Med Oral Pathol Oral central incisor with distoangular root dilaceration. J Endod Radiol Endod 2009; 107(4):493-498. 2010; 36(4):755-759. 182 Annali di Stomatologia 2013; IV (2): 174-183 2-Laganà_- 21/06/13 10:36 Pagina 183 Post-traumatic impaction of maxillary incisors: diagnosis and treatment 10. Becker A. The orthodontic treatment of impacted teeth. Unit- cisor in mixed dentition. J Am Dent Assoc 2002; 133(1):61-66. ed Kingdom: Informa Healthcare Editor; 2006. 21. Lin YT. Treatment of an impacted dilacerated maxillary cen- 11. Chaushu S, Chaushu G, Becker A. The role of digital vol- tral incisor. Am J Orthod Dentofacial Orthop 1999; 115(4):406- ume tomography in the imaging of impacted teeth. World J 409. Orthod 2004; 5(2):120-132. 22. Smailiene D, Sidlauskas A, Bucinskiene J. Impaction of the li 12. Huber KL, Suri L, Taneja P. Eruption disturbances of the max- central maxillary incisor associated with supernumerary teeth: illary incisors: a literature review 1: J Clin Pediatr Dent 2008; initial position and spontaneous eruption timing. Stomatologija na 32(3):221-230. 2006; 8(4):103-107. 13. Sawamura T, Minowa K, Nakamura M. Impacted teeth in the 23. Bryan RA, Cole BO, Welbury RR. Retrospective analysis of maxilla:usefulness of 3D dental-CT for preoperative evalu- factors influencing the eruption of delayed permanent incisors ation. Eur J Radiol 2003; 47:221-226. after supernumerary tooth removal. Eur J Paediatr Dent 2005; 14. Walker L, Enciso R, Mah J. Three-dimensional localiza- 6(2):84-89. io tion of maxillary canines with cone-beam computed to- 24. Kearns HP. Dilacerated incisors and congenitally displaced mography. Am J Orthod Dentofacial Orthop 2005; incisors: three case reports. Dent Update 1998; 25:339-342. 128(4):418-423. 25. Kokavi D, Becker A, Zilbermann Y. Surgical exposure, or- 15. Chokron A, Reveret S, Salmon B. Vermelin L. Strategies for thodontic movement and final tooth position as factor in pe- az treating an impacted maxillary central incisor. Int Orthod 2010; riodontal breakdown treated palatally impacted canines. Am 8(2):152-176. J Orthod Dentofacial Orthop 1984; 85:72-77. 16. Machtei EE, Zyskind K, Ben-Yehouda A. Periodontal con- 26. Crawford LB. Impacted maxillary central incisor in mixed den- siderations in the treatment of dilacerated maxillary incisors. tition treatment. Am J Orthod Dentofacial Orthop 1997; rn Quintessence Int 1990; 21(5):357-360. 76:310-315. 17. Uematsu S, Uematsu T, Furusawa K, Deguchi T, Kurihara 27. Farronato GP, Santoro F, Pignanelli M. Terapia chirurgico S. Orthodontic treatment of an impacted dilacerated maxil- ortodontica di denti inclusi in soggetti adulti. Mondo Ortodon- lary central incisor combined with surgical exposure and api- tico 1982; 1:38-49. coectomy. Angle Orthod 2004; 74(1):132-136. 28. Vanarsdall RL, Corn H. Soft-tissue management of labially te 18. Chew MT, Ong M M-A. Orthodontic-surgical management positioned unerupted teeth. Am J Orthod 1977; 72:53-64. of an impacted dilacerated maxillary central incisor: a clin- 29. Vermette ME, Kokich VG; Kennedy DB. Uncovering labial- ical case report. Pediatric Dent 2004; 26:341-344. ly impacted teeth: apically positioned flap and closed-erup- 19. Farronato G, Maspero C, Farronato D. Orthodontic move- tion techniques. Angle Orthod 1995; 65:23-32. ment. Dent Traumatol 2009; 25(4):451-456. In ment of a dilacerated maxillary incisor in mixed dentition treat- 30. Cozza P, Marino A, Condò R. Orthodontic treatment of an impacted dilacerated maxillary incisor: a case report. J Clin 20. Tsai TP. Surgical repositioning of an impacted dilacerated in- Pediatr Dent 2005; 30(2):93-98. o ni izi Ed C CI © Annali di Stomatologia 2013; IV (2): 174-183 183 

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5-Falisi_- 21/06/13 10:42 Pagina 196 Case report Implant stability evaluation by resonance frequency analysis in the fit lock technique. A clinical study li na Giovanni Falisi, DDS, PhD1 nique showed a similar stability as reported with Massimo Galli, MDS1 other techniques. io Pedro Vittorini Velasquez, MDS2 In light of the results, the authors confirm that the Juan Carlos Gallegos Rivera, DDS3 primary stability represents the basic requirement Carlo Di Paolo, MDS1 to guarantee a correct healing of the implant and demonstrate that the fit lock technique also all ows az reaching this condition when bone availability is 1 Department of Oral and Maxillo-Facial Sciences, minimal. Sapienza University of Rome, Italy 2 Maxillo-Facial Clinic Cochabamba, Bolivia. Key word: resonance frequency analysis, bone graft- rn 3 Department of Dentistry, Municipal Japanese ing, dental implants. University Hospital, Santa Cruz de la Sierra, Bolivia. Introduction te Corresponding author: Giovanni Falisi The pneumatization of the sinus is a frequently occur- Department of Oral and Maxillo-Facial Sciences ring phenomenon in absence of dental elements, caus- Sapienza University of Rome Via del Vivaio, 19 In ing a vertical reduction of bone availability and limiting the implant placement for prosthetic rehabilitation (1). 00172 Rome, Italy The approach strategy to this anatomical zone has al- Phone: +39 06 2304775 ways been debated, both in the case of a surgical ap- E-mail: g.falisi@tiscali.it proach and concerning the possible post-surgical com- ni plications (2-5). From the international literature, it is clear that in cases Summary where bone availability is less than 4 mm, as in the classification IV of Misch, a first reconstructive-regener- o Surgical procedures for the application of implants ative phase is indispensable, followed by a second sur- in the lateral-superior sectors are affected by the gical phase for the implant placement (6, 7). This izi availability of the residual bone. should be done with the goal of implant primary stabili- When this condition is lower than 5 mm it is recom- ty, which according to long term studies have a suc- mended that techniques involving two therapeutic cess similar to the implants inserted in normal bone phases, a reconstructive and an applicative one, as conditions (8). Ed reported in the international literature, are adopted. Some authors consider the possibility of placing the im- The authors propose here a new method with the plants at the same surgical time by using extra-oral au- potential to apply implants simultaneously with the tologous bone graft (from hip or fibula) in order to ob- reconstructive phase. tain the primary stabilization (9). Other authors The aim of this longitudinal retrospective study was (Vollmer, Lang, Engelke) proposed resorbable plaques to evaluate the stability of implants applied with the from extrasinus osteosynthesis, but not for the primary C fit lock technique in the upper maxillarys in us with implant stability (10-12). bone availability lower than 4 mm by measuring However, as reported by some authors, the survival is CI resonance frequency at different follow-up periods also affected by the quality and density of the bone, The seme as urements, carried out on 30 implants, which is reduced in these zones and thereby can affect were analysed with specific statistical procedures. the stability (13, 14). The results indicate that the stability of the im- The authors have proposed the fit lock technique, plants inserted with the fit lock method increases which allows the implants to be placed simultaneously progressively over time in a statistically significant with residual bone thickness less than 4 mm, while har- © manner. The stability recorded after one year from vesting intraoral autologous bone (15). Given the long the insertion (ISQ T2) is significantly higher than term results, a longitudinal study has been conducted that recorded after six months (ISQ T1), and this is on 11 patients treated with this technique while using a significantly higher than that recorded at the time new implant design to guarantee better stability of the of implant placement (ISQ T0). graft also in cases of insufficient bone density. The implants inserted in the maxillary zones with The aim of the study, retrospective and longitudinal, is scarce bone availability and applied with this tech- to evaluate by resonance frequency across the follow- 196 Annali di Stomatologia 2013; IV (2): 196-203 5-Falisi_- 21/06/13 10:42 Pagina 197 Implant stability evaluation by resonance frequency analysis in the fit lock technique. A clinical study up periods the degree of the stability of the implants ap- Osstell Mentor (Osstell instrument, Integration Diagnos- plied with the fit lock technique in the upper sinus with tics AB, Gothenburg, Sweden) at time 0 (T0) of implant bone availability lower than 4 mm. The stability mea- placement, after 6 months (T1), and after 12 months surement has been carried out by resonance frequency (T2), upon progressive load. analysis with Osstel Mentor (Osstell instrument, Inte- The recordings were carried out with double directional li gration Diagnostics AB, Gothenburg, Sweden) (16-20). measurement (vestibular oral or oro vestibular and mesio- The Tekka implants underwent measures of resonance distal or disto-mesial) on the Smart Peg (Type 49) as re- na frequency at the time of the initial placement, six months, ported by the company indications, and the value reported and 12 months after progressive load to evaluate the de- in Table 1 is the arithmetic mean of the two (21, 22). gree of osteointegration; moreover, radiographic TC dentalscan and Orthopanoramic RX were carried out io both at the diagnosis time and following treatment. Statistical analysis • Normality test on the distribution of the stability val- Materials and methods ues (Kolmogorov-Smirnov test, Lilliefors test, az Shapiro-Wilk test). Diagrams a-b-c. About 50 patients were visited between January 2011 • Descriptive statistics of the stability values: mean, and January 2012 for implant-supported rehabilitation median, mode, variance, standard deviation standard of the posterior-superior sectors at the Municipal error, quartiles) Diagram d. rn Japanese University Hospital of Santa Cruz de la Sier- • Non parametric analysis of variance (Friedman ra, Bolivia and at the Department of Odontostomatolog- ANOVA). Diagram e. ic Sciences, Sapienza University of Rome. • Post hoc tests. te All patients were studied following our clinical-implanto- logic protocol for prosthetic rehabilitation. During this Aim: to verify if the implant stability, measured by “im- period 11 patients were selected according to the fol- plant stability quotient” (ISQ), increases progressively, lowing exclusion and inclusion criteria. and in a statistically significant manner, from the mo- Exclusion criteria: In ment of the placement (ISQ T0) up to six months (ISQ T1) and one year (ISQ T2). • Low oral hygiene, • Acute or chronic synusitis of the maxillary sinus, • Patients with high risk factors, Results ni • Patients under Cadwell Luc treatments, • Patients under radiotherapy, The overall results reported in Table 1 show the loss of • Patients with a bone height above ≥ 4 mm. only two implants in position 24 and 27 on the same • Inclusion criteria: patient, due to a post-surgical infection occurring 15 o • Bone height ≤ 4 mm (X-ray assessment), days after placement. • Bone availability for harvesting at the ramus-symph- No complications occurred for the remaining 18 im- izi ysis donor site, plants across the study period. • Patient’s consent to participate in the clinical study, The evaluation of the data across the three follow-up • Patient’s consent to undergo regular clinical follow-up. periods showed a distribution that significantly deviated from normality. From the graphs it can be seen that two Ed From the initial 50 patients 15 were excluded, 20 did of the selected variables (ISQ T0 and ISQ T1) have a not give consent, 4 did not undergo the follow-up. The skewed distribution, although the deviation from nor- remaining sample consisted of 11 patients. mality is statistically significant depending on the test This final sample was composed by 6 men, mean age (Diagrams a-b-c). 58.2, and 5 women, mean age 59.8. In total there were The Friedman non parametric test showed that implant 15 sinus elevations and 30 implant placements. stability (mean and median values) progressively in- C All patients where treated with Tekka grade 5 titanium im- creased over time; ISQ T2 is higher than ISQ T1, and plants, with a half-conical full screw shape, double pro- this latter is higher than ISQ T0 (Diagram d). CI gressive condensing thread, SA2 surface (sandblasted The differences were statistically significant (Diagrams and double acid etch) that consists in sandblasting trough e-f). corundum micro beads of 260 micron diameter, followed Moreover, the post-hoc tests for the three possible by a double chemical treatment with acid tipping. comparisons showed the following results: for ISQ T0 The allocation of the 30 implants was as follows: 2 in area vs ISQ T1, z = 3.408; for ISQ T0 vs ISQ T2, z = 7.016; 14; 2 in area 15; 6 in area 16; 5 in area 17; 1 in area 24; 2 for ISQ T1 vs ISQ T2, z = 3.608; critical Z = 2.394. The © in area 25; 7 in area 26; 5 in area 27. All implants were of critical value for significance was always passed. 11.5 lenght and 4.0 mm diameter (Tab. 1). The implantology surgical protocol is the same de- scribed in a previous article by the authors, although Discussion and Conclusions the operators were not always the same (Figs. 1-13). The Tekka implants were evaluated with measures of In literature the implant survival in posterior lateral ar- resonance frequency during the follow-up periods using eas (type SA4) - ranges between 90 and 97%. Annali di Stomatologia 2013; IV (2): 196-203 197 5-Falisi_- 21/06/13 10:42 Pagina 198 G. Falisi et al. Table 1. Specimen description. Patient Age Sex Implant side Implant ISQ T0 ISQ T1 ISQ T2 misure H Ø li 1 63 F 14 11,5 4 52 52 64 na 16 11,5 4 49 54 66 17 11,5 4 51 52 71 2 58 F 16 11,5 4 42 48 63 io 3 64 M 25 11,5 4 53 59 67 26 11,5 4 54 55 64 az 4 59 M 26 11,5 4 38 48 66 27 11,5 4 42 49 64 16 11,5 4 55 56 68 rn 17 11,5 4 51 51 66 5 57 F 27 11,5 4 55 56 71 te 6 52 M 25 11,5 4 36 49 59 26 In 11,5 4 41 49 58 7 55 M 16 11,5 4 44 49 67 17 11,5 4 41 48 68 8 50 F 15 11,5 4 42 51 65 17 11,5 4 46 53 62 ni 26 11,5 4 44 52 61 27 11,5 4 32 43 67 o 9 49 M 14 11,5 4 53 62 62 izi 15 11,5 4 52 63 63 16 11,5 4 55 71 71 24 11,5 4 27 0 0 Ed 26 11,5 4 39 47 59 27 11,5 4 30 0 0 10 51 M 26 11,5 4 61 61 71 27 11,5 4 52 55 69 C 16 11,5 4 55 55 66 CI 17 11,5 4 41 49 59 11 50 F 26 11,5 4 44 49 58 These data are influenced by several factors (Del Fab- non treated implants is about 85.6%, while the per- © bro, 2004): centage rises to 95.8% if implants are treated su- - for example, the survival of the only autologous perficially and made rough ones; bone is about 87.70%, while in combination with - timing of the insertion - the implant can be applied bone substitutes is about 94.88% and when only in the same surgical procedure (one-stage surgery) bone substitutes are used the survival is about or when the regeneration is complete: in first case 95.98%; the survival rate is 92.17%, while in the second - implant production methodology - the survival of case is 92.93% (23). 198 Annali di Stomatologia 2013; IV (2): 196-203 5-Falisi_- 21/06/13 10:42 Pagina 199 Implant stability evaluation by resonance frequency analysis in the fit lock technique. A clinical study li na io Figure 1. Pre-surgical intraoral view of the patient. az Figure 4. Intrasurgical measurement with caliper for resid- ual bone evaluation. rn te In Figure 2. Pre-surgical orthopanoramic X-ray. o ni izi Ed Figure 5. Sampling of the inlay bone from the mandibular ramus. C Figure 3. Pre-surgical Tc Panorex. CI Some surgical protocols suggest that, if the bone avail- able is thinner than 4 mm, as in Misch IV classification, first is necessary a reconstructive-regenerative phase and then a second surgical phase of implant insertion (6, 7). These protocols are justified by the fact that, as © reported by the authors, the survival of the implant is al- so influenced by the quality and density of the bone which is reduced in these areas (13, 14). Nedir et al, in 2009, proposed one-stage surgery with simultaneous insertion of implants in patients with atrophic maxilla without grafting, provided that primary stability was Figure 6. Placement and stabilization of the implant with guaranteed (24). Later other authors have proposed, in the inlay bone. Annali di Stomatologia 2013; IV (2): 196-203 199 5-Falisi_- 21/06/13 10:42 Pagina 200 G. Falisi et al. li na io Figure 11. Tc Panorex control. Figure 7. Analysis of implant stability with ostellmentor in az surgical phase. rn te In Figure 12. Analysis of implant stability with ostellmentor at the time of application of the healing screws. o ni izi Ed Figures 8 and 9. Filling with heterologous bone of the C residual spaces of the maxillary sinus. CI Figure 13. Provisional prosthesis. a wider caseload, the contextual placement of the im- plant without filling or with PRF (platelet-rich fibrin), re- © porting a 100% of success also in cases of lower bone availability (25, 26). The described technique seems to ensure a good suc- cess rate in cases of Misch IV class with contextual im- plant placement, with a success percentage of 93.4% one year after placement. The technique allows an im- mediate stabilization of the implants also due to the Figure 10. Post-surgical orthopanoramic X-ray. new design that improves performance in those cases 200 Annali di Stomatologia 2013; IV (2): 196-203 5-Falisi_- 21/06/13 10:42 Pagina 201 Implant stability evaluation by resonance frequency analysis in the fit lock technique. A clinical study li na io az A B rn te In Diagrams a-b-c. Frequency distribution of implant stability values (ISQ) and outcome of the normality tests (Kol- mogorov-Smirnov, Lilliefors, Shapiro-Wilk) at time T0 (a), T1 (b), and T2 (c). See “Materials and Methods” section for details. C o ni izi Ed Table 2. Descriptive statistics of implant stability values (ISQ) at time T0, T1, and T2. The ISQ values (mean and median) progressively increase over time (see also diagram f). C CI © Diagram e. Outcome of the Friedman ANOVA test indicating the overall significance of the time effect. Annali di Stomatologia 2013; IV (2): 196-203 201 5-Falisi_- 21/06/13 10:42 Pagina 202 G. Falisi et al. and Prof. Claudio Rastelli and Dr. Massimo Vullo for par- ticipating to the interventions. References li 1. Razavi R, Zena RB, Khan Z, Gould AR. Anatomic site eval- na uation of edentulous maxillae for dental implant placement. J Prosthodont 1995 Jun; 4(2):90-94. 2. Jung JH, Choi BH, Jeong SM, Li J, Lee SH, Lee HJ. A ret- rospective study of the effects on sinus complications of ex- posing dental implants to the maxillary sinus cavity. Oral Surg io Oral Med Oral Pathol Oral Radiol Endod 2007 May; 103(5):623-625. E pub 2007 Jan 25. 3. Doud Galli SK, Lebowitz RA, Giacchi RJ, Glickman R, Ja- az cobs JB. Chronic sinusitis complicating sinus lift surgery. Am Diagram f. Temporal profile of the ISQ values at T0, T1, J Rhinol 2001; 15:181-186. T2. The small centered squares are medians, the boxes in- 4. McDermott NE, Chuang SK, Woo VV, Dodson TB. Maxillary dicate the highest and the lowest quartiles, the vertical sinus augmentation as a risk factor for implant failure. Int J Oral Maxillofac Implants 2006; 21:366-374. rn bars indicate minimum and maximum values. 5. Li J, Wang HL. Common implant-related advanced bone graft- ing complications: classification, etiology, and management. with reduced bone density. Compared to similar tech- Implant Dent 2008 Dec; 17(4):389-401. doi: 10.1097/ID. niques it appears simpler and reproducible, it does not 0b013e31818c4992. Review. te depend on the operator and allows a lower biological 6. Misch CE. Maxillary sinus augmentation for endosteal im- and economic effort for the patient, considerably reduc- plants: organized alternative treatment plans. Int J Oral Im- ing the time of prosthetic rehabilitation. plantol 1987; 4:49-58. The results suggest that the stability of the implants ap- 7. Tischler M, Misch CE. Extraction site bone grafting in gen- In plied with the fit lock technique increases progressively eraldentistry. Review of applications and principles. Dent- Today 2004; 23:108-113. over time in a significant manner. 8. Georgescu CE, Rusu MC, Sandulescu M, Enache AM, The implant stability one year after placement (ISQ T2) Didilescu AC. Quantitative and qualitative bone analysis in the is significantly higher than the stability recorded after maxillary lateral region. Surg Radiol Anat 2012 Aug; 34(6):551- six months (ISQ T1), and this latter score is higher than 8. doi: 10.1007/s00276-012-0955-6. E pub 2012 Mar 22. ni the stability recorded at the beginning (ISQ T0), as evi- 9. Blomquist je et al. Retrospective analysis of one stage max- dent from the post hoc tests. The ISQ value is in line illary sinus augmentation with end osseous implants. Int J with other studies concerning reliability, allowing a de- oral maxillofac implants 1996; 11:512-21. o layed loading of the implants, and compatibly with the 10. Wollmer R et al. Sinus elevation and siglestage surgical im- biological times (27, 28). plant placement with a titanium ostheosyntesis bar. Pract The main disadvantage, as already published, is the im- Proced Aesthet Dent 2002; 14:307-311. izi 11. Lang M. Der Sinus-Implantat-Stabilisator in Extremfällen. Im- possibility of using implants with a diameter higher than plantologie J 1999; 3:27-30. 4 mm, since the graft diameter also can’t be more than 8 12. Lindorf HH, Müller-Herzog R. Der autologe Sinus-Implantat- mm due to anatomical limitations of the antrum, or when Stabilisator (ASIS). ZMK 2004; 4:180-189. Ed for reasons of dental-implant discrepancy, an only graft is 13. Jaffin RA, Berman CL. Theexessive loss of Branemark Fixture required. in tipe IV bone. 5 year analysis. J Periodontol 1991; 62:2-4. This method certainly represents a therapeutic alterna- 14. Turkyilmaz I, McGlumphy EA. Influence of bone density on tive, given the clinical results are comparable to other implant stability parameters and implant success: a retro- techniques described in the literature (29, 30). spective clinical study. BMC Oral Health. 2008 Nov 24; 8:32. In light of these results, the authors confirm that the pri- doi: 10.1186/1472-6831-8-32. 15. Vittorini Velasquez P et al. Self-bone graft and simultane- C mary stability represents the basic requirement to guar- ous application of implants in the upper jawbone. (Fit lock antee a correct healing of the implant and show that the technique) Acta Odontol. Latinoam. 2011 Vol. 24; 2:163- fit lock technique also allows reaching this state in con- 167. CI ditions of lower bone availability. 16. Fuster-Torres MÁ, Peñarrocha-Diago M, Peñarrocha-Oltra Because of the low sample size, these results need to be D, Peñarrocha-Diago M. Relationships between bone den- complemented by an istomorphometric analysis and the sity values from cone beam computed tomography, maximum use of more patients, although to date they represent, to- insertion torque, and resonance frequency analysis at implant gether with the previous report, the main published clin- placement: a pilot study. Int J Oral Maxillofac Implants 2011 Sep-Oct; 26(5):1051-1056. © ical records. 17. Cassetta M, Ricci L, Iezzi G, Dell'Aquila D, Piattelli A, Per- rottiV. Resonance frequency analysis of implants inserted with a simultaneous grafting procedure: a 5-year follow-up Acknowledgments study in man. Int J Periodontics Restorative Dent 2012 Oct; 32(5):581-589. We thank Tekka implant Global D for the donation of all im- 18. Scarano A, Degidi M, Iezzi G, Petrone G, Piattelli A. Cor- plantological material used, Prof. Alberto De Biase for his relation between implant stability quotient and bone-implant collaboration in the analysis with frequency of resonance, contact: a retrospective histological and histomorphometri- 202 Annali di Stomatologia 2013; IV (2): 196-203 5-Falisi_- 21/06/13 10:42 Pagina 203 Implant stability evaluation by resonance frequency analysis in the fit lock technique. A clinical study cal study of seven titanium implants retrieved from humans. or maxilla: report of 2 cases. J Oral Maxillofac Surg 2009 May; Clin Implant Dent Relat Res 2006; 8(4):218-222. 67(5):1098-103. 19. Nkenke E, Lehner B, Fenner M, Roman FS, Thams U, 25. Tajima N, Ohba S, Sawase T, Asahina I. Evaluation of si- Neukam FW, Radespiel-Tröger M. Immediate versus delayed nus floor augmentation with simultaneous implant placement loading of dental implants in the maxillae of minipigs: follow- using platelet-rich fibrin as sole grafting material. Int J Oral li up of implant stability and implant failures. Int J Oral Max- Maxillofac Implants 2013 Jan-Feb; 28(1):77-83. illofac Implants 2005 Jan-Feb; 20(1):39-47. 26. Rajkumar GC, Aher V, Ramaiya S, Manjunath GS, Kumar na 20. Park JC, Kim HD, Kim SM, Kim MJ, Lee JH. A comparison DV. Implant placement in the atrophic posterior maxilla with of implant stability quotients measured using magnetic res- sinus elevation without bone grafting: a 2-year prospective onance frequency analysis from two directions: a prospec- study. Int J Oral Maxillofac Implants 2013 Mar-Apr; 28(2):526- tive clinical study during the initial healing period. Clin Oral 30. Implants Res 2010 Jun; 21(6):591-597. doi: 10.1111/j.1600- 27. Hirsch JM, Ericsson I. Maxillary sinus augmentation using io 0501.2009.01868.x. E pub 2010 Feb 1. mandibular bone graft and simultaneous installation of im- 21. Gupta RK, PadmanabhanTV. Resonance frequency analy- plants. Clin Oral implants Res 1991; 2:91-6. sis. Indian J Dent Res 2011 Jul-Aug; 22(4):567-573. doi: 28. Khoury F. Augmentation of sinus floor with mandibular bone 10.4103/0970-9290.90300. Review block and simultaneous implantation: 6 year clinical inves- az 22. Nedir R, Bischof M, Szmukler-Moncler S, Bernard J-P, Sam- tigation. Int J Oral Maxillofac Implants 1999; 14:557-64. son J. Predicting osseointegration by means of implant pri- 29. Chaushu G, Mardinger O, Calderon S, Moses O, Nissan J. mary stability. Clin Oral Implants Res 2004Oct; 15(5):520-528. The use of cancellous block allograft for sinus floor aug- 23. Del Fabbro M, Testori T, Francetti L, Weinstein R. System- mentation with simultaneous implant placement in the pos- rn atic review of survival rates for implants placed in the graft- terior atrophic maxilla. J Periodontol 2009 Mar; 80(3):422- ed maxillary sinus. Int J Periodontics Restorative Dent 2004 8. Dec; 24(6):565-577. 30. Mardinger O, Nissan J, Chaushu G. Sinus floor augmenta- 24. Nedir R, Nurdin N, Szmukler-Moncler S, Bischof M. Os- tion with simultaneous implant placement in the severely at- teotome sinus floor elevation technique with out grafting ma- rophic maxilla: technical problems and complications. J Pe- te terial and immediate implant placement in atrophic posteri- riodontol 2007 Oct; 78(10):1872-7. In o ni izi Ed C CI © Annali di Stomatologia 2013; IV (2): 196-203 203 

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7-biagi_- 19/06/13 10:38 Pagina 212 Case report Multiple traumatic injury to maxillary incisors in an adolescent female: treatment outcome with two years follow-up li na Roberto Biagi, MD, DDS, MSc1 Educational programs are essential to optimize the Filippo Cardarelli, DDS, MSc2 treatment outcome both at the accident site and al- io Ennio Storti, MD, DDS3 so at the dental office. Alessandra Majorana, MD, DDS4 Giampietro Farronato, MD, DDS, MSc1 Key words: permanent incisor, extrusive luxation, avulsion, crown fracture, replantation, root resorption. az 1 Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Department of Orthodontics and Paediatric Introduction Dentistry, School of Dentistry, University of Milan, Italy rn 2 Private practice of Orthodontics and Paediatric Den- Number, type and severity of dental injuries per patient tistry, Isernia, Italy differ according to the patient’s age and the cause of 3 Department of Orthodontics, School of Dentistry, accident (1). Traffic accidents may be focused as a te “Vita - Salute San Raffaele” University, Milan, Italy possible increasing cause of dental injuries and repre- 4 Department of Paediatric Dentistry, Dental School, sented 10% of the etiologic factors in a sample of Nor- University of Brescia, Italy wegians aged 7-18 years (2) and 7.5% in Austrians with a mean age of 17.8 years (SD error 0.287) (3). Corresponding author: In Car accidents particularly accounted for 5.6% of the oral and dental injuries in Israeli population during Roberto Biagi, MD, DDS, MSc childhood and adolescence (4) and for 2% in a study Fondazione IRCCS Cà Granda conducted at the Boston Children’s Hospital Medical Ospedale Maggiore Policlinico Center and two private pedodontic officers in 1979 (5). ni Department of Orthodontics and Paediatric Dentistry, The trauma group resulting from pedestrian-, bicycle-, School of Dentistry, University of Milan and car-related injuries is usually dominated by multi- Via della Commenda, 10 ple dental injuries, injuries to the supporting bone and 20122 Milano Italy soft-tissue injuries (6). o Phone: +39 02 50320240 The present case report describes the treatment out- E-mail: roberto.biagi@unimi.it come of traumatic maxillary incisors injuries of a 16.2- izi year-old female due to a car accident, with a follow-up of 2 years. Summary Ed Number, type and severity of dental injuries per pa- Case report tient differ according to the patient’s age and the cause of accident. The trauma group resulting from A healthy 16.2 year-old female was referred to the den- pedestrian-, bicycle-, and car-related injuries is tal office after suffering trauma to her maxillary incisors, usually dominated by multiple dental injuries, in- following a car accident occurred 75 minutes before. juries to the supporting bone and soft-tissue in- Facial bone and TMJ examination revealed no patho- C juries. logical signs and symptoms, while intraoral examination This report describes a case of a 16.2-year-old fe- showed concussion of tooth 12; extrusive luxation of CI male who suffered traumatic injuries to her perma- tooth 11; avulsion of tooth 21 and subluxation with nent maxillary incisors after a car accident. Con- complicated crown fracture of tooth 22 (Figs. 1 and 2). cussion of tooth 12, extrusive luxation of tooth 11, Tooth 21 was dry stored for 15 minutes, then in milk for avulsion of tooth 21 and subluxation with compli- 60 minutes. Panoramic and periapical radiographs ex- cated crown fracture of tooth 22 were observed at cluded bone and root fractures (Fig. 3). Spontaneous the emergency visit 75 minutes after the trauma. pain was present in the region of maxillary incisors. © Tooth 21 was dry stored for 15 minutes, then in With the parents’ and patient’s informed consent, a lo- milk for 60 minutes. The treatment plan according cal anesthetic was administered. The tooth 11 was to IADT guidelines was performed with the satisfac- gently pushed back into its socket; the root of tooth 21 tion of the dentists and the patient. After 1 year fol- was rinsed with saline, such as its alveolus to remove low-up a replacement root resorption of tooth 21 the contaminated coagulum, prior to its replantation in was diagnosed; it was then considered severe at its socket with a gentle pressure; the tooth 22 was the time of the 2 year control visit. treated with pulp capping with calcium hydroxide and a 212 Annali di Stomatologia 2013; IV (2): 212-217 7-biagi_- 19/06/13 10:38 Pagina 213 Multiple traumatic injury to maxillary incisors in an adolescent female: treatment outcome with two years follow-up li na io Figure 1. Intraoral view at the time of traumatic injury. az rn te Figure 3. Periapical radiograph at the time of traumatic in- jury. In o ni Figure 4. Functional splinting with an orthodontic 0.016- izi inch stainless steel wire and composite resin. Figure 2. Tooth 21. The patient was scheduled for follow-up and was moni- Ed dentin bonding agent to create a seal against bacterial tored weekly in the first month after the trauma, then af- invasion into dentinal tubules. The fractured crown frag- ter 3 months, 6 months, 1 year and 2 years. ment wasn’t available. The dentin and pulp protection An initial phase of replacement root resorption of was incorporated into the splint. tooth 21 was suspected at the 6 months radiographic A functional splinting with an orthodontic 0.016-inch control (Figs. 8 a, b) and became evident 6 months stainless steel wire and composite resin was positioned later (1 year follow-up) (Figs. 9 a, b). The last radi- C from tooth 13 to tooth 23 (Fig. 4) for a period up to 2 ographic examination during the 2 years recall re- weeks, as suggested by the guidelines of the Interna- vealed a dramatic increase of replacement root re- tional Association of Dental Traumatology (IADT). CI sorption of tooth 21 (Fig. 10), so that its survival rate Systemic antibiotic (amoxicillin 2 g for day for 7 days) and became low. Clinically, a gingivitis particularly on the analgesic medicament on demand were prescribed. The maxillary arch due to poor oral hygiene was diag- patient received instructions about an appropriate soft di- nosed (Fig. 11). et and about an adequate oral personal hygiene (chlorhexidine 0.12% mouth rinse twice a day for 1 week © and a soft toothbrush to brush her teeth after each meal). Discussion After 3 weeks, and not after 2 weeks as planned, teeth 11, 21 and 22 where endodontically treated (Fig. 5) and In case of multiple injuries the treatment can be compli- the splint was removed. cated and usually requests a multidisciplinary team ap- Afterwards tooth 22 was restored with a glass-fiber en- proach. The present clinical report refers about 5 con- dodontic post build-up and an alumina ceramic crown current types of dental trauma involving teeth mineral- (Figs. 6 and 7). ized tissues and their supporting tissues: concussion of Annali di Stomatologia 2013; IV (2): 212-217 213 7-biagi_- 19/06/13 10:38 Pagina 214 R. Biagi et al. 8A li na io az rn te 8B In Figure 5. Periapical radiograph after endodontic treatment when the splint was removed. o ni izi Ed Figure 6. Glass-fiber endodontic post build-up and prepa- ration of tooth 22. C CI Figures 8A and B. Periapical radiographs at 6 months con- trol visit. © tooth 12, extrusive luxation of tooth 11, avulsion of tooth 21, subluxation and complicated crown fracture of tooth 22, according to Andreasen’s classification (7), which is the most frequently used (8) and the more comprehensive system which allows for minimal sub- Figure 7. Restoration of tooth 22 with an alumina ceramic jective interpretations (1). crown. Extrusive luxation is an uncommon type of injury in per- 214 Annali di Stomatologia 2013; IV (2): 212-217 7-biagi_- 19/06/13 10:38 Pagina 215 Multiple traumatic injury to maxillary incisors in an adolescent female: treatment outcome with two years follow-up 9A li na io az rn te Figure 10. Periapical radiograph at 2 years recall visit. 9B In o ni izi Figure 11. Intraoral view at 2 years recall visit. ing. Up to 43% of prevalence of pulp necrosis was re- Ed ferred by Lee et al. (9) and Humphreys et al. (10), so an endodontic treatment was considered for tooth 11. Tooth 21 on the contrary was avulsed. Avulsion repre- sents a dramatic situation in dental traumatology, par- ticularly in subjects who have not yet reached the maxi- mum peak growth rate. Although replantation is the C usual procedure, it must be considered a temporary measure because many teeth are lost due to root re- CI sorption. Prognosis depends mainly on length and type of extra-alveolar storage, stage of root development and contamination of the root surface (11). In this clini- Figures 9A and B. Periapical radiographs at 1 year recall visit. cal case, the development of the root was already com- pleted, so that the revascularization of the pulp was ex- tremely limited; the first 15 minutes it was kept dry and © manent dentition. The tooth, in this case report tooth in the next 60 minutes in milk. In 1981, Andreasen JO 11, appears elongated with bleeding from periodontal (12) observed 70.5 ± 17.3% of periodontal healing of ligament and mobile. Pain is present during occlusion mature permanent incisors of monkeys after 18 minutes and an increased periodontal ligament space is diag- of dry storage. Milk can be considered the best storage nosed by means of a periapical radiograph. The stage medium for avulsed teeth available at the time of trau- of root formation and the severity of extrusive luxation ma or shortly after. Blomlöf (13) referred that 71% of are usually the major parameters influencing pulp heal- periodontal ligament cells were viable after 3 hours in Annali di Stomatologia 2013; IV (2): 212-217 215 7-biagi_- 19/06/13 10:38 Pagina 216 R. Biagi et al. milk storage and 50% after 12 hours. Other re- So educational programs are essential to optimize the searchers such as Huang et al. (14) and Rozenfarb et treatment outcome that depend both on a timely and al. (15) confirmed the validity of milk as storage medium adequate emergency treatment at the site of the acci- for exarticulated teeth. dent, and on a multidisciplinary therapeutic approach Before prosthodontic rehabilitation, tooth 22 was emer- by the dentists. li gency treated with calcium hydroxide for pulp capping and a dentin bonding agent mainly to control pain and na sensitivity sealing dentinal tubules. A definitive restora- Acknowledgements tion with glass-fiber post build-up and alumina ceramic crown was chosen to maximize the patient’s esthetic The authors have appreciated the useful comments of request. Dr. Silvia Faverzani Gibbs. io Finally a wire-composite splint was placed from tooth 13 to tooth 23 according to IADT guidelines (16, 17). Splint is justified by medico-legal aspects, periodontal References az ligament cells protection and patient comfort. Flexible splint was preferred to rigid splint to preserve physio- 1. Bastone EB, Freer TJ, McNamara JR. Epidemiology of den- logic teeth mobility and avoid further damage to peri- tal trauma: a review of the literature. Aust Dent J 2000; 45:2- odontal ligament as dentoalveolar ankylosis. Wire-com- 9. 2. Skaare AB, Jacobsen I. Etiological factors related to dental rn posite splinting, in this case 0.016-inch stainless steel injuries in Norvegians aged 7-18 years. Dent Traumatol 2003; wire and composite resin, is a simple and fast tech- 19:304-308. nique without laboratory procedures and it is useful 3. Gassner R, Bösch R, Tuli T, Emshoff R. Prevalence of den- when an emergency treatment occurs with a compro- tal trauma in 6000 patients with facial injuries. Implications te mised working field. Moreover it allows a good oral hy- for prevention. Oral Surg Oral Med Oral Pathol Oral Radiol giene (11, 18). Endod 1999; 87:27-33. The patient was scheduled for follow-up: recall visits 4. Levin L, Samorodnitzsky GR, Schwartz-Arad D, Geiger SB. were planned weekly in the first month, then after 3 and Dental and oral trauma during childhood and adolescence 6 months, yearly in the first 5 years. In in Israel: occurrence, causes, and outcomes. Dent Traumatol 2007; 23:356-359. Unfortunately the patient deserted the 2 weeks recall 5. Meadow D, Lindner G, Needleman H. Oral trauma in chil- visit, so the splint was removed only after 3 weeks and dren. Pediatr Dent 1984; 6:248-251. the endodontic treatment of teeth 11, 21 and 22 was 6. Glendor U. Aetiology and risk factors related to traumatic den- performed in the same occasion. ni tal injuries - a review of the literature. Dent Traumatol 2009; Replacement root resorption of tooth 21 was suspected 25:19-31. after 6 months, was confirmed after 1 year and appeared 7. Glendor U, Marcenes W, Andreasen JO. Classification, epi- severe after 2 years recall. All the other teeth were in demiology and etiology. In: Andreasen JO, Andreasen FM, o good condition and a poor oral hygiene was observed. Andersson L, eds. Textbook and Color Atlas of Traumatic Although splinting time of 14 days or less is recom- Injuries to the Teeth. 4th Ed. Oxford, UK. Blackwell Publishing Ltd 2007; 217-254. izi mended by IADT and 1 week may be adequate, its du- 8. Feliciano KMPC, de França Caldas Jr A. A systematic re- ration doesn’t affect the likelihood of successful peri- view of the diagnostic classifications of traumatic dental in- odontal healing after replantation (19, 20). However a juries. Dent Traumatol 2006; 22:71-76. short period must be considered the best practice to- 9. Lee R, Barret EJ, Kenny DJ. Clinical outcomes for perma- Ed day. So in this case the replacement root resorption nent incisor luxations in a pediatric population II. Extrusions may be caused by an inadequate tooth storage: if the Dent Traumatol 2003; 19:274-279. tooth isn’t kept in milk immediately but only after a peri- 10. Humphreys K, Kinirons M, Welbury RR, Cole BOI, Bryan od in dry storage, the prognosis would probably be the RAE, Campbell O, Fung DE. Factors affecting outcomes of same of any other dried and replanted tooth. Dead cells traumatically extruded permanent teeth in children. Pediatr Dent 2003; 25:475-478. cannot be revitalized by milk (21). C 11. Andreasen JO, Andreasen FM. Avulsions. In: Andreasen JO, Finally, infraocclusion of tooth 21 wasn’t observed be- Andreasen FM, Andersson L, eds. Textbook and Color At- cause of physical maturity of the patient (22), for which las of Traumatic Injuries to the Teeth. 4th Ed. Oxford, UK. CI a future implant rehabilitation is planned. Blackwell Publishing Ltd; 2007:444-488. 12. Andreasen JO. Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation Conclusion of mature permanent incisors in monkeys. Int J Oral Surg 1981; 10:43-53. Traumatic injuries to permanent maxillary incisors rep- 13. Blomlöf L. Storage of human periodontal ligament cells in a © resent a dramatic situation from an aesthetic point of combination of different media. J Dent Res 1981; 60:1904- 1906. view that involve the social and psychological behavior 14. Huang S, Remeikis NA, Daniel JC. Effect of long-term ex- of the patient. posure of human periodontal ligament cells to milk and oth- The dentist can offer an emotional support to the young er solutions. J Endod 1996; 22:30-33. patients and their parents, but when the accident caus- 15. Rozenfarb N, Kupietzky A, Shey Z. Milk and egg albumen es multiple complex dental injuries the prognosis is of- are superior to human saliva in preserving human skin fi- ten unfavorable and the teeth survival is compromised. broblast. Pediatr Dent 1997; 19:347-348. 216 Annali di Stomatologia 2013; IV (2): 212-217 7-biagi_- 19/06/13 10:38 Pagina 217 Multiple traumatic injury to maxillary incisors in an adolescent female: treatment outcome with two years follow-up 16. Flores MT el al. Guidelines for the management of traumatic matol 2008; 24:2-10. dental injuries. I Fractures and luxations of permanent teeth. 20. Hinckfuss SE, Messer LB. Splint duration and periodontal out- Dent Traumatol 2007; 23:66-71. comes for replanted avulsed teeth: a systematic review. Dent 17. Flores MT et al. Guidelines for the management of traumatic Traumatol 2009; 25:150-157. dental injuries. II Avulsion of permanent teeth. Dent Traumatol 21. Blomlöf L, Lindskog S, Andersson L, Hendström KG, Ham- li 2007; 23:130-136. marström L. Storage of experimentally avulsed teeth in milk 18. von Arx T. Splinting of traumatized teeth with focus on ad- prior to replantation. J Dent Res 1983; 62:912-916. na hesive techniques. J Calif Dent Assoc 2005; 33:409-414. 22. Malmgren B, Malmgren O. Rate of infraposition of reimplanted 19. Kahler B, Heithersay GS. An evidence-based appraisal of ankylosed incisors related to age and growth in children and splinting luxated, avulsed and root-fractured teeth. Dent Trau- adolescents. Dent Traumatol 2002; 18:28-36. io az rn te In o ni izi Ed C CI © Annali di Stomatologia 2013; IV (2): 212-217 217 

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Review article From Nuremberg to bioethics: an educational project for students of dentistry and dental prosthesis li na Silvia Marinozzi, PhD1 Eugenic theories in Europe in the XVIII Gilberto Corbellini, PhD2 and XIX century io Livia Ottolenghi, MD, DDS3 Francesca Ripari, PhD, DDS3 The diffusion of the Hippocratic oath formed the basis of Antonio Pizzuti, PhD4 the principles of medical deontology, morally constraining Marcello Pezzetti, MA5 the doctors to follow specific norms and forbidding atti- az Fabio Gaj, MD6 tudes and practices that would violate the “purity of art”. Deontology, as a set of norms regulating the professions, reflects principles and models of the general moral of a 1 Department of Molecular Medicine, “Sapienza” given culture and society, but also builds the foundations n University of Rome, Italy and reinforces an internal culture characterizing socially 2 Department of Medical and Surgical Sciences and and legally the main self commitment (mandate) of each er Biotechnology, “Sapienza” University of Rome, Italy profession. 3 Department of Oral and MaxilloFacial Sciences, The care of patients as primary goal of the doctor, primum “Sapienza” University of Rome, Italy non nocere, a guide principle of the medical behaviour, to 4 5 6 University of Rome, Italy nt Department of Sperimental Medicine, “Sapienza” Director of the Museum of Shoah of Rome, Italy Department of General Surgery, Surgical Specialties equally care for all humans without discrimination, are val- ues sanctioned in the hippocratic code, confirmed by all authors, both doctors and non doctors, that in the course of the centuries have dealt with ethical and deontological iI and Transplants, “Sapienza” University of Rome, Italy aspects of the medical profession never put in discussion or denied in the medical communities of the XVIII and XIX century on However, in the course of the XIX century, experimental Corresponding author: research in biology and medicine started to develop, Silvia Marinozzi, PhD while anthropological studies validating the biological the- Department Molecular Medicine ories proposed classifications of human races that be- i “Sapienza” University of Rome came the presupposition of the doctrine constituting the iz Viale dell’Università 34/A ideologic basis of the politics of “racial hygiene” and eu- 00185 Rome, Italy genetics in nazi Germany. Phone: +39 06 64451721 The cruel and lethal medical experiments carried out on Ed E-mail: silvia.marinozzi@uniroma1.it the jewish and other prisoners used as human guinea pigs in the concentration camp, provides the core of the debate that from after the Nuremberg trials has deter- mined that there is the need of an univocal normative lim- Summary iting the biomedical research within the boundaries of In the lessons of medical-scientific methodologies of moral and ethical lawfulness. IC the medical faculty at the Sapienza University of Rome, basic notions on the ethical and deontologic aspects characterizing the history of the medical profession are “Racial hygiene” in the nazi Germany provided, including the formulation and application of C bioethical principles to clinics and biomedical research. Within such framework, an educational project has been The programme of “racial hygiene”, proposed and per- initiated on the historical origin of the current normative formed by Hitler, freely interpreted and misinterpreted and juridic dispositions in the regulation of experimen- the idea of the eugenics started in 1883 by the English sci- entist Francis Galton, cousin of Charles Darwin, who © tal biomedical research and the relationship between health operators and patients, with particular attention to considered that the progress of the human race de- the procedure, the meaning the value either professional pended on the improvement of selective transmission of or deontologic, of ethics and the legality of the informed heritable traits in the population to future generations. In consensus. Emphasis is put on medical and experimen- Germany, the eugenics movement was already very ac- tal abuses that occurred in Germany during the nazi tive in the XIX century and the work of their founders Wil- regime. helm Schallmayer and Alfred Ploetz had distorted its meaning; in 1908 in the period when Germany had Key words: history of bioethics, dentistry in the nazi colonies in South West Africa, all mixed marriages were Germany. annulled and the germans involved in mixed marriages 138 Annali di Stomatologia 2013; IV (1): 138-141 From Nuremberg to bioethics: an educational project for students of dentistry and dental prosthesis were deprived of their civil rights. After 1933, when the ment had given the license to marry to persons with oral nazis came to power, the eugenic ideas became ripe for schisis or with a anamnestic positive family history only if political purposes that aimed through euthanasia, sterili- sterilized, subsequently forbade the union of a healthy zation and selectivity of marriages to reach the ambitious person with a person pre-emptively sterilized, on the as- goal of creating a “superior race”. sumption that the goal of the marriage is mainly the pro- li duction of healthy offspring for the Nation. The attempts to avoid such dictates were eluded by the certainty that na “Useless lives”: the T4 experience the “sick” subjects would have survived as stowaway for their entire life, since the Ministry of Public Instruction Hitler put in charge some hierarchs to extend medical au- banned access to schools to the children or access to any thority to evaluate those persons considered beyond cure public job to the adults, thus excluding them from any so- io after accurate diagnostic evaluations, to whom a “merci- cial contact. ful death” would be allowed. The “Reich Committee for the The atrocity judged at the Nuremberg process were part scientific research of serious diseases of heritable origin” of a global system that had been encouraged by eugenic had prepared the registration forms to record useful infor- euthanasia, such as the obligatory sterilization, the selec- az mation to select the persons “worthy of help” from those tive marriages on the basis of the genetic health and considered “useless lives” and the distribution of such racial hygiene, among which also the subjects with oro- questionnaires was carried out in the long stay hospitals, maxillofacial malformations were included. the sanatoria and in the madhouses. The directional cen- n ter for the “euthanasia” operation had its residence in Berlin in a house at n. 4 of Tiergartenstrasse. All men- Racial hygiene and oro-maxillo facial district er tioned questionnaires were sent to this address where each case was examined by a doctor; the selected pa- As all professionals in the medical field, dentists were tients were then transported and killed in one of the five obliged to report about all patients affected by congenital 4 operation. nt centers for euthanasia in Germany or in the one in Aus- tria (Linz). This procedure went down in history as the T- There are not reliable data on the number of people killed malformations. The racial health became an obligatory subject in all stu- dent classes of medicine and dentistry and the scientific literature on the same topic was very prolific in the 30s, iI by “euthanasia”; it is said between 120.000 and 275.000 as it can be deduced from the proclamations with racial cases and that only 15% of the mentally ill people of content. Among them, the “Neue Grundlagen der Rassen- Germany survived the program of the third Reich. forschung” states that the movements of mastication of on It is interesting to note that those that constituted the the arian men are horizontally oriented to allow mastica- program of so-called euthanasia were not ignorant, nor tion with closed mouth, while in men of different race, as mentally insane, but doctors, hospital nurses and bu- in animals, the movements of mastication are perpendi- reaucrats seduced by the idea of a “pure” nation in which cular, to let them chew with an open mouth; moreover, i chronic disease and disability were considered an unjus- while the canines of an arian man are not higher than the iz tifiable burden. Among them famous scientists as C. H. other teeth, in the other races they are in general higher, Schroeder, pioneer in the etiology and mechanisms of round and large, as in animals. heritable transmission of oral schisis, who in 1931 recom- Since the beginning, the german dentists and their scien- Ed mended to carry out the eugenic measures for those in- tific and professional organizations were involved in the dividuals affected stating that the prevalence of this consequences of the power achieved by the nazis in pathology was increased because the surgical interven- 1933. tion contrasted natural selection. In the same year, Ernstt Stuck became Reichzah- The law for the Prevention of birth of persons affected by narztefuehrer (i.e. head doctor of the Reich) and decided heritable disease of 14 July 1933 envisages the obligatory that each dentist working in private had to complete a IC sterilization, thus making explicit the concept already ex- course of ideologic and military education over eight pressed by Hitler in Mein Kampf to systematically prevent weeks in order to get access to funds from social welfare; all unhealthy individuals to generate diseased and in- in his opinion, each dentist should become a national-so- sane offspring, as a “compassionate action”, that would cialist, trust the Fuehrer and follow him faithfully in his C spare undeserved suffering and improve the health of the progress to contribute to reach the victory. The results was race on the whole. Also in this case, the tribunals in that during the first months of the war 6000 dentists en- charge of the selection of the subjects were composed by rolled in the german army. a qualified commission represented by a lawyer, a fam- Still in 1933, a law was approved forbidding the Jewish © ily doctor, and a doctor specialist in hygiene; they had the dentists to exert their profession in favour of the funds of duty to select the risky categories, including deafness, social welfare, until in 1939 the profession was finally acute alcoholism, epilexy, blindness, but also physical completely forbidden to them, so that the number of jew- malformations such as oral schisis and all doubtful cases ish dentists went down from 1064 (on a total of 11.332 of cranio-facial malformations such as the simple open surgeon dentists) in 1934, to 372 in 1939. bite, which in the uncertainty were anyway sterilized. In this period, especially following the promulgation of the The program that planned to “protect the german honour racial laws of Nuremberg, the health policy included the and blood” was even more ambitious, therefore the “law ban of marriage among german citizens “pure” and jew- for the prevention of heritable diseases”, that in a first mo- ish, and afterwards, simple “impure” individuals, with the Annali di Stomatologia 2013; IV (1): 138-141 139 S. Marinozzi et al. defense of the arian species the pillar of the measures of due to well defined racial characteristic and that it would public hygiene, so that the medical and health prevention be possible to differentiate the various ethnic groups from coincided with the idea of racial hygiene and prevention. the study of the mandible. Combining his interest for the Among the numerous scientific works aimed at demon- facial development and the experiments conducted in strating the dangerousness and the risks of contamination genetics by professor Otmar Freiherr von Verschuer of the li coming from uncontrolled marriage unions and to give prestigious Goethe University of Frankfurt am Main, to suppert to the ban of reproduction not only for those that whom he was committed, Mengele, was concerned that na could actually transmit heritable pathologies, but also so- the progress in the surgical treatment of oral schisis matic and genetic stigmata judged as incongruous and would not have decreased the incidence of these congen- antithetic to the selection of the pure race, there are also ital malformations genetically transmitted. He carried out studies concerning the connection between maxillo-den- a study on 17 families of 110 patients affected by both io tal anomalies and some psychiatric pathologies, such as labial and palatal schisis resident in Frankfurt: the results the frequency of prognatism and of an ogival palate suggested that 47% (a higher proportion than that re- among the mentally ill patients. The basic idea, in absolute ported in previous studies) had a heritable component. coherence with the phrenology doctrines of the time, was Moreover, Mengele found an association between “cleft az to nosologically embed some physiognomics for the diag- lip with/without palatal schisis” and other conditions such nosis of mental diseases thought to be congenital, to as hernia, hemangioma, phimosis, foot malformation, prevent heritable transmission through the sterilization of polydactyly and syndactyly, scoliosis, hydrocefalon and the subjects. spina bifida. Therefore, he hypothesised a link between n From the association of ogival palate-prognatism with oral schisis and mental retardation, deafness, strabis- heritable diseases, it was concluded that all people pre- mus and the delayed closure of the cranial sutures, ex- er senting this kind of malocclusion were carriers of congen- plaining in this way the pathogenesis of the oral schisis as ital mental disability and therefore had to be included in a “global perturbation of the fetal development” with dif- the categories to be sterilised. ferent degrees of seriousness. nt In this respect, the concerns for some oro-maxillo-facial anomalies, was that the knowledge on the transmission patterns of the labio-palatal-schisis in 1930 was very lim- ited. The different authors, among which included As known by now, the nazi dentists did the extraction of golden teeth at the beginning only from the mouth of the cadavers in the lager, then also from live prisoners in or- der to reutilize the metal in various ways. Xavier Rioux in iI Schroeder, observed that oral schisis were present with his works on the history of dentistry in Germany during the an incidence of 40.5% among the offspring of affected in- nazi period highlighted how the general order or the den- dividuals, that the transmission patterns were multiple tal treatment of the prisoners in the concentration camps on even if the recessive heredity seemed prevalent in 75% was to reduce at the minimum the medical care and to of cases, that in 64.3% of cases the affected individuals avoid the use of anesthesia during operations, considered were males and that in particular the labial schisis mani- by Dr. H. Pock, head dentist of all concentration camps, fested with a higher frequency in the left lip and was not a practice “too human”for individuals thought to be “less i necessarily associated to palatoschisis. The results pro- human” (2). iz vided scientific support to the obligatory sterilization of the adults and to the euthanasia of children affected by oral schisis. They hypothesised a correlation between the From Nuremberg to modern bioethics Ed oral pathology and other malformations manifested by the same individual or in kins, such as bifid tongue, poly- The elimination and the forced sterilization of the “impure” dactyly, malformations of the foot fingers, hydrocephalon, Germans, or those not matching the biological “arian” stiff neck, and some ocular pathologies. ideal, the planning of a “final solution” of the Jewish ques- The social anathema imposed to the subjects with oral tion, the total elimination of a whole people, and the per- schisis was clearly described by Beatty in 1936. Referring formance of medical experimentations carried out on the IC to subjects who were surgically treated to solve the oral prisoners of the concentration camps used as human schisis, he affirmed that if operated early, both the lan- cavias, constitute the core of the debate that after the guage and the aesthetics seemed to improve sufficiently Nuremberg trial there was a need for a univocal norma- to prevent pain and the sense of repulsion from the oth- tive that would limit the biomedical research into the C ers. Moreover, since the aesthetic defects of the boundaries of moral and ethical lawfulness. palatoschisis were enhanced by the simultaneous pres- The Nuremberg code of 1947, promulgated just a few ence of the cleft lip, the psychological effects of such days before the end of the process to the nazi officials and pathology on the children should not be overlooked, risk- health people, underlines the indispensability of the re- © ing to hamper the natural process of socio-cultural growth spect of the integrity and the dignity of individuals, and rat- rendering the subject, even if healthy, insecure and with ifies on one side the priority of a voluntary consensus of excessive educational and mental delays. the patients and of the individuals under experimental pro- Also Mengele dedicated his studies to the oro-maxillofa- tocols, while on the other side the sense of ethical respon- cial malformations, obtaining his degree with a thesis en- sibility, professionality and legality required of the doctor titled “Morphologic racial research on the inferior part of whenever an experimental research would result harmful the maxilla of four racial groups” in which he made com- to the individual. The “voluntary consensus” becomes an plex measurements of the alveolar region of the mandible. “essential” prerequisite for a morally acceptable conduct He concluded that the variation in measurements were of the experiments on humans. 140 Annali di Stomatologia 2013; IV (1): 138-141 From Nuremberg to bioethics: an educational project for students of dentistry and dental prosthesis In 1948 the World Medical Association approved the integrating the classes of Medical Deontology and Applied Geneve Declaration, updated the Hippocratic oath and Bioethics through the historical reconstruction of the con- committed doctors not to use their knowledge against hu- siderations that have been developing from the Nurem- man rights “even under obligation”. The debate and the berg Code in the medical and scientific community of the discussions in the medical community that followed post- western countries. The goal is to offer an educational con- li Nuremberg, and the issue of normatives always being tribution on the history of medical bioethics through the re- more oriented towards the free consensus of the pa- construction of the historical-cultural prerequisites of the na tients and/or subjects under experimental research, de- race doctrine, the systems adopted in Germany to carry lineate the historical origins of the current bioethics ap- out “racial hygiene”, from the elimination of disabled to the plied in the medical and clinical field. The Helsinki discrimination of the impure races, the experiments con- declaration (1964) confirms and reinforces the principle of ducted on human beings in the extermination camps un- io free and voluntary consensus, which must also be explicit, til the successive response of the international community, thus highlighting the need of a normative procedure that from the Nuremberg Code of 1947 to the Belmont Report, further supports the right of autodetermination of the in- and to the definition of bioethical “codes” in current med- dividuals, the guarantee of the welfare of the individual, icine, with particular relevance to the concept, the history az but also the terms by which the consensus of the patient and the worthiness of the “informed consensus” (1). can be valid (major age, psychical conditions, etc.). In 1971 the American oncologist Van Rensselaer Potter published “Bioethics: a bridge to the future”, and pro- Acknowledgements n posed the term “bioethic” as explicitation of an ideal proj- ect where the medical ethical problems are inserted in We thank Prof. Antonella Polimeni, Director of the Depart- er those more general of an “environmental” ethic, integrat- ment of Oral and MaxilloFacial Sciences of “Sapienza” ing the new biological knowledge with the human values, University of Rome, and Prof. Ersilia Barbato, Responsi- centered on the problems of the demographic develop- ble of the Advenced Degree Course in Dentistry and nt ment, ecological degradation, and for an adjustment of the technologic and scientific progresses to the moral refer- ence values (global bioethics). In a more strict medical field, in 1978 the National Commission for the protection Dental Implants, to having allowed this didactical and educational project. iI of Human Subjects in the Biomedical and Behavioural Re- References search of USA, drew up the document “Ethical Principles and Guidelines for the Protection of Human Subjects of 1. Conforti M, Corbellini G, Gazzaniga V. Dalla cura alla on Research” (known as Belmont Report), in which the three scienza. Malattia, salute e società nel mondo occidentale. fundamental principles of the current medical bioethics are Varese: Encyclomedia 2011. 2. Riaud X. Story of three SS dentists during World War II: Pr ratified: beneficence and non-maleficence; equity and jus- Hugo Blaschke, Dr Hermann pook and Dr Willy Frank. tice; respect of the decisional autonomy of the patient. Vesalius. 2006 Dec; 12 (2): 79-93; Three tragic destinies of i The relevance of the treated themes in bioethical consid- surgeon-dentists: Bernard Holstein, Danielle Casanova and iz erations induced institutionalisation of an educational Dr Rene Maheu during World War II. Vesalius. 2005 Dec; 11 route for the students of the Courses of the Medical Fac- (2): 88-97; The German army dental corps in World War II” ulties of the Sapienza University of Rome, with seminars Vesalius. 2005 Jun; 11 (1): 38-47. Ed IC C © Annali di Stomatologia 2013; IV (1): 138-141 141 

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Original article Microcomputed tomographic analysis of the furcation grooves of maxillary first premolars li na Saad Misfer Al-Shahrani, BDS, MSD, SBE1 post cannot be avoided, it should not extend 6.5 mm Dina Al-Sudani, DDS, MSEd2 from the CEJ. io Majed Almalik, BDS3 Gianluca Gambarini, MD, DDS4 Key words: Buccal furcation groove, maxillary premolar, Faisal Ahmed AlRumaihi, BDS, DSc5 microcomputed tomography, morphometric analysis. az 1 Armed Forces Hospital, Riyadh City, Saudi Arabia Introduction 2 King Saud University, College of Dentistry, Riyadh City, Saudi Arabia Maxillary first premolars (MFPs) have a unique anatom- n 3 Karolinska institute, Division of Endodontics, ical features includes bifurcated roots, a narrow furcation Solna, Sweden entrance, deep mesial concavities, and multiple canals er 4 “Sapienza” University of Rome, Italy (1). Few studies have mentioned the presence of the 5 Riyadh Military Hospital, Riyadh City, Saudi Arabia furcation grooves in the palatal aspects of the buccal roots of the MFPs (2-5). The prevalence of this phenom- enon was reported to be very high, ranging from 62% to Corresponding author: Dina Al-Sudani, DDS, MSEd King Saud University, College of Dentistry, nt 100% (6-8). A lack of knowledge about the extent and thickness of the dentin in this area might lead to exces- sive thinning or perforation of the dentinal wall during ei- iI P.O. Box 60169, 11545, Riyadh City, Saudi Arabia ther endodontic or restorative procedures, increasing the Phone: +966 504441941 possibility of vertical root fractures (9-11). E-mail: drdina_2000@yahoo.com Furthermore, morphometric studies on the palatal groove on of the buccal root and its relationship to the dentin width found that the palatal wall in unprepared roots was, on av- erage, less than 1 mm (4, 5, 9-12). Nevertheless, several Summary Objectives. The aims of this study were to conduct a studies have shown that posts must be surrounded by 1 i morphometric analysis on the buccal furcation grooves mm of sound dentin (13-15). iz in freshly extracted bifurcated maxillary first premolars Several methods have been used to assess tooth mor- (MFPs) and to correlate all anatomical measurements us- phology, including the use of simple visual inspection of ing microcomputed tomography. sectioned or cleared teeth (16, 17) and radiographic ex- Ed Materials and Methods. Twenty-three human MFPs with amination (18-21). The furcation grooves in MFPs were bifurcated canals were selected for this study. The spec- investigated initially by Tames et al. (4). They used the imens were analyzed with microcomputed tomography. Tool Makers Microscope after embedding the teeth in The length, the beginning, and the ending of the grooves acrylic and sectioning them into 1-mm-thick slices from were measured. The minimum cross-sectional canal wall the apex to the furcation. Lammertyn et al. (22) used a thickness in the grooves was located, and the width of sectioning method and profile projector to assess the IC the dentin thickness was calculated. All measurements furcation grooves in the buccal roots of MFPs. This ap- were recorded and statistically analyzed. proach is complicated, time consuming, and can introduce Results. The concavity of the grooves begins before the artifacts and distortion of internal tooth anatomy (23). Al- bifurcation site in 9/23 samples and after the bifurcation though the authors produced three horizontal slices (2 C in 56.5% of samples. The groove length varied between mm from the furcation, 2 mm from the anatomic apex, and 1.1-9 mm; the cross-sectional area with minimum palatal the third slice equidistant between the first and second dentin thickness was 0.78±0.14 mm, which was located slices), they still could not provide a complete picture of at a mean distance of 7.1 mm from the cementoenamel the furcation grooves. © junction (CEJ) and 1.38 mm from the furcation. Recently, a more advanced and non-destructive method Conclusions. The presence of the furcation grooves in the palatal aspects of the buccal roots of the MFPs was to evaluate furcation grooves has been made available. 100%. The length, depth, location, and width of the dentin Microcomputed tomography (MCT) scanning is a non-de- thickness of the grooves varied in relation to tooth structive method and, allowing the view of three-dimen- length, bifurcation, and CEJ. These parameters should sional structures, has promising applications in endodon- be taken into consideration before any endodontic or tics (24, 25). MCT has been used to investigate the restorative procedures are performed. Reducing dentin presence of anatomical structures (13, 26) and evaluate width too vigorously by intracanal instrumentation can the centering ability and efficiency of rotary systems and predispose to vertical root fractures or perforations; if a hand files when used for root canal preparations (27-29). 142 Annali di Stomatologia 2013; IV (1): 142-148 Microcomputed tomographic analysis of the furcation grooves of maxillary first premolars However, to date, there are no reports on the use of SKYSCAN, Kontich, Belgium) at 100 kV and 100 μA with MCT scanning to assess the furcation grooves in the a resolution of 18.6 μm and a 0.5-mm-thick aluminum fil- buccal roots of MFPs. ter and 54% beam-hardening reduction. Using NRecon This in vitro study aimed to conduct a morphometric software (SKYSCAN), these images were reconstructed, analysis on the palatal grooves of the buccal roots in a producing two-dimensional, cross-sectional slices of the li sample of freshly extracted bifurcated MFPs using MCT. tooth structure. Subsequently, CT Analyzer software (SKYSCAN) was used for the linear measurements of all na variables, including canal length (measured coronally Materials and methods from the first slice where enamel appear to the last slice of the root dentin disappear apically) (Fig. 1), the points Twenty-three untreated human bifurcated permanent where the grooves begin and end (starting from the first io MFPs were selected from a pool of teeth that were freshly slice where grove depression appear to the last slice extracted from an adult Saudi population for orthodontic where the depression of the groove disappear) (Fig. 2) in reasons and stored in 10% neutral buffered formalin. relation to the cementoenamel juction CEJ (measured Teeth were scanned using a MCT scanner (1172 scanner; from the last slice show enamel on the buccal canal) n az er nt iI i on iz Figure 1. Canal length. Ed IC C © Figure 2. Groove start and end points. Annali di Stomatologia 2013; IV (1): 142-148 143 S. M. Al-Shahrani et al. (Fig. 3) and furcation, groove length, and the location of Statistical analysis the minimum cross-sectional canal wall thickness in the grooves (all slices in the groove length measured and the Collected data were statistically analyzed using SPSS 15 one with minimum cross section thickness selected and for Windows software (SPSS Inc, Chicago, IL); Pearson average reading were recorded) (Fig. 4). correlation coefficients r with two-tailed significance were li na io n az er nt iI Figure 3. CEJ measures. i on iz Ed IC C © Distance = 0.784 mm Figure 4. Dentin thickness measurements. 144 Annali di Stomatologia 2013; IV (1): 142-148 Microcomputed tomographic analysis of the furcation grooves of maxillary first premolars calculated for all pairs of measurements. The test was The concavity of the grooves began before the bifurcation considered statistically significant when p < 0.05. site in 9/23 samples (39.1%) with a mean value of 0.47±0.43 mm and exactly where the furcation began in one sample (4.4%) (Fig. 6). In the rest of the samples Results (13/23 [56.5%]), the grooves began after the furcation with li a mean value 0.77±0.98 mm (Tab. 1). Palatal invagination on the bifurcation aspect of the buc- The groove lengths varied between 1.1-9 mm with a na cal roots was present in all samples selected for this mean ±SD value of 4.7±2.08 mm; the mean ±SD cross- study. Measurements were taken at the vertical and hor- sectional area with minimum palatal dentin thickness was izontal planes (Fig. 5). 0.78±0.14 mm, located at a mean distance of 7.1 mm io n az er nt iI i on iz Figure 5. Measurements at vertical and horizontal planes. Ed IC C Groove start Cross section with minimum dentin thickness © Groove end Figure 6. Sample with groove starts before furcation (a). Cross section at furcation area (b). Sample with groove starts after furcation (c). Cross section at furcation area (d). Annali di Stomatologia 2013; IV (1): 142-148 145 S. M. Al-Shahrani et al. Table 1. Mean±SD, and groove length in relation to furcation. N % Range (Min/Max) Mean±SD Groove begins before furcation 13 39.10 0.10–1.60 0.48±0.43 Groove begins at furcation 1 4.40 - - li Groove begins after furcation 9 56.50 0.10–3.20 0.78±0.99 na from the CEJ and 1.38 mm from the furcation (Tab. 2). and periradicular bone destruction (32, 33). Moreover, our Correlation coefficients and significance between all pairs current technique overcomes the shortcomings of previ- of measurements in the vertical and horizontal planes are ously reported techniques (16, 22). In addition, with the presented in Table 2. Significant positive correlations ex- use of MCT, cross-sections can be made at a precise dis- io ist between A and C (r = 0.62, p = 0.00), A and E (r = 0.59, tance from the apex, furcation, or CEJ. p = 0.00), A and F (r = 0.44, p = 0.04), E and F (r = 0.86, It was possible to trace the grooves from their start points p = 0.00), and E and G (r = 0.59, p = 0.00). The length of (where the concavity appears coronally) to their ends az groove F was negatively correlated with dentin thickness (where the concavity disappears). The groove lengths var- of palate wall I, that is, as the length increased, the palatal ied between 1.1-9 mm with a mean ±SD value of 4.7±2.08 dentin thickness decreased, and vice versa (r = - 0.42, p mm in 39.1% of the samples, and the grooves began be- = 0.02); a similar relationship was present between G and fore the furcation with a mean ±SD value of 0.47±0.43 mm n I (r = - 0.41, p = 0.05) (Tab. 2). and a mean ±SD distance of 5.5±1.05 mm from the CEJ. er Table 2. Mean, SD, correlation coefficient, and significance of measurement sites in the vertical and horizontal planes. Mean SD Correlation Coefficient and (Significance) A 23.92 1.73 A nt B .25 .26 C .62** .00 D .26 .23 E .59** .00 F .44* .04 G .41 .06 H .23 .27 -.41 .05 I iI B 5.74 1.34 -.42* .74** .27 -.14 .50* -.23 -.19 .05 .00 .24 .54 .01 .28 .37 C 9.10 1.56 -.17 .41 .48* .11 .48* -.31 on .43 .05 .02 .61 .02 .15 D 5.56 1.05 .19 -.33 .46* -.10 -.01 .40 .13 .03 .65 .96 E 10.31 2.03 .86** .59** .43* -.52* .00 .00 .04 .01 i F 4.71 2.08 .36 .50* -.42* iz .09 .01 .02 G 7.16 1.86 .70** -.41* Ed .00 .05 H 1.38 1.64 -.28 .11 I 0.78 0.14 ** Correlation is significant at the 0.01 level (2-tailed). IC * Correlation is significant at the 0.05 level (2-tailed). Discussion These results disagree with those of Tamse et al. (4) who described the grooves as concavities that begin at C Several studies found the presence of grooves on the fur- the bifurcation. These findings make the CEJ a more re- cation aspects of the buccal roots of MFPs varied be- liable and clinically relevant reference point than the fur- tween 62% and 100% of cases using different evaluation cation. methods (2-8), supporting the results of the current inves- Another interesting finding is the highly significant cor- © tigation. relation between the length of canal A and the end of Our study appears to be the first study to investigate fur- groove E (r = 0.59, p = 0.00); as canal length increased, cation grooves using MCT, which made it possible to ob- the groove was longer and ended further from the CEJ, tain a two-dimensional analysis of the external and inter- resulting in a natural thinning of the palatal dentin thick- nal macromorphologies of the root complex. MCT is ness of the buccal root. Therefore, discretion should be non-destructive and a very accurate and useful tool with taken to avoid over-instrumentation, especially with long which to study external and internal tooth anatomy. Par- roots. allel findings have been previously reported using MCT to Several studies have shown that posts must be sur- study external and internal tooth morphologies (30, 31) rounded by 1 mm of sound dentin (14, 34). Other studies 146 Annali di Stomatologia 2013; IV (1): 142-148 Microcomputed tomographic analysis of the furcation grooves of maxillary first premolars measured the average groove depths and dentin thick- mesial root surface of the adolescent maxillary first bicus- nesses at different levels (4, 8, 22). Tamse et al. (4) found pid. J Periodontol 1985; 56:666-70. that the concavities reach a maximum value of 0.40 mm 8. Joseph I, Varma BBR, Bhat KM. Clinical significance of fur- at a mean distance of 1.18 mm from the furcation, 5.3 mm cation anatomy of the maxillary first premolar: a biometric study on extracted teeth. J Periodontol 1996; 67:386-9. from the apex, and a mean distance of 0.81 ± 0.24 mm 9. Gutmann JL. The dentin-root complex: anatomic and bio- li from the invagination to the canal wall. In the present logic considerations in restoring endodontically treated teeth. study, the cross-sectional area with minimum palatal J Prosthet Dent 1992; 67:458-66. na dentin thickness within the groove for each sample was 10. Kishen A. Mechanisms and risk factors for fracture predilec- located and measured. The mean ± SD thickness was tion in endodontically treated teeth. Endod Topics 2006; 0.78 ± 0.14 mm, and the mean ± SD distance was 7.1 ± 13:57-83. 1.8 mm from the CEJ and 1.3 ± 1.6 mm from the furca- 11. Testori T, Badino M, Castagnola M. Vertical root fractures in endodontically treated teeth: a clinical survey of 36 cases. io tion. Therefore, before any endodontic or restorative pro- cedures are performed, it should be noted that reducing J Endod 1993; 19:87-91. 12. Katz A, Wasenstein-Kohn S, Tamse A, Zuckerman O. Resid- the dentin width too vigorously by instrumentation with ei- ual dentin thickness in bifurcated maxillary premolars after ther hand files or rotary instruments could predispose to az root canal and dowel space preparation. J Endod 2006; vertical root fractures or perforations. 32:202-5. Based on previous discussions about the extent of post 13. Lloyd PM, Palik JF. The philosophies of dowel diameter prepa- preparation in the buccal canal of an MFP if the buccal ration: a literature review. J Prosthet Dent 1993; 69:32-6. root cannot be avoided as an anchor for the post, at 14. Caputo AA, Standlee JP. Pins and posts: why, when and n least 7 mm of gutta-percha must remain (4, 9). This rec- how. Dent Clin North Am 1976; 20:299-311. ommendation is in agreement with the findings of the 15. Assif D, Gorfil C. Biomechanical considerations in restoring en- er present study: the post must not extend more than 6.5 dodontically treated teeth. J Prosthet Dent 1994; 71:565-7. mm from the CEJ, as the groove begins with a mean of 16. Cambruzzi JV, Marshall FJ. Molar endodontic surgery. J Can Dent Assoc 1983; 49:61-6. 5.5 ± 1.05 mm from the CEJ. Even if the root is long 17. Vertucci FJ. Root canal anatomy of the human permanent nt enough (as indicated above), there is a highly significant correlation between the length of the tooth and the end of the groove: as tooth length increases, the groove length- ens and ends further from the CEJ. 18. teeth. Oral Surg Oral Med Oral Pathol 1984; 58:589-99. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgeno- graphic investigation of 7,275 root canals. Oral Surg 1972; 33:101-10. iI In conclusion, the length, depth, location, and width of the 19. Deutsch AS, Musikant BL. Morphological measurements of lingual dentin thickness of the groove vary in relation to anatomic landmarks in human maxillary and mandibular mo- tooth length, bifurcation, and CEJ. These parameters re- lar pulp chambers. J Endod 2004; 30:388-90. on quire the clinician close attention and assessment of the 20. Deutsch AS, Musikant BL, Gu S, Isidro M. Morphological measurements of the anatomic landmarks in the pulp cham- quantity of dentin removed during endodontic preparation bers of human maxillary furcated bicuspids. J Endod 2005; or post application on the buccal root of the MFPs. 31:570-3. 21. Lee MM, Rasimick BJ, Turner AM, Shah RP, Musikant BL, i Deutsch AS. Morphological measurements of anatomic iz Acknowledgment landmarks in pulp chambers of human anterior teeth. J En- dod 2007; 33:129-31. Special thanks to Engineer Abdulla Bugshan Growth Fac- 22. Lammertyn PA, Rodrigo SB, Brunotto M, Crosa M. Furca- Ed tors & Bone Regeneration Research Chair for the support tion groove of maxillary first premolar, thickness, and dentin structures. J Endod 2009; 35:814-7. and the grant of the Micro-CT Lab coded NRM 0001. 23. Guillaume B, Lacoste JP, Gaborit N et al. Microcomputed to- mography used in the analysis of the morphology of root canals in extracted wisdom teeth. Br J Oral Maxillofac Surg References 2005; 44:240-4. IC 24. Tachibana H, Matsumoto K. Applicability of X-ray comput- 1. Belliui R, Hartwell G. Radiographic evaluation of root canal erized tomography in endodontics. Endod Dent Traumatol anatomy of in vivo endodontically treated maxillary premo- 1990; 6:16-20. lars. J Endod 1985; 11:37-9. 25. Nielsen RB, Alyassin AM, Peters DD, Carnes DL, Lancaster 2. Matthews D, Tabesh M. Detection of localized tooth-related J. Microcomputed tomography: an advanced system for C factors that predispose to periodontal infections. Periodon- detailed endodontic research. J Endod 1995; 21:561-8. tol 2000-2004; 34:136-50. 26. Mannocci F, Peru M, Sherriff M, Cook R, Pitt Ford TR. The 3. Awawdeh L, Abdullah H, Al-Qudah A. Root form and canal isthmuses of the mesial root of mandibular molars: a micro- morphology of Jordanian maxillary first premolars. J Endod computed tomographic study. Int Endod J 2005; 38:558-63. © 2008; 34:956-61. 27. Peters OA, Peters CI, Schonenberger K, Barbakow F. Pro- 4. Tamse A, Katz A, Pilo R. Furcation groove of buccal root of Taper rotary root canal preparation: effects of canal anatomy maxillary first premolars:a morphometric study. J Endod on final shape analysed by micro CT. Int Endod J 2003; 2000; 26:87-90. 36:86-92. 5. Walton RE, Torabinejad M. Principles and practice of en- 28. Rhodes JS, Ford TR, Lynch JA, Liepins PJ, Curtis RV. A dodontics. Philadelphia. WB Saunders Co, 2002; 172. comparison of two nickel titanium instrumentation tech- 6. Gher M, Vernino AR. Root morphology: clinical significance niques in teeth using microcomputed tomography. Int Endod in pathogenesis and treatment of periodontal disease. J Am J 2000; 33:279-85. Dent Assoc 1980; 101:627-33. 29. Tasdemir T, Aydemir H, Inan U, Unal O. Canal preparation 7. Booker BW 3rd, Loughlin DM. A morphologic study of the with Hero 642 rotary Ni-Ti instruments compared with stain- Annali di Stomatologia 2013; IV (1): 142-148 147 S. M. Al-Shahrani et al. less steel hand K-file assessed using computed tomography. 32. Von Stechow D, Balto K, Stashenko P, Muller R. Three-di- Int Endod J 2005; 38:402-8. mensional quantitation of periradicular bone destruction by 30. Plotino G, Grande NM, Pecci R, Bedini R, Pameijer CH, microcomputed tomography. J Endod 2003; 29:252-6. Somma F. Three dimensional imaging using microcom- 33. Oi T, Saka H, Ide Y. Three-dimensional observation of pulp puted tomography for studying tooth macromorphology. J cavities in the maxillary first premolar tooth using micro-CT. Am Dent Assoc 2006; 137:1555-61. Int Endod J 2004; 37:46-51. li 31. Bjorndal L, Carlsen O, Thuesen G, Darvann T, Kreiborg S. 34. Ouzounian ZS, Schilder H. Remaining dentin thickness af- External and internal macromorphology in 3D-reconstructed ter endodontic cleaning and shaping before space prepara- na maxillary molars using computerized X-ray microtomogra- tion. Oral Health 1991; 81:13-5. phy. Int Endod J 1999; 32:3-9. io n az er nt iI i on iz Ed IC C © 148 Annali di Stomatologia 2013; IV (1): 142-148 

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Original article Influence of file motion on cyclic fatigue of new nickel titanium instruments li na Alessio Giansiracusa Rubini, DDS1 Introduction Gianpaolo Sannino, MD1 io Giancarlo Pongione, DDS1 The introduction of Nickel-Titanium (NiTi) alloy in en- Luca Testarelli, DDS, PhD1 dodontics was a significant improvement, allowing excel- Dina Al Sudani, DDS2 lent result in terms of cleaning and shaping of root canals, while reducing operative time and minimizing iatrogenic az Jeeraphat Jantarat, DDS3 Massimo De Luca, MD, PhD1 errors. Thanks to the superior mechanical properties of Gianluca Gambarini, MD, PhD1 the NiTi alloy (1) it was possible to use endodontic instru- ments in continuous rotation, increasing the effective- ness and rapidity of the cutting. However, several studies n 1 Department of Oral and Maxillo Facial Sciences, reported an increased tendency to intracanal separation “Sapienza” University of Rome, Italy of NiTi Rotary instruments when compared to stainless er 2 King Saud University, Riyadh City, Saudi Arabia steel manual instruments (2-4). 3 Mahidol University, Bangkok, Thailand This increased risk of intracanal separation is due to the continuous rotation movement inside a curved canal, Corresponding author: Alessio Giansiracusa Rubini, DDS nt Department of Oral and Maxillo Facial Sciences, which submits NiTi instruments to greater flexural stress and consequently to increased metal fatigue, when com- pared to stainless steel file used manually (5). Despite the improvements in instrument design over the iI “Sapienza” University of Rome last 20 years, intracanal separation of NiTi rotary instru- Via Giuseppe Rosso, 5 ments remains a quite common (from 2% to 9% of cases) 00136 Rome, Italy procedural error, which can dramatically affect the out- on Phone: +39 06 3231452 come of the endodontic treatment (6). E-mail: alessiogiansiracusa@gmail.com Instrument fracture can occur because due to excessive torsion or fatigue, or, more often, due to a combination of Summary the two factors. Torsional fracture occurs when the tor- i Aim. The aim of the present study was to compare the re- sional torque applied to the instrument exceed torsional iz sistance to cyclic fatigue of Hyflex® (Coltene-Whale- elastic limit of instrument itself. Clinically it could be hap- dent, Allstatten, Switzerland) size 40 taper.04 nickel tita- pen when an instrument is locked into the canal while the nium instruments used in continuous rotation versus the motor continues to apply a moment of force. Ed use with a reciprocating motion. The null hypothesis Fatigue fracture occurs when instrument undergoes to a was that different file motions had no influence on the cyclic stress. A material submitted to cycle of stress lower lifetime of instruments subjected to a cyclic fatigue test. than fracture force limit get a fracture without any previ- Methodology. 24 Hyflex® size 40 taper.04 nickel titanium ous sign of plastic deformation. instruments were randomly divided in two groups (n=12 Intracanal failure is not clinically predictable; because it is each), and submitted to a cyclic fatigue test. The first not possible to evaluate how much fatigue an instrument IC group (CR group) were used with a continuous rotation, accumulates during its work inside the canal. Research while the second one (RCP group) with a reciprocating has shown that intracanal cyclic fatigue which an instru- motion. The cyclic fatigue tests were performed by us- ment accumulates during canal shaping of curved canals ing a stainless steel block containing an artificial canal depends on anatomy (7), rotation speed (8). Instrument C shaped with a 135° angle. All instruments were rotated or design and manufacturing (9, 10). reciprocated until fracture occurred. The time to fracture Recently, a new manufacturing technique has been devel- was recorded visually with a 1/100 second chronometer. oped and commercialized: the Hyflex® nickel titanium in- Data were recorded and statistically analysed. struments (Coltene-Whaledent, Allstatten, Switzerland). © Results. Results indicated that instruments used with a These NiTi files have been manufactured utilizing a reciprocating motion showed a significant increase in the meantime to failure when compared to those used in process that controls the material’s memory, making the continuous rotation. files extremely flexible, while significantly reducing the Conclusions. The null hypothesis was rejected. Results of restoring force. This gives the file the ability to precisely the present study showed that reciprocating motion ex- follow and respect the original root canals trajectories, re- tended resistance to cyclic fatigue of the tested nickel tita- ducing the risk of ledging and transportation or perfora- nium instruments, when compared to continuous rotation. tion. Moreover the thermally treated alloy (CM wire tech- nology) used for the manufacturing of Hyflex instruments Key words: cyclic fatigue, nickel titanium, instruments. has been shown to improve cyclic fatigue resistance (11). Annali di Stomatologia 2013; IV (1): 149-151 149 A. Giansiracusa Rubini et al. In order to minimize these risks, Yared proposed the use of nickel titanium instruments of increased tapers in a re- ciprocating motion (12). In the proposed technique, canal is negotiated with a stainless steel size 08 hand file and than an F2ProTaper NiTi rotary instrument is used for the li canal preparation in a clockwise (CW) and counter clock wise (CCW) movement. The CW and the CCW rotations na used by Yared were four-tenth and two-tenth of a circle re- spectively and the rotational speed was 400 rpm (12). The concept of using a single NiTi instrument to prepare the entire root canal is interesting, and it is possible due to the io fact that reciprocating motion reduced instrumentation stress. However, such a drastic change in the movement kinematics needs to be assessed in terms of in vitro test- ing of facture resistance. Recent literature seems to show az that reciprocating movements can provide mechanical ad- Figure 1. The testing apparatus. vantages compared to continuous rotation (13, 14). These preliminary positive results need further studies, also be- cause many different reciprocating movement and many compared to continuous rotation. In continuous rotation n different instrument designs can be used in clinical prac- (CR group) instruments mean time to failure was 8,75 sec tice, thus affecting the overall results. (SD 1,34) while for the reciprocating motion (RCP group) er The aim of the present study is to valuate if reciprocating mean time to failure was 14,55 sec (SD 1,56). motion can increase Hyflex instrument lifetime in a cyclic fatigue test compared to continuous rotation. The null hy- related to the different operative mode. nt pothesis is that there is no difference in fatigue resistance Discussion The results of the present study showed that reciprocat- ing motion could extend cyclic fatigue life of Hyflex NiTi in- iI Materials and methods struments compared with continuous rotation. The null hy- pothesis was rejected, since the different movements 24 Hyflex® size 40 taper.04 nickel titanium instruments affected the lifespan of the NiTi instruments. These results on were randomly divided in two groups (n=12 each). All in- are in accordance with another recent research article, struments had been previously inspected by using an op- which demonstrated that movement kinematics, had a tical stereomicroscope with 20 magnification for morpho- significant influence on cyclic fatigue life (13). logic analysis and for any signs of visible deformation. If Fatigue failure usually occurs by the formation of micro defective instruments were found, they were discarded. i crack at the surface of the file that starts from surface ir- iz All instruments were then submitted to a cyclic fatigue regularities. During each loading cycle micro cracks de- test. The first group (CR group) were used with a contin- velop, getting deeper in material, until complete separa- uous rotation, while the second one (RCP group) with a tion of the file (15). All endodontic file shows some Ed reciprocating motion. A specific endodontic motor (Acteon irregularities on the surface, and inner defect, as a con- dual endoSatelec, France), that allows both movements, sequence of the manufacturing process, and distribution was used. The selected reciprocation motion was the of these defects influence fracture strength of the en- following one: 150 degree of counter clock wise (CCW) ro- dodontic instruments (16, 17). Consequently instrument tation followed by a 30 degree of clock wise (CW) rotation. fatigue life can be regarded as a function of the load, ir- In both movements speed was set at 300 rpm. regularities and size of crack on the surface (15). IC The cyclic fatigue tests were performed by using a stain- Endodontic rotary file are subjected to a bending stress less steel block containing an artificial canal shaped to during their clinical use in a curved canal. A bending form a 135° angle (Fig. 1). Instruments were placed into force applied to an instrument result in a tensile stress, the artificial canal at the same depth, and rotated or re- that tends to open micro cracks, on the convex side, and C ciprocated until fracture occurred. The time to fracture was in a compression stress, that tend to close micro cracks, recorded visually with a 1/100 second chronometer. The on the concave side. When an instrument is in continuous same operator performed all tests. rotation in a curve, tensile stresses follow a sinusoid Means and standard deviations of time to fracture were trend. In fact there is an alternation of tensile and com- © calculated, and statistical analysis were performed by pression stresses when a certain portion of the instrument using univariate analysis or post-hoc analysis in soft- translate from convex side to concave side. ware (SPSS for Windows 11.0) and the level of signifi- Each 360° rotation identify one loading cycle in which cance was set to p<0.05. each point of instrument surface go through maximum tensile stress and maximum compressive stress. Results In other words during one cycle the crack open and close once. On the opposite, the Reciprocating motion used in Results indicated that reciprocating motion showed a the present study consisted in 150° of rotation CCW and significant increase (p<0,05) in the time to failure when 30° of CW rotation. 150 Annali di Stomatologia 2013; IV (1): 149-151 Influence of file motion on cyclic fatigue of new nickel titanium instruments Therefore, the instrument approximately turned 5/12 of the struments: a large cohort clinical evaluation. J Endod 2006; cycle (150 degrees) and returned 1/12 of the cycle (30 de- 32:1139-41. grees), which meant that only after three complete recip- 3. Parashos P, Messer HH. Rotary NiTi instrument fracture and rocating movements the instrument completed one entire its consequences. J Endod 2006; 32:1031-43. 4. Iqbal MK, Kohli MR, Kim JS. A retrospective clinical study rotation. Therefore, in the same amount of time (overall ro- of incidence of root canal instrument separation in an en- li tational speed, which is calculated by number of rotations dodontics graduate program: a PennEndo database study. per minute) the risk of opening and closing cracks is lower, J Endod 2006; 32:1048-52. na when compared to the continuous rotation. 5. Peters OA. Accessing root canal systems: requirements Therefore the improvement in cyclic fatigue resistance and techniques. PractProcedAesthet Dent 2006 Jun; showed by the reciprocating movement should be re- 18(5):277-9. lated to two main factors. First, the rotation cycles are 6. Gambarini G. Cyclic fatigue of nickel-titanium rotary instru- ments after clinical use with low-and high-torque endodon- io slightly reduced and consequently the overall number of rotation is reduced. Secondly, during reciprocation, ten- tic motors. J Endod 2001; 27:772-4. 7. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing sile stress in a point of the material surface have a sinu- of nickel-titanium endodontic instruments. J Endod 1997 soid trend, being interrupted by the counter rotation, in az Feb; 23(2):77-85. which tensile stress invert his trend. In other words there 8. Zelada G, Varela P, Martın B, Bahı´llo JG, Magan F, Ahn S. is a different distribution of the same tensile values dur- The effect of rotational speed and the curvature of root ing time, and this can reduce the overall accumulation of canals on the breakage of rotary endodontic instruments. fatigue. Journal of Endodontics 2002; 28:540–2. n There are no previous reports on the effect of reciprocat- 9. Xu X, Zheng Y. Comparative study of torsional and bending ing motion on the cyclic fatigue life of Hyflex instruments. properties for six models of nickel-titanium root canal instru- er According to the manufacture (18) the innovative manu- ments with different cross-sections. J of facturing technique (CM wire technology) used in the Endod 2006; 32:372-5. 10. Gambarini G, Pompa G, Di Carlo S, De Luca M, Testarelli production of the Hyflex® instruments allowed a significant L. An initial investigation on torsional properties of nickel-ti- nt improvement versus traditional NiTi rotary instruments. It is interesting to note that, besides this increase in fatigue resistance related to the innovative CM wire technology, there was still room for improvement related to the move- 11. tanium instruments produced with a new manufacturing method. Aust Endod J 2009; 35(2):70-2. Grande NM, Plotino G, Vincenzi V, Testarelli L, Gambarini G. Valutazione sperimentale di strumenti endodontici in iI ment kinematics. Further studies are needed to confirm NiTi a memoria di forma “self-restoring”. G Ital Endod 2011; these experimental results and to evaluate their clinical 25/1:XII-XIX. relevance. 12. Yared G. Canal preparation using only one Ni-Ti rotary in- on strument: preliminary observations. International Endodon- tic Journal 2008; 41:339-44. 13. De-Deus G, Moreira EJL, Lopes HP, Elias CN. Extended Conclusions cyclic fatigue life of F2 Pro Taper instruments used in recip- rocating movement. Int Endod J. 2010 Dec; 43(12):1063-8. i We may conclude that reciprocating motion extended re- 14. You SY, Bae KS, Baek SH, Kum KY, Shon WJ, Lee W. Lifes- iz sistance to cyclic fatigue of the tested nickel titanium in- pan of One Nickel-Titanium Rotary File with Reciprocating struments, when compared to continuous rotation. The Motion in Curved Root Canals. J Endod. 2010 Dec; null hypothesis (different file motions had no influence on 36(12):1991-4. Ed the lifetime of instruments subjected to a cyclic fatigue 15. Christ HJ. Fundamental mechanisms of fatigue and fracture. test) was rejected. Student Health Technology Information 2008; 133:56-67. 16. Anderson ME, Price JW, Parashos P. Fracture resistance of electropolished rotary nickel-titanium endodontic instru- ments. J of Endod 2007; 33:1212-26. References 17. Wei X, Ling J, Jiang J, Huang X, Liu L. Modes of failure of IC ProTaper nickel-titanium rotary instruments after clinical 1. Walia H, Branteley WA, Gerstein H. An Initial Investigation use. Journal of Endodontics 2007; 33:276-9. of the Bending and Torsional Properties of Nitinol Root 18. Testarelli L, Plotino G, Al-Sudani D, Vincenzi V, Giansiracusa Canal Files. J Endod 1988; 14:346-351. A, Grande NM, Gambarini G. Bending properties of 2. Wolcott S, Wolcott J, Ishley D, Kennedy W, Johnson S, Min- a new nickel-titanium alloy with a lower percent by weight C nich S, Meyers J. Separation incidence of protaper rotary in- of nickel. J Endod 2011 Sep; 37 (9): 1293-5. HYFLEX. © Annali di Stomatologia 2013; IV (1): 149-151 151 

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Original article The influence of three different instrumentation techniques on the incidence of postoperative pain after endodontic treatment li na Gianluca Gambarini, MD, PhD1 structions and all canals were shaped, cleaned and obtu- Luca Testarelli, MD, PhD1 rated in a single-visit by the same operator. The assess- ment of postoperative pain was carried out at 3 days by io Massimo De Luca, MD, PhD1 using a visual analogue scale. VAS pain scores were com- Valerio Milana, MD, PhD1 pared using one-way ANOVA post hoc Tukey test. A value Gianluca Plotino, MD1 of p < 0.05 was required for statistical significance. az Nicola Maria Grande, MD1 Results. Results for VAS pain scores showed a statisti- Alessio Giansiracusa Rubini, DDS1 cally significant difference was found between the Dina Al Sudani, DDS2 WaveOne (p=0,021) technique and the other two tech- Gianpaolo Sannino, MD1 niques. No statistical significant differences were found n between TF and TF Adaptive (p= 0,087). 1 Department of Oral and MaxilloFacial Sciences, When evaluating patient experiencing sever pain the in- “Sapienza” University of Rome, Italy er cidence of symptoms was significantly higher with the 2 King Saud University, Riyadh City, Saudi Arabia WaveOne technique. Conclusions. Since the incidence of preoperative pain, the type of tooth and the pulp and periodontal pathology Corresponding author: Valerio Milana, MD, PhD nt Department of Oral and MaxilloFacial Sciences were quite similar between the three tested groups, and all the other variables (operator, irrigation, obturation) were identical, we may conclude that the difference in postoperative pain can be mainly related to the different iI “Sapienza” University of Rome Via Caserta, 6 instrumentation techniques. 00161 Rome, Italy Key words: root canal treatment, pain, endodontic instru- on Phone: +39 3283129607 ments. E-mail: valeriomilana@gmail.com Summary Introduction i Aims. Apical extrusion of infected debris to the peri- iz radicular tissues is one of the principal causes of post- The completion of endodontic therapy can be done in a operative pain and discomfort. Recent researches have single appointment or with multiple visits. Clinical reports shown that reciprocating instrumentation techniques have shown that patients generally tolerate and prefer sin- Ed seem to significantly increase the amount of debris ex- gle-visit endodontic therapy (1-2). Therefore, single-visit truded beyond the apex and, consequently, the risk of root canal treatment has become a common practice postoperative pain. The goal of the present study was to also in non-vital cases, and offers several advantages, in- evaluate and compare postoperative pain using three dif- cluding a decreased number of operative procedures (3), ferent nickel-titanium instrumentation techniques: a ro- and no risk of inter-appointment leakage through tempo- tary crown-down technique using TF instruments (Sybro- rary restorations (1). In addition, single-visit root canal IC nEndo, Orange, Ca), a reciprocating single-file technique therapy is less time consuming and more economical; as using WaveOne instruments (Maillefer DEntsply, Bail- a consequence, innovative manufacturing processes to lagues, CH), and a novel instrumentation technique (TF produce better istruments (4-7), and new instrumentation Adaptive, SybronEndo, Orange, Ca), using a unique, techniques have been recently commercialized to im- C proprietary movement, combining reciprocation and prove simplicity and safety of treatment by using recipro- continuous rotation. cation motion instead of continuous rotation and by reduc- Methods. Ninety patients requiring endodontic treatment ing the number of nickel titanium (NiTi) instruments and on permanent premolar and molar teeth with non vital consequently instrumentation time (8-10). © pulps preoperatively were included in the study. The pa- More precisely, a few years ago Dentsply Maillefer (Bail- tients were assigned into three groups of 30 patients each, trying to make the groups very similar, concerning lagues, Switzerland) and Dentsply VDW (Munchen, Ger- the number of root canals, presence of initial pain and pe- many) have developed two different nickel titanium instru- riapical lesions. The teeth in group 1 (n = 30) were instru- ments of greater tapers (Waveone® and Reciproc®), mented with a crown-down technique using TF instru- which are designed to be used with an innovative, propri- ments, whilst those in group 2 (n = 30) were instrumented etary reciprocating movement, and allow root canals to be with a single-file technique using Waveone 08 25. The third prepared with one single instrument: in the majority of group (n = 30) used the 3-file Tf Adaprtive sequence. All cases a taper.08 size 25 instrumentis selected. The two techniques were performed following manufacturers’ in- above-mentioned instruments are slightly different in de- 152 Annali di Stomatologia 2013; IV (1): 152-155 The influence of three different instrumentation techniques on the incidence of postoperative pain after endodontic treatment sign and motion, but performance is quite similar (9-10). ously taken antibiotics or analgesics were excluded. Age, More recently, a new instrumentation technique (TF Adap- gender, tooth location, pulp vitality and radiographically tive®) has been developed by SybronEndo (Orange, Ca), visible lesions were recorded. An electric pulp-testing de- aiming at combining the advantages of both continuous vice (Elements pulp vitality tester, Sybron endo, Orange, rotation and reciprocation. More precisely it is a patented, Ca) was used to assess pulp vitality. li undisclosed, unique motion which automatically adapts to Before initiating treatment, each tooth was examined ac- instrumentation stress. When the TF Adaptive instrument cording to clinical complaints, including the presence or na is not (or very lightly) stressed the movement can be de- absence of pain. Overall, 41 patients had symptomatic scribed as a continuous rotation, allowing better cutting ef- (preoperative pain) and 49 had asymptomatic teeth, re- ficiency and removal of debris, since cross-sectional and spectively. Of the 90 teeth previously diagnosed as non- flute design are meant to perform at their best in a clock- vital, 76 showed periapical lesions. io wise motion (11-12). On the contrary while negotiating the A single clinician evaluated all patients, using radiographic canal, due to increased instrumentation stress and metal and clinical findings, and the the same clinician was as- fatigue, the motion of the TF Adaptive instrument changes signed for treatment of all cases. This procedure was per- into a reciprocation mode, with specifically designed CW formed to eliminate or minimize interpersonal variability in az and CCW angles. Moreover these angles are not con- the treatment between clinicians. stant, but vary depending on the anatomical complexities The patients were assigned into three groups of 30 pa- and the intracanal stress.This “adaptive” motion is there- tients each, trying to make the groups very similar, con- fore meant to reduce the risk intracanal failure, without af- cerning the number of root canals, presence of initial n fecting performance, due to the fact that the best move- pain and periapical lesions. After isolation and access, the ment for each different clinical situation is automatically canals of all teeth were prepared using two different in- er selected by the Adaptive motor. strumentation techniques, irrigated with 5% NaOCl and The TF Adaptive technique is basically a 3-file technique, 17% EDTA, and obturated with gutta percha and a zinc- designed for all canals, with differences between small, oxide eugenol sealer using warm vertical compaction. The nt difficult canals andlarge, easy ones, allowing in both cases an adaquate taper and increased apical prepara- tion. The number of instruments within the sequence can also vary and adapt to canal anatomy, being the last in- teeth in group 1 (n = 30) were instrumented with a crown- down technique using TF instruments, whilst those in group 2 (n = 30) were instrumented with a single-file technique, using WaveOne 08 25. The teeth in group 3 iI strument of the sequence used only when a greater api- were instrumented using a TF Adaptive technique (n = cal enlargement is needed due to larger original canal di- 30), using both sequences for small or large canals de- mensions and/or enhanced final irrigation techniques. pending on the initial tooth anatomy. All the three instru- on It is well known that a small, inadvertent extrusion of de- mentation technique strictly followed manufacturers’ in- bris and irrigants into periapical tissues is a frequent structions. All canals were shaped, cleaned and obturated complication during the cleaning and shaping proce- in a single-visit. dures, both with manual stainless steel and nickel-titanium Although no systemic medication was prescribed, the pa- i rotary instrumentation techniques (13-14). However, re- tients were instructed to take mild analgesics (400 mg of iz cent studies have shown that reciprocating instrumenta- ibuprofen), if they experienced pain. The assessment of post tion techniques seem to significantly increase the amount operative pain was carried out at 3 days after initial appoint- of debris extruded beyond the apex and, consequently, ment by one independent evaluator without knowledge of Ed the risk of postoperative pain (15). A previous clinical visit group under examination. The presence or absence of study comparing Reciproc and NiTi rotary instruments has pain, or the appropriate degree of pain was recorded as also confirmed these findings (16). Based on these prem- none, slight, moderate, or severe, by using a visual ana- ises, the goal of the present study was to evaluate and logue scale (VAS), validated in previous studies (3): compare the incidence and intensivity of postoperative - No pain: the treated tooth felt normal. Patients don’t pain using three different nickel-titanium instrumentation have any pain. IC techniques: a rotary crown-down technique using Twisted - Mild pain: recognizable, but not discomforting, pain, Files (TF) instruments (SybronEndo, Orange, Ca), a re- which required no analgesics. ciprocating single-file technique using WaveOne instru- - Moderate pain: discomforting, but bearable, pain ments (Maillefer Dentsply, Baillagues, CH) and a novel in- (analgesics, if used, were effective in relieving the C strumentation technique (TF Adaptive, SybronEndo, pain). Orange, Ca.), using a unique, proprietary movement, - Severe pain: difficult to bear (analgesics had little or combining reciprocation and continuos rotation. no effect in relieving the pain). VAS pain scores were compared using one-way ANOVA © post hoc Tukey test. A value of p < 0.05 was required for Materials and methods statistical significance. Ninety patients requiring endodontic treatment on perma- nent premolar and molar teeth with non vital pulps preop- Results eratively were included in the study. These patients rangedin age from 19 to 73 years (average 46,5 years), Results are shown in (Table 1). For VAS pain scores a sta- and all were in good health, as determined from a written tistically significant difference was found between the health history and oral interview. Patients who had previ- Wave One (p=0,021) technique and the other two tech- Annali di Stomatologia 2013; IV (1): 152-155 153 V. Milana et al. Table 1. Overall incidence of post operative pain with TF, Reciproc and TF Adaptive instrumentation techniques. Technique No pain Mild Moderate Severe TF15 ( 50%) 7 (23,3%) 6 (20%) 2 (6,6%) – WaveOne 9 (30%) 5 ( 16,6%) 8 ( 26,6%) 8 (26,6%) li TF Adaptive 14 (46,6%) 8 ( 26,6%) 6 (20%) 2 (6,6%) na niques. No statistical significant differences were found bris but push them apically. Reciproc and WaveOne mo- between TF and TF Adaptive (p= 0,087). tion is very similar (even if not precisely disclosed by When comparing patients who developed no pain, TF and manufacturers), and this fact could also explain the higher io TF Adaptive instrumentation technique showed signifi- incidence and intensitivity of postoperative pain that was cantly better results. When evaluating patient experienc- found in the present study in the WaveOne group. ing sever pain the incidence of symptoms was signifi- Moreover, both WaveOne and Reciproc techniques use az cantly higher with the Wave Onesingle-file technique. a quite rigid, big single-file of increased taper (usually 08 Overall, severe pain occurred in 13,3% patients. More taper, size 25), which directly reach the apex. In many precisely, it occuredin 30% of patients treated with cases, in order to reach the apical working length, recip- WaveOne and in 6,6% of patients treated with TF and TF rocating instruments are used with force directed api- n Adaptive. cally, which makes an effective piston to propel debris from a patent apical foramen. Since instruments are used er without any preliminar coronal enlargement. This results Discussion in agreater engagement of flutes and, consequently, more torque or applied pressure are needed. More over cutting nt Root canal preparation procedures are not easy to per- form, due to anatomical complexities and limitations of the endodontic instruments, which often result in a high risk of intracanal failure and other iatrogenic errors (17-18). In ability of a reciprocating file is smaller when compared to a continuous rotation, and also debris removal is smaller, thus increasing the frictional stress and torque demand, due to entrapment of debris within the flutes (19). iI most cases dentine chips, pulp tissue fragments, necrotic The TF Adaptive technique has been proposed in order tissue, microorganisms and intracanal irrigants may be to maximize the advantages of reciprocation, while min- extruded from the apical foramen during the canal instru- imizing disadvantages, by using a unique, patented mo- on mentation. This is of concern since material extruded tion and a 3-file technique. The aim of a sequence is to from the apical foramen may be related to inflamation of reduce frictional stress and torque demand, while the periapical tissue, postoperative pain and or to a flare-up patented adaptive motor selects automatically the best (13-14). While there are statistical predictors of postoper- angles for best performance and safety. In the present i ative pain (nonvital teeth, patients already in pain, asymp- study TF Adaptive technique showed very similar results iz tomatic teeth with lesions, etc.), its occurrence is not in- to the TF instrumentation technique which utilize contin- evitable, and to a large extent, can be avoided, by using uous rotation. No statistical significant differences were proper instrumentation and irrigation techniques. Severe found between the two techniques for both incidence Ed postoperative pain should be relatively uncommon. In and intensitivity of postoperative pain. On the contrary large measure, its prevention is a function of providing ex- both techniques were found to produce less post-opera- cellent treatment, more precisely by creating a well- tive pain when compared to the Reciproc technique. cleaned and shaped canal andby minimizing extrusion of Since the incidence of preoperative pain, the type of canal contents during the process. tooth and the pulp and periodontal pathology were quite It is quite a common experience during endodontic instru- similar between thetested groups, and all the other vari- IC mentation courses on extracted teeth, that partecipants vi- ables (operator, irrigation, obturation) were identical, this sualize the creation of the “endodontic worm”, a tubular difference was mainly related to the different instrumen- mass of canal debris produced primarily by debris pro- tation technique. These findings maybe related to two dif- pelled through the apical foramen by forceful instrumen- ferent factors: the movement and the sequence. C tation, improper irrigation, and a lack of recapitulation. Despite the fact that the angles are not closed by manu- This worm is more likely to occur when reciprocation mo- facturers, visual inspection and/or video recordings shows tion is used. In clinical practice this worm of debris in- that the TF Adaptive motion is a reciprocating motion cludes bacteria, dentin chips, irrigants, and inflamed or with cutting angles (CW angles) much greater than © dead pulp, that when pushed into the periapical tissues WaveOne movements. As a consequence the TF Adap- may elicitate postoperative pain. tive instrument is working more time with a CW angle, In a previous study (16) a reciprocating single-file tech- which allows better cutting efficiency and removal of de- nique (Reciproc) was found to produce a more significant bris (and less tendency to push debris apically), because inflamatory response and pain when compared to a rotary the flutes are designed to remove debris in a CW rotation. nickel-titanium crown down instrumentation technique In such case TF Adaptive is taking advantage of the use (TF). Since reciprocation movement is formed by a wider of a motion that is more similar to continuous rotationfor cutting angle and a smaller releasing angle, while rotat- optimal debris removal. There are obviously some ing in the releasing angle, the flutes will not remove de- changes in the angles depending on canal anatomy (the 154 Annali di Stomatologia 2013; IV (1): 152-155 The influence of three different instrumentation techniques on the incidence of postoperative pain after endodontic treatment more complex, the smaller the CW angle), but they do not 6. Plotino G, Grande NM, Mazza C, Petrovic R, Testarelli L, seem to significantly influence the overall result. On the Gambarini G. Influence of size and taper of artificial canals contrary, these changes influence resistance to metal fa- on the trajectory of NiTi rotary instruments in cyclic fatigue tigue, since TF instruments used with the Adaptive motion studies. Oral Surg 2010; 109:60-66. 7. Testarelli L, Plotino G, Al-Sudani D, Vincenzi V, Giansiracusa were found to have superior resistance to cyclic fatigue A, Grande NM, Gambarini G. Bending properties of a new li when compared to the same TF instruments used in con- nickel-titanium alloy with a lower percent by weight of nickel. tinuous rotation. J Endod 2011; 375 na Moreover the use of a sequence and the use of more flex- 8. Kim HC, Kwak SW, Cheung GS, Ko DH, Chung SM, Lee W. ible NiTi instruments can be also a important factors in de- Cyclic fatigue and torsional resistance of two new nickel-ti- termining a lower incidence and intensivity of postopera- tanium instruments used in reciprocation motion: Reciproc tive pain, by reducing the amount of apical transportation versus WaveOne. J Endod 2012; 38:541-4. 9. Pedullà E, Grande NM, Plotino G, Palermo F, Gambarini G, io and by avoiding to push debris by forcing instruments api- cally. TF instruments were found to be the most flexible Rapisarda E. Cyclic fatigue resistance of two reciprocating nickel-titanium instruments after immersion in sodium Niti instruments, being significantly more flexible that Pro- hypochlorite. Int Endod J 2012; 3 [Epub ahead of print] taper and M2, which are instruments with design and az 10. Plotino G, Grande NM, Testarelli L, Gambarini G. Cyclic fa- mass very similar to WaveOne and Reciproc (20-21). tigue of Reciproc and WaveOne reciprocating instruments. In the most complex cases, the initial use of a small NiTi Int Endod J 2012; 45:614-618. instrument (the Tf Adative sequence uses a.04 20 instru- 11. Gambarini G, Gergi R, Naaman A, Osta N, Al Sudani D. ment, which can be considered as a reciprocating Cyclic fatigue analysis of twisted file rotary NiTi instruments n pathfinder) could be very useful. It has been shown with used in reciprocating motion. Int Endod J 2012; 45:802-806. Reciproc and WaveOne instrumentation techniques that 12. Gambarini G, Rubini AG, Al Sudani D, Gergi R, Culla A, De er the use of a small Niti rotary pathfinder is very helpful in Angelis F, Di Carlo S, Pompa G, Osta N, Testarelli L. Influ- reducing iatrogenic errors, such as extrusion of debris and ence of Different Angles of Reciprocation on the Cyclic Fa- tigue of Nickel-Titanium Endodontic Instruments. J Endod apical transportation (22). 2102; 38:1408-11. nt Hence we may conclude that the new TF Adaptive tech- nique is a unique reciprocating technique that is able to minimize the risk of pushing debris apically and conse- quently higher postoperative pain, a risk which is always 13. Oginni A, Udoye C. Endodontic flare-ups: comparison of in- cidence between single and multiple visit procedures in pa- tients attending a Nigerian teaching hospital. BMC Oral Health 2004; 4:4-6. iI present in a reciprocating morion (to a less or higher ex- 14. Siqueira JF, Jr Rocas IN, Favieri A, Machado AG, Gahyva tent), due to the fact that in one sense of rotation the flutes SM, Oliveira JC, Abad EC. Incidence of postoperative pain remove debris, while in the opposite sense the debris are after intracanal procedures based on an antimicrobial strat- on pushed apically. egy. J Endod 2002; 28:457-460. 15. Bürklein S, Schäfer E. Apically extruded debris with recip- rocating single-file and full-sequence rotary instrumentation systems. J Endod 2012; 38:850-2. Acknowledgments 16. Gambarini G, Sudani DAL, Di Carlo S, Pompa G, Pacifici A, i Pacifici L, Testarelli L. Incidence and intensivity of postop- iz Authors thank SybronEndo for supporting the study by erative pain and periapical inflammation after endodontic providing the Adaptive TF instruments and motor. treatment with two different instrumentation techniques. Eu- rop J Inflam 2102; 10:99-103. Ed 17. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini G. Measurement of the trajectory of different NiTi rotary in- References struments in an artificial canal specifically designed for cyclic fatigue tests. Oral Surg 2009; 108:152-6. 1. Sathorn C, Parashos P, Messer HH. Effectiveness of single- 18. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini versus multiple-visit endodontic treatment of teeth with api- G. Review of cyclic fatigue testing of nickel-titanium rotary cal periodontitis: a systematic review and meta-analysis. Int IC instruments J Endod 2009; 35:1469-76. Endod J 2005; 38:347-355. 19. De-Deus G, Barino B, Zamolyi RQ, Souza E, Fonseca A Jr, 2. Inamoto K, Kojima K, Nagamatsu K, Hamaguchi A, Nakata Fidel S, Fidel RA. Suboptimal debridement quality pro- K, Nakamura H. A survey of the incidence of single-visit en- duced by the single-file F2 ProTaper technique in oval- dodontics. J Endod 2002; 28:371-374. shaped canals. J Endod 2010; 36:1897-900. C 3. Lohbauer U, Gambarini G, Ebert J, Dasch W, Petschelt A. 20. Gambarini G, Pongione G, Rizzo F, Testarelli L, Cavalleri G, Calcium release and pH-characteristics of calcium hydrox- Gerosa R. Bending properties of nickel-titanium instru- ide plus points. Int Endod J 2005; 38:683-689. ments: a comparative study. Min Stomat 2008; 57:393-398. 4. Plotino G, Grande NM, Melo MC, Bahia MG, Testarelli L, 21. Gambarini G, Gerosa R, De Luca M, Garala M, Testarelli L. © Gambarini G. Cyclic fatigue of NiTi rotary instruments in a Mechanical properties of a new and improved nickel-titanium simulated apical abrupt curvature. Int Endod J 2010; 43:226- alloy for endodontic use: anevaluation of file flexibility. Oral 230. Surg 2008; 105:798-800. 5. Al-Sudani D, Grande NM, Plotino G, Pompa G, Di Carlo S, 22. Berutti E, Paolino DS, Chiandussi G, Alovisi M, Cantatore Testarelli L, Gambarini G. Cyclic fatigue of nickel-titanium ro- G, Castellucci A, Pasqualini D. Root canal anatomy preser- tary instruments in a double (S-shaped) simulated curvature. vation of WaveOne reciprocating files with or without glide J Endod 2012; 38:987-989. path. J Endod 2012; 38:101-4. Annali di Stomatologia 2013; IV (1): 152-155 155 

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Original article Epidemiological analysis on 2375 patients with TMJ disorders: basic statistical aspects li na Carlo Di Paolo, MD1 not able to reach the pain threshold. To support this hy- G. Damiana Costanzo, MD2 pothesis is the data founded in this report that showed how many patients suffered, at the same time, by mus- io Fabrizio Panti, MD1 Alessandro Rampello, MD1 cle and spinal pain associated to headache, pain that Giovanni Falisi, MD1 occur with high frequency from the same side. The Andrea Pilloni, MD1 presence of these painful conditions tends to underes- az Piero Cascone, MD3 timate the dysfunctional problems even if they occur Giorgio Iannetti, MD3 with greater clinical prevalence. Further research should be carried out to clarify these controversial is- sues. n 1 Department of Oral and Maxillofacial Sciences, Key words: temporo-mandibular disorders, statistical “Sapienza” University of Rome, Italy er analysis, epidemiology. Clinical Gnathology Unit 2 Department of Economic, Statistical and Financial Sciences, University of Calabria, Italy Introduction 3 “Sapienza” University of Rome, Italy Maxillofacial Surgery Unit nt Department of Oral and Maxillofacial Sciences, The Temporo-Mandibular Disorders (TMD) are a set of dysfunctional patterns concerning the temporo-mandibu- iI lar joints (TMJ) and the masticatory muscles with frequent Corresponding author: involvement of other structures of various body districts Fabrizio Panti, MD with the result of making complicated the classification on Department of Oral and Maxillofacial Sciences, and the diagnostic processes (1-4). “Sapienza” University of Rome, This complexity has led, in recent years, to consider the Clinical Gnathology Unit origin of the TMD as multifactorial both for the undoubted Viale Regina Elena, 287/A frequent association of several factors in causing the dis- i 00161 Roma, Italy ease then for the current inability of the researchers to iz Phone: +39 3358372914 recognize the real factors causing the dysfunction (5- E-mail: fabrizio.panti@fastwebnet.it 10). In this context it might be useful to have clinical data emerging from epidemiological studies of large numbers Ed of patients to better understand the various and complex Summary symptomatology and to try to framing the patient need of The aim of this work was to present data from a large care in particular to be able to set an early diagnosis and sample of patients with Temporo-Mandibular Disorders to apply prevention therapies (11-12). (TMD) in order to clarify some aspects of the develop- The data analyzed in this work are the outcomes of the ment of pathological conditions that affect large parts of patients who spontaneously arrived requiring a specialist IC the population. visit at the Gnathological Service of the Oral and Maxillo- This preliminary work put in relation, through an epi- Facial Department of University “Sapienza” of Rome dur- demiological evaluation, anamnestic and clinical data ing the period from July 1983 to July 2006. collected from a sample of 2375 patients affected by Taking into account as diagnostic reference the C TMD. Personal data were provided by questionnaire RDC/TMD, our researches are related exclusively to the (age, sex, status, etc.), while clinical data were col- Axis 1 clinical aspects, complemented by other possible lected following a specific medical chart compiled in ac- variations in the clinical section of muscle disorders. cordance with international criteria for TMD. An analy- All data were analyzed with statistical evaluation tech- © sis of these data clearly showed that there were large quantities of variables involved in these disorders and niques and, in view of the amount and complexity of the which occur with a wide variety possible of clinical results, they were divided into two papers. In this early signs. This complexity, in accordance with the current work the authors have been illustrated and described knowledge that it is not able to clarify the etiology of the epidemiological basic characteristics of the sample these disorders, makes intricate both diagnostic then with the aid of elementary statistical techniques and tools. therapeutic aspects. You would find in front of a multi- This preliminary phase was necessary to carry out further factorial systemic disease that, interfering with the in- analysis aimed for identifying most sophisticated and sig- dividual bioavailability, exposes him to the possibility nificant links between the different dysfunctional frames. of perceiving noxious stimuli which otherwise would In order to give a logical and statistically useful to the large Annali di Stomatologia 2013; IV (1): 161-169 161 C. Di Paolo et al. amount of clinical variables describing the population af- to introduce a severity code of each case. The last part fected by temporo-mandibular disorders (TMD), it was has been left to the spaces specially dedicated to the de- necessary to encode the different aspects studied in this scription of the working diagnosis and the subsequent work in an analytical way. The mat and met paragraph ex- treatment plan, and finally an adequate space for describ- plained the details of the type of coding adopted for the ing the evolution of symptoms during treatment controls li symptomatic variables considered and highlighted the was added. The final version of the medical records used motivations that have addressed these scientific choices. for TMD patients was put into current use in the mid- na Following the same codifications we were described and nineties, this explains the choice of the period under re- analyzed the results and through their analysis the sub- view. sequent concluding remarks. Based on the semeiotics suggested by the structure of medical proceedings it was therefore possible to identify io four groups of variables, for a total of 33 characteristics Materials and methods that clearly define a TMJ disorders: 1. General features and age; 1.1 Selection of sample 2. Biomechanical characteristics, which include data re- az lating to the symptoms of functions and dysfunctions As mentioned above, patients were selected retrospec- and occlusal characteristics; tively from the medical records registered at the Clinical 3. Muscle characteristics, including data related to the Gnathology Service of the Oral and MaxilloFacial Sci- presence/absence of the different type of neuromus- n ences Department of Sapienza University of Rome. The cular pain; Service was created at the chair of Maxillofacial Sur- 4. Data describing the treatments and their outcome. er gery, then it was transferred under the direction of the Periodontal chair and finally it became special unit, dur- In the first section were enclosed the variables described ing the entire period the division has always been below: nt managed by the same calibrated team. The patients considered in the study were selected with two inclu- sion/exclusion criteria, the only inclusion criterion adopted was to have a diagnosis of TMJ disorders, the - Sex: several studies have to give particular important to this issue not only because it is well know the high percentages of women compared to men involved in the temporo-mandibular disorders. iI only one for exclusion was not having the medical - Age: to analyze this variable was deemed appropri- records duly completed. The authors were considered ate to adopt, in the following analysis, a division into those who have made a specific treatment and those different classes of age: 0-15 years (children), 16-25 on who were only observed and recorded because these years, 26-40 years, 41-50 years, 51-60 years, 61-70 data could be useful for epidemiological and statistical years, more than 70 years. considerations. The period from 1983 to 2006 was the - Civil status: Although not known for many of the pa- time interval considered, during that time patients come tients examined, in our view, it is an aspect to be con- i to clinical attention were over 8000. The lack of informa- sidered in order to evaluate the emotional impact of iz tion founded in medical records present in the chart private life context (separation, divorce, bereave- compiled during the first years, however, has required ment). the authors to take into account only the data related to - Occupation: the occupation and the type of activity Ed the patients who have come for a visit during the decade performed by any subject may be determinant to 1996-2006, this examination has involved 3087 pa- evaluate certain attitudes, postural factors and the so- tients. In the light of the application of above mentioned cial stress. Furthermore this variable was again di- selection criteria the study sample has been composed vided by grouping different professions in the nine cat- of 2375 patients. egories proposed by Istat Classification of Occupations: intellectual professions and scientific, IC technical and specialized, used, non-specialized in 2.2 Description and coding of variables: commercial, craft, industrial and services; house- from the medical records to statistical data wives, students, pensioners, unemployed; more. - Existence of a history of trauma: this file is clinically C The medical chart which were originally used at the De- considered as a factor that most often lead to TMJ partment was formed by 2 front pages. Later also to ob- (temporo-mandibular joint) functional alterations with serve the international criteria for the diagnosis of TMD related pain, neck pain and or other type of pain. the medical records has been changed to 4 pages, in - Presence of a previous treatment: this element has © which were sequentially well-ordered: the patient’s per- been recorded in order to assess if the visited patients sonal data, history, subjective pain symptoms, symptoms have previously undergone to some therapies in one and objective by masticatory muscles and articular joint or more of the stomatognathic components. These functionality other articular features, occlusal and struc- variables have been codify for type of therapy tural examination, symptoms of other districts. This chart (gnathologic, orthodontic or prosthetic) and for num- was subsequently update to improve and complete the bers of treatments one, two or more. medical records introducing specific area regarding the in- - Presence of a disease (different from TMD): it was de- tra-and extra oral inspection, the presence of structural or cided to organize, the corresponding variable col- systemic diseases, to describe the results of the imaging, lected by the questionnaire, into four major groups: 162 Annali di Stomatologia 2013; IV (1): 161-169 Epidemiological analysis on 2375 patients with TMJ disorders: basic statistical aspects absence of pathology, presence of systemic diseases, Another cluster of variables considered were the one re- presence stomatognathic diseases or both. lated to the masticatory muscles disorders. In this group, The information collected in the “biomechanical charac- the following variables were embraced: teristics” section, were combined in the following vari- - Masticatory muscles pain: we was detected only the ables: presence / absence not considering the size and li - Presence of tmj pain on the right side and presence soreness; of pain on the left side: for these two variables other - Headache: this pain condition was considered without na than the presence/absence of pain it was also quan- classifying, evaluating only the side of onset when its tified the pain intensity using the Visual Analogic referred. For these two characteristics it was used as Scale (VAS). To both variables were assigned the fol- a method of evaluation based on the VAS scale work- lowing classes of values: 0 (no pain joints), 0-20 (mild ing with the same classes of encoding methods uti- io pain), 20-50 (moderate pain), 50-80 (severe pain), 80- lized for the TMJ pain: 0 (no headache), 0-20 (mild 100 (severe pain). headache), 20-50 (moderate headache), 50-80 (se- - Presence of joint noise both left and right side: the vere headache), 80-100 (very severe headache). sounds considered were: click, crepitus, noise of dif- - Spinal pain: there have been recorded the presence az ferent nature and not attributable to the two previous / absence regardless of the location (cervical, lumbar types called unclassifiable. If the same structure had or sacral). The presences of these symptoms were an multiple symptoms, we have based the classification important aspect to be investigated because, in the lit- on the severity of the disease considering as princi- erature, several studies agree in highlighting a possi- n pal noise the presence of crepitus. The categories of ble correlation or comorbidity with TMD; the variables considered were: No noise, Click, Crepi- - Emotional factors: state of anxiety or generic stress er tus, Other. that could help to promote the onset of dysfunction, - Value of the maximum opening of the mouth: this were evaluated by clinical method and deducted by feature was expressed in mm and divided into the fol- the anamnestic records. nt lowing classes of values: 0-20 mm, 21-30 mm, 31-40 mm, 41-45 mm, 46-50 mm and more than 50 mm. - Missing teeth in the left and/or right dental arch: the corresponding variables were coded by defining the - Parafunctions: these parameters were divided into two different comportments “bruxism” and “clenching“, they were assessed from the clinic analysis of the masticatory muscles and from the evaluation of the iI following classes of modes: 0 (presence of all dental teeth status. elements in the right or left arch), 1-2, 3-4, 5-8 (num- The last parameters that we have been evaluated from ber of missing teeth in the posterior area). the comparison of the above variables were the therapies on - Missing teeth in anterior area (upper an lower arch in- performed and its results. Under the wording therapies the cluding): for this area we had considered the same pa- authors have included the main type of conservative rameter explained above: 0 (presence of all dental el- treatment used in different and custom combinations to ements), 1-2, 3-6, more than 6 (number of missing solve a TMD: plates, physiotherapy and pills. i teeth in the anterior area). Outcome of the therapy: the results of the treatments were iz - Molar Occlusal Classes (right and left): whereas that classified in 4 possible outcomes: healed, improved, sta- for many occlusal situations the occlusal class it often ble, worsened. This evaluation has been assumed from was not attributable, we were considered four modes: the pre and post treatment comparison of the semeiolog- Ed occlusal Class I, occlusal Class II, occlusal Class III, ical data of each patient. The development of any other occlusal Class not definable; new symptoms or the aggravation of the previous indi- - Limitation of maximum opening of the mouth: we cated a worsening condition. The presence of the same have considered only the presence/absence symptoms showed a stable condition, the only improve- - Laxity of ligaments: we have considered only the ment without a complete resolution of the symptoms presence/absence. showed an improved situation, the stable absence of any IC Other variables of which have been calculated only the symptoms indicated a condition of healing. The authors presence/absence were the following: included in this analysis only the treated patients with a - TMJ Subluxation: discriminating only the sides (right, long distance assessments. left or both); C - Mandibular Dislocation discriminating only the sides (right, left or both); 2.3 Statistical analisys - Asymmetry of the mandible: comparing the right with the left side with clinical approach and following the In this work, the statistical analysis of the data obtained © cephalometric procedures proposed by Habets; from medical questionnaire and medical charts were pri- - Steep Incisal guidance: it was considered to be ver- marily used to characterize the basic epidemiological as- tical when the cephalometric measure of the angle pects of the 2375 dysfunctional patients. For this purpose formed by long axis of central upper incisor and descriptive statistical tools, as frequency distributions Frankfurt plan is less or equal to 100°; and percentages, graphical representations and - ac- - Decrease of posterior vertical dimension of occlu- cording to levels of data measurement - various measures sion: this parameter was inferred from a clinical and of central tendency (including mean, median and mode) radiological evaluations without specific measure- and variability (i.e. standard deviation and variance), were ment; essentially used. Annali di Stomatologia 2013; IV (1): 161-169 163 C. Di Paolo et al. Results In conclusion with respect to age and gender variables it was established that, the patient type that addressed to Considering the high number of variables that have been the Dental Clinic Department of Sapienza University of submitted to statistical analysis, in this section will be pre- Rome during the years 1996-2006 asking a gnathologic sented and discussed only the most significant results. In visit was mostly a women, aged between 26 and 40 li order to make more clear the subsequent illustration of the years. general characteristics of our dataset, the most important The medical records about the civil state of patients were na descriptive statistics of the quantitative variables are pre- known only in 16.2% of cases, (statistically insignificant), sented in Table 1. while their “profession” was widely known (75 7%). An in- spection on such the data indicated that students, house- wives and employees were the “working” categories that io 3.1 Defining general aspects characterize mostly our sample data. We found a very rel- evant percentage of subjects belonging to the intellectual Firstly, we considered composition of our sample by gen- and scientific professions, as well to the so called un- der and age. About gender, we observed a strong preva- skilled workers. az lence of women over men, with a percentage respectively Concerning the “trauma” variable, 79.2% of the patients of 79.5% for women and of 20.5% for men. These results didn’t told a history of trauma previous their dysfunction. confirmed the 8/3 - 8/1 ratio already known in the literature. While, for the “stomathognathic treatments performed The age of the patients was known for almost all those before the onset of the TMD” variable, the descriptive n visited (97.1%). The analysis of age data showed an analysis showed that only 2.8% of the patients underwent high percentage of patients belonging to the middle to two treatments, 21.7% to one treatment, and the ma- er compared to the pediatric age (0-15 class of years): jority of 75.5%, said that they did not have undergone to 36.8% and 3.6% respectively. The same results were any dental treatment. found for the advanced senile age (70 +), 1.8% of sub- We have reported the frequency distribution of the 2375 (Tab. 1). nt jects. The mean and median matched with the class 26- 40 years, in particular, the mean age was 35.6 years The high number of students in the sample could explain patients respect to other diseases (systemic and/or stomathognathic) in Table 2. We can observe that that the majority of subjects 84.2%, (2000) had no disease, while the 13.1% (310) had a systemic diseases in their medical iI the high presence of patients in the group of 16-25 years. history. Since the lowest frequencies were found in the most ex- As mentioned earlier, the low frequencies associated treme age groups, this confirms that young and the eld- with the 12 groups of systemic diseases and the 4 groups on erly people represent a minority in the sample. Further, of stomathognathic diseases originally considered, did not when we analyzed the gender respect to age, results allow to deduce any evident connection between these showed that mean and median both matched the 26-40 variables and TMD’s; that is, it was not possible to detect class years. However, these measures for women (36 and any statistically significant association between such vari- i 33 years respectively) were greater than men (34 and 30 ables which might substantiate some pathogenic interac- iz years respectively). tions. Table 1. Descriptive statistics of the quantitative variables. Ed Variable Meaw Median Standard deviation Minimum Maximum Age 35,64 32,00 15,047 2 86 Riht articular pain* 22,57 ,00 28,891 0 100 Right articular pain** 49,58 50,00 22,227 5 100 IC Left articular pain* 21,16 ,00 28,838 0 100 Left articular pain** 50,35 50,00 22,559 5 100 Maximum mouth opening 43,58 45,00 8,911 1 68 C Maximum mouth opening*** 46,21 46,00 6,786 1 68 Missing teeth in the arch right 1,08 ,00 1,746 0 8 Missing teeth in the arch left 1,10 ,00 1,747 0 8 Missing teeht in front area ,42 ,00 1,639 0 12 © Headache right* 24,91 ,00 32,241 0 100 Headache right** 58,53 50,00 21,775 10 100 Headache left* 24,01 ,00 31,939 0 100 Headache left** 58,60 50,00 21,504 15 100 * These variables are, in this case, not considered quantitative and ordinal. ** The values of the indices calculated refer to the variable considered in relation to the symptomatic sample. *** The values of the indices are calculated in relation to the variable “maximum mouth opening”, evaluated by excluding cases with the presence of LAB. 164 Annali di Stomatologia 2013; IV (1): 161-169 Epidemiological analysis on 2375 patients with TMJ disorders: basic statistical aspects Table 2. Composition of the sample by type of other diseases. Pathology Values of disease Percentages Absence values of disease 2000 84,2 li Systemic disease/stomatognatic 2 0,1 Systemic disease 310 13,1 na Stomatognatic pathology 63 2,7 Total 2375 100,0 io 3.2. The analysis of the bio-mechanical In order to assess the relative meaning of the different characteristics degrees of “TMJ pain” (left and right) only in the symp- az tomatic sample, we excluded all those subjects showing The statistical analysis of the TMJ pain in the sample zero VAS value from the sample. Such new sub sample showed that the 63% of patients presented articular pain was made up of 1081 patients with right “TMJ pain” and (compared with the 37% asymptomatic); in particular, 998 patients with left “TMJ pain”; data in Tab. 4 show that n 24.6% of them had bilateral pain, while about 38% of them the moderate degree of articular pain was the most fre- showed pain to one of the temporo-mandibular joints. quently occurring in about half of the cases, followed by er The analysis of the symptom “TMJ pain” have been mild and strong; pain assessed as serious showed a carried out considering separately the two joints. Table very low frequency in both joints, 2.3% and 2.8% respec- 3 presents the frequency distribution of “TMJ pain” in tively. the form of class VAS intervals. The frequencies in Further, for both joints we investigated the relation be- nt such table show that more than a half of the subjects (54.5% and 58% respectively) had no pain in both joints. In both right and left “TMJ pain”, the means fall tween pain and age: analysis showed an high frequency of subjects falling in the middle-class (20-50 class of years), but the media was closer to the class endpoint of iI in the 20-50 class with a very close value to the low of 50 years of age. 20, which indicates a moderate degree of pain (the me- The analysis of noisy symptoms led to the following re- dians both coincide to “0”, that is no right and left sults: 53.2% of the patients had joint noises, 35.2% of on pain); dispersion measures were almost similar in both them had noises at one joint, 18% of them had noisy situations. symptoms at both joints (TMJ). Table 3. Frequency distribution right and left articular pain (VAS scale class intervals). i iz Classes VAS Right TMJ pain Left TMJ pain Absolute value Percentages Absolute value Percentages Ed 0 1294 54,5 1377 58,0 1-20 275 11,6 243 10,2 20-50 515 21,7 469 19,7 50-80 266 11,2 258 10,9 IC 80-100 25 1,1 28 1,2 Total 2375 100,0 2375 100,0 C Table 4. Frequency distribution of right and left "TMJ pain" in symptomatic sub sample. Classes VAS Right TMJ pain Left TMJ pain © Absolute value Percentages Absolute value Percentages 1-20 275 25,4 243 24,3 20-50 515 47,6 469 47,0 50-80 266 24,6 258 25,9 80-100 25 2,3 28 2,8 Total 1081 100,0 998 100,0 Annali di Stomatologia 2013; IV (1): 161-169 165 C. Di Paolo et al. Also for the noisy symptoms we considered separately the mouth” variable, all the patients who have some difficul- right and left temporo-mandibular joints. The basic statis- ties in performing the mandibular opening movement (the tical data showed that: the 35.3% of the subjects had dimension of resulting new sample was 1522 subjects). noises at the right tmj, 21.1% of them had noise identified In this last case we found that, for both women and men, as “clicking”, 5.5% diagnosed as “crepitus“ and a share of the mean and median were increased compared to the li 8,7% have noisy symptoms unidentifiable in the two pre- whole sample and falling in the class opening 46-50 mm. vious categories. About the left side, the 36% of the sam- If now consider the gender of such 1522 subjects, despite na ple had noises in the left TMJ, the 21.7% of them had di- the average and the median value increased both for agnosis of noise identified as clicking, 9.7% as women then for men, we found that female gender non-specific and only a portion 4.4% showed a noises showed lower values than male one. Therefore, these re- classified as crepitus. Also in this case to evaluate the rel- sults confirm the quantitative difference in the maximum io ative importance of the three types of the TMJ noises, the opening of the mouth in favors of men than women, and authors have been considered only the symptomatic also confirm that female gender has been shown to be sample excluding from the statistical calculation the sub- more sensitive to the TMJ internal disorders. jects who did not show any articular noises, this has Dislocation of the jaw was analyzed by considering the two az been done both to total count then for each of left and right joints in the right and left sides separately. This dysfunc- joint sides. The results showed that the symptomatic tional alteration occurred at the right TMJ in 3.6% of the sample respectively consists of 838 and 852 patients. In subjects and at the left side in 3.8% of the subjects. Also both cases it was found that the clicking sounds were the about the condylar subluxation, the authors carried out an n kind of articular noises that occur more frequently having analysis by right and left side separately. Frequency distri- a high relative statistical weight, followed by the not iden- bution showed that 1.6% of the sample suffered of this func- er tifiable noises and finally the crepitus, both as a much tional characteristic at the right TMJ, while 1.5% of the sub- more reduced percentage. jects suffered at left side. TMJ laxity of ligaments was Considering the “limitation of mouth opening“ variable, found to be present in 14.1% of the sample. nt data showed a significant percentage of the sample, 78.7% with “no limitation of mouth opening” and, then only the 21.3% of the subjects was found affected by this symptom. These elements see med to question on the possibility that, a ligamentous laxity and/or a joint hypermobility fo- cused to the TMJ, had a possible role in the determinism of internal disorders of this articulation. iI Consider now the “maximum opening of the mouth” vari- The evaluation of the absence of teeth examined in the able, evaluated in millimeters; we had data for such vari- patients had led to the following results, the 42.9% of the able in the 83.7% of the medical records. In analyzing sample had missing teeth in at least one of the three sec- on such data we found that mean, median and mode falling tors investigated (posterior right and left dental arches, an- in the same class 41-45 mm; further, the smallest open- terior area), these sectors were instead simultaneously in- ing value was 1 mm while the largest was 68 mm (Tab. volved in 9.3% of cases. The frequency distributions in 1). The patients were distributed in a rather uniform way these three specific areas are reported in Tab. 5. In the i starting from 31 mm value until 40 mm value, and only the right sector we found the 84.7% of subjects having at least iz 8.1% of patients fallen in a mouth opening class “less than 1 or 2 missing teeth. The mean fells in “1-2” class, while 30 mm“. Considering the gender of such subjects, we also the median coincided with the mode “0”, indicating the found that mean and median were higher in the group of presence of all the dental elements; the maximum num- Ed men compared to women, and, in addition, by comparing ber of missing teeth in the posterior right arches has these measures with those calculated for the whole sam- been equal to eight teeth missing (Tab. 1). ple, we found that the mouth opening mean and median The 84% of the sample showed one or two missing teeth in women were lower than those ones, while for men the in the posterior left arch. Also in this case, the average same values were higher. Further, in order to avoid influ- value fells in the “1-2” class and the median coincided with ences by those subjects suffering by a limitation, we ex- the mode “0”, as well the maximum number of missing IC cluded from the analysis of “maximum opening of the teeth was equal to eight (Tab. 1). Table 5. Frequency distribution of the “missing teeth”. C Number Missing teeth in the right Missing teeth in the left Missing teeth in the front side posterior dental arch posterior dental arch © Absolute Percentages Absolute Percentages Number Absolute Percentages value value value value 0 1363 57,4 1341 56,5 0 2074 87,3 1–2 649 27,3 654 27,5 1–2 197 8,3 3–4 212 8,9 235 9,9 3–6 61 2,6 5–8 151 6,4 145 6,1 6+ 43 1,8 Total 2375 100,0 2375 100,0 Total 2375 100,0 166 Annali di Stomatologia 2013; IV (1): 161-169 Epidemiological analysis on 2375 patients with TMJ disorders: basic statistical aspects In the anterior area the 87.3% of the sample has not pre- be considered a complex patient with concomitant is- sented missing teeth, the maximum number of missing sues that often lead to problems both in diagnosis than in teeth founded was “12 “teeth (Tab. 1). therapeutic approach. These data seem to give particular importance to the The impact of emotional factors such as stress and anx- absence of teeth, especially in the posterior region. On the iety was 8.9%. li basis of this significance, although preliminary, the authors The parafunction “bruxism” was highlighted in 9.3% of hypothesized that the loss of teeth could be a very impor- cases, while the “clenching” was positive in 28.5% of na tant factor in the determination of TMJ dysfunction. This subjects analyzed; such last parafunction seems to be the finding should also be considered in the prevention phase most widespread and the most potentially harmful for although out of line with the data present in the current lit- the individuals who are affected. erature. About the “headache” almost half of the sample ana- io The evaluation of dental classes was separately con- lyzed, 46.8%, presented this symptom, the most of the ducted for the right and the left sides. Concerning the right sample showed, according to VAS scale, an average side we found that the 44.5% of the sample had a class level of pain (20-50). This data confirms the high co-mor- I, the 25.5% a class II and the 10% a class III; in the 20% bidity of this disease with the TMD’s; the data was in az of cases was not possible to ascertain the class due to agreement with the findings emerging from the literature. particular dental situations that made it impossible to def- The data led the authors to state the hypothesis that po- inite it. On the left side the 42.6% of the sample presented tentially, at least for the group of patients analyzed in this a class I, followed by a 26.4% who had a class II and by study, a patient with headache could be considered at risk n 10.8% of a class III. This finding according to what for dysfunction and vice versa. The frequency distribution emerged from the literature has demonstrated the lack of by site of headache is reported in Tab. 6. er reliability of the relationship between occlusal classifica- To assess the relative impact of different degrees of tions and TMJ disorders. cephalic pain in the sample, it was necessary to exclude Two other data relating to the occlusion were particularly from analysis all those who were free from this symptom nt significant, the first was the steep of incisal guidance (vertical incisal guide) which was detected in the 26.1% of the sample, the second was the loss of posterior ver- tical dimension which was detected in the 27.3% of cases. (Tab. 7). In that way it was possible to detected how the moderate degree of headaches, followed by high-grade headaches, were the most commons among those who were suffering. iI These variables, which were positive in previous epi- It was also possible to observe that the majority of patients demiological studies, may deserve closer attention in the revealed a medium or high intensity head pain, this has evaluation of occlusal pathogenic factors for TMJ disor- led us to reflect on the capacity of the dysfunctional pa- on ders. tients to underestimate the headache until it reaches high With regard to facial asymmetry, this variable was pres- threshold levels. ent in 3.8% of cases. This finding seems to confirm a lack In conclusion to the illustration of the previous results we of relation, at least in the sample considered in this paper, now present data on “treatment variable” and its out- i between the presence of facial asymmetry and TMD. comes. iz About treatment the 48.5% of sample was subjected to a conservative treatment (pills, plates and physiotherapy), 3.3. Analysis of muscle characteristics the 15.9% of patients was suggested a distance re- Ed assessment of the disorders, the remaining part (35.6%) As concerns this group of variables, we observed that the of patients were not treated due to one of the following muscular pain was present in the 30.7% of the cases, reasons: while the spinal (postural) pain was present in the 37.7% - did not require specific treatment; of the cases analyzed. These so high percentages could - in need of other therapy than that gnathological; be related to the presence of a strong comorbidity be- - needed surgery (Orthognathic or TMJ surgery); IC tween TMD and other pain arising from different areas of - refused or couldn’t practice, for personal grounds, the spine. Therefore the dysfunctional patient needed to the proposed therapeutic plan. C Table 6. Frequency distribution of headache symptoms (VAS scale class intervals). Classes VAS Right headache Left headache © Absolute value Percentages Absolute value Percentages 0 1364 57,4 1402 59,0 1–20 132 5,6 119 5,0 20–50 454 19,1 449 18,9 50–80 369 15,5 351 14,8 80–100 56 2,4 54 2,3 Total 2375 100,0 2375 100,0 Annali di Stomatologia 2013; IV (1): 161-169 167 C. Di Paolo et al. Table 7. Frequency distribution of headache symptoms in the symptomatic sample. Classes VAS Right headache Left headache Absolute value Percentages Absolute value Percentages li 1–20 132 13,1 119 12,2 na 20–50 454 44,9 449 46,1 50–80 369 36,5 351 36,1 80–100 56 5,5 54 5,5 Total 1011 100,0 973 100,0 io It was therefore interesting to evaluate the efficacy of ther- data collected in this preliminary retrospective study were az apy carried out. The results are presented in Tab. 8. The subjected to a simple statistical analysis to describe the sample was made up of 649 patients (we excluded those basic epidemiology aspects of a large sample of patients patients for which the therapeutic process was still under with TMJ dysfunctions (2375 patients). way). The first data to be collected are related to age and gen- n For the 649 patients who had finished their course of treat- der. These variables in the sample, are similar to those in- ment and had also completed a period of post-treatment dicated in the literature, in fact, the average age was er control, and for whom it was possible to make a judgment 35.6%, and the majority of patients are in the group of about the validity of the therapy it has been claimed that years ranging from 26 to 40; the gender proportion is gen- the 37.8 % of patients were recovered and the 46.4% erally about 8 to 2 in favor of the female. This confirms the were improved. The 84,1% of patients had a positive or reliability of the current sample. nt very positive post-treatment conclusion. The 14.5% of the treated sample showed no change in symptom and was considered stable, while only the 1, 4 % reported a wors- Between the symptoms analyzed, the more detected was the joint pain present in over 60% of the sample exam- ined, with a double prevalence compared to muscle pain, iI ening of their initial symptoms. which has proved to be present in just over 30% of pa- These findings have led us to state that the gnathologic tients this finding does not agree with the literature treatments performed can be considered to be particularly (Kononen et all. 1996, Magnusson et all 2000). The tar- on effective in treating temporo-mandibular disorders. Our re- get of population that has turned in our Service of sults are consistent with the current literature that indicates Gnathology seems mainly affected by biomechanical the individualized management of conservative gnatho- TMJ dysfunctions and that the masticatory muscle are in- logic treatment as the most appropriate versus the TMD. volved secondary to the functional problems. This result i is confirmed by the second prevalent symptom founded iz that was the joint noises, which have been revealed, in 4. Discussion and conclusions clicking form, in the 53.2% of the sample. The postural pains in the spine and especially the Ed The large quantity of data that has been collected from the headache appear simultaneously present in just under an examination of thousands of medical records during the half of the sample (respectively 37% and 46%). These years 1996-2006 suggested to us to separate the study data confirm the high relationship, at least of co-morbid- in two parts, the second, carried out by more refined sta- ity, present between TMD and the above painful condi- tistical means, will aim to identify any possible relation and tions. In the case of headache it could even be argued significant associations between the symptoms and the that a TMD patient is potentially at risk for some headache IC different clinical forms of the dysfunctional disorders. The development forms (probably tensive type) and vice Table 8. Frequency distribution of outcome treatment. C Result Absolute values Percentage valid Percentage valid Cured 245 10,6 37,8 © Improved 301 13,0 46,4 Worse 9 0,4 1,4 Stable 94 4,1 14,5 Total 649 28,1 100,0 Missing 1664 71,9 Total 2313 100,0 168 Annali di Stomatologia 2013; IV (1): 161-169 Epidemiological analysis on 2375 patients with TMJ disorders: basic statistical aspects versa. The clinician who should be confronted with pa- shades. This complexity is in line with the current knowl- tients affected by these painful complaints, especially edge that it not be able to clarify the etiology of these dis- when they are chronic, should always be suspected in the orders making intricate both diagnostic and therapeutic diagnostic phase, the possible presence of the other aspects. We may be in front of a multi-systemic disease pathological forms, and also during the therapeutic man- that it interferes with the bioavailability of the individual, li agement he shall be prepared to approach these pa- exposing him to the possibility of suffering noxious stim- tients with combined multidisciplinary treatments. uli, which otherwise not could able to achieve the pain na The statistics also revealed a direct proportionality be- threshold. Confirmation of this it has been shown, with a tween the different levels of pain intensity reported by pa- high frequency, that many patients contemporary pre- tients, regardless of location. This may mean that a pa- sented muscle pain, spinal pain and headache to over- tient who reports a moderate headache suffered by the shadow the dysfunctional type problems even if they oc- io same grade of pain both joint and masticatory muscle. cur with a greater clinical prevalence. Finally we have to Moreover a patient who simultaneously presents noises mention the good results obtained from the patients un- and pain, is very likely that he refer this symptoms to the dergoing to a complete specialist conservative treatments same joint and at the same side. who are about half of the sample. In fact over 80% of az The biomechanical variables analysis led to the following these patients showed a complete recovery or a signifi- considerations. The average value of opening of the cant improvement of the previous state. mouth of a dysfunctional population was found to be 43.5 Further researches should be carried out to clarify these mm that is slightly lower than that considered normal (45 controversial aspects. n mm), with mean values increased by about 3 mm in the male compared to female. Patients who have skilled a sig- er nificant limitation of this parameter (less than 30 mm) Reference were a minority, the 8.1%, but they still significant in view of the seriousness of this problem. This information should 1. Di Paolo C, Cascone P. Patologia dell’articolazione Tempo- romandibolare. UTET 2004. nt address the clinical approach in the evaluation of the opening of the mouth to consider the quantitative value al- ways in association with the qualitative and with the pain. The joint hyper mobility was detected in about 15% of the 2. Segu M, Sandrini G, Lanfranchi S, Collegano V. La patoge- nesi delle cefalee di tipo tensivo: ruolo dei disordini cranio- cervico-mandibolari. Protocollo di ricerca. Minerva Stoma- iI tol Jun 1999. sample. This data should be confirmed in other studies as 3. List T, Walhund K, Wenneberg B, Dworkin SF. TMD in chil- it calls into question the possible role of ligaments laxity dren and adolescents: prevalence of pain, gender differ- as a risk factor for a joint disorders. ences, and perceived treatment need. Journal Of Orofacial on Several values related to the state of the occlusion merit Pain Winter 1999. some reflections. 4. Al Ani MZ, Davies SJ, Sloan P, Glenny AM. Stabilization The first data confirm that the analysis of occlusal classes splint therapy for TM pain dysfunction syndrome. The Cochrana Database of Systematic Rewiews 2004. does not represent a substantial interest when analyzing 5. Graff-Radford, Newman: The role of temporomandibolar i patients with TMD in fact, the findings are in line with that iz disorders and cervical dysfunction in tension-type headache. of the population free from dysfunctions and this is in Curr Pain Headache Rep Oct 2002. agreement with the results aroused from the literature. 6. Magnusson T, Syren M. Therapeutic jaw exercises and in- Between the evaluations of the static occlusion the most terocclusal appliance therapy. A comparison between two Ed significant data was the steepness of the incisal guidance common treatments of temporomandibolar disorders. Swed present in 26.1% of the sample. Dent Jan 1999. Another indicative value was the absence of the teeth. This 7. Pettengill C. A comparison of headache symptoms between condition is present in over 40% of the subjects in partic- two groups: a TMD group and a general dental practise ular in the posterior dental arches. If we add to this the group. Cranio Jan 1999. 8. Liljestrom, Jamsa, LeBell, Alanen, Anttila, Metsahonkala, value of the reduction of the posterior vertical height of oc- IC Aromaa, Sillanpaa. Signs and symptoms of temporomandi- clusion, present in 27.3% of the subjects, it becomes pos- bolar disorders in children with different types of headache. sible to assume that the loss of dental elements can be a Acta Odontol Scand Dec 2001. risk factor for the development and maintenance of a TMJ 9. Freund BJ, Schwartz M. Relief o tension-type headache dysfunction. Highly dangerous seems to be the contempo- symptoms in subjects with temporomandibolar disorders C rary association of the two factors that lead the mandible treated with botulinum toxin-A. Headache Nov Dec 2002. in a posture which would facilitate the development of a 10. Ekberg E, Vallon D, Nilne M. Treatment outcome of disc dislocation. Another risk factor could be the over- headache after occlusal appliance therapy in a randomized loaded caused by the clenching, type of parafunction controlled trial among patients with temporomandibular dis- © order of mainly artrogenous origin. Swed Dent J 2002. which has present in almost 30% of patients. 11. Thilander B, Rubio G, Pena L, de Mayorga C. Prevalence So we can suggest that these are some of the factors on of Temporomandibular Dysfunction and Its Association With which it would be appropriate to take action as a preven- Malocclusion in Children and Adolescents: An Epidemiologic tive measure in order to ensure that a “healthy” subject Study Related to Specified Stages of Dental Development. does not become “dysfunctional” patient. 12. Pedroni CR, De Oliveira AS†, Guaratini MI. Prevalence A proper analysis of the full data, clearly shows that there study of signs and symptoms of temporomandibular disor- are a large amount of variables involved in these disor- ders in university students. Journal of Oral Rehabilitation ders that occurred in a wide range of possible clinical 2003; 30:283-289. Annali di Stomatologia 2013; IV (1): 161-169 169 

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Case report Ameloblastomatous calcifying ghost cell odontogenic cyst - a rare variant of a rare entity li na Harkanwal Preet Singh, MDS1 Introduction Madhulika Yadav, MDS2 io Amit Nayar, MDS1 Epithelial-lined cysts seldom occur in skeletal bones, Chanchal Verma, MDS3 because embryonic epithelial rests are normally not Palak Aggarwal, MDS3 found in them. They do, however, occur in the jaws Sandeep Kumar Bains, MDS4 where the majorities are lined by epithelium derived from az remnants of the odontogenic apparatus. These odonto- genic cysts are classified as either of developmental or 1 Department of Oral and Maxillofacial Pathology and inflammatory origin. The calcifying ghost cell odonto- Microbiology, Swami Devi Dyal Hospital and Dental genic cyst (CGCOC) is a rare example of a developmen- n College, Barwala, Panchkula, Haryana. India tal odontogenic cyst, its occurrence constituting about 2 Department of Pedodontics and Preventive Dentistry, 0.37% to 2.1% of all odontogenic tumors (1). The calci- er Faculty of Dental Sciences, King Georgeʼs Medical fying ghost cell odontogenic cyst (CGCOC) was first de- University, Lucknow, Uttar Pradesh, India scribed by Gorlin et al. who were impressed by the sig- 3 Department of Oral and Maxillofacial Pathology nificant presence of the so-called ghost cells (2). At that 4 Uttar Pradesh, India nt and Microbiology, ITS Dental College, Ghaziabad, Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Barwala, time, they suggested that this cyst may represent the oral counter part of the dermal calcifying epithelioma of Mal- herbe (3, 4). Over the years since its first description, it has become clear that the calcifying ghost cell odonto- iI Panchkula, Haryana. India genic cyst (CGCOC) has a number of variants, including features of a benign odontogenic tumor. It was classified as SNOMED code 9301/0, in the World Health Organi- on Corresponding author: zationʼs (WHO) publication Histological Typing of Odon- Dr. Harkanwal Preet Singh, MDS togenic Tumors (5). WHO in 2005 have classified all Oral and Maxillofacial Pathology and Microbiology, COCs under the category of odontogenic tumours (6). Swami Devi Dyal Hospital and Dental College, One of the histological features of the condition is the i Barwala, Panchkula, Haryana, India presence of ghost cells. Fejeskov and Krough are of the iz Phone: +91 8570023088 opinion that the lesion initially presents as a solid tumor, E-mail: hkps0320@gmail.com consisting mainly of ghost cells and that the cyst devel- opment is a secondary phenomenon. They suggested a Ed new descriptive term of ghost cell odontogenic tumor for the lesion (7). We hereby, present a rare case report of Summary ameloblastomatous calcifying ghost cell odontogenic Calcifying odontogenic cyst (COC) is an uncommon be- cyst in 24 year old female. nign cystic neoplasm of odontogenic origin, which shows extensive diversity in its clinico-pathological ap- IC pearances and biological behavior. It most commonly oc- Case report curs in broader age group of 1-82 years in anterior part of jaws which is classically described by presence of 24 year old female patient reported with the chief com- ghost cells. There are variants of COC according to clin- plaint of swelling on left side of face since 6 months. Pa- C ical, histopathological, and radiological characteristics. tient was apparently asymptomatic 6 months back then Therefore a proper categorization of the cases is needed she noticed a pea sized swelling intra-orally in buccal for better understanding of the pathogenesis of each vestibule in 33, 34 region. Swelling gradually increased in variant. Here we report a rare case of ameloblastomatous size and manifested extra-orally on face. No associated © calcifying ghost cell odontogenic cyst in 24 year old fe- male with brief review of literature. Presence of pain or paraesthesia was present. ameloblastomatous proliferation and impacted canine General physical examination revealed that the patient presented a diagnostic dilemma and was diagnosed by was moderately built and nourished. All the vital signs careful radiographic and histopathogical interpretation. were within normal limits. Extra-oral examination re- Long follow up and more case report are required to vealed a firm swelling with normal coloured overlying skin shed light on its behaviour as there scarcity of data of on the left lower third of the face extending from corner this lesion in literature. of mouth to line joining outer can thus of eye to inferior border of mandible (Fig. 1). None of the lymph nodes Key words: cyst, ghost cells, neoplasm, odontogenic. were palpable. 156 Annali di Stomatologia 2013; IV (1): 156-160 Ameloblastomatous calcifying ghost cell odontogenic cyst - a rare variant of a rare entity li na ➡ ➡ → ➡ ➡ io Figure 3. Orthopantomograph demonstrating a solitary well de- fined radiolucency (large red arrow) with sclerotic margins extend- ing from 38 to distal aspect of 45 and impacted 33 (small red ar- az row). gion with buccal and lingual cortical plate expansion (Fig. 4). Axial Computed tomography (CT) scan showed expan- n sion of the tumour mass with thinning of cortical outline (Fig. 5). 3-Dimensional computed tomography volumetric er reconstruction showed gross bone destruction with specks of calcification in mandibular anterior region (Fig. 6). nt Figure 1. Extra-oral photograph showing a swelling extending from corner of mouth to line joining outer can thus of eye to infe- iI rior border of mandible. Intra-oral examination revealed solitary well defined pain- on ➡ less swelling measuring 5 cm×3 cm, ovoid in shape, firm ➡ ➡ in consistency, smooth texture with intact overlying mu- cosa (Fig. 2). → ➡ i iz Ed Figure 4. Mandibular occlusal radiograph demonstrating well defined radiolucency (large red arrow) in mandibular anterior re- gion and impacted canine (small red arrow). ➡ IC →→ ➡ C Figure 2. Intra-oral photograph showing solitary well defined swelling (large black arrow) measuring 5 cm × 3 cm, ovoid in © shape with intact overlying mucosa. In roentenographic examination orthopantomograph showed a solitary well defined radiolucency with sclerotic margins extending from 38 to distal aspect of 45. Superi- orly it extends up to alveolar process and inferiorly to 2 mm Figure 5. Axial Computed tomography (CT) scan showing expan- above the inferior border of mandible. It also showed im- sion of the tumour mass to adjacent soft tissue at the buccal side on soft tissue shadow imaging and expansion (large red arrow), pacted 33 (Fig. 3). Mandibular occlusal radiograph re- thinning of cortical outline (small red arrow) with large unilocular veals well defined radiolucency in mandibular anterior re- radiolucency. Annali di Stomatologia 2013; IV (1): 156-160 157 H. P. Singh et al. → → → li na → → io az Figure 6. 3-Dimensional CT volumetric reconstruction demon- Figure 8. Photomicrograph showing ameloblastic islands(large strated gross bone destruction (large red arrow) with specks of black arrow) with stellate reticulum like areas (blue arrow) along calcification (small red arrow) in mandibular anterior region. with numerous ghost cells (small arrow) (H&E X10). n Haematological and urine examinations did not reveal any er abnormal findings. Clinical differential diagnosis of dentigerous cyst, ameloblastoma and Calcifying cystic ep- ithelial odontogenic tumour were given. Incisional biopsy was performed and the tissue was sub- nt mitted to the Department of Oral Pathology. Histopatho- logic examination showed 6-8 layered cystic lining com- posed of prominent basal cell layer with few areas of iI palisading arrangement. Cells above the basal cell layer are loosely arranged resembling stellate reticulum (Fig. 7). i on iz Figure 9. Photomicrograph showing dentinoid (red) and ghost cells (yellow) (Massonʼs trichrome; x10). Ed Based on these clinical, radiographic and histopatholog- ical features confirmatory diagnosis of Ameloblastoma- tous Calcifying odontogenic cyst was arrived. The oper- ation was performed under general anaesthesia by enucleation of the lesion and enucleated specimen was cystic approximately 5 mm to 6 mm in diameter, entire IC specimen was sent for histopathological evaluation, and it was reconfirmed as Ameloblastomatous calcifying ghost Figure 7. Photomicrograph showing proliferating cystic lining (large balck arrow) with stellate reticulum like areas. (H&E X10) cell odontogenic cyst. The patient was followed up for 2 inset showing spherical to irregular calcification (small balck ar- years with no evidence of recurrence. C rows) (H&E X10). Discussion Numerous ameloblastic islands along with ghost cells © with distinct cell outline and numerous spherical calcifica- Gorlin and colleagues identified CGCOC as a distinct tions are seen within the epithelium and connective tissue pathological entity in 1962 although according to Altini and capsule (Fig. 8). Connective tissue is fibrocellular in na- Farman, the condition had previously been described in ture with chronic inflammatory cells, odontogenic islands, German literature in 1932 by Rywkind (8). The CGCOC spherical calcifications, few sebaceous nests and few has also been reported under a variety of other designa- ghost cells with few multinucleated giant cells. Extensive tions (Tab. 1). areas of haemorrhage are also evident. Van gieson and In 1992, the World Health Organization (WHO) classified massonʼs trichrome staining was done to differentiate CGOC as a neoplasm rather than a cyst but confirmed ghost cell from other acidophilic bodies (Fig. 9). most of the cases are non-neoplastic. In view of this du- 158 Annali di Stomatologia 2013; IV (1): 156-160 Ameloblastomatous calcifying ghost cell odontogenic cyst - a rare variant of a rare entity Table 1. Terminology of the so-called calcifying odontogenic cyst (9). (Modified from Toida 2008) Gorlin et al. 1962 Calcifying odontogenic cyst Gold 1963 Keratinizing calcifying odontogenic cyst (KCOC) li Bhaskar 1965 Keratinizing ameloblastoma na Fejerskov and Krogh 1972 Calcifying ghost cell odontogenic tumor (CGCOT) Freedman et al. 1975 Cystic calcifying odontogenic tumor (COCT) io Praetorius et al. 1981 Dentinogenic ghost cell tumor (DGCT) Ellis and Shmookler 1986 Epithelial odontogenic ghost cell tumor (EOGCT) az Colmenero et al. 1990 Odontogenic ghost cell tumor (OGCT) n ality, many different terminologies have been applied to opacities near apices of teeth. Presence of ghost cells cystic and solid CGOC variants, but calcifying odonto- are considered as characteristic but not pathognomonic er genic cyst is the preferred term (9). Several classifications for diagnosis of Calcifying odontogenic cyst. Numerous of CGOC subtypes have been proposed, but most of ghost cells were observed in our case and many of them have limitations in separating cystic and neoplastic them have undergone calcification. variant. - Type 1. Cystic type: - (A) simple unicystic type, nt First classification is proposed by Praetorius et al. (3): Ghost cells may undergo calcification and lose their cel- lular outline to form sheet like-area. Levy also supported the concept of calcification of ghost cells and held is- chemia as a responsible factor. Many investigators have iI - (B) odontoma-producing type, made effort to clarify the nature of ghost cells by employ- - (C) ameloblastomatous proliferating type. ing special histochemical methods, transmission elec- - Type 2. Neoplastic type: dentinogenic ghost cell tron microscopy, and scanning electron microscopy, and on tumor. various theories have been proposed without any general The odontogenic origin of the CGCOC is widely ac- agreement. Gorlin et al., Ebling and Wagner, Gold, cepted (10, 11). The cells responsible for the calcifying Bhasker, Komiya et al., and Regezi et al. all believed that odontogenic cyst are dental lamina rests (rests of Ser- ghost cells represent normal or abnormal keratinization. i res) within either the soft tissue or bone. Therefore, cal- Sedano and Pindborg thought the ghost cells represented iz cifying ghost cell odontogenic cysts are cysts of pri- different stages of normal and aberrant keratin formation mordial origin and are not associated with the crown of and that they were derived from the metaplastic transfor- an impacted tooth (12). It most often occurs as a central mation of odontogenic epithelium. Other investigators Ed (intraosseous) lesion (11, 12), whereas peripheral (ex- suggested or implied that ghost cells may represent the traosseous) localization in the soft tissue is rare (13, 14). product of abortive enamel matrix in odontogenic epithe- It occurs most commonly in 1 yr – 82 yrs of age. There lium. However, the morphology of ghost cells seems dif- is a distinct peak in the second decade. Equal sex ferent from that of enamel matrix. Ghost cells are not predilection has been observed. Majority of the cases unique to CGCOC, but are also seen in odontoma, are seen in the jaw bones with equal distribution in ameloblastoma, craniopharyngioma, and other odonto- IC maxilla and mandible. Anterior part of the jaws is the genic tumors (8). Our case represents the classical fea- commonest site of occurrence (15). In our present case tures of calcifying odontogenic cyst, according to Praeto- reported COC occurred in 24 year old female patient in rius et al. (3) it comes under category of Type 1(c) anterior region of mandible which falls well within the ameloblastomatous proliferating type, and according to C data given in the literature. According to Shear et al. sev- Reichart (6), it comes under the category of calcifying eral cases may cross the midline in the mandible, but it ghost cell odontogenic cyst (CGCOC) non-neoplastic is unusual in maxilla (4). In our case lesion extends from (simple cystic) variant with unicystic, plexiform arneloblas- 38 and crossed the midline to reach the distal aspect of tornatous proliferation of epithelial lining. Simple enucle- © 45. This is also consistent with the findings observed in ation is sufficient treatment, and there is little risk of recur- literature. Radiographically, they appear as radiolucent rence. areas often associated with complex odontome leading Ameloblastomatous COC microscopically resembles uni- to the appearance of dense opacities in the cyst. Re- cystic ameloblastoma except for the ghost cells and calci- sorption of roots of adjacent teeth is a frequent finding fications within the proliferative epithelium. Ameloblastom- and a very important x-ray feature (15). Present case atous COC occurs only intraosseously. This subtype of showed well defined radiolucency extending from 38 to COC is distinct from true ameloblastoma arising in COC. 45 with root resorption of 31, 32, 33, 41, 42, 44, 45 when In contrast to ameloblastoma ex COC, the ghost cells and radiograph was carefully evaluated it showed specks of dystrophic calcifications are within the proliferative epithe- Annali di Stomatologia 2013; IV (1): 156-160 159 H. P. Singh et al. lium, which lacks histopathologic criteria as suggested by plastic potential. Acta Odontologica Scandinavica 1981; Vickers and Gorlin, and is confined to the cyst lumen. 39:227-40. Ameloblastoma ex COC designates an ameloblastoma 4. Shear M, Speight P. Calcifying odontogenic cyst (Calcifying arising from the cyst lining epithelium of COC. Our review cystic odontogenic tumors). Cyst of the Oral and Maxillofa- cial Region, Blackwell Munksgaard, New York, NY, USA, 4th of the literature revealed only four cases (16). edition, 2007; 100-107. li Ameloblastoma ex COC occurs intraosseously, appear- 5. Kramer IRH, Pindborg JJ, Shear M. Histological typing of ing as cyst-like, radiolucent lesions. Whether these tumors odontogenic tumours. 2nd ed, Springer-Verlag, Berlin 1992; na are potentially as destructive as typical ameloblastoma 7-20. and have the same propensity for recurrence is unknown. 6. Philipsen HP. Keratocystic odontogenic tumour. In: Barnes Whether ameloblastoma ex COC should be classified L, Eveson JW, Reichart P, Sidransky D (EDS). Head and as a subtype of ameloblastoma or as a subtype of COC neck tumours. Pathology and Genetics. WHO Classification of tumours. IARC Press, Lyon, 2005: 306-7. io may be open to discussion. Buchner suggested that if the COC was associated with an ameloblastoma, its behav- 7. Fejerskov O, Krough J. The calcifying ghost cell odontogenic tumor or the calcifying odontogenic cyst. J Oral Pathology ior and prognosis would be of the same as an ameloblas- 1972; 1:273. toma, not COC (16). az 8. Sonone A, Sabane VS, Desai R. Calcifying Ghost Cell Odontogenic Cyst: Report of a Case and Review of Litera- ture. Case Reports in Dentistry 2011; 1-5. Conclusion 9. Toida M. So-called calcifying odontogenic cyst: review and discussion on the terminology and classification. J Oral n Calcifying odontogenic cyst has long been recognized as Pathol Med 1998; 27(2):49-52. a distinct clinical entity. Some authorities believe that it is 10. Hong SP, Ellis GL, Hartman KS. “Calcifying odontogenic er more appropriately called as tumour (Dentinogenic ghost cyst. A review of ninety-two cases with reevaluation of their cell tumour). It can sometimes pose a diagnostic dilemma nature as cysts or neoplasms, the nature of ghost cells, and which should be diagnosed based upon vigilant compre- subclassification,” Oral Surgery Oral Medicine and Oral hensive analysis of radiographic and histopathologic find- Pathology, vol. 72, no. 1, 1991; 56-64. nt ings. More number of case reports is required to exactly delineate the biological behaviour of such a rare histolog- ical variant of rare odontogenic cyst. 11. Marx RE, Stern D. “Odontogenic and nonodontogenic cysts,” in Oral and Maxillofacial Pathology: A Rationale for Diagnosis and Treatment, Quientessence Publishing, Hanover Park, Ill, USA, 1st edition, 2003; 607. iI 12. Altini M, Farman AG. “The calcifying odontogenic cyst: eight new cases and a review of the literature”. Oral Surgery References Oral Medicine and Oral Pathology 1975; 40:751-9. on 13. Neville BW, Damm DD, Allen CM, Bouquot JE. Odontogenic 1. Erasmus JH, Thompson IOC, Rensburg LV, Westhuijzen A. cysts and tumors,” in Oral and Maxillofacial Pathology,” W. Central calcifying odontogenic cyst. A review of the literature B. Saunders, Philadelphia, Pa, USA, 2nd edition, 2002; and the role of advanced imaging techniques. Dentomaxillo- 590. facial Radiology 1998; 27(1):30-5. 14. Kenzevic G, Sokler K, Kobler P, Manojlovic S. Calcifying i 2. Gorlin RG, Pindborg JJ, Clausen FP, Vickers RA. The cal- odontogenic cyst - Gorlinʼs cyst - report of two cases. Coll iz cifying odontogenic cyst - a possible analogue of the cuta- Antropol 2000; 28(1):357-62. neous calcifying epithelioma of Malherbe: an analysis of fif- 15. Patil A. Calcifying Odontogenic Cyst - A Case Report. JIDA teen cases. Oral Surgery, Oral Medicine, Oral Pathology 2010; 4(12):547-549. Ed 1962; 15(10):1235-43. 16. Nosrati K, Seyedmajidi M. Ameloblastomatous Calcifying 3. Prætorius F, Hjørting-Hansen E, Gorlin RJ, Vickers RA. Odontogenic Cyst: A Case Report of a Rare Histologic Vari- Calcifying odontogenic cyst. Range, variations and neo- ant. Arch Iranian Med 2009; 12 (4):417-20. IC C © 160 Annali di Stomatologia 2013; IV (1): 156-160 

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Review article Peri-implant mucositis treatments in humans: a systematic review li na Blerina Zeza, DDS, MS Key words: peri-implant mucositis, non-surgical treat- Andrea Pilloni MD, DDS, MS ment, diagnosis parameters, effectiveness evaluation parameters, study in humans. io Department of Stomatology and Maxillofacial Sciences, Chair of Periodontology, Sapienza University of Rome, Italy Introduction az Peri-implant mucositis by definition is the inflammation Corresponding author: confined to peri-implant soft tissues only and is caused by Blerina Zeza, DDS, MS dental plaque accumulation (1-3). It is similar to its coun- n Department of Stomatology and Maxillofacial Sciences, terpart gingivitis (4), but with a stronger response (3), al- Chair of Periodontology, Sapienza University of Rome, Italy though soft tissues appear to be identical around im- er Via Caserta, 6 plants as well as around natural teeth (5). It is present in 00161 Rome, Italy 39.4-80% of patients restored with dental implants (6-8). Phone: +39 3894385231 Only in the USA, counting for 30% of the global market, 1.3-2 million implants are being placed each year (9). Email: bler.jeshil@hotmail.com nt Peri-implant mucositis is reversible (3) but if left untreated it may lead to peri-implantitis. Inflammation progressively and rapidly (10) extends into tissues with weaker de- iI Summary fence mechanisms than periodontal tissues due to lack of Aim. Peri-implant mucositis affects 39.4-80% of pa- periodontal ligament and a reduced number of fibroblasts tients restored with dental implants. If left untreated it and blood vessels (11). Peri-implantitis does not have any on evolves in peri-implantitis. Thus far no predictable suc- predictable successful treatment yet (12), ultimately caus- cessful treatment has been reported for peri-implanti- ing implant failure (5-11%) (13). The clinical importance tis, resulting in implant failure. Proper diagnosis and of peri-implant mucositis early diagnosis and effective treatment of peri-implant mucositis is of crucial impor- treatment is evident. i tance. This study aims to provide a comprehensive re- The main objective of the present study is to provide a sys- iz view of the available data regarding the effectiveness of tematic review and collect data on the quality and quantity peri-implant mucositis treatments in humans, parame- of studies dealing with peri-implant mucositis, the parame- ters used for the diagnosis and treatment effect evalu- ters used for both the diagnosis and the evaluation of treat- Ed ation. ment effects. This information may contribute in designing Materials and methods. A literature search for RCT and a protocol for the diagnosis, treatment effect evaluation observational studies on peri-implant mucositis treat- and guide future studies on data missing on this topic. ments in humans was conducted on Pubmed up to Jan- We chose to enrol only RCTs and observational stud- uary 2012. CONSORT/STROBE and PRISMA checklists ies on humans because: (i) these types of studies pro- guided the evaluation of studies found and the writing of this review, respectively. vide the most reliable data; (ii) the real benefits of med- IC Results. Only 5 studies fulfilled the selection criteria. Few ical intervention can only be ascertained in human possibly effective treatments were studied. Diagnostic studies (14). More specifically, the predictability of the parameters reported were clinical only, while treatment implant treatment and treatment of peri-implant inflam- effect evaluation was based on clinical and microbiolog- mation is related to predisposing factors as well, such as C ical changes, except for one study reporting biochemi- smoking (15), diabetes mellitus (15), oral hygiene and cal analysis. An evident heterogeneity characterized the other, factors that differ between humans and animals follow-up intervals and methods used for reporting pa- (i.e. animals do not smoke or perform domiciliary oral hy- rameters changes. giene); (iii) animal studies are proposed to evaluate © Conclusions. Neither of studied treatments gave com- side effects of a treatment/substance that if not harmful plete resolution of peri-implant mucositis. Different will be further tested in a human population. Peri-implant treatment strategies need to be studied. Authors sug- mucositis treatments are mainly of local non-surgical gest guidelines for a protocol of parameters used for type and previously tested for their effectiveness on pe- determining the sample size, diagnosis and treatment riodontal inflammation or inflammatory systemic dis- effect, as well as follow-up periods, in order to permit eases/disorders. Thus it can be considered safe and evidence and comparison of different treatments effec- more appropriate to study peri-implant mucositis treat- tiveness. ment in humans. Annali di Stomatologia 2012; III (3/4): 83-89 83 B. Zeza et al. Review of the current literature Selection procedure Study selection process was divided in three steps: (i) find Strategies for literature searching and identification articles based on the keywords used; (ii) read abstracts and of studies exclude articles on animals, in vitro studies, narrative stud- Firstly, we searched for the most recent review/meta- ies, reviews and studies on peri-implantitis; (iii) read full text li analysis on peri-implant mucositis treatment. We found articles excluding those which included an incipient loss of one article that compares the outcomes of peri-implant peri-implant bone in the diagnostic criteria, those which did na inflammation treatments in humans with treatments in not report appropriately and fully the follow-up results and animals (14), showing no statistically significant differ- those that did not specify the diagnostic criteria for the peri- ences between the two. This article was considered for implant mucositis. Each selected article was controlled ac- three purposes: (i) to follow similar steps, when possi- cording to the STROBE and CONSORT checklist for ob- io ble, in order to complete this previous work with more re- servational studies and RCT, respectively. Jadad scale cently published evidence; (ii) to guide the aim of our was used for the quantification of the RCTs quality. work in making a more detailed review and meta-analy- sis, if possible, not only focused on the treatment effi- Data selection az cacy, but also on the diagnostic criteria, the influence of From the enrolled articles there were selected data with re- predisposing factors on the efficacy of the treatment gards to the diagnosis (diagnostic parameters) and treat- etc. and (iii) to see if the remarks regarding the small ment of peri-implant mucositis (type of treatment, parame- sample size, the lack of power report and study design ter used for the evaluation, follow-up periods and intervals n heterogeneity have been corrected in the articles pub- of evaluation, treatment effectiveness). Patients selection lished afterwards. criteria and the evaluation of the influence of the predispos- er In a second step a further literature search was con- ing factors (smoking, prosthetic restoration margins, etc.) on ducted in Pubmed up to January 2012 using the key the effectiveness of the treatment were considered as well. words: peri-implant mucositis treatment, peri-implant mu- nt cositis AND laser therapy, peri-implant mucositis AND antimicrobial therapy, peri-implant mucositis AND antibi- otic therapy, peri-implant mucositis AND photodynamic therapy, peri-implant mucositis AND mechanical therapy, Results and discussion Quantity, quality, impossibility to conduct a meta-analysis iI peri-implant mucositis AND vector therapy, peri-implant Peri-implant inflammation has become a great challenge mucositis AND xylitol, peri-implant mucositis AND cran- to periodontology and implantology worldwide. Actually, berry juice therapy/phytotherapy, peri-implant mucositis the only manageable stage of peri-implant inflammation on AND probiotics. is peri-implant mucositis. In the era of evidence-based medicine the clinician takes best decisions for patient Selection limits management based on the best scientific evidence col- Only RCT and observational studies were included. These lected in systematic reviews. Randomized clinical trials i studies were conducted in adult human patients with at are considered the best scientific evidence. The key word iz least one dental implant presenting signs of peri-implant “peri-implant mucositis treatment” corresponds to 56 mucositis (bleeding on probing with absence of peri-im- available scientifically trusted studies, compared to a list plant bone loss) who were treated non-surgically and fol- of 5553 studies on gingivitis treatment. In this scarce lit- Ed lowed-up for at least 3 months. They reported data on the erature even fewer (only 5) were the RCT and observa- modification of the parameters used for the evaluation of tional studies in humans reported according the CON- the effect of the treatment applied. SORT/STROBE checklist (Fig. 1). It was noticed that IC C © Figure 1. Diagram of the article selection process. The articles included in the review were only 5. 84 Annali di Stomatologia 2012; III (3/4): 83-89 Peri-implant mucositis treatments in humans: a systematic review both observational studies were conducted from the same of studies on peri-implant mucositis treatment in humans group of study in populations with approximately the following a similar protocol for the sample size determina- same characteristics. According to Jadad scale the se- tion, diagnosis, treatment effect evaluation and follow-up lected RCTs were of high quality (Tab. 1). We decided to intervals in order to help comparison of the different treat- limit the evaluation of the observation studies to the ments. The quality of future studies should be maintained li STROBE checklist only, as Newcastle-Ottawa-scale va- high. RCTs in periodontics have a median report quality lidity assessment is still under development (16). score of 2 (17). Authors suggest a more updated evalu- na Our first intention was to conduct a meta-analysis to eval- ation of the report quality of researches in periodontics. uate the effectiveness of peri-implant mucositis treat- ment. This was not possible mainly because of the het- Treatment erogeneity characterizing: (i) the type of parameters used Peri-implant mucositis has an infective nature as such its io for the diagnosis and treatment effect evaluation; (ii) the therapy should be anti-infective. Mechanical removal of number of sites chosen for parameters measurement; (iii) dental plaque has been proven to be a successful treat- the way the parameters were expressed, and (iv) the dif- ment but not completely resolving the inflammation (18). ferent follow-up periods and intervals. Consequently adjunctive treatments are proposed. In the az Authors emphasize the need for an increase in quantity selected studies (Tabs. 2, 3) it was reported that the use Jadad scale Heitz-Mayfield et al.,2011 Thöne-Mühling et al.,2010 Ramberg et al., 2009 n 1. Randomisation Reported 1 1 1 er Adequately 1 1 Inadequately Not reported 2. Double-blinding Reported Adequately Inadequately 1 1 nt 1 1 iI Not reported 0 3. Withdrawal/Dropouts on Reported 1 1 1 Not reported Quality point 5 3 4 i Table 1. Jadad scale for quality assessment of RCT (High quality RCT presenting ≥ 3 points). iz * allocation concealment was reported in all the three studies Study Type Power Treatment No of patients/implants Follow-up Ed 80% For a mean difference Heitz-Mayfield et al., 2011 RCT of 1.1mm mechanical treatment +CHX gel vs mechanical 15/15 vs 14/14 3 months in PPD treatment alone between IC groups 78% Thöne-Mühling M et al., 2010 RCT Effect full mouth disinfection vs full mouth mechanical 6/22 vs 5/14 8 months C size 1.4 treatment 80% for a difference Ramberg P. et al., 2009 RCT between 0.3% triclosan dentifrice vs sodium fluoride dentifrice 30 vs 29 6months © groups of 12% for the BOP Màximo MB et al., 2009 Obs P< 0.05 mechanical treatment + abrasive sodium corbonate 12p/16i 3months air-powder Duarte PM et al., 2009 Obs P< 0.05 mechanical treatment + abrasive sodium corbonate 10p/10i 3 months air-powder Table 2. Description of the included studies. Annali di Stomatologia 2012; III (3/4): 83-89 85 B. Zeza et al. of CHX as a gel (19) or mouthrinse in the FMD (20) re- (main parameter chosen for the evaluation of the effect), sulted in improved inflammation signs but not statisti- (ii) the difference of this parameter wanted to be seen be- cally significant to be considered part of the treatment pro- tween groups after treatment application, and (iii) the tocol as adjunctive therapy. On the other hand, sodium power of the study. In the selected studies the parameters carbonate abrasive air powder was demonstrated to be chosen where periodontal probing depth (Heitz-Mayfield li an effective treatment (21,22). Randomized controlled et al., 2011; 80% of power for a 1.1 mm PPD difference be- trials are required on this treatment. Finally, the everyday tween control and test) and bleeding on probing [Ramberg na use of triclosan vs fluoride dentifrice was suggested for et al., 2009 (80% power for a12% difference of BoP be- the reduction of signs and symptoms of peri-implant in- tween groups); Thöne-Mühling et al., 2009 (78% power for flammation (23). In this regard, further studies are needed and effect size of 1.4)], both parameters of periodontitis, on the side effects of the regular use of triclosan dentifrice. counterpart of peri-implantitis (Table 5). io Table 5 summaries the parameters used for the evalua- Peri-implant mucositis presents a stage of inflammation tion of the effectiveness. Authors noticed that no evi- not necessarily associated with increased PPD (10). dence-based explanation was provided in any of the Determining the sample size on a parameter that could studies for the different instruments selected for the me- not be present at all among selected patients could ef- az chanical debridement. fect the final results of the treatment. On the other hand, Further treatments such as photodynamic therapy, local provoked bleeding is always present and it is worldwide chemical therapy, phytotherapy, xylitol therapy, probiotics accepted even as part of the definition of peri-implant therapy previously tested or being studied currently for mucositis (10). To author’s knowledge, marginal bleed- n their effectiveness in gingivitis/periodontitis need to be ing is considered more appropriate than bleeding on evaluated in peri-implant mucositis treatment. Surprisingly probing when dealing with inflammation confined to soft er some of these therapies have been studied as treat- tissues only. Marginal bleeding bears the advantages of ments of peri-implantitis (antibiotic and photodynamic probing depth when compared to other signs of inflam- therapy) rather than peri-implant mucositis. mation. It is an objective sign of inflammation preceding nt The review provided here suggests that the effective- ness of a treatment depends on the type of anti-infective treatment itself, as well as on: (i) the sample size, (ii) pa- rameters selected for the evaluation of the effectiveness, discoloration and swelling, easily measured by inserting an inexpensive instrument (periodontal probe) in the peri-implant/gingival sulcus in an angulation of approx- imately 60° with the long axis of the tooth/implant and iI (iii) proper diagnosis, and (iv) considerations and elimina- running it along the gingival margin. This angulation fa- tion of the local predisposing factors. Thus, further re- cilitates the measurement of the parameter despite the search is needed on already studied treatments as well quality of the prosthesis. Marginal bleeding is a more on as anti-infective treatments hypothesized to be effective sensitive indicator of gingival inflammation and is less for the resolution of peri-implant mucositis. likely to elicit false-positive bleeding than probing to the bottom of the pocket (25). Marginal bleeding can be Sample size, diagnosis and treatment used as the main clinical parameter when determining i effect evaluation parameters the sample size, treatment effect and peri-implant mu- iz Sample size is an important factor when it comes to as- cositis diagnosis. Authors suggest: (i) a four grade mar- sessing the validity of a study. Small sized samples may ginal bleeding index (Newbrun 1997 reporting Mombelli give the impression that treatments compared are equally et al., 1967 classification), (ii) measured in six sites per Ed effective as long as statistically significant difference is implant, (iii) reported as mean value of the implant, (iv) missing (14). calculating the number of sites presenting each grade of Sample size is determined based on: (i) the parameter BoP (19), to evaluate the reversibility of mucositis (% of wanted to be positively influenced by the applied treatment sites completely recovered). IC Study Age (mean ± SD) Gender F:M Periodontal history Smoking General health exclusions Heitz-Mayfield T/57 C/53 T/6:8 C/9:6 Untreated periodontitis, T/2 C/2 healthy C et al., 2011 FMNS>25% Thöne-Mühling M T/46.3 C/53.3 T/2:4 C/1:4 Untreated periodontitis T/3 C/2 healthy, no antibiotics et al., 2010 ±10.1 ±11.3 within the last 6 month © Ramberg P. T/57 ± 7 C/58 ± 8 T/20:10 C/19:10 Untreated periodontitis not reported healthy, no antibiotics et al., 2009 within the last 1 month Màximo MB 55.8±17 8F:4M Untreated periodontitis non smokers healthy, non antibiotics et al., 2009 within the last 6 months Duarte PM 55.8±17 6F:4M Untreated periodontitis non smokers healthy, no antibiotics et al., 2009 within the last 6 month Table 3. Demographic data. 86 Annali di Stomatologia 2012; III (3/4): 83-89 Peri-implant mucositis treatments in humans: a systematic review Furthermore, dealing with patients that smoke, studies Predisposing etiologic factors should consider that smoking interferes with the bleeding Dental plaque is worldwide accepted as the etiologic fac- response of soft tissues, consequently smokers and non- tor of peri-implant mucositis. The quantity of plaque, neither smokers when included in the protocol should be its dichotomous presence, are necessarily related with the analysed separately (24). None of the studies (except presence of inflammation (25). The total bacterial count or li Duarte et al., 2009 and Maximo et al., 2009 that ex- proportion of different complexes, or even specific types of cluded smokers) made such a separation or mentioned microorganism can be analysed, but the presence of pu- na smoking cessation counciling as part of the therapy. tative periodontal pathogens around teeth does not neces- Proper diagnosis influences the effect of treatment. Non sarily lead to periodontal tissue breakdown (26). surgical treatment is effective on mucositis but not on Only three studies reported microbiological effect evalu- peri- implantitis. The lack of peri-implant bone loss and ation (19-21). After treatment, a microbiological equilib- io suppuration were unanimously chosen as differential di- rium compared to the baseline was noticed (19, 20). One agnosis of peri-implant mucositis from peri-implantitis. study evaluated the influence of local predisposing factors The reported diagnostic parameters (Tab. 4), clinical on treatment effect (19) while only the observational stud- only, were PPD ≥ 4mm (23), BoP (all selected studies) ies (21, 22) explicitly included the elimination of this fac- az and GI (20). In the enrolled studies no treatment gave a tors as treatment plan. complete resolution of the inflammation on the entire Once it is professionally removed the continuing pres- sample chosen. 38% (19) and 56.3% patients showed ence of dental plaque depends on patient’s compliance, absence of BoP at 3 months after treatment with CHX gel and persistence of local predisposing factors such as n and abrasive sodium carbonate air-powder respectively. overcontoured restoration margins and other plaque re- This could be related to various factors, such as im- tentive factors. Local treatment is suggested to include er proper sample size, ineffective treatment, persistence of the elimination or modification of local predisposing fac- predisposing factors etc. Authors speculate that even tors. The further presence of plaque suggests lack of within peri-implant mucositis different stages could be compliance. Authors suggest the use of mPIl, measured compared to a more incipient stage. Biochemical nt distinguished. Perhaps if the inflammation reaches a specific stage, it does not respond equally positively if changes appear earlier than clinical changes in an inflam- in 6 sites, to reinforce oral hygiene in specific sites where more needed. Dental plaque indexed or microbi- ological measurements seems to be more appropriate for patient compliance monitoring and identification of lo- iI matory process. Further-more, based on the latest re- cal retentive factors than for the diagnosis or treatment ports peri-implant mucositis reversibility after 3 weeks of effect evaluation of the presence of inflammation around treatment is only biochemical indicating that clinical re- implants. on covery takes a longer time to be established (3). Authors speculate that the identification of inflammatory media- Follow-up period and intervals tors would be important in the diagnosis of incipient Follow-up periods varied from 3 months (19, 21,22) to 6 stages of peri-implant mucositis and treatment effect months (23) and 8 months (20), emphasizing that in none i evaluation. Only one study reported biochemical changes of the studies the interval or the follow-up selected was iz after treatment applied (23), concluding that the levels of explicitly justified. Follow-ups differed not only in length TNF-a and the OPG/RANKL ratio may be modulated by but evaluation intervals as well. Actually, the 1st month re- the treatment. Further studies are needed on this regard sults were reported only in two studies (19,20), 2nd, 4th and Ed and on the type of inflammatory mediators that could be 8th month only in the Thöne-Mühling et al., 2010 study, the the more appropriate for this purpose (see existing stud- 6th month only in the Ramberg et al., 2009 and the 3rd ies on AST, IL-1, etc.) (Tab. 5). month from four studies (19,21-23). Study Bleeding Marginal Gingival Periodontal Suppuration Bone loss IC on probing bleeding index probing depth Heitz-Mayfield et al., 2011 Dichotomous absence Thöne-Mühling M et al., 2010 Dichotomous GI≥ 1 at least at absence 2 C at least at one site one site at baseline Ramberg P. et al., 2009 Dichotomous PPD≥4mm absence © Màximo MB et al., 2009 Dichotomous Dichotomous absence absence Duarte PM et al., 2009 Bop: 15 seconds after gentle probing Dichotomous absence absence1 (Dichotomous) Table 4. Diagnosis of the peri-implant mucositis in the included studies. MB: Marginal bleeding: presence (score 1) or absence (score 0) of bleeding obtained by running a probe along the soft tissue margin without probe penetration inside the sulcus or pocket. Dichotomous: presence(1)/absence(0). (2) Absence of bone loss during the last 2 years before baseline of the study. (1) Peri-apical intraoral radiographs were obtained for each implant baseline using the paralleling technique and a radiographic positioner. The radiographs were analyzed for peri-implant bone loss by the same examiner (PMD) using abutments and the threads of the implants as reference points. Annali di Stomatologia 2012; III (3/4): 83-89 87 B. Zeza et al. Study Intervals PPD BOP MB PI MO analysis BCH analysis CAL Form Form Heitz-Mayfield et al., 2011 Baseline/ Sum of Mean number Socransky 1 month PPD(mm) of sites with BOP et al 1998 li 3 months in 4 sites + S. aureus na Thöne-Mühling M et al., 2010 Baseline/ Mean mBI Sillnes & Loe, PCR 1/2/4/8 PPD(mm) 1964 months In 4 sites Ramberg P. et al., 2009 Baseline/ Mean Mean % of sites Mean % of impl io 6 months PPD (mm) with BOP surf harbouring In 4 sites plaque az Màximo MB et al., 2009 Baseline/ Mean Mean % of sites Mean % of Ainamo Socransky 3 months PPD (mm) with BOP sites with MB & Bay, 1975 et al, 1998 In 6 sites DNA-DNA hybridization n Duarte PM et al., 2009 Baseline/ Mean Mean % of sites Mean % of Ainamo & IL-4, -10, -12, 3 moths PPD (mm) with BOP sites with MB Bay, 1975 TNF-α, OPG, RANKL In 6 sites er Table 5. Parameters for the evaluation of the effect of treatments applied. nt The clinical relevance of the follow-up period is to deter- mine in terms of time: (i) the evidence of the treatment ef- fect, (ii) the duration of this effect, and (iii) the frequencies Acknowledgement This study had no financial support. Authors report no iI of the follow-up visits in the maintenance phase. It has conflict of interest. been demonstrated that 3 weeks after plaque removal only biochemical reversibility could be detected (3). Fur- on thermore, re-evaluation after non-surgical therapy is sug- Clinical relevance gested 6-8 weeks after the last step of initial phase of treatment to permit tissue healing almost completed at 3 Peri-implant mucositis treatment is the only way to prevent months (27). In the enrolled studies it was noticed that sta- the establishment of peri-implantitis and consequent im- i tistically important improvements could be detected in the plant loss. This review provided a summary of the avail- iz first month after treatment, not always followed by simi- able data on peri-implant mucositis treatment. It was no- lar improvement in the subsequent evaluations. Authors ticed little evidence on this matter and a lack of studies on suggest that when evaluating the treatment effect prior to various possibly effective treatments. The comparison of Ed 6-8 weeks, the least invasive methods, such as biochem- the existing studies showed an evident heterogeneity. ical evaluation, should be chosen. For one single applica- This observations were used to guide a protocol on future tion treatments, authors find it reasonable to be followed studies on peri-implant mucositis treatment. up for 3 months. A longer follow-up period would reflect more the quality of the domiciliary oral hygiene rather than to the direct effect of the treatment applied. References IC 1. Pontoriero R, Tonelli MP, Carnevale G, Mombelli A, Nyman SR, Lang NP. Experimentally induced peri-implant mucosi- Conclusion tis. Aclinical study in humans. Clin Oral Imlants Res 1994; 5: C 254-259. Peri- implant mucositis is accepted as a reversible and 2. Zitzmann NU, Berglundh T, Marinello CP, Lindhe J. Experi- treatable stage of inflammation, worldwide. From the few mental peri-implant mucositis in man. J Clin Periodontol high quality studies found on this topic, none reported 2001; 28: 517-523. complete treatment of the patient. Authors emphasized 3. Salvi GE, Aglietta M, Eick S, Sculean A, Lang NP, Ramseier © the need for a stronger evidence base, encouraging future CA. Reversibility of experimental peri-implant mucositis com- studies on peri-implant mucositis treatment following ba- pared with experimental gingivitis in humans. Clin Oral Im- plants Res 2012; 23: 182-190. sically a similar evidence-based protocol regarding study 4. Lang NP, Bosshardt DD, Lulic M. Do mucositis lesions design, sample size, diagnostic and effectiveness pa- around implants differ from gingivitis lesions around teeth? rameters and follow-ups. The heterogeneity characteriz- J Clin Periodontol 2011; 38:182-187. ing the existing studies was previously reported by Fag- 5. Schüpbach P, Glauser R. The defence architecture of the hu- gioni et al., 2010. Some of the enrolled studies on the man peri-implant mucosa: a histological study. J Prosthet present review were published afterwards, but we confirm Dent 2007; 97:S15-25. the same observation. 6. Rinke S, Ohl S, Ziebolz D, Lange K, Eickholz P. Prevalence 88 Annali di Stomatologia 2012; III (3/4): 83-89 Peri-implant mucositis treatments in humans: a systematic review of peri-implant disease in partially edentulous patients: a 18. Renvert S, Roos-Jansåker AM, Claffey N. Non-surgical treat- practice-based cross-sectional study. Clin Oral Implants Res ment of peri-implant mucositis and peri-implantitis: a litera- 2011; 22:826-33. ture review. J Clin Periodontol 2008; 35:305-15. 7. Koldsland OC, Scheie AA, Aass AM. Prevalence of peri-im- 19. Heitz-Mayfield LJ, Salvi GE, Botticelli D, Mombelli A, Faddy plantitis related to severity of the disease with different de- M, Lang NP. Anti-infective treatment of peri-implant mucosi- grees of bone loss. J Periodontol 2010; 81:231-8. tis: a randomised controlled clinical trial. Clin Oral Implants li 8. Zitzmann NU, Berglundh T. Definition and prevalence of Res 2011; 22:237-41. peri-implant diseases. J Clin Periodontol 2008; 35: 286-91. 20. Thöne-Mühling M, Swierkot K, Nonnenmacher C, Mutters R, na 9. Goszkowski R. Down but not out: Implant makers navigate Flores-de-Jacoby L, Mengel R. Comparison of two full-mouth economic storm. This week in Perio 2011; 3 October. approaches in the treatment of peri-implant mucositis: a pi- 10. Lang NP, Berglundh T. Peri-implant diseases: where are we lot study. Clin Oral Implants Res 2010; 21:504-12. now? J Clin Periodontol 2011; 38:178-181. 21. Máximo MB, de Mendonça AC, Renata SV, Figueiredo LC, 11. Berglundh T, Abrahamsson I, Welander M, Niklaus PL, Feres M, Duarte PM. Short-term clinical and microbiological io Lindhe J. Morphorgenesis of the peri-implant mucosa: an ex- evaluations of peri-implant diseases before and after me- perimental study in dogs. Clin Oral Implants Res 2007;18:1- chanical anti-infective therapies. Clin Oral Implants Res 8. 2009; 20:99-108. az 12. Faggion CM Jr, Listl S, Tu YK. Assessment of endpoints in 22. Duarte PM, de Mendonça AC, Máximo MB, Santos VR, studies on peri implantitis treatment- a systemic review. J Bastos MF, Nociti FH. Effect of anti-infective mechanical Dent 2010; 38; 443-450. therapy on clinical parameters and cytokine levels in human 13. Norowski PA, Bumgardner JD Jr. Biomaterial and antibiotic peri-implant diseases. J Periodontol 2009; 80:234-43. strategies for peri-implantitis. J Biomed Materials Res Part B: 23. Ramberg P, Lindhe J, Botticelli D, Botticelli A. The effect of n Applied Biomaterials 2010; 88; 530-543. a triclosan dentifrice on mucositis in subjects with dental im- 14. Faggion CM Jr, Chambrone L, Gondim V, Schmitter M, Tu plants: a six-month clinical study. J Clin Dent 2009; 20: 103- er YK. Comparison of the effects of treatment of peri-implant in- 107. fection in animal and human studies: systematic review and 24. Newbrun E. Indices to measure gingival bleeding. J Peri- meta-analysis. Clin Oral Implants Res 2010; 21:137-47. odontol 1996; 67:555-561. 15. Anner R, Grossmann Y, Anner Y, Levin L. Smoking, diabetes 25. Trombelli L, Scapoli C, Calura G, Tatakis DN. Time as a fac- nt mellitus, periodontitis, and supportive periodontal treatment as factors associated with dental implant survival. A long-term retrospective evaluation of patients following up to 10 years. Implant Dent 2010; 19; 56-64. tor in the identification of subjects with different susceptibil- ity to plaque-induced gingivitis. J Clin Periodontol 2006; 33: 324-328. 26. Quirynen M, Vogels R, Peeters W, van Steenberghe D, iI 16. Stang A. Critical evaluation of the Newcastle-Ottawa scale for Naert I, Haffajee A. Dynamics of initial subingival coloniza- the assessment of the quality of nonrandomized studies in tion of “pristine” peri-implant pocket. Clin Oral Implants Res meta-analyses. Eur J Epidemiol 2010; 25:603-605. 2006; 17: 25-37. on 17. Sjögren P, Halling A. Quality of reporting randomised clinical 27. Lindhe J, Lang NP, Karring K. Clinical Periodontology and Im- trials in dental and medical research. Br Dent J 2002; plant Dentistry. 5th edition, p. 688, p. 774; 2008: Oxford. 192;100-103. Blackwell Munksgaard. i iz Ed IC C © Annali di Stomatologia 2012; III (3/4): 83-89 89 

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Original article Cognitive experience of oral cancer among young people of “Sapienza” University of Rome li na Livia Ottolenghi, DDS1 where there is a lack of knowledge concerning oral Umberto Romeo, DDS1 cancer prevention. io Francesco Carpenteri, DDS1 Sergio Fiorentini, Student1 Keywords: oral cancer, prevention, late diagnosis. Dimitri Boatta, Student1 Anna Rita Vestri, MD2 az Ersilia Barbato, DDS1 Introduction Antonella Polimeni, MD1 Oral cancer is one of the most common cancers world- wide and is highly invasive and debilitating. With approx- n Sapienza University of Rome, Italy imately 6000 new cases per year in Italy, oral cancer 1 Faculty of Medicine and Dentistry, Department represents a public health problem. Squamous cell car- er of Odontostomatological and Maxillofacial Sciences cinoma of the oral cavity represents about 2% of all ma- 2 Faculty of Pharmacy and Medicine, Department lignant neoplasms and 47% of those developing in the of Public Health and Infectious Diseases head and neck area, with survival rates that are among the lowest of all major cancers. More deadly than breast Corresponding author: Francesco Carpenteri, DDS nt cancer, cervical cancer and prostate cancer, oral cancer was estimated to kill one person every hour, every day (1,2). The tongue is the most common site involved, and iI Faculty of Medicine and Dentistry, Department this incidence is increasing mainly in young people, pos- of Odontostomatological and Maxillofacial Sciences, sibly related to human papilloma virus infections. Progno- Sapienza University of Rome, italy sis depends on the stage: the 5-year survival rate of on Largo Beltranelli, 36 tongue squamous cell carcinoma, whatever the T stage, 00157 Rome, Italy is 73% in pN0 cases, 40% in patients with positive nodes Phone: +39 06 89571787 without extracapsular spread (pN1 ECS–), and 29% when Email: francescocarpenteri@gmail.com nodes are metastatic with extracapsular spread (pN1 i ECS+: p ≥ 0.0001) (3-6). iz These statistics are dramatic, especially if we consider Summary that the disease arises in the foreground on the oral mu- Aims: the aim of this study was to analyse the awareness cosa, which is easily accessible to endoral objective ex- Ed of oral cancer among young adults in the city of Rome. amination. Thus, the lesions are ignored or not observed Materials and methods: during the orientation period by patients or healthcare professionals. In part, the late di- for new graduates students, or “Porte aperte“, organised agnosis may result from an incomplete understanding or by the Sapienza University of Rome in July 2009 and a lack of awareness that small asymptomatic lesions 2010, a survey among young people regarding their have a significant malignant potential. knowledge on the risk factors, the importance of early di- Furthermore, a delay in diagnosis or monitoring of the dis- IC agnosis, and the methods for primary and secondary ease in advanced stages may be caused by the patient prevention of oral cancer was conducted. A total of 1125 or health personnel (7). Health education with programs questionnaires were administered to subjects who designed to motivate patients to undergo periodic checks agreed to respond to assess the level of knowledge of are the best way to promote prevention (8). C the disease. Dental health care providers play a key role in the preven- Results: only 45.3% of the sample population was aware tion of oral cancer; these health workers, with the detec- of the existence of oral cancer; among these individuals, tion of neoplastic disease and the proper health educa- 36.9% did not perceive seriousness of the malignancy. tion, contribute to the reduction of poor outcomes from this © High school students who attended a scientific high school knew the risk factors better than the students serious disease. Recent research conducted in a group who attended classical and technical high school. of Italian cancer centres demonstrated that an average of Conclusions: rigorous educational programs along with 6 months elapses between the diagnosis of cancer and diagnostic strategies promise to reduce the burden of the start of an appropriate therapy, a period that irre- oral cancer. The data obtained from this study highlight versibly influences the therapeutic approach to this dis- the need to increase health education, especially ease. It is reasonable that all patients who present symp- among young people in humanistic or technical high toms of suspected neoplastic nature have access to a schools and universities (Classical High School, Tech- specialist visit no later than 2 weeks from the first contact nical Institutes, Faculty of Letters, Faculty of Law) with services and to have a definitive diagnosis no later 106 Annali di Stomatologia 2012; III (3/4): 106-112 Cognitive experience of oral cancer among young people of “Sapienza” University of Rome than one month (objective set by the British National Faculty of Medicine and Odontology. This group admin- Health Service in relation to time considered desirable in istered 1125 questionnaires to subjects who agreed to cancer diagnos) (9). Currently, early diagnosis is, for participate (661 subjects in 2009 and 464 subjects in many neoplastic diseases, essential to achieve good 2010) to assess the knowledge of oral disease within this therapeutic results, with a positive impact in terms of not population. Data were collected regarding the type of li only prolonged survival but also improved quality of life work or study activities, the age of population, the pres- (10,11). An early cancer diagnosis made when the dis- ence of doctors in the family context and the possibility to na ease is not at an advanced stage allows the possibility to made preventive specialist check-ups (Tabs.1-4). offer the patient surgical techniques that are less invasive Afterwards informational brochures (13) were distributed and destructive. to the students illustrating the incidence of various risk fac- Thus, early diagnosis represents an important chapter of tors, the general characteristics of the disease, the signs io cancer care that must be solved by services through two and symptoms and what to do when they are present. Our different points of view: work has focused on risk factors that the international sci- - the view of a single patient who presents as a “sus- entific literature indicates as being the most involved in the pect case” with the target of rapid diagnosis, obtained aetiopathogenesis of oral cancer, i.e., smoking, alcohol az through a careful clinical examination by operators and sunlight (14-23). able to identify the symptoms that qualify the patient as the bearer of a possible tumour; - the view of the whole population whose goal is early Statistical analysis n diagnosis when the disease has not yet clinically manifested itself by offering participation in screening The data are reported using frequency counts and per- er programs. centages. To evaluate the possible associations between This project, was set-up as a campaign to raise aware- variables the chi-squared test or the Fisher’s exact test ness of such a disease that, despite being serious, is only were used, where appropriate. Tests are adjusted for all little known to the general public. Materials and methods nt pairwise comparisons within a row of each innermost subtable using the Bonferroni correction. The statistical significance was set at 5%, and the analysis was con- ducted with SPSS v13. iI In the orientation period for high school graduates stu- dents, organised by the Sapienza University of Rome in Results on July 2009 and 2010, a survey among young people was conducted. The survey concerned the knowledge of risk A total of 1125 questionnaires were completed, which factors, importance of early diagnosis, and the methods could be divided into the following populations: 248 work- of primary and secondary prevention of oral cancer (12). ers (22.1%), 402 High School students (35.7%), and 475 i During the three days of the “Porte aperte alla Sapienza”, University students (42.2%). iz a team of students enrolled to the degree course of Den- The High School students were further subdivided into the tistry has been working at the stand dedicated to the following groups: 130 from Classical High School (11.6%), Ed Category Frequency Percentage High School students 402 35.7 Classical High School 130 11.6 IC Scientific High School 167 14.8 Technical High School 105 9.3 University students 475 42.2 C Law 122 10.8 Letters and Philosophy 118 10.5 Medicine and Surgery 112 10.0 © SMFN* 123 10.9 Other 248 22.1 Total 1125 100 *Faculty of Mathematical, Physical and Natural Sciences Table 1. Sample composition. Annali di Stomatologia 2012; III (3/4): 106-112 107 L. Ottolenghi et al. Type Activities Mean N SD Median Minimum Maximum Workers 37.35 248 7.786 37.00 24 61 High School students 18.75 402 1.097 19.00 16 25 li University students 21.79 475 2.462 21.00 18 29 na Total 24.13 1125 8.219 21.00 16 61 Table 2. Sample age. io Question Frequency Percentage az 1. Have you ever heard about the oral cancer? No 615 54.7 Yes 510 45.3 Tot. 1125 100.0 n 2. Oral cancer is a benign or malignant tumour? Malignant 493 43.8 er Benign 83 7.4 Do not know 549 48.8 Tot. 1125 100.0 nt 3. Smoking may increase the risk of developing oral cancer? No Yes Do not know 24 903 198 2.1 80.3 17.6 iI Tot. 1125 100.0 4. Alcohol may increase the risk of developing oral cancer? No 194 17.2 on Yes 474 42.2 Do not know 457 40.6 Tot. 1125 100.0 5. A long exposure to sunlight may contribute No 317 28.2 i iz to the onset of oral cancer? Yes 230 20.4 Do not know 578 51.4 Tot. 1125 100.0 Ed 6. Early diagnosis of oral cancer may help? No 8 0.7 Yes 893 79.4 Do not know 224 19.9 Tot. 1125 100.0 IC 7. Do you know that you can make a visit for prevention No 638 56.7 of oral cancer? Yes 487 43.3 Tot. 1125 100.0 C 8. Have you ever made a dentist’s visit for prevention No 1093 97.2 of oral cancer? Yes 32 2.8 Tot. 1125 100.0 © 9. Has your dentist ever proposed a prevention visit to you? No 1102 98.0 Yes 23 2.0 Tot. 1125 100.0 10. Do you think that it is helpful to make a prevention visit No 30 2.7 even if there are no symptoms? Yes 908 80.7 Do not know 187 16.6 Tot. 1125 100.0 Table 3. Questionnaire administered. 108 Annali di Stomatologia 2012; III (3/4): 106-112 Cognitive experience of oral cancer among young people of “Sapienza” University of Rome 167 from Scientific High School (14.8%), and 105 from The highest results were obtained among the University Technical High School (9.3%). The university students students of scientific faculties, which largely knew about were further subdivided into the following groups: 122 fre- oral cancer (74% Faculty of Medicine and Surgery; 65% quented the Faculty of Law (10.8%), 118 the Faculty of Faculty of Mathematical, Physical and Natural Sciences). Letters and Philosophy (10.5%), 112 the Faculty of Med- A university education increases knowledge of oral can- li icine and Surgery (10.0%), and 123 the Faculty of Math- cer in a statistically significant way in comparison with the ematical, Physical and Natural Sciences – SMFN high school students (p<0.0001) (Tabs. 3,5). na (10.9%). Of those interviewed, 81.2% identified smoking as a risk Of the entire study population, 45.3% (510 subjects) factor, with the highest values found in areas of scientific knew of the existence of oral cancer; among these, 36.9% study (91.1% Faculty of Medicine and Surgery; 86.2% (444 subjects) do not perceive the seriousness of the ma- Faculty of Mathematical, Physical and Natural Sciences). io lignancy. There is a statistically significant difference in the Knowledge of oral cancer was found to be lower in sub- perception of malignancy between those ones who have jects with humanistic preparation (73.8% Faculty of Law; heard about oral cancer and those who have not 73.7% Faculty of Letters and Philosophy). Although smok- (p<0.0001). Importantly, having a family member who ing was perceived by the population as a clear risk fac- az practices a medical discipline significantly improved tor in the aetiopathogenesis of oral cancer, it should be knowledge of the disease (54.3%) (p<0.0001) (Tab.4). emphasised that alcohol and sunlight were less known n Question 1: Have you ever heard about oral cancer? No Yes er Frequency Percentage Frequency Percentage Question 2: Oral cancer is a benign or malignant tumour? nt Malignant Benign 171 56 27.8 9.1 322 27 63.1 5.3 iI Do not know 388 63.1 161 31.6 Tot. 615 100.0 510 100.0 on Presence of family members who practice medical disciplines No 478 77.7 347 68.0 Yes 137 22.3 163 32.0 Tot. 615 100.0 510 100.0 i Table 4. Knowledge of oral cancer in the sample. iz Question 1: Have you ever heard about oral cancer? Ed No Yes Category Frequency Percentage Frequency Percentage High School students 256 41.6 146 28.6 IC Classical High School 68 11.1 62 12.2 Scientific High School 123 20.0 44 8.6 Technical High School 65 10.5 40 7.8 C University stundents 221 35.9 254 49.8 Law 79 12.8 43 8.4 Letters and Philosophy 70 11.4 48 9.4 Medicine and Surgery 29 4.7 83 16.3 © SMFN * 43 7 80 15.7 Other 138 22.5 110 21.6 Total 615 100.0 510 100.0 *Faculty of Mathematical, Physical and Natural Sciences Table 5. Knowledge of oral cancer per category. Annali di Stomatologia 2012; III (3/4): 106-112 109 L. Ottolenghi et al. factors. Of those interviewed, 42.4% (for alcohol) and tor in their family recognised smoking as a risk factor, 21.1% (for sunlight) considered these factors as possible 50.3% recognised alcohol and 24.3% identified expo- causes of oral cancer. sure to sunlight as a risk factor. Among the High School students, those who attended a Regarding the prevention of oral cancer, only 43.3% (487 scientific high school had a greater knowledge of the risk of 1125 interviewed subjects) were aware of the possibil- li factors than those who attended a Classical High School ity of preventive health screenings, whereas 80.7% (908 or Technical High School. More specifically, with regard to of total) recognised this as a useful event even in the ab- na smoking, 83.2% of scientific high school students identi- sence of symptoms; however, only 2.8% (32 subjects of fied smoking as a clear risk factor compared with 76.9% 1125) had received a specialist check, with 12.5% (4 of those who attended classical high school. There is a subjects of 32) of these interviewed students having re- statistically significant difference of knowledge of the risk ceived a specialist check due to suggestions from their io factor “smoke“ between the humanistic studies (Classical dentist. In our population, only 2% (23 subjects out of High School, Faculty of Letters) and scientific studies 1125) were asked by their own dentist to make a visit for (Scientific High School, Faculty of Medicine and Sur- the prevention of oral cancer. gery) (p = 0.0399). az Importantly, even among high school students, there is a lower perception of the importance of alcohol and sunlight Discussion and conclusions as possible aetiologic factors. Thus, alcohol is recognised as a risk factor by 51.5% of Scientific High School students In general, knowledge of oral cancer is poor among the n compared with 38.1% of the students attending Technical interviewed people, and the majority of the population was High School and 43.8% of the students attending Classi- not aware of the existence of oral cancer. Importantly, it er cal High School. There is a statistically significant differ- should be noted that high school or university courses that ence of knowledge of the risk factor “alcohol” between Sci- specialise in scientific branches provide significantly bet- entific and Technical High School (p = 0.0331). ter awareness of the disease and its risk factors to stu- nt Finally, sun exposure is known as a risk factor by 28.1% of students in Scientific High School compared with 18.5% of the students in Classical High School and 13.3% of the students in Technical High School. There is a statistically dents enrolled in these courses. In addition, individuals with doctors in the family have a better perception of the disease than the rest of the sample. Recently in Italy, knowledge of cancer prevention has iI significant difference of knowledge of the risk factor “sun- spread widely, especially regarding lung or breast cancer, light“ between the humanistic studies (Technical High for which check-ups and preventive instrumental tests are School, Faculty of Letters) and scientific studies (Scien- regularly performed in the population. This culture of pre- on tific High School, Faculty of Medicine and Surgery). vention is absent for oral cancer, as evident from the re- (p = 0.0057) (Graphs 1,2,3). sults of the study. Therefore, it is crucial to inform and ed- Additionally, having a doctor in the family can improve the ucate the public regarding this serious disease: if this knowledge of the risk factors involved in oral cancer. In tumour is known and monitored with regular check-ups, i fact, 88.3% of the interviewed students who have a doc- it can be prevented or treated effectively. iz Ed IC C © Graphic 1 - Perception of smoking as a risk factor among the subjects who reported being aware of oral cancer. (QUESTION 3 = Smoking may increase the risk of developing oral cancer?) 110 Annali di Stomatologia 2012; III (3/4): 106-112 Cognitive experience of oral cancer among young people of “Sapienza” University of Rome li na io n az er nt iI Graphic 2 - Perception of alcohol as a risk factor among the subjects who reported being aware of oral cancer. (QUESTION 4 = Alcohol may increase the risk of developing oral cancer?) i on iz Ed IC C © Graphic 3 - Perception of sunlight as a risk factor among the subjects who reported being aware of oral cancer. (QUESTION 5 = A long exposure to sunlight may contribute to the onset of oral cancer?) Annali di Stomatologia 2012; III (3/4): 106-112 111 L. Ottolenghi et al. The prevention of oral cancer has a major role in dental Rapido accesso alla diagnosi per il paziente con sospetta pa- practice. Due to the identification of malignant disease tologia oncologica. and a proper health education, health care professionals 10. Yellowitz JA, Horowitz AM, Drury TF, Goodman HS. Survey can contribute to decreasing the prevalence of this seri- of US dentists’ knowledge and opinions about oral pharyn- geal cancer. J Am Dent Assoc 2000;131:653-661. ous disease. 11. Sciubba JJ. Improving detection of precancerous and cancer- li The data obtained from this study highlight the need to ous oral lesions. Computer-assisted analysis of the oral increase health education, especially among younger brush biopsy. US Collaborative OralCDx Study Group. J Am na people in high schools and university faculties, with hu- Dent Assoc 1999 130:1445-1457. manistic or technical programs, in which the knowledge 12. www.nidcr.nih.gov/OralHealth/Topics/OralCancer/Detectin- regarding prevention is more limited. A delay in the diag- gOralCancer.htm nosis and a long waiting period prior to a confirmed di- 13. www.nidcr.nih.gov/OralHealth/Topics/OralCancer/Oral- Cancer.htm io agnosis favour the progression of the tumour to a more advanced stage, placing the life of the patient at serious 14. Nagler R, Ben-Izhak O, Savulescu D, Krayzler E, Akrish S, Leschiner S et al. Oral cancer, cigarette smoke and mito- risk. chondrial 18kDa translocator protein (TSPO) - In vitro, in vivo, Currently, early diagnosis for many neoplastic diseases is az salivary analysis. a prerequisite to achieve good therapeutic results, with a Biochim Biophys Acta. 2010 May;1802(5):454-61. Epub 2010 positive impact in terms of prolonged survival and im- Jan 18. proved quality of life. 15. Tsai KY, Su CC, Lin YY, Chung JA, Lian IeB. Quantification of betel quid chewing and cigarette smoking in oral cancer n patients. References Community Dent Oral Epidemiol 2009; 37: 555-561. er 16. Sasco AJ, Secretan MB, Straif K. Tobacco smoking and 1. Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Can- cancer: a brief review of recent epidemiological evidence. cer statistics. CA Cancer J Clin 2007;57(1):43-66. Lung Cancer 2004, 45 (Suppl 2) S3-S9. 2. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T et al. Can- 17. Petti S, Scully C. Polyphenols, oral health and disease: A re- 3. nt cer statistics. CA Cancer J Clin 2008;58(2):71-96. Mashberg A, Samit AM. Early detection, diagnosis, and man- agement of oral and oropharyngeal cancer. CA Cancer J Clin 18. view. J Dent. 2009 Jun;37(6):413-23. Epub 2009 Mar 19. Ogden GR, Wight AJ. Aetiology of oral cancer: alcohol. Br J Oral Maxillofac Surg 1998;36:247-51. iI 1989;39:67-88. 4. Calabrese L, Bruschini R, Ansarin M, Giugliano G, De 19. Wight AJ, Ogden GR. Possible mechanisms by which alco- Cicco C, Ionna F et al. Role of sentinel lymph node biopsy hol may influence the development of oral cancer. A review. in oral cancer. Acta Otorhinolaryngol Ital. 2006 Dec;26(6): Oral Oncol 1998;34:441-7. on 345-9. 20. Petti S, Scully C. Oral cancer: The association between na- 5. Silverman S, Gorsky M. Epidemiologic and demographic tion-based alcohol-drinking profiles and oral cancer mortal- update in oral cancer: California and national data, 1973- ity. Oral Oncol. 2005 Sep;41(8):828-34. 1985. J Am Dent Assoc 1990;120:495-9. 21. Markopoulos A, Albanidou-Farmaki E, Kayavis I. Actinic cheilitis: clinical and pathologic characteristics in 65 i 6. http://www.registri-tumori.it cases. iz 7. Bilancetti M. La responsabilità penale e civile del medico, CEDAM, Padova, 2000. Oral Diseases 2004, 10, 212-216. 8. Messadi DV, Wilder-Smith P, Wolinsky L. Improving oral 22. Schwartz RA. Therapeutic perspectives in actinic and other cancer survival: the role of dental providers. J Calif Dent As- keratoses. Ed soc. 2009 Nov;37(11):789-98. Int J Dermatol 1996, 35: 533-538. 9. SNLG-ISS (Sistema Nazionale Linee Guida - Istituto Supe- 23. Barnaby JWJ, Styles AR, Cockerell CJ. Actinic keratoses: dif- riore di Sanità). http://www.snlg-iss.it/PNLG/LG/001onco/a- ferential diagnosis and treatment. Drugs Aging 1997, 11: introd.htm 186-205. IC C © 112 Annali di Stomatologia 2012; III (3/4): 106-112 

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Original article Influence of occlusal splint on competitive athletes performances li na Vittorio D’Ermes, MD, PhD3 cal-thoracic-lumbar spine with occasional associations Mario Basile, MD2 to the sacred girdle, the pelvic girdle, hip joints, knees and io Alessandro Rampello, MD2 toes. The maintenance of good postural balance be- Carlo Di Paolo, MD1 tween all these segments allows the human body to maintain a feasible and ergonomic energy efficiency. This postural balance facilitates the dynamic functions (7), az 1 Associate Professor Head Responsible of Unit which is particularly important in the presence of struc- of Clinical Gnathology - Department of Oral and tured subjects and qualitatively active persons such as Maxillofacial Sciences, Sapienza University of Rome high level competitive athletes. 2 Private Professional Dentists in Rome Several studies have been proposed with the aim to high- n 3 Department of Oral and Maxillofacial Sciences light correlations between the dento-mandibular apparatus Sapienza University of Rome and the skeletal muscle system of the human body even er in regions distant from the oral cavity (4,6,29,32,33). The first scientific studies were based on dental kinesiol- Corresponding author: ogy, which was first developed in America in the mid-nine- Vittorio D’Ermes, MD, PhD Department of Oral and Maxillofacial Sciences Sapienza University of Rome Via Caserta 6 nt teenth century by Daniel David Palmer (1895). Today, fur- ther insights have led to the development of applied kinesiology, which earnings precise attention to the tem- poromandibular joint (TMJ) (8-10). iI 00162 Roma, Italy In a work presented by Gelb in 1977 he noted an improve- Phone: +39 3282570935 ment in the performance of competitive athletes after the E-mail: vittoriodermes@libero.it application of a special orthopedic interocclusal device on which he called MORA (Mandibular Orthopedic Reposi- tioning Appliance) (11-13). Summary Iwasaki in 1994 (14) investigated the forces of occlu- The purpose of this study was to evaluate the influence sion in athletes. He concluded that the maximum force i of an orthopedic oral device on the performance of in occlusion was significantly higher than those of nor- iz competitive athletes. Seven athletes from different mal individuals, showing a relation between the mas- sports have been examined during athletic tests with ticatory muscles involved in dental occlusion mecha- and without an oral device. The athletes were examined nism and the force developed by the spine postural Ed by two calibrated gnathologic operators and with spe- muscles. cific radiography. All of the subjects were submitted to An analysis of current scientific literature reveals that a postural exam on an electronic platform with and there is still a limited amount of works on this topic with a without the oral device applied. All subjects under- little scientific reliability (16), because there are no ran- went objective tests, performed by federal trainers in domized trials and/or meta-analysis that may help to clar- specialized centers, to evaluate the athletic perform- ify the relationship between occlusion, TMJ, and sports IC ance with and without the occlusal splint. The results showed an improvement of all the tests carried out. performance (36). Our findings lead us to believe that the use of a cos- Some recent studies assess muscular and postural tumed oral device, it is able to optimize neuro-muscu- changes through kinesiology tests (26), but they are not complete nor do they provide the proven scientific valid- C lar coordination and to improve the competitive per- formance of athletes, while the muscular strength not ity of such tests as the Meesserman test or the stomatog- respond significantly. nathic reset (17,18,34). On the other and, the relationship between occlusion, the Key words: splint, postural balance, athletes perform- mandible, posture and musculature has gained much © ances. more importance in sports (15,19,21,22,31). Since com- petitive at athletes require a high performance level to achieve maximum results, they exercise at the highest Introduction levels of their physical limits, and they stress the physical structure more exhaustively and rapidly allowing a more Clinical experience and scientific research has found that comprehensive analysis of the possible reciprocal influ- there are frequent symptomatic connections between the ences of the correlations (30). Applying scientific methods elements that form the postural chain (1-3), particularly to study athletes would therefore be desirable to obtain between the cranial-mandibular structures and the cervi- more concrete evidence of the relationship between oc- Annali di Stomatologia 2012; III (3/4): 113-118 113 V. D’Ermes et al. clusion, mandible, posture and skeletal muscle system ified by the Unit of Gnathology of the Department of (27-28). At the same time, however, the recruitment of Oral and Maxillofacial Sciences of University of Rome these subjects, and their continued commitment, does not which are based on integrating the international allow constant monitoring or easy availability (20,35). Rdc/Tmd. The exclusion criteria included: having under- The purpose of this article is to analyze any changes gone previous ortognatodontic treatments; presence li in the athletic performance of national and interna- of prosthetic restorations; cervical, dorsal, lumbar or tional competitors, before and after the application of temporomandibular pain; worst in general health; tak- na an intraoral device, such as a occlusal appliance or ing medication; no more than two missing teeth for emi splint. Athletes of different sport disciplines were se- jaw, including third molars. The occlusal class was not lected and diagnostic tools associated with scientifically considered as a valid selection criterion. All these cri- verifiable postural tests to measure the performance teria were evaluated clinically by 2 specialists previously io were used. calibrated. Therefore, according to the subjective willingness of the athletes to join the study and the characteristics required Materials and methods by the selection criteria, the study was conducted on a to- az tal of seven athletes: two swimmers, a boxer, four rugby The sample selection involved the search for competitive players (Tab. 1). athletes who had an high level activity inserted into a na- They were all of national and international competitive tionally and internationally recognized federation, there- level, with many victories under their belts and well aware n fore those who had already followed standardized exer- of their potential maximum, accredited to federations and cise protocols. followed by federal coaches. The athletes were six male er The athletes were selected according to the authors’ abil- and a female with mean age of 25 years. They were ity to contact the offices of sports training facilities and the contacted by their respective sport’s federation, their in- positive response to the project by the company. The dividual coaches, and through individual contacts for the nt sports selected were: swimming, boxing, rugby. The second stage of selection was directly related to the availability of competitive athletes. Among the subjects chosen were those with residence in Rome and sur- direct management and recording of clinical and instru- mental data. Each athlete was subjected to the following collection of records: iI rounding for practical and logistical reasons. The initial - extraoral and Intraoral photographs; sample was 21 athletes. - orthopanoramic and individualized tomographic study From this initial screening all subjects underwent a of TMJ. on specialist visit to assess the exclusion criteria, which To test the hypothesis of the study, we recorded changes was applied to reduce the influence of occlusion and to in competitive results as a result of changes in the oc- determine the health of the TMJ and masticatory mus- clusal proprioceptions, with a removable interocclusal cles. This was done following the diagnostic criteria cod- device applied to all subjects. i iz Sport Sex Age N. dental Ed elements missing Athlete 1 Swimming F 26 4 IC Athlete 2 Swimming M 24 0 Athlete 3 Boxing M 27 5 C Athlete 4 Rugby M 23 4 © Athlete 5 Rugby M 23 0 Athlete 6 Rugby M 24 0 Athlete 7 Rugby M 32 0 Table 1. 114 Annali di Stomatologia 2012; III (3/4): 113-118 Influence of occlusal splint on competitive athletes performances The appliance used in the study needed to be a device For the two swimmers (swimmer 1: dolphin style; swim- which had to facilitate easy insertion and extraction. It had mer 2: freestyle) the average time for each session were to place minimal stress on the teeth, and to be as small calculated. Each athlete was subjected to: as possible in the mouth. It also had to have good dimen- - stabilometric platform with and without bite; sional stability, well-polished contact surfaces with bound- - detection performance with professional timing made li aries that would comply with the gums and mucous mem- by federal coaches. branes. It had to have rounded edges to prevent For the boxer and four rugby players instead, where we na disturbance to the tongue, and it had to allow for easy could not have seen the results on the track type of train- swallowing and breathing. Finally, it could not be fitted with ing, they were submitted to: metal anchors, but constructed to be stabilized by using - stabilometric platform with and without bite; natural undercuts. The material used had to be biocom- - mognoni Test; io patible, non-toxic, non-allergenic, odorless, and taste- - lactate PRO ARKRAY test. less. We therefore chose an elastomer, SBS (styrene-bu- The performance evaluation for the boxer and rugby tadiene-styrene). In addition to the above mentioned players was performed using the Mognoni test for the cal- requirements we also added the following clinical re- culation of instantaneous spot heart rate and ending az quirements: a defined occlusal stability, a valid condyle- heart rate, and the Lactate PRO ARKRAY test for the disc-fossa relationship and a repeatable and efficient measurement of lactic acid produced during the exercise. neuromotor pattern. In the Mognoni test every athletes had to perform 1350 The choice fell on oral devices with functional orthope- meters in 6 minutes while maintaining a constant speed n dic repositioning that allowed for a joint occlusal-de- of 13.5 Km / h. To make the test accurate and reliable, fined position and to be guided and easily modified by pins were positioned on the path at regular intervals er the control data performed by instrumental examina- (every 50 m) so that athletes could get an audio signal tions. Furthermore, the splint was considered as the when they passed over a pin. The Lactate PRO ARKRAY occlusal device best suitable for the study in question test allowed us to measure with extreme easy and pre- nt since it is bound to the jaw and is best able to express the physical exertion of the subject. It was applied to the upper arch during competitive activities of the ath- letes to evaluate the influence of occlusion on the cision the blood lactate level and a precise volume of blood (5 microliters). iI physical activity and its effect on skeletal muscle per- Results formance. The dental plate was constructed with the indirect method The results showed how one of the most important pa- on of using the die casting technique. The impressions were rameters of the evaluation carried out on the postural first taken with alginate and from these plaster casts stabilometric platform, i.e. the percentage of load di- were derived. Individual custom trays were then designed vided into the two supports breech, is modified with and for a second cast of precision silicone. The models were without the occlusal splint insertion. In fact, the varia- i then placed in the articulator and the centric relation was tion of the percentage of load varies from a maximum iz detected by recording the wax occlusal position of the of 6% (rugby player 4) to a minimum of 1% (boxer), mandible. The flasking model was then made and ran the with a single case of neutrality (rugby player 2). There- injection cycle: fore an average variation of 3% in static load between Ed • melting temperature: 165 oC; the values with and without the oral plate were ob- • holding time above the melting point: 20 minutes; tained. • cooling time under pressure: 20 minutes; The performance time of the two swimmers were as fol- • injection pressure: 4 bar. lows: After building the plates, they were tested for each ath- lete in order to customize the features and to clinically Swimmer 1: IC evaluate, through instrumental examination, the effec- - 100 meter dolphin style: the average time without tive global postural balance prior to their use during the the bite was between 1 minute and 28 seconds and active competitive phase. The stabilometric platform 1 minute and 32 seconds, while with the bite a con- was performed with the purpose of evaluating the pos- stant average of 1 minute and 25 seconds were ob- C tural balance of the subject and the eventual changes tained. when the oral device was used. And then it was re- peated after the agonistic performance to check for Swimmer 2: any changes. - 100 meters freestyle: the average time without the bite © All measurements were performed 10 times each in total, was 1 minute and 16 seconds, with the bite the aver- with and without the oral splint, at 30 day intervals. age was 1 minute and 14 seconds. The training sessions were organized in consecutive The boxer and the four rugby players reported the fol- days as follows: lowing heart rate values expressed in bpm and rela- - the first day workout without bite; tive values of lactic acid produced expressed in mil- - second day: training with bite; limoles (ml/mol) checked one minute after the end of Each athlete carried out the exercise in their own specific the Mognoni test with (Tab. 2) and without the splint discipline. (Tab. 3). Annali di Stomatologia 2012; III (3/4): 113-118 115 V. D’Ermes et al. Heart rate Bpm 1’ after end of test Lactic Acid in ml/mol Boxer After 1’ 146 bpm 140 2,7 3’ 151 bpm li 5’ 158 bpm 6’ 164 bpm na Rugby player 1 After 1’ 167 bpm 165 11,6 3’ 180 bpm 5’ 186 bpm io 6’ 189 bpm Rugby player 2 After 1’ 160 bpm 151 5,3 az 3’ 173 bpm 5’ 178 bpm 6’ 182 bpm n Rugby player 3 After 1’ 160 bpm 169 8,7 3’ 168 bpm er 5’ 171 bpm 6’ 181 bpm Rugby player 4 After 1’ 163 bpm 174 10,1 nt 3’ 171 bpm 5’ 178 bpm 6’ 179 bpm iI Table 2. on Heart rate Bpm 1’ after end of test Lactic Acid in ml/mol i Boxer After 1’ 144 bpm 119 2,4 iz 3’ 150 bpm 5’ 156 bpm 6’ 156 bpm Ed Rugby player 1 After 1’ 158 bpm 148 10,8 3’ 173 bpm 5’ 174 bpm 6’ 178 bpm IC Rugby player 2 After 1’ 159 bpm 137 8,1 3’ 168 bpm 5’ 174 bpm C 6’ 176 bpm Rugby player 3 After 1’ 150 bpm 154 6,7 3’ 167 bpm © 5’ 169 bpm 6’ 173 bpm Rugby player 4 After 1’ 155 bpm 105 8,4 3’ 163 bpm 5’ 165 bpm 6’ 168 bpm Table 3. 116 Annali di Stomatologia 2012; III (3/4): 113-118 Influence of occlusal splint on competitive athletes performances Discussion The cronometric values, the results obtained from com- puter platforms, the heart rate values and the Lactate The purpose of this study was to assess any changes that PRO ARUPAY test, all significantly changed in a positive could occur with the application of an occlusal splint in the way with the application of a bite. It would seem that the athletic performance of national and international compet- mechanical receptive stimulus created by changing the ra- li itive athletes. tio of occlusal-mandibular posture is able to influence the The sample of competitive athletes had been selected so work of the muscles and of the neuromuscular component. na as to be free of dysfunctional problems, and that would The results of our study are consistent with those pre- meet the above requirements. All athletes were subjected sented by Edwards (22,23), which showed that the oc- to the stabilometric platform to evaluate postural muscle, clusal relationships can interfere with both the body pos- and from this we saw a change in the distribution of the ture and neuromuscular balance. io load resting on both feet, and therefore posture. The most important limits of our study are in the number of samples examined and the diversity of sports investi- gated. Then, the data obtained is numerically small and the comparison of that does not allow for more than a de- az scriptive analysis of the base and not a statistical obser- vation. Considering these limits, the results still seem to indicate that the presence of an occlusal splint can lead to greater control of neuromotor coordination, resulting in n improved efficiency and effectiveness of competitive sports performance. er A study conducted on high-level professional athletes can analyze the change of body patterns and the neuro- muscular dynamics but not the change in dysfunctional Fig. 1 nt symptoms (24,25). These subjects express dynamic movement of the entire body at the highest levels of stress to neuro-musculo-articular relationships and may therefore represent the best individuals to be studied to iI evaluate these relationships. With the bite inserted, the percentage values of the load distribution were more likely to approach the ideal bal- on ance, i.e. 50% of load resting on the right foot and 50% Conclusions of resting on the left foot. Figure 1 shows the mean values of the load distribution The study showed, in the subjects examined, a positive on both sides, right and left, and displays how with the bite influence that a stimulus balancing occlusal device seems i inserted these values tend to be closer to an equitable to have on the sporting performance of national and inter- iz sharing of the percentages. In fact, starting from an aver- national competitive athletes. Restoring a better balance age load distribution of 48.3% on the left and right of in the occlusal receptor could allow an improvement of the 51.7% without support of the bite we get to a distribution neuro-muscular dynamic and to learn more effective mo- Ed load value of 50.4% on the left and 49.6% on the right with tor patterns. These observations are sequential changes the bite inserted. in a positive sense of the competitive performance of The variation from an ideal condition (50% of load support athletes who were involved in this preliminary analysis. for both sides) without the repositioning bite is 1.7%, In all of the athletes of this study, the application of a while with mandibular bite in place it is 0.4%. mandibular bite resulted in a better balanced redistribu- The swimmers found a decrease in time at 100 meters for tion of the load between the two sides of the body, demon- IC their own style. Swimmer 1 without the bite took 1 minute strating the role that the dental occlusion has in posture and 29 seconds on average; while with the bite in place, through the neuromuscular system, and that these are Swimmer 1’s time improved by about 4 seconds on aver- such as to influence the muscular work itself. age, down to 1 minute and 25 seconds constants. The In the fact, with the bite, the two swimmers improved the C same goes for the Swimmer 2, which had improved time water resilience, achieved a greater resistance to fatigue, of approximately 2 seconds passing from 1 minute and 16 and enhanced the performance during the training ses- seconds to 1 minute and 14 seconds. sions. In addition they have obtained excellent competi- The boxer and the four rugby players, in addition to the tive performance that saw Swimmer 1 qualify for the first © improvement of the values recorded with stabilometric time in tenth place in the World Championship 2006 Mas- platform, recorded a decrease in the production of lactic ters Champion and she became Italian Champion in the acid when they practiced the exercise test with a bite and 50 meters dolphin style. how the intra-oral device had also impacted the heart rate Worthy of note also are the results of the boxer who won values. the title of the European Union Welterweight. Finally, for This means that, with bite, there is a decrease in muscu- the latter as for the four rugby players, instrumental val- lar effort. This made be due to the drop of the production ues, confirmed by heart rates and those of lactate pro- of lactic acid and heart rate leadind to a better recovery duced, showed that the changes of the neuro-musculo- time after muscular effort. joint mediated by mandibular repositioning bite have a Annali di Stomatologia 2012; III (3/4): 113-118 117 V. D’Ermes et al. positive impact on the work of the body’s muscles, lead- 19. Veltri N, Basile F, Giammatei S. Posture errate: kinesiologia ing to better muscle performance and to less fatigue. applicata. Diagnosi e terapia in campo odontoiatrico (Doc- The final results are therefore auspicious. The setting of tor OS; 1992; 8). scientific and clinical studies are desireable when validated 20. Aloi A. Cranio Clin Int. 1991;1(2):99-105. 21. Lai V, Deriu F, Chessa G. The influence of occlusion on and found to allow for standardization of protocols. As with sporting performance. Minerva Stomatol. 2004 Jan-Feb;53(1- li Formula 1 racing where technological developments are 2):41-7. later adopted by the broader market, the opportunity to 22. Esposito GM. Teoria del range propriocettivo tridimensionale na benefit from the availability of athletes at this level should Occlusale. Il Dentista Moderno, maggio 1989. be managed so that the results which emerge from the re- 23. Esposito GM. Il triangolo della salute. Salutenatura, Anno 1, search could lead to developments that can lead to pos- n°0, febbraio 1989. sible positive effects on the daily life of each individual. 24. Roettger M. Compend Contin Educ Dent. 2009 Jul-Aug; 30 Spec No 2:4-8. io 25. Verban EM Jr. The MORA. Its application in the field of ath- letics. Basal Facts. 1987;9(2):63-8. References 26. Nozaki S, Kawai M, Shimoyama R, Futamura N, Matsumura az T, Adachi K, Kikuchi Y. Range of motion exercise of temporo- 1. Strini, Machado, Gorreri, Ferreira, Sousa, Fernandes Nedo: mandibular joint with hot pack increases occlusal force in pa- J Appl Oral Sci. 2009; 17(5):539-43. tients with Duchenne muscular dystrophy. Acta Myologica • 2. Wright, Domenech Fischer jr: JADA, Vol.131 February 2000; 2010; XXIX: p. 392-39. 202-210. 27. Manfredini D, Castroflorio T, Perinetti G, Guarda-Nardini L. n 3. Esposito GM. Valutazione della relazione esistente tra l’oc- Dental occlusion, body posture and temporomandibular dis- clusione e la postura. Il dentista moderno Maggio 1989. orders: where we are now and where we are heading for. J er 4. Esposito GM. Problemi posturali di pertinenza odontostoma- Oral Rehabil 2012 Jun;39(6):463-71. tologica. Il dentista moderno. Maggio 1988. 28. Moon HJ, Lee YK.The relationship between dental occlu- 5. Schubert MM, Guttu RL, Hunter LH, Hall R, Thomas R. sion/temporomandibular joint status and general body health: Changes in shoulder and leg strength in athletes wearing part 1. Dental occlusion and TMJ status exert an influence 6. nt mandibular orthopedic repositioning appliances. J Am Dent Assoc. 1984 Mar;108(3):334-7. Sannajust, Thiery, Poumarat, Vanneuville, Barthélémy, Mondie. Rev.Stomatol Chir Maxillofac. 2002 Jun;103(3): on general body health. J Altern Complement Med 2011 Nov;17(11):995-1000. 29. Michelotti A, Buonocore G, Manzo P, Pellegrino G, Farella M. Dental occlusion and posture: an overview. Epub 2011 Jan iI 141-7. 20 Prog Orthod 2011;12(1):53-8. 7. Urzi D. Protocollo interdisciplinare di valutazione dei sistemi 30. Baldini A, Beraldi A, Nota A, Danelon F, Ballanti F, Longoni di controllo posturale. Formenti 1997. S. Gnathological postural treatment in a professional basket- on 8. Gerz A. Kinesiologia applicata, storia e fondamenti. Medicina ball player: a case report and an overview of the role of den- Naturale, Aprile 1993. tal occlusion on performance. Annali di Stomatologia 2012, 9. Esposito GM. 2° Congresso mondiale di kinesiologia. Garda 3(2):51-58. 5 Ottobre 1995. 31. Manfredi M, Lombardo L, Bragazzi R, Gracco A. An investi- 10. Scalia. Osteopatia e Kinesiologia applicata. Marrapese Edi- gation into explosive force variation using occlusal bites. i tore, 1999, Roma. Prog Orthod 2009;10(2):54-63. iz 11. David S. Walther: Una nuova teoria in Kinesiologia odontoia- 32. Tardieu C, Dumitrescu M, Giraudeau A, Blanc JL, Cheynet trica. Kinesiologia applicata - synopsis - 1998 - Systems F, Borel L. Dental occlusion and postural control in adults. DC. Neuroscience Letters 2009, 450(2):221-224. Ed 12. Gelb H, Mehta NR, Forgione AG. N Y State Dent J. 1995 33. Bergamini M, Pierleoni F, Gizdulich A, Bergamini C. Dental Nov; 61(9):58-66. occlusion and body posture: a surface EMG study. Cranio 13. Allen ME, Walter P, McKay C, Elmajian A. Can J Appl Sport 2008 Jan;26(1):25-32. Sci. 1984 sep; 9(3):148-52. 34. Cuccia AM. Interrelationships between dental occlusion and 14. Iwasaki H, Inaba R, Iwata H. Nippon Eiseigaku Zasshi 1994 plantar arch. Journal of Bodywork and Movement Therapies Aug; 49(3):654-9. 2011, 15(2):242-250. IC 15. Gangloff, Louis, Perrin. Neuroscience Letters 293(2000) 35. Sakaguchi K, Mehta NR, Abdallah EF, Forgione AG, Hi- 203-206. rayama H, Kawasaki T, Yokoyama A. Examination of the re- 16. Gelb, Mentha, Forgione. Cranio 1996 oct; 14(4):320-5. lationship between mandibular position and body posture. 17. CONSENSUS CONFERENCE 2008 Milano. Cranio 2007 Oct;25(4):237-49. 18. Esposito GM. Problemi posturali di pertinenza odontostoma- 36. Hanke BA, Motschall E, Türp JC. Association between ortho- C tologica (Atti del II° Congresso Mondiale di Kinesiologia, pedic and dental findings: what level of evidence is available? Garda, 1995). J Orofac Orthop 2007 Mar;68(2):91-107. © 118 Annali di Stomatologia 2012; III (3/4): 113-118 

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Original article Flexibility and resistance to cyclic fatigue of endodontic instruments made with different nickel-titanium alloys: a comparative test li na Giancarlo Pongione, DDS resistant to cyclic fatigue than instruments produced by Giorgio Pompa, MD a traditional manufacturing process or a thermally treated NiTi alloy (M-wire). io Valerio Milana, PhD Stefano Di Carlo, MD Alessio Giansiracusa, DDS Key words: cyclic fatigue test, NiTi alloy, rotary instru- Emanuele Nicolini, PhD ments, resistance of endodontic instruments. az Francesca De Angelis, PhD Introduction Department of Oral and Maxillofacial Sciences, Sapienza n University of Rome, Italy It is well known that during root canal preparation, en- dodontic instruments are subjected to different forces, in- er Corresponding author: cluding flexion, torsion, traction and apical pressure. Thus, Giorgio Pompa, MD they should have properties capable of preventing me- Department of Oral and Maxillofacial Sciences, Sapienza chanical failure and also minimizing the possibility of unde- University of Rome, Italy Via Caserta 6 00161 Rome, Italy Phone: +39 06 49976614 nt sirable alterations in canal anatomy. Loss of flexibility may result in ledges, transportations and perforations. This is why nickel-titanium (NiTi), a very unique alloy with specific prop- erties very suitable for the endodontic use, has become pop- iI E-mail: giorgio.pompa@uniroma1.it ular in the last decades. The super-elastic property of the al- loy can be described briefly. The stress value remains fairly constant up to a certain point of instrument deformation. At on Summary the same time, when the deformation rebounds, the stress Aim. A new manufacturing method aiming at to produc- value remains fairly constant. These characteristics are ing more flexible and resistant NiTi endodontic instru- ments has been recently developed (Hyflex, produced very useful in clinical practice, allowing an increased elas- with CM wire). The purpose of the study was to determine tic deformation and, consequently, increasing flexibility of the i whether this new manufacturing method produces NiTi endodontic instruments. The process of manufacturing of iz instruments (Hyflex) of superior flexibility and/or supe- endodontic instruments from nickel-titanium was investi- rior resistance to cyclic fatigue, when compared with in- gated initially by Walia et al.(1), who demonstrated that struments produced by a traditional manufacturing NiTi instruments have a greater degree of elastic flexibility Ed process or thermally treated NiTi alloy (M-wire). in bending and torsion, as well as superior resistance to tor- Materials and methods. Twelve .06 size 25 Hyflex instru- sional fracture, when compared with stainless-steel instru- ments (Coltene, Allstatten, Switzerland), and twelve 06.25 ments manufactured with the same process. The mechan- Vortex instruments (Dentsply-Tulsa, OK, USA) and twelve ical properties of endodontic instruments, like flexibility and 06.25 Endosequence instruments (Brasseler, Savannah, resistance to fracture, are affected by several factors, such GA, USA) were initially evaluated for stiffness on bend- as dimensions, tip size and conicity, design, chemical com- IC ing, followed by a cyclic fatigue test. For the stiffness test position of the metallic alloy and thermo-mechanical test procedures strictly followed ISO 3630-1, and bend- processes applied during manufacturing (2-4). To date, de- ing moment was measured when the instrument attained spite the fact that NiTi alloys demonstrate improved elastic- a 45 degrees bend. The cyclic fatigue test was performed ity, which significantly reduces the restoring force, and re- C in a customized artificial stainless steel canal (60° degree duces the amount of transportation that occurs during canal curvature with 5 mm radius). Instruments were rotated at preparation, this elasticity is limited by the size and taper of 300 rpm until fracture. All data obtained were recorded instrument used (5,6). Therefore the fabrication of instru- and statistically analyzed using an ANOVA test. ments of greater taper resulted in a significant increase of © Results. Statistical analysis of data showed that bending moments were significantly greater (P < .05) for Vortex the stiffness of rotary instruments, and increased risk of fa- and EndoSequence instruments (mean values 59.06 g/cm tigue failure (7). This is not an ideal characteristic for an in- and 48,98 g/cm respectively), compared to the Hyflex in- strument which is going to reach full working length in a struments (mean value 35.60 g/cm). For the cyclic fa- curved canal, resulting in an increased risk of canal trans- tigue test Hyflex and Vortex were significantly more re- portation in the portion of the canal after the start of the cur- sistant than EndoSequence instruments (P < .05). vature, and in an increased risk of intracanal failure. Conclusions. Results of the present study demonstrate An ideal solution to increase instruments’ performance is the ability of the new CM-wire manufacturing process to to use an improved nickel-titanium alloy with superior flex- produce NiTi rotary instruments more flexible and more ibility and resistance to fracture. Recently, new manufac- Annali di Stomatologia 2012; III (3/4): 119-122 119 G. Pongione et al. turing processes (which are patented and not disclosed by VDW motor (Munich, Germany) until fracture occurred. manufacturers) involving heat treatment of the alloy have For each instrument, the time in seconds was recorded by been developed in order to improve mechanical properties the same operator with a chronometer to an accuracy of of the alloy for the endodontic use. The M-wire technology 0.1 s. After positioning the instrument in the canal and as developed by Tulsa Dental was one of the first thermally soon as rotation started, timing was initiated. Timing li treated NiTi alloy used for the endodontic use. A new stopped when instrument breakage was observed. Num- manufacturing method aiming at to producing more flexi- ber of cycles at failure (NCF) was calculated for each in- na ble and resistant NiTi endodontic instruments has been re- strument, by multiplying time to failure (in seconds) by 5 cently developed by Coltene (CM wire). On these basis, (which is 5 rotation x second = 300 rpm). For both tests the aim of the present study was to evaluate the bending all data were recorded and subjected to statistical evalu- properties and the cyclic fatigue resistance of NiTi rotary ation (p<.05) using ANOVA test. io instruments produced with thermally treated alloys and compare them with those of commercially available NiTi in- struments manufactured with traditional methods. Results az For the bending test mean values and standard deviation Materials and methods for each group of instruments are shown in Table 1. The higher the value, the more rigid the instruments. Table 2 Twelve instruments of each following NiTi rotary instru- shows a statistical comparison of results: Hyflex were n mentation technique were selected for the study: found to be the most flexible instruments, showing a sig- nificant difference (P < .05) in comparison with the other er a) EndoSequence 0625 (Brasseler, Savannah, GA, USA); instruments. Vortex were not found to be significantly b) Hyflex 0625 (Coltene, Allstatten,Switzerland); more flexible than EndoSequence instruments). c) Vortex 0625 (Denstply-Tulsa, Tulsa, OK, USA). For the cyclic fatigue test mean values and standard de- nt The NiTi rotary instruments were selected based on a similar cross-sectional design and according to three dif- ferent manufacturing processes: traditional grinding of viation for each group of instruments are shown in Table 3. The higher the value, the more resistant the instru- ments. Table 4 shows a statistical comparison of results: Hyflex were found to be the most resistant instruments, iI NiTi (EndoSequence), M-wire (Vortex) and CM wire showing a significant difference (P <.05) in comparison (Hyflex) technologies. with EndoSequence and Vortex instruments. Before the tests, all instruments were examined under a on measuring microscope at D3 and D16 to ensure uniformity of dimensions (according to the tolerance indicated by Discussion ISO 3630-1), and under a stereo microscope (magnifica- tion x20) to ensure uniformity of cutting flutes and defect In the last years many new endodontic instruments, alloys i free surfaces. All defective instruments were eliminated and manufacturing processes have been commercial- iz from the study, and substituted by other new instruments ized in an attempt to improve performance and safety of from the same manufacturer. Bending moment was meas- root canal instrumentation. When new root canal instru- ured when the instrument attained a 45° bend. Experimen- ments with innovative manufacturing process which dif- Ed tal procedures strictly followed testing methodology de- fers markedly from conventional ones are produced, sev- scribed in ISO 3630-1 (8), using a computerized device. eral characteristics need to be investigated and tested to After the stiffness test the same instruments were sub- allow an efficient and safe clinical usage. On these basis, jected to a cyclic fatigue test. The cyclic fatigue testing de- the aim of the present study was to determine whether a vice used in the present study has been used in many new manufacturing method (CM wire) produces NiTi in- previous studies on cyclic fatigue resistance performed by struments of superior flexibility and fatigue resistance, IC the authors (9-14). The device consists of a mainframe to when compared with instruments produced by a tradi- which a mobile plastic support for the electric hand-piece tional or a thermally treated NiTi alloy (M-wire). is connected and a stainless steel block containing the ar- Results from the present study showed that Hyflex were tificial canals. The electric hand-piece was mounted on a the most flexibile instruments, with a significant improve- C mobile device to allow the precise and reproducible place- ment (P <.05) in flexibility ranging over the other tested ment of each instrument inside the artificial canal. This commercially available instruments produced with the M- placement ensured three-dimensional alignment and the wire or the traditional grinding process (Tabs. 1-2). De- positioning of the instruments to the same depth. The ar- © tificial canal was manufactured by reproducing an instru- Mean values Standard deviation ment’s size and taper, thus providing the instrument with a suitable trajectory that respects the parameters of the Hyflex 0625 19,46 (SD 2,7) curvature chosen. A simulated root canal with a 60° an- gle of curvature and 5-mm radius of curvature was con- Vortex 0625 67,58 (SD 4,2) structed for instrument type. The center of the curvature was 5 mm from the tip of the instrument, and the curved EndoSequence 0625 62,11 (SD 5,7) segment of the canal was approximately 5 mm in length. Table 1. Bending test: mean value and standard deviation for All of the instruments were rotated at 300 rpm using a group of instruments. 120 Annali di Stomatologia 2012; III (3/4): 119-122 Flexibility and resistance to cyclic fatigue of endodontic instruments made with different nickel-titanium alloys… These improvements in the manufacturing process shown Hyflex vs Vortex Significant difference by the CM wire technology can very useful in clinical prac- (P<.05). tice. Nickel-titanium possess an unique flexibility that can usually withstand the rapid, repeated distortions of rotation Hyflex vs EndoSequence Significant difference in curved canals (10), but, unfortunately, flexibility is lim- (P<.05). li ited by the size and taper of instrument used. Therefore, a tip 25/06 taper NiTi rotary instrument is usually more rigid Vortex vs EndoSequence No significant difference na (P>.05). than small stainless steel K-files, i.e. size 15 or 20. Sev- eral changes in cross-sectional and flute design have Table 2. Statistical comparison of results: Hyflex were found the been introduced in the last years in order to increase flex- most flexible in comparison with the other instruments. ibility of greater tapered instruments which are intended to io be used in apical portion of curved root canals, but no clin- spite the fact that flexibility is influenced by instruments ically significant improvement was achieved (2). Therefore design, such a great improvement is mainly related to the a significant improvement in the flexibility of the alloy new manufacturing process (CM wire), which seems to should be highly beneficial, providing NiTi instruments of az play a major role in increasing flexibility of the Hyflex in- greater taper with a superior ability to negotiate curved strument. No significant difference were noted between canals, to reduce the tendency of iatrogenic errors and to Vortex and EndoSequence. Even if some articles report allow dimensionally adequate apical preparations of an increased flexibility of CM-wire vs traditional NiTi, data curved canals while maintaining the original path (21-23). n from the present study does not support those findings. Moreover, endodontic files that show an increased flexi- Since the tested instruments were similar but not identi- bility are also perceived to be more resistant to cyclic fa- er cal in cross-sectional design, it can be stated that the the- tigue. A possible explanation is that when the instrument oretical increase of flexibility of m-wire is not enough to is rotated inside a curved canal and is subjected to ten- overcome a slight increase of stiffness due to a different sile and compressive stress, a more flexible instruments cross-sectional design. nt In the present test M-wire technology did not produced a significant improvement in the cyclic fatigue testing over the traditional grinding method, while a statistically could accommodate this stress in a better way, thus in- creasing fatigue resistance. In the present study such cor- relation between flexibility and fatigue resistance was found to be valid for the all the tested instruments. iI significant difference was noted with CM wire (Tabs. 3- 4). Such differences may be due to the different alloys but also due to different instrument design. In fact, while References on cross-sectional design among the three tested instru- ment is similar, flute design is different. It is well know 1. Walia H, Brantley WA, Gerstein H. An initial investigation of that flexural fatigue is highly influenced by the flute de- the bending and torsional properties of Nitinol root canal files. sign, and therefore the complex design of Endose- J Endod 1988:14; 346-51. i 2. McSpadden JT. Mastering Endodontic Instrumentation, quence instrument could result in more stress concen- iz Cloudland Institute,Chattanooga, TN 2007. tration points and, as a consequence, less resistance to 3. Gambarini G. Cyclic fatigue of ProFile rotary instruments af- cyclic fatigue. ter prolonged clinical use. Int Endod J 2001: 34, p386-9. 4. Parashos P, Messer H. Rotary NiTi instrument fracture and Ed its consequences. J Endod 2006 32: 1031-43. Mean values Standard deviation 5. Xu X, Eng M, Zheng Y, Eng D. Comparative study of torsional and bending properties for six models of nickel-titanium root Hyflex 06 25 424,4 (SD 63,2) canal instruments with different cross-sections.J Endod 2006:32; p372-5. Vortex 06 25 287,8 (SD 52,8) 6. Kazemi RB, Stenman E, Spångberg LS. A comparison of IC stainless steel and nickel-titanium H-type instruments of EndoSequence 06 25 280,2 (SD 37,6) identical design: torsional and bending tests.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000, 90: p500-6. Table 3. Cyclic fatigue test: mean values and standard deviation 7. Gambarini G, Gerosa R, De Luca M, Garala M, Testarelli L. C for each group of instruments. Mechanical properties of a new and improved nickel-titanium alloy for endodontic use: an evaluation of file flexibility. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 105:798-800. Hyflex vs Vortex Significant difference 8. International Standard Organization: ISO 3630-1. Dental © (P<.05). root canal instruments. Part 1: files, reamers, barbed broaches, rasps, paste carriers, explorers and cotton Hyflex vs EndoSequence Significant difference broaches. Ed. International Standard Organization Geneve, (P<.05). Switzerland 1992. 9. Gambarini G, Gergi R, Naaman A, Osta N, Al Sudani D. Vortex vs EndoSequence No significant difference Cyclic fatigue analysis of twisted file rotary NiTi instruments (P>.05). used in reciprocating motion. Int Endod J 2012; doi:10.1111/j.1365-2591.2012.02036. (Epub ahead of print) Table 4. Statistical comparison of the test results: Hyflex were 10. Plotino G, Grande NM, Testarelli L, Gambarini G. Cyclic fa- the most flexible resistant instruments. tigue of Reciproc and Wave One reciprocating instruments. Annali di Stomatologia 2012; III (3/4): 119-122 121 G. Pongione et al. Int Endod J 2012;doi:10.1111/j.13652591.2012. 02015. (Epub 17. Gambarini G, Tucci E, Bedini R, Pecci R, Galli M, Milana V, ahead of print) De Luca M, Testarelli L. The effect of brushing motion on the 11. Plotino G, Costanzo A, Grande NM, Petrovic R, Testarelli L, cyclic fatigue of rotary nickel titanium instruments. Ann Ist Su- Gambarini G. Experimental evaluation on the influence of au- per Sanita. 2010;46:400-4. toclave sterilization on the cyclic fatigue of new nickel-tita- 18. Gambarini G. Cyclic fatigue of nickel-titanium rotary instru- nium rotary instruments. J Endod. 2012;38:222-5. ments after clinical use with low- and high-torque endodon- li 12. Plotino G, Grande NM, Melo MC, Bahia MG, Testarelli L, tic motors. J Endod. 2001;27:772-4. Gambarini G. Cyclicfatigue of NiTi rotary instruments in a 19. Iqbal MK, Kohli MR et al. A retrospective clinical study of in- na simulated apical abrupt curvature. IntEndod J. 2010; cidence of root canal instrument separation in an endodon- 43:226-30. tics graduate program: a PennEndo database study. J Endod 13. Plotino G, Grande NM, Mazza C, Petrovic R, Testarelli L, 2006; 32: 1048-52. Gambarini G. Influence of size and taper of artificial canals 20. Ounsi H F, Al-Shalan T et al. Quantitative and qualitative el- on the trajectory of NiTi rotary instruments in cyclic fatigue emental analysis of different nickel-titanium rotary instru- io studies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod ments by using scanning electron microscopy and energy 2010;109:60-6. dispersive spectroscopy. J Endod 2008; 34: 53-5. 14. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini G. 21. Gambarini G et al. Bending properties of GT Rotary Files. J az Influence of theshape of artificial canals on the fatigue resist- Dent Res 80, April 2001, CED 1999 Divisional Abstract ance of NiTi rotary instruments. Int Endod J. 2010;43:69-75. n.341. 15. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini G. 22. Testarelli L, Plotino G, Al-Sudani D, Vincenzi V, Giansiracusa A review of cyclic fatigue testing of nickel-titanium rotary in- A, Grande NM, Gambarini G. Bending properties of a new struments. J Endod. 2009;35:1469-76. nickel-titanium alloy with a lower percent by weight of nickel. n 16. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini G. J Endod. 2011;37:1293-5. Measurement of the trajectory of different NiTi rotary instru- 23. Gambarini G, Plotino G, Grande NM, Al-Sudani D, De Luca er ments in an artificial canal specifically designed for cyclic fa- M, Testarelli L. Mechanical properties of nickel-titanium rotary tigue tests. Oral Surg Oral Med Oral Pathol Oral Radiol En- instruments produced with a new manufacturing technique. dod. 2009;108:52-6. Int Endod J 2011;44:337-41. nt iI i on iz Ed IC C © 122 Annali di Stomatologia 2012; III (3/4): 119-122 

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Original article Effectiveness of tips for delicate micro-ultrasonic root planing comparing to tips for traditional ultrasonic root planing li na Gianna Maria Nardi, RDH, DHA the connective tissue attachment and the alveolar bone. Roberto Di Giorgio, MD, DDS Plaque and bacteria are generally recognized as the pri- io Silvia Sabatini, RDH, DHA mary cause of the periodontal disease. Nowadays, scal- ing and root planning (SRP) represents the most widely used procedure in the treatment of the periodontitis. Its Department of Oral and Maxillofacial Sciences, Sapienza main goal is the removal of the components of the sub- az University of Rome, Italy gingival biofilm, which have the major role in the initiation and in the progression of the disease. A primary goal in the treatment of periodontitis is the re- Corresponding author: moval of bacterial deposits and the arrest of disease pro- n Gianna Maria Nardi gression. Mechanical removal of these deposits from the Department of Oral and Maxillofacial Sciences, root surface is required for establishing and maintaining pe- er Sapienza University of Rome, Italy riodontal health (1). Large number of studies has reported Via Caserta, 6 beneficial results from mechanical therapy in term of both 00161 Rome, Italy clinical and microbiological aspects (1,2). Since long, the Phone: +39 3289850146 E-mail: giannamaria.nardi@uniroma1.it nt hand instruments were the first choice of clinicians. It was believed that these instruments produced a smooth root surface; however, considerable manual dexterity is re- quired for their effective operation. Moreover, hand instru- iI Summary ments are more time consuming and are unable to reach Aim. The present study wants to evaluate the effective- deeper root surface where pockets are more than 4 mm ness in the improvement of several periodontal indices, deep (3). Ultrasonic tips were originally designed for gross on such as probing pocket depth, bleeding on probing and scaling and removal of supragingival calculus and stains. plaque index, and the patient subjective preference to the More recently, these power driven instruments have been treatment of root planning with tips for delicate -micro ul- trasonic therapy comparing to traditional ones. modified to have smaller diameter tips and longer working Methods. Thirty patients were selected for our randomized lengths, thereby providing better access to deep probing i split mouth study; in each patient two quadrants (test) sites and more efficient subgingival instrumentation. iz were treated with tips for delicate micro-ultrasonic root It is known from literature (1-3) that ultrasonic scaling and planing, and two quadrants (control) with tips for traditional root planing have the same effectiveness of manual in- ultrasonic root planing. Probing pocket depth, bleeding on strumentation in biofilm removal and in creating a biolog- Ed probing and plaque index were collected at baseline, after ically compatible surface on the root treated. It has been six weeks and after six months. Patients were asked to as- already proposed that there is no difference in the results sess the subjective preference of the type of treatment with of different ultrasonic therapies (4), but to define which Visual Analogue Scale (Vas) especially designed and im- mediately administered after the treatment. kind of available technology is better to use for an ideal Results. Probing pocket depth and plaque index had a minimally invasive treatment plan is necessary. All this parallel improvement in both groups, while the bleeding could improve the patient acceptance and cutting the IC on probing improved significantly in test group. The ma- work time. jority of patients (23 to 30, 76,6%) has expressed prefer- “Root planing” can’t be considered as an appropriate ence with VAS for the treatment with new tips. definition to describe the procedures of the non-surgical Conclusions. The new tips created for periodontal main- periodontal therapy, since it emphasizes the “polishing” or C taining can be really advantageous in terms of reduction “smoothing” of the roots only, while the main aim of such of plaque and bleeding indexes; the main point in favor a treatment is to decontaminate and lower the bacterial of these tips is the reduction of the discomfort for the pa- load of the periodontal pocket. In the past the attention of tient. Finally this approach tends to be less time consum- dental hygienists and dentists was to smoothen the roots © ing than a manual instrumentation method. as much as possible, many times with too aggressive ap- Key words: root surfaces, periodontal disease, ultra- proaches of instrumentation, and this often jeopardized sonic instrumentation, cementum. the root. Nowadays clinical research makes us aware of the importance of a minimally invasive approach of instru- mentation, to respect the surfaces of roots, particularly the Introduction cementum and cementogenesis. The objective of this study is to evaluate the effectiveness Periodontitis is an immuno inflammatory disease charac- in the improvement of several periodontal indices, such terized by the loss of tooth supporting structures included as probing pocket depth, bleeding on probing and plaque 90 Annali di Stomatologia 2012; III (3/4): 90-94 Effectiveness of tips for delicate micro-ultrasonic root planing comparing to tips for traditional ultrasonic root planing index, and the patient subjective preference to the treat- ment of root planning with tips for micro-delicate ultrasonic therapy comparing to traditional ones. li Materials and methods na Study population and design This research is a randomized split mouth study. Thirty pa- tients who were 18 years old or older and able to sign an io informed consent form were selected for the study. They were under periodontal maintenance, in a good systemic health condition and they have at least a residual pocket Figure 2. Fluorescein plaque detector with curing light. depth of ≥5 mm and a positive bleeding on probing for az each quadrant. The criteria for exclusion were as fol- lows: smoking, assuming medications that could affect the Once this clinical index had been collected, each patient re- periodontal therapy such as long-term non-steroidal anti- ceived ultrasonic supragingival scaling using a standard tip inflammatory drug therapy, use of bisphosphonates, un- Mectron® S1, with semi-circular cross-section for work on n willingness to return for the follow-up examination. In large areas on all tooth surfaces (Fig. 3), and subgingival each patient two quadrants (test) were treated with tips for scaling and root planing using a traditional periodontal tip er delicate micro- ultrasonic root planing, and two quad- Mectron® P1 for the quadrants taken as control and a new rants (control) with tips for traditional ultrasonic root plan- tip Mectron® P10 for delicate micro-ultrasonic root planing ing. Each quadrant was randomly allocated to a test for the other ones (Fig. 4). The insert P1 is straight with a nt group or control group using a specific software package (Random Allocation Software version 1.0, downloadable on http://mahmoodsaghaei.tripod.com/Softwares/randal- loc.html). round tip for universal root planing, the insert P10 is more anatomic with a straight, thin and curved working tip (Fig. 5). No anesthetic has been used. iI Treatment on In each patient two quadrants (test) were treated with tips for delicate micro- ultrasonic root planing, and two quad- rants (control) with tips for traditional ultrasonic root plan- i ing. Clinical indices were collected at baseline (T0), after iz six weeks (T1) and after six months (T2). At baseline (T0) probing pocket depth (PPD) and bleed- ing on probing (BOP) were collected using a periodontal Ed probe (Fig.1). To collect plaque index (PI) was used a flu- orescein plaque detector with Blue Phase curing light (Ivoclar®) to motivate the patients to the importance of correct brushing and to make us have more information about their oral hygiene behavior (Fig. 2). Each patient had at least a pocket depth of ≥ 5 mm, PI was IC 37% in the test group and 35% in the control one, and BOP was 15% in the test group and 16% in the control one. C © Figure 1. Collecting clinical indexes with a periodontal probe. Figure 3. This picture shows the design of tip S1. Annali di Stomatologia 2012; III (3/4): 90-94 91 G. M. Nardi et al. li na io Figure 4. Delicate micro ultrasonic root planing with tip P10. Figure 6. Airpolishing treatment with glycin powder. az We gave oral hygiene instruction for home maintenance, suggesting to brush twice per day for two minutes at least with oscillating rotating mechanical toothbrush (Fig. n 7) using a pea size quantity of generic fluoride toothpaste and to rinse mouth after brushing with zero alcohol essen- er tial oils mouthwash for 30 seconds. Patients had to per- form this protocol for six weeks, until they received the control visit. nt iI i on iz Ed Figure 7. Home maintenance protocol instruction with oscillating mechanical toothbrush. Clinical indices were collected again after six weeks from the treatment (T1), to assess if PI, PPD and BOP have had any improvement. There was a general improve- IC ment of clinical indices, so we performed airpolishing with glycine powder to remove the new biofilm where nec- essary and let the patients continue with the same home maintenance protocol until the final evaluation of the C Figure 5. This image shows the anatomic design of tip P10. study after six months from the initial treatment (T2). At T2 PI, PPD and BOP were collected again and profes- After scaling and root planing have been performed, all sional oral hygiene was scheduled for each patient the dental surfaces, both of crowns and roots, received an air- week after. © polishing treatment with glycine powder (Fig. 6). Patients were asked to assess the subjective preference of the type of treatment with Visual Analogue Scale (VAS) Results especially designed and immediately administered after the treatment. The scale consisted of ten possible values, The PI at baseline was 37% in test group and 35% in the corresponding to six different stages of pain: 0 was “no control one, and after six weeks both groups showed a PI pain”, from 1 to 2 “mild annoying pain”, from 3 to 4 “un- of 15%. Each patient had at least a residual pocket depth comfortable pain”, from 5 to 6 “distressing pain”, from 7 ≥ 5 mm at baseline, while after the treatment no probing to 8 “intense pain” and from 9 to 10 “worst possible pain”. depths ≥ 3 mm were collected in both groups. BOP at 92 Annali di Stomatologia 2012; III (3/4): 90-94 Effectiveness of tips for delicate micro-ultrasonic root planing comparing to tips for traditional ultrasonic root planing baseline was 15% in the test group and 16% in the con- Statistical analysis indicated that differences between test trol one. At T1 it was 8% in the test group and 15% in the and control sites were significant (t= -2.37, sdev=0.431, de- control group. The values were the same at T2: the test grees of freedom = 22, the probability of this result, assum- group showed PI = 15%, PPD ≤ 3 mm and BOP = 8%, ing the null hypothesis, is 0.027< 0.05). while the control group showed PI = 15%, PPD ≤ 3 mm The majority of patients (23 to 30, 76,6%), has expressed li and BOP = 15% (Figs. 8, 9). preference with VAS for the treatment with new tips. The na io n az er nt iI on Figure 8. Graph showing the changing of BOP from baseline to T2. i iz Ed IC C © Figure 9. Graph showing the changing of PI from baseline to T2. Annali di Stomatologia 2012; III (3/4): 90-94 93 G. M. Nardi et al. Tips Score 0 1 2 3 4 5 6 P10 14 12 4 - - - - P1 3 10 11 5 - - 1 li Table 1. Table showing numbers of patients that expressed scores collected with VAS after the treatment with tip P1 and tip P10. na 7 who did not preferred the tip P10 found no differences high speed (2,00,000 revolutions per minute) and ultra- between the two inserts. The maximum score attributed sonic instruments caused more damaged to root surface to the treatment with P10 was “2” (mild annoying pain), when compared with hand curettes (11). io while the maximum one given to treatment with P1 was All in all this research stresses the idea that these new tips “6” (distressing pain). Using the test tip, the patients gave created for periodontal maintaining can be really advan- the following scores to the treatment: fourteen patients tageous in terms of reduction of plaque and bleeding in- az gave “0”, twelve patients gave “1” and four patients gave dexes. Moreover it should be considered that the main “2”; using the control tip the scores were: three patients point in favor of these tips is the reduction of the discom- gave “0”, ten patients gave “1”, eleven patients gave “2”, fort for the patient. Finally this approach tends to be less five patients gave “3” and one patient gave “6” (Tab. 1). time consuming than a manual instrumentation method. However what the effective advantage in term of preser- n vation of cementum is remains elusive. Further re- Discussion searches in this area might include a quantitative study of er tooth substance loss with various periodontal instruments Analyzing the clinical indices, they show a parallel im- and effects of root surface characteristics on fibroblast at- provement in PPD and PI. No patient had residual pocket tachment after mechanical debridement. Such studies nt depth ≥ 3 mm at T1 or T2, and PI was 15% in both groups after six weeks and also after six months. There were no significant differences in the indices measured in the treated sites with the new tips comparing to those will be very helpful in opening new vistas of research for understanding the treatment modalities for optimal regen- eration of supporting tissue onto the tooth surface affected by periodontitis. iI treated with traditional ones, except in BOP, which showed an improvement in the test sites (test group: BOP = 8%, control group: BOP = 15%), both at T1 and References on T2. These results mean that ultrasonic therapy is efficient in clinical indices’ reduction, as the patients of both groups 1. Wilkins EM. La pratica clinica dell’igienista dentale, PICCIN show improvement, but that the tip for a micro- delicate 2010. root planing is more efficient in managing bleeding on 2. Singh S, Uppoor A, Nayak D. A comparative evaluation of the i efficacy of manual, magnetostrictive and piezoelectric ultra- probing than the universal tip. iz sonic instruments—an in vitro profilometric and SEM study. The partial results were satisfying, but more satisfying J Appl Oral Sci. 2012 Feb;20(1):21-6. were the final results: no differences were showed among 3. Dahiya P, Kamal R, Gupta R, Pandit N. Comparative evalu- the values collected at T1 and those collected at T2, Ed ation of hand and power-driven instruments on root surface meaning that the home maintenance protocol was effi- characteristics: A scanning electron microscopy study. Con- cient and the clinical situation can be considered perma- temp Clin Dent. 2011 Apr;2(2):79-83. nent. 4. Silva LB, Hodges KO, Calley KH, Seikel JA. A comparison of 23 on 30 patients preferred the treatment with the test tip dental ultrasonic technologies on subgingival calculus re- and the other 7 found no difference between the two tips moval: a pilot study. J Dent Hyg. 2012;86(2):150-8. used; no patients received anesthetics, so the insert P10 5. Clark S, Group H, Mabler D. The effect of ultrasonic instru- IC mentation on root surfaces. J Periodontol. 1968;39:125-32. for micro delicate root planing can be used as minimally 6. Garrett JS. Effects of non-surgical periodontal therapy on Pe- invasive treatment. riodontitis in humans.A review. J Clin Periodontol. Ultrasonic instruments have been used as valuable ad- 1983;10:515-21.[PubMed] juncts to conventional hand instruments for many years. C 7. Dragoo MR. A clinical evaluation of hand and ultrasonic in- Newly designed thin ultrasonic tips have allowed better struments on subgingival debridement. Part I with unmodified access to sub-gingival areas previously accessible only and modified ultrasonic inserts. Int J Periodontol. with hand instruments. Earlier studies using older tip de- 1992;12:311-7. signs generally showed that ultrasonic instruments left a 8. Drisko CL. Scaling and root planing without over instrumen- © “stippled” root surface and had a greater potential for tation: Hand versus poser – driven scalers. Curr Opin Peri- odontol. 1993;3:78-84. [PubMed] producing root surface damage than curettes (5-7). More 9. Jacobson L, Blomlof J. Root surface texture after different recent studies, especially those using the newer, thinner scaling modalities. Scan J Dent Res. 1994;102:156-60. tips show that ultrasonic instruments can produce root 10. Lie T, Mayer K. Calculus removal and loss of tooth sub- surfaces as smooth as or smoother than what is produced stances in response to different periodontal instruments. J by the curettes (8,9). Current evidence suggests that ul- Clin Periodontol. 1977;4:250-62. [PubMed] trasonic tips used on medium power may do less damage 11. Wilkinson RF, Maybury JE. Scanning electron microscopy of to the root surface than the hand or sonic scalers (10). root surface following instrumentation. J Periodontol. Some studies suggested that the rotary instruments at 1973;44:559-63. [PubMed] 94 Annali di Stomatologia 2012; III (3/4): 90-94 Effectiveness of tips for delicate micro-ultrasonic root planing comparing to tips for traditional ultrasonic root planing li na io n az er nt iI i on iz Ed IC C © Annali di Stomatologia 2012; III (3/4): 90-94 95 

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Original article Cephalometric evaluation of the hyoid triangle before and after maxillary rapid expansion in patients with skeletal class II, mixed dentition, li and infantile swallowing na Valeria Parisella, DDS1 Introduction Iole Vozza, DDS, PhD1 io Francesca Capasso, DDS1 The tongue plays an indispensable role during all stages Valeria Luzzi, DDS, PhD1 of embryonic development. With every act of swallowing, Gaetano Ierardo, DDS, PhD1 contact of the tongue against the palate determines the Italo Nofroni, MD2 correct expansion of the latter, and its absence results in az Antonella Polimeni, MD, DDS1 failure of the palate to form correctly, such as in Pierre Robin syndrome (1). Rocabado’s hyoid triangle is the only cephalometric parameter that can be used to assess 1 Oral and Maxillofacial Sciences Department, the effects of orthodontic treatment of tongue posture (2). n Sapienza University of Rome The hyoid bone is located at the root of the tongue, and 2 Experimental Medicine Department, is the only bone of the human body that is not articulated er Sapienza University of Rome with any other bone. It is located at the fourth cervical ver- tebra and is held in place by several muscular formations. Its position in the frontal area of the neck is divided into Corresponding author: Iole Vozza DDS, PhD Oral and Maxillofacial Sciences Department Sapienza University of Rome nt cranial (suprahyoid) and caudal (subhyoid) regions. The muscles of the subhyoid region generally contribute to lowering of the hyoid bone, securing it in a more caudal position than in the rest position. The suprahyoid mus- iI Via Caserta 6 cles, on the other hand, allow mandible lowering (if the 00161 Rome, Italy hyoid bone has been set caudally in advance) or raising Phone: +39 06 49976619 of the hyoid bone (followed by raising of the larynx, at- on E-mail: iole.vozza@uniroma1.it tached to the hyoid bone) (3). This bone is indispensa- ble for speech and chewing, and especially for jaw open- ing. Swallowing is another important function, involving Summary the upper airways and digestive tract. In this situation, the i Background. Rocabado’s hyoid triangle is the only mandible stabilizes itself on the maxilla, normally with a iz cephalometric parameter that can assess the effects of or- centric occlusion; the tongue exerts its force balanced be- thodontic treatment on tongue posture. Aim. To evaluate tween the palate and the palatal surface of the upper the restoration of tongue posture and function by conduct- teeth. The tongue is a muscular complex comprising 16 Ed ing a cephalometric assessment of the hyoid triangle be- smaller muscular bellies. Dynamic alterations of the fore and after rapid maxillary expansion. Methods. Sixty- tongue influence the horizontal position of the hyoid four healthy patients aged 6-11 years with skeletal class II bone and its different physiological actions and synergy malocclusion, mixed dentition, and infantile swallowing in both medium and long terms. The hyoid bone is the took part in this study. They submitted to lateral cephalo- bony support of the tongue, it has 24 muscle attach- metric radiography before and after orthodontic maxillary ments, and is related to the skull muscles (stylohyoid IC rapid expansion, in order to assess the resulting changes muscle and posterior belly of digastric muscle), the “fun- in the proportions of the hyoid triangle (following Ro- nel chest” (sternohyoid and sternothyroid muscles), and cabado’s parameters). The cephalometric findings were scapulae (omohyoid muscle). For these connections, compared according to sex, age, and divergence using the the hyoid bone is a center of coordination that signals the C chi-square McNemar test at the 5% significance level brain and its related structures and allows mandibular (p<0.05). Results. The orthodontic treatment resulted an im- and cervical kinematics. Monitoring of tongue position is provement from skeletal class II malocclusion to class I, guaranteed by anastomosis of the hypoglossal nerve with elimination of infantile swallowing in 81.8% of male pa- with the first four cervical roots, rendering the cervical and © tients [95% confidence interval (CI)=61.5–92.7%], in 87.1% of patients aged 6–7 years (95% CI=71.1–94.9%). Conclu- lingual dynamics interdependent. The hyoid bone and sions. This cephalometric analysis revealed that the hyoid tongue are the links between oral functions and vertebral triangle was modified by the orthodontic maxillary expan- column functions. The hyoid bone is the protagonist in sion, reconditioning of tongue posture and function partic- the craniocervical–mandibular relationship, being con- ularly among male, aged 6-7 years old with skeletal class nected to the skull, tongue, jaw, cervical spine, clavicle, II malocclusion, mixed dentition, and infantile swallowing. scapula, pharynx, and larynx (4). It participates in mandibular movements that occur during swallowing, Key words: cephalometric evaluation, orthodontic treat- chewing, respiration, and speaking, and it responds to ment, infantile swallowing, mixed dentition, hyoid triangle. vertebral muscle solicitations and postural changes. The Annali di Stomatologia 2012; III (3/4): 95-99 95 V. Parisella et al. tongue is the protagonist of temporomandibular joint de- Materials and methods velopment and modeling of the dental arches. It has a morphogenetic role in the developmental stage because From February 2011 to February 2012 1,152 patients pre- it acts as a balance in the intermediate step and as a sented to the Pediatric Dentistry Division, Sapienza Univer- compensator in the adult stage. At the end of tooth erup- sity of Rome for an orthodontic evaluation. All patients un- li tion the tongue is located at the equator of the palatal sur- derwent lateral cephalometric radiography in order to faces of the incisors; that is coronal to the point corre- execute a cephalometric analysis (Planmeca Romexis®, na sponding to the depth of the pits. In pathological Planmeca, Finland). The X-ray was performed in occlusion situations, the tongue diverts its posture to compensate and without swallowing. For the present study, 64 healthy and fill the vertical, frontal, and lateral spaces. The swal- patients (22 males and 42 females), aged 6–11 years lowing movement is preceded by preparation of the bo- (mean age 7.76 years) with skeletal class II malocclusion, io lus in the oral cavity. True swallowing begins once the bo- mixed dentition, and infantile swallowing were selected. The lus has reached the center of the dorsal surface of the infantile swallowing was assessed according to the Peng tongue thanks mainly to contraction of the intrinsic lingual method (9). According to the initial cephalometry executed muscles and the styloglossus muscle. The tip of the during the first orthodontic visit, the patients were divided az tongue (i.e., the apex) presses against the palate in the into three groups: normodivergent (group A, n=22), hypo- area between the back of the retroincisive papilla and the divergent (group B, n=14), and hyperdivergent (group C, first wrinkles of the palatine rugae (i.e., tongue position n=28) patients. Then it was assessed the hyoid triangle against the palate even at rest), and then movement of cephalometrically (following Rocabado’s parameters). The n the tongue dorsum progressively crushes from front to triangle was drawn by joining the following points: RGN (the back, inducing progression of the bolus toward the phar- lowest and most posterior point of the symphysis), H (the er ynx. The inability of the tongue to implement this action highest and most anterior point of the hyoid bone), and VC3 for whatever reason (e.g., anatomic problems or dysfunc- (the lowest and most anterior angle of the third cervical ver- tional activity) impairs swallowing. Furthermore, there is tebra). The cephalometric evaluation was performed by two nt a functional correlation between the tongue and the first cervical vertebrae, because tongue protrusion, retru- sion, and torsion are associated with atlas protrusion, retrusion, and torsion, respectively (5). The influence of double-blinded examiners. The hyoid triangle was classi- fied from 1 to 5 according to the form of the obtained trian- gle as follows: 1=normal triangle, 2=narrow triangle, 3=elongated triangle, 4=normal inverted triangle, and iI body posture on the posture of the head has been em- 5=narrow inverted triangle (Tab. 1). The patients were sub- phasized in recent decades by Rocabado, who found a jected to orthodontic treatment with rapid maxillary expan- frequent association between second-class occlusion, sion (RME) with an average active expansion of 15 +/- 2 on forward position of the head, decreased cervical lordosis, days. 6.25 +/- 0.15 months after RME the patients re- posterior rotation of mandible, and increased lower facial peated the lateral cephalometric radiography in order to as- height (6, 7). A cephalometric parameter proposed by sess eventual tongue posture changes (the X-ray was Bibby and Preston (8) and Rocabado (2) for evaluating performed in occlusion and without swallowing). i the position of the hyoid bone from the mandible and the iz cervical spine, is based on a triangle constructed by joining the following anatomical points: Ed T1: normal triangle • H-point: the upper edge of the frontal area hyoid body; • The retrognathic (RGN) point: the posterior-lower point of the mandibular symphysis; • The VC3ai point: the anterior-lower point of the body T2: narrow triangle of the third cervical vertebra (C3). IC This triangle is assessed in a proportional and nonlinear manner and is quantifiable by the projection of H onto the VC3-RGN segment. The cephalometric position of the C hyoid bone depends on the posture of the tongue, the T3: elongated triangle mandible, and the spine. The triangle is positive when the bone is at the top, but lower compared to the VC3ai-RGN base, and vanishes and becomes negative during physi- © ological swallowing in hyperdivergent patients with a back T4: normal inverted triangle growth vector and cervical kyphosis (4). So the aim of this study was to assess the restoration of tongue posture and function by conducting a cephalometric assessment of the hyoid triangle through lateral cephalometric radiography of the skull in patients with skeletal class II malocclusion, T5: narrow inverted triangle mixed dentition, and infantile swallowing, characterized by malocclusion with sagittal and transverse discrepancies, Table 1. Classification of the hyoid triangle before orthodontic before and after orthodontic treatment. treatment. 96 Annali di Stomatologia 2012; III (3/4): 95-99 Cephalometric evaluation of the hyoid triangle before and after maxillary rapid expansion in patients with skeletal class II… The cephalometric results of the triangle before and after orthodontic treatment were compared according to sex, age, and divergence, using the chi-square McNemar test at the 5% significance level (p<0.05). li Results na Following orthodontic therapy with rapid maxillary ex- pansion, 51 out of 64 subjects (79.7%) experienced suc- cessful outcomes with complete resolution of infantile io deglutition, and a class I skeletal pattern was obtained. The changes in the hyoid bone triangle differed between the three groups as follows: a post-treatment turned over and/or normal triangle (group A), a reduced post-treat- az ment turned over triangle (group B), and a reduced post- treatment triangle that was not turned over before therapy (group C). The improvement in tongue posture was re- markable for patients who were classified as having a pre- n treatment T5, T3, and T2 hyoid bone triangle (Figs. 1-6). Figure 3. Normodivergent patient before therapy. er nt iI i on iz Ed Figure 1. Hypodivergent patient before therapy. Figure 4. Normodivergent patient after therapy. IC C © Figure 2. Hypodivergent patient after therapy. Figure 5. Hyperdivergent patient before therapy. Annali di Stomatologia 2012; III (3/4): 95-99 97 V. Parisella et al. treatment T3 hyoid bone triangle experienced a clinical improvement of their skeletal pattern class and tongue posture (95% CI=72.2–100.0%), with eight and two pa- tients achieving a T1 and T2 hyoid bone tri- angle, respectively. Table 2 gives the results of the 18 pa- li tients with a pretreatment T2 hyoid bone triangle: the triangle shape changed to T1 in 15 out of 18 patients na (83.3%; 95% CI=60.8–94.2%). The success of maxillary expansion therapy differed ac- cording to age, sex, and pretreatment clinical situation of the subjects. In 18 out of 22 (81.8%) male subjects and io 33 out of 42 (78.6%) female subjects, the skeletal pattern switched from class II to class I (95% CI=61.5–92.7% and 64.1–8.3%, respectively). Maxillary expansion was asso- ciated with a complete elimination of infantile deglutition az and I class skeletal pattern (i.e., a desirable outcome) in 27 out of 31 (87.1%) patients aged 6-7 years (95% CI=71.1–94.9%), but in only 24 out of 33 (72.7%) patients aged ≥8 years (95% CI=55.8–84.9%). Among the 22 pa- n tients with normodivergence, 19 (86.4%) changed to a class I skeletal pattern with complete elimination of infan- er Figure 6. Hyperdivergent patient after therapy. tile deglutition (95% CI=66.7–95.3%). Following therapy, 12 out of 14 (85.7%) hypodivergent individuals had a Out of 27 individuals with a pretreatment T5 hyoid bone positive clinical outcome (95% CI=60.1–96.0%). In addi- nt triangle, 26 (96.3%) experienced a clinical improvement [95% confidence interval (CI)=81.7–99.3%], with 14 and 12 subjects obtaining a T1 and T2 hyoid bone triangles, respectively. All ten subjects (100%) classified with a pre- tion, 20 out of 28 (71.4%) individuals with hyperdiver- gence achieved a class I skeletal pattern with complete elimination of infantile deglutition (95% CI=52.9-84.7%). The findings are summarized in Table 3. iI Triangle Number of patients Number of patients who Percentage of patients with on before treatment improved after treatment tongue posture improvement after treatment T2 18 15 (15T1) 83.3% (95% CI=60.8–94.2%) i iz T3 10 10 (8 T1–2 T2) 100% (95% CI=72.2–100%) T5 27 26 (14 T1–12 T2) 96.3% (95% CI=81.7–99.3%) Ed Table 2. Percentage of patients who improved after tongue posture treatment relative to the shape of the hyoid triangle. Patients Number of patients Number of patients Percentage of patients with before treatment with skeletal class I skeletal class I and without IC after treatment infantile swallowing after treatment Male 22 18 81.8% (95% CI=61.5–92.7%) C Female 42 33 78.6% (95% CI=64.1–88.3%) Younger than 7 years 31 27 87.1% (95% CI=71.1–94.9%) © Older than 7 years 33 24 72.7% (95% CI=55.8–84.9%) Normodivergent 22 19 86.4% (95% CI=66.7–95.3%) Hypodivergent 14 12 85.7% (95% CI=60.1–96%) Hyperdivergent 28 20 71.4% (95% CI=52.9–84.7%) Table 3. Percentage of patients who improved after tongue posture treatment according to sex, age, and divergence. 98 Annali di Stomatologia 2012; III (3/4): 95-99 Cephalometric evaluation of the hyoid triangle before and after maxillary rapid expansion in patients with skeletal class II… Discussion needed with a larger number of cases to confirm these findings. The position of the tongue at rest is considered to have a greater effect on the position of teeth than the short-term pressure of perioral soft tissues (10). It has been shown References li that in patients with severe maxillary constriction, the space required to accommodate the tongue close to the 1. Robin P. La Glossopatose. Doin G (Ed), Editions Semaine na roof of the palate is inadequate, and tongue posture is Dentaire, Paris, 1928. lower than desirable (11). Because maxillary expansion 2. Rocabado M. Biomechanical relationship of the cranial, cer- vical, and hyoid regions. J Craniomandibular Pract. 1983; may create the additional space needed to accommodate 1(3):61-6. the tongue, it may be hypothesized that in patients with 3. Doual A, Léger JL, Doual JM, Hadjiat F. [The hyoid bone and io stable results, the tongue may be spontaneously position- vertical dimension]. Orthod Fr. 2003; 74(3):333-63. ing itself closer to the roof of the palate. Not only might this 4. Rocabado M, Iglarsh ZA. Musculoskeletal Approach to Max- result in balanced cheek and tongue pressure on denti- illofacial Pain. J.B. Lippincott, Philadelphia, 1991. az tion but also in a modification of craniofacial growth and 5. Rocabado M. Diagnosis and treatment of abnormal cranio- development patterns (12). After orthopedic/functional cervical and cranio-mandibular mechanics. In: Solberg WK, treatment to alter the jaw and improve its functional activ- Clarck GE (Eds). Abnormal Jaw Mechanics Diagnosis and ity, we observed an increase in the space available for the Treatment. Quintessence, Chicago, 1984a. correct positioning of the tongue and its posture. However, 6. Rocabado M. Joint distraction with a functional maxillo- n mandibular orthopedic appliance. J Craniomandibular Pract. it is important to emphasize that since lingual dysfunction 1984;2(4):358-63. is difficult to intercept and correct, it is important to pro- er 7. Rocabado M. The importance of soft tissue mechanics in sta- vide these patients with myofunctional-logopedic rehabil- bility and instability of the cervical spine: a functional diagno- itation that guarantees stability of the final result achieved sis for treatment planning. Cranio 1987;5(2):130-8. with the aid of orthodontic treatment (13). The cephalo- 8. Bibby RE, Preston CB. The hyoid triangle. Am J Orthod. nt metric analysis of patients at the beginning of therapy re- vealed a reversed triangle hyoid (i.e., with the top facing upward); this indicates an incorrect tongue posture, but is a common physiological factor in hyperdivergent patients 9. 1981; 80(1):92-7. Peng CL, Jost-Brinkmann PG, Yoshida N, Miethke RR, Lin CT. Differential diagnosis between infantile and mature swal- lowing with ultrasonography. Eur J Orthod. 2003; 25(5): iI 451-6. and in patients with a vertical growth tendency. However, 10. Proffit, WR. Equilibrium theory revisited: factors influencing maxillary expansion therapy successfully modified the position of the teeth. Angle Orthod 1978; 48:175-186. triangle, supporting the hypothesis that palatal expansion on 11. Okhiba T, Hanada K. Adaptive functional changes in the can induce positive reconditioning of tongue posture and swallowing pattern of the tongue following expansion of the function (14). maxillary dental arch in subjects with and without cleft palate. Tongue posture improvement due to orthodontic maxillary Cleft Palate Craniofac J 1989; 26:21-30. expansion was achieved in all three experimental groups 12. Ricketts RM. The wisdom of the bioprogressive philosophy. i of patients (i.e., normo-, hypo-, and hyperdivergent), all of Semin Orthod 1998; 4:201-209. iz whom initially had skeletal class II malocclusion, mixed 13. Gallerano G, Ruoppolo G, Silvestri A. Myofunctional and dentition, and infantile swallowing, as revealed using speech rehabilitation after orthodontic-surgical treatment of dento-maxillofacial dysgnathia. Prog Orthod. 2012 cephalometric evaluation of the hyoid triangle before and Ed May;13(1):57-68. after treatment. This treatment was especially successful 14. Ozbek MM, Memikoglu UT, Altug-Atac AT, Lowe AA. Stabil- among male, normodivergent, or hypodivergent patients ity of maxillary expansion and tongue posture. Angle Orthod. aged between 6 and 7 years. However, further studies are 2009 Mar;79(2):214-20. IC C © Annali di Stomatologia 2012; III (3/4): 95-99 99 

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Case report Impacted maxillary incisors: diagnosis and predictive measurements li na Chiara Pavoni Key words: eruption disturbances, odontoma, maxillary Manuela Mucedero expansion, orthodontic traction, close eruption tech- nique. io Giuseppina Laganà Valeria Paoloni Paola Cozza Introduction az Department of Orthodontics, University of Rome Tor Impaction of the maxillary incisor poses a problem at an Vergata, Italy earlier age (1); this pathologic condition is reported less frequently than that of third molars or canines. Impaction n of maxillary permanent incisors occurs in 0,2-1% of the Corresponding author: population (2), early referral of patients in the mixed den- er Giuseppina Laganà tition is common due to concern of parents and general Department of Orthodontics, University of Rome dentists regarding delayed eruption of the permanent Tor Vergata, Rome, Italy maxillary central incisors (3,4). Via G. Baglivi, 5/E As missing upper incisors are regarded as unattractive 00161 Roma, Italy Phone: +39 06 44232321 E-mail: giuseppinalagana@libero.it nt this may have an effect on self-esteem and general so- cial interaction, and it is important to detect and manage the problem as early as possible (5). iI The maxillary incisors are the most prominent teeth in an individual’s smile, they are also the teeth that are on maximum display during speech in most individuals and on Summary the normal eruption, position and morphology of these Background. When the incisors do not erupt at the ex- teeth are crucial to facial esthetics and phonetics (6). pected time, it is crucial for the clinician to determine the Early diagnosis is very important and interceptive ortho- etiology and formulate an appropriate treatment plan. dontic treatment could not only improve skeletal malrela- Aim. The aim of this report is to provide useful informa- i tionship and eliminate functional interferences, but also tion for immediate diagnosis and management of iz may correct disturbances during the eruption (7). impacted maxillary incisors using the interceptive treat- ment: removal of obstacles and rapid maxillary expan- sion (RME). Ed Design. An accurate diagnosis may be obtained with Etiology clinical and radiographic exam such as panoramic radi- ograph, computerized tomography (CT) and cone beam Literature reveals several causes of failure or delayed computerized tomography (CBCT). It’s important to know eruption of maxillary incisors. the predictive measurements of eruption evaluated on Eruption failure may occur if pathological obstructions, panoramic radiograph: distance from the occlusal plane, such as supernumerary teeth, odontomas, cysts, develop IC maturity, angulation and vertical position of the in the eruptive path of the incisor (6,8). unerupted incisors. Early diagnosis is important and in- Supernumerary teeth and odontomas are the most com- terceptive orthodontic treatment, such as removal of mon cause: 56-60% of supernumerary teeth cause im- obstacles and orthopedic rapid maxillary expansion paction of permanent incisors due to a direct obstruction C (RME), may correct disturbances during the eruption for the eruption (9). through recovering space for the incisors and improving Eruption failure can also be caused by tooth malformation the intraosseus position of delayed teeth. or dilacerations. Dilacerations occur after trauma to a Results. RME treatment following the surgical removal of primary tooth, where the developing permanent tooth © the obstacle to the eruption of maxillary incisors leads bud is damaged due to close proximity to the primary to an improvement of the intraosseus position of the tooth. The degree of damage of the permanent tooth de- tooth. Conclusions. The angulation and the vertical position of pends on the developmental stage of the tooth in ques- the delayed tooth appear to be important in trying to pre- tion, as well as the type and direction of the trauma in- dict eruption. The improvement of the intraosseus posi- flicted (6,10). tion of the unerupted incisor, obtained by removal of the Other possible causes of lack of eruption of maxillary in- odontoma and rapid maxillary expansion, permits a con- cisors are: ectopic position of the tooth bud (11), non-vi- servative surgery and the achievement of an excellent tal or ankylosed primary teeth (12), early extraction (or esthetics and periodontal result. loss) of deciduous teeth, mucosal barriers in the path of 100 Annali di Stomatologia 2012; III (3/4): 100-105 Impacted maxillary incisors: diagnosis and predictive measurements eruption that acts as a physical barrier to eruption, en- mesiodistal and vestibulopalatal dimensions at its summit docrine abnormalities, bone disease (5). signifies that the tooth is impacted deeper (8). Radiographic assessment Diagnostic procedures Diagnosis of impacted tooth is verified and its location de- li termined through radiographic evaluation (13). When the incisors do not erupt at the expected time, it is Panoramic radiograph is considered the standard radi- na crucial for the clinician to determine the etiology and for- ographic first-step examination for treatment planning of mulate an appropriate treatment plan. An accurate diag- impacted teeth because it imparts a low dose while giv- nosis may be obtained after thorough clinical and radi- ing the best radiographic survey (11,17). This film is ographic exams. It is also imperative to review a patient’s useful because it is unique in that it will show the entire io medical history to rule out local or systemic conditions (6). dentition as a whole (6), it may reveal the existence of an Patients and parents should be questioned regarding impacted tooth, the degree of root resorption for the cor- any history of dental trauma even in early childhood (13). responding primary tooth (15), and the depth of im- Diagnosis of the delayed tooth is usually made on the ba- paction (8). az sis of clinical and radiographic findings (14). Lateral cephalometric is another film that is particularly Clinical inspection and palpation of the alveolar process useful if there is a supernumerary tooth or dilacerations is recommended (15). present because it allows visualization in several dimen- sions (6). n Clinical examination To be in a position to recommend the best line of treat- An intra-oral examination should be undertaken to iden- ment and to plan an appropriate strategy, the orthodon- er tify retained deciduous teeth, buccal-palatal swelling and tists requires the following information: the exact positions availability of suitable space for the incisor (9mm for a of the crown and root apex of the impacted tooth and the central and 7 mm for lateral incisors) (5). 3-dimensional orientation of its long axis; the proximity of nt Important clinical signs are over-retention of the corre- sponding primary teeth while the contralateral perma- nent tooth has already erupted; substantial reduction in the available space for permanent tooth eruption or space the impacted tooth to the roots of the adjacent teeth; the presence of pathology such as supernumerary teeth, odontomes, apical granulomas or cysts, and their spatial relationship with the impacted tooth; the presence of ad- iI closure; rotation and inclination of the adjacent teeth; el- verse conditions affecting the adjacent teeth, including evation of the soft tissue of the palatal or labial mucosa root resorption; the 3 dimensional anatomy of the crown depending on the tooth location; absence of a bulge in the and root of the impacted tooth (17). on buccal sulcus at 1-1.5 years before the expected time of CT has proved to be superior to other radiographic tooth eruption (11,14,15). method in visualizing bone tissue: 3D CT images clearly The pathognomic sign which indicates impaction of a show the intraosseus location, inclination and morphology central incisor is the presence on the arch of the homo- of impacted teeth as well as the distance from adjacent i lateral lateral incisor, as this points to an anomaly in the structures (18,19). iz central incisor eruption process (8). Due to the highly detailed three-dimension information ob- Deviation from normal sequence of eruption, e.g. lateral tained, computerized tomography is the method of choice incisors erupt prior to the central incisor, or eruption of ad- for accurately defining the position of an unerupted tooth Ed jacent teeth occurred 6 months previously (with both in- and identifying any root resorption of adjacent teeth not cisors unerupted-lower incisors erupted one year previ- detectable by other methods (6). The highly detailed in- ously), are other signs of delayed eruption of maxillary formation and the excellent tissue contrast without blur- incisors (5,16). ring and overlapping of adjacent structures outweighs The position of the adjacent teeth in the arch should be the high radiation dose, limited availability, and high cost noted as well as whether they are upright or tilted toward (18,20). IC the missing tooth. This may be helpful in determining the Three-dimensional imagery enables analysis of the precise location of the unerupted tooth: once it is close to its nor- location and orientation of impacted teeth, their situation mal eruption path the neighboring teeth may tilt, but when relative to obstacles to eruption, their external and internal the unerupted tooth is far from its normal eruption path the anatomy, the labial and palatal bone thickness; any resorp- C adjacent teeth may close the space in a more bodily kind tion of the adjacent teeth or pathological bone loss; the of movement (10). presence or absence of a continuous radiolucent line be- tween the root and the bone (possible ankylosis) (8). Palpation of the alveolar region Recently cone-beam CT (CBCT) has been introduced ad © Palpation is a valuable adjunct in final location of the a technique dedicated to the imaging of dental and max- unerupted tooth, it may also help in the radiographic illofacial structures. It has one-sixth of the radiation of evaluation (10). computed tomography, is more time efficient, more cost On palpation of the area, the clinician is likely to en- effective, is still able to provide three dimensional images, counter a palatal or labial bulge that will help determine excellent bone differentiation and an unlimited number of the position of the unerupted tooth (6). In order to locate views (6,17). Its disadvantages include spatial resolu- the crown of the impacted tooth, we locate a painless, in- tion of subtle structures that is slightly inferior to that of CT compressible, palatal or vestibular fibromucosal protruber- and limited representation of soft tissues (due to the ance. An edentulous ridge with particularly small lower radiation dose) (17). Annali di Stomatologia 2012; III (3/4): 100-105 101 C. Pavoni et al. Predictive measurements of eruption evaluated on panoramic radiograph Mitchell and Bennet in 1992 classified the distance of the unerupted permanent tooth from the occlusal plane as: near, vertical displacement within coronal 1/3 root of ad- li jacent teeth, horizontal displacement < ½ tooth width; mid, vertical displacement within middle 1/3 root of adjacent na tooth, horizontal displacement > ½ tooth width but <1 tooth width; far, greater displacement (21) (Fig. 1). The maturity of the unerupted incisors is assessed by Cvek’s classification. The teeth with wide, divergent root ends io and a root estimated to be less than half the final length were allocated to group 1. Those teeth with roots between Figure 3. Brian et al. measurement. one-half and two-thirds the final root length were allocated to group 2, and those with roots two-thirds of their final az length to group 3. The teeth with open apical foramina and nearly full root length were placed in group 4 and those with completed roots in group 5 (22) (Fig. 2). n er nt iI Figure 4. Smailiene et al. measurement. Case report on Figure 1. Mitchell and Bennet measurement. Aim of this report was to show the interceptive manage- ment of a case with an impacted central maxillary incisor caused by odontoma in a young patient. i iz History and initial examination A 9-year-old Caucasian girl was referred by his general dentist to the Department of Orthodontics of the Univer- Ed sity of Rome “Tor Vergata” for evaluation. The chief com- plaint was concern about an eruption disturbance, which had resulted in an unaesthetic appearance. Diagnosis The patient had balanced facial pattern with a convex pro- IC file, and an asymmetric ugly smile. Intraoral clinical exam- Figure 2. Cvek’s classification. ination showed a mixed dentition, an altered sequence of eruption and the absence of the maxillary right central in- cisor (Figs. 5, 6). C Bryan et al. estimated the angle of the long axis of the unerupted permanent tooth to the mid-sagittal plane (23) (Fig. 3). The vertical position of impacted permanent incisors in © relation to the contralaterally erupted central incisor was analyzed by Smailiene et al.. To determine initial verti- cal position of impacted tooth, the thirds of the root length of the erupted contralateral central incisor were used. Three possible vertical positions of impacted inci- sor have been defined: v1- sector at the level of gingi- val third of the root; v2- sector at the level of middle third of the root; v3 – sector at the level of apical third of the root (9) (Fig. 4). Figure 5. Pretreatment intraoral photograph, frontal view. 102 Annali di Stomatologia 2012; III (3/4): 100-105 Impacted maxillary incisors: diagnosis and predictive measurements li na Figure 7. Measurements at T1. Treatment plan io The odontoma was removed (2), and a Palatal Expander was bonded in the maxillary arch. The expansion of up- per arch permitted to obtain good correction of the inter- az arch relationship to favour teeth alignment, dental inter- cuspation and functional movements, and to improve intra osseous incisor position (24) (Fig. 8). n er nt iI on Figure 6. Pretreatment extraoral photograph, smile view. Figure 8. Intraoral frontal view during maxillary expansion. Occlusal analysis revealed a molar Class I relationship. There was significant dental crowding in the upper and i lower arches. The maxillary right central incisor was ab- The patient underwent a modify Rapid Maxillary Ex- iz sent and the maxillary right lateral incisor was erupting pander (25) designed with two Crozat wire Chromium with lack of space for the central incisor in the line of the Cobalt 0.028 arms soldered on the metal arms placed in arch. Overjet and overbite were 3 mm. a forward position; these arms are situated mesial to the Ed Radiological examinations are performed to complete right deciduous canine and to the left central incisor in clinical evaluation. The panoramic radiograph showed order to create and mantain space for the absent tooth an odontoma located in the eruption path of permanent (Fig. 9). Activation of the screw was continued until the maxillary right incisor. It was not possible to exactly define palatal cusps of the maxillary posterior teeth were in con- the place of impacted incisor. tact with the buccal cusps of the mandibular posterior TC-Dentascan evaluation confirmed the presence of a teeth. After expansion, the patient was retained with IC composite odontoma in the body of the premaxilla, near the expander in place for 6 months. Following the reten- the crown of impacted incisor. tion period the expander was removed and the patient Cephalometric analysis revealed a skeletal Class I mal- occlusion (ANB T1: 3°) and a dolichofacial pattern (FMA C T1: 31°). Lower incisor showed good inclination on mandibular plane (IMPA T1: 92°). The vertical position of the delayed permanent incisor in relation to the contralaterally erupted central incisor was © v2, while its angulation to the mid-sagittal plane was 20° (Fig. 7). Treatment objectives The following treatment objectives were established: 1) surgical removal of obstacle, 2) orthopedic maxillary ex- pansion to recover space for the eruption of the incisor and to improve the intra osseous position of delayed maxillary incisor, 3) recovery of impacted tooth. Figure 9. Intraoral occlusal view during maxillary expansion. Annali di Stomatologia 2012; III (3/4): 100-105 103 C. Pavoni et al. was made available for clinical examination and radi- ographs to monitor the intra osseous position of the de- layed incisor. On the panoramic radiographs the right central incisor showed an improvement of the initial vertical position li (sector v1) and angulation (12°) (Fig. 10). na io Figure 12. Intraoral frontal view at the end of orthodontic traction. az Figure 10. Measurements at T2. 8 months after odontoma removal a surgical exposure n and traction of the impacted right central incisor were planned. Surgical exposure has been performed using a er closed eruption technique (4), in which the raised flap that incorporates attached gingival is fully replaced to its for- mer position. In fact the gingival flap was sutured back in nt such a way that the bracketed crown was not exposed into the oral cavity. Special care was given to preserve the bone, mucoperiostum and gingival tissues around the crown. The patient returned two weeks later, after soft tis- iI sue healing, and the elastomeric chain (60-90 g) was tied with tension to the open coil (8). The patient was seen Figure 13. Post treatment intraoral photograph, frontal view. every three weeks (Fig. 11). i on iz Ed IC Figure 11. Intraoral frontal view of the orthodontic traction stages. Once the impacted tooth had erupted, brackets were C placed on the upper arch and it was tied to an archwire (0.016 x 0.022-in multibraid stainless steel) (Fig. 12). Interim radiographs were requested to verify the root po- sitioning. © Active treatment took 14 months to recovery delayed in- cisor in dental arch. She is currently on routine patient re- call. At the end of dentition the patient will be revaluated for a second phase of treatment with fixed appliance. Treatment results The patient showed a good smile arch and balanced pro- file (Figs. 13, 14). The impacted maxillary right central incisor was brought Figure 14. Post treatment extraoral photograph, smile view. 104 Annali di Stomatologia 2012; III (3/4): 100-105 Impacted maxillary incisors: diagnosis and predictive measurements into proper position. The final appearance of the tooth was 6. Huber KL, Suri L, Taneja P. Eruption disturbances of the max- esthetically pleasing, with gingival margins at the same illary incisors: a literature review 1: J Clin Pediatr Dent 2008; level with similar clinical crowns sizes. The tooth re- 32(3): 221-230. sponded well to vitality and did not show abnormalities in 7. Cozza P, Marino A, Laganà G. Interceptive managment of eruption disturbances: case report. J Clin Pediatr Dent 2004; crown shape. From a periodontal point of view a band of 29(1): 1-4. li labial keratinized gingival measuring 4 mm was present, 8. Chokron A, Reveret S, Salmon B. Vermelin L. Strategies for and pocket depth ranged from 1 to 2 mm. treating an impacted maxillary central incisor. Int Orthod na The final radiographs indicated intact roots, proper root 2010 Jun; 8(2): 152-176. alignment, and no root disease. 9. Smailiene D, Sidlauskas A, Bucinskiene J. Impaction of the A skeletal class I (ANB T1:3°, T2:3°) was mantained. An central maxillary incisor associated with supernumerary ideal overbite (T1: 3mm, T2: 2mm) and overjet (T1: 2mm, teeth: initial position and spontaneous eruption timing. Stom- atologija 2006; 8(4): 103-107. io T2: 2mm) were established and a Class I molar and ca- nine relationship was presented. Upper and lower incisors 10. Brin I, Zilberman Y, Azaz B. The unerupted maxillary central incisor: review of its etiology and treatment. ASDC J Dent showed good inclination (IMPA T1: 92°, T2: 91°; U1^FH Child 1982 Sep-Oct; 49(5): 352-356. T1: 108°, T2: 113°). az 11. Becker A. The orthodontic treatment of impacted teeth. 1998. 12. Betts A, Camilleri GE. A review of 47 cases of unerupted maxillary incisors. International Journal of Paediatric Dentistry Conclusions 1999; 9: 285-292. 13. Douglas DE. Management of impacted anterior teeth utiliz- n When the incisors do not erupt at the expected time, it is ing basic orthodontic principles. ASDC J Dent Child 1989; crucial for the clinician to determine the exact etiology and 56(5): 353-357. er formulate an appropriate treatment plan. 14. Duncan WK, Ashrafi MH, Meister F Jr, Pruhs RJ. Manage- Early diagnosis of delayed eruption is important and it is ment of the nonerupted maxillary anterior tooth. J Am Dent made on the basis of clinical and radiographic findings. Assoc 1983; 106(5): 640-644. The use of TC-dentascan or CBCT should be considered 15. Kavadia-Tsatala S. Orthodontic and periodontal considera- nt a routine diagnostic aid in cases where the treatment of impacted teeth is being considered, because it gives highly detailed three-dimension information. 16. tions in managing teeth exhibiting significant delay in erup- tion. World Journal of Orthodontics 2004; vol.5 N 3. Roberts-Harry D, Sandy J. Orthodontics. Part 10: Impacted teeth. Br Dent J 2004; 196(6): 319-327. iI The interceptive treatment consists of surgical removal of 17. Chaushu S, Chaushu G, Becker A. The role of digital volume obstacles followed by the orthopaedic rapid maxillary ex- tomography in the imaging of impacted teeth. World J Orthod pansion and creation of space for the delayed tooth 2004; 5(2): 120-132. on through Modify Rapid Maxillary Expander, which permits 18. Sawamura T. Minowa k. Nakamura M. Impacted teeth in the to improve intraosseus incisor position. maxilla:usefulness of 3D dental-CT for preoperative evalua- In the described case, thanks to the interceptive ap- tion. Eur J radiol 2003; 47: 221-226. proach, satisfactory functional and aesthetic results were 19. Chen Y, Duan P, Meng Y, Chen Y. Three-dimensional spiral computed tomographic imaging: a new approach to the di- i obtained, gingival attachment was maintained and in- agnosis and treatment planning of impacted teeth. Am J Or- iz tegrity of the dental arch was restored. thod Dentofacial Orthop 2006 Jul; 130(1): 112-116. 20. Walker L, Enciso R, Mah J. Three-dimensional localization of maxillary canines with cone-beam computed tomography. Ed References Am J Orthod Dentofacial Orthop 2005 Oct; 128(4): 418-423. 21. Mitchell L, Bennet TG. Supernumerary teeth causing delayed 1. Pinho T, Neves M, Alves C. Impacted maxillary central inci- eruption. A retrospective study. Br J Orthod 1992; 19(1): 41- sor: surgical exposure and orthodontic treatment. Am J Or- 48. thod Dentofacial Orthop 2011 Aug; 140(2): 256-265. 22. Cvek M. Prognosis of luxated non-vital maxillary incisors 2. Kurol J. Early treatment of tooth eruption disturbances. Am treated with calcium hydroxide and filled with gutta percha. J Orthod Dentofacial Orthop 2002; 121: 588-591. IC A retrospective clinical study. Endod Dent Traumatol 1992; 3. Kolokitha OE, Papadopoulou AK. Impaction and apical root 8: 45–55. angulation of the maxillary central incisors due to supernu- 23. Bryan RA, Cole BO, Welbury RR. Retrospective analysis of merary teeth: combined surgical and orthodontic treatment. factors influencing the eruption of delayed permanent incisors case report. Am J Orthod Dentofacial Orthop 2008 Jul; after supernumerary tooth removal. Eur J Paediatr Dent C 134(1): 153-160. 2005; 6(2): 84-89. 4. Becker A, Brin I, Ben-Bassat Y, Zilberman Y, Chaushu S. 24. Baccetti T, Mucedero M, Leonardi M, Cozza P. Interceptive Closed-eruption surgical technique for impacted maxillary in- treatment of palatal impaction of maxillary canines with rapid cisors: a postorthodontic periodontal evaluation. AJODO maxillary expansion: A randomized clinical trial. Am J Orthod © 2002; 122: 9-14. Dentofacial Orthop 2009; 136: 657-661. 5. Jones J. W. A Medico-legal Review of Some Current UK 25. Cozza P, Giancotti A, Petrosino A. Rapid Palatal Expansion Guidelines in Orthodontics: A personal View. J. Orthod 1999; in Mixed Dentition using a Modified Expander: a cephalomet- 26: 307-324. ric investigation. J Orthod 2001; 28: 129-134. Annali di Stomatologia 2012; III (3/4): 100-105 105 

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Case report 3D imaging reconstruction and impacted third molars: case reports li na Andrea Tuzi, DDS reconstruction with a dedicated software. By our study Roberto Di Bari, DDS we deduce that 3D images are not indispensable, but they can provide a very agreeable assistance in the most io Andrea Cicconetti, MD complicated cases. Department of Oral and Maxillofacial Sciences, School Key words: IAN Inferior Alveolar Nerve, 3M third molar, az of Dentistry, Sapienza University of Rome, Italy CBCT Cone-Beam Computed Tomography, Dental CT Scan, DICOM image, 3D reconstruction. Corresponding author: n Andrea Cicconetti, MD Introduction Department of Oral and Maxillofacial Sciences, School of er Dentistry, Sapienza University of Rome, Italy Extraction of lower third molars, both impacted and not, Via Caserta, 6 Italy has become a standard procedure in the clinical dental 00161 Rome, Italy practice. In most cases, this surgical treatment implies lit- Phone: +39 06 49976633 Summary nt tle or no risk for the adjacent anatomic structures that comprise first of all the inferior alveolar nerve (IAN), and the lingual nerve. However, in very few cases, the third molar is so close to the IAN that its extraction might ex- iI There is a debate in the literature about the need for pose patients to the risk, more or less relevant, of post- Computed Tomagraphy (CT) before removing third mo- operative neuro sensitive alterations of the skin and the lars, even if positive radiographic signs are present. In mucosa of the homolateral lower lip and chin. on few cases, the third molar is so close to the inferior Moreover, extraction of the third molar is the primary alveolar nerve that its extraction might expose patients cause of the permanent neurologic deficit of the inferior to the risk of post-operative neuro-sensitive alterations alveolar nerve, being even more important than implant of the skin and the mucosa of the homolateral lower lip and orthognathic surgery (1,2). Other less frequent and chin. Thus, the injury of the inferior alveolar nerve i causes of IAN injury reported in literature are: loco-re- iz may represent a serious, though infrequent, neurologic complication in the surgery of the third molars rendering gional injection of anaesthetic for IAN block, endodontic necessary a careful pre-operative evaluation of their treatment of lower premolar and molar after overfilling, malignant expansive lesions, metastases, mandibular Ed anatomical relationship with the inferior alveolar nerve by means of radiographic imaging techniques. This con- fractures, local infections(osteomyelitis) and pre-pros- tribution presents two case reports showing positive thetic surgery (3,4). The incidence of temporary (re- radiographic signs, which are the hallmarks of a possi- versible) injuries ranges from 3,3% to 13.0% and repre- ble close relationship between the inferior alveolar nerve sents the third most common complication after alveolitis and the third molars. We aim at better defining the rela- and post-operative infections; the incidence of permanent tionship between third molars and the mandibular canal (irreversible) lesions of the IAN ranges from 0,2% to 9% IC using Dental CT Scan, DICOM image acquisition and 3D (Tab.1) (5). Thus, the injury of the inferior alveolar nerve C Temporary IAN Injury Permanent IAN Injury Brann CR et al., 1999 13.0% 1.0% Carmichael FA, McGowan DA, 1992 3.9% 9.0% © Gülicher D, Gerlach KL, 2000 3.6% 9.0% Kipp DP et al., 1980 4.5% 1.0% Smith AC et al., 1997 5.2% 0.2% Strietzel FP, Reichart PA, 2002 3.6% 0.9% Wofford DT, Miller RI, 1987 3.3% Table 1. Incidence of IAN injury after extraction of the third molar (5). Annali di Stomatologia 2012; III (3/4): 123-131 123 A. Tuzi et al. represents a serious but infrequent neurologic complica- tween the IAN and the mesiolingual and distolingual tion in the surgery of the third molars, which is usually due roots of the right third molar, and between the IAN and to the close anatomic relationship between IAN and third the mesial root of the left third molar. Moreover we can molars. Therefore, this anatomical relationship must be in- evaluate the mandibular canal on its axial view (Figs. 2, vestigated pre-operatively by means of the radiographic 9). Using the three scholding tools of the software we are li imaging techniques currently available (1). In this study able to obtain a 3D recostraction of the 3M teeth. We clinical cases are presented where the Orthopanoramic na radiography shows positive radiographic signs, which are the hallmarks of a possible close relationship be- tween the IAN and the third molars. This paper aims at better defining the relationship between third molars and io the mandibular canal using Dental CT Scan, DICOM im- age acquisition and 3D reconstruction with a dedicated software Simplant (Materialise, Ann Arbor, MI 1997). az Cases reports Case 1 n A patient (female, age 35) was referred for the removal of both lower third molars. The panoramic radiography er showed a darkening of the roots of the right third molar and a deviation of the canal of the left third molar. These Figure 2. Axial view passing through the tooth roots and show- ing the canal traced at the level of the left and right third molars are telltale signs of a close relationship with the mandibu- (Case 1 - Right third molar). nt lar canal. In order to confidently proceed to surgery, the patient underwent a Dental CT Scan to better evaluate the relationship between the canal and the roots of the third molar as this was not sufficiently clear on the first-level bi- iI dimensional examination (orthopanoramic radiography). After an accurate analysis of the CT, axial, paraxial and panoramic slices, given the close relationship between the on roots and the IAN and the complex anatomic morphology of the examined third molars, we decided to proceed to the 3-D reconstruction of the surgical area by means of a dedicated software (Simplant). i First step was to obtain the panoramic reconstruction iz carried out on the basis of the CT data (Fig. 1). On this image we traced the right and left mandibular canal by means of a dedicated tool (“nerve tool”) and the software Ed automatically traced it also on the axial and paraxial sec- tions. Then we have studied the right and left mandibu- lar canal, highlighted by the software, on the paraxial Figure 3. Paraxial (coronal) views of the area of the right third mo- sections (Figs. 3, 10). In both cases, we can appreciate lar highlighting the canal (Case 1 - Right third molar). IAN’s lingual position to the roots as well as the area of contact (interruption of the cortical wall of the canal) be- IC can decide to visualize only the tooth, the mandibular canal or all the anatomical structures (also in trans- parency modality). 3D reconstructions help the surgeon in analysing the relationship between the canal and the C roots of the third molar from different perspectives (Figs. 4, 5, 6, 11, 12). For the right molar the buccal and mesiobuccal views providing information on both the morphology and crown-root angulation with respect to © the canal pathway. Notice the apical hook-like shape of mesiolingual root, which was not clearly detectable on the CTs (Figs. 4, 5). The bottom view providing accurate information on the number and diameter of the tooth roots, 2 mesial and 2 distal roots- all separated, and on which root is in contact with the canal (Fig. 6). After the Figure 1. CT image of a panoramic reconstruction showing the extraction we take some photos of the tooth: notice the impacted third molars and the right and left mandibular canal par- correspondence between real anatomical details and 3D tially traced in Simplant (Case 1 - Right third molar). reconstruction (Figs. 7, 8). 124 Annali di Stomatologia 2012; III (3/4): 123-131 3D imaging reconstruction and impacted third molars: case reports li na io az Figure 4. 3D reconstruction buccal views showing the anteropos- n terior pathway of the IAN. The other teeth are not shown (Case 1 - Right third molar). er nt Figure 7. Buccal View - extracted right molar (Case 1 - Right third molar). iI i on iz Ed Figure 5. 3D reconstruction mesiobuccal views showing the an- teroposterior pathway of the IAN. The other teeth are not shown (Case 1 - Right third molar). IC C © Figure 6. 3D reconstruction bottom view showing the contact be- Figure 8. Bottom view - extracted right molar (Case 1 - Right third tween the IAN and the mesiolingual and distolingual roots (Case 1 molar). - Right third molar). Annali di Stomatologia 2012; III (3/4): 123-131 125 A. Tuzi et al. li na io Figure 9. Axial view left molar (Case 1 - Left third molar). n az er Figure 12. 3D reconstructions from different perspectives confirm- ing what was already highlighted on the paraxial views, i.e. the nt IAN’s lingual position and its contact with the third upper portion of the mesial root (Case 1 - Left third molar). Also for the left 3M molar a photo-analysis of the extracted iI tooth confirm the quality of 3D reconstruction (Fig. 13). Figure 10. CT image of paraxial (coronal) views of the area of the left third molar showing the mandibular canal, in Simplant, pass- ing lingually to the roots and in close contact with the mesial root on (Case 1 - Left third molar). For the left molar, lingual and distal views indicate the presence of two separate roots, a distal and a mesial one i respectively; the mesial root is in contact with the IAN iz while the distal root has no relationship with the canal (Figs. 11, 12). Ed IC C © Figure 11. 3D reconstructions from different perspectives confirm- ing what was already highlighted on the paraxial views, i.e. the IAN’s lingual position and its contact with the third upper portion of the mesial root (Case 1 - Left third molar). Figure 13. The extracted Tooth (Case 1 - Left third molar). 126 Annali di Stomatologia 2012; III (3/4): 123-131 3D imaging reconstruction and impacted third molars: case reports Case 2 The patient (female, 30 years) had to remove both lower third molars and a supernumerary tooth in the right mo- lar region. The first-level panoramic X-ray showed posi- tive radiographic signs, including interruption of the cor- li tical bone of the roof of the canal and darkening of the roots of the left lower third molar; darkening of the roots na and deviation of the canal when passing nearby the left lower third molar. These signs indicated the presence of a close relationship between the IAN and the roots of the third molars. This was an indication to proceed to the sec- io ond-level examination, i.e. Dental CT Scan and 3D analy- sis using the dedicated Simplant software. We started with a panoramic reconstruction (Fig. 14) tracing the mandibu- Figure 16. Paraxial slices (coronal) of the region of the right third molar with highlighted canal (Case 2 - Right third molar). n az er nt iI Figure 14. CT image of panoramic reconstruction showing im- pacted third molars and the right and left mandibular canal traced Figure 17. 3D reconstruction with the mandible in transparent in Simplant (Case 2 - Right third molar). mode: we can appreciate the tooth roots and the pathway of the on mandibular canal (Case 2 - Right third molar). lar canal that is also traced on the paraxial and sagittal sections (Figs. 15, 16, 19). Furthermore, in both cases the IAN is lingual to the roots and seems to be in contact with i them. The 3-D reconstrucions confirmed the information iz provided by CT images, and in particular gave us the pos- sibility to appreciate an array of anatomical details that were not easily detectable on the CTs: the presence of a Ed mesio-lingual root, with a 90° curvature in the distal direc- tion, lying on the canal roof (Figs. 17, 18); the IAN partially entrapped between the buccal and lingual roots (Fig. 18); the direct contact between the distal root and the IAN IC C © Figure 18. 3D reconstruction with different views showing the re- lationship between the third molar and the IAN which is partially Figure 15. Axial slice showing the canal traced at the level of the entrapped between the buccal and lingual roots (Case 2 - Right third molars (Case 2 - Right third molar). third molar). Annali di Stomatologia 2012; III (3/4): 123-131 127 A. Tuzi et al. li na io Figure 19. Images of paraxial (coronal) slices showing the mandibular canal, traced in Simplant, lingual to and in contact with az the roots of the third molar (Case 2 - Left third molar). and the IAN’s close relationship with the mesial root (Fig. 20); the contact between the IAN and the disto-buccal root n of the left third molar that showed a depression on the lin- gual surface due to the direct contact with the IAN (Fig. er 21) and an intimate relationship (but no direct contact) with the mesio-buccal root. The software can zoom-in the relevant area highlighting anatomic details that help the Figure 21. 3D reconstructions, distal views, respectively, confirm- and in planning the operation (Figs. 20, 21). nt surgeon both in assessing the risk of damaging the IAN ing the contact between roots and mandibular canal that creates a depression on the lingual surface of the distal root (Case 2 - Left third molar). iI In fact, it has many major limitations linked to superim- position, and thus to improper visualization of all anatom- on ical structures, as well as to the operator’s difficulty in ap- propriately positioning the film without causing major discomfort to the patient (2). Currently in oral surgery, panoramic radiography is the first-level imaging of choice i in the pre-operative evaluation of the third molar (6). iz Rood e Shehab (1990) described a series of radiographic signs, detectable on the OPT, that indicate the presence of a close relationship between the IAN and the lower Ed third molar (Tab. 2) (7,8). There is no consensus in the literature about which of these 9 signs, detected on the panoramic radiography, is the most useful one in order to predict exposure of the IAN or clinical complications, such as paraesthesia, after the removal of a third molar (10). Some studies report that darkening of the roots, in- IC terruption of the cortex of the roof of the canal, and canal deviation are the radiographic signs, detected pre- operatively, that are most often associated with IAN’s ex- posure and injury (1,6,8,10). Sedaghatfar et al. found an C association even between root narrowing and increased possibility of visualizing the IAN after removal of the Figure 20. 3D reconstruction, disto-buccal view, showing both third molars (10). Instead, Bell reported, a close relation- ship between the third molar and the inferior alveolar © the buccal roots fused, with distal curvature extending apically beyond the IAN and partially enveloping it (Case 2 - Left third nerve in 51% of cases where the panoramic radiography molar). showed a darkening of the roots, and only in 11% of cases where the OPT detected an interruption of the cor- tical bone of the roof of the canal (8). De Melo Albert et Discussion al. report that root darkening, detected on the OPT, co- incides in 92% of cases with a direct relationship between Despite its wide use in the dental clinical practice, peri- the IAN and the roots of the third molar, detected on the apical endoral radiography is not the ideal imaging tech- CT (13). A review of literature indicates that most authors nique to study impacted and non impacted third molars. agree that root deviation, bifid apex and canal narrowing 128 Annali di Stomatologia 2012; III (3/4): 123-131 3D imaging reconstruction and impacted third molars: case reports 1. Radiotrasparent band darkening the root of the third molar due to its reduction in density caused by the mandibular canal crossing the area. 2. Interruption of the white line making up the cortical bone of the roof and ceiling of the canal due to the root of the third molar crossing it. li 3. Deviation of the mandibular canal: abrupt change of direction of the canal at the point na in which it is superimposed on or in contact with the roots of the third molar. 4. Narrowing of the canal: narrowing of the mandibular canal at the point where it superimposes on or comes in contact with the roots of the third molar. io 5. Deviation of the root: abrupt deviation (dilaceration) of the roots of the third molar at the point where they superimpose on or come in contact with the mandibular canal. az 6. Narrowing of the root: index of an area of root depression at the point in which they are crossed by the IAN. 7. Bifid apex with root darkening of the third molar at the point where they are crossed by the IAN. 8. Superimposition: superimposition involving the roots of the third molar and the mandibular canal. n 9. Contact with the mandibular canal: the roots of the third molar are in contact with the roof of the mandibular canal. er Table 2. Radiographic signs, detectable on the OPT, that indicate the presence of a close relationship between the IAN and the lower third molar (7,9). posure and injury. nt may have a lower predictive value in terms of IAN’s ex- We can thus deduce that for pre-operative diagnostic Tomography (CBCT). These methods will provide a bet- ter way to evaluate the relationship between the third mo- lar’s roots and the IAN (2,9,10,16). As OPT is a bi-dimen- iI purposes, the absence of positive radiographic signs on sional examination, it does not provide information on the the panoramic radiography is preferable to their presence. depth of the anatomical structures studied. Indeed, it lo- Without positive radiographic signs the risk of IAN injury cates the mandibular canal only in the vertical and not in on is considered very low, while the presence of one or the horizontal plane (2,6). Furthermore, the evaluation of more signs is not a good predictor of IAN injury, although the position of the mandibular canal in the vertical plane it indicates a high probability of intra-operative exposure is not always reliable due to magnification variables- 20- of the vascular nervous bundle. This probability, in turn, 30% difference. Moreover, there may be other confound- i increases with an increase in the number of positive ra- ing sources of variation, e.g. the position of patient’s iz diographic signs detected on the OPT (9,10,15). In a head on the pantograph, and also the area of interest study by Susarla and Dodson, the authors conclude that given that the amplification might not be homogeneous the specificity of orthopanoramic radiography to predict across the whole image (5,19). Other challenges with Ed IAN injury ranges between 96% and 98% (ability to ex- OPT are the superimposition of air shadows and soft tis- clude a direct IAN/M3 relationship); while its sensitivity sues as well as phantom images (20). Furthermore, the ranges between 24% and 38% (6,16) (ability to identify a OPT does not detect either the buccolingual width or the direct IAN/M3 relationship). This means that, in the ab- atrophy of the alveolar crest (20). A positive feature of bi- sence of positive radiographic signs, the OPT enables us dimensional images, in standard radiological techniques, to detect with almost 100% accuracy- the cases of third is the high resolution and contrast of anatomical details IC molars that are not in direct relationship with the IAN which is not provided by CT images (8). It is important to (high negative predictive value), whose extraction is thus notice that the anatomical structures that are out of the not associated with the risk of damaging the IAN. How- centre of rotation of the source/detector are blurred and ever, given its low sensitivity, in the presence of positive distorted. Impacted or ectopic third molars are frequently C radiographic signs, OPT does not allow to detect- with out of the centre of rotation and thus cannot be properly equal accuracy- the cases where third molars are in direct visualized. Hence it is often difficult to make a diagnosis relationship with the IAN (low positive predictive value), based only on OPT. Neugebauer et al. (5) compared the and whose extraction entails the risk of injuring the IAN diagnostic accuracy of OPT vs CBCT in detecting the po- © (6,17). In fact, it has been shown that relying only on the sition of the root apex of third molars with respect to the positive radiographic signs to make a pre-operatory diag- IAN. There were no significant differences in diagnostic in- nosis, can lead to an overestimate of the actual possibil- formation between the two radiographic techniques with ity of contact between the IAN and third molars, thus er- respect to the vertical plane. In fact, both provide the cli- roneously classifying a situation as a high risk one (false nician with the same type of information. Conversely, positive) (18). Therefore, the presence of positive radi- there was a significant difference between the two tech- ographic signs on the OPT should be regarded just an in- niques with respect to the horizontal plane, and the diag- dication to proceed to second-level instrumental investi- nostic information provided by CBCT was clearly prefer- gations with CT Dental Scan or Cone-Beam Computed able (5). The latter is a 3-D exam, which enables us to: Annali di Stomatologia 2012; III (3/4): 123-131 129 A. Tuzi et al. - evaluate the buccolingual relationship between the highlight the single components (bone, teeth, canal, im- IAN and the roots of the third molar, so as to avoid im- plants, etc.) in different combinations (9). pacting the tooth with movements that can cause a impingement of the nerve’s root; plan the appropriate interradicular section if it is evident that the IAN Conclusions li crosses the roots (21); - identify the presence or the partial/total absence of There is currently debate in literature about the need for na cortical bone around the IAN (21); CTs before removing third molars, even if one or more - visualize the number of roots and the exact root positive radiographic signs, as mentioned before, are anatomy of the third molar; define the inclination of the present on the panoramic radiography. Indeed, there are tooth and the position of the crown with respect to the oral and maxillofacial surgeons who disagree about the io buccal or lingual surface of the mandible (21). need to resort to CTs, as they consider the panoramic ra- To conclude, most authors in the literature agree that diography as the first choice examination for the pre-op- Dental CT Scan and CBCT are the most effective imag- erative evaluation of impacted and non impacted third mo- ing techniques to detect both the localization of the canal lars. These surgeons infact underline both the high cost az in relation to its superior/inferior and bucco/lingual di- of CT and the high dose of radiation patients are exposed mensions, and the exact crown-root morphology of third to. So, unlike OPT, CTs are not seen by these surgeons molars (5). In the last decade, 3-D reconstruction soft- as a routine examination for the evaluation of third molars. wares- designed for the study of the jaws have been in- However, CT evaluation should not be excluded a priori n troduced to help clinicians both in the diagnosis and in the as a potential diagnostic tool for clinicians (9). Indeed, it treatment plan. should be used only for those patients whose first-level er These softwares, initially introduced in implantology, rep- OPT shows one or more of the nine radiographic signs in- resent an excellent tool for the study of the relationship dicating a close relationship between the IAN and the between mandibular canal and third molars. They are tooth root, and when this relationship cannot be defined nt useful especially in challenging diagnostic cases, where the 3-D visualization of the IAN/M3 relationship enables clinicians both to decide the appropriate planning of the surgical step, and to avoid jeopardising the integrity of the sufficiently using conventional radiology (2,9,10,16). In particular, Jhamb et al. (18) deem that a CT examination is absolutely necessary when the OPT detects one or more of the following radiographic signs: darkening of the iI mandibular canal (9). One of the first softwares to be mar- roots; interruption of the white line with narrowing of the keted is SimPlant (Materialise, Ann Arbor, MI 1997). This canal and superimposition of the roots and the mandibu- software accepts images in DICOM format (Digital Imag- lar canal. Moreover, CT examination is recommendable on ing and Communications in Medicine), i.e. the first stan- in all those instances in which it may have a direct impact dard format for the distribution and viewing of any type of on the planning of the surgical steps, and on the evalua- medical image. Simplant is able to recognize DICOM im- tion of sequelae, outcome and morbidity. ages from many different types of CTs and CBCTs. It should also be stressed that the advent of CBCT in the i So to pass from a Digital CT or CBCT to a 3D reconstruc- early 2000s has reduced the cost for patients, and mostly iz tion we have to import DICOM files in Simplant. A 3d re- it has improved the risk-benefit profile by reducing the construction doesn’t need an higher dose of radiation to dose of radiations for patients if compared to conventional patient; it allows to optimize the information contained in CT scans (10). Moreover, in those cases where the root Ed CT or CBCT files. of the third molars shows a complex morphology, and it Once imported in SimPlant, the images show maxillary is located in contact with the mandibular canal, the new sections on the axial, paraxial (coronal) and sagittal 3D reconstruction softwares supporting CTs provide sur- planes (panoramic reconstructions). These images are geons with an additional planning tool that offers: realistic representations of the maxilla (1:1 scale), allow- • immediate and neat visualization of the noble struc- ing accurate measurements of anatomical structures. tures that have to be respected and their localization IC Importantly, SimPlant enables surgeons to trace the in the three spatial planes; path of the mandibular canal. It can be traced either on • the exact morphology of the relevant root apex; the paraxial sections (coronal) or on the sagittal sec- • a 360° view of the relationship between the IAN and tions (panorex); usually it is easier to use than the the third molar; C panoramic images as the IAN can be more easily iden- • the exact point in which the root is in relationship tified and the software automatically detects it also on with the canal. the paraxial views. The buccolingual position of the The complete anatomical image’s details and the friendly IAN (in the horizontal plane) is detected on the parax- and dynamic approach to them can influence the surgical © ial views, while the position in the vertical plane can be approach: single or multiple odontotomy, depth of os- assessed both in the panoramic and on the paraxial im- teotomy or direct of luxation can be programmed more ac- ages. The great advantage of SimPlant, and similar curately. softwares, is the possibility to have virtual 3-D recon- To conclude, we can state that although 3D images are structions of the bones, of the teeth, of the mandibular not essential for the pre-operative evaluation of third mo- canal as well as of other structure of the face. lars, they definitely enhance the information provided by The most interesting feature of the software is its capa- CT scans, and thus represent an added value in the bility to rotate images, thus providing clinicians with a 360° choice of the therapy to adopt in order to minimize pos- view of the anatomic structures. Moreover it can hide or sible injuries of the IAN. 130 Annali di Stomatologia 2012; III (3/4): 123-131 3D imaging reconstruction and impacted third molars: case reports References 12. Savi A, Manfredi M, Pizzi S, Vescovi P, Ferrari S. Inferior alve- olar nerve injury related to surgery for an erupted third mo- 1. Dodson TB. Role of computerized tomography in manage- lar. Oral Med Oral Pathol Oral Radiol Endod 2007; 103: ment of impacted mandibular third molars. N Y State Dent J, e7-e9. November 2005. 13. Guimaraes D, de Melo ADG, Gomes ACA, do Egito Vascon- 2. Flygare L, Ohman A. Preoperative imaging procedures for celos BC, de Oliveira e Silva ED, Holanda GZ. Comparison li lower wisdom teeth removal. Review. Clin Oral Invest 2008; of ortho-pantomographs and conventional tomography im- 12:291-302. ages for assessing the relationship between impacted lower na 3. Jerjes W, Upile T, Shah P, Nhembe F et al. Risk factors as- third molars and the mandibular canal. J Oral Maxillofac sociated with injury to the inferior alveolar and lingual nerves Surg 2006; 64:1030-1037. following third molar surgery. Oral Surg Oral Med Oral Pathol 14. Tantanapornkul W, Okouchi K, Fujiwara Y, Yamashiro M, Oral Radiol Endod 2010; 109:335-345. Maruoka Y, Ohbayashi N, Kurabayashi T. A comparative study of cone-beam computed tomography and conven- io 4. Tolstunov L, Pogrel MA. Delayed paresthesia of inferior alve- olar nerve after extraction of mandibular third molar: case re- tional panoramic radiography in assessing the topographic port and possible etiology. J Oral Maxillofac Surg 2009; relationship between the mandibular canal and impacted 67:1764-1766. third molars. Oral Surg Oral Med Oral Pathol Oral Radiol az 5. Neugebauer J, Shirani R, Mischkowski RA, Ritter L, Scheer Edod 2007; 103:253-9. M, Keeve E, Zoller JE. Comparison of cone beam volumet- 15. Jozsef S, Lempel E, Jeges S, Szabò G, Olasz L. The prog- ric imaging and combined plain radiographs for localization nostic value of panoramic radiography of inferior alveolar of the mandibular canal before removal of impacted lower nerve damage after mandibular third molar removal: retro- spective study of 400 cases. Oral Surg Oral Med Oral Pathol n third molars. Oral Surg Oral Med Oral Pathol Oral Radiol End 2008; 105:633-42. Oral Radiol Endod 2010;109:294-302. 6. Atieh MA. Diagnostic accuracy of panoramic radiography in 16. Susarla SM, Dodson TB. Preoperative computed tomogra- er determining relationship between inferior alveolar nerve and phy imaging in the management of impacted mandibular mandibular third molar. J Oral Maxillofac Surg 2010; 68:74-82. third molars. J Oral Maxillofac Surg 2007; 65:83-88. 7. Koong B, Pharoah MJ, Bulsara M, Tennant M. Methods of 17. Susarla SM, Sidhu HK, Avery LL, Dodson TB. Does com- determining the relationship of the mandibular canal and puted tomographic assessment of inferior alveolar canal geons. Aust Dent J 2006; 51: 64-68. nt third molars: a survey of Australian oral maxillofacial sur- 8. Bell GW. Use of dental panoramic tomographs to predict the cortical integrity predict nerve exposure during third molar surgery? J Oral Maxillofac Surg 2010; 68:1296-1303. 18. Jhamb A, Dolas R, Pandiwar PK, Mohanty S. Comparative efficacy of spiral computed tomography and orthopantomog- iI relation between mandibular third molar teeth and the infe- rior alveolar nerve. Radiological and surgical findings, and raphy in preoperative detection of relation of inferior alveo- clinical outcome. Brit J Oral Maxillofac Surg 2004; 42: 21-27. lar neurovascolar bundle to the impacted mandibular third 9. Friedland B, Donoff B, Dodson TB. The use of 3-dimen- molar. J Oral Maxillofac Surg 2009; 67:58-66. on sional reconstruction to evaluate the anatomic relationship of 19. Angelopoulos C, Thomas S, Hechler S, Parissis N, Hlavacek the mandibular canal and impacted mandibular third molars. M. Comparison Between Digital Panoramic Radiography J Oral Maxillofac Surg 2008; 66:1678-1685. and Cone-Beam Computed Tomography for the Identification 10. Sedaghatfar M, August MA, Dodson TB. Panoramic radi- of the Mandibular Canal as Part of Presurgical Dental Implant ographic findings as predictors of inferior alveolar nerve ex- Assessment. J Oral Maxillofac Surg 2008; 66:2130-2135. i posure following third molar extraction. J Oral Maxillofac 20. Liu T, Xia B, Gu Z. Inferior alveolar canal course: a radi- iz Surg 2005; 63:3-7. ographic study. Clin Oral Implants Res 2009; 20:1212-1218. 11. Hillerup S. Iatrogenic injury to the inferior alveolar nerve: eti- 21. Pippi R. A case of inferior alveolar entrapment in the roots of ology, signs and symptoms, and observations on recovery. a partially erupted mandibular third molar. J Oral Maxillofac Ed J Oral Maxillofac Surg, 2008; 37:704-709. Surg 2010; 68:1170-1173. IC C © Annali di Stomatologia 2012; III (3/4): 123-131 131 

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Case report Esthetic integration between ceramic veneers and composite restorations: a case report li na Davide Farronato, DDS, PhD1 Introduction Francesco Mangano, DDS2 io Stefano Pieroni, MD1 Ceramics and composites present different superficial Giuseppe Lo Giudice, MD4 nano-texturing and this leads in a different light reflection Roberto Briguglio, MD3 at the surface. In the esthetic zone this difference could Francesco Briguglio, DDS, PhD1 represent a limit to the choice of the restoring material be- az cause the two substances differently interact with the light incidence. If little amount of saliva wets the surfaces 1 Department of Prosthodontic and Implantology, this difference can be noticed as shiny and well defined Fondazione IRCCS Ca’ Granda, University glassy reflections on the ceramics against matte and n of Milan, Italy blurred reflections on the composites. 2 Department of Biomaterials Science, Università There are techniques that allow to manually polish the ce- er dell’Insubria, Varese, Italy ramic surface in order to maintain a certain grade of nano 3 Department of Periodontology University roughness at the surface, such to obtain a composite like of Messina, Italy reflection of the light. 4 of Messina, Italy nt Department of Restorative Dentistry, University In the presented case is described a solution to obtain fine integration between the two materials. The technician was requested to manual polish the ceramic surfaces in order to achieve the same light reflections characteristic iI Corresponding author: of composites, by keeping a lightly augmented roughness. Francesco Briguglio, DDS, PhD Department of Prosthodontic and Implantology, on Fondazione IRCCS Ca’ Granda, University of Milan, Italy Case presentation Via Commenda, 10 20100 Milano, Italy The patient at the end of orthodontic treatment presents Phone: +39 3392034125 aesthetic problems in the upper frontal area. In particular, i E-mail: fra.briguglio@alice.it clinical examination detects inadequate composite iz restorations at 1.1, 1.2 e 2.1; tooth 2.2 is conoid and pres- ents inter-proximal diastema. Summary 2.1 presents root canal filling, while the other tooth of the Ed The tooth structure preservation is the best way to post- sextant presents vital with optimal periodontal tissues. pone more invasive therapies. Especially in young pa- Light discolorations affect 1.2 and 2.1 (Fig. 1). tients more conservative techniques should be applied. Direct multilayered composite restorations upon 1.1, 1.2 Bonded porcelain veneers and even more the direct e 2.3 and bonded feldspathic porcelain veneers at 2.1 and composite restorations, are the two therapeutic proce- 2.2 are programmed to finalize the case (3-5). dures that require the fewer sacrifice of dental tissue, fi- IC nalized to the optimal recovery of aesthetic and func- tional outcome. Although the two techniques require different methods and materials, is possible to achieve a correct integration C of both the methods by some technical and procedural measures. In the presented case is planned a rehabilita- tion of the four upper incisors by ceramic veneers and di- rect composite restorations. © Care is taken for the surface treatment of ceramic restorations, with the objective of achieving integration, not only between natural teeth and restorations, but also between the different materials in use. The purpose of this article is to show how a proper de- sign of the treatment plan leads to obtain predictable re- sults with both direct and indirect techniques. Figure 1. Frontal view at baseline: the patient presents ameloge- netic defects at 1.2, old and inadequate composite restorations Key words: ceramic veneers, composite resin, esthetic at 1.1. The tooth 2.1 is devitalized, discolored and widely restored rehabilitation, mimetic restoration. by composite, 2.2 is conoid and presents inter-proximal diastema. 132 Annali di Stomatologia 2012; III (3/4): 132-137 Esthetic integration between ceramic veneers and composite restorations: a case report Materials and Methods The early stages of the project include the creation of a diagnostic wax-up based on aesthetic directions. A trans- parent silicone index (Regofix, Dreve Dentamid GmbH, li Germany), built from the additive wax-up, is made to simulate the final outcome in patient’s mouth through a di- na rect mock-up6 through a self curing resin (Fig. 2). io n az er Figure 2. The transparent silicone index (Regofix, Dreve Den- tamid GmbH, Germany) is the impression of the wax-up and is nt used to obtain the direct mock-up. Acetate matrixes are embed- ded in cuts made in the interproximal areas. These divisions help finishing the mock-up into the interproximal areas. iI The mock up is helpful to establish phonetic, functional and aesthetic limits (Fig. 3) and at an extra-oral view, Figure 4. Extra oral view of the mock-up: patient’s face and asymmetry is shown related to the face and the smile-line, on smile-line is asymmetric and gummy-smile is present. which is angled to the left. It is also shown a high smile- line with wide exposure of keratinized gingiva. The devel- opment of the lower lip follows the front incisal edge with Adhesion interfaces are prepared (Clearfil Se-Bond, Ku- an asymmetric posture (Fig. 4). raray Medical Inc., Japan) (Fig. 5). i The transparent silicone index is used as template for the iz palatal and interproximal composite layers. Acetate ma- trixes are embedded in cuts made in the interproximal ar- eas. Buccal surface of the silicone is cut approximately Ed 0,3 mm apical to the incisal edge, thus providing informa- tion about the thickness of the incisal portion of the restoration. On the silicone index, extraorally, are located resin com- posite masses avoiding light-curing: a thin layer of enamel is painted into the matrix and incisal halo is drawed by the IC use of staining resins. Figure 3. Mock-up in position: phonetic and aesthetic consider- C ations can be done and any mock-up modification has to be reg- istered by a new impression. The silicon was rebased with a self- curing resin composite without preparing for adhesion. © Adaptation of the modified mock-up are registered through an impression to be sent to the technician. New templates with the morpho-functional update are required for the following sessions. The technician also provides temporary resin veneers for 2.1 and 2.2. Previous restoration are removed and sections of the new template are used as a reference. Operating field’s isolation is obtained by rubber dam sta- Figure 5. The old composite and the enamel defect are removed, bilized by knotting Gore wire (Glide, Crest, Toronto). surfaces are smoothed and prepared for adhesion. Annali di Stomatologia 2012; III (3/4): 132-137 133 D. Farronato et al. Index is placed in mouth with the composite still uncured. Tooth number 2.3 is shaped with mesial and incisal incre- A good control of ambient lighting is necessary in order to ments with the aim of improving relations with the lip and avoid unintended polymerization. Furthermore, it is rec- harmony of the smile line without interefring with the ca- ommended to use heated composite, in order to better nine guidance. spread the masses in thin layers. Tooth 2.1 and 2.2 are prepared using the template as a li After curing the template is removed (the matrix can be reference. A map of the discromies was drawn for the tec- lived in the mouth) and the reconstructions of 1.1 and 1.2 nician using 3D Master as a reference and pictures were na can begin (Fig. 6). captured and sent to the tecnician. Temporary veneers (Fig. 8) are rebased in mouth with flowable composite. Regofix index is used as a guide, so that the provisional restorations are placed in the right po- io sition. Resin veneers are bonded according with spot etching technique (10) (Fig. 9). n az er Figure 6. A silicon index guided the palatal and incisal edges shaping. nt The masses of dentin are stratified with cromaticity desat- urated from cervical to incisal and from palatal to buccal iI (from A4 to A2). Figure 8. Temporary resin veneers on the model. Among dentinal mamelons, the three-dimensional effects and the translucence effects, are obtained by the applica- on tion of characterizations like Opalescent Blue; a thin layer of ocher is spread at the incisal third. A final layer of enamel is spread to finalize the facial surface of the restorations (Fig. 7), which is thoroughly cured under i oxygen insulation (glycerol). iz Ed IC Figure 9. Temporary veneers are cemented with the spot etching technique. Patient is discharged and followed weekly. A month later C lip’s profile and smile line are positively evaluated. Figure 7. The restoration are ultimated and are ready for the fin- After removing the temporary restorations, preparations ishing. are polished using sonic and ultrasonic instruments (Figs. 10, 11). The final impression is taken and the tech- © nician can ultimate the ceramics. A Try-In simulation is Masses of composite enamel should be thinner than the tested to ceck the optimal shading of the discromies and one of natural teeth, in order to avoid inconsistencies in the bleaching of 2.1 was confirmed to be unnecessary. value (7-9). The cementation of the two porcelain veneers (3M Re- Interproximal and palatal portions are finished by the use liX) is performed to complete the treatment (11) (Figs. of burs and abrasive strips. 12, 13). Surfaces’ polishing is performed with diamond teflon Essential shrewdness is to ask the technician to avoid mir- brushes mounted on the handpiece and diamond pastes ror-glazing ceramics to simulate the composite gentile applied with cotton pads at high-speed. opacity (12) (Fig. 14). 134 Annali di Stomatologia 2012; III (3/4): 132-137 Esthetic integration between ceramic veneers and composite restorations: a case report li na io Figure 10. Tooth preparation before the cementation of the ce- ramic veneers: frontal view. 2.1 was quite damaged and a large amount of dentine was exposed: it needed an extended prepa- az ration to the palatal side to gain enamel adhesion at the veneer Figure 14. Two months follow-up: frontal view. edges. At two years follow up the result is stable (Figs. 15, 16). n The new tooth profiles has allowed an improved lip sup- port and a propioceptive conditioning of the development er of the lower lip during the smile gesture. Dental relations seems harmonic and smile’s horizon has a good link with the lower lip line reducing the original sense of asymme- try (13) (Figs. 17, 18). nt iI on Figure 11. Tooth preparation before the cementation of the ce- ramic veneers: occlusal view. The conoid is slightly prepared such to obtain a good ceramic support at the interproximal areas. i iz Ed Figure 15. Two years follow-up: zoom of the veneers edges. IC Figure 12. Veneers before the cementation: frontal view. C © Figure 16. Two years follow-up: the result is stable and the opac- Figure 13. Veneers before the cementation: internal view. ity of both ceramics and composites is still similar. Annali di Stomatologia 2012; III (3/4): 132-137 135 D. Farronato et al. tions associated to composite veneers at 2.1 and 2.2. The option was excluded, because at the time of the treatment the literature was not able to show evidence of pre- dictable results at long therms follow-up. Nowdays this treatment option could support interesting discussions. li The treatment option choosed with the patient was rep- resented by the optimal solution with a modication of the na ceramic surface: direct multilayered composite restora- tions on 1.1, 1.2 e 2.3 and bonded feldspathic porcelain veneers at 2.1 and 2.2. The technician was requested to manually polish the ceramic surface in order to maintain io a certain grade of nano roughness at the surface, such to obtain a composite like reflection of the light. The solution leads a good integration between composite and porce- lain restorations. az Figure 17. The new tooth profiles has allowed an improved lip Some authors are convinced that a good polishing can support and a propioceptive conditioning of the development of substitute a heat glazing of ceramics, even if the clean- the lower lip during the rest gesture. ing capabilities of the smear layer is lightly different (1,2). Considering the accessibility of the site this was not con- n sidered a consistent problem against the possibility to achieve a good integration between adjacent composite er and porcelain restorations. Furthermore the Try-in simulations revealed that bleach- ing of 2.1 was unnecessary to achieve the expected re- nt sult, because the composite chosen for the cementation of 2.1 was sufficient to mask the light discoloration. iI Conclusion For aesthetic restorations, both porcelain veneers and on composite restorations are predictable treatments (14-16). To achieve a good integration in the appearance and in the form, two points are essential: a close collaboration Figure 18. Dental relations seems harmonic and smile’s horizon with technician allows a correct design of the case through has a good link with the lower lip line reducing the original sense i of asymmetry. the basic steps of diagnostic wax-up and direct mock-up. iz Secondarily particular attention must be dedicated to the surface finishing of ceramic that has to mimic the slight Discussion surface roughness typical of many composites subjected Ed to function’s wear and to abrasive toothpastes (12). The treated patient showed a wide smile and elevated ex- pectations in terms of aesthetic and conservativity. The optimal treatment options between the frontal teeth were References different due to the residual healthy substance (5,14,15): porcelain veneers at 2.1, 2.2 and direct composite restora- 1. Mehulic K, Svetlicic V, Segota S, Vojvodic D, Kovacic I, IC tion to 1.1, 1.2 e 2.3. This solution could subtend a prob- Katanec D, Petricevic N, Glavina D, Celebic A. A study of the lem: the surface finishing of ceramic generally leads to surface roughness of glazed and unglazed feldsphatic ce- ramics. Coll Antropol. 2010; 34:235-8. bright glossy surfaces, and the result lasts along the 2. Aykent F, Yondem I, Ozyesil AG, Gunal SK, Avunduk MC, years. Instead composite resin surfaces seems to lose the C Ozkan S. Effect of different finishing techniques for restora- perfect polishing during time, due to function’s wear and tive materials on surface roughness and bacterial adhesion. to abrasive toothpastes, acquiring a typical matty and J Prosthet Dent. 2010;103:221-7. opaque surface (12). This difference could be unnoticed 3. Guess PC, Stappert CF. Midterm results of a 5-year prospec- while observing wet teeth, but could be revealed while © tive clinical investigation of extended ceramic veneers. Dent teeth dries. Mater 2008;24:804. A different treatment choice could be five veneers with site 4. ADA Council on Scientific Affairs. Direct and indirect restora- preparation: in this case we should have prepared three tive materials. J Am Dent Assoc 2003;134:463-72. 5. Pena C, Viotti R, Dias W, Santucci E, Rodrigues J, Reis A. more teeth in contrast with the conservative request. An- Esthetic rehabilitation of anterior conoid teeth: comprehen- other treatment choice could be five veneers without any sive approach for improved and predictable results. Eur J Es- site preparation on 1.1, 1.2 e 2.3 but positioning and thet Dent 2009;4:210-224. margin finishing could be difficoult to manage in order to 6. Magne P, Magne M. Use of additive waxup and direct intra- obtain a perfect integration. Beside also another choice oral mock-up for enamel preservation with porcelain laminate could be taken into consideration: composite restora- veneers. Eur J Esthet Dent 2006;1:10-19. 136 Annali di Stomatologia 2012; III (3/4): 132-137 Esthetic integration between ceramic veneers and composite restorations: a case report 7. LeSage BP. Aesthetic anterior composite restorations: a guide 12. Lee YK, Lu H, Powers JM. Optical properties of four esthetic to direct placement. Dent Clin North Am 2007;51:359-78. restorative materials after accelerated aging. Am J Dent 8. Devoto W, Saracinelli M, Manauta J. Composite in everyday 2006,19:155-8. practice: how to choose the right material and simplify appli- 13. Davis NC. Smile design Dent Clin North Am 2007;51:299- cation techniques in the anterior teeth. Eur J Esthet Dent. 318. 2010;5:102-124. 14. Lambert DL. Conservative aesthetic solutions for the adoles- li 9. Yu B, Lee YK. Difference in opalescence of restorative ma- cent and young adult utilizing composite resins. Dent Clin terials by the illuminant. Dent Mater 2009;25:1014-21. North Am 2006;50:87-118. na 10. Dumfahrt H, Gobel G. Bonding porcelain laminate veneer 15. Sadowsky SJ. An overview of treatment considerations for provisional restorations: An experimental study. J Prosthet esthetic restorations: a review of the literature. Int J Prostho- Dent 1999;82:281-5. dont 2006;96:433-42. 11. Peumans M, Van Meerbeek B, Yoshida Y, Lambrechts P, 16. Calamia JR, Calamia CS. Porcelain laminate veneers: rea- Vanherle G. Porcelain veneers bonded to tooth structure: an sons for 25 years of success. Dent Clin North Am. io ultra-morphological FE-SEM examination of the adhesive in- 2007;51:399-417. terface. Dent Mater 1999;15:105-19. n az er nt iI i on iz Ed IC C © Annali di Stomatologia 2012; III (3/4): 132-137 137 

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Editorial The sheer volume of scientific data published each year in specialist journals can make it difficult for non- specialist dentists to identify and evaluate the best scientific evidence available and use it as a basis for making decisions. Indeed, it is not always easy to distinguish between hi-tech experimental protocols, li applicable to a limited number of cases and still lacking adequate long-term follow-ups, and validated pro- na cedures that can be used successfully and safely in daily practice. To overcome this difficulty and arrive at diagnostic and therapeutic certainties on which to base clinical decisions, a scientific publication should include, alongside reports on the most advanced experimental io research, also case series and insights into traditional methods, which tend to be overlooked in favour of studies (such as ones on animal models) that are certainly more valuable in scientific terms but do not have immediate practical application. az The aim of a journal like Annali di Stomatologia is not only to provide essential scientific updating, pub- lishing the results of the most advanced studies in all the fields of dentistry, but also to promote overall n professional growth, rather than just the enhancement of expertise in very specific sectors and specialties. Similarly, the publication of case studies, case reports and technical notes can help to further a dentist’s er professional development, providing a means of checking the appropriateness of his clinical conduct and of verifying results achieved using particular material or method. nt iI Susanna Annibali on Editor in Chief i iz Ed IC C © Annali di Stomatologia 2012; III (2): 37 37 

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Original article Caries prevalence in a 7- to 15-year-old Albanian schoolchildren population li Giuseppina Laganà, DDS, MS1 Introduction Francesco Fabi, DDS2 na Ylka Abazi, DDS4 Dental caries is an infective transmittable bacterial dis- Ada Kerçi, DDS4 ease characterised by a multifactorial pathology; it is a Megi Jokici, DDS† preventable disease and it can be stopped and even po- Evisi Beshiri Nastasi, DDS4 tentially reversed during its early stages. People remain io Françesca Vinjolli, DDS4 susceptible to the disease throughout their lives (12, 19). Paola Cozza, MD, DDS, MS3 It is widely accepted that factors such as socioeconomic status, educational level, and behavioural factors (e.g. az usual reasons for dental attendance, frequency of tooth 1 Department of Orthodontics, School of Dentistry, Fa- cleaning and use of additional methods for tooth clean- culty of Medicine, University of Rome Tor Vergata, Italy ing like flossing) have an effect on oral health (5). 2 Research Fellow CIBB Centre for Biostatistics and Bio- In the developed countries, decline in dental caries n informatics, University of Rome Tor Vergata, Italy prevalence has been attributed to population-based 3 Head Department of Orthodontics, School of Dentistry, preventive programmes with use of fluoride, improved er Faculty of Medicine, University of Rome Tor Vergata, partecipation in oral health programmes and changes in Italy oral hygiene and sugar intake habits. On the other hand, 4 Dentist in Tirana in many developing countries an increase in dental car- Corresponding author: Giuseppina Laganà, DDS, MS nt ies has resulted from unhealthy dietary habits, limited use of fluoride and poor access to oral health services. In many developing countries, most oral health services provide symptomatic treatment with little priority given to iI Department of Orthodontics, School of Dentistry, Faculty restoration and prevention. The urbanisation and adop- of Medicine, University of Rome Tor Vergata, Italy tion of Western lifestyles into many developing countries Via G. Baglivi, 5/E in the absence of public prevention programmes have on 00161 Roma, Italy also caused a sudden increase in dental caries. Dental Phone: +39 06 44232321 caries affects 60-90% of schoolchildren in most devel- e-mail: giuseppinalagana@ibero.it oped countries, and in several developing countries the prevalence rates are increasing (2). Many epidemiologi- i cal studies on the prevalence of caries in different ethnic iz groups have been published in the last years. They re- Summary ported a prevalence of caries that varied in the different Ed populations (4, 6, 7, 11, 14). The aim of this study was to determine the caries Epidemiological surveys to monitor the changes in oral prevalence in urban and suburban Albanian schools. health status have not been conducted in Albania on A large sample (n= 2617) of subjects, aged 7-15, was a regular basis or by specialised institutions. Sporadic examined by a clinical observation without radio- studies by the dental school or by people who are con- grams. The sample comprised 1257 males and 1360 ducting research for higher degrees have been under- IC females. For each subject an anamnestic question- taken. The data from the last epidemiological study con- naire about feeding, fluoride, dentist attendance and ducted in 2000 (using WHO indicators and age-groups) familiar informations was obtained. Gender and age are: 6 years old (caries free 83.7%), 12 years old (DMFT differences were compared by Chi-square test. The 3.02), 18 years old (DMFT 4.7). Other national studies C total dmft index (decayed, missing and filled teeth in of dental caries experience for 12-year-olds indicated deciduous dentition) was 2.082; dmft in males was that in 2005 the national mean Decayed, Missing, or 2.137, in females was 2.032. The total DMFT index Filled Teeth (DMFT) index was 3.1. A more recent study (Decayed, Missing and Filled Teeth in permanent shows DMFT 3.8 in a 12 years old schoolchildren pop- © dentition) was 2.327; DMFT in males was 2.253, in ulation (9). The data show worse oral health status in females was 2.396. Decayed teeth was principal children compared with the situation before 1990. Rea- component of both dmft and the DMFT index. Car- sons for higher oral disease prevalence are: increases ies prevalence results higher in girls than boys in in consumption of refined foods and fizzy drinks and of a deciduous and in permanent teeth. wide variety of sweets, under utilisation of fluoride sup- plements or sealants, the lack of widespread and regular Key words: prevalence of caries, oral hygiene hab- use of toothbrushes and fluoride toothpaste, the lack of its, Albanian schoolchildren. dental health education and promotion, the privatisa- 38 Annali di Stomatologia 2012; III (2): 38-43 Caries prevalence in a 7- to 15-year-old Albanian schoolchildren population tion of the dental services and the resultant high prices lasted 20 minutes per child, following the WHO guide- and largely ineffective public dental services (3,9). Other lines. To assess dental caries DMFT (Decayed, Missing reasons for this situation are the following: low fluoride and Filled Teeth) index was used. The systematic ex- level in drinking water (below 0.3 ppm), lack of financial amination includes the crown and exposed root of every resources for applying a caries prevention strategy all primary and permanent tooth, each crown and root are li over the country and absence of national caries and oral assigned a number based on the result of that exam. health preventive programme. The numbers are recorded in boxes corresponding to na Aim of this study was to determine the caries prevalence each tooth to provide a DMFT chart. Data were collected in a schoolchildren population of Tirana. in an individual clinical chart that comprised anamnestic questionnaire and clinical examination measurements. io Subjects and methods Statistical methods Data were registered in Microsoft Excel 2007 and elabo- Study population rated by Statistical Package for the Social Sciences Win- az A cross-sectional study was carried out and the study dows, version 15.0 (SPSS, Chicago, Illinois, USA). De- target population consisted of subjects, between 7 years scriptive statistics were calculated for every measured and 15 years of age, attending the public schools in variable, in order to evaluate the studied sample. Cat- Tirana (Albania). The fifteen examined schools, ten in egorical variables were analysed using the chi-square n the town and five in the province of Tirana, were cho- test of Pearson to determine differences. The P value for sen by the Statistical Department of Teaching Direction statistical significance was set at 0.05, so any value less er of Tirana, using a stratified selection technique, in order than P<0.05 was interpreted as statistically significant. to represent the distribution of socio-economical condi- The relationship between caries prevalence and oral hy- tions during the school year 2009-2010. Classes within giene was assessed by Chi-square test. schools were sampled systematically and all students nt attending the sampled classes were examined. Written consent was obtained from the schoolchildren and their parents, before starting examination. A questionnaire Results iI was structured containing questions on socio-demo- A total of 2617 subjects, 1257 males (48.40%) and 1360 graphic factors, perceived oral and general health, oral females (51.60%), 7 to 15 years old, were examined. hygiene, fluoride assumption and oral diet. Table 1 describes the composition of the sample by age on Sample size was calculated assuming a 50 per cent and gender. prevalence ratio for any characteristics with a 95 per cent Table 2 shows dmft results: the total dmft index (de- confidence interval. This assumption leads to the highest cayed, missing and filled teeth in deciduous dentition) sample size with precision 1.9%. Two thousand six hun- was 2.082: dmft in males was 2.137, in females 2.032. i dred and seventeen students, 1257 males and 1360 fe- The subjects presenting caries in deciduous dentition iz males, were randomly selected according to multistage were 1115 (42.60% of the total sample), 561 females stratified cluster sampling design. This is in according to (41.25%) and 554 males (44.07%). The subjects pre- WHO guidelines for national pathfinder surveys which senting missing teeth in deciduous dentition were 242 Ed ensure the partecipation of a satisfactory number of peo- (9.24% of the total sample), 114 females (8.38%), 128 ple that may present different disease prevalence in the males (10.18%). The subjects presenting filled teeth in conditions being examined (14, 17). deciduous dentition were 132 (5.04% of the total sam- Selection criteria for examination were: presence of de- ple), 71 females (5.22%) and 61 males (4.85%). The ciduous cuspid and deciduous second molar in primary highest number of subjects (n=193) presented only one dentition and mixed dentition, presence of permanent decayed deciduous teeth and they were 7.4% of the IC cuspid and first molar in permanent dentition. The exclu- sample, 104 females (7.6% of the sample) and 86 males sion criteria for this study were: subjects with craniofa- (6.8% of the sample). One missing teeth in deciduous cial anomalies (clefts and syndromes) and no Albanese dentition was registered in the majority of the subjects C students. (n=133, 5.1% of the sample), 63 were females (4.6%) and 70 were males (5.6%). One filled teeth in deciduous Clinical examination dentition was observed in 60 schoolchildren (2.3% of the The examination was carried out by five examiners. Be- total sample), 32 subjects (2.4%) were females and 28 © fore clinical registration, they took part in a course on were males (2.2%). methods of clinical research and orthodontic diagnosis. The total DMFT index (Decayed, Missing and Filled A pilot study on 50 children was conducted before begin- teeth in permanent dentition) was 2.327; DMFT in males ning the present investigation to ensure the accuracy of was 2.253, in females was 2.396 (Tab. 3). The subjects diagnosis and to standardize the procedures; no statis- presenting caries in permanent dentition were 1235 tically significant differences were found (P>0.05). The (47.19% of the total sample), 647 females (47.57%) and schoolchildren were examined in the medical room of 588 males (46.77%). The subjects presenting missing the schools. The oral conditions were assessed by us- teeth in permanent dentition were 391 (17.56% of the to- ing latex gloves and mouth mirrors. The examination tal sample), 196 females (14.41%), 195 males (18.36%). Annali di Stomatologia 2012; III (2): 38-43 39  Table 1 - Composition sample (n = 2617) by age and gender G. Laganà et al. Composition Composition sample Table 1 - Composition sample (nsample Total Sample = 2617) by age and by age gender by gender Age M F M+F M+F Composition Males Females Composition sample n Total Sample n n sample%by age %by gender% Table 1. Composition sample (n = 2617) by Age7 132 137 269 10.3% 49.10% 50.90% age and gender. M F M+F M+F Males Females 8 101 n 140 n 241 n 9.2% % 41.90% % 58.10% % li 7 132 137 269 10.3% 49.10% 50.90% 9 143 145 288 11.0% 49.70% 50.30% na 8 101 140 241 9.2% 41.90% 58.10% 10 127 145 272 10.4% 46.70% 53.30% 9 143 145 288 11.0% 49.70% 50.30% 11 136 151 287 11.0% 47.40% 52.60% 10 127 145 272 10.4% 46.70% 53.30% io 12 140 153 293 11.2% 47.80% 52.20% 11 13 136 164 151 142 287 306 11.0% 11.7% 47.40% 53.60% 52.60% 46.40% az 1214 140 167 153 179 293 346 11.2% 13.2% 47.80% 48.30% 52.20% 51.70% 1315 164 147 142 168 306 315 11.7% 12.0% 53.60% 46.70% 46.40% 53.30% 14 167 179 346 13.2% 48.30% 51.70% n Total 1257 1360 2617 100.0% 48.40% 51.60% 15 147 168 315 12.0% 46.70% 53.30% er Total 1257 1360 2617 100.0% 48.40% 51.60% Table 2 – dmft (deciduous teeth) Males Females nt Total years, in the permanent dentition the highest value of DMFT (3.609) was registered at the age of fifteen years. iI Table 2 – dmft (deciduous teeth) Table 5 shows dmft and DMFT according to age and dmft 2.137 2.032 2.082 gender with inferior and superior confidence interval Males Females Total (Sup CI, Inf CI): in 7-9 years group median of total DMFT on decayed was 5.84, in 10-12 years group median of total DMFT subjects was 4.25 and in 13-15 years group median of total DMFT dmft (n) 2.137 554 561 2.032 1.115 2.082 was 3.36. DMFT in males was 2.253 and in females was subjects (%) 44.07 41.25 42.60 2.396; the difference between gender was not significant missing i decayed (P>0.005). subjects(n)(n) 128 114 242 iz subjects 554 561 1.115 Caries prevalence results higher in girls than boys in de- subjects subjects (%) (%) 10.18 44.07 8.38 41.25 9.24 42.60 ciduous and in permanent teeth, but this difference is not filled statistically significant. missing Ed subjects (n) 61 71 132 Frequencies and percentages of first dental visit by age subjects (n) 128 114 242 groups are described in Table 6. subjects (%) 4.85 5.22 5.04 subjects (%) 10.18 8.38 9.24 Significant correlation obtained by Chi square index at filled any age was found between low oral hygiene and DMFT Table 2. dmft (deciduous teeth). (P=0.000), described in Figure 1. subjects (n) 61 71 132 Level of oral hygiene in the total sample is reported in IC subjects (%) 4.85 5.22 5.04 The subjects presenting filled teeth in deciduous denti- Table 7. Oral hygiene was classified in three grades of tion were 863 (32.97% of the total sample), 467 females evaluation (good, not sufficient, absent): the subjects (34.33%) and 396 males (31.50%). The highest number presenting a good level of oral hygiene were only 1117 (42.6% of the total sample), the majority of examined C (n=421) of subjects presented one decayed permanent teeth and they were 16.1% of the sample, 210 females subjects ( n= 1203, 45.9% of the sample) presented a (15.4% of the sample) and 211 males (16.8% of the not sufficient condition of oral hygiene. Oral hygiene by sample). One missing permanent teeth was registered age and gender is reported in Tables 8 and 9. © in most of the subjects (n=209, 8.0% of the sample), 104 No significant correlation was observed between the dif- were females (7.6%) and 105 were males (8.4%). One ferent socio-economical level, oral use of fluoride and filled permanent teeth was observed in 276 schoolchi- natural/artificial feeding. dren (10.5% of the total sample), 140 (10.3%) were fe- males and 136 were males (10.8%). Decayed teeth was Discussion the principal component of both the dmft index and the DMFT index (Tab. 2 and 3). The results showed that 47.19% of the examined school- Table 4 reports dmft and DMFT according to the age: children, 1235 subjects, presented decayed permanent the highest value of dmft (5.178) was observed at eight teeth, while 391 (17.56%) subjects presented missing 40 Annali di Stomatologia 2012; III (2): 38-43  DMFT 2.253 2.396 2.327 Decayed subjects (n) 588 647 1235 Caries prevalence subjects (%) in a 7-46.77 to 15-year-old Albanian schoolchildren 47.57 47.19 population Missing Table 3 – DMFT (permanent teeth) subjects (n) 195 196 391 subjects (%) 18.36 Males Females 14.41 17.56 Total teeth and 863 (32.97%) subjects presented filled teeth. Filled DMFT index was 2.327 and this is according to other studies of same population for age (WHO, 2004); this subjects DMFT(n) 396 2.253 467 2.396 863 2.327 DFMT index can be classified as high dental caries ex- subjects Decayed (%) 31.50 34.33 32.97 perience. li subjects (n) 588 647 1235 The overall DMFT results of the studied sample was subjects (%) 46.77 47.57 47.19 lower than results of another study on a smaller (n= na Missing 372) population, completed in Tirana in 2010 that shows DMFT 3.8 in a 12 years old schoolchildren group(9). subjects (n) 195 196 391 These DMFT data are lower than the last epidemiologi- subjects (%) 18.36 14.41 17.56 cal study, conducted in 2000, that indicated DMFT 3.02 io Filled in a 12 years-old group and DMFT 4.7 on a 18 years-old subjects (n) 396 467 863 group (3). Other national studies of dental caries experi- subjects (%) 31.50 34.33 32.97 ence for 12-year-olds indicated that in 2005 the national az mean Decayed, Missing, or Filled Teeth (DMFT) index Table Table 4 – dmft 3. DMFT and DMFT (permanent teeth). by age was 3.1 (8). These results are similar to other examined groups, as Age dmft DMFT Norwest Russian (6), Romanian (10) and Greek popula- n 7 5.052 0.844 tion (14). 8 5.178 1.220 DMFT in Albanian sample is lower than Hungarian adult er 9 3.924 1.413 population (5), Iranian (2) and Indian population (15). 10 3.217 2.033 In Western European countries the situation is complete- ly different: DMFT in Albanian schoolchildren was higher 11 1.683 2.425 than other European population as Spain (1), Nether- Table 4 – dmft and DMFT by age2.614 12 13 14 Age 0.853 0.209 0.110 dmft 2.990 3.168 DMFT nt lands, United Kingdom, Germany and Italy (18). Decayed teeth was the principal component of both the dmft index and the DMFT index and this is another im- iI 157 0.009 5.052 3.609 0.844 portant indicator of lacking dental prevention. 8 5.178 Table 4. dmft and DMFT by age. 1.220 Table 5 9– dmft and DMFT by gender 3.924 and age 1.413 on 10 3.217 2.033 Total 11 7-9 years 1.683 2.425 10 -12 years 13 -15 years DMTF Inf CI Sup CI Median Inf CI 12 0.853 2.614 Sup CI Median Inf CI Sup CI Median Males 5.36 6.32 5.84 4.00 4.96 4.48 2.94 3.38 3.16 13 0.209 2.990 i Females14 5.44 0.110 3.168 4.41 iz 6.24 5.84 3.66 4.04 3.27 3.83 3.55 15 0.009 3.609 M+F 5.53 6.15 5.84 3.95 4.55 4.25 3.18 3.54 3.36 Ed dmft 7-9 years 10 -12 years 13 -15 years Inf CI Sup CI Median Inf CI Sup CI Median Inf CI Sup CI Median Males 4.37 5.05 4.71 1.86 2.45 2.16 0.03 0.13 .08 IC Females 4.34 4.96 4.65 1.40 1.87 1.63 0.03 0.22 .13 M+F 4.45 4.91 4.68 1.70 2.07 1.88 0.05 0.16 .10 C DMTF 7-9 years 10 -12 years 13 -15 years Inf CI Sup CI Median Inf CI Sup CI Median Inf CI Sup CI Median Males 0.85 1.40 1.12 2.03 2.60 2.32 2.86 3.29 3.07 © Females 0.99 1.39 1.19 2.16 2.64 2.40 3.16 3.68 3.42 M+F 0.99 1.33 1.16 2.17 2.55 2.36 3.08 3.42 3.25 Table 5. dmft and DMFT by gender and age. Annali di Stomatologia 2012; III (2): 38-43 41  G. Laganà et al. Table 6 – First dental visit and age First dental visit No Yes Total It is possible to observe a low improvement of oral hy- 7-9 years Frequencies 112 502 614 giene status in older subjects (good hygiene 7-9 years Percentage 18.2% 81.8% 100.0% = 349, 13-15 years = 424), and females appear gener- 10-12 years Frequencies 82 528 610 ally better than males. A significant correlation is evident Percentage 13.4% 86.6% 100.0% between grade of oral hygiene and DMFT, as shown in li 13-15 years Frequencies 68 627 695 other studies (9, 12, 20). Percentage 9.8% 90.2% 100.0% The results of the study show that just 1919 subjects na Total Frequencies 262 1657 1919 (73.3% of the total sample) were visited by a dentist: it Percentage 13.7% 86.3% 100.0% is possible to note that the number of visited subjects is Table76. First dental visitin and age. higher in the 13-15 age group. These data demonstrate Table – Oral hygiene the total sample that oral prevention is not frequent and the age of first io dental visit has to be earlier in order to plan preventive Oral Figure 1 –Hygiene Frequencies Correlation between oral hygiene andPercentage DMFT programmes. The current dental situation in Albania is Absent 297 11.3 not valid to reach WHO global goals for oral health 2020: Not sufficient 1203 45.9 az - to minimise the impact of diseases of oral and craniofa- Good 1117 42.6 cial origin on health and psychosocial development, giv- Total 2617 100 ing emphasis to promoting oral health and reducing oral Table Oral6 – First Table 8 – Oral hygiene by age Table dental visit and age Table 87.– Oral hygiene hygiene by in agethe total sample. disease amongst populations with the greatest burden of n Oral hygiene level Absent Not Good Total such conditions and diseases; sufficient Oral hygiene level 7-9 years Frequencies Absent 80 Not 369 Good 349 Total 798 - to minimise the impact of oral and craniofacial manifes- First dental visit No Yes of systemic Total er sufficient tations diseases on individuals and society, Percentage 10.0% 46.2% 43.7% 100.0% 7-9 years Frequencies 80 369 349 798 7-9 years 10-12 years Frequencies Percentage Frequencies 100 10.0% 407 46.2% 342 43.7% 112 849 100.0% and502to use these manifestations for early diagnosis, pre- 614 Percentage 11.8% 47.9% 40.3% 100.0% 10-12 years Frequencies 100 407 342 849 vention and effective management of systemic diseases. 13-15 years Frequencies Percentage Percentage 116 11.8% 426 47.9% 424 40.3% 18.2% 966 100.0% 81.8% 100.0% The process of formulating a regional, national or local 13-15 years Total Total Percentage Frequencies 10-12 years 12.0% Frequencies Percentage Percentage Frequencies Percentage 12.0% 116 11.3% 44.1% 426 Frequencies 296 1202 44.1% 46.0% Percentage 296 11.3% 1202 46.0% nt 43.9% 424 1115 43.9% 42.7% 1115 42.7% 100.0% 966 82 2613 100.0% 100.0% 13.4% 2613 100.0% 528 oral tive 86.6%strategy 610necessitates many stages. A preven- health strategy must be programmed for the Albanese fam- 100.0% ilies including dental knowledge, routine care visits, the iI 13-15 years 68 627 695 Table 8. Oral hygiene by age. Frequencies infectious nature of dental caries, awareness of dental Table 9 – Oral hygiene by gender Percentage 9.8% 90.2% and 100.0% benefits access through Medicaid and awareness Table 9 – Oral hygiene by gender 262 of1657 dentists and1919 dental clinics in the community. Further- Total Frequencies on Oral hygiene level Absent Not Good Total sufficient more, appropriate interventions could be developed to Oral7hygiene Table Females– Oral level hygiene in Frequencies the Percentage Absent total 123 Not sample 557 Good 678 13.7% Total 1358 86.3% view 100.0% and manage caries as a chronic disease (13, 16). sufficient Percentage 9.1% 41.0% 49.9% 100.0% Females Frequencies 123 557 678 1358 Males Frequencies 173 645 437 1255 Oral Hygiene Percentage Frequencies 9.1% Percentage 41.0% 49.9% 100.0% Percentage 13.8% 51.4% 34.8% 100.0% Absent 173 297 645 11.3 i Males Frequencies 437 1255 Total Frequencies Not sufficientPercentage 296 13.8% 1202 1115 51.4% 34.8% 2613 100.0% Conclusions 11.3% 120346.0% 45.9 iz Percentage 42.7% 100.0% Total Frequencies 296 1202 1115 2613 Good Percentage 11.3% 111746.0% 42.6 100.0% 42.7% Figure Total Table 1 hygiene 9. Oral – Correlation between100 by gender. 2617 oral hygieneThe andoral health status of children living in Tirana can DMFT be classified as quite poor: this situation indicates the Ed need for preventive and restorative strategies. Adequate IC C © Figure 1. Correlation between oral hygiene and DMFT. 42 Annali di Stomatologia 2012; III (2): 38-43 Caries prevalence in a 7- to 15-year-old Albanian schoolchildren population public dental health programmes including school-based in Northwest Russia. Community Dent Health 2012; oral health education and primary oral care, increasing 29(1):20-4. the number of dentists and oral hygienists, and decreas- 7. Hamissi J, Hamissi H. Prevalence of dental caries among ing the patient: dentist ratio can be recommended to the elementary school attendees in Iran. East Afr J Public Albanian authorities. Health 2010; 7(4):338-41. li In Albania there is a need for dental education to im- 8. Hysi D. A survey of caries experience in the age 6-th, 12- prove behaviour toward oral health and the current den- th, 18-th years old in Albania, pilot study, Ministry of Health na tal situation is not valid to reach WHO global goals for Albania, 2005. oral health 2020: 9. Hysi D, Droboniku E, Toti C, Xhemnica L, Petrela E. Den- - to minimise the impact of diseases of oral and craniofa- tal caries experience and oral health behaviour among cial origin on health and psychosocial development, giv- 12- year-olds in the city of Tirana, Albania. Journal of Oral io ing emphasis to promoting oral health and reducing oral Health and Dental Management 2010; 9: 229-234. disease amongst populations with the greatest burden of 10. Jipa IT, Amariei C. May Oral health status of children aged such conditions and diseases; 6-12 years from the from the Danube Delta Biosphere Re- az - to minimise the impact of oral and craniofacial manifes- serve. Oral Health Dent Manag 2012;11(1):39-45. tations of systemic diseases on individuals and society, 11. Joseph C, Velley AM, Pierre A, Bourgeois D, Muller-Bolla and to use these manifestations for early diagnosis, pre- M. Dental health of 6-year-old children in Alpes Maritimes. vention and effective management of systemic diseases. France. Eur Arch Paediatr Dent 2011; 12(5):256-63. n Considering the economic development of the country, 12. Kawashita Y, Kitamura M. Early childhood caries. Intern- special oral health education programmes are neces- Journal of Dentistry Article ID 2011; 725320: 1-7. er sary in order to reach the WHO oral health goals for 13. Nelson S, Mandelaris J, Ferretti G, Heima M, Spiekerman 2020. It remains an important challenge for the Dental C, Milgrom P. School screening and parental reminders in Public Health Service to improve access to dental care increasing dental care for children in need: a retrospective and start preventive programmes. cohort study. J Public Health Dent 2011; 10; 45-52. References nt 14. Oulis CJ, Tsinidou K, Vadiakas G, Mamai-Homata E, Poly- chronopoulou A, Athanasouli T. Caries prevalence of 5, 12 and 15-year-old Greek children: a national pathfinder sur- iI vey. Community Dent Health 2012; 29(1):29-32. 1. Alvarez-Arenal A, Alvarez-Riesgo JA, Pena-Lopez JM, 15. Sigh A, Purhoit B, Sequeira P, Acharya S, Bhat M. Maloc- Fernandez-Vazquez JP. DMFT, dmft and treatment re- clusion and orthodontic treatment need measured by the on quirements of schoolchildren in Asturias Spain. Communi- dental aesthetic index and its association with dental car- ty Dentistry and Oral Epidemiology 1998; 26; (3):166-169. ies in Indian schoolchildren. Community Dent Health 2011; 2. Ahmed NA, Astrøm AN, Skaug N, Petersen PE. Dental car- 28(4):313-6. ies prevalence and risk factors among 12-year old school- 16. Thelen DS, Trovik TA, Bårdsen A. Impact of traumatic den- i children from Baghdad, Iraq: a post-war survey. Interna- tal injuries with unmet treatment need on daily life among iz tional Dental Journal 2007; vol 57 (1):36-44. Albanian adolescents: a case-control study. Dent Trauma- 3. Bogdani M. Oral health care and preventive strategies in tol 2011; 27(2):88-94. Albania - a country in transition International Dental Jour- 17. World Health Organization Oral Health Country/area profile Ed nal 2003; 53, 166-171. programme. Caries for 12 years old by country/area 2004. 4. Delgado-Angulo EK, Hobdell MH, Bernabé E. Childhood Geneva: World Health Organization. stunting and caries increment in permanent teeth: a three 18. World Health Organization 2010 WHO Oral Health Coun- and a half year longitudinal study in Peru. Int J Paediatr try/Area Profile Programme. Dent 2012; 20. 19. Xhemnica L, Sulo D, Rroço R, Hysi D. Fluoride varnish IC 5. Faragó I, Nagy G, Márton S, Túry F, Szabó E, Hopcraft application: a new prophylactic method in Albania. Effect M, Madléna M. Dental Caries Experience in a Hungarian on enamel carious lesions in permanent dentition. Eur J Police Student Population. Caries Res 2012; 17;46(2):95- Paediatr Dent 2008; 9(2):93-6. 101. 20. Zini A, Sgan-Cohen HD, Marcenes W. The social and be- C 6. Gorbatova MA, Grjibovski AM, Gorbatova LN, Honkala havioural pathway of dental caries experience among Jew- E. Dental caries experience among 12-year-old children ish adults in Jerusalem. Caries Res 2012; 46(1):47-54. © Annali di Stomatologia 2012; III (2): 38-43 43 

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Original article Macroscopic and microscopic evaluation of a new implant design supporting immediately loaded full arch rehabilitation li na Stefano Tetè, MD, DDS1 coupling between endosseous and prosthetic com- Vincenzo Zizzari, DDS2 ponents, as it allows an easy insertion of the fixture Alessandro De Carlo, DDS1 even in conditions of reduced bone availability, and io Bruna Sinjari, DDS1 in cases of immediately loaded full-arch rehabilita- Enrico Gherlone, MD, DDS3 tions. az 1 Department of Medical, Oral and Biotechnological Key words: dental implant, Scanning Electron Sciences, “G. d’Annunzio” University, Chieti, Italy Microscope (SEM), implant connection. 2 Department of Drug Science “G. d’Annunzio” University, Chieti, Italy n 3 Department of Oral Sciences,”Vita-Salute San Raffaele” Introduction University, Milano, Italy er Osseointegrated implantology, thanks to many studies, is now considered a surgical discipline with proven ef- Corresponding author: fectiveness. Success in implant dentistry consists in get- Stefano Tetè, MD, DDS ting a good rate of integration between implant and host nt Department of Medical, Oral and Biotechnological Sciences, “G. d’Annunzio” University, Chieti, Italy e-mail: tete@unich.it bone, which defines a good osseointegration according to the principles initially introduced by Branemark and subsequently developed by numerous studies over the iI years (1-3). The implant design is a key factor to achieve good pri- mary stability. It should be designed to guarantee the es- on Summary tablishment of a direct connection between bone tissue and implant surface during the early stages of the heal- The purpose of this study is to evaluate macroscop- ing process, without the interposition of fibrous tissue, ic and microscopic appearance of a new implant de- as well as to achieve an even distribution of the loads i sign, with particular emphasis given to the type of which, through the masticatory system, are transmitted iz prosthesis connection. Two dental implants of the to the peri-implant bone tissue whilst chewing (4,5). same type (Torque Type®, WinSix®, BioSAFin. S.r.l. There are two fundamental aspects of implant design: - Ancona, Italy), with sandblasted and acid etched the macro-structure, characterized by the shape of the Ed surfaces ( Micro Rough Surface®), but differing from body, the characteristics of the neck and the apex, by each other for the prosthesis connection system, the design, by the number and pitch of the thread, and were examined by scanning electron microscope the microstructure, characterized by the surface treat- (SEM) analysis at different magnifications: TTI im- ment. In addition, there is also the good accuracy of the plant, with a hexagonal internal connection, and prosthetic components (6-8). TTX implant, with a hexagonal external connection. It is known that differences in implant shapes induce IC SEM analysis showed that the Torque Type® implant significant changes in force distribution on the surround- is characterized by a truncated cone shape with ta- ing bone (9). The macroscopic geometric pattern of a pered tips. The implant body showed a double loop dental implant can assume a cylindrical or conical form. C thread and double pitch with blunt tips. For both For some years some companies have marketed the ta- types of connection, the implant neck was 0.7 mm pered form, with the aim of combining the advantages in height with a 3% taper. This implant design may of both designs. A tapered implant creates the basis for be able to guarantee osteotomic properties at the an excellent primary stability by gradually allowing thin © time of insertion in a surgical site suitably prepared, ridge expansion and determining the least stress pos- a facilitated screwing, thanks to the thread pitch and sible at the interface with the surrounding bone (10,11). to the broad and deep draining grooves, thereby The design of the implant neck, or crestal module, has ensuring a good primary stability. The different con- undergone considerable evolution in recent years. The nection design appears defined and precise, in order implant neck represents the transosseous area of the to ensure a good interface between the fixture and implant body where the highest concentration of me- the prosthetic components. Therefore, this design chanical stresses are evinced and where the transition appears to be particularly suitable in cases where between the hard tissue and soft tissue support occurs. a good primary stability is necessary and a precise Discriminating elements of the crestal module could be 44 Annali di Stomatologia 2012; III (2): 44-50 Implant design for full arch rehabilitation identified in the geometrical design and in the surface tant role regarding the long-term survival of the osseoin- type. The possible geometric profiles of the implant neck tegrated implants (18). are essentially three: straight walls, diverging walls and The titanium surface can be prepared with different tech- converging walls. Despite the diverging walls type seem- niques in order to obtain an optimal degree of roughness ing to be the best form, as it can provide a slightly higher of the surface, as it has been shown that the wider the li primary stability after the implant insertion, from the clini- functional surface is in contact with the bone, the better cal point of view the behavior of the bone before and the support for the prosthesis (19,20). na after the load is not dissimilar between the three geo- The rough implant surfaces determine a slightly better metric figures. In fact, an aspect commonly observed at bone tissue response in quantitative terms of bone- the level of the crestal module is the different bone level implant contact percentage (21-23). The purpose of before and after the occlusal loading. Before loading, if the surface treatment is to increase the contact area io the implant was positioned so that the prosthetic plat- between the bone and the implant, thus improving the form is at the level of the crestal bone, there will always osseointegration. Even with only the threads, the resis- be a clinical situation where the bone covers the entire tance degree to tensile forces and compression is great- az implant neck. After application of the load there is invari- er than smooth implants not threaded, and the presence ably a vertical bone loss, the level of which is located in of microretentions on the surface of the fixture allows to correspondence of the first thread. All this takes place increase the tensile and torsion strength of the implant. independently from the geometrical shape and the level In addition, some authors have demonstrated how mac- n of the first thread. rophages, epithelial cells and osteoblasts, have a high The crestal module height was reduced over time by tropism against rough surfaces (24,25). er various manufacturers, until today, when the height of In order to obtain a surface topography able to promote the smooth collar is reduced to less than 2 mm. the process of osseointegration, various surface treat- The morphology of the crestal module evolved in the ments have been tried out, such as sandblasting (26), same way - from a smooth surface to a treated sur- acid etching (27), combined treatment of blasting and nt face with microthreads for increased stability of bone in the coronal zone, to favour aesthetics and peri-implant health (12). etching (28), surface coating with micro-granules of hydroxyapatite (29) or particles of titanium oxide (30), or electrochemical deposition (31). Recent researches iI The use of the smooth neck arises from the necessity highlighted how the micro-roughness obtained by blast- to limit the plaque retention at the border zone between ing and acid etching is compatible with best clinical and the implant, bone and soft tissue. The presence of micro histological results. on retentions at the level of the crestal module is designed Several options also affect the types of connections to adequately dissipate forces that are expressed at the between the endosseous fixture and implant prosthetic cervical area of the bone-implant interface in the pres- components. ence of occlusal stress, in all implant types, thus allow- External hexagonal connection was the first connec- i ing to maintain the height of the bone spikes in accor- tion system used in implantology which was ideated by iz dance with the law of Wolff (13), a phenomenon that in Branemark only as coupling mechanism to easily guide the presence of a smooth neck does not happen. the stump insertion; its function was then expanded to As regards the design and the pitch of the threads, become a real anti-rotation mechanism. The interface Ed these must be designed to maximize the transmission and the tightening screw are subject to very high mas- of forces between the implant and surrounding bone tis- ticatory loads, subjecting the screw to insidious lateral sue, and to correctly distributed stress arising between bending forces, tilting and elongation that may mobilize the bone interface and the implant (14). Their main role it (32). is to increase primary stability and extend the available Of the internal connections, the most widely used are IC surface of the implant for bone contact. internal hexagonal, internal octagonal, conical screw Among the various thread designs, the V-shaped threads and Morse connections. The internal connections have and the broader square threads have been shown to shown an increased stability, better mechanical stability generate less stress and to better distribute the loading and resistance to lateral forces than external ones. C forces compared to the thin threads and tapered apex The aim of this study is to describe the macroscopic and threads (15). The phenomenon is best appreciated in the microscopic appearance of a new implant design, with bone marrow, while no difference have been found in particular emphasis on the type of prosthesis connec- cortical bone. tion. © Another important factor necessary to achieve success in implantology is represented by the surface properties of the material used (16). The micro-topography of the Materials and Methods implant surface is able to affect the percentage of BIC (Bone-to-Implant Contact) and the cellular response of In this study, the macroscopic and microscopic appear- the host tissue (17). The treated surfaces stimulate os- ance of a new implant design was evaluated, with par- teoblast proliferation, as demonstrated by the increased ticular emphasis on the type of prosthetic connection. expression of biological markers, which transposes into Two dental implants of the same type (Torque Type®, an increase of osteogenesis, thus assuming an impor- WinSix®, BioSAFin S.r.l., Ancona, Italy), with sandblast- Annali di Stomatologia 2012; III (2): 44-50 45 S. Tetè et al. ed and acid etched surfaces (Micro Rough Surface®), but differing from each other for the prosthesis connec- tion system, were examined by scanning electron micro- scope (SEM) analysis at different magnifications: TTI im- plant (Torque Type® Implant I), with a hexagonal internal li connection, and TTX implant (Torque Type® Implant X), with a hexagonal external connection. na The macrostructure of the geometrical design of the different segments of the fixture, the characteristics of the prosthetic connection, and the microstructure of the implant surface were analyzed by Scanning Electron io Microscope (Zeizz EVO-50, Cambridge, UK). Electron acceleration potential was kept between 15 and 25 kV, and the working distance kept between 9 and 12 mm, az according to the different requirements and types of samples. Figure 2 - SEM visualization of a TT implant-prosthetic connec- tion with a deep lodging of hexagonal form and smooth crestal n Results module. er At SEM analysis, both TTI and TTX implants were char- acterized by a truncated cone shape, with a tapered apex (Fig. 1). Both implants showed a reduced crestal module repre- nt sented by a smooth neck 0.7 mm height and 3% taper. The implant-prosthetic connection was characterized by a very deep lodging for the fixing screw, with a hex- iI agonal form with a double parallel type connection (Fig. 2). The TTX implant includes a crestal module with a smooth surface, dominated by the external hexagonal on connection module (Fig. 3). At SEM analysis, the neck surface seemed completely smooth and well polished; at 3000x magnification there were signs of lathing, typical of machined surfaces (Fig. 4). i With regard to the implant body, this was equipped with iz a double thread and double pitch. The thread pitch was 0.60 mm. The threads are “V” shaped with rounded tips and slopes inclined at approximately 45°. Figure 3 - SEM visualization of a TTX external implant-prosthetic Ed The main thread has a step along its apical side which connection constitute of smooth crestal module dominated by an hexagonal connection. forms the smaller thread (Fig. 5). The depth of the main threads is 0.375 mm, as long as the depth of the second- ary threads is 0.125 mm. The main thread width ranges from 0.07 mm at the top to 0.50 mm at the base, while IC C © Figure 1 - SEM visualization of WinSix® TT and TTX implants. Figure 4 - SEM visualization of the machined neck surface (149x It may be noticed the truncated shape of the fixture with tapered magnification). apex. 46 Annali di Stomatologia 2012; III (2): 44-50 Implant design for full arch rehabilitation the distance between each thread is 0.10 mm at the dental implants play a decisive role in obtaining success base and 0.53 mm at the peak. The implant shape is in osseointegrated implantology (33). In particular, the maintained constant along the entire implant body. geometrical design of the threads, their position and The apical portion shows a bevel apex, nearly flat, char- acterized by broad and deep drainage furrow, with in- li creasing size apically (Fig. 6). The surface of the implant body, defined by the manu- na facturer of Micro Rough Surface®, and realized by a sub- traction process for etching and sandblasting, was reg- ularly distributed along the surface (low magnification) (Fig. 7). In the apical portion, at 1980x magnification, it io can be seen how the rough aspect of this surface recalls that typical of tooth enamel after acid etching. At higher magnification the surface appears to be characterized az by small depressions and elevations of 2-4 µm (Fig. 8). Discussion n In scientific literature it is widely reported that the mac- er roscopic structure and the surface characteristics of Figure 7 - SEM visualization of the Micro Rough Surface® regu- larly distribuited (721x magnification). nt iI i on iz Ed Figure 5 - SEM visualization of the continuous step that forms the smaller threads from the main threads (192x magnification). Figure 8A IC C © Figure 6 - SEM visualization of the bevel apex characterized by Figure 8B - SEM visualization of the Micro Rough Surface® at furrows drain. higher magnification (A:1980x; B: 7330x). Annali di Stomatologia 2012; III (2): 44-50 47 S. Tetè et al. their pitch along the implant body determine a different TTi and TTX implants also have a double loop thread, a response to functional loads and transmission of those principal and a secondary smaller one, due to the pres- forces to the surrounding bone tissue (34). The implant ence of a groove on the apical side of the main thread. design plays an even more important role if surgical An implant with double coil has an insertion speed twice protocols providing immediate loading are adopted. It is as fast compared to an implant with a single coil. Some li known that in the initial stages following implant inser- studies report that implants with a high number of loop tion, and especially after immediate loading, implant sta- threads and a reduced pitch possess a high percentage na bility should be guaranteed by mechanical relationship of BIC, due to increased surface area (40). Some stud- between the fixture and the bone tissue rather than a ies showed how the ideal threads pitch to obtain a good biological bone integration. Therefore, the percentage of primary stability, and an optimal distribution of the stress bone-implant contact and the friction that is obtained dur- should be not more than 0.8 mm (41). A thread pitch less io ing the insertion play an important role in the mechanical than this measurement was seen to positively influence behaviour of immediate loaded prosthetic implants. the load distribution along the peri-implant bone walls, The tapered shape of the implant fixtures TTI and TTX accompanied by a smaller crestal bone resorption (42). az ensures a gradual expansion of the thin crests during The osteotomic effect at the implant site during the im- the insertion phase of the fixture by determining the least plant screwing phase is further achieved through the ta- possible stress to the surrounding bone. This factor is of pered apex and the self-tapping implant design with the fundamental importance in cases of reduced bone avail- cutting apical portion. Moreover, the presence of deep n ability, where preserving cortical bone tissue is appropri- grooves at the apical level, constituting an anti-rotational ate, as well as carrying out a three-dimensional expan- system, is necessary for bone chip collection and clot er sion and compaction of the walls of the newly formed al- discharge during the screwing phase (43). veolar bone. The implant type analyzed showed a thread With regard to the crestal module, the manufacturer’s design that allows to release more force and give easy choice to use a smooth neck reflects the concept to access to good primary stability. The thread geometry guarantee the minimum plaque retention, allowing to nt contributes to obtaining primary stability, responsible for the biomechanical behaviour of the bone-implant inter- face after the healing process (35). obtain an optimal integration with the bone tissue (44). The constant size of the internal hexagon for the various implant diameters allows the use of few components, iI The thread height is defined as the distance between making the prosthetic steps and the eventual choice to the major and the minor diameter of the coil. A shallow adopt the Platform Switching technique easier. thread depth, as well as those present in the Torque The connection type through a long screw, ensures high on Type implants, favors insertion. In fact, although deeper connection stability, with considerable reduction of the threads ensure an increase of the surface and represent stress between abutment and implant, and a greater an advantage in areas of low density bone and high oc- contact surface which limits the microcirculation of bio- clusal stress, on the other hand shallow threads allow an logical fluids (45). i easy insertion in alveolar ridges with more dense bone Another important factor analyzed was the implant sur- iz without the need to perform tapping before the implant face, because the surface of the fixture is the only part insertion (36). to come into direct contact with the host tissue, influenc- In a study conducted by finite element analysis, it was ing cellular and biochemical responses, acting also on Ed demonstrated that the height of the thread more than the stability between bone and implant (46). SEM analy- its thickness is able to influence primary stability, and in sis allowed to assess the degree of roughness present particular threads with a height exceeding 0.44 mm is on the implant body and on the apical portion, typical able to provide excellent biomechanical response when of a sandblasted and acid etched surface with signs of inserted into bone tissue of medium or low density with streaks, depressions and elevations highly variable in immediate loading (37). IC size and shape. In addition, these threads have an osteotomic effect, Recent clinical studies showed how an implant with a allowing to pack the peri-implant bone using a surgical rough surface can be loaded before the traditional treat- technique that provides preparation of the implant site ment protocols (47). Some studies showed that dental C according to “press-fit” protocol. In vitro studies showed implants with low roughness values, as for the implant that in case of poor quality bone, such as in the posterior with machined surface, can promote the formation of fi- maxilla, implants with chamfer thread design produced brous tissue around the implant, reduce the percentage lateral compressive forces which increased the bone- of bone-implant contact and show a lower resistance to © implant contact and consequently improved the primary the removal than implants with rough surfaces (48). stability (38). This factor is very important in case of im- The implants with sandblasted and etched surfaces, mediate load technique of several implants, as in the for the presence of more regular micro-roughness pro- case of rehabilitation providing the immediate solidifica- duced by the etching treatment, seem to favor the bone tion using bar techniques (Just on 4® and Just on 6®). healing process, also by the marked incidence of the in- Furthermore, as already demonstrated, under vertical creased cytokine production, such as osteogenic prosta- load the presence of threads with bevel peak allows a re- glandin E2 (PGE2), and transforming growth factor-beta duction of divergent forces, thereby reducing the stress (TGF-b1), with the latter less sensitive to surface rough- at the bone implant interface (39). ness than in the case of PGE2 (49). According to some 48 Annali di Stomatologia 2012; III (2): 44-50 Implant design for full arch rehabilitation authors, this treatment promotes osseointegration due to Choi YC, Baik HK, Ku Y, Kim MH. Evaluation of design pa- an increase in initial cell anchorage by osteoblasts (50). rameters of osseointegrated dental implants using finite el- All in all, the results obtained prove that dental implants ement analysis. eJ Oral Rehabil. 2002 Jun; 29(6): 565-74. of a design that complies with the results of research 15. Hansson S, Werke M. The implant thread as a retention el- regarding the macrostructural aspect and the micro- ement in cortical bone: the effect of thread size and thread li structural surface topography, if used according to cor- profile: a finite element study. J Biomech. 2003 Sep; 36(9): rect surgical and prosthetic protocols assure safe and 1247-58. na predictable results. 16. 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Original article Cyclic fatigue resistance of four nickel-titanium rotary instruments: a comparative study li Eugenio Pedullà, DDS, PhD1 Introduction Gianluca Plotino, DDS, PhD2 na Nicola Maria Grande, DDS, PhD2 All nickel-titanium rotary (NTR) instrument systems cur- Alfio Pappalardo, DDS1 rently on the market are constructed from “Nitinol” an Ernesto Rapisarda, DMD,DDS1 alloy that was applied in endodontics since 1988 (1). Endodontic treatment has benefited from the introduc- io 1 Department of Surgery, tion of NTR root canal instruments (2). This is due to a University of Catania, Italy combination of unique mechanical properties of the al- 2 Department of Endodontics, loy, innovative file design, greater tapers and a crown az ‘Sapienza’ University of Rome, Italy down instrumentation procedure (3). As a result, there are now many systems available commercially, that use NTR instruments of different designs and dimensions, to Corresponding author: produce a desirable tapered root canal form, with a low n Eugenio Pedullà, MD risk of transporting the original canal foramen and fa- Via Cervignano, 29 cilitate cleaning and shaping procedures (4-7). However, er 95129, Catania, Italy clinicians remain concerned about their breakage in use Phone: +39 339 2613264 although the actual prevalence of such breakages has E-mail: eugeniopedulla@gmail.com been indicated to be low (about 5%) (8). Several studies have attempted to examine the reasons for fracture of Summary nt NTR instruments after clinical or simulated use and have shown that fractures can occur as a result of tensional or cyclic fatigue (9-13). Torsional fatigue is the twisting iI of a metal about its longitudinal axis at one end while Aims. The aim of this study is to investigate cyclic the other end is in a fixed position. Cyclic fatigue oc- fatigue resistance of four nickel – titanium rotary curs when a metal is subjected to repeated cycles of ten- on (NTR) instruments produced by a new method or sion and compression that causes its structure to break traditional grinding processes. down, ultimately leading to fracture (14). Methods. Four NTR instruments from different Cyclic fatigue failure was implicated in more than one- brands were selected: group 1. Twisted File pro- third of those instruments fractured clinically and occurs i duced by a new thermal treatment of nickel – tita- unexpectedly without any sign of previous permanent iz nium alloy; group 2. Revo S SU; group 3. Mtwo deformation (9, 15, 16). and group 4. BioRaCe BR3 produced by traditional The fracture was due to the alternating tension/compres- grinding processes. A total of 80 instruments (20 for sion cycles which instruments are subjected to, when Ed each group) were tested for cyclic fatigue resistance flexed in the region of maximum curvature of the canal inside a curved artificial canal with a 60 degree angle (17). of curvature and 5 mm radius of curvature. Time to Since the introduction of nickel-titanium alloy to end- fracture (TtF) from the start of the test until the mo- odontics, there have been many changes in instrument ment of file breakage and the length of the fractured design, but no significant improvements in the raw ma- tip was recorded for each instrument. Means and IC standard deviations (SD) of TtF and fragment length terial properties, or enhancements in the manufacturing were calculated. Data were subjected to one-way processes. Recently, a new manufacturing process was analysis of variance (ANOVA). developed by SybronEndo (Orange, CA), to create a Results. Group 1 (Twisted File) showed the high- NTR instrument called Twisted File (TF). It is produced C est value of TtF means. Cyclic fatigue resistance of by twisting the alloy after heat treatment in order to im- Twisted File and Mtwo was significantly higher than prove super-elasticity and increase cyclic fatigue resis- group 2 (Revo S SU) and 4 (BioRace BR3), while no tance (18). significant differences were found between group 1 The purpose of the present in vitro study was to compare © (Twisted File) and 3 (Mtwo) or group 2 (Revo S SU) the cyclic fatigue resistance of a nickel – titanium rotary and 4 (BioRaCe BR3). instrument produced by a new method (Twisted File) to Conclusions. The cyclic fatigue resistance of Twist- three instruments produced by traditional grinding pro- ed File was significantly frigher than instruments cesses. produced with traditional grinding process except of Mtwo files. Key words: cyclic fatigue, grinding process, nickel- titanium, rotary instruments, twisted file. Annali di Stomatologia 2012; III (2): 59-63 59 E. Pedulla et al. Materials and methods Means and standard deviations (SD) of TtF and frag- ment length were calculated for each system. Data were Four different NTR instruments from different brands, subjected to one-way analysis of variance (ANOVA) and of identical sizes (.06 taper and 0.25 tip diameter) were Dunn’s multiple comparison post-hoc test to determine selected and evaluated: group 1. Twisted File (Sybro- significant differences between groups. Significance was li nEndo, Orange, CA, USA) produced by a new ther- set at the 95% confidence level. mal treatment of nickel – titanium alloy; group 2. Revo na S SU (MicroMega, Besancon, France); group 3. Mtwo (Sweden-Martina, Padova, Italy) and group 4. BioRaCe Results BR3, (FKG, La Chaux de Fonds, Switzerland) produced by traditional grinding processes. Twenty NTR files from Mean values and standard deviation of Time to Fracture io each manufacturer were tested for cyclic fatigue resis- (TtF) and fragment lengths are displayed in Table 1. A tance, resulting in 80 instruments. All instruments had higher TtF is due to a higher resistance to cyclic fatigue been previously inspected using a measuring micro- of the tested instruments. Group 1 (Twisted File) showed az scope for dimensional analysis, and for any signs of vis- the highest value of TtF means. Cyclic fatigue resistance ible deformation. None was discarded. Size 06-25 was of Twisted File (Group 1) and Mtwo (Group 3) was signif- selected, being the master apical NTR file in many op- icantly higher than group 2 (Revo S SU) and 4 (BioRace erative sequences. Cyclic fatigue tests were performed BR3) (P<0.05). No statistically significant difference was n by a device as described in previous studies (19, 20). noted between groups 1 (Twisted File) and 3 (Mtwo) or The device consists of a main frame to which a mobile groups 2 (Revo S SU) and 4 (BioRaCe BR3) (P>0.05) er plastic support for the hand-piece is connected, and a (Fig. 2). stainless-steel block containing the artificial canals. The Mean length of the fractured segment was also recorded hand-piece was mounted upon a mobile device to allow to evaluate the correct positioning of the tested instru- precise and reproducible placement of each instrument ment inside the canal curvature, and whether similar nt inside an artificial canal. This ensured three-dimension- al alignment, and positioning of the instruments to the same depth. stresses were being induced. No statistically significant difference (P>0.05) was reported in the mean length of the fractured fragments for all of the instruments tested iI The artificial canal was manufactured reproducing in- (Fig. 3). strument size 25 and taper .06. It provided the instru- ment with a suitable simulated root canal with a 60 de- on gree angle of curvature and 5 mm radius of curvature (Fig. 1). Radius was measured to the central axis of the curvature. The center of the curvature was 6 mm from the tip of the instrument and the curved segment of the i canal was approximately 5 mm in length. Instruments iz were rotated at a constant speed of 300 rpm using a 6:1 reduction hand-piece (Sirona Dental Systems GmbH, Bensheim, Germany), powered by a torque-controlled Ed motor (VDW Silver, VDW GmbH – Dentsply International Inc., Munich, Germany). Torque was set at 2N/cm. All instruments were rotated until fracture occurred. Time to fracture (TtF) from the start of the test until the moment of file breakage was recorded with a chronometer to an Figure 2 - Column bar plot of Time to Fracture (TtF) for instru- IC accuracy of 0.1 second. The length of the fractured tip ments. was also recorded for each instrument. C © Figure 1 - Mtwo instrument inserted in the stainless-steel artifi- Figure 3 - Column bar plot of fragment length for instruments. cial canal. 60 Annali di Stomatologia 2012; III (2): 59-63 Cyclic fatigue resistance of four nickel-titanium rotary instruments Table 1 - Time to Fracture and fragment length (mean and SD) of size 25, taper.06 instruments. Instruments Time to Fracture (TtF) Fragment length Mean SD Mean SD (seconds) (millimeters) Twisted File 148.5 17.48 5.25 0.58 li Revo S SU 43.5 5.66 5.05 0.49 Mtwo 112 21.49 5.9 0.87 na Biorace BR3 42.9 10.97 5.8 0.95 Table 1 - Time to Fracture and fragment length (mean and SD) of size 25, taper.06 instruments. io Discussion creased phase transformation temperatures and its su- az perior flexibility (26). File fracture is a major concern during endodontic treat- Results of this study showed that size 25.06 of Twisted ment. Although multiple factors are responsible for in- File was more resistant to cyclic fatigue than the other strument separation in use, cyclic fatigue has been tested size 25.06 NTR instruments in absolute value. n shown to be an important cause because the rotary It has been shown that the fatigue life of NTR instru- instrument might be used in curved root canals (9, 13, ments made from conventional NiTi wire and that are the er 16). The shorter the radius of curvature, the greater is same size, was not significantly affected by differences the chance of fatigue breakage (13, 21). Cyclic fatigue in cross-sectional shape and/or design of the cutting occurs when a metal is subjected to repeated cycles flutes (27). Another recent study showed no obvious dif- of tension and compression that cause its structure to ference on the fatigue life among ProFile, TYP (triangu- nt break down (as a result of concentration of stress at the propagating crack front) and ultimately fracture (21, 22). Among the four instruments tested, Twisted Files were lar configuration), and DS NEYY (square configuration) files, which were made from conventional NiTi wire (28). Moreover, Twisted file and Bio Race BR3 both have an iI produced by processes of heating and twisting while equilateral triangular cross-section, but significant differ- the other three instruments were produced by traditional ences were found between TtF of Twisted Files and Bio grinding methods. Race BR3 or Revo S SU in our study (P<0.001) (29). on No scientific method was developed to date, which eval- So the improvement in cyclic fatigue resistance for size uated the resistance to fatigue of NTR instruments (18). 25.06 Twisted File would be also related to the manufac- Device or methods for fatigue testing didn’t incorporate turing processes. In fact, heating treatment of Twisted into international standards for endodontic instruments. Files transform the austenitic crystalline structure of NiTi i The cyclic fatigue testing device used in this study has alloy into the rhombohedral (R-) phase (30). R-phase iz been utilized in previous studies of cyclic fatigue resis- shows good super-elasticity and shape memory effect tance and has generated the maximum stress at the (30); its Young’s modulus typically is lower than that of center of simulated curve (about 6 mm from the tip) (23). austenite. Thus, an instrument made up of the R-phase Ed No difference (P > 0.05) between fragment lengths of all would be more flexible, allowing a greater amount of de- NiTi files confirmed the correct positioning of the tested formation than austenitic NiTi. (29, 31). instrument inside the canal curvature, and whether simi- On the other hand, cross-sectional configuration and lar stresses were being induced. manufacturing processes may influence flexibility of Although the simulated canal does not duplicate the in NTR instruments and have a substantial impact on their IC vivo situation, it allows the comparative testing of differ- fatigue lifetime (32, 33). ent instruments in a standardized environment (24). Our study showed no statistically significant difference Among the four instruments tested, Twisted Files were of TtF between Twisted File and Mtwo. Indeed, although produced by processes of heating and twisting, while the produced by the traditional grinding processes, Mtwo C other three instruments (Revo S SU, Bio Race BR3 and instruments showed resistance to cyclic fatigue only Mtwo) were produced by traditional grinding methods. slightly lower in absolute value than of new instruments Kuhn & Jordan proposed some suggestions to improve manufactured by thermal methods, such as Twisted the longevity of endodontic files, which include the fol- File. This is probably due to the lower flexural rigidity for © lowing: (1) thermal treatments before machining to de- cross-section of Mtwo rather that one of Twisted File. crease the work-hardening of the alloy; (2) choosing ma- Moreover a significant difference was found between chining conditions adapted to the NiTi alloy; and (3) elec- Mtwo and Bio Race BR3 or Revo S SU despite being tropolishing to reduce the machining damage on the sur- both made by traditional grinding processes. Instead face. The production method for manufacturing Twisted the comparison of TtF of Bio Race BR3 and Revo S SU File instruments would incorporate the first two of these showed no significant difference (P>0.05). suggestions (25). Hou suggested that new method of The lower resistance to cyclic fatigue of instruments pro- manufacturing NiTi instruments by twisting coupled with duced by traditional grinding process can be explained heat treatment of Twisted File might contribute to the in- by the fact that it has many drawbacks. More precisely, Annali di Stomatologia 2012; III (2): 59-63 61 E. Pedulla et al. cutting across the grain of the crystalline structure of nium root canal instruments with different cross-sections. J the nickel-titanium wire limits the overall strength of the Endod. 2006; 32: 372-375. instruments, due to the formation of micro-cracks and 8. Cheung GS, Darvell BW. Fatigue testing of a NiTi rotary in- strument. Part 1: Strain-life relationship. Int Endod J. 2007; defects along the surface of the instruments and with- 40: 612-618. in the internal structure (29). Kuhn et al. described the 9. Sattapan B, Nervo GJ, Palamara JEA, Messer HH. Defects li crack nucleation stage being facilitated by a high density in rotary nickel–titanium files after clinical use. J Endod. of surface defects, and then fatigue failure is largely a 2000; 26: 161–5. na crack propagation process (34). 10. Spanaki-Voreadi AP, Kerezoudis NP, Zinelis. Failure For the cyclic fatigue resistance, residual stresses have mechanism of ProTaper nickel–titanium rotary instruments been considered as an important factor not only after during clinical use: fractographic analysis. Int Endod J (simulated) clinical uses but also for a brand-new instru- 2006;39:171–178. io 11. Zelada G, Varela P, Martın B, Bahıllo JG, Magan F, Ahn ment (35, 36). When an instrument is machined (ie, be- S. The effect of rotational speed and the curvature of root ing ground), plastic deformation occurs at the surface of canals on the breakage of rotary endodontic instru- ments. the metal, resulting in residual stresses that remain at J of Endod 2002; 28: 540–542. az the surface (37). Although the exact nature and extent 12. Yared G. In vitro study of the torsional properties of new of such residual stress after manufacture are unknown, and used ProFile nickel titanium rotary files. J Endod 2004; any internal stresses might act as a negative factor to 30: 410–2. the martensite substructures (38). 13. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing n It is important for clinicians to realize that preexisting of nickel-titanium endodontic instruments. J Endod 1997; 23: 77–85. conditions associated with the manufacturing process 14. HibbelerRC.Mechanicsofmaterials.3rded.UpperSaddleRiv- er might contribute to the propagation of instrument frac- er, NJ: PrenticeHall; 1997. tures during use (39, 40). 15. Peng B, Shen Y, Cheung GSP, Xia TJ. Defects in ProTaper S1 instruments after clinical use: longitudinal examination. Int Endod J 2005; 38: 550–557. Conclusions nt Twisted Files 25.06, produced by thermal and twisted 16. Shen Y, Cheung GS, Bian Z, Peng B. Comparison of de- fects in ProFile and ProTaper systems after clinical use. J Endod. 2006; 32: 61–65. iI 17. Gambarini G. Cyclic fatigue of nickel-titanium rotary instru- processes, showed the best cyclic fatigue resistance that ments after clinical use with low-and high-torque endodon- was significantly better than the other NTR instruments tic motors. J Endod. 2001; 27: 772-774. tested produced with the traditional grinding process, ex- 18. Testarelli L, Grande NM, Plotino G, Lendini M, Pongione G, on cept Mtwo files. 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Cyclic fatigue and frac- chanical response of nickel-titanium instruments with dif- ture characteristics of ground and twisted nickel-titanium ferent cross-sectional designs during shaping of simulated na rotary files. J Endod. 2010; 36: 147-152. curved canals. Int Endod J 2009; 42: 593–602. 31. Miyai K, Ebihara A, Hayashi Y, Doi H, Suda H, Yoneyama 37. Shaw MC. (2005) Surface integrity. In: Crookall JR, Shaw T. Influence of phase trans- formation on the torsional and MC, Suh NP, eds. Metal cutting principles. 2nd edn; pp. bending properties of nickel-titanium rotary endodontic in- 432-5 New York: Oxford University Press. io struments. Int Endod J 2006; 39: 119–26. 38. Liu Y, Van Humbeeck J, Stalmans R, Delaey L. Some as- 32. Viana AC, Chaves Craveiro de Melo M, Guiomar de Aze- pects of the properties of NiTi shape memory alloy. J Alloys vedo Bahia M, Lopes Buono VT. Relationship between Compd 1997; 247: 115–21. flexibility and physical, chemical, and geometric character- 39. Alapati SB, Brantley WA, Svec TA, Powers JM, Mitchell az istics of rotary nickel-titanium instruments. Oral Surg Oral J. Scanning electron microscope observation of new and Med Oral Pathol Oral Radiol Endod 2010; 110: 527-33. used nickel-titanium rotary files. J Endod. 2003; 29: 667–9. 33. Zhang EW, Cheung GS, Zheng YF. A mathematical model 40. Alapati SB, Brantley WA, Svec TA, Powers JM, Nusstein for describing the mechanical behaviour of root canal in- JM, Daehn GS. SEM observations of nickel-titanium rotary n struments. Int Endod J 2011; 44: 72-6. endodontic instruments that fractured during clinical use. J 34. Kuhn G, Tavernier B, Jordan L. Influence of structure on Endod. 2005; 31: 40–3. nickel-titanium endodontic instruments failure. J Endod. er 2001; 27: 516–20. nt iI i on iz Ed IC C © Annali di Stomatologia 2012; III (2): 59-63 63 

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Original article Knowledge, attitudes and behavior of Italian mothers towards oral health: questionnaire validation and results of a pilot study li na Gianna Maria Nardi ,Rdh1 134 items and 127 questions, we get an alpha value Guglielmo Giraldi, MD2 of 0.784. Paola Lastella, Rdh 1 Conclusions. The questionnaire for the mothers Giuseppe La Torre, MD, Mph, Msc, Dsc2 showed a good reliability in the pilot study and it io Emilia Saugo, B.Sc.N.3 seems it made good results in terms of internal co- Francesca Ferri, J.S.D.3 herence and validity. The online administration al- Luciano Pacifici, MD, DDs1 lowed the opportunity to optimize the data collection az Livia Ottolenghi, DDs1 avoiding complications with papers and it offers po- Fabrizio Guerra, MD, DDs, Phd1 tentially, a tool able to rapidly gather a vast sample Antonella Polimeni, MD, DDs1 in which to perfect other studies. Key words: Knowledge, attitudes, behavior, Italian n 1 Department of Oral and Maxillo Facial Sciences, mothers, oral health. “Sapienza” University of Rome, Italy er 2 Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Italy Introduction 3 Italian National Association of Mothers With the extension of the average life in industrialized Corresponding Author: Paola Lastella, Md nt countries, the current epidemiological picture has been delineated, characterized by the prevalence of chronic degenerative diseases. Their role assumed in the de- iI Department of Oral and Maxillofacial Sciences terminism of multiple factors, especially behavioral and Via Caserta, 6 00161 Roma, Italy lifestyle factors, requires the focusing of attention on Phone: +39 06 49918151 the promotion of health. This is founded not only on the on e-mail: paolalastella@yahoo.it study of health determinants but also on the public medi- cal programs that have proven their efficacy and on the fight against inequalities, and it entails the collaboration of the medical system with other sections of society to i Summary develop improvements in favor of health (1). iz The European Union Council recognizes that unhealthy Aims. The study is focused on the analysis of knowl- lifestyles contribute in a noteworthy and growing way to edge, attitudes and behaviors of Italian mothers in the severity of diseases. Improvement of health condi- Ed regards to their oral health, deepening the under- tions of the population is therefore a main end for the standing of how the initiation of habits and behav- states that are members of the European Council and iors for a healthy lifestyle may influence the empow- to its adherents. Healthier lifestyles could lead not only erment process of their children. to better health conditions and the decrease of disease Methods. The questionnaire was composed by 14 but, in the context of ever growing health prices, to better sections and has been conducted using an online disease prevention. It’s a good investment and it’s also a IC questionnaire on the mothers association’s website. very profitable approach in terms of costs (2). Reliability analysis was tested and content valid- Damaging behaviors create diseases that are a burden ity was evaluated using Cronbach’s alpha to check for health and social systems therefore, in order to fight C internal consistency with the intention to obtain no them political action is necessary: misunderstanding results. Statistical analysis was • to encourage mobility and physical exercise in peo- performed through SPSS 19.0. ple (public transportation and urban green); Results. The total number of the compiled ques- • to support the consumption of fruits and vegetables; © tionnaires was 192. The highest value of the Cron- • to reduce the percentage of salt, sugars, and fats bach’s alpha is obtainable in Section 13 (Quality of in food; Life in relation to dental health between 8-17 years • to reduce the amount of highly caloric food in the diet; old kids) with a value of 0.998 (on 5 items). The total • to reduce the abuse of alcohol (3). value of the Cronbach’s alpha considering the part Poor oral hygiene is the main cause of gum disease, of questionnaire dedicated only to the mothers that a chronic infection of the tissue surrounding the teeth. have more than 18 years old children is 0.490 on 116 It’s one of the most prevalent chronic diseases and it items. is associated with a reduced systemic inflammatory re- Considering all the sections of the questionnaire on sponse (4), as well as the increase in the concentration Annali di Stomatologia 2012; III (2): 69-74 69 G. M. Nardi et al. of the reactive protein C and other inflammatory bio- markers (5,6). Structure of the questionnaire The transfer of bacterial endotoxins and the action of The questionnaire which was anonymous, was a combi- chemical mediators of the inflammation produced by the nation of many scientifically proven questionnaires, that mother, may have a role in causing premature and un- take into account different ways to express the concept li derweight births (7). of health, from the practical and technical side to the Regular teeth brushing is considered the best preven- psychological aspects that provide the foundation of the na tion for the control of dental plaque. Brushing teeth with behavior of a person. a fluorine toothpaste twice a day is the current medical These are the questionnaires used as the reference advice (5,8). Flossing and regular dental check-ups are for the final one used in this study: SF12 Question- equally important in order to keep oral health (9). naire (evaluation of life style) (19), IPAQ Questionnaire io There is currently a large focus on the beginning of gum (physical activity evaluation) (20), HU-DBI questionnaire disease during infancy (10), as a matter of fact in the oral (Hiroshima University, Dental Behavior Inventory) (21), health field, it is already well-known that psychosocial, EGOHID Questionnaire (European Global Oral Health az cognitive maternal-behavioral factors are associated Indicators Development Project) (22). with the oral behavior of children like teeth brushing (11). The questions are about topics that concern not only The adoption of good habits during childhood begins at personal life habits like physical activity, alcohol con- home with the parents, especially with the mother who sumption and smoking habits, and oral hygiene habits, n becomes the main reference of behavior (12) and it’s but they are aimed at revealing the level of knowledge also well-known that the social state (13) and even eth- about some different topics like prevention, therapies, er nicity (14) may influence the level of oral health. aesthetic factors and the anxiety level of receiving a Motivating mothers to assume the correct behavior for clinical treatment. oral health and assuming a better life style in general, The questionnaire is composed by the following sec- may produce positive changes that would determine an tions: nt increase in the long term benefits for the health of both mother and child (15). In the last years the number of people who use the Web Section 1 - Anamnestic and social-demographic. Section 2 - (Part1) Attention to the mothers’ oral hygiene; iI increased substantially. The Web is used for multiple (Part2) Protections and oral hygiene habits and preven- medical means (16) and for patients who use it primar- tive behaviors. ily as a source of information about their health (17,18). Section 3 - Risk factors, habits. on Because of the fact that the Web is a huge mass com- Section 4 - Level of oral health. munication system, it can be used as a big collector of Section 5 – Oral health related quality of life. data on statistical medical surveys and for studies about Section 6 – Quality of Life evaluation. the habits and behaviors of a population. Section 7 - Physical Activity evaluation. i Section 8 - Oral health level of 3-17 years old kids. iz Aim of the study Section 9 - Community programs for 3-17 years. The aim of the present work is to realize a study that is Section 10 - Attitudes and risk factors of 5-17 years old focused on the analysis of knowledge, attitudes and be- kids and 12-17 years. Ed haviors of Italian mothers in regards to their oral health. Section 11 - Dental assistance sources. This work, made in collaboration with the Department Section 12 - Preventive visit for pregnant women. of Dentistry and Maxillary-Facial Sciences, the Depart- Section 13 - Oral health related quality of life in 8-17 ment of Public Health and Infectious Diseases of the years old kids. “Sapienza” University of Rome, the National Association Section 14 - Orthodontic and dental traumas. of Mothers and the Academy of Dentistry and Dentistry IC Prevention “Il Chirone”, presents the first results of an Statistical analysis initial study, that will carry on the analysis of important The descriptive analysis uses averages and standard statistical data about the behaviors of the mothers in deviations for quantitative variables and frequencies for C regards to their own oral health, deepening the under- qualitative variables. standing of how the initiation of habits and behaviors for To measure the internal coherence of the items group- a healthy lifestyle may influence the empowerment pro- ing the α of Cronbach has been used and, in order to cess of their children, meaning the education and volun- check if some elements didn’t cohere with the rest of © tary embracing of good health rules. the scale and should therefore be discarded, an analysis of reliability has been performed. Adding and eliminat- ing the elements one by one created the total correlation Materials and methods between the items and the alpha variability between the elements. When Cronbach’s alpha is equal to 1 it means Participant and setting that the questions have an almost identical construct, This survey has been conducted using an online ques- with consequential coherence. Generally, a value of an tionnaire on the mothers association’s website (www.as- alpha of 0.7 is considered acceptable (23). sociazionemamme.it) in which 192 mothers participated. The data collected has been put in a database cre- 70 Annali di Stomatologia 2012; III (2): 69-74 Knowledge, attitudes and behavior of Italian mothers towards oral health: questionnaire validation and results of a pilot study ated with Excel and analyzed with SPSS for Windows of the mothers and the career category to which they (release 19). The analysis was made only on the items belong, with a response level higher than 15% and the sections already validated in the literature have been excluded Validation of the questionnaire from the analysis. The level of significance was fixed in In Table 1 is reported the analysis of the questionnaire li p<0.05. by sections. The highest value of the alpha of Cronbach is obtainable na in section 13 - Oral health related quality of life between Results 8-17 year old kids - with a value of 0.998 (5 items). In this section 61.5% of mothers declare ignorance about how The total number of the compiled questionnaires was often their own children 13 find difficulty eating, or feel pain, io 192. tension or embarrassment because of dental problems. Section 10 - Attitudes and risk factors of 5-17 year old children and 12-17 year old children - shows a value of az 13 alpha of 0.969 (15 items). 83.3% of mothers answered no to the question of whether their kids brush their teeth each time they eat, and they answered “never” to the question of if their kids smoke. n In section 8 - Health level of children between 3-17 - the value of alpha is 0.881 (3 items). 62.5% of the moth- er ers didn’t know with what frequency their own child brushes his or her teeth, 64.1% and 63.5% didn’t know respectively if the toothpaste used was fluoride based FigureFig.2 1 - -Marital status Education level of the themothers. mothers. or if fluoride was used in other forms in addition to the Fig.2 - Education level of the mothers. nt toothpaste. In section 9 - Community programs of 3-17 year old chil- dren - the result is a value of an alpha of 0.771 (3 items). iI To the question of if there is a program of disease pre- vention for dental health for kids at school, 63% of moth- ers didn’t know what to answer and 22.9 % answered on no; 62.5% didn’t know or wasn’t sure if their own kids were visited by a dentist in the last 12 months for the prevention of oral diseases. Section 5 - Oral health related quality of life - had a value i of alpha of 0.761 (8 items). Regarding some sides about iz oral health in the last 12 months, 83.9% of mothers nev- Figure 2 - Education level of the mothers. er found 14 difficulties to eat because of mouth problems, 81.3% never felt pain to their teeth and gums, almost Ed never for 68.2% and for the 67.2% of mothers the con- dition of their teeth was cause for embarrassment and they avoided smiling. Section 3 - Risk factors and habits - (27 items, al- pha=0.773) reveals that 67.6% of mothers ate more than IC 6 times a day. 72.3% of the sample ate between 5 and 9 portions of bread each week, pasta was consumed by Fig. 3 - Employment of the mothers. 81.9% at the most four times a week, beans were not eaten by 64.9% of the mothers during the week, fruit C (consumed up to nine times a week) and vegetables Fig. 3 - Employment of the mothers. (up to four times a week) were consumed by 74.5%, red Figure 3 - Employment of the mothers. meat by 68.1% up to 9 portions a week in respect to 88.3% that consumed at the most four portions of white © meat, cheese and fish are consumed up to four times a The mothers involved had an average age of 45.9 years week by 89.4 % and finally 67% of mothers don’t con- (SD 12.5). Figure 1 describes the marital status of the sume any amount of sweets during the week. 92.6% of mothers. 15.6 % of the sample refers to those affected mothers say they don’t smoke and 92% don’t drink al- by diabetes and 12% to those with cardiovascular dis- cohol. eases, particularly hypertension (9.4%). In regards to Considering section 12 - Preventive visit for pregnant the number of children, 44.8% of the mothers had just women - (2 items, alfa =0.720) it appears that 72.9% of one, 34.9% two kids, only 1.6% had four. mothers were never visited by a dentist during their last Figures 2 and 3 show respectively the level of education pregnancy. Annali di Stomatologia 2012; III (2): 69-74 71  Table 1 – Analysis of the questionnaire by sections: number of questions, number of items and value of G. M. Nardi et al. Cronbach’s alpha. Number of Number of α Sections of questionnaire questions items value Section 1. Anamnestic and social-demographic. 13 10 0.555 li Part 1. Attention to the mothers' oral hygiene. 28 28 0.564 na Section 2. Part 2. Protections and oral hygiene habits and 18 18 -0.330 preventive behaviors. Section 3. Risk factors, habits. 10 27 0.733 io Section 4. Level of oral health. 3 2 0.586 Section 5. Oral health related quality of life. 8 8 0.761 az Sections of questions for mothers who have children 6 5 -0.266 with less 18 years Section 8. Oral health level of 3-17 years old kids. 4 3 0.881 n Section 9. Community programs for 3-17 years. 5 3 0.771 er Section 10. Attitudes and risk factors of 5-17 years old kids and 12- 6 15 0.969 17 years. Section 11. Dental assistance sources. 4 4 0.609 nt Section 12. Preventive visit for pregnant women. Section 13. Oral health related quality of life in 8-17 years old kids. 3 6 2 5 0.720 0.998 iI Section 14. Orthodontic and dental traumas. 13 6 0.133 Total considering all sections 127 134 0.784 on Table 1 - Analysis of the questionnaire by sections: number of questions, number of items and value of Cronbach’s alpha. tist less then a year ago, 84.7% of those, for a check up. i 68.1% declared not having a dentist located less then 30 iz In section 11 - Dental Assistance Sources - (4 items, alfa minutes from home or the place of work. 0.609) 97% of the mothers declared that 75.4% of their The total value of the alpha of Cronbach, considering own children never went to the dentist because of a lack the part of questionnaire dedicated only to the mothers Ed of revealing diseases in the last year. that have more than 18 years old children, is 0.490 on By the answers in section 4 - Dental health level - (2 116 items. items, alfa = 0.586) it shows that 9% of mothers have In total, considering all the sections of the questionnaire 20 or more natural teeth and that 98.4% doesn’t have on 134 items and 127 questions, we get an alpha value dentures. of 0.784. Mothers that answered section 2 - Attention to oral IC health of the mother - declared that 63.7% of them never taught their children dental hygiene; 65.8% didn’t know Discussion if there is a relation between oral health and general C health and 65.8% didn’t know if a check up by the dentist The World Health Organization asked to begin cam- or hygienist would be useful. 82.6% of the mothers actu- paigns for the promotion of healthy lifestyles aimed at Fig. ally do 1go- Marital statusand to the dentist, of the mothers. brush their teeth carefully. the promotion of corrective intervention to these “modifi- 69.5% think that they can brush their teeth in a satis- able” risk factors that are at the base of the major inci- © factory way without using toothpaste and 84.7% declare dents of serious diseases (24). that bad breath is a problem that worries them. 75.3% of Often oral health is considered not relevant (25), instead the mothers also referred to brushing their teeth twice a the correlation between periodontal pathologies, heart day, 72.1% brush them less then 2 minutes, and 95.8% disease and adverse pregnancy outcomes is significant; use a manual toothbrush. The toothbrush is changed ev- the mechanism that links oral health to the preceding is ery 6 months by 73.2% of the mothers, 79.5% don’t use systemic inflammation (26). mouthwash habitually. Floss is used only by 27.4% of The main goal of periodontal disease prevention is the the mothers but in 64.2% of cases with a daily frequency. checkup and inhibition of bacterial plaque creation in the 79.5% of the mothers declared having been to the den- patients, and between the different strategies of preven- 72 Annali di Stomatologia 2012; III (2): 69-74 Knowledge, attitudes and behavior of Italian mothers towards oral health: questionnaire validation and results of a pilot study tion the most significant portion of these is about activi- sults about the evaluation of risk that mothers’ behaviors ties that promote dental self-care. The growth and the may have on their children’s dental health. development of a child is a continuous process that has to create an indipendent individual (27) and children Acknowledgements: We are grateful to the Italian National As- showed to adopt behaviors and food preferences of their sociation of Mothers for their cooperative and assistance. li mother since the beginning of infancy (28,29). Talking about the consumption of sweets, for example, na a relationship seems to exist between children’s habits References and those of their mothers. Also, it was demonstrated that dental health and the socioeconomic state influence 1. Piano Nazionale della Prevenzione 2010-2012 http://www. children’s attitudes and the prevalence of cavities devel- ccm-network.it/Pnp_2010-2012_contenuti io oping (30,31). 2. Presidenza italiana del Consiglio dell’Unione Europea - In order to prevent cavities and gum diseases maternal Progetto di conclusioni del Consiglio sugli stili di vita salu- support is essential: Sasahara et al. (32) showed that tari: istruzione, informazione e comunicazione. Anno 2003, az mothers gingival condition, as a result of oral health be- Allegato 4. http://www.salute.gov.it/resources/static/primo- havior, had been associated with the prevalence and se- piano/199/allegato4.pdf. verity of dental caries in their 3 year old children. 3. Istituto Nazionale di Statistica (ISTAT). L’uso e l’abuso di Mothers with regular access to dental care are more in- alcol in Italia. Anno 2009, 22 Aprile 2010. http://www.istat. n clined to bring their child to the dentist and develop be- it/it/archivio/1132. haviors and habits that promote good dental health (33). 4. D’Aiuto F, Ready D, Tonetti MS. Periodontal disease and er In the analysis of the study it emerged that, nonetheless C-reactive protein-associated cardiovascular risk. J Peri- an average, high school level (high school, university) of odont Res. 2004; 39: 236-41. most of the mothers that took part to the study, there is 5. Loos BG, Craandijk J, Hoek FJ, Wertheim-van Dillen PM, a lack of attention in many cases to children’s health, re- van der Velden U. Elevation of systemic markers related nt sulting in a large percentage of subjects being unaware about the dental care of their children, about the diet, and the substances used for disease prevention like flu- to cardiovascular diseases in the peripheral blood of peri- odontitis patients. J Periodontol. 2000; 71: 1528-34. 6. Slade GD, Ghezzi EM, Heiss G, Beck JD, Riche E, Offen- iI orine. Some mothers did not even know if in school there bacher S. Relationship between periodontal disease and is a dental disease prevention program. Even the level of C-reactive protein among adults in the atherosclerosis risk disease state perception is underrated. in communities study. Arch Intern Med. 2003; 163: 1172-9. on Therefore, two fundamental data emerge: an incapability 7. Alpagot T, Bell C, Lundergan W.Longitudinal evaluation of of the institutions to sustain an efficient plan of health pro- GCF MMP-3 and TIMP-1 levels as prognostic factors for motion and spread in the whole school institute; a lack of progression of periodontitis. J Clin Perio. 2001; 28: 353- information and mostly, assumption of responsibility by 359. i the mothers for their own health that reflects itself in an 8. Brothwell D, Jutai D, Hawkins R. An update of mechanical iz absent participation in their children oral health. oral hygiene practices: evidence-based recommendations The thoughts brought up by this data is about the neces- for disease prevention. J Canadian Dent Assoc. 1998 64: sity for creating a wider awareness of oral health prob- 295-306. Ed lems on a national level, to prevent complications made 9. Muttappillymyalil J, Divakaran B, Sreedharan J, Salini K, by neglect and a lack of selfcare, supporting a path of Sreedhar S. Oral health behaviour among adolescents in acquisition of correct lifestyles through the assumption Kerala, India. Italian J Public Health. 2009; 6: 218-224. of correct hygienic and dietary behaviors, like periodic 10. Bimstein E, Matsson L. Growth and development consid- dental visits, selfcare, starting a process of empower- erations in the diagnosis of gingivitis and periodontitis in ment. The first form of education to children’s health children. Pediatr Dent. 1999; 21: 186-91. IC should be learned by the mother, the maternal/infancy 11. Finlayson TL, Siefert K, Ismail AI, Sohn W. Maternal self- consultants during pregnancy continuing then in school efficacy and 1-5 year-old children’s brushing habits. Com- no matter what the level is. The assumption of responsi- munity Dent Oral Epidemiol .2007, 35: 272-81. C bility and the voluntary embrace of a healthy lifestyles by 12. Blinkhorn AS. Dental preventive advice for pregnant and the parents, particularly the mother would assume con- nursing mothers--sociological implications. Int Dent J. sequentially an important educational model for children. 1981; 31: 14-22. The questionnaire for the mothers showed a good reli- 13. Deli R, Oliva B, Macrì LA, et al. The impact of social context © ability and it seems it made good results in terms of in- on the perception of dental appearance in 8-9 years old ternal coherence and validity. The online administration children. Ital J Public Health. 2009; 6: 172-6. allowed the opportunity to optimize the data collection 14. Corridore D, Guerra F, Di Thiene D, et al. 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Original article Effectiveness of adjunctive subgingival administration of amino acids and sodium hyaluronate gel on clinical and immunological parameters in the treatment of chronic li periodontitis na Lorenzo Bevilacqua, DDS, MS1 crevicular fluid were assessed at baseline and on Jessica Eriani, MD2 day 7 and 45. Ilde Serroni, DDS, MS3 Results. Statistical significance was found between io Giuliana Liani, MD2 baseline and day 45 in relation to probing depth re- Violetta Borelli, MD4 duction and bleeding on probing between groups for Gaetano Castronovo, MD1 both of the tested treatments. Significant reductions az Roberto Di Lenarda, DDS, MS1 in µg/sample of calprotectin and myeloperoxidase were found after 1-week and an increase at 45 days in both groups. There were no statistically signifi- 1 Department of Clinical Medical Sciences, cant differences between other variables evaluated n Surgical and Health in this study. University of Trieste, Trieste, Italy Conclusions. These data suggest that subgingival er 2 Dental hygienist, Private practice, Trieste, Italy application of hyaluronic acid following ultrasonic 3 Private practice, Gorizia, Italy mechanical instrumentation is beneficial for improv- 4 Department of Life Sciences ing periodontal parameters. University of Trieste, Trieste, Italy Corresponding author: nt Key words: hyaluronic acid, periodontitis, calprotec- tin, myeloperoxidase. iI Lorenzo Bevilacqua, MD Aggregate Professor Introduction University Department of Clinical Medical Sciences on Surgical and Health of Trieste, Trieste, Italy A successful treatment of periodontal disease is based UCO of Dental Sciences of Trieste on an adequate maintaining of infection control in the Piazza dell’Ospitale 1 subgingival area. According to recent systematic re- 34100 Trieste, Italy views (1,2), there is no major difference in the efficacy i Phone: 0403992567 – Fax: 0403992665 of debridement techniques of plaque and calculus from iz E-mail: l.bevilacqua@fmc.units.it root and tooth surfaces using manual or ultrasonic in- strumentation. Ultrasonic mechanical instrumentation combined with effective self-performed supragingival Ed plaque control measure, allows infection control by al- Summary tering the subgingival ecological environment through disruption of the microbial biofilm and suppression of the Aims. The aim of this clinical trial was to compare inflammation (3). clinical and biochemical healing outcomes following This goal is frequently not completely attainable; it is ultrasonic mechanical instrumentation versus ultra- nearly impossible to expect to set the root completely IC sonic mechanical instrumentation associated with free from calculus specially in deeper pockets. Probing topical subgingival application of amino acids and of the root surface for detection of remaining deposits sodium hyaluronate gel. is an unreliable method to determine whether adequate C Methods. Eleven systemically healthy subjects debridement has been achieved, while clinical signs of with moderate-severe chronic periodontitis, who resolution of the inflammatory lesion would indicate suf- had four sites with pocket probing depth and clini- ficient removal of biofilm/calculus (4). cal attachment level greater than or equal to 5 mm Several recent studies have demonstrated additional © were randomly assigned to two different types of improvements in clinical parameters using local or sys- treatment: two pockets were treated with ultrasonic temic antimicrobial agents (5-7). debridement (Control Group) and two pockets with Nevertheless, antibacterial agents locally or systemically ultrasonic mechanical instrumentation associated applied in periodontal pockets, proved to be more effec- with 0,5 ml of amino acids and sodium hyaluronate tive only when they were used in combination with ultra- gel (Test Group). Probing depth, clinical attachment sonic mechanical instrumentation. Physical disruption of level, plaque index and bleeding on probing were the biofilm is fundamental for the control of periodontal recorded at baseline, 45 and 90 days. Levels of cal- diseases (8). The use of systemic antibiotics should be protectin and myeloperoxidase activity in gingival limited because of the development of resistant organ- Annali di Stomatologia 2012; III (2): 75-81 75 L. Bevilacqua et al. isms, allergic reactions and drug interactions. Materials and methods Some articles proposed topical applications of hyaluron- ic acid (HA) to complement mechanical debridement Patient selection and pocket selection (9,10). HA is a non-sulfated glycosaminoglycan with a The study design was a split-mouth clinical trial of high molecular weight. It is one of the components of the 12-weeks duration. li extracellular matrices of the connective tissue and was 11 healthy patients with moderately advanced chronic detected in the gingiva (11,12). It has an anti-inflamma- periodontitis, 7 males and 4 females (mean age was 51 na tory and anti-edematous effect (13) and promotes wound years SD ± 9,8), were recruited for the study following healing (14). Hyaluronan gel application demonstrated a a screening examination including full-mouth probing better reduction of the clinical parameters and inflamma- and radiographic evaluation. The following criteria were tory infiltrate in the treatment of plaque-induced gingivitis used: io (15,16). Recently, Pistorius and colleagues confirmed a reduction in the sulcus bleeding index and in the gingival Inclusion criteria: crevicular fluid (GCF), but not in the plaque values after • age 40 to 70 years, az topical hyaluronic acid application in gingivitis therapy • a minimum of 18 teeth, (17). • at least two sites per quadrant with probing depth Currently, researchers are establishing the potential ben- (PPD) and clinical attachment level (CAL)≥ ³5 mm. efits of local subgingival application of HA adjunctive to n scaling and root planing for the treatment of periodontitis Exclusion criteria: owing to its tissue healing and regenerative properties • use of locally or systemic antimicrobial agents 6 er (14). Research is also under way to establish that topical months before the study, applications of HA in alveolar bony defects accelerate • subgingival instrumentation within 6 months before the periodontal wound healing (18). baseline examination, In 2001 Engstrom’s clinical, immunological and microbi- • previous periodontal therapy during the last 6 months, nt ological responses to hyaluronan were studied to evalu- ate the anti-inflammatory effect on surgical and non-sur- gical periodontal treatment (9). Parameters considered • pregnancy and lactation period, • smokers, • systemic diseases that could possibly influence the iI were periodontal probing depth, gingival crevicular fluid condition of the periodontal tissue and the subgingival immunoglobulin G (IgG), C3, prostaglandin E2 (PGE2) microflora. and presence of plaque. on The anti-inflammatory effect of hyaluronan could not be Power calculation based on the detection of a difference verified in this study in relation to the immune responses in the mean PPD reduction of 0,5 mm between differ- (IgG, C3 and PGE2). In another study by Xu and col- ent treatment, standard deviation (SD) 0,035, a error de- leagues it was found that no clinical or microbiological fined to 0.05 and b error defined to 0.20, revealed that i improvement was achieved by the adjunctive use of HA at least 18 sites in each treatment were required (PS iz gel compared to scaling and root planing alone in the 2.1.31 for windows) (24). treatment of periodontitis. Only sulcus flow rate was af- Approval of the study protocol by the Ethics Committee fected by the use of HA gel in terms of a more rapid at Azienda Ospedaliero-Universitaria “Ospedali Riuniti” Ed reduction in the test sites (10). of Trieste (n. 27/2008) was obtained, and all participat- In 2009 Johannsen asserted that the application of hy- ing subjects provided informed consent before the start aluronan gel in conjunction with scaling and root planing of the study. may have a beneficial effect on periodontal health in pa- tients with chronic periodontitis (19). Assessment baseline IC Recent reports showed that a gel containing HA promot- The following variables were recorded for each site: ed wound healing in post-surgical wounds (20-22). Plaque index (PI) (25): presence/absence of plaque at In order to determine the amount of HA needed to lead the cervical area of the tooth. to clinically significant periodontal healing we planned to Bleeding on probing (BOP) (26): presence/absence of C evaluate the clinical and the putative anti-inflammatory bleeding within 15s following pocket probing. effects of application of amino acids and sodium hyal- Clinical attachment level (CAL): distance between a uronate gel as an adjunct to ultrasonic mechanical in- fixed reference point on the tooth (cemento enamel junc- strumentation in patients with chronic periodontitis. To tion, CEJ, or the margin of a restoration) to the bottom of © this purpose as clinical parameters we evaluated PPD, the clinical pocket, measured with a manual periodontal CAL, plaque index (PI) and bleeding on probing (BOP). probe (UNC15 Hu-Friedy®, Chicago, IL, USA). As inflammatory parameters we evaluated calprotectin Probing depth (PPD): distance from gingival margin to concentration and myeloperoxidase activity in gingival the bottom of the clinical pocket, measured with a man- crevicular fluid, since these are directly related with both ual periodontal probe (UNC15 Hu-Friedy®, Chicago, IL, the extent of polymorphonuclear neutrophils (PMNs) in- USA). filtration and the severity of periodontal disease (8,23). In another session were recorded in the same site: Level calprotectin and myeloperoxidase (MPO): The selected area was isolated with cotton rolls and gently 76 Annali di Stomatologia 2012; III (2): 75-81 Effectiveness of adjunctive subgingival administration of amino acids and sodium hyaluronate gel on clinical and immunological air-dried. Then, a perio paper strip (PerioCol Collection (Maxi Mixer 714, Asal Srl., MI, Italy) and eluted by cen- Strip, Oraflow, Plainview, NY, USA) was inserted into the trifugation at 3000 cycles/min for 5min (MSE, Sanyo, sulcus at PPD less than 1 mm and removed after 10s. Singapore). Strips visibly contaminated with blood were discarded. The crevicular protein content was quantified with the After the measurements, samples were stored separate- Bradford method (28) using bovine - serum - albumin li ly in 200 µl sterile phosphate-buffered saline at -80°C (BSA) as standard. until further processing. na Gingival crevicular fluid volume (GCF): after 10 minutes Calprotectin of the quantitative evaluated of calprotectin and MPO, Crevicular calprotectin levels were measured by en- sites were reisolated with new cotton rolls and gently air- zyme-linked-immunosorbent assay using a commercial dried. Then new perio paper strip (PerioCol Collection kit (Calprest, Eurospital, TS, Italy). The assays were per- io Strip, Oraflow, Plainview, NY, USA) was inserted into the formed according to the manufacturer’s instructions, and sulcus and removed after 10s. The gingival crevicular the results referred to a calibration curve expressed in fluid volume was determined using a calibrated moisture µg/µl. Samples were diluted using assay buffer to 1:100 az meter (Periotron, Siemens, Bensheim, Germany) and and assayed in triplicate. calculated in µl from a standard curve. The Periotron was calibrated by pipetting known volumes of four dif- Salivary myeloperoxidase (MPO) ferent liquids (phosphate-buffered saline, human saliva, Crevicular peroxidase (MPO) activity was calculated n human serum, PBS phosphate buffered saline) on perio from the rate of H202-dependent oxidation of TMB (29). paper strips (27). Calibration to baseline was performed Briefly the activity of crevicular MPO was determined er with a dry perio paper. at room temperature in 96 wells microtiter plate using a reaction mixture containing 1mM (final concentration) Treatment procedures tetramethylbenzidine (TMB) (29) [added from a 25 mM After initial measurements and collection had been done, stock solution in dimethylsulphoxide (DMSO)] as sub- nt the selected patients have been treated with full-mouth subgingival debridement using a piezoceramic ultrason- ic instrument (Piezosteril 5, Castellini, MI, Italy). The in- strate, 0,02% cetyltrimethylammonium bromide (CTAB). The reaction was started by adding 0,30 mM hydrogen peroxide (final concentration), stopped after 2 minutes iI strumentation was considered completed when the root by adding 0,4N H2SO4 (final concentration) and the re- surface was clinically judged to be clean and smooth. action product was quantitated spectrophotometrically at Then, a split mouth method design was applied. After ul- 413nm. Since PMN are the only source of peroxidase on trasonic debridement, four sites, two per quadrant, were activity in the crevicular fluid (30) the concentration of randomly allocated (computer generated randomization MPO in crevicular fluid was calculated by referring to a list, Random Generator) to test group or control group. calibration curve obtained with pure human MPO (Rz The additional treatment at the test sites consisted of 0.8) prepared from human neutrophils (31) as previously i subgingival administration of 0,5 ml of amino acids and described (32). iz sodium hyaluronate gel (Aminogam Ò A, lotto 190308A, Calprotectin and peroxidase data were presented in µg/ Errekappa Euroterapici Spa, MI, Italy) by a syringe with µl for concentrations and in µg/sample for total amounts blunt needle placed 3 mm to bottom of the clinical pock- in the selected sites. Ed et; in the same way 0,5 ml of placebo gel (Aminogam Ò B, lotto 190308B, Errekappa Euroterapici Spa, MI, Italy) Statistical analysis was applied in two control sites. Operator did not know Statistics were performed with the site as the unit of anal- the contents of the gel. Aminogam A and Aminogam B ysis. The mean of all the analysed periodontal param- were made at the sites following the same procedure at eters was calculated. The c2 test was used to determine IC 7, 15, 30 and 45 days. the differences in dichotomous variables (PI and BOP). The patient was instructed not to drink or eat or tooth- The distribution of continuous variables was initially ana- brush for 1 hour after device administration. All patients lysed with Kolmogorov-Smirnov and Shapiro-Wilks. Dif- were included in a personalized hygiene program. ferences between mean values for gingival crevicular C fluid volume were statistically analysed by the use of the Clinical and biochemical assessment after treatment repeated measurements analysis of variance. Differenc- At day 45 and day 90, a dental hygienist registered new es in PPD and CAL between the groups at baseline, day values of PI, PPD, CAL and BOP for all of the treated 45 and day 90 were tested by the use of Mann-Whitney © sites and oral hygiene motivation was given when indi- U-test with exact test Monte Carlo Sig (1-talied) based cated. on 10000 sampled tables. Changes of concentrations of The quantity of calprotectin, MPO and gingival crevicu- calprotectin and MPO were analysed by non-parametric lar fluid volume was evaluated and recorded at test and test. Statistical significance was defined as p<0.05. control sites at 7 and 45 days. A software program (SpSS 16.0 for Windows, SPSS Inc., Chicago, IL, USA) was used for all calculations. Biochemical analyses To extract the GCF from the perio paper strip, the sam- ples were thawed, vortexed for 60 s by a vortex-mixer Annali di Stomatologia 2012; III (2): 75-81 77 L. Bevilacqua et al. Results Bleeding on probing (BOP) The number of bleeding sites was markedly reduced All eleven participants completed the study and there following both treatments. At 45 days, the BOP was re- were not protocol deviations. No adverse effects were duced from 72,7% to 27,3% in sites treated with only reported (Fig. 1). ultrasonic instruments and from 72,7% to 9,1% in sites li treated with ultrasonic instruments and amino acids and sodium hyaluronate gel. At re-evaluation at 90 days, na bleeding sites were reduced in both groups but those treated only with non-surgery mechanical periodontal therapy obtained higher BoP scores (test group=4,5%; control group =18,2%). io There was statistically significant difference in BOP be- tween the two treatment groups (p<0.05). az Clinical attachment level (CAL) At re-evaluation at 45 days a CAL gain amounted 0.64 mm (test group) and 0,55 mm (control group) was ob- tained. At 90 days, CAL mean was reduced from 5,91 n mm to 4,86 mm in test group, from 5,91 mm to 5,05 mm in control group. er There was no statistically significant difference in CAL gain between baseline and re-examination intervals (45 and 90 days) for both groups (p>0.05). There was no statistically significant difference in CAL gain between Figure 1 - Flow diagram of the trial. nt sites treated with ultrasonic instruments and those treat- ed with mechanical instruments combined with amino acids and sodium hyaluronate gel (p>0.05). iI Clinical findings Probing pocket depth (PPD) The clinical characteristics of the sites included in the A marked reduction of probing pocket depth was ob- on study are reported in Table 1. served in both groups. At the 45 days re-examination, mean PPD reduction was 0,96 mm for test group and Plaque index score (PI) 0,54 mm for control group. At 90 days, PPD was reduced The plaque index score in the two study groups im- from 6,36 mm to 5,36 mm in sites treated with ultrasonic i proved during the study period. The PI was reduced by iz 31,8% in the test group, by 36,4% in the control group. No statistically significant difference between the two treatment groups was observed at any of the examina- Ed tion intervals. IC C © Table 2 - Biochemical group characteristics; mean values (95% CI). *N=21 #p<0.001; #p-values represent differences between test Table 1 - Clinical group characteristics; mean values (95% CI). group and control group. 78 Annali di Stomatologia 2012; III (2): 75-81 Effectiveness of adjunctive subgingival administration of amino acids and sodium hyaluronate gel on clinical and immunological instruments only and from 6,14 mm to 4,64 mm in sites sodium hyaluronate gel in adjunction to subgingival de- treated with ultrasonic instruments and amino acids and bridement in test sites has shown statistically significant sodium hyaluronate gel. Mann-Whitney U-test demon- reduction of bleeding and probing depth, while no statis- strated significant differences in pocket depth reduction tically significant difference between the two treatment at 45 days (p<0.03) and 90 days (p<0.02) between test groups was observed regarding plaque index score (PI), li group and control group. clinical attachment level (CAL) and crevicular fluid vol- ume. na Biochemical finding From a clinical point of view, probing pocket depth and Gingival crevicular fluid markers bleeding reduction exerts a positive influence in the Biochemical characteristics of the sites included in the prognosis of a dental element by decreasing specific risk study are reported in Table 2. parameters. Nevertheless, amino acids and sodium hy- io aluronate gel addition could not outcome in a complete At baseline, statistically significant differences were de- elimination of periodontal pockets, leading the clinician tected for the µg/sample of Myeloperoxidase between to perform corrective surgical therapy. az the two groups (p<0.02). No other differences between The use of HA has shown statistically significant im- groups were found. provement of clinical parameters in the treatment of gin- givitis (15) and accelerates periodontal wound healing Gingival crevicular fluid volume (GCF) (18). Besides, the topical application of hyaluronic acid n At 1-week, a tendency towards a decrease in GCF in combination with non-surgical periodontal treatment was observed in both groups (test group Tbaseline=74,09 might be useful in reducing bleeding and probing pocket er (CI: 56,93-91,26) T7 days=32,82 (CI: 23,93-40,71) T45 days depth, owing to its properties of increasing the extent =33,38 (CI: 27,58-39,18); control group Tbaseline=70,95 of fibrin polymerization, stabilizing the clot and exerting (CI: 52,57-89,34) T7 days=34,45 (CI: 27,68-41,23) T45 days antiexudative activity (34,35). =38,36 (CI: 30,56-46,17)). Statistical significance was Conversely, from a biochemical perspective there was nt achieved at re-evaluation at 1-week and at 45 days post- instrumentation (p<0.001). However, no statistical signif- icance was found for any re-evaluation for both groups. no evidence for any Aminogam-related difference in cal- protectin levels and peroxidase activity in crevicular fluid. Previous data reported by Engström and colleagues also iI failed to demonstrate the anti-inflammatory effect of HA in Calprotectin relation to immunological (PGE2, IgG, C3) responses in Significant reductions in µg/sample of calprotectin were gingival crevicular fluid (9). Gingival crevicular fluid MPO on found after 1-week (p<0.01) and an increase at 45 days and calprotectin are directly related with both the extent was found in both groups (p<0.01). The concentration of of polymorphonuclear neutrophils (PMNs) infiltration and calprotectin elevated after 7 days (p<0.001). There was the severity of periodontal disease (8). HA modulation of no evidence for difference for concentrations and in µg/ PMNs function in vitro and in vivo is still controversial, i sample between test and control group. since both stimulating (36,37,38) and inhibiting activity iz (39,40) have been reported. Our findings reported that Myeloperoxidase concentrations of myeloperoxidase and calprotectin did Significant reductions in µg/sample of MPO were found not change during the time of treatment, indicating that Ed after 1-week (p<0.01) and an increase at 45 days was the hyaluronic acid does not significantly affect the activ- found in both groups (p<0.01). The concentration of ity and recruitment of crevicular neutrophils in the inflam- MPO elevated after 7 and 45 days (p<0.001). There was matory response as recently reported for human isolated no evidence for difference for concentrations and in µg/ PMNs exposed to a hyaluronate-carboxymethylcellulose sample between test and control group. membrane (Seprafilm). IC Recently it has been reported that hyaluronan plays an important role as moderator of inflammation and it also Discussion functions in the negative feedback loop of inflammatory activation, through interacting with fibroblasts’s TSG6 C The aim of this study was to evaluate whether the appli- (14). On this basis further investigations should be per- cation of amino acids and sodium hyaluronate gel could formed to analyze the effect of hyaluronic acid and ami- enhance the results obtained by subgingival ultrasonic no acids on the activity of cells involved in the healing instrumentation only in patients with chronic periodon- process, through exploring inflammatory markers, such © titis. as metalloproteinases. In this study, ultrasonic periodontal debridement with and without amino acids and sodium hyaluronate gel resulted in an improvement in all clinical parameters. Acknowledgements: The authors declare that they have no These results are consistent with those of Badersten et conflicts of interests. The study was self-supported by Depart- colleagues (33) who stated that nonsurgical periodontal ment of Clinical Medical Sciences, Surgical and Health of Uni- versity of Trieste. Company Errekappa Euroterapici Spa (Milan, therapy is effective in improving periodontal clinical pa- Italy) provided free materials to be used in the study. rameters. In the present investigation, the use of amino acids and Annali di Stomatologia 2012; III (2): 75-81 79 L. Bevilacqua et al. References 15. Jentsch H, Pomowski R, Kundt G, Göcke R. Treatment of gingivitis with hyaluronan. J Clin Periodontol 2003 Feb; 1. Tunkel J, Heinecke A, Flemmig TF. A systematic review 30(2): 159-64. of efficacy of machine-driven and manual subgingival de- 16. Sapna N, Vandana KL. Evaluation of hyaluronan gel (Gen- bridement in the treatment of chronic periodontitis. 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Håkansson L, Hällgren R, Venge P, Artursson G, Vedung S. of high-molecular-weight hyaluronates on the functions of Hyaluronic acid stimulates neutrophil function in vitro and guinea pig polymorphonuclear leukocytes. Semin Arthritis n in vivo. A review of experimental results and a presenta- Rheum 1993 Jun; 22: 4-8. er nt iI i on iz Ed IC C © Annali di Stomatologia 2012; III (2): 75-81 81 

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Case Report Gnathological postural treatment in a professional basketball player: a case report and an overview of the role of dental occlusion on performance li na Alberto Baldini , DDS, PhD1 occlusal splint and physiotherapy sessions, the pa- Alessandro Beraldi , DDS2 tient no longer complained of low back pain prob- Alessandro Nota, DDS1 lems and the symptoms associated with the sto- Furio Danelon, MMD3 matognathic apparatus improved considerably. In io Fabiana Ballanti, DDS1 particular, after the tests carried out on an isokinetic Salvatore Longoni, DDS4 machine, a force increase related to the quadriceps muscles was detected when the patient was wearing az the occlusal splint. 1 Department of Orthodontics, University of Rome Conclusions. All athletes must however be analysed “Tor Vergata”, Italy individually and carefully with clinical and instru- 2 Italian Sports Dentistry Association SIOS, Italy mental analyses in order to consider the possible n 3 Isokinetic Sports Medicine Section Milan, Italy real effectiveness of an occlusal splint for improving 4 Department of Neurosciences and Biomedical postural structure and sports performance. er Technologies, University of Milano-Bicocca, Italy Key words: posture, dental occlusion, bite force, oc- clusal splint, sports performance, sports medicine. Corresponding author: Alberto Baldini, MD Centro Medico Polispecialistico Baldini Via S. Orsola, 5 nt Introduction iI 24122 Bergamo, Italy During competitions and training many professional Phone: +39 035/691247 athletes wear occlusal splints to improve their sports Fax: +39 035/694280 performance. In order to achieve the best possible per- on E-mail: studiomedicobaldini@gmail.com formances, higher-level athletes must be able to adapt totally to movements even when subject to particularly harsh stress. They must have constant control of bal- ance changes and the use of muscular force as well as i Summary excellent coordination capacity. iz An athlete’s motor control is very important as regards Aims. During competitions and training many pro- improving performance and depends on the visual, ves- fessional athletes use to wear occlusal splints to im- tibular, proprioceptive responses as well as reflexive and Ed prove their sports performance. However, notwith- voluntary muscle responses (1, 2). It was observed that standing some studies concluded that achieving a professional dancers and gymnasts have better postural balanced cranial-occlusal system could bring to an control than normal subjects (3, 4). improvement of sports performances, the results Over the past years, scientific research and clinical evi- are still contrasting. dence highlighted an anato-functional and physio-path- IC Probably the gnathological postural treatment of ological connection between craniomandibular (CMD) athletes has greater influence on performance when and craniocervical dysfunctions, aggregating various the individual suffers of Temporomandibular Joint areas of the organism in a single “tonic-postural system” Disfunction (TMJ) or physio-postural pathologies (5- 7). C owing to the consequent alteration of the “tonic- Notwithstanding some studies concluded that achieving postural system”. This clinical case details a gna- a balanced cranial-occlusal system could bring to an im- thological postural approach to a professional bas- provement of sports performances (8, 9, 10), the results ketball player suffering from muscular problems are still contrasting (11). © related to the stomatognathic apparatus and a low Probably the gnathological postural treatment of athletes back pain unresolved with the only physiotherapy, has greater influence on performance when the individu- which limited her performance. al suffers of TMJ or physio-postural pathologies owing to Methods. Force platform and T-Scan III appliances the consequent alteration of the “tonic-postural system”. were used in order to check the postural and occlu- This report is intended to be a presentation of a clinical sal condition of the athlete and as an aid to clini- approach regarding a professional basketball player. cal parameters in achieving a correct splint balance. Results. After the treatment involving inserting an Annali di Stomatologia 2012; III (2): 51-58 51 A. Baldini et al. Clinical case The patient G.M., a 28-year-old professional female bas- ketball player who played for the Italian national basket- ball team and currently plays in a second division team, li had frequent low back pain complaints which occurred 1 or 2 times a month for 4 or 5 days, making training and na playing in matches impossible. In the past the patient had suffered a minor trauma that distorted her hip, however this did not require surgery. The radiographic, physiological and orthopaedic analy- io ses showed no vertebral column structural disorder. The medical staff of the basketball team, who failed in healing the pain with physiotherapy, requested a gnatho- az logical postural analysis in order to consider the occlusal system’s possible interference with the postural system. Figure 2 - Lateral intra oral photograph (right). The player underwent the gnathological postural exami- nations normally carried out on athletes referred to our n section: clinical stomatognathic apparatus analysis, pos- tural static scoliometer and podoscope analysis, stabilo- er metric postural analysis via force platform, and comput- erised occlusion analysis. Following a particular episode, the patient reported pain caused by both spontaneous and provoked (palpations) nt muscular problems, at the right masseter muscle with moderate frontal bilateral localized tension cephalea oc- curring once or twice a week. iI The athlete had a normally physiologically and sym- metrically mouth opening with no functional limitation or articular noise. on The occlusal analysis showed bilateral crosses at 16/46 and 26/36 and crowns on 11, 21 and 22 (Figs. 1, 2, 3). A static posture analysis was carried out on a scoliom- Figure 3 - Lateral intra oral photograph (left). eter showing slight asymmetry (Fig. 4). i A posturometric analysis was carried out on a “Correkta iz Dl Medica” force platform: each recording lasted 51.2 sec, under the following conditions: mandibular rest po- sition, with eyes opened and closed; mandibular posi- Ed tion of centric occlusion, with eyes opened and closed; mandibular position with cotton rolls and eyes opened and closed; the athlete underwent an additional test in mandibular rest position with eyes closed and with ret- roflexed head for evaluating cervical interference (12). Cotton rolls 8 mm. thick and 37 mm. long were positioned IC C © Figure 1 - Occlusal intra oral photograph. Figure 4 - Static postural evaluations of posture on scoliometer. 52 Annali di Stomatologia 2012; III (2): 51-58 Gnathological postural treatment in a professional basketball player on the mandibular teeth distal to the canines. Quiet con- ity of the exam: a hand was placed under the foot of ditions were maintained during the exam, and disturbing the subject, lifting the foot until it reached the following elements were eliminated. A force plate was placed in criteria using the markers painted on the surface of the order to position subjects perpendicularly faced to the platform: wall at 150 cm. The subjects were required to remain as - Feet angle of 30° following the principal red line. li stable as possible, relaxed, with their arms hanging free - Calcaneal tendon positioned in correspondence of the beside their trunk, and facing the wall without concen- length of the foot, expressed in French points and cen- na trating on a precise point on it. Moreover, all the subjects tered on the principal red line. were asked to avoid alcohol, sport and conservative - Malleolus positioned in correspondence of the angled therapies during the 24 h before the clinical recordings. red line. The standardized placement of the subjects on the force - Second foot finger root projection correspondent to the io plate is fundamental to reduce the intersession variabil- principal red line. - Foot outline correspondent to the areas drawn on the surface of the platform. az This showed anteriorization of posturometric loads (Fig. 5), frequent finding in basketball players since it seems their postural struc- ture can prepare the system for a jump or n sprint, however with slight torsion. In par- ticular, the postural structure improved, be- er coming more symmetrical when cottons rolls were inserted in the patient’s mouth (thus eliminating occlusal interferences) (Fig. 6). The force platform analysis showed that the nt postural system seemed perturbed when the teeth were in contact (Fig. 7). Romberg index (R.I.) and the cervical inter- iI ference index (ICS) were calculated in order to evaluate the cervical and ocular interfer- ence on posture: not significant values as- on sessed the absence of these kinds of inter- ferences (12). The computerised occlusion analysis was carried out using the T-Scan III (Tek-Scan i Figure 5 - Posturometry on force platform with accentuation of Boston, USA) a computerized system whose iz the projection of the loads towards the front in centric occlusion. sensor, when inserted between the dental arches and connected to software, allows for the distribution of the masticatory forces Ed to be evaluated thoroughly (13, 14). Thus, the T-Scan III sensor was inserted between the athlete’s dental arches, mak- ing three to four contacts between the dental arches to verify the test’s repeatability, sys- IC tem seemed to suggest the occlusal sys- tem’s interference related to the left molar sector, with the postural system (Fig. 8). A stabilization splint, to be worn 15/16 hours C a day, including during training sessions and matches, was fabricated for the athlete lower arch, allowing for the unobstructed excursive glides of the mandible in protrusive position © and laterality and occlusal balance in centric position in order to achieve a better postural balance which would had been able to con- tribute in prevent the painful symptomatol- ogy to be frequent and improving sport per- formance. The splint was designed in the laboratory by mounting models of the upper and lower den- Figure 6 - Posturometry on force platform with improvement of postural position using cotton rolls. tal arches to a semi-adjustable articulator. Annali di Stomatologia 2012; III (2): 51-58 53 A. Baldini et al. Figure 7 - Kinesiogram shows the perturbation of the postural system in centric occlusion. li na io n az er nt iI i on iz Ed IC Figure 8 - T-Scan III shows the asymmetry of the occlusal loads. Figure 9 - T-Scan III shows a balance of the occlusal loads wear- ing the occlusal splint. C Wax bite registration was then taken, seeking centric re- return in the glenoid cavity (16, 17). Then the occlusal lation with the Dawson’s bilateral manipulation, which is splint was balanced using the computerized occlusion a manual technique that allows the gnathologist to posi- system evaluation and clearly improved the patient’s oc- tion the mandible and its condyles in a recordable and clusion. © modifiable position, studies in literature concluded this With the insertion of the occlusal splint in the oral cavity, technique to be trustworthy and reliable for recording the the occlusal loads appeared more symmetrical and bal- patient’s centric relation position (15). anced (Fig. 9). The operator has to stand behind the patient and place A posturometric analysis of the athlete was carried out us- three fingers (first finger, middle finger, and ring finger) ing a force platform (Correkta DL Medica, Milan Italy) when under the horizontal branch of the mandible with the he was wearing an occlusal splint inserted in the oral cavity thumb firmly positioned on the chin and the little finger resulting in better postural control with minor expenditure of on the rear of the vertical branch of the mandible so the energy; the centre of gravity appeared smaller and with a operator can pull the mandible, allowing the condyles to more homogeneous distribution (Fig. 10). 54 Annali di Stomatologia 2012; III (2): 51-58 Gnathological postural treatment in a professional basketball player Figure 10 - Kinesio- gram with bite shows more homogeneous distribution of pos- tural loads. li na io n az er nt iI The gnathological treatment was joined with the physio- quadriceps’ muscular efficiency of the custom fit instru- therapy of the cervical and lumbar tract of the vertebral mentally balanced splint compared to a semi-individual column and after six months of wearing the splint and mouthguard (Powerguard Isasan) using an isokinetic on doing physiotherapy, the patient no longer complained machine. of episodes of low back pain or symptoms related to the After 10 minutes of warming up via bicycle, walking and stomatognathic apparatus. leg muscle stretching exercises, the athlete underwent In order to evaluate the effect of the splint on the mus- a muscular test in the “Isokinetic” Sports Medicine De- cular force also in areas distant from the stomatognathic partment of Milan using an isokinetic machine (model i iz apparatus the athlete underwent an isokinetic test wear- REV9000, Technogym) in order to evaluate the concen- ing the splint. tric force expressed during the extension and flexion The aim of this report is also to evaluate the effect on movements of the right and left knee joints with one 90° Ed angle per second for 4 consecutive repetitions (Fig. 11). The parameters considered were peak of force (Nm) and work done (W). The analysis of the force was carried out in three differ- ent mandibular conditions: with teeth in contact, wear- ing the custom fit and instrumentally controlled occlusal IC splint and wearing a semi-individual adaptable mouth- guard (Powerguard Isasan, Italy). The results reported in the Tables (Table 1 and Table 2) in the average range of values of the other members C of her team, show an improvement of the performance analysed by the isokinetic machine both wearing the custom fit occlusal splint and the semi-individual mouth- guard compared with the “teeth in contact” condition. © Discussion Different kinds of athletes (motorcycle racers, footballers, etc.) also wear occlusal splints during competitions in or- der to improve performance. Research and publications in medical and dentistry magazines assessed that oc- Figure 11 - Isokinetic machine test. Annali di Stomatologia 2012; III (2): 51-58 55 A. Baldini et al. M. Greenberg et al (19), who, in 1981, published a con- trolled double-blind clinical study on the correlation be- tween mandibular position and force of the upper part of the body, based on the principle that increasing the vertical dimension of occlusion with occlusal devices li seemed to be able to increase muscular force. The authors studied a selected sample of 14 members of na a basketball team of the University of Pennsylvania who were not involved in a strengthening program during the observation period and with no evident TMJ problems. Occlusal devices were constructed and applied to the io posterior mandibular sectors and a shoulder adduction and abduction test was then carried out using an iso- kinetic dynamometer capable of evaluating the intensity az of the muscular force. The athletes underwent a first Table 1 - Isokinetic test results (Peak of Force). session consisting of three series of five abductions followed by another three series of adductions at a dis- tance of three minutes and a second session consisting n of the same exercises this time using the occlusal device and the placebo. er Having processed the data via ANOVA statistical analy- sis (p < 0.05), no relevant differences were observed be- tween the three conditions and consequently it appears that any increase of the muscular force due to the use nt of the occlusal device is correlated to the placebo effect rather than a direct relationship with the splint. In 2000 P. Gangloff, J. Louis and P. Perrin implemented iI a different type of protocol, evaluating the repercussions dental occlusion has on postural control in a controlled study (20) based on a test sample of 8 professional on shooters compared with a study of the same number of Table 2 - Isokinetic test results (Work). individuals with perfect oral health. The protocol consists in using the force platform to re- clusal factors can influence body posture and that con- cord the variations of the center of foot pressure (CFP) i sequently sports performances of professional and non- in an interval of 20 seconds, showing the data with a iz professional athletes can increase. statokinesiogram, and carrying out each test with and This could be really important when the gnathological without the visual component. Four mandibular positions treatment could help the athlete to resolve frequent pain- using occlusal splints were considered for both groups: Ed ful symptomatology that prevents him from having a cor- maximum intercuspation, centric relation, lateral physi- rect and continuous training program. ological occlusion and contralateral occlusion. The results achieved in this clinical case presented show The best results were achieved with the jaw positioned how the gnathological postural protocol with the inser- in centric relation. The statistically significant difference tion of an intraoral device could bring to a reduction of between the various mandibular positions confirmed a IC the symptomatology related to both the lumbar system relationship between occlusion and postural control and and the stomatognathic apparatus and a consequent the authors confirm this emerged as better sports per- better postural control and improvement of the perfor- formances for the professional shooters included in the mance of quadriceps’ muscular force. study. C However, the conclusions of the different studies regard- A study carried out by Ferrario et al. in 2001 (21) analysed ing the matter are not unanimous. two groups of subjects, one group whose parameters of In particular the studies which analyse the relationships occlusion were in the norm and the other with recogni- between occlusion and sports performance in sportsper- sable alterations to the stomatognathic apparatus (one © sons mainly consider two aspects: the fact that correct or more teeth missing, crossbite), in order to analyse the occlusion or wearing splints increases the muscular functional relationship between the stomatognathic ap- force also in areas which are some distance from the oral paratus and the muscles of other areas of the body and cavity (18) and the fact that wearing a splint improves between various occlusal conditions and neuromuscu- postural balance and therefore as a consequence can lar performance. 29 young men who regularly practised prevent injuries and improve performance bringing to one or more sports were examined and for each of these very contrasting results. subjects, six mandibular positions were considered: with The first to carry out an significant study on the relation- mouth open, without teeth in contact, with slight dental ship between occlusion and sports performance were contact, maximum intercuspation, maximum intercuspa- 56 Annali di Stomatologia 2012; III (2): 51-58 Gnathological postural treatment in a professional basketball player tion with two cotton rolls (10 mm thick) placed between electromyography and kinesiographical tests using the the posterior teeth, maximum intercuspation with only Transcutaneous Electrical Nerve Stimulation (TENS) one cotton roll placed at the right or left side of the pos- technique. Using the OPTOJUMP™ equipment, the ath- terior mandibular teeth. For each position the patient had letes carried out two functional evaluation tests: coun- to use the dominant limb to lift a load of weight previ- termovement jump and stiffness jump. These tests were li ously established on the basis of his build, for as long both carried out in two different sessions (with and with- a time as possible. In the two groups analysed all the out the splint) on just after the first wearing of the device na subjects more or less carried out the test with the same (T0, T1) and two months after its first wearing (T2, T3). maximum weight but unexpectedly the group of subjects The data obtained were processed using the Analysis with malocclusion were able to do the task for a longer of variance ANOVA statistical analysis system and high- time than those with normal occlusion. lighted a statistically significant difference only between io Lai’s work (22) analysed the relationship between dental T3 and T0 and between T3 and T2. This has led the au- occlusion and physical performance via the Ergo-jump thors to conclude that the splint did not improve athletic platform in order to highlight whether there are actually performance, sustaining that the statistical differences az connections between occlusal correction and variations detected were due only to an improvement caused by in sports performance. the players’ training. Literature thus does not paint a very Two groups of patients who did not practise sports com- clear picture of the role which dental occlusion can have petitively were selected for this study: one group with on the muscular force of areas which are distant from the n cranial-cervical-facial disorders and condylar-meniscus oral cavity since the performance required vary greatly incoordination, initial clicking on opening the mouth, for each sport: in some sports which are considered sta- er dental class I or II with occlusal instability and postural tionary (shooting, for example), it appears fundamental modifications related to occlusion, and a second group to have better postural balance thus all devices which with no pathology or disorder. Following the gnathologi- aim to improve stability would seem to improve perfor- cal examination, a resin splint with canine guidance and mance. nt occlusal contacts was inserted. This was intended to correct malocclusion in the group of patients with pathol- ogies/disorders, while in the others it provoked maloc- On the other hand, the evaluations carried out in active sports, in which various factors can interfere with the performances, appear more complicated. iI clusion, inserting a greater thickness of around 2 mm at the canine and the first right premolar. The results showed the performance of the dysfunction- Conclusions on al subjects to improve with the use of the splint. On the other hand, the performance of the patients with no TMJ In conclusion, it seems that, in this clinical case as dem- pathology worsened with the occlusal corrections. onstrated in other scientific studies, it is really important In 2008, Ebben et al. (23) noticed that during situations for athletes to have good occlusal balance, in order to i which require a particular muscular force or power it is achieve a perfect postural balance which could bring iz somewhat common for athletes to clench their teeth, greater results during competitions, prevent injuries, and consequently developing facial and neck muscular ten- maybe also increase muscular force (25, 26). sion, and to activate certain muscles also through a Gnathological treatment could be really important in Ed modified Valsalva manoeuvre, presumably in order to some individuals, as an aid to physiotherapy in heal- achieve a potential ergonomic advantage. 14 male and ing frequent painful symptomatology that prevents the female athletes were chosen for this study. During the athlete from having a correct and continuous training test these subjects did a countermovement jump on a program, this could be the key of interpretation of the force platform, which analysed the force developed in performance improvement assessed by this case report. two conditions; rest position and maximum intercuspa- IC As stated in a revision of the literature (18), there is cur- tion. In particular, the percentage of force developed dur- rently no scientific evidence that a splint can improve ing maximum intercuspation was 19.5 % greater than in sports performance owing to the low number or pub- rest position. lished studies and their contrasting results. C M. Manfredi et al. published a controlled randomized ex- All athletes must be individually and carefully analysed periment (25) in 2009. The study analysed the relation- with clinical and instrumental analyses and possibly ship between occlusion and athletic performance using treated with reversible occlusal treatments in order to a device similar (OPTOJUMP™) to the one used in the evaluate the real effectiveness of an occlusal splint in © previous study and based on a sample of 15 profession- improving postural structure and sports performance be- al basketball players from the Italian “serie A” Benetton cause literature does not provide a clear picture of the Treviso team. The authors considered 2 groups, a sur- role which occlusion can have on sports performance. vey group and a control group, composed respectively of 8 and 7 sportspersons not undergoing dental treatment or affected by problems in other parts of the body which References could interfere with the postural system. In order to identify the myocentric position useful for 1. Isableu B, Ohlmann T, Cremieux J, Amblard B Selection of the construction of the splint, the players underwent spatial frame of reference and postural control variability. Annali di Stomatologia 2012; III (2): 51-58 57 A. Baldini et al. Exp Brain Res 1997; 114(3):584-589. 15. Hickman DM, Cramer R The effect of different condylar 2. Johnston RB, Howard ME, Cawley PW, Losse GM Effect positions on masticatory muscle electromyographic activ- of lower estremity muscular fatigue on motor controlper- ity in humans. Oral Surg Oral Med Oral Pathol Oral Radiol formance. Med Sci Sports Exerc 1988; 30(12):1703-1707. Endod. 1998; 85(1): 18-23. 3. Golomer E, Cremieux J, Dupui P, Isableu B, Ohlmann T 16. Baldini A, Tecco A, Cioffi D, Rinaldi A, Longoni S Gnatho- li Visual contribution to self-induced body sway frequences Postural Treatment in an Air Force Pilot. Aviat Space Envi- and visual perception of male professional dancers. Neu- ron Med. 2012 83(5); 522-527. na rosci Lett 1999; 267(3): 189-192. 17. Baldini A, Cravino G, Rinaldi A, Cioffi D Gnathological pos- 4. Vuillerme N, Danion F., Forestier N, Nougier V Postural tural analysis and treatment in Air Force pilots: a case re- sway under muscle vibration and muscle fatigue in hu- port Mondo Ortodontico 2011; 36(5); 208-215. mans. Neurosci Lett 2001; 303 (2): 83-86. 18. Baldini A, Cravino G, Dental occlusion and athletic perfor- io 5. Bergamini M, Pierleoni F, Gisdulich A, Bergamini C Dental mances. A review of literature Mondo Ortodontico 2011; occlusion and body posture. Cranio. 2008; 26(1): 25-32. 36(3): 131-141. 6. Sakaguchi K., Metha NR, Abdallah EF, Forgione AG, Hi- 19. Greenberg MS, Cohen SG, Springer P, Kotwick JE, Vegso az rayama H, Kawasaki T. et al. Examination of the relation- JJ. Mandibular position and upper body strength: a con- ship between mandibular position and body posture. Cra- trolled clinical trial. J Am Dent Assoc. 1981; 103(4): 576- nio. 2007; 25(4):237-249. 579. 7. Hanke BA, Motschall E, Turp JC Association between 20. Gangloff P, Louis JP, Perrin PP. Dental occlusion modifies n orthopedic and dental findings: what level of evidence is gaze and posture stabilization in human subjects. Neurosci available? J. Orofac. Orthop. 2007; 68(2): 91-107. Lett. 2000; 293(3): 203-206. er 8. Sforza C, Tartaglia GM, Solimene U, Morgun V, Kapranskly 21. Ferrario V.F, Sforza C., Serrao G., Fragnito N., Grassi G. RR, Ferrario VF. Occlusion, sternocleidomastoid muscle The influence of different jaw positions on the endurance activity and body sway: a pilot study in male astronauts. and electromyographic pattern of the biceps brachii mus- Cranio 2006; 24(1): 43-49. cle in young adults with different occlusal characteristics. J nt 9. Smith SD. Muscular strength correlated to jaw posture and temporomandibular joint. (1978) NY State Dent J. 1978; 44 (7): 278-285. Oral Rehabil. 2001; 28(8): 732-739. 22. Lai V, Deriu F, Chessa G. (2004) The influence of occlusion on sporting performance. Minerva Stomatologica. 2004; iI 10. Gelb H., Metha NR, Forgione AG. The relationship be- 53(1-2): 41-47. tween jaw posture and muscular strength in sport dentistry. 23. Ebben WP, Flanagan EP, Jensen RL (2008) Jaw clench- Cranio 1996; 14(4): 320-325. ing results in concurrent activation potentiation during the on 11. Perinetti G. Dental occlusion and body posture: no detect- countermovement jump. J Strenght Cond Res 2008; 22(6): able correlation. Gait Posture 2006; 24(2): 165-168. 1850-1854. 12. Monzani D, Guidetti G, Chiarini L, Setti G. Combined effect 24. Manfredi M, Lombardo L, Bragazzi R, Gracco A, Siciliani of vestibular and craniomandibular disorders on postural G. An investigation into explosive force variation using oc- i behaviour. Acta Otorhinolaryngol Ital. 2003; 23(1):4-9. clusal bites. Prog Orthod. 2009; 10(2):54-63. iz 13. Baldini A. Clinical and instrumental treatment of a patient 25. Jakush J. Divergent views: can dental therapy enhance with dysfunction of the stomatognathic system: a case re- athletic performance? J Am Dent Assoc. 1982; 104(3): port. Ann Stomatol (Roma) 2010; 1(2):2-5. 292-298. Ed 14. Baldini A, Beraldi A, Nanussi A The clinical importance 26. Gelb H, Mehta NR, Forgione AG. Relationship of muscular of computerized evaluation of occlusion. Dental Cadmos strength to jaw posture in sports dentistry. N Y State Dent 2009; 77(4):47-54. J. 1995; 61(9): 58-66. IC C © 58 Annali di Stomatologia 2012; III (2): 51-58 

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Case Report Ultrasonic bone surgery in the treatment of impacted lower third molar associated to a complex odontoma: a case report li na Maria Paola Cristalli, DDS, PhD1 ture (4-5). Rare complications are brain abscess, epi- Gerardo La Monaca, DDS, PhD1 dural abscess, benign paroxysmal positional vertigo, Nicola Sgaramella, MD, DDS2 subcutaneous and tissue space emphysema, subdural io Iole Vozza, DDS, PhD1 emphysema, and herpes zoster syndrome (6). The in- cidence of inferior alveolar nerve (IAN) injuries ranges 1 Department of Oral and Maxillofacial Sciences, “Sapi- from 0.41% to 8.1% for temporary decreases of sensitiv- az enza” University, Rome, Italy ity and from 0.014 % to 3.6% for prolonged signs and 2 Department of Surgical Sciences, Foggia University, symptoms (7). When the radiographic signs of proximity Italy of the mandibular canal to the roots of the third molar are present, the incidence of damage can be as high as n 35% (8). Corresponding Author: Risk factors also include advanced age, surgeon’s ex- er Maria Paola Cristalli, DDS, PhD perience, the use of burs during bone removal or tooth Department of Oral and Maxillofacial Sciences, Oral sectioning, and surgical difficulty associated with deeply Surgery Unit, “Sapienza” University of Rome impacted teeth, particularly if distal bone removal is re- 6, Caserta, St. 00161, Italy quired (9,10). Phone: +39 06 49976651 Fax: +39 06 44230811 E-mail: mariapaola.cristalli@uniroma1.it nt Thus, any technique that could reduce the possibility of these nerve damages is worthy of exploration: a good example is the Ultra Sonic Bone Surgery (UBS). This iI technique consists of inducing energetic micro-vibra- tions with a frequency in the 20–32 kHz range, above the audible spectrum. The vibrations are generated by on Summary a transducer, which is electrically, piezo-electrically or magnetically controlled. Piezo-electric materials vary in The removal of impacted mandibular third molar is size when they are submitted to an intense electric field, a common surgical procedure entailing some risk of typically in the 500-750 V/mm range. These deforma- i complications, especially when the tooth and the in- tions can further transmit energetic micronic mechanical iz ferior alveolar nerve and/or lingual cortical plate are forces to a tip vibrating up to amplitudes of 200µm. UBS in close proximity. A technique that can reduce the uses piezo-electrical transducers, because the generat- possibility of damage is the Ultra Sonic Bone Sur- ed movements are more energetic. Ultrasonically moved Ed gery. The aim of this report is to present a paradig- knives have the ability to cut hard tissues, like teeth and matic case of an impacted mandibular third molar bone. In contrast, soft tissues like gingiva, blood vessels, closely associated with a complex odontoma, which nerves and sinus membranes are preserved from injury was treated with the Ultrasonic Bone Surgery (UBS) because they vibrate with the tip. This makes UBS par- device. This technique appeared to be a valid alter- ticularly suitable for a broad spectrum of surgical appli- native to manual or mechanical treatment, strongly cations including apicectomy, bone block section, sinus IC minimizing trauma to the inferior alveolar nerve, lifting, split-crest, nerve lateralization, resective bone vascular tissues, or surrounding dental tissues. surgery, and biopsies (11). We present here a case of a deeply located odontoma encompassing an impacted C Key words: lower third molar, odontoma, ultrasonic left mandibular third molar in close proximity to the inferi- bone surgery. or alveolar nerve, which was treated by Ultrasonic Bone Surgery (UBS) device. © Introduction Case report The extraction of the lower third molar is one of the most frequent procedures in oral surgery (1). Common com- A 40-year-old man was referred to the Oral Surgery Unit plications following third molar surgery include sensory - Department of Oral and Maxillofacial Sciences (Sapi- nerve damage, alveolar osteitis, infection, or haemor- enza University of Rome, Italy) for recurrent episodes rhage during or after surgery (2,3). Less common com- of infection and pain in the mandibular left third molar plications are severe trismus, iatrogenic damage to the region. Clinical examination revealed the presence of a adjacent second molar, and iatrogenic mandibular frac- partially impacted left mandibular third molar showing 64 Annali di Stomatologia 2012; III (2): 64-68 Ultrasonic bone surgery in the treatment of impacted lower third molar associated to a complex odontoma: a case report mild signs of gingival inflammation (plaque retention and bleeding on probing), without deformations or swelling of the region (Fig.1). The panoramic x-ray (Fig.2) revealed the presence of two large dense radiopaque masses in close association mesially and distally to the roots of the li impacted tooth, consistent with the provisional diagno- sis of complex odontoma. A computed tomography (CT) na with the Dentascan program (Siemens Rs Somaton Vol- ume Zoom Kv 120 mA 140; Siemens, Erlangen, Germa- ny) (Figs. 3, 4), obtained in order to define the extension of the lesion and the anatomical topography, showed an io intimate relationship between the inferior alveolar nerve and the odontoma-tooth unit. Surgical removal of the impacted third molar and the associated odontoma was az planned. The patient received a single dose of 2 g of amoxicillin and clavulanic acid (Augmentin 1 g, GlaxoS- Figure 3 - Panorex CT scan obtained in order to define the exten- mithKline, Verona, Italy) 1 h before surgery, together with sion of the lesion and regional anatomical topography. a single dose (100 mg) of non-steroidal anti-inflammato- n ry drug (Nimesulide, Aulin, Hoffmann-La Roche, Basel, Switzerland). Surgery was performed under local anes- er thesia. Local anaesthesia was performed (2% mepiva- caine with 1:100,000 epinephrine) by IAN block injection and tissue infiltration. A mucoperiosteal buccal flap was reflected and bone was removed on the mesial, buccal nt and distal aspect of the third molar area with the Ultra- iI i on iz Ed Figure 4 - Sagittal CT scan examination showing an intimate re- lationship between the inferior alveolar nerve and the odontoma- tooth unit. IC Sonic Bone Surgery UBS® device (Italia Medica, Milan, Figure 1 - Clinical examination of the impacted left mandibular Italy) (Fig.5). The same device was used to separate the third molar showing mild signs of gingival inflammation. odontoma from the tooth. After sectioning, both the third molar and the associated lesion were gently removed C using root elevators (Figs. 6, 7). The wound was care- fully irrigated and the flap was repositioned and sutured with 4.0 suture (Vicryl®, ETHICON GmbH, Germany) (Figs. 8, 9). On macroscopic examination, the masses © appeared to be a complex odontoma (Fig. 10), and the histopathological examination confirmed this diagnosis (12). After surgery, amoxicillin and clavulanic acid (1 g twice a day for 1 week) and nimesulide (100 mg twice a day for 2 days, and then as needed) were prescribed to the patient. Immediate postoperative wound healing was Figure 2 - Appearance of two large dense radiopaque masses satisfactory, and the post-operative panoramic radio- closely associated to the roots of the impacted lower third molar graph showed the integrity of the mandibular canal (Fig. at the orthopanoramic examination. 11). No symptoms or signs of neurosensory impairment Annali di Stomatologia 2012; III (2): 64-68 65 M. P. Cristalli et al. li na io n az Figure 5 - Mucoperiosteal buccal flap reflection and bone remov- Figure 7 - The third molar sectioned and then removed using al with the Ultrasonic Bone Surgery. er root elevators. nt iI i on iz Ed Figure 6 - The separation of the odontoma from the third molar Figure 8 - The wound after third molar removal. and its removal with the ultrasonic device. IC of the innervated area, the inferior alveolar nerve, or the lingual nerve could be detected. We confirm that we have read the Helsinki Declaration and have followed the guidelines concerning this report. C Discussion © The present case showed an impacted lower third molar associated with a relatively large complex odontoma in an intimate relationship with the inferior alveolar nerve canal. Surgical technique seems to play a major role in causing complications related to third molar extraction (13). Thus, a careful operating technique and adequate instruments may limit the occurrence of complications. Here, the removal of the odontoma-tooth unit was car- ried out by using an ultrasonic surgery device in order Figure 9 - The flap repositioned and sutured. 66 Annali di Stomatologia 2012; III (2): 64-68 Ultrasonic bone surgery in the treatment of impacted lower third molar associated to a complex odontoma: a case report seems similar (18) or even improved because piezoelec- tric bone surgery seems to induce an earlier increase in neo-osteogenesis, resulting in a more positive osse- ous response (19, 20). The latter may depend on the cavitation effect induced by ultrasonic cutting that allows li an effective cooling avoiding significant hyperthermia and coagulation damages to the surrounding area (21). na The same effect is responsible for a higher visibility dur- ing surgery compared to conventional instruments due to the evacuation of detritus with the aerosol formation (14). In the present case, the piezoelectric device used io is the Ultra Sonic Bone Surgery UBS® (UBS). The vibra- tion frequency of UBS is in the 20-32 kHz range and the maximum ultrasound power is 90 W. Increased power of az the ultrasonic vibration and a higher vibrating frequency may result in a higher cutting efficiency in hard bone. Therefore, less pressure on the working tip is required further reducing the risk of thermal damage to the bone. n High power also allows for good cutting in case there is Figure 10 - The complex odontoma. soft bone, since the softer the bone the higher the ul- er trasound power required (21). Finally, the decrease of post-surgical complications with the use of ultrasound bone surgery after lower third molar removal must be considered, as reported by different authors (22,23). nt Conclusion iI The use of Ultrasound Bone Surgery in surgical cases, where risk for noble soft tissue damage is high, appears on to be a valid alternative technique confirming other lit- erature reports. Figure 11 - The post-operative orthopanoramic radiographs showing the integrity of the mandibular canal. i References iz to reduce risk for inferior alveolar nerve damage. Ultra- sonic surgery is a tissue-selective technique that allows 1. Marciani RD. Third molar removal: an overview of indica- a micrometric, precise and smooth cut into mineralized tions, imaging, evaluation, and assessment of risk. Oral Ed tissue, while adjacent soft tissue such as nerves, ves- Maxillofac Surg Clin North Am. 2007 Feb; 19(1): 1-13. sels, periosteum or Schneiderian membrane (in case 2. Bui CH, Seldin EB, Dodson TB. Types, frequencies, and of maxillary sinus surgery) remain uninjured, because risk factors for complications after third molar extraction. J surgical action ceases when the device tips come in Oral Maxillofac Surg. 2003 Dec; 61(12): 1379-89. contact with non-mineralized tissue (14,15). An in vitro 3. Malkawi Z, Al-Omiri MK, Khraisat A. Risk indicators of post- study concerning inferior alveolar nerve transposition by IC operative complications following surgical extraction of piezoelectric surgery showed that after surgery the epi- lower third molars. Med Princ Pract. 2011; 20(4): 321-5. neurium became roughened without any damage to the 4. Chrcanovic BR, Custódio AL. Considerations of mandibular deeper structures (16). Compared to traditional surgery angle fractures during and after surgery for removal of third C by conventional burs or chisels, ultrasonic cutting pre- molars: a review of the literature. Oral Maxillofac Surg. cision and selectivity constitute important advantages, 2010 Jun; 14(2): 71-80. particularly in those cases where the surgery target is in 5. Woldenberg Y, Gatot I, Bodner L. Iatrogenic mandibular close relationship with noble soft tissue structures (17). fracture associated with third molar removal. Can it be © As a result, even less experienced surgeons (though prevented? Med Oral Patol Oral Cir Bucal. 2007 Jan 1; properly trained) can perform such procedure, since 12(1): E70-2. the learning curve with ultrasonic surgery technique is 6. Brauer HU. Unusual complications associated with third strongly reduced compared to traditional surgery with ro- molar surgery: a systematic review. Quintessence Int. tating instruments (15). Nevertheless, a careful surgical 2009 Jul-Aug; 40(7): 565-72. approach remains critical considering that soft tissue can 7. Renton T, McGurk M. Evaluation of factors predictive of be damaged by excessive mechanical force while using lingual nerve injury in third molar surgery. Br J Oral Max- the device. In addition, when compared with traditional illofac Surg. 2001 Dec; 39(6): 423-8. surgery, bone healing following piezoelectric surgery 8. Tay AB, Go WS. Effect of exposed inferior alveolar neuro- Annali di Stomatologia 2012; III (2): 64-68 67 M. P. Cristalli et al. vascular bundle during surgical removal of impacted lower Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 third molars. J Oral Maxillofac Surg. 2004 May; 62(5): 592- Dec; 108(6): e1-5. 600. 17. Chiriac G, Herten M, Schwarz F, Rothamel D, Becker J. Au- 9. Tolstunov L. Lingual nerve vulnerability: risk analysis and togenous bone chips: influence of a new piezoelectric de- case report. Compend Contin Educ Dent. 2007 Jan; 28(1): vice (Piezosurgery) on chip morphology, cell viability and li 28-31. differentiation. J Clin Periodontol. 2005 Sep; 32(9): 994-9. 10. Ziccardi VB, Zuniga JR. Nerve injuries after third molar 18. Preti G, Martinasso G, Peirone B et al. Cytokines and na removal. Oral Maxillofac Surg Clin North Am. 2007 Feb; growth factors involved in the osseointegration of oral tita- 19(1): 105-15. nium implants positioned using piezoelectric bone surgery 11. Blus C, Szmukler-Moncler S, Vozza I, Rispoli L, Polastri versus a drill technique: a pilot study in minipigs. J Peri- C. Split-crest and immediate implant placement with ultra- odontol. 2007 Apr; 78(4): 716-22. io sonic bone surgery (piezosurgery): 3-year follow-up of 180 19. Vercellotti T, Kim DM, Wada K, Fiorellini JP. Osseous re- treated implant sites. Quintessence Int. 2010 Jun; 41(6): sponse following respective therapy with piezosurgery. Int 463-9. J Periodontics Restorative Dent. 2005 Dec; 25(6): 543-9. az 12. Philipsen HP, Reichart PA. Classification of odontogenic 20. Emam TA, Cuschieri A. How safe is high-power ultrasonic tumours. A historical review. J Oral Pathol Med. 2006 Oct; dissection? Ann Surg. 2003 Feb; 237(2): 186-91. 35(9): 525-9. 21. Blus C, Szmukler-Moncler S. Split-crest and immediate 13. Brann CR, Brickley MR, Shepherd JP. Factors influencing implant placement with ultra-sonic bone surgery: a 3-year n nerve damage during lower third molar surgery. Br Dent J. life-table analysis with 230 treated sites. Clin Oral Implants 1999 May 22; 186(10): 514-6. Res. 2006 Dec; 17(6): 700-7. er 14. Barone A, Santini S, Marconcini S, Giacomelli L, Gherlone 22. Goyal M, Marya K, Jhamb A, Chawla S, Sonoo PR, Singh E, Covani U. Osteotomy and membrane elevation during V, Aggarwal A. Comparative evaluation of surgical out- the maxillary sinus augmentation procedure. A compara- come after removal of impacted mandibular third molars tive study: piezoelectric device vs. conventional rotative using a Piezotome or a conventional handpiece: a pro- 511-5. nt instruments. Clin Oral Implants Res. 2008 May; 19 (5): 15. Schlee M, Steigmann M, Bratu E, Garg AK. Piezosurgery: spective study. Br J Oral Maxillofac Surg. 2011 Nov 14. [Epub ahead of print] 23. Barone A, Marconcini S, Giacomelli L, Rispoli L, Calvo JL, iI Basics and Possibilities. Implant Dent. 2006 Dec; 15(4): Covani U. A randomized clinical evaluation of ultrasound 334-40. bone surgery versus traditional rotary instruments in lower 16. Degerliyurt K, Akar V, Denizci S, Yucel E. Bone lid tech- third molar extraction. J Oral Maxillofac Surg. 2010 Feb; on nique with piezosurgery to preserve inferior alveolar nerve. 68(2): 330-6. i iz Ed IC C © 68 Annali di Stomatologia 2012; III (2): 64-68 

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Editorial In an interesting article entitled “Academic publishers make Murdoch look like a socialist”, published in “The Guardian” on August 29 last year, Georg Monbiot railed against the monopoly of large multinational publishing houses, placing them at the top of the list of the Western world’s most ruthless capitalists. li What he was complaining about was the excessive costs of gaining access to science. “Everyone claims to agree that people should be encouraged to understand science and other academic research. na Without current knowledge, we cannot make coherent democratic decisions. But the publishers have slapped a pad- lock and a “keep out” sign on the gates. Reading a single article published by one of Elsevier’s journals will cost you $31.50. Springer charges €34.95, Wiley- Blackwell, $42. Read 10 and you pay 10 times. And the journals retain perpetual copyright. You want to read a letter io printed in 1981? That’ll be $31.50.” This article gave me the inspiration for this short editorial, which opens the first issue of 2012, a space graciously granted me by the Scientific Directorate, for which I am most grateful. az This historic Italian dentistry publication has now attained the same level of international prestige enjoyed by the Ital- ian school of dentistry. Our goal of getting the journal indexed in the most important bibliographic databases has been reached and “Annali di Stomatologia” is, today, the only Italian journal offering open access. Different studies show that open access (OA) to research literature has the potential to accelerate recognition and dissemination of research rn findings. Articles published as immediate OA articles on a journal website have higher impact than self-archived or oth- erwise openly accessible articles. We found strong evidence that, even in a journal that is widely available in research libraries, OA articles are more immediately recognized and cited by peers than non-OA articles published in the same journal. OA is likely to benefit science by accelerating dissemination and uptake of research findings. te It is not only individual researchers who benefit from open access. Their institutions benefit as well, if the research out- put from that institution is available for all to read and build upon. The main benefits of open access, for an institution, are increased visibility and presence on the Web and therefore increased impact for its research; the open access col- In lection in the repository provides the means for the institution to manage its research programmes more effectively; the open access collection also provides the means for the institution to measure and assess its research programmes. In conclusion, none of the advantages of traditional scientific journals need be sacrificed in order to provide free online access to scientific journal articles. Objections that open access to scientific journal literature requires the sacrifice of peer-review, revenue, copyright protection, or other strengths of traditional journals, are based on misunderstandings. ni The road to heaven is still long, but much has already been achieved, and for this I wish to extend my warm thanks to all those who have made a contribution. io Raffaele Salvati iz The Publisher Ed IC C © Annali di Stomatologia 2012; III (1): 1 1 

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Review article Localization of impacted maxillary canines using cone beam computed tomography. Review of the literature li Giulia Rossini, DDS, PhD Student Introduction na Costanza Cavallini, MD Michele Cassetta, DDS, PhD Maxillary canines have the highest frequency of Gabriella Galluccio, DDS impacted localization after the third molars, with a Ersilia Barbato, DDS, MS prevalence ranging from 1% to 3% (1-4), and with a 2:1 female to male ratio (5). Impacted maxillary io canines lead to aesthetic and functional drawbacks: “Sapienza” University of Rome, Italy alteration in the aesthetic of the smile, resorption of Department of Oral Sciences lateral incisors, cystic degeneration (5). Moreover, their az surgical and orthodontic management is not easy and time consuming to treat. Consequently, the accurate Corresponding Author: localization of impacted maxillary canines is essential, Dr.ssa Giulia Rossini especially if surgical intervention is required. rn Via Pasubio 15 In the daily practice the first radiographic image that 00195, Rome, Italy is required to support the clinical examination is the Tel/Fax +39.063223523 panoramic radiography. The localization of impacted teeth te E-mail: giulia.rossini@uniroma1.it can be improved radiographically using a combination of other bi-dimensional images: occlusal and periapical, which allow the localization of impacted canines, treatment planning, and evaluation of the treatment Summary In result. However the diagnostic accuracy of these bi- dimensional radiographic techniques presents many This review analyzed the literature focused on Cone- limitations such as distortion projection errors, blurred Beam Computed Tomography (CBCT) diagnostic images and overlapping of structures, thus increasing ni accuracy and efficacy in detecting impacted the risk of the lack of some important information. In the maxillary canines, and evaluated the possible modern practice the localization of impacted maxillary advantages in using CBCT technique compared canines and the assessment of lateral root resorption io with traditional radiographs. PubMed and Embase can be drastically improved using information obtained searches were performed selecting papers since from 3D investigations. Several previous studies used 1998 up to September 2011, moreover reference Computed Tomography (CT) (6-9). However, the high iz lists were hand searched. Two reviewers selected effective dose and the relatively high costs limit the relevant publications on the basis of predetermined use of this technique in the daily practice. With the inclusion criteria. The literature search yielded introduction of low dose volumetric CT system, Cone Ed 94 titles, of which 5 were included in the review. Beam Computed Tomography (CBCT), clinicians can Three studies used CBCT technique to 3D localize take advantages from 3D information provided by a low maxillary impacted canines and assess root radiation dose and with relatively low costs. resorption of adjacent teeth. Other two publications The aim of this study was to evaluate the evidence for compared traditional radiographs with CBCT images the diagnostic accuracy of CBCT in detecting impacted in the diagnosis of maxillary impacted canines. Only maxillary canines and to analyze the literature focused IC three studies presented the results using statistical on the comparison between the diagnostic effectiveness analysis. The present review highlighted that the of CBCT with that of conventional radiography in the use of CBCT has a potential diagnostic effect and localization of impacted maxillary canines and the may influence the outcome of treatment when assessment of adjacent roots resorption. C compared with traditional panoramic radiography for the assessment of impacted maxillary canines. Furthermore it underlines the need of future studies Materials and methods performed according with high level methodological © standards, investigating diagnostic accuracy and The PRISMA 2009 Checklist (10) was used to conduct effectiveness of CBCT in the diagnosis of maxillary this review. Only Studies that matched (at least) one impacted teeth. of the following inclusion criteria were selected: (1) studies that detected impacted maxillary canines with Key words: cone-beam computed tomography, volu- CBCT; (2) studies that described diagnostic and/or metric computed tomography, maxillary impacted therapeutic accuracy and efficacy of CBCT technique in canine. the diagnosis of maxillary impacted canines and incisors 14 Annali di Stomatologia 2012; III (1): 14-18  Localization of impacted maxillary canines using cone beam computed tomography. Review of the literature roots resorption; (3) studies that compared the efficacy of CBCT with that of conventional radiographic images in PubMed, Embase diagnosis of impacted maxillary canines. 94 abstracts The in vitro studies were excluded. No language limitations were applied. li The following electronic data bases were searched from 1998 up to September 2011: PubMed and Embase. 87 abstracts excluded na The choice of that time period was justified by the introduction in the late 1990s of CBCT in the clinical practice. The searches were not limited to particular types of study design so as to include all human clinical studies (i.e. randomized controlled trials). The following io keywords were used: CBCT, volumetric computed 7 full text publications tomography, impacted teeth. To determine whether the keywords covered all articles on the diagnostic accuracy az of CBCT for maxillary impacted canines, the following 2 publications exclude for journals were manually screened: The American method limits Journal of Orthodontics and Dentofacial Orthopedics; The Oral Surgery, Oral Medicine, Oral Pathology, Oral rn Radiology and Endodontology; The European Journal of Orthodontics. Finally, all relevant abstracts were read, and the full texts of all relevant articles were collected and reviewed. Ambiguous articles were also read to te avoid inappropriate exclusion. All procedures were 5 original studies performed independently by two authors (GR, CC), and controversies were solved by reading again the articles and discussing them until consensus was reached. In Figure 1 - Flowchart of the selection strategy used in the review. the proximity of the impacted canine to the lateral Results Figure 1 ‐ Flowchartand central of the incisors, selection the used strategy follicleinsize, the existence of the review. ni deciduous canines and the alveolar width in the canine A total of 94 abstracts were found using the search meth- area. No diagnostic accuracy was described in these ods described. Seven abstracts were judged to meet the three studies and the study sample was different among io inclusion criteria and were read in full (4,10-16). Two of the mentioned articles. the collected studies were excluded for methodological The other two publications (14,15) performed a limits: the first one (11) compared different radiographic comparative analysis between traditional radiographs iz exams for the localization of impacted maxillary canines and CBCT images in the diagnosis of maxillary of four different subjects; the other one (13) compared impacted canines. Haney et al. (14) evaluated also the efficacy of CBCT images in diagnosis of maxillary im- the diagnostic accuracy of CBCT in detecting impacted Ed pacted canines with traditional radiographs (panoramic maxillary canines. These Authors used as 2D traditional and maxillary occlusal) not generated using traditional radiographic methods the panoramic radiographs to systems but obtained from CBCT data. Finally, only five evaluate the vertical position and the occlusal x-rays to papers met the inclusion criteria and resulted relevant evaluate the proximity to adjacent teeth; two periapical for the review (Fig.1). radiographs were used to determine the labio-palatal Three studies (4,12,16) used CBCT imaging as the position. The clinicians’ confidence of the accuracy of IC standard method with the purpose to localize maxillary diagnosis and treatment plan was statistically higher for impacted canines in 3D and assess root resorption of CBCT images (P <0.001). No root resorption of adjacent adjacent teeth. Two of these studies (4,16) described teeth was assessed. Alqerban et al.(15) compared the exact position of impacted maxillary canines and traditional panoramic radiograph with two different CBCT C their spatial relationship with neighboring anatomical systems: 3D Accuitomo-XYZ Slice View Tomograph® structures using CBCT images. Only the third (J. Morita, Kyoto, Japan) and Scanora® 3D CBCT publication (12) compared the differences between (Soredex, Tuusula, Finland). the variations of impaction with a control group (30 The Authors describe the diagnostic accuracy for the © normally erupted canines). While Oberoi et al.(16) localization of maxillary impacted canines and the described the localization of the maxillary impacted detection of root resorption of maxillary incisors of these canines in 3D (“mesial”, “distal”, “facial”, “palatal” and three different radiographic systems. They found that a “gingival” impactions) and assessed root resorption of greater agreement between observers for all variables lateral incisors (“no root resorption”, “slight”, “moderate”, was achieved when using CBCT. No statistically “severe” root resorption), Walker et al. (4) and Liu et al. significant differences among the different CBCT devices (12) focused their attention also to the type of impaction, were found. Annali di Stomatologia 2012; III (1): 14-18 15  G. Rossini et al. Authors Sample size CBCT machine Records collected Results Walker et al. 19 patients: 16 bilateral impacted NewTom QR-DVT 9000, -Type of impaction –Resorption 92.6% palatal impactions. 2005 canines, 5 left unilateral Verona, Italy of incisors –Proximity of Resorption: 66.7% lateral impacted canines, 6 right impacted canine to incisors – incisors, 11.1% central incisors. unilateral impacted canines Follicle size –Existence of Impacted canine side vs erupted deciduous canines –Alveolar canine side: the alveolus was li width in the area of the canine – narrower. No common location Location of impaction. where eruption was arrested. Great variation in the inclination na of the impacted canine. Liu et al. 2008 175 patients: 210 impacted NewTom QR-DVT 9000, -3D variations of impaction - Impaction: 45.2% buccal- canines Verona, Italy Linear and angular labially, 40.5% palatally, 14.3% measurements of the inclination in the midalveolus. Locations: and location of the impacted 67 mesial-labial, 74 mesial- teeth –Follicle size – Proximity palatal, 31 in situ, 12 distal, 18 io of impacted canine to incisors – horizontal, 8 inverted. Root Resorption of incisors resorption: 27.2% of lateral incisors, 23.4% of central incisors, 94.3% of these occurred az where the impacted canines were in close contact with the incisors. Oberoi et al. 29 patients: 26 bilateral impacted Hitachi MercuRay CBCT -3D variations of impaction – Average degree of impaction: 2012 canines, 16 unilateral impacted (Hitachi Medical Corporation, Resorption of incisors mesial 10.1mm, distal 4.2mm, canines Tokyo, Japan) facial 4.16mm, palatal 1.8mm, gingival 10mm. Root resorption rn of lateral incisors: 40.4% no, 35.7% slight, 14.2% moderate, 4% severe. Table 1 - Search results. CBCT localization of maxillary impacted canines and incisors root resorption. te Table 1 - Search results. CBCT localization of maxillary impacted canines and incisors root resorption. A summary of the results from the 5 articles is presented substantially modify the management of patients with in Tables 1 and 2. potentially complex orthodontic problems. In The aim of this review was to analyze the literature focused on the CBCT accuracy in giving information Discussion about the localization of impacted maxillary canines, and to evaluate the advantages of CBCT images compared The advantages of 3D medical computed tomography with those of conventional radiographs. Only few studies ni (CT) imaging are already well established in different matched the inclusion criteria of this review, differing 1 dental specialties: management of trauma to the for the sample size and the methods used. Walker et maxillofacial skeleton, surgical facial reconstruction, al. (4), Oberoi et al. (16) and Liu et al.(12) evaluated, io orthognathic surgery, dental implants, complicated using CBCT data, the localization of impacted maxillary extractions and endodontic treatments (17-20). canines and assessed lateral root resorption lesions. Nevertheless, its use has been limited in orthodontics Walker et al.(4) collected 19 patients, ranged from 8 iz due to high-radiation dose, high cost, lack of availability, to 20 years (average, 13.3; SD, 2.98), with a total of poor resolution and difficulty in interpretation. These 27 impacted maxillary canines. The Authors focused issues may be addressed by recent CBCT innovations their attention on the type of impaction, the resorption Ed in CT technology and the use of CBCT systems could of incisors, the proximity of the impacted canine to the Authors Sample size CBCT machine Records collected Results Haney et al. 18 patients: 25 impacted canines Hitachi MercuRay CBCT –Location of impaction –Root 21% disagreement in the IC 2010 (Hitachi Medical Corporation, resorption –Orthodontic perceived mesiodistal cusp tip Tokyo, Japan) treatment plan (recover/extract) position. 16% difference in the –Recovery vector –Expect will perceived labiopalatal position. erupt unassisted –Expect Perception of root resorption of additional root resorption – adjacent teeth: 36% lack of Request for additional images congruence. The clinicians’ C confidence of the accuracy of diagnosis and treatment plan: statistically higher for CBCT images (P<0.001). Alqerban et al. 60 patients: 89 impacted or -3D Accuitomo-XYZ Slice View -Permanent maxillary canine: Highly significant difference © 2011 ectopically erupting maxillary Tomograph ® (J. Morita, Kyoto, width of the crown, width of ht between the 2D and 3D images canines Japan) follicle, development, location, in all variables calculated. -Scanora ® 3D CBCT (Soredex, angulation –Presence/absence or Tuusula, Finland) resorption of primary maxillary canines –Contact relationship between canines and incisors - Resorption: location and severity Table 2 - 2Search Table - Searchresults. Conventional results. Conventional radiographs radiographs vsinCBCT vs CBCT in diagnosis diagnosis of maxillaryof maxillary impacted impacted canines canines and incisors and incisors root resorption. root resorption. 16 Annali di Stomatologia 2012; III (1): 14-18  Localization of impacted maxillary canines using cone beam computed tomography. Review of the literature lateral and central incisors, the follicle size, the existence conventional radiographic imaging is inadequate for the of deciduous canines, the alveolar width in the area of detection of root resorption and the characterization of the canine, and the location of the impacted canines resorptive lesions. (coronal or frontal, sagittal, axial or horizontal). The Based on the results of this review, the following study sample of Liu et al.(12) comprised 175 patients conclusions can be made: li with 210 impacted maxillary canines. The age range 1) the studies on 3D localization of impacted was not specified. The Authors evaluated the 3D maxillary canines and assessment of lateral na variations of impaction (vertical inclination, mesio-distal root resorption showed that CBCT system is a migration, bucco-lingual crown location), linear and reliable method for detecting canine impaction; angular measurements of the inclination and location 2) the studies on comparison between traditional of the impacted canines related to maxillary anatomical radiographs and CBCT, demonstrated that structures made on axial and transaxial views, based CBCT is superior to other radiographic methods io upon the methods used by Walker et al. (4). The Authors for visualizing the maxillofacial region and it is also evaluated follicle size, contact of impacted canine a useful aid for the diagnosis and visualization to the incisors and resorption of the incisors (assessed of the position and complications of impacted az by axial and transaxial views and graded in 4 categories maxillary canines; based on the grading system suggested by Ericson 3) methodological differences among selected and Kurol (21): no resorption: intact root surface; mild studies (i.e. study sample, materials and resorption: resorption midway to the pulp or more, the methods) revealed the lack of studies rn pulp lining being unbroken; moderate resorption: the performed using methodological standards for pulp is exposed by the resorption, the involved length of diagnostic accuracy and effectiveness of CBCT the root is less than one third of the entire root; severe in the diagnosis of maxillary impacted teeth. resorption: the pulp is exposed by the resorption, and te the involved length is more than one third of the root). Oberoi et al.(16) analyzed 29 CBCT of orthodontic References patients with a total of 42 impacted maxillary canines. Age range was 10.6 to 28.0 years with a mean age of In 1. Mason C, Papadakou P, Roberts GJ. The radiographic 16.6 years. The objective of this study was to localize the localization of impacted maxillary canines: a comparison impacted canines in 3D and determine the most common of methods. Eur J Orthod 2001;23:25-34. location of impaction. The Authors also assessed lateral 2. Preda L, La Fianza A, Di Maggio EM, Dore R, Schifino ni root resorption, but they did not focuse their attention on MR, Campani R, et al. The use of spiral computed the follicle size, the existence of deciduous canines and tomography in the localization of impacted maxillary the alveolar width in the area of the canine. canines. Dentomaxillofacial Radiol 1997;26:236-41. 3. Stewart JA, Heo G, Glover KE, Williamson PC, Lam io All the papers selected agreed on the following EW, Major PW. Factors that relate to treatment duration conclusions: 3D volumetric imaging of impacted for patients with palatally imapcted maxillary canines. maxillary canines can determine with extreme precision Am J Orthod Dentofac Orthop 2001;119:216-25. iz the presence and absence of the canine, the size of 4. Walker L, Enciso R, Mah J. Three-dimansional the follicle, the inclination of the long axis of the teeth, localization of maxillary canines with cone-beam the relative buccal and palatal positions, the amount computed tomography. Am J Orthod Dentofac Orthop Ed of bone covering the teeth, the anatomical bone 2005;128:418-23. structures, the 3D proximity and resorption of roots of 5. Peck S, Peck L, Kataja M. The palatally displaced adjacent teeth, the condition of adjacent teeth, the local canine as a dental anomaly of genetic origin. Angle anatomic considerations, and finally the overall stage Orthod. 1994;64:249-56. of dental development. Therefore, all Authors agreed 6. Ericson S, Kurol J. CT diagnosis of ectopically erupting on the reliably assessment of the 3D position and on maxillary canines – a case repost. European Juornal fo IC the improved localization and surgical-orthodontic Orthodontics 1988;10:115-21. management of maxillary impacted canines using CBCT 7. Ericson S, Kurol J. Incisor root resorption due to technique. ectopic maxillary canines imaged by computerized Considering studies that compared traditional tomography: a comparative study in entracte teeth. Angle Orthodontist 2000;70;276-83. C radiographic analysis and CBCT images (14-15), CBCT 8. Ericosn S, Bjerklin K, Falahat B. Does the canine dental was found more sensitive than conventional radiography follicle cause resorption of permanent root? A computed for maxillary impacted canines localization and tomography study of erupting maxillary canines. Angle identification of root resorption in adjacent teeth. Haney Orthodontist 2002;72:95-104. © et al.(14) concluded that the orthodontic treatment plans 9. Schmuth GP, Freisfeld M, Koster O, Schuller H. The were significantly influenced by the radiographic modality application of computerized tomography (CT) in cases (P <0.0001). Alqerban et al. found greater agreement of impacted maxillary canines. European Journal of between observers for all the variables studied when Orthodontics 1992;14:296-301. using CBCT. In addition, this two Authors confirmed the 10. Liberati A, Altman DG, Tetzlaff J, Murlow C, Gøtzsche literature data (21-23): panoramic radiography is not a PC, et al. The PRISMA Statement for Reporting reliable method for localization of impacted canines, and Systematic Reviews and Meta-Analyses of Studies That Annali di Stomatologia 2012; III (1): 14-18 17  G. Rossini et al. Evaluate Health Care Interventions: Explanation and of impacted canines and root resorption using cone Elaboration. PLoS Med 6(7):e1000100.doi:10.1371/ beam computed tomography. Oral Surg Oral Med Oral journal.pmed.1000100. Pathol Oral Radiol Endod 2012;xx:xxx. 11. Maverna R, Gracco A. Different diagnostic tools for 17. Scarfe WC, Farman AG, Sukovic P. Clinical applications the localization of impacted maxillary canines: clinical of cone-beam computed tomography in dental considerations. Prog Orthod. 2007;81:28-44. practice. Journal of the Canadian Dental Association li 12. Liu D, Zhang W, Zhang Z, Wu Y, Ma Y. Localization 2006;72,75–80. of impacted maxillary canines and observation of 18. Nair MK, Nair UP. Digital and advanced imaging in na adjacent incisor resorption with cone-beam computed endodontics: a review. J Endod. 2007 Jan;33(1):1-6. tomography. Oral Surg Oral Med Oral Pathol Oral 19. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Radiol Endod 2008;105:91-8. Detection of periapical bone defects in human jaws 13. Katheria BC, Kau CH, Tate R, Chen JW, English J, Bouquot using cone beam computed tomography and intraoral io J. Effectiveness of Impacted and Supernumerary radiography. Int Endod J. 2009 Jun;42(6):507-15. Epub Tooth Diagnosis from Traditional Radiography Versus 2009 Mar 2. Cone Beam Computed Tomography. Pediatr Dent 20. Quereshy FA, Savell TA, Palomo JM. Applications of 2009;32(4):304-9. cone beam computed tomography in the practice of az 14. Haney E, Gansky SA, Lee JS, Johnson E, Maki K, Miller oral and maxillofacial surgery. J Oral Maxillofacial Surg AJ, Huang JC. Comparative analysis of traditional 2008;66:791-6. radiographs and cone-beam computed tomography 21. Eriscon S, Kurol J. Resorption of incisors after ectopic volumetric images in the diagnosis and treatment eruption of maxillary canines: a CT study. Angle Orthod rn planning of maxillary imparte canines. Am J Orthod 2000;70:415-23. Dentofacial Orthop 2010;137:590-7. 22. Nagpal A, Pai KM, Setty S, Sharma G. Localization 15. Alqerban A, Jacobs R, Fieuws S, Willems G. Comparison of impacted maxillary canines using panoramic of two cone beam computed tomographic system radiography. Journal of Oral Science 2009;51:37-45. te versus panoramic imaging for localization of imparte 23. Heimisdottir K, Bosshardt D, Ruf S. Can the severity maxillary canines and detection of root resorption. Eur of root resorption be accuratle judged by means of J Orthod 2011;33:93-102. radiographs? A case report with histology. Am J Orthod 16. Oberoi S, Knueppel S. Three-dimensional assessment In Dentofacial Orthop 2005;128:106-9. ni io iz Ed IC C © 18 Annali di Stomatologia 2012; III (1): 14-18 

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Review article Tissue-supported dental implant prosthesis (overdenture): the search for the ideal protocol. A literature review li Domenica Laurito, DDS1 tion depend on factors such as age, sex, facial anatomy, Luca Lamazza, DMD, DDS1 metabolism, oral hygiene, parafunctions, general health, na Michael J. Spink, MD, DDS2 nutritional status, systematic diseases, osteoporosis, Alberto De Biase, MD, DDS1 drug administration and time of edentulism (2,3). Studies to verify the influence of conventional fully-re- movable dentures as factor of bone resorption are re- io 1 Sapienza University of Rome, Italy plete; patients wearing complete dentures will present Department of Oral and Maxillofacial Sciences with smaller edentulous ridges than edentulous patients Division of Oral Surgery with never receiving prosthetics (4). The implant-re- az 2 Department of Oral & Maxillofacial Surgery tained prosthesis is an alternative treatment option in Baystate Medical Center, Springfield, MA, USA edentulous patient’s rehabilitation, providing more re- tention, stability, function and esthetics especially in the mandible. The use of implants for edentulous patients rn Corresponding author: will actually preserve existing bone compared to conven- Dott. Alberto De Biase tional dentures (5). Department of Oral and Maxillofacial Science This literature review analyzes the current concepts Division of Oral Surgery about indications, implant diameter, length, number, te Via Caserta 6, 00161 Rome, Italy position, prosthetic rehabilitation, early and immediate Phone: +39- 06-49976626 loading, attachment systems, and implant success rate E-mail: alberto.debiase@uniroma1.it in mandibular and maxillary overdentures. In Methods Summary ni This study searches for the subject’s validity and efficacy Aims. The success of maxillary and mandibular tis- of available information from English published literature sue supported implant prostheses varies in the lit- within PUBMED from 1991-2011. The search identifies erature, and the ideal protocol may be elusive from io the key words: overdenture, dental implant, osseointe- given the numerous studies. The oral rehabilitation gration, edentulous. A manual search of aforementioned option is an alternative to conventional dentures and articles’ reference lists expands this subject’s informa- should improve function, satisfaction, and retention. iz tion. The purpose of this review article is to clarify these This composite search narrows if the articles meet the questions. Methods. The search of literature re- views English non-anecdotal implant overdentures following criteria: 1) type of study (randomized controlled Ed articles from 1991 to 2011. Results. The results dis- trial, review of the literature with or without meta-anal- play an aggregate comprehensive list of categorical ysis, longitudinal experimental clinical studies, longitu- variables from the literature review. Overall success dinal prospective studies, and longitudinal retrospective of maxillary and mandibular implant overdenture studies); 2) period of publication (1991 to 2011); and 3) was respectively, 86.6% and 95.8%. Conclusion. type of patient (maxillary and/or mandibular fully edentu- The literature indicates that the implant overdenture lism for tooth decay and periodontal disease). IC prosthesis provides predictable results – enhanced The exclusion criteria is: 1) type of study (case reports, stability, function and a high-degree of satisfaction case sequence, clinical innovation report, description of compared to conventional removable dentures. the surgery complications, advice from experts); and 2) type of patient (oral cancer patients). C Key words: overdenture, dental implant, osseointe- gration, edentulous. Results © The data explores mandibular and maxillary overden- Introduction ture’s indications, implant diameter, length, number and position, prosthetic rehabilitation, immediate and early Bone resorption will occur in an edentulous alveolus. The loading, attachment system and implant success rates. ubiquitous phenomenon is a progressive and irrevers- The following categorical variables display an aggregate ible (1). The amount and rate of alveolar bone resorp- comprehensive list from the literature review: 2 Annali di Stomatologia 2012; III (1): 2-10  Tissue-supported dental implant prosthesis (overdenture): the search for the ideal protocol. A literature review Indications plants necessary to support a maxillary overdenture (26,27). A minimum of four well-spaced implants is often The following patients would benefit from a tissue-sup- recommended for an implant-supported and retained- ported implant overdenture: overdenture. The increased minimum of implants com- • advanced atrophy eliminating the potential for total pared to the mandible is due to the softer bone and type li implant-supported prosthesis; of distribution of occlusal forces in the maxilla. However, • augmentation procedures are excluded for any the use of only two maxillary implants may not compro- na reasons; mise implant survival or patient satisfaction. The most • possess natural teeth in the opposing arch, fixed or posterior implant should be inserted as far distally as removable prostheses supported by implants and possible to reduce the extension of cantilever (28). teeth; • elderly patients who, having had complete io dentures for many years, lose their motor skills and Implant position no longer feel able to wear complete dentures (6); Although not standard, studies recommend four intrafo- • compromised conventional denture retention, e.g. raminal implants for cases of advanced atrophy or thin az resection defects, xerostomia or parafunction. mandibular ridges. For these instances, implants should be equidistant apart, or as an alternative one can mount a cantilever-fixed prosthesis; in fact, the bar segments Implant diameter and length may become rather short, and short female bar retainers rn The implant diameter depends on the alveolar width, are subject to frequent loosening or loss. The length of whereas the available bone height determines the im- the bar segments can range from 15 to 25 mm. The total plant length (7). The implant length should be ≥ 10 mm, number of intraforaminal implants distribution should be te and a minimum diameter of 3.3 - 4.1mm for the man- related to the shape of the ridge. If a large or V-shaped dibular anterior while 4.1mm for the maxilla (8). The lit- anterior ridges exists, three to four implants will provide erature provides evidence of an increased failure rate for a more favorable design of the bar and the prosthe- for short implants – 7 and 10 mm (9). Narrow diameter In sis. In presence of U-shaped mandibular jaw, two ante- implants (2.5 to 3 mm) can be successfully used to treat rior implants could provide for a bar of adequate length. narrow bone ridges although more long-term studies are A U-shaped mandible with large curvature allow for an needed to compare narrow and conventional diameter adequate placement of four implants and a connecting implant outcomes (10,11). In both the maxilla and the bar. Alignment of the implants in a rather straight line is ni mandible, wide-diameter implants may provide addition- not favorable for fixed prostheses. al support for removable partial dentures. However, the The best anchorage design for the maxilla is four equi- use of wide-diameter implants for anchorage of remov- distance implant, but six implants for compromised bone io able partial dentures still requires critical evaluation to (29). Positioning the implants in anterior maxilla, me- assess whether wide-diameter implants affect the supra- sial to the first premolars enhances the stability of the structure design. Using standard-diameter implants, the overdenture. For a design without palatal coverage, the iz suprastructure may frequently be better designed and consensus favors a minimum of four implants (30-34). more comfortable for the patient (12). In order to avoid dramatic changes in prosthetic design, one investigator recommends six implants (35). Despite Ed this recommendation, others clinicians implant progno- Implant number sis were not compromised with the presence of compro- The two-implant overdenture therapy is a very reliable mised quality and quantity of bone, off-ridge relations, or therapy for patients with an edentulous mandible (13). A high applied forces, and palatal coverage (36). several authors hypothesizes that it is appropriate to use two implants with an interconnector parallel to the hinge IC axis and a resilient overdenture on an ovoid or round bar Prosthetic rehabilitation (14-16). The bar’s purpose is to enhance free rotation There is a direct correlation between the number of im- during dorsal loading with twist-free load transmission plants and prosthetic design. The number of implants C to the implants (17). Comparative prospective studies influences type and design of prosthesis whereas the validate the benefit of two or four implants in the edentu- prosthetic design determines the number of implants. lous mandible (18-22). Survival rates in the two-implants Additionally, the distribution of the implants over the arch overdenture groups compared with four-implant over- is related to size, curvature and shape of the ridges. © denture groups appear to be equivalent for patient sat- A rigid bar connecting multiple implants and cast metal isfaction (23). One ten-year trial displays no significant framework reinforce denture base to ensures stabil- clinical and radiographic differences in patients treated ity and stiffness. Several investigators demonstrate, in with two or four implants overdenture (24). However, a vitro and in vivo, that bars provide more retention than mandibular overdenture with two implants and a bar has solitary anchors when subjected to both vertical and fewer complications (25). oblique forces (37-39). If a bar connector interferes with There are no specific guidelines for the number of im- space for tongue, then ball anchors are best. Anterior Annali di Stomatologia 2012; III (1): 2-10 3  D. Laurito et al. positioned mandibular implants may result in a shorter single attachments to bars, there are data shows that prosthetic bar length; however, it may be adequate in bars are more retentive while the magnetic attachments presence of three or four intraforaminal implants. As are less retentive (54,55). The data hints that bars-clip an alternative, four intraforaminal implants can support assembles appear to be more retentive for the break a fixed-cantilever mandibular prostheses. The attach- load when subject to both vertical and oblique forces. li ment system seems not to interfere with prognosis of These attachments also provide the fastest release peri- two implants mandibular overdenture writes a ten-year ods. Their selection is ideal when there is a requirement na randomized clinical trial of splinted and unsplinted oral for high degree of retention, e.g. cases with extremely implants retaining mandibular overdentures (40). resorbed ridges without tissue undercuts. The retentive An in vitro edentulous maxilla study utilizing four im- forces of most attachment systems are in the range of plants demonstrates improved retention of bar over- about 20N (56). Forces of 20N are probably sufficient for overdentures in the edentulous mandibles is a be- io dentures with distal ERA® attachments rather than a cantilevered bar with Hader clips (41). The distribution lievable documented assumption. Published research of supporting implants may influence their survival due agrees on the fact that the least retentive attachments to forces acting on the prosthesis in the maxilla (42). The are the magnets. This clinical approach lost popularity, az rationale of fabricating a single bar supported by two or particularly when clinicians discovered that this attach- more implants, allowing pure rotational movement of the ment system corrode rapidly in saliva. Their attractive prosthesis to equitably share support with the mucosa, is force is weaker (mean of 2N or less) than ball or bar at- not practical because of the difficulty of optimal position- tachments (57,58). Since magnets will displace with ex- rn ing of the implants. This type of hinging design does not cessive force, some investigators suggest their use with improve implant survival (43). A broadly distributed im- bruxers (55). However, newly designed rare-earth alloys plant-supported design, spanning the anterior-premolar seems to provide more magnetic force per unit size, and te region and tuberosities, shows the most favorable stress new laser-welding techniques contribute to the construc- transfer to bone compared to a concentrated array of im- tion of strong and durable containers for protecting the plants in the anterior region supporting a cantilever (44). magnets from salivary corrosion (59). Bars with distal cantilevers tend to increase the loads In Literature data about peri-implantitis shows no signifi- on the terminal implants by more than three-times in the cant differences between different attachment systems. maxilla (45). If parallel alignment of the implant axes is Cehereli in his systematic review writes that no differenc- possible, a ball anchor-supporting maxillary overdenture es exist regarding bone loss around mandibular implant can be a long-term provisional restoration. However, the retained/supported overdentures with different types of ni use of two ball anchors results in a hinging movement of attachment systems (60). However, investigators specu- the denture that may cause discomfort. late for the reason this loss due to different loading pat- Magnets display the least retentive of all attachment sys- terns or bone conditions. io tems, but may be appropriate for patients with bruxism Evaluation of soft tissue reactions to different attachment or dexterity problems (46). Unsplinted anchorage sys- systems exists. The maxilla is more prone to hyperplasia tems may require less space within the prosthesis, may and mucositis around implants. The excellent denture iz be easier to clean and more economical, as well as less retention avoiding a sufficient cleaning mechanism of technique sensitive (47). In the vertical axis, a minimum saliva may be responsible for these adverse reactions. distance of 13-14 mm from the implant platform to the in- Plaque accumulation is significantly higher for magnets Ed cisal edges is necessary with a bar design, allowing 4.0 than for ball attachments whereas there is no significant mm for the bar and 1.0 mm below the bar for hygiene, differences between bar and ball design, or bar and as well as space for the clip and acrylic/tooth housing magnets. (48). However, the use of attaching mechanisms such Another study finds less bleeding with ball attachments, as a bar-clip (Hader, Attachments Intl., Inc., San Mateo, when compared to a single bar attached to two implants or triple bar to four implants. Ball attachments are, in fact, IC Ca, USA) requires a minimum distance of 10-12 mm be- tween implants, otherwise a milled bar with a frictional fit easier to clean than bars (18). Two studies conclude that superstructure is needed (49). Solitary anchors require implant-supported overdentures may maintain health only 10 to 11 mm of vertical space above the implant and stability independent of the retentive device used C platform to incisal edges and also allow for more flex- for anchorage (61). It is likely that peri-implant health for ibility in positioning, given anatomic limitations (50,51). overdentures is not influenced by the number of implants (62). However, by increasing the number of implants, the potential for single axis fulcrum movement decreases © Attachment systems and so do the retention-release episodes during func- Implant overdentures use one of three attachment sys- tion. Different stress distribution is a result of the type of tems: 1) resilient attachments on freestanding implant attachment system. abutments; 2) resilient attachments to join the denture to Photoelastic studies demonstrate the ideal stress dis- a rigid bar assembly that interconnects osseointegrated tribution concerning length, geometry, and diameter of implants (52,53); 3) or magnets system (54). implants, although some limitations exist with this type The comparison between the retentive properties of of study. The best design would compare different stress 4 Annali di Stomatologia 2012; III (1): 2-10  Tissue-supported dental implant prosthesis (overdenture): the search for the ideal protocol. A literature review patterns from different retentive mechanisms from im- (73). Insufficient data exist to support early and immedi- plants of the same length, geometry, and diameter. ate loading for the maxillary overdentures (74-76). The ball (O-ring) attachments transfers less stress than bar and clips when applying vertical forces on a two implant supported mandibular overdenture. In vitro Early-loading of the implant-supported li and in vivo studies compare the stresses on the bone mandible overdentures surrounding two implants with either a bar- clip or ball The literature review draws the following conclusions na attachments for overdentures (63,64). Their discovery about mandibular overdentures: success or survival of is a greater stress exist on the peri-implant bone with implant is not in jeopardy with early-loading, but few a bar- clip attachment. Photoelastic studies reproduce studies exist; both splinted and unsplinted implants with- the findings (18). In vitro and in vivo studies verify the stand the biomechanical demands of early-loading (77); io higher stability with ball attachments and how load is success is a function of bone quality and primary sta- evenly dispersed onto the residual ridge of both site of bility; and, survival and success rates for early-loaded the dental arch (63,65,66). This finding may result from implants are comparable to conventionally-loading pro- an allowed flexure of the mandible. tocols. az Advocates of the bar-clip attachment design speculates No deleterious effects up to twenty-four months exist that the denture can freely rotate around the bar, thus with immediate or early-loading, although there appears compensating for the resilience of the supporting mucosa to be more support for early over immediate-loading. In and reducing the torsion forces to the implants (57). How- order to provide the most astute evidence to support the rn ever, measured force transmission onto implants support- most appropriate time to load implants, study designs ing overdentures with piezoelectric transducers show the should be randomized -controlled clinical and a follow- maximum forces measured in the vertical direction are up period greater than twenty-four months (78). te higher with single telescopes than with bars and clips. One review exists that compares three different tim- And, rigid bars contribute to load sharing between the im- ing of loads: early progressive loading, early functional plants (67). Contrary to the rationale and theory of free loading, and immediate-early functional loading. In the rotation, recent data suggests that even if a bar that al- In early progressive loading, the patient does not wear their lows rotational movement, a higher load will transfer to the dentures for one to two weeks, or else worn, but com- implants because of the difficulty to obtain optimum im- pletely relieved from the healing abutment. Typically, the plant position, which would allow a pure rotational move- practitioner relines the prosthesis at three to four months ment (43). Therefore, a design should be an equilibrium when the definitive prosthesis connects to attachments ni between load of implant and denture bearing area. (ball or bar assembly). In early functional loading, there Nevertheless, the literature is in disagreement – longitu- is a hiatus after surgery for two weeks prior to relining the dinal prospective studies conclude that is no differences dentures. Then, the protocol connects the retentive com- io in implant survival rate, peri-implantitis, or marginal bone ponents (ball attachments) within three weeks. Finally, loss in the two different anchorage systems on two im- for immediate-early functional loading protocols, the plants retaining an overdenture (68,69). Furthermore, protocol requires to connect the retentive attachments iz another study concludes that the direction of occlusal within five days. The authors stated that the loading dif- forces is more influential than the connection of implants ferences between the three groups are rather tenuous, and that the difference in stress concentration between since the time and method of loading overlaps (79). Ed models with and without a bar is small (70). In an in vivo Studies also suggest that implants splinted together with study using a two-implant supported model, investiga- a bar within a short period of time to prevents axial ro- tors observe that the anchorage system may has less of tation and implant micromotion (80,81). However, other an influence than other parameters, such as superstruc- studies describe the use of fewer implants (minimum of ture fit and occlusion, and may also determine loading of two) that were left exposed and unsplinted after an initial IC implants (71). healing phase of two to three weeks. Therefore, one can There is no significant difference in stress distribution contend that splinting implants in the anterior mandible between stud attachments and resilient bar-clip designs is not a definite requirement for osseointegration with if the prostheses are well-designed prosthesis and both these protocols (82). In addition splinted or unsplinted C under ideal conditions. However, rigid designs and can- design seems to not influence implant survival rate and tilever bars are more will increase the force transmitted periimplant outcome (83). to the implant fixtures. © Implant success rate Immediate-loading of Implant-supported overdentures Studies carried out in the last years to assess the ben- The literature review draws the following conclusions efits of implant-supported overdenture with at least five about mandibular overdentures: immediate loading of years of follow-up show that survival of implants support- mandibular overdentures does not jeopardizes the sur- ing overdentures in the medium and long term is very vival rate when designed with four implants (72); and, high. Table-1 displays a report of several studies. success is a function of bone quality and primary stability The analysis of the available literature shows that im- Annali di Stomatologia 2012; III (1): 2-10 5  D. Laurito et al. plant-supported prosthetic restoration offers excellent tures (89). Many options are available for retention of rates of success in mandible and maxilla if practitioners the prosthesis, including magnets, clips, bars and ball. follow common protocols (84,85). The resultant implant-supported overdenture has good In many cases, the edentulous maxilla rehabilitation re- stability and retention. Most authors agree on a require- quires more elective procedures rather than in mandible, ment of a passive fit between the prosthesis framework li because a different degree of atrophy, prospective loca- and osseointegrated dental implants. tion of the implants and inclination of the implant axis, In 1983, Branemark defined passive fit, and he proposed na tissue volume dimensions, facial morphology, esthetics, this should be at the level of 10 μm to enable bone matu- function and phonetics exists. ration and remodeling in response to occlusal loads (90). There is a high failure rate for maxillary overdentures, In 1991, Jemt defined passive fit as the level that did not i.e. over 20% (86). A critical analysis of the treatment cause any long-term clinical complications (91). And he io outcomes reveals that overdenture is often a treatment suggests misfits of smaller than 150 μm as acceptable. option in compromised patients, where fixed prostheses Although these preceding values are a reference, they fails (71). Otherwise, there is high survival rate of implant are of empirical origin. when the overdenture is well planned (43). The survival rates for the mandible are clearly better than az the maxilla – a function of the mandible’s denser bone and shorter prosthetic lever arms that promote resist a Discussion hinging movement. Treatment considerations for implant overdentures on the maxilla appear to be different than rn A variety of treatment options exist to rehabilitate fully for those on the mandible. Atrophy of edentulous jaws edentulous patients: two to up to six or more implants, may limit implant placement on the maxilla, whereas in removable implant-retained overdenture, fixed implant- the mandible, the reduction of residual ridge often leaves te supported bridge, etc (87). The basis for individual treat- a significant depth and width of basal bone anteriorly to ment options is a factor of: accommodate implants. The maxilla’s bone trabecular • Patient-related factors: patient’s expectations, bone is less dense and not as capable of stabilizing and subjective aesthetics, phonetics, In financial supporting implants. Anatomic limitations and bony mor- commitment, comfort, compliance, and maintenance phology may compromise implant number, length, and of oral hygiene; inclination. The maxillary overdenture reports a greater • Absence of signs and symptoms: persistent pain, burden of maintenance care and higher failure rates in infection, neuropathy, invasion of the mandibular contrast to the mandible. ni channel or chronic sinusitis; In longitudinal studies, the average annual alveolar ridge • Extraoral factors: patient’s co-morbidities, objective height resportion is approximately 0.4 mm in the eden- aesthetics, facial profile, type of smile line, and lip tulous anterior mandible. The anterior mandibular bone io support; under an implant overdenture may resorb as little as 0.5 • Intraoral factors: local anatomy (fibromas, bands, mm over a five-year period, and long-term resorption muscle attachments, floor of mouth frenula), may remain at 0.1 mm annually (57,58). One study ob- iz maxillo-mandibular relationship, presence or serves that the functioning or loading of implants creates absence of buccal fold, keratinized attached mucosa positive bone remodeling in the anterior mandible (89). and jaw bone quality and quantity, edentulous This effect appears to be independent of the attachment Ed crestal morphology (shape, height and width) and system (18). prosthesis crown position in the sagittal plane. Overdenture wearers show a masticatory performance and chewing cycles similar to those with natural teeth. The implant-retained overdenture proves to be predict- They also document an increase of comfort and satis- able and effective management for edentulous patients. IC Biological (e.g. non-osseointegration, peri-implantitis, Study Implant success rate Follow up mucositis with or without inflammatory hyperplasia) and biomechanical complications (e.g. bar fracture, fracture Maxilla Mandible or detachment of the clip anchorage fracture of the pros- C thesis or its parts, etc.) can occur, but the literature still Naert (33) 88,6% 4 years reports years of success (88). Bergendal (43) 75.4% 100% 7 years The implant-supported overdenture’s biggest advantage is a better distribution of occlusal forces between implant Naert (40) 100% 10years © and bone. This results in a reduction of alveolar ridge Jemt (91) 72.4% 94.5% 5-years resorption; longitudinal clinical studies report a loss of Kiener (30) 95.5% 8 years bone height adjacent to implants of approximately 1.2 mm at the end of the first-year and 0.2 mm annually. Visser (21) 99.9% 5 years This resorption is lower compared with a reduction of 4 mm at the end of the first year and 0.4 mm annually Table 1. Clinical studies showing implant success rate in maxil- after tooth extraction when fitting with conventional den- lary and mandibular overdentures. 6 Annali di Stomatologia 2012; III (1): 2-10  Tissue-supported dental implant prosthesis (overdenture): the search for the ideal protocol. A literature review faction in patients with their overdentures compared implants for mandibular denture retention. J Calif Dent As- to patients wearing conventional dentures. A study ad- soc. 2008 Apr;36(4):283-286. dressing two mandibular implant-supported overden- 12. Krennmair G, Waldenberger O. Clinical analysis of wide- ture concludes that this significantly improves measure diameter frialit-2 implants. Int J Oral Maxillofac Implants. of oral function. After ten years of function, values for 2004 Sep-Oct;19(5):710-715. li maximum bite force and masticatory performance re- 13. Vercruyssen M, Marcelis K, Coucke W, Naert I, Quirynen main unaltered. Thus, the improved oral function lasts M. Long-term, retrospective evaluation (implant and na for a long period of time with high levels of satisfaction patient-centred outcome) of the two-implants-supported regarding various aspects of patients denture function. If overdenture in the mandible. Part 1: survival rate. Clin Oral similar oral functions problems exist, implant-supported Implants Res 2010 Apr 1;21(4):357-365. patients report a greater level of satisfaction (92,93). 14. Misch CE. Contemporary implant dentistry. 2nd ed. St. io The literature indicates that the implant overdenture Louis (MO): Mosby; 1999. p. 179. prosthesis provides predictable results – enhanced sta- 15. Wright PS, Watson RM. Effect of prefabricated bar design bility, function and a high-degree of satisfaction com- with implant- stabilized prostheses on ridge resorption: a clinical report. Int J Oral Maxillofac Implants 1998; 13:77- az pared to conventional removable dentures. This is as a result of positive outcomes of long-term clinical studies, 81. specifically using a conventional loading protocol. Fur- 16. Naert I, Gizani S, Vuylsteke M, Van Steenberghe D. A randomised clinical trial on the influence of splinted and ther studies focusing on immediate and early loading in unsplinted oral implants in the mandibular overdenture rn maxillary overdenture are necessary. therapy. A 3-year report. Clin Oral Investig 1997;1:81-88. 17. Sadowsky SJ. Mandibular implant-retained overdentures: a literature review. J Prosthet Dent 2001 Nov; 86(5):468- te References 473. 18. Batenburg RHK., Raghoebar GM, Van Oort, RP, Heijden- 1. Carlsson GE. Clinical morbidity and sequelae of treatment rijk K, Boering G. Mandibular overdentures supported by two or four endosteal implants. A prospective, comparative with complete dentures. J Prosthet Dent 1998;79:17-23. In 2. Kreisler M, Behneke N, Behneke A, D’Hoedt B. Residual study. Int J Oral Maxillofac Surgery 1998b; 27: 435-439. ridge resorption in the edentulous maxila in patients with 19. Wismeijer D, Van Waas MAJ, Mulder J, Vermeeren JI, Kalk implant-supported mandibular overdentures: an 8-years W. Clinical and radiographical results of patients treated retrospective study. Int J Prosthodont 2003;16:265-300. with three treatment modalities for overdentures on im- ni 3. Carlsson GE. Responses of jawbone to pressure. Ger- plants of ITI dental implant system. A randomized con- odontology 2004;21:65-70. trolled clinical trial. Clin Oral Implants Res 1999;10: 297- 4. Campbell RL. A comparative study of the resorption of the 306. io alveolar ridges in denture-wearers and non-denture-wear- 20. Mau J, Behneke A, Behneke N, Fritzemeier CU, Gomez- ers. J Am Dent Assoc 1960;60:143-153. Roman G, D’Hoedt B, Spiekermann H, Strunz V , Yong M. 5. Salinas TJ. Implant Prostthodontics. In: Miloro M, Ghali Randomized multicenter comparison of 2 IMZ and 4 TPS iz GE, Larsen PE, Waite PD. Peterson’s Principles of Oral screw implants supporting bar-retained overdentures in And Maxillofacial Surgery. London: BC Decker Inc Hamil- 425 edentulous mandibles. Int J Oral Maxillofac Implants ton; 2004 p. 263. 2003; 18: 835-847. Ed 6. Mericske-Stern RD, Taylor TD, Belser U. Management of 21. Visser A, Raghoebar GM, Meijer HJA, Batenburg RHK, the edentulous patient. Clin Oral Impl Res 2000;11 (Sup- Vissink A. Mandibular overdentures supported by two or pl.): 108-125. four endosseous implants. A 5-year prospective study. Clin 7. Weingart D, Ten Bruggenkate CM. Treatment of fully eden- Oral Implants Res 2005; 16:19-25. tulous patients with ITI implants. Clin Oral Impl Res 2000; 22. Stoker GT, Wismeijer D, Van Waas MAJ. An eight-year fol- 11 (Suppl.): 69-82. low-up to a randomized clinical trial of aftercare and cost- IC 8. Romeo E, Chiapasco M, Lazza A, Casentini P, Ghisolfi M, analysis with three types of mandibular implant-retained Iorio M, Vogel G. Implant-retained mandibular overden- overdentures. J Dent Res 2007; 86:276-280. tures with ITI implants. Clin Oral Implants Res 2002 Oct; 23. Timmerman R, Stoker GT, Wismeijer D, Oosterveld P, Ver- 13(5):495-501. meeren JIJF, Van Waas MAJ. An eight-year follow-up to C 9. Sadowsky SJ. Treatment considerations for maxillary im- a randomized clinical trial of participant satisfaction with plant overdentures: A systematic review. J Prosthet Dent three types of mandibular implant-retained overdentures. J 2007 Jun; 97(6):340-348. Dent Res 2004; 83: 630-633. 10. Anitua E, Errazquin JM, de Pedro J, Barrio P, Begoña L, 24. Meijer HJ, Raghoebar GM, Batenburg RH, Visser A, Vis- © Orive G. Clinical evaluation of Tiny® 2.5- and 3.0-mm sink A. 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Original article Microleakage in class V gingiva-shaded composite resin restorations li Claudio Poggio, MD, DDS Introduction Marco Chiesa, DDS Cervical lesions are frequently found in daily practice. na Alberto Dagna, DDS Degenerative processes and gingival recession, as Marco Colombo, DDS, PhD result of chronic periodontal inflammation or aggressive Andrea Scribante, DDS, PhD1 periodontal therapy, expose root dentin predominantly in older patients (1). The aetiology of cervical lesions is multifactorial (2). Non-carious cervical lesions are io University of Pavia, Italy characterized by the loss of dental hard tissue at Department of Operative Dentistry cementum-enamel junction as a result of abrasive 1 Department of Orthodontics or erosive effects (3); additionally cuspal flexure and az tensile stresses in cervical region of the teeth are hypothesized to cause disruption of the bonds among Corresponding author: the hydroxyapatite crystals, leading to cracks and loss Prof. Claudio Poggio of enamel and underlying dentin (4). Food acids and rn Insegnamento di Odontoiatria inappropriate tooth brushing procedures promote the Policlinico S. Matteo development of saucer- or wedge-shaped lesions in P.le Golgi, 3 the cervical area of the teeth (1). In such patients, low 27100 Pavia, Italy dental care and non-effective preventive programs lead te E-mail: claudio.poggio@unipv.it to rapid development of caries. The treatment regimen depends on the individual cause of the cervical lesion (5). Instructions for adequate oral hygiene, dietary advices, In occlusal adjustment and restoration of the defect are Summary recommended (6). Small non-carious cervical defects with no hypersensitivity, especially in the posterior region, The purpose of this study was to evaluate the may require only dietary consulting and oral hygiene ni microleakage in Class V cavities restored with a new instruction in order to avoid further progression (1,5). gingiva-shaded microhybrid composite resin and Pain-associated or caries-affected Class V lesions need with a conventional microhybrid composite resin to be restored. Particular attention is required in anterior io using three different dentin bonding systems (DBS). teeth, both for small non-carious and for big carious Class V cavities were prepared in sixty freshly lesions, where aesthetic reasons are perdominant. Glass extracted human teeth with the incisal margin in ionomer cements, compomers and composite resins are iz enamel and the apical margin in dentin/cementum. being mostly used to restore class V defects (1,3,6-8). Restored specimens, after thermocycling, were Amalgam and gold restoration were used in the past but placed in 2% methylene blue solution for 24 hours. today the increased demand for aesthetic decreased Ed Longitudinal sections were obtained and studied their utilization. Composite resins combined with dentin with a stereomicroscope for assessment of the bonding systems have already substituted glass ionomer microleakage according to degree of dye penetration cements and compomers in Class V restorations because (scale 0-3). Data were analyzed with Kruskal-Wallis of their excellent aesthetics, superior mechanical and test and with Mann-Whitney U-test. physical properties and higher bond strength to enamel In this study there was no leakage in enamel: all the and dentin (1,9,10). The complex morphology of Class IC cavities showed no dye penetration at the incisal V defects with margins partly in enamel as well as in margins (located in enamel). None of the DBS used root dentin presents challenging task for the restorative eliminated microleakage in apical margins (located material (1). Bond strength and sealing ability of adhesive in dentin or cementum): three-step total-etch and systems to dentin is still inferior compared to enamel C single-step self-etch were more effective in reducing cavity segments (11). In Class V the polymerization of microleakage in dentin margins when compared with composite resins competes with the bond strength of the two-step total-etch. This in vitro study concluded adhesive systems and challenges marginal integrity and that microleakage in Class V cavities restored with sealing ability especially in dentin segments. Marginal © the composite resins tested is similar. gap formation leads to leakage, responsible for marginal discoloration, secondary caries and partial or total loss Key words: gingiva-shaded composite resin, dentin of the restoration (6,12). However, newly formulated bonding systems, microleakage. improved bonding systems provide a better adhesion of the composite resin to dentin, although this is an unresolved problem. The exposed and frequently worn cervical areas of teeth often lack a pleasing appearance Annali di Stomatologia 2012; III (1): 19-23 19  C. Poggio et al. when restored with conventional materials such as After application of DBS (according to Manufacturers’ glass ionomer cements or tooth coloured composite instructions) cavities were restored with composite resins, especially when associated with aging and loss resin in three increments. Each increment of composite of gingiva. Today the interest is directed toward the resin was light-cured for 40 seconds with a curing light development of new restorative materials that permit in softstart-polymerization mode (Celalux 2 High-Power chair side gingival shade matching, in order to restore li LED curing-light, Voco GmbH, Cuxhaven, Germany). aesthetic and function of cervical areas exposed after The restorations were finished and polished with na gingival recession (discoloured or hypersensitive necks finishing/polishing disks (Sof-Lex Pop-On, 3M ESPE, of teeth) and cervical V-shaped defects (13). St. Paul, MN, USA) in decreasing granulation. All teeth The purpose of this in vitro study was to investigate the were coated with two layers of nail varnish up to 1 mm microleakage in Class V cavities restored with a new from the restorations margins, while the apical part was gingiva-shaded microhybrid composite resin (Amaris sealed with wax. The restored teeth were then subjected io Gingiva) and with a conventional microhybrid composite to artificial aging by thermocycling. All specimens were resin (Amaris) using three different dentin bonding immersed alternately in water baths at 5 and 60°C for systems (three-step total-etch, two-step total-etch and 1000 cycles, with at dwell time of 60 seconds in each bath az single-step self-etch). The null hypothesis of the study and a transfer time of 15 seconds. After thermocycling, was that there is no significant difference in microleakage the specimens were immersed in a 2% methylene blue scores among the various groups. dye solution and incubated at 37°C for 24 hours. rn Microleakage analysis Materials and methods The teeth were rinsed with distilled water, dried for 10 minutes, and sectioned longitudinally in a buccolingual Specimen preparation te direction with a low-speed water-cooled diamond Sixty caries-free vital human teeth freshly extracted cutter. All specimens were examined at 25´ in a for periodontic or orthodontic reasons were used in stereomicroscope (Inspective 4Geek, Serravalle, RSM) this study. The teeth were cleaned with dental scalers, and standardized digital images were obtained. Two polished with pumice and stored in a 0.25% mixture of In observers scored each section blindly; consensus was sodium azide in Ringer solution until the date of use. In forced if disagreements occurred. An ordinal scale from 0 each tooth two standardized Class V cavities (on buccal to 3 was used to score microleakage separately at incisal and on lingual surfaces) were prepared with a round- (enamel) and apical (dentin/cementum) margins of each ni nosed no.245 carbide bur (Dentsply/Caulk, Milford, DE, section based on the following criteria, as described in USA) at high-speed with air/water spray, according to Osorio et al.(15) and in Moldes et al.(16): 0 = no leakage procedure described in Corona et al. (14): the cavities visible at tooth/restoration interface, 1 = dye penetration io were prepared with the incisal margin located in enamel along the interface up to one-half of the cavity depth, 2 = and the apical margin located in dentin/cementum (3 mm dye penetration greater than one-half of the cavity depth, beyond the cementum-enamel junction); the dimensions 3 = dye penetration to and along axial wall. iz of Class V cavities were similar, with mesiodistal width, incisal-apical measure and depth of 4 mm. The same Statistical analysis trained operator prepared all the cavities. The teeth were The results of microleakage evaluation were submitted Ed randomly assigned to six experimental groups (of 10 to statistical analysis using “Stata 7.0” computer specimens and 20 cavities each); Class V cavities were software (Stata Corp., Station College, TX). A Kruskal- filled with two composite resins and with three dentin Wallis test and a Mann-Whitney U-test were performed. bonding systems (DBS) as follows: group 1: Solobond Significance was predetermined at p<0.05. Plus + Amaris Gingiva, group 2: Solobond Plus + Amaris, group 3: Solobond M + Amaris Gingiva, group 4: IC Solobond M + Amaris, group 5: Futurabond NR + Amaris Results Gingiva, group 6: Futurabond NR + Amaris. The same manufacturer (Voco GmbH, Cuxhaven, Representative photographs revealing dye penetration Germany) prepared the composite resins and the DBS. of sectioned specimens are shown in Figures 1-6. C DBS tested are shown in Table 1. Microleakage scores values at incisal margins (in enamel) are presented in Table 2 and microleakage scores values at apical margins (in dentin/cementum) are presented in etch for 20 sec with 37% two-step orthophosphoric acid, rinse Table 3. The results of the Kruskal-Wallis test indicated © Solobond M 0949326 total-etching with water, apply DBS, gently the presence of significant differences among the dry and light cure for 20 sec apply DBS for 20 sec, dry with microleakage values of the various groups (P<0.05). Futurabond M 0940451 single-step air for 5-10 sec to evaporate Post-hoc Mann-Whitney’s Test showed no significant self-etching solvents and light cure for 20 sec difference in microleakage scores between gingival- shaded (groups 1, 3, and 5) and conventional (groups Table Table 1 -1 - Dentin Dentin bonding bonding systemssystems (DBS) (DBS) used used in this study. in this study. 2, 4, and 6) composite resins both for occlusal and gingival margins (P>0.05). Moreover, when evaluating 20 Annali di Stomatologia 2012; III (1): 19-23  Microleakage in class V gingiva-shaded composite resin restorations Figure 1. Figure 4. Representative ste- Representative stereo- reomicroscopic photo- microscopic photograph graph of group 1 (Solo- of group 4 (Solobond M bond Plus + Amaris + Amaris) original mag- Gingiva) original mag- nification 25x. li nification 25x. na io az rn Figure 2. Figure 5. Representative stereo- Representative ste- te microscopic photograph reomicroscopic photo- of group 2 (Solobond graph of group 5 (Fu- Plus+Amaris) original turabond NR+Amaris magnification 25x. Gingiva) original mag- In nification 25x. ni io iz Ed Figure 3. Figure 6. Representative ste- Representative ste- reomicroscopic pho- reomicroscopic photo- tograph of group 3 graph of group 6 (Fu- IC (Solobond M+Amaris turabond NR+Amaris) Gingiva) original mag- original magnification nification 25x. 25x. C © Annali di Stomatologia 2012; III (1): 19-23 21 Table 1 - Dentin bonding systems (DBS) used in this study. groups C. Poggio et al.Score 0 Score 1 Score 2 Score 3 1 18 (90%) 2 (10%) 0 (0%) 0 (0%) 2 19 (95%) 1 (5%) 0 (0%) 0 (0%) 3 17 (85%) 2 (10%) 1 (5%) 0 (0%) 4 17 (85%) 3 (15%) 0 (0%) 0 (0%) the priming and the bonding steps (also defined total- groups 5 Score 17 0 Score (85%) 1 Score 3 (15%) 0 (0%)2 Score 0 (0%)3 etch systems); two-step systems include self-priming 16 16 (90%) 18 (80%) 23 (10%) (15%) 01 (0%) (5%) 0 (0%) adhesives (that require a separate etching step) or self- 2 19 (95%) 1 (5%) 0 (0%) 0 (0%) etching primers (that require a separate bonding step); 3 17 (85%) 2 (10%) 1 (5%) 0 (0%) finally, the recently introduced single-step (self-etching) 4 17 (85%) 3 (15%) Table 2 - Occlusal margin-microleakage 0 (0%) for each scores obtained 0 (0%) experimental group combine all bonding procedures in a single adhesives li 5 17 (85%) 3 (15%) 0 (0%) 0 (0%) application, consisting of a mixture of acid monomers (n=20). 6 16 (80%) 3 (15%) 1 (5%) 0 (0%) na that etch enamel and dentin as well as primers that permits penetration of resin into the demineralized dentin Table 2 - Occlusal margin-microleakage scores obtained for each (27). No DBS currently available achieved a perfect seal Table 2 - Occlusal margin-microleakage experimental group (n=20). scores obtained for each experimental group in dentin/cementum (15,19,20,28,30-34). The causes of microleakage are usually associated with the composite io (n=20). groups Score 0 Score 1 Score 2 Score 3 resin used, the occlusal load, the location of the prepared 1 13 (65%) 5 (25%) 2 (10%) 0 (0%) margins and the polymerization shrinkage (23): DBS 2 12 (60%) 7 (35%) 1 (5%) 0 (0%) have the aim to minimize those effects. az 3 3 (15%) 9 (45%) 5 (25%) 3 (15%) The restoration of cavities with margins located in dentin/ 4 2 (10%) 11 (55%) 6 (30%) 1 (5%) cementum is an unresolved problem in operative dentistry; groups 5 Score 14 (70%)0 Score 4 (20%)1 Score 2 (10%)2 Score 0 (0%)3 microleakage has clinical effects and causes failure of 16 12 (65%) 13 (60%) 5 (25%) 23 (10%) (15%) 0 (0%) resin restorations. The reason for this difference between rn 2 12 (60%) 7 (35%) 1 (5%) 0 (0%) apical and incisal leakage scores is that bonding to Table 33- Gingival 3 (15%) 9 (45%) 5scores margin-microleakage (25%)obtained 3 (15%) for each dentin/cementum is much more technique-sensitive and Table 3 - Gingival 4 2 (10%)(n=20).11 scores margin-microleakage experimental group (55%) obtained 6 (30%) for 1 (5%)experimental each substrate-sensitive than bonding to enamel (25,30-34). 5 14 (70%) 4 (20%) 2 (10%) 0 (0%) te 6 margin group (n=20). occlusal 12 (60%) scores,5 no(25%) 3 (15%) significant 0 (0%)were differences showed among the three different adhesives tested Conclusion (p>0.05). On the other hand, when analyzing gingival Table 3 - Gingival margin-microleakage margin scores, groups 3 and scores obtained 4 showed In for each higher significant experimental This study showed no differences between the frequency of microleakage scores of “1” (P<0.05) than microleakage in class V cavities restored with the group (n=20). the other groups, that both showed higher frequency of 13 composite resins tested: Amaris Gingiva (gingiva-shaded score “0”. microhybrid composite resin) and Amaris (conventional ni microhybrid composite resin). Within the limitations of this study it may be concluded that microleakage among Discussion two composite resins tested is similar. The microleakage 13 io of all DBS tested in enamel is significantly reduced or The null hypothesis of the study was partially rejected. null, but three-step total-etch and single-step self-etch The results of the present investigation showed no were more effective in reducing microleakage in dentin/ significant differences in microleakage values among iz cementum margins when compared with a two-step the gingiva-shaded microhybrid composite resin (Amaris total-etch. Gingiva) and the conventional microhybrid composite resin (Amaris). The microleakage of the DBS tested in Ed enamel is significantly reduced or null. The results of References this study are in agreement with findings in Literature (14,15,17,20): all the specimens showed less dye 1. Manhart J, Chen HY, Mehl A, Weber K, Nickel R. Marginal penetration at incisal margins (in enamel), with no quality and microleakage of adhesive class V restorations. differences emerging between the different adhesive J Dent 2001;29:123-130. systems. On the other side, the results revealed that IC 2. Schupbach P, Guggenheim B, Lutz F. Human root caries. none of the DBS used eliminated microleakage in J Oral Pathol Med 1989;18:146-56. margins located in dentin or cementum of any teeth, as 3. Levitch LC, Bader JD, Shugars DA, Heymann HO. Non- confirmed by other studies (14,21-23). Bonding agents carious cervical lesions. J Dent 1994;22:195-207. require etching of enamel and decalcifying of dentin to C 4. Lee WC, Eakle WS. Possible role of tensile stresses in the promote micromechanical bonding; for several years etiology of cervical erosive lesions of teeth. J Prosthet Dent phosphoric acid has been used to treat enamel and 1984;52: 374-80. dentin substrates before adhesive application: this total- 5. Tyas MJ. The class V lesion: aetiology and restoration. etching technique remove smear layer, open dentinal © Aust Dent J 1995;40:167-70. tubules and increase dentinal permeability (24). 6. Krejci L, Lutz F. Marginal adaptation of class V restorations In attempt to simplify clinical procedures, DBS were using different restorative techniques. J Dent 1991;19: 24- developed consisting of a lower number of passages. 32. DBS are currently available as three-step, two-step and 7. Manhart J, Weber K, Mehl A, Hickel R. Marginal quality of single-step systems (17,25,26): three-step systems dentin adhesives/composites in mixed class V cavities. J are traditional adhesives, which involve the etching, Dent Res 1999;78:444-51. 22 Annali di Stomatologia 2012; III (1): 19-23  Microleakage in class V gingiva-shaded composite resin restorations 8. Van Meerbek B, Peumans M, Gladys S, Braem M, Lam- 20. Kolinotou-Koumpa E, Dionysopoulos P, Koupia E. In vivo brechts P, Vanherle G. Three-year clinical effectiveness evaluation of microleakage from composites with new den- of four total-etch dentinal adhesive systems in cervical le- tine adhesives. J Oral Rehabil 2004;31:1014-22. sions. Quintessence Int 1996;27:775-84. 21. Haller B. Recent development in dentin bonding. Am J 9. Abdalia AI, Alhadainy HA, Garcia-Godoy F. Clinical evalu- Dent 2000;13:44-50. ation of glass ionomers and compomers in class V carious li 22. Amaral CM. Microleakage of hydrophilic adhesive systems lesions. Am J Dent 1997;10:18-20. in class V composite restorations. Am J Dent 2001;14:31- na 10. Gladys S, Van Meerbek B, Braem M, Lambrechts P, Van- 3. herle G. Comparative physico-mechanical characteriza- 23. Arias VG, Campos IT, Pimenta LAF. Microleakage study of tion of new hybrid restorative materials with conventional three adhesive systems. Braz Dent J 2004;15:194-8. glass-ionomer and resin composite restorative materials. J 24. Fusayama T, Nakamura M, Kurosaki N, Iwaku M. Non- Dent Res 1997;76:883-94. pressure adhesion of a new adhesive restorative resin. J io 11. Dietrich T, Losche AC, Losche GM, Roulet JF. Marginal ad- Dent Res 1979;58:1364-70. aptation of direct composite and sandwich restorations in 25. Tay FR, Pashley DH. Permeability of single-step, self-etch class II cavities with cervical margins in dentine. J Dent adhesives: the cost of saving time. In: Proceedings of the az 1999;27:119-28. International symposium’ 01 in Tokio June 26,2001 Edited 12. Sparrius O, Grossman ES. Marginal leakage of composite by Junji Tagami resin restorations in combination with dentinal and enamel 26. Gladys S, Van Meerbeek B, Lambrechts P, Vanherle G. bonding agents. J Prosthet Dent 1989;61:678-84. Microleakage of adhesive restorative materials. Am J Dent rn 13. Günay H, Geurtsen W, Lührs AK. Conservative treatment 2001;14:170-6. of periodontal recessions with class V-defects using 27. Nikaido T, Nakajima M, Higashi T, Kanemura M, Pereira Pn, gingiva-shaded composite--A systematic treatment con- Tagami J. Shear bond strength of a single-step bonding cept. Dent Update. 2011;38:124-32. te system to enamel and dentin. Dent Mater J 1997;16:40-7. 14. Corona SAM, Borsatto MC, Pecora JD, De Sa Rocha RAS, 28. Prati C, Nucci C, Davidson CL, Montanari G. Early mar- Ramos TS, Palma-Dibb RG. Assessing microleakage of ginal leakage and shear bond strength of dentin bonding different class V restorations after Er:Yag laser and bur systems. Dent Mater 1990;6:195-200. preparation. J Oral Rehabil 2003;30:1008-14. In 29. Abo T, Uno S, Sano H. Comparison of bonding efficacy of 15. Osorio R, Toledano M, de Leonardi G, Tay F. Microleak- an all-in-one adhesive with a self-etching primer system. age and interfacial morphology of self-etching adhesives in class V resin composite restorations. J Biomed Mater Res Eur J Oral Sci 2004;112:286-92. B Appl Biomater 2003; 66:399-409. 30. Ateyah NZ, Elhejazi AA. Shear bond strengths and micro- ni 16. Moldes VL, Capp CI, Navarro RS, Matos AB, Youssef MN, leakage of four types of dentin adhesive materials. J Con- Cassoni A. In vitro microleakage of composite restorations temp Dent Pract 2004;5:63-73. prepared by Er:YAG/Er,Cr:YSGG lasers and conventional 31. Fortin D, Swift EJ, Denehy GE, Reinhardt JW. Bond io drills associated with two adhesive systems. J Adhes Dent strength and microleakage of current dentine adhesives. 2009;11:221-9. Dent Mater 1994;10:253-8. 17. Ferrari M, Goracci G, Garcia-Godoy F. Bonding mechanism 32. Pashley EL, Agee KA, Pashley DH, Tay FR. Effects of one iz of three “one bottle” system to conditioned and uncondi- versus two applications of an unfilled, all-in-one adhesive tioned enamel and dentin. Am J Dent 1997;10:224-30. on dentine bonding. J Dent 2002;30:83-90. 18. Hannig M, Reinhardt KJ, Bott B. Self-etching primer vs 33. Yaseen SM, Subba Reddy VV. Comparative evaluation of Ed phosphoric acid : an alternative concept for composite-to- microleakage of two self-etching dentin bonding agents enamel bonding. Oper Dent 1999;24:172-80. on primary and permanent teeth. An in vitro study. Eur J 19. Shigetani Y, Tate Y, Okamoto A, Iwaku M, Abu-Bakr N. A Paediatr Dent. 2010;11:127-31. study of cavity preparation by Er :YAG laser effects on the 34. Kirk PC, Fitchie JG, Phillips SM, Puckett AD. Microleak- marginal leakage of composite resin restoration. Dent Ma- age evaluation of four self-etching adhesive systems. Gen ter J 2002;21:238-49. Dent. 2010;58:104-9. IC C © Annali di Stomatologia 2012; III (1): 19-23 23 

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Original article Surgical protocol in patients at risk for bisphosphonate osteonecrosis of the jaws: clinical use of serum telopetide CTX in preventive monitoring of surgical risk li na Fabrizio Carini, Md, Dmd Introduction Vito Saggese, Mds Gianluca Porcaro, Mds Bisphosphonates are drugs used to treat osteoporosis Lorena Barbano, Bds when taken orally (1) and in the therapy of bone me- io Marco Baldoni, Md, Dmd tastases, multiple myeloma and Paget’s disease when taken parenterally. Bisphosphonates exert their phar- macological action accumulating mainly in places with az University of Milan-Bicocca, Monza (MB), Italy elevated bone metabolism; being inorganic pyrophos- School of Oral Surgery phate analogues, bisphosphonates have a high affin- ity for calcium and are consequently removed from the circulation and then bind to mineralized bone. After re- Corresponding author: rn peated doses they accumulate in the bone matrix. Dur- Dott. Gianluca Porcaro ing resorption, the osteoclast acidifies the bone matrix, School of Oral Surgery causing the dissolution of hydroxyapatite crystals and University of Milan-Bicocca, Monza (MB), Italy then the release of the bisphosphonate that was linked te Phone and Fax: +39 (0) 2333482 to the crystals themselves. In this way it may come in Clinica Odontoiatrica - Villa Serena - Ospedale San Gerardo contact with osteoclasts inhibiting their resorption power. Via Pergolesi, 33 Bisphosphonates are therefore drugs able to affect bone 20900 Monza, Italy E-mail: porcarogianluca@libero.it In metabolism. Marx in 2002 (2) defined the proportions of the putative causes of osteonecrosis: dental extractions 37.8%, peri- Summary odontal and endodontic surgery 12%, implants interven- tions 3.4%. He also indicated a generic relationship with ni Aim: This study investigates the association be- periodontal disease in 28.6% of cases (3). Patients with tween cross linked C-terminal telopetide test (CTX) osteoporosis have an estimated risk of developing os- and individual surgical risk of osteonecrosis in pa- teonecrosis between 0.01% and 0.04%, which rises to io tients taking oral bisphosphonates. 0.09-0.34% if they have performed dental extractions. Materials and Methods: 32 patients receiving Patients with multiple myeloma and bone metastases bisphosphonate were treated surgically. Patients pass from 0.88% and 1.15% risk to 6.67% and 9.1% (4). iz were divided into three groups according to type of The CTX is a serum test proposed by the American So- drug administrated and were subjected to a treat- ciety of Bone Mineral Research Task Force on osteone- ment of oral surgery, such as simple tooth extrac- crosis of the jaws. It is capable of measuring a specific Ed tions and extraction of all residual teeth of the oral marker of bone turnover and for this reason it could be cavity, upon evaluation of CTX values and antibiotic used as a risk indicator in pre-operative assessment. It prophylaxis. is considered a useful test to assess serum and urinary Results: Within the sample of 32 patients, 12 patients metabolites typical of bone resorption. The index serum had been treated with bisphosphonates for several CTX can detect changes in the bone remodeling in a years and none developed osteonecrosis of the jaw range of time comprised between a few days up to two IC upon surgery. As for CTX, patients treated with oral weeks, therefore much earlier than with the use bone bisphosphonates showed a mean value of serum C- mineral density (BMD). The assessment of BMD is a telopetides of 0.2869 ng/ml. The mean value of CTX rough procedure, though it remains very useful in the did not differ significantly between patients taking quantitative assessment of skeletal bone mass because C oral bisphosphonates and healthy patients not treat- it measures the relative bone density. Instead, the value ed with bisphosphonates. of CTX test is rather useful for the quantitative assess- Conclusion: None of the patients subjected to pre- ment of bone resorption through the degree of bone re- operative antibiotic prophylaxis developed osteone- newal and such information is of great importance when © crosis of the jaw after surgery. The pharmacological assessing the risk of ONJ (5). and surgical protocol tested appeared valid in the The dosage of CTX requires the removal of 1 ml of blood prevention of osteonecrosis associated to bisphos- collected in a test tube at room temperature. Sampling phonates. should be collected in the morning, because changes during the day could lead to elevated values in the late Key words: serum C-terminal C-telopeptide (CTX), afternoon or evening. The serum can be analyzed af- bisphosphonate, osteonecrosis of the jaw (ONJ). Annali di Stomatologia 2012;III (1): 31-36 31  F. Carini et al. ter 15 minutes needed for blood clotting and provides patients in order to obtain information concerning the a reliable result up to over 16 hours of storage at room remote and recent physiological, pathological and phar- temperature for three days if kept refrigerated and three macological anamnesis, and preoperative CTX test was months if frozen. performed in order to evaluate the residual bone turn- Upon several studies, Marx and co-workers (5) proposed over. The patients were scheduled for oral surgery de- li guidelines for risk assessment in the laboratory of pa- pending on the value of CTX obtained, the clinical evalu- tients taking bisphosphonates: CTX values between 0.3 ation during the oral examination and the radiographic na and 0.6 ng/ml are not associated with ONJ, values be- analysis (orthopantomography of jaws and Dentascan tween 0.150 and 0.299 ng/ml are associated with none Tc). For patients taking oral bisphosphonates for less or minimal risk of ONJ, values between 0.101 and 0.149 than three years, in the absence of obvious risk factors ng/ml are associated with an intermediate risk of ONJ, it is not necessary to change or delay the oral surgical and finally CTX values ≤ 0.100ng/ml are associated with treatment plan. For patients treated for less than three io a high risk of ONJ. years but with at least one systemic risk associated, it is necessary to contact the physician to discontinue the bisphosphonate (drug holiday) at least three months be- az Materials and methods fore the surgical procedure and the resumption should be delayed until three months after its execution. At the Between October 2009 and June 2010 at the Dental first examination and three months later it is necessary to Clinic of the University Milano-Bicocca 32 patients were measure the CTX. Values lower than 0.150 ng/ml would rn recruited of which 12 were treated with oral bisphospho- advise against surgical procedures and an interruption nates, 11 with intravenous bisphosphonates and 9 not prolonged for another three months. In case of detection yet treated (Fig. 1). Our study group consisted of patients of CTX values greater than 0.150 ng/ml, it may be al- te who were or are currently treated with oral bisphospho- lowed the introduction of elective surgery, informing the nates and about to receive invasive dental procedures. patients of the risk of developing ONJ, albeit very small. Of the 12 patients treated with oral bisphosphonates 3 Bisphosphonate should not be reintroduced until three patients were taking risedronate acid, 8 alendronic acid months upon healing. For patients taking oral bisphos- and one ibandronic acid (Fig. 2). The control group con- In phonate for more than three years in the absence of sisted of patients not receiving bisphosphonates. Pa- risk factors it is recommended to contact the physician tients showed up at our department and were included in order to agree to an interruption of the drug for three in the study sample depending on their bisphosphonate months before to three months after the surgical ses- ni assumption. A complete clinical record was made for all sion. Moreover, it is recommended to study the level of the cell turnover marker CTX at the first examination and before conducting the planned procedures. A val- io ue greater than or equal to 0.150 ng/ml is the minimum requirement to perform surgical procedures in patients who belong to this group. If there is an urgent need for iz oral surgery while taking oral bisphosphonates, as in the presence of odontogenic abscesses requiring extraction Parenteral bisphosphonates or abscess drainage to decrease pain and to manage Ed infection, the patient should be subjected to the appro- priate procedure rather than maintaining the condition of pain and infection. Usually, the precursors of osteoclasts regain their activity to allow good bone healing following a three-month discontinuation of the bisphosphonate. In any case, it is important to remove all odontogenic foci in Figure 1 - Type of bisphosphonate assumption in the sample. IC the oral cavity, which are associated to an increased risk of ONJ. It is therefore necessary to inform the patient of possible risks. It has been estimated that for the first 2-3 years, the risk of developing ONJ is low for patients tak- C ing oral bisphosphonates (5-11). All patients in the sample, two weeks before and one week after oral surgery, carried out at the dental clinic of the Milano-Bicocca University according to the criteria © of minimal invasiveness and high radicality to remove any odontogenic focus, underwent a pharmacological prophylaxis (6,7). Such prophylaxis started two weeks prior to surgery and consisted of amoxicillin and clavu- lanic acid tablets (1 g every 12 hours), metronidazole tablets (250 mg every 8 hours) and omeprazole tablets Figure 2 - Typology of oral bisphosphonate. (20 mg once daily) for the duration of antibiotic cover- 32 Annali di Stomatologia 2012;III (1): 31-36  Surgical protocol in patients at risk for bisphosphonate osteonecrosis of the jaws age, associated to rinsing with chlorhexidine 0.2% im- - the mean value of CTX in patients with oral bisphos- mediately before surgery. The 12 patients receiving phonates was 0.2869 ng/ml; oral bisphosphonates were subjected to 15 surgeries of - the mean value of CTX in patients not yet treated with which 2 full-mouth tooth extractions and 18 extractions bisphosphonates was 0.225 ng/ml, which falls within, the of compromised dental elements (Fig. 3). In the group of range of values reported in literature indicating values between 0.150 and 0.299 ng/ml. In our control sample, li patients treated with oral bisphosphonates, due to the known complications that these drugs can induce, a total including patients not treated with bisphosphonates, one na of 12 surgeries were performed, of which 26 extractions subject showed a CTX value of 0.88 ng/ml. This value of hopeless teeth and a full-mouth tooth extraction pro- does not conform to the rest of the sample. A possible cedure (Fig. 4). The antiseptic and antibiotic prophylaxis explanation may be sought in medical history of this pa- was continued for one week after surgery to prevent in- tient that revealed she was suffering by bone metasta- fection, in order to avoid that it further delays the healing ses from breast cancer. Marx in his 2005 study claimed io of the surgical wound. All patients in the sample under- that the CTX is reliable only in non-cancer patients and went a close follow-up 1, 4 and 12 weeks after surgery, in cancer patients without bone metastases, because then every 3 months until the following year and every the latter could alter the real value of bone turnover(4). az 6 months thereafter. At each visit the surgical sites were After having categorized patients belonging to the group checked clinically and radiographically to assess epithe- treated with oral bisphosphonates in ascending order ac- lialization, bone sequestra and bone infections. cording to the duration of drug exposure we proceeded to observe the change in the CTX value (Fig. 5). Based rn on the values of CTX belonging to patients in our study treated with oral bisphosphonates, it was performed a statistical test of hypothesis to compare the CTX values in patients taking oral bisphosphonates with those in pa- te tients of the control group. Null hypothesis was that CTX values in the two groups are equivalent. The value of the test statistic (z = 0.4166) was lower than the value In of t-Student (t (n-1) = 2.262). In addition, the confidence interval at 95% indicated, including 0, that it was not pos- sible to exclude the null hypothesis. Thus, in the sample considered for the study, the dif- ni ference in CTX values between patients taking oral Figure 3 - Typology of oral surgery in patients treated with oral bisphosphonates and patients of the control group, was bisphosphonate in the sample. not statistically significant. In the group of patients tak- io ing oral bisphosphonates, on a total of 15 surgeries no signs of osteonecrosis in the longitudinal follow-up were found. Nine patients showed an uneventful healing, that iz is with a full epithelial filling of the surgical site within 30- 45 days after surgery, while 6 surgical wound showed a delayed healing within 45-90 days (Figs. 6-7). In the Ed group of patients that at the time of surgery did not take bisphosphonates, 10 surgical sites showed a normal healing within 30-45 days and two a delayed healing within 45-90 days (Figs. 8-9). IC Figure 4 - Typology of oral surgery in patients not treated with bisphosphonate in the sample. C Results All patients taking bisphosphonates orally or parenterally © who addressed our department to undergo surgery were treated according to the aforementioned surgical proto- col. In addition, patients were asked to go to a labora- tory for CTX testing to determine the bone turnover. The values of CTX obtained from the patients in the sample Figure 5 - CTX values in patients treated with oral bisphospho- were as follows: nate versus timing of the therapy. Annali di Stomatologia 2012;III (1): 31-36 33  F. Carini et al. li na io Figure 10 - Healing comparison between patients treated with oral bisphosphonate and patients not treated with bisphospho- Figure 6 - Timing of wound healing in patients treated with oral nate. az bisphosphonate. Therefore, comparing the two groups, study and control, it can be observed that patients not taking bisphospho- nates had a better post-operative healing than patients rn treated with BF, in which we should consider the pos- sible delayed healing and therefore it becomes neces- sary a rigid follow-up (Fig. 10). te Case report A woman (about 55 years old) addressed our depart- ment for the simultaneous extraction of 3.6 and 4.7 In residual roots. Antibiotic prophylaxis was administered in accordance to the protocol, since different operat- Figure 7 - Wound healing in patients treated with oral bisphos- ing sessions would require antibiotic administration at phonate. close times. From the compilation of medical records ni the patient resulted treated with oral bisphosphonates for about ten years. After preoperative evaluation by means of orthopantomography (Fig. 11), we performed the intraoral examination (Fig. 12) and CTX test, which io was found to be 0.3 ng/ml, so with associated low risk of osteonecrosis of the jaw. We then proceeded with the administration of antibiotic prophylaxis, as previously de- iz scribed. The extraction of residual roots was performed following the surgical protocol previously explained (Fig. 13). After the surgery a suture 3/0 was performed, which Ed was removed after 8 days (Fig. 14). The patient con- tinued the antibiotic prophylaxis and the antimicrobial therapy with chlorhexidine 0.2% for one week after the surgery. Follow-up checks were scheduled at 2, 4, 6 and Figure 8 - Timing of wound healing in patients not treated with 12 months (Fig. 15). IC bisphosphonate. C © Figure 9 - Wound healing in patients not treated with bisphos- phonate. Figure 11 - Pre-operative orthopantomography. 34 Annali di Stomatologia 2012;III (1): 31-36  Surgical protocol in patients at risk for bisphosphonate osteonecrosis of the jaws li na io Figure 15 - Orthopantomography two months later. az Discussion According to current knowledge, bisphosphonates are a very useful and effective therapeutic aid in the treat- rn Figure 12 - Pre-operative clinical situation. ment of cancer-induced and metabolic bone diseases, beneficial effect an increasing number of patients makes prolonged use of these drugs; especially in post-menu- te pausal women (8,9), the use of bisphosphonates has become so ordinary that sometimes it is not even speci- fied in anamnesis before performing a dental surgical therapy. However, patients should be informed of possi- In ble complications related to the bisphosphonates intake after invasive surgical treatments (10). According to what stated above and based on the results collected by the pharmacological and surgical protocol ni adopted in the dental clinic of the University of Milano- Bicocca, inside the Hospital of San Gerardo of Monza, it is essential to consider patients treated with bisphospho- io nates at risk of ONJ. For this reason, it is necessary to monitor these patients during dental treatment after the surgery, in order to act quickly in case of complications. iz The observed operative protocol is based on an ade- quate and well-defined system of pre-operative prophy- laxis, a surgery conducted in a sterile environment and Ed aimed to be minimally invasive, the complete debride- ment of all infected and inflammatory tissue, a suture warranting a rapid healing, and finally on a close follow- up program. Given the excellent results obtained by ap- plying the above pharmacological and surgical protocol in terms of reductions in the number of osteonecrosis IC Figure 13 - Extraction of 3.6 and 4.7 and suture. developed after oral surgery, it should be emphasized the importance of applying this protocol to all patients treated with oral, intramuscular or intravenous bisphos- phonates two weeks before and one week after surgery. C Finally, as regards the use of serum telopeptide CTX in terms of preventive monitoring of the risk of developing ONJ in patients with oral bisphosphonates in the sample of the study, compared with the values of CTX in healthy © patients, at present there is no sufficient evidence to affirm that the difference between the CTX values ob- tained in the two patient groups is statistically significant, perhaps because of the limited sample size. Neverthe- less, it is important to highlight that the relevance of CTX as an indicative value to consider patients treated with Figure 14 - Clinical situation after 8 days. bisphosphonates at potential risk of osteonecrosis. Annali di Stomatologia 2012;III (1): 31-36 35  F. Carini et al. For this reason, this serum test is an important clinical 2004; 62: 527-534. support in the therapeutic planning of the patient treated 7. Rosen HN, Moses AC, Garber J, Iloputaife ID, Ross DS, with bisphosphonates. Lee SL, Greenspan SL. Serum CTX. A new marker of bone resorption that shows treatment effect more often than other markers because of low coefficient of variability ad li References large changes with biphosphonate therapy. Calcif Tissue Int 2000; 66: 100-103. na 1. Rutkowsi JL, Johnson DA, Smith DM. Clinical concerns 8. Bone HG, Hosking D, Devogelaer JP, Tucci JR, Emkey of alendronate use. J Oral Maxillofac Surg 2007; 65: 363- RD, Tonino RP, Rodriguez-Portales JA, Downs RW, Gupta 364. J, Santora AC, Liberman UA. Ten years’ experience with 2. Marx RE, Stern DS. Oral and Maxillofacial Pathology: A alendronate for osteoporosis in postmenopausal women. N Engl J Med 2004; 350: 1189-1199. io Rationale for Diagnosis and Treatment. Chicago. Quintes- sence; 2002. 9. Miller PD, McClung MR, Macovei L, Stakkestad JA, Luck- 3. Marx RE. Reconstruction of defects caused by Bisphos- ey M, Bonvoisin B, Reginster JY, Recker RR, Hughes C, phonate- Induced Osteonecrosis of jaws. J Oral Maxillofac Lewiecki EM, Felsenberg D, Delmas PD, Kendler DL, Bo- az Surg 2009; 67:107-119. lognese MA, Mairon N, Cooper C. Monthly oral ibandro- 4. Marx RE, Sawatari Y, Fortin M, Broumand V. Biphospho- nate therapy in post-menopausal osteoporosis. One year nate induced exposed bone (osteonecrosis/osteopetrosis) results from the MOBILE study. J Bone Miner Res 2005; of the jaws: Risk factors, recognition, prevenction and 20: 1315-1322. rn treatment. J Oral Maxillofac Surg 2005; 63:1567-1575. 10. Ruggiero SL, Gralow J, Marx RE, Hoff AO, Schubert MM, 5. Marx RE, Cillo JE, Ulloa JJ: Oral Bisphosphonate induced Huryn JM, Toth B, Damato K, Valero V. Practical guidelines osteonecrosis: Risk Fac­tors, prediction of risk using serum for the prevention, diagnosis and treatment of osteonecro- te CTX testing, prevention and treatment. J Oral Maxillofac sis of the jaw in patients with cancer. J Clin Oncol Prac Surg 2007; 65: 2397-2410. 2006; 2: 7-14. 6. Ruggero SL, Mekrota B, Rosenberg TJ, Engroff SL. Os- 11. Sook-Bin W, Hellstein WJ, Kalmar RJ. Systematic Review: teonecrosis of the jaws associated with the use of bisphos- Bisphosphonates and Osteonecrosis of the Jaws. Ann In- In tern Med 2006; 144: 753-761. phonates: A review of 63 cases. J Oral Maxillofac Surg ni io iz Ed IC C © 36 Annali di Stomatologia 2012;III (1): 31-36 

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Case report Eosinophilic ulcer of oral mucosa: a case report Marcelo Carlos Bortoluzzi, MD1 Introduction Fabrício Passador-Santos, MD2 li Diogo L. Capella, MS3 Eosinophilic ulcer (EU) is a rare self-limiting chronic be- Gabriel Manfro, MD4 nign lesion of the oral mucosa. Clinically, the ulceration na Rudy José Nodari Jr, MD5 has been most frequently found in tongue and it is char- Andréia Antoniuk Presta, MD6 acterized by the presence of mildly indurated borders which may resemble malignancies, traumatic ulcerations and some infections such as deep fungal infections, tu- io 1 Stomatology and Maxillofacial Surgery Professor, berculosis and primary syphilis (1-8). EU also has been School of Dentistry, Health Bioscience Postgraduate referred as traumatic ulcerative granuloma with stromal Program, Tissue Aspects for Health Prognosis and Inter- eosinophilia, traumatic eosinophilic granuloma, trau- az vention Laboratory (LAPROG), Santa Terezinha Univer- matic granuloma and ulcerative eosinophilic granuloma. sity Hospital (HUST), Oeste de Santa Catarina In infants, usually on the ventral surface of the anterior University (UNOESC) tongue secondary to trauma from newly erupted primary 2 Department of Pathology, São Leopoldo Mandic teeth, EU is referred as Riga-Fede disease (1-8). rn Institute and Research Centre The pathogenesis of the EU is still unclear, however the 3 School of Dentistry, Oeste de Santa Catarina lesion is thought to be reactive since trauma has been University (UNOESC) implicated as initiating factor, nevertheless trauma can- 4 Head and Neck Surgery Service, not be demonstrated in many cases. Histopathological te Santa Terezinha University Hospital (UNOESC) findings consist of eosinophil-rich mixed infiltrates in- 5 Health Bioscience Postgraduate Program, Tissue As- volving the superficial mucosa and the deeper muscle pects for Health Prognosis and Intervention Laboratory layer, accompanied by a population of large mononucle- (LAPROG), Oeste de Santa Catarina University In ar cells that may correspond either to histiocytic cells, (UNOESC) myofobroblastic cells or activated lymphoid cells. Immu- 6 Health Bioscience Postgraduate Program, nohistochemical studies showed the expression of CD3, Oeste de Santa Catarina University (UNOESC) CD4, CD8, CD20, CD43, cytotoxic granules (TIA-1) and for the large cells expression of CD30, vimentin and ni CD68. Lymphocytes may also express the proliferation Corresponding author: marker Ki-67 in small and large cells. The markers ALK Marcelo Carlos Bortoluzzi, MD (anaplastic lymphoma kinase), CD5, Beta-F1 and CD56 io Universidade do Oeste de Santa Catarina (UNOESC) were all described as negative. The differential histo- Faculdade de Odontologia pathologic diagnosis may include Langerhans cell his- Av. Getúlio Vargas, 2125, Bairro Flor da Serra, tiocytosis, Kimura disease, angiolymphoid hyperplasia iz Joaçaba, Santa Catarina, Brazil CEP (ZIP) 89600-000 with eosinophilia, atypical histiocytic granuloma, CD30+ Phones: + 55 49 3551 2047 or + 55 49 3551 2112 lymphoproliferative disorder of the oral mucosa, lympho- E-mail: mbortoluzzi@gmail.com ma, allergic reactions and parasitic diseases. Definite Ed or marcelo.bortoluzzi@unoesc.edu.br diagnosis can be achieved only by combining histologic findings with clinical follow-up (1-10). Summary Case report Eosinophilic Ulcer (EU) is a rare self-limiting chronic IC benign lesion of the oral mucosa with pathogenesis A 33 year-old male patient searched treatment due a still unclear, however it may resemble malignancies, solitary and painful ulcerative lesion in his right lateral traumatic ulcerations and some infections such as border of the tongue with two months of evolution and deep fungal infections, tuberculosis and primary with no history of associated trauma (Fig. 1). Examina- C syphilis. This is a case report of a patient with EU tion revealed a painful ulcer with relative firmness but not in the lateral border of the tongue with no history of indurated, containing borders bringing two aspects, ery- associated trauma and refractory to treatment with thematous or nodular, with a central ulcer reaching 4-5 drugs. The ulcer rapidly healed after an incisional cm in diameter that had a white-yellow fibrinous base. © biopsy and the definite diagnosis was achieved There were no significant regional lymphadenopathies. only combining histologic findings and the clinical The patient was non smoker and had a past of alcoholism follow-up. (has stopped for more than a year) with no actual alcohol abuse. The patient reported a previous clinical treatment Key words: eosinophilic ulcer, oral mucosa, ulcer- with his physician with no improvement or healing of the ative eosinophilic granuloma. lesion. He was admitted to Santa Terezinha University Annali di Stomatologia 2012; III (1): 11-13 11  M. Bortoluzzi et al. nohistochemistry for CD68 antibody revealed a diffuse pattern of stain mostly in large cells localized from the surface of the ulcerated area until the skeletal muscle. Positive stain for CD34 antibody was observed only in blood vessels present within the lesion. Periodic acid- li Schiff (PAS) and Ziehl-Nielssen stains were negative for microorganisms. At this point the histopathological diag- na nosis was inconclusive, however it was possible to reach the diagnosis of EU by combining histologic findings with the clinical follow-up. Forty-five days later the patient went through a cor- rective surgery due to the permanence of the exofitic io growths in the tongue and the histopathological analysis of this removed tissue brought none additional or inter- esting information. After an additional period of 30 days az the tongue showed a complete healing (Fig. 4). Fig. 1. Initial clinical aspect of the eosinophilic ulcer. Discussion rn Eosinophilic ulcer of the oral mucosa may be best re- garded as a reactive pattern of unclear etiology (5) and is characterized as rare benign entity which occurs as te In ni io Fig. 2. Clinical aspect of the lesion following the incisional bi- opsy. iz Hospital due to his clinical debilitating condition and due the complaint of severe pain with significant impairment of food intake. He was medicated empirically with intra- Ed venous Cephazolin 500 mg (three times a day), topical Fig. 3. Histopathological aspect of the tongue lesion. Notice that Tetracycline (three times a day, mouthwash), topical cor- the infiltrate extends from the ulcer base deep into subjacent ticoid (Dexamethazone, three times a day, mouthwash), skeletal muscle (H&E; 100x). non steroidal antiinflammatory and opioid analgesics for five days with no signs of healing. Preparing for a bi- opsy, blood tests were taken with none alterations found IC in complete blood count, hemosedimentation velocity, HIV test, rheumatoid factor, antinuclear antibody and fluorescent treponemal antibody-absorption test (FTA- ABS) though, C-reactive protein showed to be very high C (51.61 mg/L while the normal parameter is below than 6.5 mg/L). Chest radiographs where normal. An incision- al biopsy was performed and the patient was delivered from the hospital. Ten days postbiopsy the ulcer was © markedly diminished in size (Fig. 2). The histopathological findings showed an ulcerated area covered with fibrinoid material. A dense polymorphous inflammatory infiltrate was seen and with numerous eo- sinophils (Fig. 3). The infiltrate extends from the ulcer base deep into subjacent skeletal muscle. There were no mitotic figures or nuclear atypia in the infiltrate. Immu- Fig. 4. Final aspect of the tongue. 12 Annali di Stomatologia 2012; III (1): 11-13  Eosinophilic ulcer of oral mucosa: a case report an ulcerated and sometimes with nodular-ulcerated le- diagnosis and monitoring these patients are important to sion which is most frequently located on the tongue. The avoid possible complications or overtreatment due to the entity brings several clinical differential diagnoses which difficulties that arise in the histopathological exam, since include mainly malignancies, infectious diseases, auto- there is no specific hallmark of the disease and, there- immune diseases or others (2,3,5-8,10). fore, the histopathological diagnosis of EU is by exclu- In our case the immunohistochemical study showed sion (5). Monitoring is also important because low-grade li positivity for CD68 similarly to what was found by oth- lymphoma in routine microscopic exam, for example, na ers (1,4,7), and this is a routine macrophage marker, may only be recognized retrospectively, when lesions which may present immunohistochemical expression for recur several times, spread to other areas, or develop monocytes, macrophages, neutrophils, basophils, large more pronounced malignant features microscopically lymphocytes, myeloid precursors, osteoclasts, mast cell, (4). synovial cells, Langerhans’ cell histiocytosis, interdigi- io tating reticulum cell sarcomas and melanomas. CD68 has been described as having diagnostic utility for true References histiocytic lymphomas and granulocytic sarcoma (11). In az the present case, the CD34 immunohistochemical reac- 1. Regezi JA, Zarbo RJ, Daniels TE, Greenspan JS. Oral tion was expressed in normal endothelial cells. The main traumatic granuloma. Characterization of the cellular infil- diagnostic utility for CD34 is the identification of endo- trate. Oral Surg Oral Med Oral Pathol. 1993;75(6):723-727. thelial differentiation. It is sensitive regardless of tumor 2. Lourenço SV, Silva MA, Nico MM. An ulcer on the lip. Clin rn grade, recognizing greater than 85% of angiosarcomas Exp Dermatol. 2005;30(2):199-200. and Kaposi’s sarcomas (11). 3. Segura S, Romero D, Mascaró JM Jr, Colomo L, Ferrando In our case a rapid improvement of the ulcer occurred af- J, Estrach T. Eosinophilic ulcer of the oral mucosa: another ter the incisional biopsy similarly to what was described te histological simulator of CD30+ lymphoproliferative disor- by other authors (4,6,7,8) and the reason for that be- ders. Br J Dermatol. 2006;155(2):460-463. havior is unknown. Accordingly to Eleni et al. (8) this 4. Hirshberg A, Amariglio N, Akrish S, Yahalom R, Rosen- behavior may be indicative that the healing response is baum H, Okon E, et al. Traumatic ulcerative granuloma reactivated to the surgical intervention. In with stromal eosinophilia: a reactive lesion of the oral mu- Several therapeutic options for EU of the oral mucosa in cosa. Am J Clin Pathol. 2006;126(4):522-529. adults has been described like wait-and-see approach, 5. Segura S, Pujol RM. Eosinophilic ulcer of the oral mucosa: antibiotics, topical, intralesional and/or systemic cortico- a distinct entity or a non-specific reactive pattern? Oral Dis. steroids, curettage, cryosurgery and surgical excision ni 2008;14(4):287-295. (10). In this presented case topical or intravenous antibi- 6. Kumar SK, Dhyllon A, Sedghizadeh PP. Indurated tongue otics as well as topical corticosteroids showed no results lesion. J Am Dent Assoc. 2008;139(2):159-161. with none signs of healing of the ulcer. Intralesional and io 7. Boffano P, Gallesio C, Campisi P, Roccia F. Traumatic ul- systemic corticosteroids where not an option since deep cerative granuloma with stromal eosinophilia of the retro- fungal infection where considered as clinical hypothesis. molar region. J Craniofac Surg. 2009;20(6):2150-2152. Accordingly to el-Mofty et al. (9) in a review of 38 cases, iz 8. Eleni G, Panagiotis S, Andreas K, Georgia A. Traumatic ul- suggest that cell-mediated immunity might play an im- cerative granuloma with stromal eosinophilia: a lesion with portant role in the pathogenesis of EU, since that topical, as well as systemic prednisone, is effective in the treat- alarming histopathologic presentation and benign clinical Ed ment of this disorder. None response with that medicine course. Am J Dermatopathol. 2011;33(2):192-194. was obtained in this case as described above and this 9. el-Mofty SK, Swanson PE, Wick MR, Miller AS. Eosino- is in accordance with Segura and Pujol (5) which stated philic ulcer of the oral mucosa. Report of 38 new cases that the use of topical steroids does not have conclusive with immunohistochemical observations. Oral Surg Oral evidence of efficacy in treating EU. Med Oral Pathol. 1993;75(6):716-722. Surgical excision is the most commonly cited treatment 10. Ada S, Seckin D, Tarhan E, Buyuklu F, Cakmak O, Arikan IC procedure among the different therapies used and this U. Eosinophilic ulcer of the tongue. Australas J Dermatol. approach showed to be a reliable method with an excel- 2007;48(4):248-250. lent end result in this case report. Considering the be- 11. Bishop PW. An immunohistochemical vademecum. 2007. nign and self-limiting behavior of EU, achieving a correct Available at www.e-immunohistochemistry.info C © Annali di Stomatologia 2012; III (1): 11-13 13 

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Case report Management of the Schneiderian membrane perforation during the maxillary sinus elevation procedure: a case report li Deborah Meleo, DDS, PhD1 to the development of standardized, predictable and Francesca Mangione, DDS1 na safe regenerative techniques (1,2). The maxillary sinus Sergio Corbi, MD, DDS2 elevation is a surgical procedure that increases vertically Luciano Pacifici, MD, DDS1 the available bone volume on the lateral-posterior areas of the maxilla giving the possibility to place osseointegrated implants (3,4). Thanks especially to the io 1 “Sapienza” University of Rome, Italy ample indications from the literature (1-4), this procedure Department of Odontostomatological represents an excellent potential for the resolution of the and Maxillofacial Sciences bone atrophies associated to edentulism. Nevertheless, az 2 “San Camillo-Forlanini” Hospital, Rome, Italy such kind of intervention is still characterized by Department of Odontostomatolgy complications, often predictable and yet unavoidable, and Maxillofacial Sciences posing limitations to its successful application (5-8). The most common adverse events reported are: i) rn haemorrhage, mainly due to lesions of the intramural Corresponding author: artery, an anastomoses between the infraorbital artery Dr.ssa Deborah Meleo and the posterior superior alveolar artery, frequently Via Guglielmina Ronconi, 55 localized on the site in which the surgeon makes the te 00156 Rome - Italy bone window to reach the antral cavity; ii) laceration Phone: + 39 3392416306 of the Schneiderian membrane, usually occurring with E-mail: deborahhh@tin.it a range of incidence comprised between 7% and 35% In of cases (9-11). The latter may occur during different phases of the procedure: during the preparation of the antrostomy, while removing or turning over the bone Summary window, during the membrane raising or upon grafting. ni Moreover, there are some anatomical risk factors, like: The maxillary sinus elevation is a standard and Underwood’s septa, which are bony walls partitioning predictable procedure allowing the realization of the sinus, usually with a vertical progress; the angle dental implant rehabilitation in patients with severe io between the buccal and palatal walls of the antral cavity, bone atrophy in the lateral-posterior areas of the as analyzed on perpendicular tomographic sections, maxilla. Despite the presence of validated surgical especially when below 30°; irregularities of the sinus methods and the broad availability of biomaterials, floor due to the protrusion of the root profiles; previous iz the procedures aimed at increasing the bone volume sinus surgery; a decreased height of the residual by lateral antrostomy still entail complications alveolar ridge. Since discontinuities in the Schneiderian with different degrees of relevance. The prosthetic Ed mucosa impair the functional homeostasis of the antral and surgical outcome is based on a successful cavity and negatively affect the surgical outcome by coping with these aspects. The perforation of bacterial contamination of the graft and dispersion of the the Schneiderian membrane is one of the most particulate, several authors have studied and suggested frequent events for which a variety of protocols specific repair techniques for each type of perforation and approaches have been suggested by different (12-16). authors. In this work is presented a case study IC in which a technique to repair the sinus mucosa laceration occurring during a maxillary sinus Schneiderian membrane perforation: predisposing elevation procedure has been successfully adopted. factors, classification and management C Key words: Schneiderian membrane, maxillary sinus The maxillary sinus elevation is a standard and augmentation, sinus lift complications, underwood predictable surgical procedure to rehabilitate severe septa. vertical bone atrophies in the lateral-posterior areas of © the maxilla by placement of osseointegrated implants (6,8,17-22). However, it is known that complications Introduction like haemorrhage and perforation of the Schneiderian membrane may affect negatively the outcome of such Nowadays, the rehabilitation by prosthetic implants, procedure. In most reported cases, intra-operative even in edentulous areas of the maxillae affected by bleeding is due to the lesion of the anastomoses severe bone atrophies, is an inescapable need leading between the infraorbital artery and the posterior superior 24 Annali di Stomatologia 2012; III (1): 24-30  Management of the Schneiderian membrane perforation during the maxillary sinus elevation procedure: a case report alveolar arteries at an average distance of 19 mm from process (46-49). In the modified method, the cover of the apical ridge, with a tendency to superficialize in the sinus walls is still carried out with the support of a conditions of marked bone resorption. Such localization resorbable membrane located only on the surface of the often coincides with the area where the antrostomy of Schneiderian membrane, leaving the bone walls free access to the sinus cavity is carried out (9-11,14). so that the blood supply from the bone can favour the However, the most frequent unfavourable event vascularization and thereby the integration of the graft li associated to such intervention is the laceration of the into this virtual space. Moreover, in such technique na sinus mucosa. Such event is often predictable, but not the resorbable membrane is fastened at the superior avoidable, since it is strictly associated to anatomo- border of the antrostomy through titanium or surgical pathological predispositions (23-26). In the literature, steel pins before being reinserted in the sinus cavity; the following predisposing factors have been identified: a second membrane is positioned on the antrostomy previous phlogistic processes, irregularities of the externally, to further protect the biomaterial (46). It has io sinus floor, e.g. due to root protrusions, thickness of been demonstrated that the protection of the osteotomic the membrane below 1,5 mm, limited expansion of the window increases implant survival if some prerequisites anterior recess, angle between buccal wall and socket are respected: membrane stability, sterility and optimal az below 30°, former surgical treatments, reduced height of cohesion, compactness and handiness of the graft the alveolar ridge (27-34). In particular, the Underwood’s material (1,6,50-62). septa, present on average in 31% of the maxillary sinuses with a height of about 8 mm (range 3,5-2,2 rn mm), can involve all areas of the sinus. Usually they are Case report partial, they run vertically in buccal-palatal direction and are higher at the level of the medial wall; more rarely The reported clinical case has been managed they are multiple within the same antrum (8,24-26,29,35- in collaboration with the Departmental Unit of te 37). Odontostomatology and Maxillo-Facial Surgery of The laceration of the sinus mucosa affects negatively the San Camillo Forlanini Hospital (Rome, Italy). The the surgical outcome by increasing the risk of iatrogenic patient (female, 45 years old) asked for a functional and sinusitis, impairment of functional homeostasis and In aesthetical rehabilitation of the lateral posterior area of dispersion of the graft material in the antral cavity as the right emi-maxilla. Personal anamnesis excluded the well its bacterial colonization (38-40). Among several presence of pathologies contra-indicating the implant possibilities of repair of the perforation, as reported in rehabilitation as well as attitudes such as smoking. ni the international literature (8,19,20,41-45), we refer here The physical exam and the radiographic evaluation to the study of Fugazzotto and Vlassis (2003), which (orthopantomography) highlighted the presence of root classifies the lesions of the sinus mucosa in relation residuals 1.4, 1.6 and of the element 1.8 compromised io to size and position and associates to each class a for periodontal evaluation (Fig. 1). In order to proceed in specific therapeutic indication (46). Class 1 identifies the best conditions such elements have been extracted. the perforations below 5 mm in size that extend to the After four weeks the mucosae upon the post-extractive iz upper border of the antrostomy, for which it is simply sockets were perfectly recovered. The anatomical state, required a further detachment of the membrane to allow according to Chiapasco’s classification, was attributed the seal of the lesioned flaps (46,47); class 2A describes to class A in the area of element 1.5 and class C in the Ed lacerations located at the borders of the osteotomy, molar region (5). The individual prosthetic plan pointed delimited from at least 4-5 mm of intact tissue, with the towards the choice of an implant supported cemented suggestion to enlarge the limits of the bone window fixed prosthesis, following optimization of the sites and to apply a resorbable membrane in case of failed through surgical procedure of lateral maxillary right sinus sealing of the margins of the perforation (46-49); classes 2B and 3 correspond respectively to lacerations that IC develop laterally from the antrostomy, delimited by less than 4-5 mm of intact tissue, and to central lesions, often preexisting and determined by former dental avulsion or oroantral fistulae. These latter can be managed with the C same treatment, known as modified Pouch Technique (46-49). The original technique, known as “Loma Linda Pouch”, consists in covering the whole sinus with a collagen © membrane simulating the natural membrane, and the graft material is completely covered in its centre by folding the membrane on the lateral wall. However, in this manner, an external barrier is created that totally isolates the biomaterial from the blood supply coming from the walls of the sinus, thus representing an obstacle to the maturation of the graft and the recovery Figure 1 - Pre-operative orthopantomogram. Annali di Stomatologia 2012; III (1): 24-30 25  D. Meleo et al. elevation. The intervention was carried out in day hospital. inner part of the sinus to for the graft containment (Fig. Four block anaesthesias were executed at the level of 3). According to the suggestions of several authors the superior posterior alveolar nerve, the major palatine (11,50,51,53,54,60,62,63) we used as filler a compact nerve, the infraorbital nerve and the nasopalatine nerve, and consistent material in order to avoid the dispersion and one anaesthesia by infiltration of the fornix and the of particles in the sinus and thereby the possibility of palatine mucosa (articaine 4% and vasoconstrictor phlogistic processes due to bacterial colonization of li 1:100.000). Thereafter, a trapezoidal mucoperiosteal flap the graft. The material is a human-derived bone paste na with linear main incision between distal margin 1.3 and in blocks, called Bioset, available on request in Italy at area 1.7 has been set up, together with divergent release Rizzoli Orthopaedic Institute (I.O.R.), that is the italian incisions extended 5 mm beyond the mucogingival national public bank of the musculoskeletal tissue; this line. The flap has been opportunistically detached and product contains demineralized bone matrix (DBM) folded down to highlight the maxillary bone surface. The and bone corticospongious particulate carried in a io antrostomy, of rectangular shape with round corners thermoplastic gel of suine collagen (Fig. 4). and approximate size of 20 x 15 mm, has been carried out with piezoelectric devices. The detachment of the az membrane was initiated with piezoelectric devices and terminated with manual devices. Despite the absence of evident anatomical abnormalities and the accuracy of the surgical procedure, a perforation of the Schneiderian rn membrane of about 8 x 6 mm occurred (Fig. 2). te In Figure 4 - A human-derived bone paste in blocks, called Bioset, containing demineralized bone matrix (DBM). ni io Figure 2 - Maxillary sinus membrane perforation iz Following the suggestions of Fugazzotto and Vlassis, we chose to continue with the procedure and decided to Ed repair the lesion through the modified Pouch Technique (46). A resorbable membrane of freeze-dried bovine pericardium (Tutopatch, Tutogen Gmbh) was modelled and blocked with titanium pins above the superior border of the antrostomy and was then folded in the IC Figure 5 - Plastic consistency and easy manipulation of Bioset. The particulate component acts as a natural osteoconductive matrix at low resorbing activity, the C DBM allows the release of morphogenetic proteins, preserved by a peculiar sterilization process undergone by the material (BioCleanse®), while the carrier confers consistency and easy manipulation: it is preserved © at –20°C for 6 months or at –80°C for 5 years and it becomes plastic, malleable and adhesive when warmed in hot water in its sterile package up to a temperature between 43°C and 49 °C, while becoming stable in size and consistency at body temperature (Fig. 5). We have Figure 3 - A resorbable membrane of freeze-dried bovine peri- compacted only 2 cc of bone paste internally (Fig. 6), cardium positioned according to modified pouch technique. since overfilling has been shown to be responsible of 26 Annali di Stomatologia 2012; III (1): 24-30  Management of the Schneiderian membrane perforation during the maxillary sinus elevation procedure: a case report li na io Figure 8 - Histology of bone neoformation at six months after sinus lift (40x, H&E). Figure 6 - Maxillary sinus filled with Bioset. az rn te In Figure 9 - Ortopantomogram at six months after implants place- ment ni Figure 7 - A second resorbable membrane applied above the antrostomy. the necrosis of the sinus membrane with dispersion io of material and chronic sinusitis; thereafter, a second resorbable membrane above the antrostomy has been applied (Fig. 7). Finally, mattress suture horizontal with iz non resorbable monophilament was carried out. Figure 10 - Paraxial views of TC dentascan at one year after The patient underwent antibiotic, analgesic and anti- prosthetic rehabilitation. edemic therapy for seven days. After six months the Ed case has been evaluated clinically and radiographically. We could ascertain complete recovery of the tissues, integration of the graft and absence of phlogistic complications. We therefore proceeded with the placement of three implant fixtures of conic shape, diameter 4,5 x 12 mm, and one of 4,5 x 10 mm sand IC blasted and acid etched (TiRADIX s.r.l.). During the preparation of the sites of implant a bone biopsy was performed with a trephine bur (internal diameter of 2 mm). The sample was fixed by buffered formalin, C stained with hematoxilin-eosin and observed at the optic microscope (40x). The sections showed the presence of lamellar bone tissue with osteocyte lacunae (Fig. 8). Figure 11 - Panoramic views of TC dentascan at one year after Some lacunae appeared without cells, separated by © prosthetic rehabilitation. fibro-vascular tissue containing amorphous material. We noted lamellar bone in development, deposited in University of Rome). proximity of young trabeculae. The active process of The orthopanoramic radiography and TC exam with bone rearrangement was highlighted by the presence the specific software dentascan (Figs. 9, 10, 11), of osteoclasts and osteoblasts (courtesy of Prof. G. performed one year after prosthetic rehabilitation, show Soda, Department of Experimental Medicine, Sapienza the reorganization of the hard tissues in the antrum Annali di Stomatologia 2012; III (1): 24-30 27  D. Meleo et al. and around the fixtures. The case was subsequently 2. Shulman LB, Jensen OT. Sinus Graft Consensus Confer- rehabilitated with a cemented metalloceramic fixed ence. Introduction. Int J Oral Maxillofac Implants 1998;13 prosthesis. The clinical result appeared aesthetically (suppl): 5, 6. and functionally satisfactory also two years after dental 3. Esposito M, Grusovin MG, Rees J, Karasoulos D, Felice implant surgery (Fig. 12). P, Alissa R, Worthington HV, Coulthard P. Effectiveness li of sinus lift procedures for dental implant rehabilitation: a Cochrane systematic review. Eur J Oral Implantol 2010;3 na (1):7-26. 4. Pignataro M, Mantovani M, Torretta S, Felisati G, Sam- bataro G. ENT assessment in the integrated management of candidate for (maxillary) sinus lift. Acta Otorhinolaryngol Ital 2008; 28:110-119. io 5. Chiapasco M, Zaniboni M. Methods to treat the edentulous posterior maxilla: implants with sinus grafting. J Oral Maxil- lofac Surg 2009; 67(4):867-71. az 6. Del Fabbro M, Bortolin M, Taschieri S, Rosano G, Testori T. Implant survival in maxillary sinus augmentation. An updat- ed systematic review. J Osteol Biomat 2010;1 (2):69-79. 7. Simion M. Bone regeneration and biomaterials: state of rn the art and future perpectives. Quality in Implantology. SIO International Congress, Rome 5-6 Febbraio 2010. Figure 12 - Clinical result at two years after implant surgery. 8. Testori T, Weinstein R, Wallace S. La Chirurgia del Seno te Mascellare e le alternative terapeutiche. Edizioni ACME, Conclusions maggio 2006. Viterbo. 9. Elian N, Wallace S, Cho SC, Jalbout ZN, Froum S. Dis- The maxillary sinus elevation is a surgical standard and tribution of the Maxillary Artery as It Relates to Sinus highly predictable procedure allowing the positioning of In Floor Augmentation. Int J Oral Maxillofac Implants 2005; osseointegrated implants also in case of serious bone 20:784–787. atrophy of the maxilla (8,64). 10. Flanagan D. Arterial supply of the maxillary sinus and po- However, this procedure is not devoid of complications. tential for bleeding complication during lateral approach ni The most frequent is the perforation of the Schneiderian sinus elevation. Implant Dent 2005 Dec; 14 (4):336-8. membrane, occurring in 7-35 % of cases. The factors 11. Zijderveld SA, van den Bergh JP, Schulten EA, ten Brug- affecting such incidence are often anatomical (8- genkate CM. Anatomical and surgical findings and com- io 11,24-26,28,36,37). Despite accurate pre-surgical plications in 100 consecutive maxillary sinus floor eleva- radiographic investigations, in some cases the laceration tion procedures. J Oral Maxillofac Surg 2008 Jul; 66 (7): is unavoidable even when the surgical manoeuvres are 1426-38. performed at best (17,21,22,27,30,32-34). iz 12. Rosano G, Taschieri S, Gaudy JF, Lesmes D, Del Fabbro In the past some authors suggested stopping the M. Maxillary sinus septa: a cadaveric study. J Oral Maxil- procedure in case of perforation and postponing it after lofac Surg 2010 Jun; 68 (6): 1360-4. Ed recovery (44). Despite Hernàndez-Alfaro demonstration 13. Gosau M, Rink D, Driemel O, Draenert FG. Maxillary si- of an inverse relationship between the size of the nus anatomy: a cadaveric study with clinical implications. laceration and the implant survival, it is currently not Anat Rec (Hoboken) 2009; 292 (3): 352-4. suggested to interrupt the surgical procedure (29). 14. Solar P, Geyerhofer U, Traxler H, Windisch A, Ulm C, In the reported clinical case the repair of the Watzek G. Blood supply to the maxillary sinus relevant to Schneiderian membrane allowed a radiological, clinical sinus floor elevation procedures. Clin Oral Implants Res IC and histological success. Therefore, the evolution of 1999; 10: 34-44. biomaterials currently available and the standardization 15. Ulm CW, Solar P, Krennmair G, Matejka M, Watzek G. of the techniques allow a higher predictability of Incidence and suggested surgical management of septa success and extend the applicative possibilities of such in sinus-lift procedures. Int J Oral Maxillofac Implants C procedure. 1995;10(4):462-5. 16. Van den Bergh JP, Bruggenkate CM, Disch FJ, Tuinzing DB. Anatomical aspects of sinus floor elevations. Clin References Oral Implants Res 2000; 11(3): 256-65. © 17. Barone A, Santini S, Marconcini S, Giacomelli L, Gherlone 1. Froum SJ, Wallace SS, Elian N, Cho SC, Tarnow DP. E, Covani U. Osteotomy and membrane elevation during Comparison of mineralized cancellous bone allograft the maxillary sinus augmentation procedure. A compara- (Puros) and anorganic bovine bone matrix (Bio-Oss) for tive study: Piezoelectric device vs conventional rotative sinus augmentation: histomorphometry at 26 to 32 weeks instrumentations. Clin Oral Implants Res 2008; 19: 511- after grafting. Int J Periodontics Restorative Dent 2006 515. Dec; 26 (6): 543-51. 18. Mandelaris GA, Rosenfeld AL. A Novel Approach to the 28 Annali di Stomatologia 2012; III (1): 24-30  Management of the Schneiderian membrane perforation during the maxillary sinus elevation procedure: a case report Antral Sinus Bone Graft Technique: The Use of a Pro- 35. Betts NJ, Miloro M. Modification of the sinus lift procedure totype Cutting Guide for Precise Outlining of the Lateral for septa in the maxillary antrum. J Oral Maxillofac Surg Wall. A Case Report. Int J Periodontics Restorative Dent 1994; 52: 332-333. 2008 Dec;28(6):569-75. 36. Kim MJ, Jung UW, Kim CS, Kim KD, Choi SH, Kim CK, 19. Testori T, Del Fabbro M, Taschieri S, Francetti L, Wein- Cho KS. Maxillary sinus septa: prevalence, height, loca- li stein RL. Il rialzo del seno mascellare. Italian Oral Sur- tion, and morphology. A reformatted computed tomogra- gery 2005,139-48. phy scan analysis. J Periodontol 2006; 77(5): 903-8. na 20. Tatum OH Jr, Lebowitz MS, Tatum CA, Borgner RA. Si- 37. Urist MR. Bone formation by autoinduction. Science 1965; nus augmentation. Rationale, development, long-term re- 150: 893-99. sults. N Y State Dent J. 1993;59(5):43-8. Review. 38. Chandra RK, Pearlman A, Conley DB, Kern RC, Chang D. 21. Vercellotti T, De Paoli S, Nevins M. The piezoelectric bony Significance of osteomeatal complex obstruction. J Oto- window osteotomy and sinus membrane elevation: Intro- laryngol Head Neck Surg 2010;39(2):171-4. io duction of a new technique for simplification of the sinus 39. Halma AR, Decreton S, Bijloos JM. Density of epithelial augmentation procedure. Int J Periodontics Restorative cells in the normal human nose and the paranasal sinus Dent 2001;21:561-567. mucosa: A scanning electron microscopic study. Rhinol- az 22. Wallace SS, Mazor Z, Froum SJ, Cho SC, Tarnow DP. ogy 1990; 28: 25-32. Schneiderian membrane perforation rate during sinus 40. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report elevation using piezosurgery: clinical results of 100 of the Sinus Consensus Conference of 1996. Int J Oral consecutive cases. Int J Periodontics Restorative Dent Maxillofac Implants 1998; 13(suppl): 11–45. rn 2007;27(5):413-9. 41. Pikos MA. Maxillary sinus membrane repair: Update on 23. Krennmair G, Ulm CW, Lugmayr H, Solar P. The inci- technique for large and complete perforations. Implant dence, location, and height of maxillary sinus septa in the Dent 2008; 17: 24-31. te edentulous and dentate maxilla. J Oral Maxillofac Surg 42. Proussaefs P, Lozada J, Kim J. Effects of sealing the per- 1999; 57 (6): 667-71; discussion 671-2. forated sinus membrane with a resorbable collagen mem- 24. Toscano NJ, Holtzclaw D, Rosen PS. The effect of piezo- brane: a pilot study in humans. J Oral Implantol 2003; electric use on open sinus lift perforation: a retrospective 29(5): 235-41. In evaluation of 56 consecutively treated cases from private 43. Vina-Almunia J, Penarrocha-Diago M, Penarrocha-Diago practices. J Periodontol 2010;81(1):167-71. M. Influence of perforation of the sinus membrane on the 25. Ulm CW, Solar P, Gsellmann B, Matejka M, Watzek G. survival rate of implants placed after direct sinus lift. Lit- The edentulous maxillary alveolar process in the region erature update. Med Oral Patol Oral Cir Bucal 2009;14(3). ni of the maxillary sinus: a study of physical dimension. Int J 44. Biglioli F, Pedrazzoli M, Colletti G. Repair of a perforated Oral Maxillofac Implants 1995;24(4):279-82. sinus membrane with a palatal fibromucosal graft: a case 26. Underwood AS. An Inquiry into the Anatomy and Patholo- report. Minerva Stomatol. 2010 May;59(5):299-302, 302- io gy of the Maxillary Sinus. J Anat Physiol 1910;44:354-69. 4. English, Italian. 27. Ardekian L, Oved-Peleg E, Mactei EE, Peled M. The clini- 45. Testori T, Stephen S,Wallace N, Del Fabbro M, Taschieri cal significance of sinus membrane perforation during S, Trisi P, Capelli M, Weinstein RL. Riparazione di grandi iz augmentation of the maxillary sinus. J Oral Maxillofac perforazioni della membrana sinusale mediante mem- Surg 2006; 64(2): 277-82. brane riassorbibili: tecniche chirurgiche con evidenza 28. Cho SC, Wallace SS, Froum SJ. Influence of anatomy on istologica e radiografica di successo. Parodontologia & Ed Schneiderian membrane perforations during sinus floor Odontoiatria Ricostruttiva 2008: 28; 1 9-17. elevation surgery: Three dimensional analysis. Pract 46. Fugazzotto PA, Vlassis J. A simplified classification and Periodont Aesthet Dent 2001; 13(2): 160-3. repair system for sinus membrane perforations. J Peri- 29. Hernández-Alfaro F, Torradeflot MM, Marti C. Prevalence odontol 2003; 74(10): 1534-41. and management of Schneiderian membrane perfora- 47. Parenti A, Capelli M, Fumagalli L, Zuffetti F, Galli F, Tas- tions during sinus-lift procedures. Clin Oral Implants Res chieri S, Del Fabbro M, Castellaneta R, Testori T. Pre- IC 2008;19(1):91-8. venzione e gestione delle complicanze. Perforazioni della 30. Suguimoto RM, Trindade IK, Carvalho RM. The use of membrana sinusale. Italian Oral Surgery 2007; 1: 29-32. negative pressure for the sinus lift procedure: a technical 48. Proussaefs P, Lozada J. The “Loma Linde Pouch”. A tech- note. Int J Oral Maxillofac Implants 2006;21(3):455-8. nique for repairing the perforated sinus membrane. Int J C 31. Tatum OH. Maxillary and sinus implant reconstruction. Periodontic Restorative Dent 2003;23:593-597. Dent Clin North Am 1986;40: 207-229. 49. Testori T, Trisi P, Del Fabbro M, Francetti L, Taschieri S, 32. Ucer C. Nasal suction technique for maxillary sinus floor Parenti A, Bianchi F, Zuffetti F. Gestione intraoperatoria di elevation: a report of 24 consecutive patients. Int J Oral ampie perforazioni della membrana del seno mascellare. © Maxillofac Implants 2009;24(6):1138-43. Italian Oral Surgery 2007; 1(6): 21-28. 33. Ucer TC. Use of negative air pressure by nasal suction 50. Arora NS, Ramanayake T, Ren YF, Romanos GE. Platelet- during maxillary sinus floor lift: audit of 13 consecutive rich plasma in sinus augmentation procedures: a system- sinus grafts. Br J Oral Maxillofac Surg 2009;47(2):151-2. atic literature review: Part II. Implant Dent 2010;19(2):145- 34. Vitkov L, Gellrich NC, Hannig M. Sinus floor elevation via 57. hydraulic detachment and elevation of the Schneiderian 51. Boyne PJ, Lilly LC, Marx RE, Moy PK, Nevins M, Spagnoli membrane. Clin Oral Implants Res 2005;16:615–21. DB, Triplett RG. De novo bone induction by recombinant Annali di Stomatologia 2012; III (1): 24-30 29  D. Meleo et al. human bone morphogenetic protein-2 (rhBMP-2) in max- 151-71. Epub 2010 Jun 21. illary sinus floor augmentation. J Oral Maxillofac Surg. 58. Nkenke E, Stelzle F. Clinical outcomes of sinus floor aug- 2005; 63(12): 1693-707. mentation for implant placement using autogenous bone 52. Browaeys H, Bouvry P, De Bruyn H. A literature review or bone substitutes: a systematic review. Clin Oral Im- on biomaterials in sinus augmentation procedures. Clin plants Res 2009; 20 Suppl 4: 124-33. li Implant Dent Relat Res 2007; 9(3): 166-77. 59. Rickert D, Sauerbier S, Nagursky H, Menne D, Vissink A, 53. Tarnow DP, Wallace SS, Testori T, Froum SJ, Motroni A, Raghoebar GM. Maxillary sinus floor elevation with bo- na Prasad HS. Maxillary sinus augmentation using recom- vine bone mineral combined with either autogenous bone binant bone morphogenetic protein-2/acellular collagen or autogenous stem cells: a prospective randomized clini- sponge in combination with a mineralized bone replace- cal trial. Clin Oral Implants Res. 2011 Mar;22(3):251-8. ment graft: a report of three cases. Int J Periodontics Re- Epub 2010 Sep 10. Erratum in: Clin Oral Implants Res. storative Dent 2010 Apr; 30(2): 139-49. 2011 Jul; 22(7): 777. io 54. Hu Z, Peel SA, Ho SK, Sándor GK, Su Y, Clokie CM. The 60. Sohn DS, Bae MS, Choi BJ, An KM, Shin HI. Efficacy of expression of bone matrix proteins induced by different demineralized bone matrix paste for maxillary sinus aug- bioimplants in a rabbit sinus lift model. J Biomed Mater mentation: a histologic and clinical study in humans. Oral az Res A. 2010 Dec 15; 95(4): 1048-54. Epub 2010 Sep 28. Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Nov; 55. Khoury F. Augmentation of the sinus floor with mandibu- 108(5): e30-5. lar bone block and simultaneous implantation: a 6-year 61. Urist MR. Bone formation by autoinduction. Science 1965; clinical investigation. Int J Oral Maxillofac Implants 1999; 150: 893-99. rn 14(4): 557-64. 62. Zhang M, Powers RM Jr, Wolfinbarger L Jr. A quantita- 56. Kim SW, Lee IK, Yun KI, Kim CH, Park JU. Adult stem tive assessment of osteoinductivity of human demineral- cells derived from human maxillary sinus membrane and ized bone matrix. J Periodontol 1997;68(11):1076-84. te their osteogenic differentiation. Int J Oral Maxillofac Im- 63. Corbi S, Meleo D, Tarquini G, Pacifici L. Impiego delle pro- plants 2009;24(6):991-8. teine ossee morfogenetiche (BMPs) nella rigenerazione 57. Moore ST, Katz JM, Zhukauskas RM, Hernandez RM, ossea guidata dei mascellari. Ann Stomatol 2009; 58(4): Lewis CS, Supronowicz PR, Gill E, Grover SM, Long 107-116. NS, Cobb RR. Osteoconductivity and osteoinductivity of In 64. Misch CE. Implantologia contemporanea. 3° edizione, Puros(R) DBM putty. J Biomater Appl. 2011 Aug; 26(2): 2009. Elsevier Masson Editore. ni io iz Ed IC C © 30 Annali di Stomatologia 2012; III (1): 24-30 

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Editorial Antibiotic prophylaxis: reasoned choice and not casual use li na Medical and dental practitioners are going through difficult years in which litigation is frequent, because of complications related to treatment vs non treatment decision as well as to each treatment option vs any others possible. This is also true as far as antibiotic prophylaxis is concerned, so litigation may io arise due to surgical or distant site infections subsequent to interventions carried out without preven- tive antibiotic treatment as well as from any kind of adverse reactions against the prescribed antibio- tic. az However, law is inclined to ascribe professional guilt to antibiotic treatment failure without evaluating the overtreatment risks whose consequences will occur most likely un-indicated in the future. There- fore, no legal problems arise from the two most important negative effects of the not ruled and excessive rn use or abuse of antibiotics, that is microbial resistance firstly and allergy secondly. Some observations have to be made in this regard. People are used to self-prescription and they often do not stick to the physician’s and dentist’s pre- te scriptions as far as antibiotic type, dosage and timing are concerned. Household medicine chests are full of many, and often expired, drugs among which and above all antibiotics. As soon as a mild in- flammatory symptom appears (slight fever, cough) people take antibiotics often without any indications In and in a non-effective way. This is a wrong approach in health care due to disinformation, bad habits, disease phobia, lack of time and money for medical and dental consultations, unavailability of medi- cal and dental practitioners, possibility to buy such drugs without specialist’s prescription and availa- bility of drugs at home. The latter is often due to the fact that pharmaceutical companies do not ma- ni nufacture and sell antibiotic packaging for prophylactic use, therefore patients are forced to buy the usual antibiotic packaging, which is for therapeutic use, and contains more tablets than those neces- sary for prophylactic use. Physicians and dentists are also responsible for this situation since they do io not update their specific knowledge on prophylactic antibiotic treatment and thus their approach is due to force of habit, they use an excess of zeal and they usually apply the concept that “melius abunda- re quam deficere” or “a little bit of antibiotics cannot harm anyone”. In the light of the above-mentio- iz ned considerations, an effective antibiotic policy is therefore necessary to avoid inappropriate use or abuse of antibiotics. In recent years an attempt to regulate prophylactic antibiotic use has been made by many internatio- Ed nal associations of surgeons, cardiologists, orthopaedics and dentists in order to verify the accuracy and the level of evidence of the existing guidelines on antibiotic prophylaxis of distant and surgical site infections. Currently, the scientific world’s position is clear as far as distant site infections are concer- ned, involving mainly the endocardium but also prosthetic joints, indwelling venous catheters and car- diovascular implantable electronic devices, with a dramatic reduction of the number of subjects in which IC antibiotic prophylaxis is considered to be necessary. The most important reasons for this reduction are the very low number of surgery-related distant site infections and the lack of evidence concerning antibiotic effectiveness in reducing the risk of occur- rence of such an infection. Only about 50% of oral surgery-related endocarditis and only a small per- C centage of prosthetic joint infections are caused by oral microbial strains and the temporal relation- ship between dental procedures and the onset of infection is not always verifiable. Most distant site infections also occur when antibiotic prophylaxis is applied and also when the responsible bacterium © was sensitive to the antibiotic used. Moreover, the cost for a routine antibiotic prophylaxis is very high if compared to the cost of the antibiotic therapeutic treatment of all the related distant site infections. In the light of these considerations, only subjects with high risk of distant site infections, in which very serious complications can develop in relation to those infections, are eligible for antibiotic prophyla- xis. This change led us to consider some different approaches for the patients, particularly for those to whom antibiotic prophylaxis was once prescribed and which is currently no longer indicated. Ac- Annali di Stomatologia 2011; II (3-4): 1-2 1  tually, they should be informed about the lack of scientific evidence supporting the use of antibiotic pro- phylaxis in their specific situation and about the problems related to repeated indiscriminate antibio- tic treatments, such as allergy, toxicity and above all bacterial resistance that induces the lack of an- tibiotic effectiveness when, on the other hand, it is actually necessary. The choice to use or not antibiotics as a preventive measure should therefore derive from a discus- li sion with the patient once he/she is completely informed. However, a problem can emerge from the na different indications that the patients can obtain from the physician, the cardiologist, the orthopaedic and the dentist regarding the need of antibiotic prophylaxis. This problem can easily be overcome if a complete written informed consent is obtained from the patient before the dental procedure is perfor- med. io The situation is very different with regard to the antibiotic prophylaxis of surgical site infections since in most oral procedures there are no guidelines or recommendations concerning the use, or not, of antibiotics provided by associations of oral and maxillofacial surgeons worldwide. Two main factors az should be always taken into consideration: the surgical infection risk of each procedure, firstly and the patient’s immunological status, secondly. To pursue the “minimum non nocere” aim, only procedures with a high risk of infection and immuno- compromised/immunosuppressed patients need antibiotic prophylaxis for surgical site infections. An- rn tibiotic prophylaxis is also necessary for procedures in which surgical infections can dramatically com- promise the final outcome, such as in regenerative surgeries. However, it is still unclear whether only one preoperative dose should be administered or if and how many further doses are needed and what te drug is better to use according to the kind of surgery performed. In the light of these uncertainties, it is advisable that the surgeon inform the patient about the real in- fection risk of the surgical procedure and about the postoperative measures which should be applied In to avoid infection. Moreover, the greater the risk of infection, the closer the follow-up sessions should be, especially if antibiotic prophylaxis was not prescribed. The natural course of healing must be ex- plained to the patient so that, for example, she/he will not think that the physiological post-operative swelling is due to an infection and decides to take antibiotics on his/her own without being examined ni first. Only if real signs or symptoms of infections appear in the post-operative period, antibiotics should be administered as therapy as soon as possible. In conclusion, since antibiotic prophylaxis of surgical site infection is under the surgeon’s responsibi- io lity, all local and general as well as environmental and climatic conditions which may increase the in- fection risk must be adequately considered although it is highly un-recommended to always and indi- scriminately prescribe antibiotics, since microbial resistance is around the corner and sooner or later iz a serious infection will appear also in the presence of specific antibiotics or they will be not effective in the treatment of an infection for which they are usually given as first choice. Ed Roberto Pippi Associate Professor of Oral Surgery, Department of Oral and Maxillofacial Sciences IC “Sapienza” University of Rome, Italy E-mail: roberto.pippi@uniroma1.it C © 2 Annali di Stomatologia 2011; II (3-4): 1-2 

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Literature review Lactoferrin and oral diseases: current status and perspective in periodontitis li na Francesca Berlutti1, BScD riodontitis in in vitro model and observational clinical Andrea Pilloni2, MD study. In in vitro model, represented by gingival fi- Miriam Pietropaoli3, BScD, LD broblasts infected with Prevotella intermedia, Lf exer- io Antonella Polimeni2, MD, DDS ted a potent anti-inflammatory activity. In the obser- Piera Valenti1, BScD vational clinical trial performed through bovine Lf (bLf) topically administered to volunteers suffering from pe- az riodontitis, bLf decreased cytokines, including IL-6 in “Sapienza” University of Rome, Rome,Italy crevicular fluid, edema, bleeding, pocket depth, gingival 1 Department of Health Sciences and plaque index, thus improving clinical attachment and Infectious Diseases levels. 2 Department of Oral and Maxillofacial Sciences Even if other clinical trials are required, these results rn 3 Microbo srl, Biotechnology Company, Rome, Italy provide strong evidence for a instead of an therapeutic potential of this multifunctional natural protein. Corresponding author: Key words: lactoferrin, oral cavity, periodontitis, in- te Prof. Piera Valenti flammation. Department of Public Health and Infectious Diseases “Sapienza” University of Rome P.le A.Moro, 5 00185 Rome, Italy In Introduction Phone: +390649914543 Lactoferrin (Lf), an 80-kDa iron-binding glycoprotein be- Fax: +390649914626 E-mail: piera.valenti@uniroma1.it longing to the transferrin family, is a component of human secretions including saliva, and it is synthesized by exo- ni crine glands and neutrophils in infection and inflammation Summary sites (1). Lf, containing 691 amino acid residues, is folded into two homologous lobes (N-lobe residues 1–333, and io Lactoferrin (Lf), an iron-binding glycoprotein able to C-lobe residues 345–691) connected by a peptide (resi- chelate two ferric ions per molecule, is a component dues 334–344), which forms a 3-turn α-helix (Fig. 1). This of human secretions synthesized by exocrine glands glycoprotein, highly conserved among human, bovine, mou- iz and neutrophils in infection/inflammation sites. Lac- se, and porcine species, is able to reversibly chelate two toferrin in saliva represents an important defence fac- ferric ions per molecule with high affinity (Kd ~ 10−20 M) tor against bacterial injuries including those related retaining ferric iron to pH values as low as 3.0, whereas transferrin retains ferric iron to pH of about 5.5 (1, 2, 3). Ed to Streptococcus mutans and periodontopathic bac- teria through its ability to decrease bacterial growth, The iron-binding affinity is high enough that, in the presence biofilm development, iron overload, reactive oxygen of Lf or transferrin, the concentration of free iron in body formation and inflammatory processes. fluids cannot exceed 10–18 M, thus preventing the preci- A growing body of research suggests that inflamma- pitation of this metal as insoluble hydroxides, inhibiting mi- tory periodontal disease involves a failure of resolu- crobial growth and hindering the formation of reactive oxy- tion pathways to restore tissue homeostasis. There is gen species and related inflammatory processes (1). IC an important distinction between anti-inflammation and Lf concentration in human exocrine secretions is reported resolution; anti-inflammation is pharmacologic inter- in Table 1. The reported concentrations increase in infec- vention in inflammatory pathways, whereas resolution tion and/or inflammation sites due to the recruitment of neu- involves biologic pathways restoring inflammatory ho- trophils: 106 neutrophils secrete 15 µg of Lf. C meostasis. An appropriate regulation of pro-inflam- matory cytokine synthesis might be useful in reducing Antibacterial activity of lactoferrin related periodontal tissue destruction. Recently, the multi- and unrelated to its iron withholding ability functional IL-6 is emerging as an important factor able The first function attributed to Lf was antibacterial activi- © to modulate bone, iron and inflammatory homeosta- ty depending on its ability to sequester iron necessary for sis. bacterial growth and survival (5). This action of Lf was con- Here, we report an overview of Lf functions as well as sidered bacteriostatic, as reversible by the addition of fer- for the first time Lf anti-inflammatory ability against pe- ric iron (6). Grants: This work was granted by Sapienza University of Rome, Italy, to AP and PV to perform in vitro anti-inflammatory activity of lactoferrin. The observational clinical study was supported by Microbo srl Biotechnology Company, Rome, Italy 10 Annali di Stomatologia 2011; II (3-4): 10-18  Lactoferrin and oral diseases: current status and perspective in periodontitis Table 1 - Lactoferrin concentration in human secretions. Biological fluids Concentration (mg/ml) Colostrum 8 Milk 1.5-4 li Tears 2 Saliva 0.008 na Joint fluid 0.001 Vaginal secretion 0,008 Seminal fluid 0.112 Cerebrospinal fluid Undetectable io Plasma 0.0004 az Figure 1 - Structure of lactoferrin. From: Baker & Baker, 2004 (4). kers of mucosal immunity as immunoglobulins, including IgA, IgM and IgG, α-amylase, lysozyme and Lf are de- tectable in saliva (27). Evidence is constantly increasing However, bacterial pathogens are able to overcome iron li- to support the use of saliva as a non-invasive tool for mo- mitation by means of two principal systems. The first is re- rn nitoring biomarkers in health and pathological human sta- presented by the synthesis of small chelators, sideropho- tus (28). res, which bind ferric ion with high affinity and transport it However, it is important to follow some guidelines prior to into bacteria through a specific receptor (7, 8). In addition saliva collection in order to minimize error variance and to the synthesis of siderophores, some highly host-adap- te chances of methodological errors (29, 30). Food or drink ted bacterial species as Porphyromonas gingivalis acqui- intake must be avoided at least 2 h prior to sampling, due re iron directly through surface receptors able to specifically to variations in saliva secretion which in turn will negati- bind Lf or other iron binding molecules as hemin and heme vely affect the results. Food or drink high in sugar content, (9, 10, 11), and transport it across the outer membrane. The In caffeine or acidity can stimulate saliva flow, and acidity will iron is then bound by a periplasmic iron-binding protein, lower mouth pH levels, both compromising antibody–an- FbpA, and transported into the bacteria via an inner mem- tigen binding and enzyme activity thus leading to invalid brane complex comprised of FbpB and FbpC (12). immunoassay results. In addition, alcohol consumption 24 An iron-independent bactericidal effect of Lf was also de- h prior to sampling should be avoided as it may cause in- ni scribed (13). A direct interaction between Lf and lipopoly- creased saliva secretion (29, 30, 31). saccharide (LPS) of Gram-negative or lipoteichoic acid of Among salivary proteins, Lf is the most important factor Gram-positive bacteria is required for the lethal effect (14, of natural immunity. Its concentration corresponds to io 15, 16). Furthermore, it has been demonstrated that the bin- 1.23 mg/l in gingival crevicular fluids (GCF) and to 8.96 and ding of Lf to the lipid A of LPS (17, 18), induces a release 7.11 mg/l in unstimulated and stimulated saliva, respec- of LPS. This bactericidal activity of Lf appears to be loca- tively. The Lf concentration in oral cavity is related to dif- iz ted in the N-terminal region as its derivative cationic pep- ferent fluid samples to be assayed. In fact, unstimulated tide (residues 17-41), called lactoferricin (Lfcin), is several saliva mainly derives from 70% submandibular, 20% pa- fold more active than the intact protein (19, 20, 21). More rotid, and 2% sublingual glands, while stimulated saliva recently, the 1-11 residues in N-terminal region of Lf has Ed mainly derives from 30% submandibular and 60% paro- shown to possess an antibacterial activity against Strep- tid glands (28). Moreover, the concentration of this gly- tococcus mutans through its binding with bacterial DNA (22). coprotein in GCF is influenced by the amount of the ex- Moreover, the Lf antibacterial activity related to its capa- creted fluid which, in turn, depends from physiological or bility to release LPS can be annulled by high calcium con- pathological status of the subject. The Lf concentration, centration in the culture media (23). As Lf is also able to measured /site, clearly shows that its levels increase from bind Ca(II) through the carboxylate groups of the sialic acid 36 ng/site in healthy humans to 63 and 90 ng/site in gin- IC residues, present on two glycan chains, it cannot be ruled gival and periodontal diseases, while its concentration cal- out that the release of LPS from Gram-negative bacteria culated /ml is similar in health and pathological conditions can be also due to this additional binding property of Lf (23). (32). Even if the detection of Lf as well as of other proteins in C Lactoferrin in saliva saliva, easily accessible source of potential local and sy- Saliva is composed of 98% water and its pH is around 6.64 stemic biomarkers of health and pathological status, the (24, 25). Saliva composition consists of hormones, pep- different amount of salivary flux in calculating the real con- tides, electrolytes, mucus, antibacterial compounds and centration of the proteins must be considered. © various enzymes (26). Steroid hormones detectable in sa- This is a very critical point which can explain the conflic- liva comprise cortisol, androgens including testosterone ting data reported by different Authors on Lf oral concen- and dehydroepiandrosterone, oestrogens and progeste- tration. Of note, several defence proteins (e.g. lysozyme, rone as well as aldosterone. Furthermore, saliva is rich Lf and histatin-1) were found significantly more abundant in organic constituents as proteins, albumin, urea, uric acid, in old (55–65 years old) than in young female (20–30 ye- lactate, and creatinine (26). Inorganic compounds are also ars old) subjects (33). These results, demonstrating that present in saliva; Na+, K+ and Ca2+ are the main cations Lf synthesis in the saliva of females is age dependent, are and Cl− and HCO3− the main anions (26). Furthermore, mar- in sharp contrast with the well ascertained data showing Annali di Stomatologia 2011; II (3-4): 10-18 11  F. Berlutti et al. that Lf synthesis is under the control of steroid hormones both a physiological process and a serious problem that (34) and consequently, it decreases in menopausal and can lead to oral illness. Efforts to control microbial adhe- postmenopausal periods. sion by anti-adhesive new materials or compounds have Summarizing, the changes of the Lf concentration depend had modest success once applied to the patient. Conse- not only from significant changes of saliva samples (un- quently, it could be very helpful to discover other com- stimulated, stimulated) but they are also age-dependent. pounds able to hinder microbial adhesion. The ability of Lf, li It was reported that Lf levels in GCF of patients with gin- in both apo- and iron-saturated form, to inhibit the adhe- givitis, adult periodontitis (chronic periodontitis), and lo- sion of S. mutans to hydroxyapatite (HA), mimicking tooth na calized juvenile periodontitis (aggressive periodontitis) are surface (47), may represent an interesting function. The similar, but higher than in normal subjects (32, 35, 36). Ano- demonstration that Lf inhibits the adhesion of S. mutans ther study indicates that Lf level in GCF correlates with the to a salivary film and HA through residues 473–538 of its clinical severity of periodontal diseases and the number C-lobe (48), further helped to understand this activity, which io of polymorphonuclear leucocytes (37). A decrease in Lf le- is unrelated to its iron binding properties. Both apo- and vels was observed in GCF and saliva after surgical pe- iron-saturated bLf also inhibit adhesion of free and ag- riodontal treatment in chronic periodontitis (38). Similar Lf gregated S. mutans cells to a dental polymer when Lfs were decrease in GCF and peripheral blood after oral hygiene pre-coated to dental polymer or bound to both dental po- az procedures in experimental gingivitis using healthy vo- lymer and bacterial cells (41). Apo-Lf but not iron-satura- lunteers was also detected (39). Lf is not synthesized in ted Lf also inhibits the attachment on HA of Prevotella ni- the healthy gingival tissues and elevated Lf levels in the grescens by binding to both HA and bacteria (49). Apo- GCF of inflamed tissues originate from invading inflam- Lf reduces the initial attachment of the commensal Strep- rn matory cells (40). Thus, Lf is released from neutrophils in tococcus gordonii by iron sequestration, but not that of pe- GCF in response to the inflammatory condition of perio- riodontopathogens Fusobacterium nucleatum and P. gin- dontitis as a potential host defence factor against perio- givalis. Interestingly, the initial attachment of mixed po- dontopathic bacteria and may be a good marker of pe- pulations of S. gordonii/F. nucleatum and S. gordonii/P. gin- te riodontal diseases. givalis is significantly reduced in the presence respect to that observed in the absence of Lf (50). In other studies, Influence of iron and lactoferrin on the lifestyle Lf has been shown to inhibit the adhesion of A. actino- of oral microbiota mycetemcomitans and P. intermedia to reconstituted ba- In human saliva, the iron content ranges from 0.1 to 1.0 In sement membrane, through ionic binding, and P. intermedia µM depending on meals but it can increase for gingival blee- to bacterial adhesins by a specific binding of Lf (51). ding due to infection and inflammatory processes. During The different nature of abiotic surfaces, the varying mi- the infection and inflammatory processes, the recruitment crobial adhesion mechanisms and the different in vitro ex- of neutrophils increases saliva Lf concentration from 20 to ni perimental conditions could explain the different results ob- 60 µg/ml (41). tained for inhibition of bacterial adhesion by apo- or iron- Therefore, saliva represents an interesting model to in- saturated Lf, which in some cases requires only ionic bin- vestigate the influence of iron and Lf concentrations on bac- ding to biomaterials, and in others specific binding to bac- io terial infections. As matter of fact, the different ratio bet- terial structures, or both. ween iron and Lf plays an important role in the lifestyle of several bacteria (42, 43) by inducing aggregation and bio- Cell surfaces iz film development (41). In particular, in a saliva pool well The ability of microbes to adhere, colonize and form bio- defined for iron and Lf content, apo-Lf (iron unsaturated film on host cells is a crucial step for the development and form) was found to enhance S. mutans aggregates and bio- persistence of infections. Ed film formation, whereas iron-saturated Lf decreased ag- A large number of Gram-positive and Gram-negative bac- gregation and biofilm development (41). Similar behaviour teria possess specific adhesins that mediate the adhesion has been recently described in the periodontopathogen Ag- process on epithelial host cells. Lf and Lfcin are all able gregatibacter (Actinobacillus) actinomycetemcomitans: iron to bind to bacterial Gram-negative and Gram-positive sur- limitation up-regulates its biofilm genes contributing to bio- faces, as well as to host cells, by binding to glycosami- film formation (44). noglycans (GAGs) (52) and in particular to heparan sul- The reported data suggest that to assess the effect of Lf phate (HS) (53) and the inhibition of bacterial adhesion se- IC in oral cavity it is necessary to evaluate preliminarily the ems generally to be mediated by Lf binding to both bac- iron content of saliva. In fact, in periodontitis patients, the terial and host cell surfaces (1). high iron concentration and the presence of hemin, which Evidences of anti-adhesive function of Lf against oral pe- can form complexes with Lf, together with Lf degradation riodontopathogens was shown by Alugupally (1997) (51) C by bacterial and human enzymes (45, 46), could be re- who demonstrated that the Lf-dependent inhibition of the sponsible, in vivo, for the lack or reduced activity of Lf even adhesion of A. actinomycetemcomitans, P. intermedia and if its concentration is increased following infection and in- P. nigrescens to fibroblasts can involve binding of lactoferrin flammation. to both the bacteria and host cells. © Recently, the Lf influence on S. mutans adhesion has been Inhibition of bacterial adhesion on abiotic tested in vitro on epithelial cells. Lf at physiological con- and cell surfaces by lactoferrin centration (20 µg/ml) is able to significantly decrease the adhesion efficiency of S. mutans to epithelial cells (Fig. 2). Abiotic surfaces Microbial adhesion and subsequent colonization, resulting Inhibition of microbial invasion in biofilm formation on abiotic surfaces such as dental sur- of host cells by lactoferrin faces and medical devices as dental prosthesis, represents Some mucosal pathogenic bacteria are capable not only 12 Annali di Stomatologia 2011; II (3-4): 10-18  Lactoferrin and oral diseases: current status and perspective in periodontitis li na io az rn Figure 2 - Bovine lactoferrin in inhibiting adhesion efficiency of Streptococcus mutans on epithelial cells. te Legend: Epifluorescence optical microscopy images of epithelial cells infected with Streptococcus mutans, stained with Ba- cLight®LIVE/DEAD viability probe, in the absence (Panel A) or in the presence (Panel B) of bovine lactoferrin (20 µg/ml). of adhering, but also of entering into non-professional pha- In chanisms that underlie pathogenicity and the interactions gocytes, such as epithelial cells. Inside host cells, bacte- between pathogenic and non-pathogenic microbes coe- ria are in a protective niche in which they can replicate and xisting on humans. These motivations are especially per- persist, thus avoiding host defences. Virulence determi- tinent in the case of the human oral flora, which compri- nants, such as surface proteins able to bind host cells, play ses at least 400 to 700 different bacterial species (55). Oral ni a key role in the entry process inside the host cells. Lf has microorganisms constitute a complex and dynamical been shown to inhibit the entry of facultative intracellular community, responsible for two important oral infectious bacteria, both Gram-negative and Gram-positive (1). diseases affecting virtually all humans: gingival and pe- io Recently, the capability of S. mutans to enter inside gin- riodontal diseases. Differently from gingivitis, confined to gival fibroblast cells has been reported (54). Preliminary gingival mucosa, periodontitis involves periodontium de- experiments show the anti-invasive activity of Lf against generation, alveolar bone resorption and gingival epithe- iz S. mutans infecting gingival fibroblasts. lium migration along tooth surface, and the resulting pe- riodontal pockets. Anti-inflammatory activity of lactoferrin in oral diseases It is well know that periodontal disease is associated to an Ed Understanding the role of microbial communities in human inflammatory process that occurs in the tissues surroun- health is emerging as a fundamental and fascinating mi- ding the teeth in response to the accumulation of sub- crobiological challenge. In the battle against infectious di- gingival bacterial plaque, mainly constituted by anaerobic seases, finally there is the awareness that the discovery Gram-negative facultative intracellular pathogens and of novel connections between infection, inflammation their LPS, one of the factors responsible for the inflam- and human diseases is a pivotal tool in the research of no- matory reaction (56, 57, 58). Differently from commensal vel antibacterial drugs. bacteria, intracellular bacteria induce the over-expression IC The increasingly frequent threats of bacterial resistance of several pro-inflammatory cytokines (59, 60, 61). In par- to antibiotics reinforce the necessity to understand the me- ticular, increased levels of pro-inflammatory cytokines have C Table 2 - Synthesis of pro-inflammatory cytokines by gingival fibroblasts uninfected or infected with Prevotella intermedia in the absence or in the presence of bovine lactoferrin. Uninfected cells Infected cells © None bLf None bLf IL-1β (ng/ml) 1.050±150 1.000 ± 97 4.800±421 900±180 IL-6 (ng/ml) 90±21 90±23 930±105 83±38 IL-8 (pg/ml) 2.100±241 2.150±210 9.450±750 5.800±550 TNF-α (pg/ml) 22±14 22±12 120±65 18±8 Annali di Stomatologia 2011; II (3-4): 10-18 13  F. Berlutti et al. tentially toxic-free iron (68) as well as to sequester LPS Table 3 - Clinical parameters and pro-inflammatory cytokine thus neutralizing its biological activity (69, 70). Moreover, levels in gingival crevicular fluids before and after bovine bLf is also able to inhibit biofilm development (42, 43) thus lactoferrin topical administration. decreasing inflammation due to the exopolisaccharides for- ming biofilm (71). Baseline After 4 weeks Recently, in several clinical trials on women suffering from li of topical administration anaemia, oral administration bLf has been found to be ef- of bovine lactoferrin fective in decreasing serum levels of IL-6, a key factor of na iron homeostasis, thus restoring the physiological distri- PPD 2.6±0.2 0.5±0.8 bution of iron between tissues and blood (72, 73, 74). As GI 0.8 ±0.1 0.5±0.1 matter of fact, the iron deficiency in blood (iron deficien- PlI 0.8 ±0.1 0.4±0.2 cy anaemia) is related to iron overload in tissues as well BOP (%) 32 0 io as to high levels of serum IL-6 (73). CAL (mm) 1.50±0.7 0.50 ±0.2 In addition to the local tooth and gum effects, periodon- IL-1β (ng/ml) 138±87 95 ±74 tal disease has been shown to influence various systemic IL-6 (ng/ml) 1.35±0.8 0.64±0.32 disorders and diseases as cardiovascular disease (75), and az IL-8 (pg/ml) 94±65 35±12 diabetes mellitus (76). Moreover, significant associations TNF-α (pg/ml) 31±21 3±2 between periodontal disease and preterm low birth weight have been demonstrated (77). Recently, the prevention of Legend: The clinical parameters and pro-inflammatory cytokine concentrations are reported as mean values ± standard deviation deriving from a total of twenty- preterm delivery, mainly associated to high levels of IL-6, rn six teeth (2 teeth/subject). PPD: probing pocket depth; GI: gingival index; PlI: has been obtained through bLf ability to decrease serum plaque index; BOP: bleeding on probing; CAL: clinical attachment level. and cervicovaginal IL-6 (78). As there is not ideal therapeutic approach to cure perio- dontitis, the anti-inflammatory efficacy of oral administra- te tion of bLf encourages new therapeutically approaches to been detected in the inflamed gingival tissue and GCF at cure periodontal diseases. infected and inflamed sites (62, 63, 64). Although inflammation is an essential component of the In vitro and in vivo influence of bovine lactoferrin on host defence response to bacterial challenge, excessive In pro-inflammatory cytokine synthesis cytokine production from host cells results in consequent As reported in the previous section, IL-6 is involved not only periodontal tissue destruction. Therefore, chronic and pro- in bone resorption but also in iron homeostasis, where its gressive infection by anaerobic Gram-negative intracellular over-expression induces iron overload in tissues and se- pathogens inducing the inflammatory process is respon- ni cretions and iron deficiency in blood (79). Consequently, sible for alveolar bone destruction. In fact, the bone is a we believe that the difficulty in resolving inflammatory pe- continuous remodelling between osteoblast (bone for- riodontal disease also involves the failure of restoring iron mation) and osteoclast (bone resorption), and its ho- homeostasis strictly related to inflammation through the io meostasis is well controlled. Among soluble regulation fac- over-expression of IL-6 (79). Therefore our opinion is that tors influencing bone homeostasis, cytokines play an im- the resolution of inflammation in the context of periodon- portant role. It is well demonstrated that the pro-inflam- tal disease should involve the decrease of iron overload iz matory cytokines having bone-resorption activity, act in oral tissues and secretions. osteoblasts and stimulate osteoclastogenesis (i.e. bone re- In physiological conditions the availability of free iron in tis- sorption ) through up-regulation of receptor activator of nu- sues and secretions do not exceed 10-18 M, while in pa- Ed clear factor (NFkB) ligand (RANKL) and down-regulation thological conditions the high concentration of free iron in- of osteoprotegerin in osteoblasts (65, 66, 67). duces microbial multiplication, biofilm development, reactive Taken together these data reinforce the evidence that ap- oxygen species, cell damage and inflammation (1). propriate regulation of cytokine production by immuno- A strategy addressed to decrease iron overload could con- modulators might be useful in reducing periodontal tissue tribute to inhibit microbial growth and biofilm development destruction such as alveolar bone resorption. There is an as well as formation of reactive oxygen species, cell da- important distinction between anti-inflammation and re- mage and related inflammation. IC solution; anti-inflammation is pharmacologic intervention Here, we first report the anti-inflammatory activity of ad- in inflammatory pathways, whereas resolution involves bio- ded bLf to infected gingival fibroblasts. logic pathways restoring inflammatory homeostasis. In- To mimic the in vivo environment, the synthesis of inter- terestingly, the resolution of inflammation is an active, well- leukin 1 (IL-1 ), IL-6, interleukin 8 (IL-8) and tumor necrosis C orchestrated return of tissue homeostasis. A growing body factor-α (TNF-α) by human gingival fibroblasts infected or of research suggests that inflammatory periodontal disease not with P. intermedia, an anaerobic Gram-negative in- involves a failure of resolution pathways to restore ho- tracellular pathogen associated to periodontitis, has been meostasis. detected. The infection of monolayers was performed in the © At present, there is no ideal therapeutic approach to cure absence or presence of bLf at 20 µg/ml concentration cor- periodontitis and achieve an optimal periodontal tissue re- responding to that detected in saliva of healthy subjects generation. and found ineffective against P. intermedia growth. The ab- Recently, the milk derivative bovine Lf (bLf) is emerging sence of antibacterial activity of bLf in our in vitro model as an important regulator of iron and inflammatory ho- is pivotal to exclude the different cytokine synthesis rela- meostasis exerting a potent effect in decreasing inflam- ted to the different number of viable bacteria. For this pur- matory host responses. The bLf ability in decreasing in- pose semi-confluent monolayers were infected with P. in- flammatory processes is related to its ability to bound po- termedia at a multiplicity of infection 100 bacteria per cell 14 Annali di Stomatologia 2011; II (3-4): 10-18  Lactoferrin and oral diseases: current status and perspective in periodontitis in the absence or in the presence of 20 µg/ml of bLf. Af- according to the World Medical Association Declaration of ter infection, the supernatants from uninfected and infec- Helsinki. ted cells with or without bLf were collected and IL-1 , IL- At each visit, GCFs to be analyzed were collected from two 6, IL-8 and TNF-α concentrations were determined using teeth affected by periodontitis/subject. All subjects were cli- standard enzyme-linked immunosorbent assays (ELISA) nically evaluated in the following periodontal measurements: (Table 2). number of teeth present, plaque index (PlI) (80), gingival li The results clearly demonstrated that bLf added to unin- index (G I) (81), probing depth (PD), clinical attachment fected monolayers did not modify cytokine synthesis, whi- level (CAL), and bleeding on probing (BOP) (82). Two te- na le it significantly decreased the synthesis of IL-1 , IL-6, IL- eth affected by periodontitis were examined per subject. 8 and TNF-α by gingival fibroblasts infected with P. inter- PlI, GI, PD, CAL and BOP (%) were measured at four si- media. tes around each tooth. These in vitro results have encouraged us to carry out an All enrolled subjects were directed to topically place 100 io observational preclinical study on volunteers suffering from mg of lyophilized bLf two times a day for 4 weeks after meal mild chronic periodontitis. The calibration was performed and correct oral hygiene as well as after extensive washings before the study with 5 volunteer subjects among the re- until the arrest of the putative gum bleeding. In particular, searchers involved in the study of bLf functions. Then other 100 mg of lyophilized bLf, contained in a pocket, were de- az volunteers suffering from mild chronic periodontitis among posited in an little container in order to be adsorbed on soft patients were enrolled at a private practice. Pregnant wo- bristles of the appropriate toothbrush and applied through men as well as the subjects with other concomitant di- a soft brush on the gums, particularly on the bleeding si- seases were excluded from this study as well as smokers, tes. rn subjects with ascertained allergic reactions to cow’s milk, Periodontal clinical parameters consisting in PPD, GI, PlI, and subjects receiving antibiotic treatment within the pre- BOP (%) and cytokine concentrations in GCFs were as- vious 3 months. sayed in all subjects before (baseline) and after 1, 2 and As a result, 13 subjects (7 female and 6 men, age range 4 weeks of therapy. The parameters at the baseline and te 42–63 years) suffering from mild chronic periodontitis were after 4 weeks of bLf topical treatment are reported as cu- enrolled in this observational preclinical trial after the un- mulated mean values because the total number of subjects derstanding and written consent. The trial was conducted in each group (seven women and six men) is very low (Ta- In ni io iz Ed IC C © Figure 3 - Putative lactoferrin mechanism in inhibiting bone resorption. High levels of IL-6 induce bone resorption through the osteo- clast activation induced by the osteoblast-mediated production of RANKL (Panel A). The topical administration of bLf by decreasing IL- 6 levels and probably RANKL may induce both the inhibition of osteoclast activation and the activation and proliferation of osteoblast (Panel B). Legend: IL-6: interleukin-6; bLf: bovine lactoferrin; RANK: receptor activator of nuclear factor NFkB; RANKL: RANK ligand. Annali di Stomatologia 2011; II (3-4): 10-18 15  F. Berlutti et al. ble 3). Therefore, the data summarized in Table 3 corre- 6. Tomita M, Takase M, Bellamy W, Shimamura S. A review: the ac- spond to the mean values deriving from a total of 13 sub- tive peptide of lactoferrin. Acta Paediatr Jpn 1994; 36: 585–91. jects and 26 teeth. 7. 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Literature review 3D cephalometric analysis obtained from computed tomography. Review of the literature li na Giulia Rossini, DDS, Ph.D student anatomical structures being imaged. The 2-D cephalometric Costanza Cavallini, MD radiography allows bidimensional evaluation of craniofa- Michele Cassetta, DDS, Ph.D cial morphology and growth, but ignore the mediolateral io Ersilia Barbato, DDS, MS axis. Frontal cephalometric radiographs are useful for fa- cial asymmetry assessment but neglect the postero-an- terior dimension. az "Sapienza" University of Rome, Rome, Italy These problems may be overcome using computed to- Department of Oral and Maxillofacial Sciences mography (CT) imaging techniques that produce three-di- mensional images of cranial bone, jaws and the sur- rounding tissues, allowing to focus the anatomic structures Corresponding author: more accurately than 2D conventional radiography. Different rn Dott. Giulia Rossini techniques has been developed in order to obtain three- Via Flaminia 808c - 00191 Rome, Italy dimensional landmarks and to generate 3-D cephalograms, E-mail: giulia.rossini@uniroma1.it after combining and integrating the data of both 2-D cephalograms (lateral and postero-anterior). te The advantages of three-dimensional medical computed tomography (CT) imaging are already well established in Summary different dental specialities: management of trauma to the In maxillofacial skeleton, surgical facial reconstruction, or- Introduction. The aim of this systematic review is to thognathic surgery, dental implants, complicated extrac- estimate accuracy and reproducibility of craniometric tions and endodontic treatments (1-3). Nevertheless, its measurements and reliability of landmarks identified use has been limited in orthodontics due to high-radiation with computed tomography (CT) techniques in 3D ce- dose, cost, lack of availability, poor resolution and difficulty ni phalometric analysis. in interpretation. These issues may be addressed by re- Methods. Computerized and manual searches were cent cone beam innovations in CT technology, and could conducted up to 2011 for studies that addressed the- substantially alter the way that patients who have poten- io se objectives. The selection criteria were: (1) the use tially complex orthodontic problems are managed. of human specimen; (2) the comparison between 2D Afterwards, the advantages brought by Cone Beam Com- and 3D cephalometric analysis; (3) the assessment of puted Tomography (CBCT) technology, as lower radiation accuracy, reproducibility of measurements and relia- iz dose, clearer images, more precision and reliability dur- bility of landmark identification with CT images com- ing the visulizing of landmarks compared with conventional pared with two-dimensional conventional radiographs. CT, bring to ask if 3D cephalometry obtained with CBCT The Cochrane Handbook for Systematic Reviews of In- technology can fully replace the traditional cephalometry. Ed terventions was used as the guideline for this article. Moreover, because many of the patients had conventional Results. Twenty-seven articles met the inclusion cri- cephalometric records in the past as part of their docu- teria. Most of them demonstrated high measure- mentation, it is important to know whether cephalometric ments accuracy and reproducibility, and landmarks re- radiographs obtained from CBCT scans are comparable liability, but their cephalometric analysis methodolo- to conventional cephalometric records when evaluating a gy varied widely. longitudinal series that contains both types of radi- IC Conclusion. These differencies among the studies in ographs. If the two types of radiographs are not compa- making measurements don’t permit a direct compa- rable, then the cephalometric data obtained from CBCT rison between them. The future developments in the scans cannot be used to evaluate growth and treatment knowledge of these techniques should provide a stan- outcomes longitudinally4. C dardized method to conduct the 3D CT cephalometric The aims of this review are to assess the quality of three- analysis. dimensional cephalometic analysis obtained from com- puted tomography and to determine if there is general con- Key words: three-dimensional cephalometry, compu- sensus in the literature concerning the reliability, accura- © ted tomography, accuracy, reliability, reproducibility. cy and reproducibility of cephalometric landmarks and measurements obtained from CT 3D images. Introduction Methods Conventional cephalometric analysis presents the same limits of the radiograph on which it is performed: the two- Criteria for considering studies for this review dimensional character and geometric distortion of the The follow criteria were used to select the studies for this Annali di Stomatologia 2011; II (3-4): 31-39 31  G. Rossini et al. review: general measures to find studies on three-di- Orthodontic and Dentofacial Orthopedics; 7 were from the mensional cephalometric analysis, specific selection cri- Angle Orthodontist; 2 from the International Journal of Oral teria to improve the quality of the study and exclusion cri- Maxillofacial Surgery, and 3 from the Oral Surgery, Oral teria. Medicine, Oral Pathology, Oral Radiology and Endodon- General selection criteria included: (1) studies that iden- tology; the last articles were selected from the Journal of tified landmarks in the maxillofacial area on CT images; Craniomaxillofacial Surgery, Dentomaxillofacial Radiolo- li (2) studies that explained how to conduct 3D cephalometric gy, Journal of Orofacial Orthopedics, Journal of Oral and analysis; (3) only human radiographic studies. Maxillofacial Surgery, European Journal of Orthodontics, na Specific selection criteria included studies that (1) evalu- Biomedical Imaging and Interventional Journal. ated accuracy and reliability of cephalometric measure- Fourteen studies used orthodontic subjects and thirteen ments conducted on three-dimensional CT images; (2) eval- human dry skulls. uated the reproducibility of cephalometric landmarks on A summary of the results from the 27 articles is present- io 3D CT images; (3) determined whether cephalometric ed in Table 1. measurements performed on CT cephalograms are com- parable with measurements on conventional cephalograms; Measurement accuracy and landmark reliability (4) used both human dry skulls and orthodontic patients. Lagravère and Major5 examined the intra-examiner relia- az Exclusion criteria: (1) measurements of internal cranial bility of a new proposed skeletal landmark, ELSA, locat- structures and temporomandibular joint (TMJ) were ex- ed equidistant to centers of foramina spinosum. Ten ado- cluded because the focus was on skeletal landmarks that lescent patients were scanned using a NewTom QR-DVT are of interest to clinical orthodontist; (2) areas outside the 9000 CBCT scanner (Aperio Services, Verona, Italy). Im- rn maxillofacial boundaries; (3) facial trauma or tumor in the ages were analyzed with AMIRA software (Mercury Com- maxillofacial area were also excluded because they puter System, Berlin, Germany). Axial, sagittal, coronal, would distort the normal anatomy of the region. and 3D reconstructions were used in locating the landmark. No sex and age restriction was applied. The intra-examiner reliability has a kappa value of 0.998. te The authors concluded that this novel landmark is an ad- Methods of this review equate landmark for use as a reference in 3D cephalometric The following electronic data bases were searched analysis with 3D volumetric images. Moshiri et al.6 com- through September 2011: Google Scholar beta, PubMed pared the accuracy of linear measurements made on con- and Science Direct. The following keywords were used: In ventional lateral cephalograms (LCs) captured on pho- three-dimensional cephalometry; computed tomography; tostimulate phosphor cephalograms (PSP) with 3 meth- accuracy cephalometric measurements; reliability three- ods for simulating lateral cephalograms with CBCT. The dimensional cephalometry; reproducibility. linear distances between anatomical landmarks on den- To determine whether the keywords had covered all arti- ni tate dry human skulls were measured by observers using cles on 3D cephalometry, the following journals were man- digital calipers for S-N, Ba-N, M-N, ANS-N, ANS-PNS, Pog- ually screened: The American Journal of Orthodontics and Go, Go-M, Po-Or, and Go-Co. The skulls were imaged with Dentofacial Orthopedics, The Angle Orthodontist, The Eu- CBCT with a single 360° rotation, producing 306 basis im- io ropean Journal of Orthodontics. ages and achieving 0.4 mm isotrophic voxel resolution on In addition, references from each identified article were volumetric reconstruction for making ray-sum recon- manually screened for articles that were missed by elec- structed cephalograms. Two other cephalogram ap- iz tronic search engines. Finally, all manual and electronic proaches were used with the CBCT system: a single trans- searches were solicited for review articles. mission image generated as a scout image designed to All abstract that dealt CT three-dimensional cephalomet- check patient positioning before CBCT, and a single-frame Ed ric analysis were read, and the full texts of all relevant ar- lateral basis image. Conventional digital lateral cephalo- ticles were collected and reviewed. Ambiguous articles were grams (LCs) were acquired with the photostimulable also read to avoid inappropriate exclusion. All procedures phosphor system. Images were imported into a cephalo- were performed indipendently by two authors (GR, CC), metric analysis program (Dolphin Imaging Cephalometric and differencies were resolved by rereading and discus- and Tracing Software, Chatsworth, Calif) to compute the sion until consensus was reached. included linear measurements. Analyses were repeated 3 times and statistically compared with measured anatom- IC ic truth with ANOVA (P ≤.05). The intraclass correlation co- Results efficient was determined as an index of intra- and inter- examiner reliability. The intraclass correlation coefficient A total of 480 abstracts without overlap were found by the (ICC) for the LCs was significantly less than for the meas- C search methods. Only 43 abstracts met the inclusion cri- ured anatomic truth and for all CBCT-derived images. CBCT teria or were retrieved because the abstract did not pro- images either produced with individual frames or recon- vide enough information to justify exclusion. Fourteen ar- structed from the volumetric data set were accurate for all ticles were excluded according to the selection and ex- measurements except Pog-Go and Go-M. CBCT scout im- © clusion criteria. Two more were excluded after reading and ages had the second highest accuracy for all measure- discussing, because one tested the accuracy of an algo- ments except Pog-Go, Go-M, and Go-Co. Conventional LCs rithm that corrects measurements made on conventional had the least accuracy, and were accurate only for Po-Or lateral head film to corresponding dimensions observed and ANS-N. In conclusion CBCT-derived 2-dimensional in a CBCT scan, and the other one scanned an acrylic head LCs proved to be more accurate than LCs for most linear phantom to determine the reproducibility of maxillofacial measurements calculated in the sagittal plane. No ad- anatomic landmarks. Therefore 27 studies remained. vantage was found over single-frame basis images in us- Nine articles were selected from the American Journal of ing ray-sum generated cephalograms from the CBCT vol- 32 Annali di Stomatologia 2011; II (3-4): 31-39  3D Cephalometric Analysis Obtained from Computed Tomography. Review of The Literature Table 1 - Search results. li na io az rn te In ni io iz Ed IC C © (continues) Annali di Stomatologia 2011; II (3-4): 31-39 33  G. Rossini et al. Table 1 - Search results. (continued) li na io az rn te In ni io iz Ed IC C © umetric data set. Olszewski et al.7 tested the accuracy of between the ACRO 3D software and the 3D measuring in- the measurements done on 3D CT surface renderings strument. Periago et al.8 performed 20 orthodontic linear (ACRO 3D) in relation to those directly taken on 26 dry skull measurements between anatomical landmarks on 23 hu- with the help of a 3D measuring instrument. There were man skulls, using a digital caliper. The skulls were imaged no significant differences in the accuracy of measurements with CBCT using the i-CAT system, and the CBCT data 34 Annali di Stomatologia 2011; II (3-4): 31-39  3D Cephalometric Analysis Obtained from Computed Tomography. Review of The Literature were exported from the XoranCat software in DICOM mul- ternal meatus left 0.84 (CI, 0.61, 0.94), auditory external ti-file and imported into Dolphin 3D (version 2.3) on the meatus right 0.90 (CI, 0.73, 0.96), orbit left 0.83 (CI, 0.52, same computer. While many linear measurements between 0.93), and orbit right 0.80 (CI, 0.49, 0.92) landmarks. Fora- cephalometric landmarks on 3D volumetric surface ren- men Spinosum (FS), Center Coordinate Point (ELSA), Au- derings obtained using Dolphin 3D software generated from ditory External Meatus (AEM), and Dorsum Foramen Mag- CBCT datasets may be statistically different from anatom- num (DFM) demonstrated adequate reliability and could li ic dimensions, most can be considered to be sufficiently be used for determining a standardized reference system. clinically accurate for craniofacial analyses. Lopes et al.9 The same Author12 afterwards confirmed his previous re- na studied the accuracy of 6 angular measurements based sults: the intra-observer reliability was good for all meas- upon 9 conventional craniometric anatomical landmarks urements. The correlation coefficient between the first and on 28 dried skulls, that were scanned with a 64-row mul- second measurements ranged between 0.69 and 0.98, with tislice CT. These angular measurements were identified in- an average of 0.91. The standard error for the conventional io dependently in 3D CT images by 2 radiologists, twice each. cephalometric radiographs was significantly smaller for nine Subsequently, physical measurement were made by a third measurements out of 12, as compared with the standard examiner. The results demonstrated no statistically sig- error of the measurements on the 3D models. Berco et al.13 nificant difference between inter- and intra-examiner determined the accuracy and reliability of 3D cranio-facial az analysis. The mean difference between the physical and measurements obtained from CBCT scans of a dry human 3D-based angular measurements was -1.18% and - skull, obtained with 2 skull orientations. Seventeen land- 0,89%, respectively, for both examiners, demonstrating high marks were identified on the skull, and twenty-nine inter- accuracy. Maxillofacial analysis of angular measurements landmark linear measurements were made directly on the rn using 3D CT volume rendering by 64-row multislice CT is skull and compared with the same measurements made established and can be used for orthodontic and dento- on the CBCT scans. All measurements were made by 2 facial orthopedic applications. Cevidanes et al.10 have used operators on 4 separate occasions. The method errors were presurgery CBCT scans of 12 patients (6 class II and 6 0.19, 0.21, and 0.19 mm in the x-, y- and z-axes, re- te class III) randomly selected from a pool of 159 patients to spectively. Repeated measures analysis of variance determine the reliability of obtained two-dimensional (ANOVA) showed no significant intra- or inter-examiner dif- cephalometric measurements using two virtual head ori- ferences. The mean measurement error was –0.01 mm entations from cone-beam computed tomography (CBCT) (SD, 0.129 mm). Five measurement errors were found to models: visual natural head position (simulated NHP) and In be statistically significantly different. The Authors concluded 3D intracranial reference planes (3D IRP). The CBCT that CBCT allows for clinically accurate and reliable 3D lin- scans were obtained by NewTom 3G (QR-NIM s.r.l., ear measurements of the craniofacial complex and that skull Verona, Italy) and the volume data were exported in DI- orientation during CBCT scanning does not affect the ac- COM format into Dolphin Imaging software (version 10.5, curacy or the reliability of these measurements. Hassan ni Dolphin Imaging & Management Systems, Chatsworth, et al.14 assessed the accuracy of linear measurements on Calif). Three observer created and digitized four CBCT-gen- 3D surface-rendered images of 8 dry human skulls gen- erated lateral cephalograms per patient, two using simu- erated from CBCT datasets and compared them with those io lated NHP and two using 3D IRP at intervals of at least 3 made on 2D tomographic slices and on 2D lateral and PA days. ICC (intraclass correlation coefficients) indicated good cephalometric projections. Moreover, the Authors evalu- reliability both within each head orientation and between ated the influence of head position of the patient in the iz orientations. Of the 50 measurements, the reliability co- scanner on measurement accuracy as Berco done13. Ten efficients were ≥ 0.9 for 45 measurements obtained with linear distances were defined for cephalometric meas- 3D IRP orientation and 36 measurements with simulated urements. The physical and radiographic measurements Ed NHP. The difference in mean values of the two orientations were repeated twice by three independent observers and exceeded 2 mm or 2° for 14 (28%) of the measurements. were compared using repeated measures analysis of vari- Lagravère et al.11 evaluated intra- and inter-examiner re- ance (P = 0.05). The radiographic measurements were also liability of 3D CBCT-generated landmarks in patients who compared between the ideal and the rotated scan posi- needed maxillary expansion. CBCT scans were taken us- tions. The radiographic measurements of the 3D images ing the NewTom 3G (Aperio Services, Verona, Italy) at 110 were closer to the physical measurements than the 2D kV, 6.19 mAs, and 8 mm aluminum filtration. CBCT images slices and 2D projection images. No statistically significant IC were converted to DICOM format and rendered into a vol- difference was found between the ideal and the rotated umetric images with AMIRA software (AMIRA, Mercury scan measurements for the 3D images and the 2D to- Computer Systems Inc, Berlin, Germany). Sagittal, axial, mographic slices. A statistically significant difference (P < and coronal volumetric slices, as well 3D reconstruction 0.001) was observed between the ideal and rotated scan C of the image, were used to determine landmark positions. positions for the 2D projection images. The findings indi- In this system, the XY-plane moves from top to bottom, the cate that measurements based on 3D CBCT surface im- XZ-plane moves from front to back, and the YZ-plane ages are accurate and that small variations in the patient’s moves from left to right. The predetermined coordinate sys- head position do not influence measurement accuracy. Van © tem and origin (0, 0, 0) established by AMIRA for each im- Vlijmen et al.4 compared the conventional cephalometric age were used and were the same for every examiner. Then measurements with those obtained with the CBCT examiners located landmarks on the images. Intra-examiner cephalometric radiographs taken from 40 dry human skulls. reliability for x, y, and z coordinates for all landmarks was Intra-examiner reliability for both the conventional cephalo- greater than 0.97 with 95% confidence interval (CI, 0.96, mentric radiographs and CBCT-constructed cephalomet- 0.99). Inter-examiner reliability for x, y, and z coordinates ric radiographs was good for all measurements. The cor- for all landmarks was greater than 0.92 (CI, 0.87, 0.96), relation coefficient between the first and the second with the exception of the x-components of the auditory ex- measurements ranged between 0.91 and 0.99, with an av- Annali di Stomatologia 2011; II (3-4): 31-39 35  G. Rossini et al. erage of 0.97. The standard error for CBCT-constructed were scanned with a Philips MX 8000 IDT Multi-slice CT cephalometric radiographs was significantly smaller for 8 System (V 2.5; Philips Medical Systems, The Netherlands) measurements, compared with the standard error of the with a high-resolution bone algorithm, 512 X 512 matrix, conventional cephalometric radiographs. Brown et al.15 com- 120 kV, and 100 mA. Axial scans were obtained with a 1- pared the in vitro reliability and accuracy of linear meas- mm slice thickness and parallel to the Frankfurt horizon- urements between cephalometric landmarks on CBCT 3D tal plane. The 3D model of the axial images was recon- li volumetric images with varying basis projection images to structed using Mimics v12.01 (Materialise) software, and direct measurements on human skulls. The Authors directly 3D cephalometric analyses were performed. Standard lat- na measured 16 linear dimensions between 24 anatomic sites eral and frontal cephalograms of the dry skulls, on which marked on 19 human skulls, which were imaged with CBCT clay markers were replaced with metallic balls and pins, (i-CAT). No difference in mean absolute error between the were taken by Odontorama PC (85kV, 10 mA; Trophy Ra- scan settings was found for almost all measurements. The diologie, Croissy-Beauborg, France). All metric meas- io average skull absolute error between marked reference urements were made between the outermost points of balls points was less than the distances between unmarked ref- and pins during manual and 3D virtual model measure- erence sites. CBCT resulted in lower measurements for ments. All measurements on 2D radiograms were made nine dimensions (mean difference range: 3.1 mm ± 0.12 between the center points of pins and balls. In all cephalo- az mm to 0.56 mm ± 0.07 mm) and a greater measurement metric analyses, 18 landmarks and 29 measurements (17 for one dimension (mean difference 3.3 mm ± 0.12 mm). lateral and 12 frontal) were used. Measurements were eval- No differences were detected between CBCT scan se- uated in three groups, as follows: group I (computer-as- quences. Moreira et al.16 demonstrated the accuracy of 15 sisted 3D cephalometric measurements), group II (phys- rn maxillofacial linear and 6 angular measurements obtained ical cephalometric measurements) and group III (con- by CBCT (i-CAT - Imaging Sciences International, Hatfield, ventional 2D cephalometric measurements). All meas- PA) images marked on 15 intact human skulls. No statis- urements were statistically insignificant between the tically significant differences were found of the compari- computer-assisted 3D and manual measurements. On the te son between the physical and CBCT-based linear and an- other hand, the differences between the conventional 2D gular measurements for both examiners (P = .968 and .915, and the manual measurements were statistically signifi- P = .844 and .700, respectively). de Oliveira et al.17 eval- cant. The greatest amount of magnification was found at uated intra- and inter-examiner reliability in 3D landmark the Nasion-Menton distance (14.6%), which was located identification using CBCT images. Twelve presurgery In at the farthest distance from the central x-ray beam in the CBCTs were randomly selected from 159 orthognathic sur- lateral cephalogram (P < .01). For the same reason, the gery patients. Three observers independently repeated 3 greatest enlargement (16.2%) was observed in the distance times the identification of 30 landmarks in the sagittal, coro- between the zygomaticomaxillary sutures on the con- nal, and axial slices. The ICC was >0.9 for 86% of in- ventional frontal cephalogram (P < .01). The computer- ni traobserver assessments and 66% of interobserver as- aided 3D cephalometric measurements were found to be sessments. Only 1% of intraobserver and 3% of interob- more accurate than the conventional cephalometric meas- server coefficients were <0.45. The systematic difference urements. Medelnik et al.20 evaluated the accuracy of dif- io among observers was greater in X and Z than in Y di- ferent cone-beam CTs (CBCTs/DVTs) and a multislice spi- mensions, but the maximum mean difference was quite ral CT (MSCT) scanner. A human fresh-frozen cadaver small. Overall the intra- and inter-observer reliability was head was scanned with four CBCTs (Accuitomo 3D, 3D iz excellent. Nalçaci et al.18 assessd the reliability of 3D an- eXam, Pax Reve 3D, Pax Zenith 3D) and one MSCT (SO- gular cephalometric approaches and the reproducibility of MATOM Sensation 64) scanner. The three- dimensional landmark identification by comparing this method with au- (3D) reconstruction of the volume data sets and location Ed thenticated traditional 2D cephalometry. Eighteen cephalo- of the anthropometric landmarks (n=11), together with lin- metric landmarks and 14 cephalometric angular meas- ear (n=5) and angular (n=1) measurements were carried urements were used. Two different orthodontists performed out by three examiners using the program VoXim® 6.1. The both 2D and 3D cephalometric analyses. To assess in- measurements were taken twice at a 14-day interval. De- traobserver reproducibility two sets of recordings made by scriptive analyses were made and the standard deviations each observer in each modality were used. The intraob- were used to compare differences in the accuracy of land- server reproducibility for the first and the second observ- mark identification. The descriptive statistics showed dis- IC er ranged from 0.35° to 0.57° and from 0.42° to 0.65°, re- tinct differences in the reference points in the three axes spectively. Furthermore, no significant differences were ob- of the coordinate system. Because of anatomical and mor- served between the measurements of the two observers phological factors, the pogonion and gnathion reference (P > 0.05). A comparison of 2D and 3D cephalometric points displayed higher standard deviations when set on C measurements showed significant differences in U1-NA the transverse plane (SDCBCT Pog: 0.66–1.57 mm; and U1-SN parameters (P < 0.05). However, the param- SDMSCT Pog: 0.14–1.09 mm; SDCBCT Gn: 1.05–1.77 eters SNA, SNB, ANB, SND, NA-Pog, AB-NPog, Ns-Ba, mm; SDMSCT Gn: 0.20–0.85 mm), thus showing less ac- IMPA, FMIA, SN Ans-Pns, L1-APog and L1- NB did not curacy. However, standard deviations on the sagittal and © show any significant differences (P > 0.05). The Authors vertical planes were smaller. Genion, anterior nasal spine also concluded that the 3D angular cephalometric analy- and infradentale had very low standard deviations on all sis is a fairly reliable method, like the traditional 2D cephalo- three planes. The distance Mfl-Mfr and angle Krl-Krr-Ge metric analysis. Olmez et al.19 used different sections of revealed significantly smaller standard deviations in the 13 dry skulls to determine the accuracy and the differences MSCT (SDCBCT Krl-Krr-Ge: 0.51–0.75 mm; SDMSCT Krl- between manual and cephalometric measurements, us- Krr-Ge: 0.22 mm). Frazão Gribel et al.21 assessed the ac- ing computer-assisted three-dimensional (3D) analysis and curacy and reliability of craniometric measurements made conventional two-dimensional (2D) techniques. The skulls on CBCT scans and lateral cephalograms of twenty-five 36 Annali di Stomatologia 2011; II (3-4): 31-39  3D Cephalometric Analysis Obtained from Computed Tomography. Review of The Literature human skulls. CT scans were made using the iCAT Next servers × 2 identifications ×9 measured distances × 2 meth- Generation (Imaging Sciences International, Hatfield, ods = 1872 measurements. The intra-observer intraclass Pa) CBCT unit. A standardized protocol of the iCAT for the coefficient of correlation for the 2D X-rays methods lay be- extended (17 X 23 cm) field of view (FOV) with 0.3 mm slice tween 0.6040 and 0.9053. The inter-observer intraclass co- thickness, 26.9 seconds acquisition time was used. The efficient of correlation for the 2D X-ray method lay between raw images were exported using the iCAT native software 0.1330 and 0.8409. The inter-observer intraclass coefficient li (iCAT Vision) into DICOM 3 multifiles. The DICOM images of correlation for the 3D CT method lay between 0.9362 were loaded into SimPlant Ortho 2.0 (Materialise Dental, and 0.9965. The Authors concluded that inter- and intra- na Lueven, Belgium) software. A custom analysis was created observer reproducibility proved to be significantly superi- using the dedicated ‘‘3D Cephalometric’’ software module. or (p < 0.0001) following the 3D CT method, compared with The custom 3D analysis (COMPASS 3D) was saved to be the Delaire’s two-dimensional cephalometric analysis. The used with all CT scans. The same skulls subsequently were same Author in 201024 measured the reproducibility of os- io used to obtain lateral cephalograms. The x-ray unit was cal- seous landmark identification from two recently described ibrated optimally at 60 kV, 66 mA, and 0.16 seconds. Lin- three-dimensional (3D) cephalometric analyses: 3D- ear and angular measurements were performed on both ACRO and 3D-Swennen analyses. A total of 1144 meas- 3D and 2D cephalograms. At the end linear distances were urements were performed to estimate intra-observer re- az directly measured using a digital caliper on the skulls. The producibility for both of the 3D cephalometric analyses. A Authors concluded that no statistically significant difference total of 2288 measurements were performed to estimate was noted between CBCT measurements and direct cran- inter-observer reproducibility for both of the 3D cephalo- iometric measurements (mean difference, 0.1 mm). All metric analyses. This study shows that the 3D-ACRO analy- rn cephalometric measurements were significantly different sis is significantly more reproducible than the 3D-Swen- statistically from direct craniometric measurements (mean nen analysis (p1⁄40.0027). Cattaneo et al.25 in order to eval- difference, 5 mm). Significant variations among meas- uate the landmarks reproducibility analyzed a conventional urements were noted. Some measurements were larger lateral cephalogram and 2 sets of CBCT-synthesized te on the lateral cephalogram and some were smaller, but a cephalograms, maximun intensity projection (MIP) and Ray- pattern could be observed: midsagittal measurements were Cast from 34 patients. The absolute differences in degree enlarged uniformly, and Co-Gn was changed only slight- between 3 observers were calculated for every angle, and ly; Co-A was always smaller. However CBCT craniomet- independently for each of the 3 imaging tecniques. The Stu- ric measurements computed by a dedicated ‘‘3D Cephalo- In dent-Newman-Keuls post-hoc test showed: significant sta- metric module’’ are extremely accurate. Damstra et al.22 de- tistical differences between the 3 observers for 3 angular termined the reliability and the measurement error (by measurements on the conventional cephalograms (Ili-ML, means of the smallest detectable error) of 17 commonly P = 0.026; NL-Ols, P = 0.045; Oli-ML, P = 0.038). No an- used cephalometric measurements made on 3-dimensional gular measurements were statistically different for the MIP ni (3D) cone-beam computed tomography images. Twenty- technique; 1 angular measurement had a statistically dif- five CBCT scans were randomly selected, and 3D images ference for the RayCast technique (N-S-Ba, P = 0.042). were rendered, segmented, and traced with the SimPlant However, in all cases, the differences were much small- io Ortho Pro software (version 2.1, Materialise Dental, Leu- er than the accepted 1 standard deviation (SD) for the re- ven, Belgium). This was repeated twice by 2 observers dur- spective angle according to the Björk analysis. The cal- ing 2 sessions at least 1 week apart. Measurement error culated measurements did not differ between the 3 image iz was determined by means of the smallest detectable dif- technique. The Ray-Cast technique proved to be more re- ference. Differences were analyzed with Wilcoxon signed producible than the MIP. Van Vlijmen et al.4 assessed the rank tests. Intraobserver and interobserver reliability val- reproducibility of the landmarks identifing 15 landmarks on Ed ues were calculated by means of intraclass correlation co- both types of cephalometric radiographs on all images 5 efficients (ICC) based on absolute agreement. The Authors times with a 1-week interval. The Authors found that the concluded that there were great variations of measurement reproducibility of measurements in the CBCT-constructed errors between the angular (range, 0.88°-6.29°) and lin- cephalometric radiographs was higher, compared with the ear (range, 1.33-3.56 mm) variables. The greatest meas- reproducibility of measurements in conventional cephalo- uring error was associated with the dental measurements metric radiographs. There was a statistically significant dif- U1-FHPL, L1-MdPL. and L1-FHPL (range, 3.80°-6.29°). ference (P<.05) between this two methods of radiographs IC ANB angle was the only variable with a measuring error for the following measurements: SNB, Ar-A, Ar-Pog, of 1° or less for both observers. The intraobserver agree- NSL/NL, NL/ML, ILs/NL, Lii/ML, interincisal angle, and Ii ment of all measurements was very good (ICC, 0.86-0.99). to A-Pog. For most of these measurements the actual mean Except for SN-FHPL (ICC, 0.76), interobserver agreement average difference ranged from – 1.54° to 1.45°, similar C was very good (ICC, >0.88). to, or smaller than, the standard error for the repeated measurements. Only the difference between CBCT meas- Reproducibility of measurements urements and conventional measurements for the absolute Park et al.23 assessed the reproducibility of the landmarks distance Ar-A and Ar-Pog was greater than their standard © and a subject was chosen at random; 19 landmarks were error, but still less than 1 mm. In 2010 the same Author26 identified 5 times in 1 session by an operator 2 weeks af- identified 17 landmarks on the cephalometric radiographs ter the first session. A paired t-test between the 2 sessions and on the 3D models. All images and 3D models were was carried out by using SAS version 8.2. The Author con- traced five times with a time-interval of 1 week and the cluded that all landmarks were reproducible, with a no sig- mean value of repeated measurements was used for fur- nificant intra-examiner error between the 2 sessions (P ther statistical analysis. Distances and angles were cal- >.0.1). Olszewski et al.7 evaluated the reproducibility of the culated. Reproducibility of the measurements on the con- 3D CT cephalometric method using 26 dry skulls ×2 ob- ventional cephalometric radiographs was higher, compared Annali di Stomatologia 2011; II (3-4): 31-39 37  G. Rossini et al. with the reproducibility of the measurements on the 3D possibility of comparing the right and the left side of the models. A statistically significant difference between the skull, and the anatomic structures were not superimposed conventional cephalometric radiographs and the 3D mod- which improved the visibility of the reference landmarks. els was found for the following measurements: ANB, SNB, The Authors found more advantages of the CT technique: NL/ML, NSL/BOP, NSL/ML, NSL/NL, Is to A-Pog. The av- the real possibility to perform three-dimensional meas- erage difference ranged from –3.118° to 0.828°. For most urements on the lines and the angles and to visualized si- li measurements this difference was considerably smaller multaneously soft tissues including the fat, muscle and the than the standard deviation of the variable measured. For air way. Cattaneo et al.25, after comparing cephalometric na SN/ML the difference (3.118) was 89% of standard devi- measurements performed on conventional cephalograms ation, for the SN/NL difference (1.748) this was 66%. For with those on CBCT-synthesized images, found that all other measurements it was less than 40%. In the study CBCT-synthesized cephalograms could successfully re- conducted by Lagravère et al.11 the principal investigator place conventional headfilms. io located the landmarks in the XY, XZ and YZ planes five Several studies have confirmed the three-dimensional geo- times on different days, and four other investigators located metric accuracy of CBCT technique8,9,19. Most Authors stat- the landmarks once for each image. Spherical markers of ed that CBCT gave accurate two- and three-dimensional 0.5 mm diameter were placed, indicating the position of measurements regardless of skull orientation, and that az the landmark. Intra- and inter-examiner reliability values CBCT was reliable for taking linear measurements of the were determined using ICCs. Intra- and inter-examiner re- maxillo-facial skeleton4,6,10,12,14,17,21,22,25-28. Most of them liability for x, y, and z coordinates for all landmarks were have used human dry skulls in order to increase meas- acceptable, all being greater than 0.80. Most of the mean urements accuracy and landmarks reliability. This reduced rn measurement differences obtained from trials within the the chance of errors in landmark identification because it principal investigator in all three axes were less than 1.5 made an accurate identification of bony landmarks more mm. Inter-examiner mean measurement differences gen- likely since there was no overprojection of soft tissues. Iden- erally were larger than the intra-examiner differences. Lud- tification of landmarks were very important in comparative te low et al.27 compared the precision of landmark identification studies. Although the landmarks could be determined on on CBCT images and conventional lateral cephalograms. computer software, clay and metallic markers were placed The Authors radiographed twenty presurgical orthodontic on dry skulls to use the exact same points in all meas- patients with conventional lateral cephalograms (Ceph) and urements. Clay markers were preferred to the metallic CBCT techniques, and then five observers plotted 24 land- In markers to prevent artifacts during the CT imaging. marks using computer displays of multi-planer recon- Berco et al.13 and Bholsothi et al.29 concluded that linear struction (MPR) CBCT and Ceph views during separate measurements on 3D shaded surface renderings from sessions. The Authors concluded that the MPR displays CBCT datasets using commercial cephalometric analysis of CBCT volume images provide generally more precise ni software had variable accuracy: most midline-to-midline identification of traditional cephalometric landmarks. More linear measurements and some midline-to-midline angu- precise location of condylion, gonion, and orbitale over- lar measurements were not different, while other types of comes the problem of superimposition of these bilateral measurements were significantly different. Moreira et al.16 io landmarks seen in Ceph. did not find statistically significant differences between the Medelnik et al.20, as reported before in this review, beyond physical and CBCT-based linear and angular measure- the accuracy landmarks evaluation, assessed the repro- ments. iz ducibility of anatomical landmarks of different cone-beam Van Vlijmen et al.26 showed that for most measurements CTs (CBCTs/DVTs) and a multislice spiral CT (MSCT) there was no clinically relevant difference between angu- scanner, on a human fresh-frozen cadaver head, from the lar and linear measurements performed on conventional Ed standard deviations on the three planes. The Authors coc- cephalometric radiographs, compared with cephalomet- nluded that MSCT yielded smaller (sometimes significantly) ric measurements on 3D models of skulls. They demon- standard deviations than CBCT in maxillary distance (Spa- strated also that the measurement error for 3D measure- Spp), mandibular height (Id-Gn), bimental width (Mfl-Mfr), ments was larger than that for conventional 2D meas- and coronoid-genio angle (Krl-Krr-Ge), and that the re- urements. This could be explained by the fact that adding producibility of landmark identification in all the volume im- the third dimension an additional source of inaccuracy is ages was good. introduced. IC Some other Authors4,7,11,20,23,24,26,28 found that the repro- ducibility of their own measurements in the CBCT-con- Discussion structed cephalometric radiographs was higher, compared with the reproducibility of measurements in conventional C The multislice CT and Cone beam computed tomography cephalometric radiographs. overcomes most of the limitations of intra-oral radiography. The increased diagnostic data should result in more ac- curate diagnosis and monitoring and therefore improved Conclusion © decision making for the management of orthodontic prob- lems. When indicated, three-dimensional CBCT scans may This review of the literature allows to reach the following supplement conventional two-dimensional radiographic conclusions: techniques and can be used in conjunction with routine • in literature there is a limited number of studies re- craniofacial bidimensional evaluation. Olszewski et al.7 af- garding the accuracy of measurements and reliabili- firmed that although diagnoses based on both two- and ty of landmarks identification with computed tomog- three-dimensional analyses were adequate, the three-di- raphy (CT) technique in the maxillofacial area; mensional analysis gave more informations such as the • the few studies present in the literature described dif- 38 Annali di Stomatologia 2011; II (3-4): 31-39  3D Cephalometric Analysis Obtained from Computed Tomography. Review of The Literature ferent landmarks identification and measurements, 14. Hassan B, van der Stelt P, Sanderink G. Accuracy of three-di- which impede a direct comparison between them; mensional measurements obtained from cone beam computed to- • a standardized and widely approved 3D cephalomet- mography surface-rendered images for cephalometric analysis: in- ric analysis is still not described; fluence of patient scanning position. European Journal of Ortho- dontics 31 (2009) 129-134. doi:10.1093/ejo/cjn088. Advance Ac- • the high accuracy and reproducibility of measurements cess publication 23 December 2008. and reliability of cephalometric landmarks on CT im- li 15. Brown AA, Scarfe WC, Scheetz JP, Silveira AM, Farman AG. Lin- ages permit to perform a successfully and safely ear accuracy of cone beam CT derived 3D images. Angle Orthod. cephalometric analysis; na 2009;79:150-7. • to obtain consistent and reproducible data from three- 16. Moreira CR, DDS, MS, Sales MAO, Lopes PML, Cavalcanti MGP, dimensional landmark identification on CT images it DDS, Pessoa J. Assessment of linear and angular measurements would be mandatory to follow a protocol for operator on three-dimensional cone-beam computed tomographic images. training and calibration. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:430- 436. io 17. de Oliveira AEF, Cevidanes LHS, Phillips C, Motta A, Burke B, Tyn- dall D. 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Original article Investigation of complete dental arches of 23 patients aged at least 75 years li na Beniamino Volpato, MD re is no doubt that several factors contribute to such a for- Stefano Di Carlo, MD, DDS tunate event, such as healthy food habits, a strong phy- Jorida Shahinas DDS, student sical constitution, and a good quality of life (1-3). In addi- io Francesca Mencio, DDS, student tion to the general environmental and systemic factors that Raimondo Fusco, DDS favor the conservation of complete dental arches, several Giorgio Pompa, MD, DDS local factors must also be taken into account (4). In such az patients, adaptive processes, together with the patient’s behavior, are structured in such a way as to shape the den- “Sapienza” University of Rome, Rome, Italy tal arches in a particular fashion, in accordance with cer- Department of Oral and Maxillofacial Sciences tain principles that have yet to be fully elucidated. Prosthodontics Unit This study focused on the structural characteristics of the rn mouths of elderly patients with conserved dentition in the light of current gnathologic, orthodontic, and periodontic Corresponding author: thinking (5). The aim of this research was to formulate a Prof. Giorgio Pompa hypothesis that would confirm the occlusal and structural te Department of Oral and Maxxillofacial Sciences requirements for maintaining the integrity of the dental ar- Via Caserta, 6 - 00161 Rome, Italy ches into old age. To this end, we observed the morpho- Phone: +390649976614 - Fax: +390644230811 logical characteristics of the dental arches of patients aged E-mail: giorgio.pompa@uniroma1.it In at least 75 years (6,7) that remain complete and functio- nally efficient, and gathered data systematically whilst eva- luating the contributing factors. Summary ni Materials and methods Numerous factors help to conserve the dentition of eld- erly patients, such as healthy food habits, a strong phys- ical constitution, and a good quality of life. The aim of Inclusion criteria io this study was to define a model that takes into account Twenty-three patients aged at least 75 years were recruited. the integration of both the structural and functional as- These patients possessed all of their dentition (both an- pects of a healthy dentition. Twenty-three patients aged teriorly and posteriorly), no dental mobility, and mandibular iz at least 75 years were recruited. The patients were re- mobility. In addition, they had no prosthetic rehabilitations quired to possess all of their dentition and have no and were asymptomatic for temporomandibular joint prosthetic rehabilitations and be asymptomatic for tem- (TMJ) disorders and tonic masticatory muscles. poromandibular joint disorders. Occlusal characteristics Data collection (Table 1). Ed were measured and recorded using the criteria adopted The following data collection protocol was applied to each by the US National Health and Nutrition Examination patient: Survey: presence or absence of rotation of the upper Anamnesis collection with special regard to the form– arches, trend of the occlusal table, and distribution of growth–function relationship and the classification of ma- occlusal contacts during movements. We believe that the locclusions. following parameters are predictive of a condition of the Clinical orthognathodontic evaluation (8,9). Occlusal cha- IC dental arches’ equilibrium: crowding and disalignment racteristics were measured and recorded using the crite- of the teeth, derotated position of the upper arches, ab- ria adopted by the US National Health and Nutrition Exa- sence of the curve of Spee, an occlusal plane trend con- mination Survey (NHANES III)(10). trary to spherical theory, and presence of group function on the working side and malocclusion on the nonwork- In more detail were examined: C ing side. We consider that these factors are merely the B1. Presence/absence of labiolingual dysfunction; consequence of correct functioning within the frame- B2. Application of the TMJ disorder (TMD) criteria: que- work of favorable environmental factors. stionnaire on mandibular function and on the chronic pain scale in order to identify their presence and intensity (11); © Key words: occlusion, TMJ disorders, oral rehabilitation, B3. Angle classes; mobile prostheses, dental geriatrics. B4. Alignment/disalignment of median lines; B5. Dental crowding. The rating of dental crowding was ba- sed on the irregularity index (12), with a score of betwe- Introduction en 0 and 3 mm considered as anterior disalignment, whi- le one exceeding 3 mm deemed to be crowding (13). The Seldom in daily practice does a dentist have the opportunity perfect alignment between the mesial face of the left ca- to observe an elderly patient with conserved dentition. The- nine and the mesial face of the right canine was scored Annali di Stomatologia 2011; II (3-4): 19-24 19  B. Volpato et al. Table 1 - Data collection Protocol. C3. Bondi-Jarabak’s ratio PFH (C-Go)/AFH (N-Gn); C4. Base angle for divergence assessment; C5. ANB angle for skeletal class assessment (this para- meter was considered as a function of point B3 above; Clinical examination of the masticatory apparatus of the soft tissues and hard tissues accompanied by photogra- li phic documentation (20,21); D1. Presence of wear (20); na D2. Evaluation of the Prosthodontic Diagnostic Index (22). Results io The cohort had a mean age of 79.6 years, and comprised 9 males and 14 females. No one presented either hypertonus or pain on palpation az of the masticatory muscles (temporal medial pterygoid and masseter) and labiolingual dysfunctions. With reference to the possible presence of TMDs, on the Axis I and Axis II questionnaires the patients tested negative rn in all anamnestic and palpatory examinations of the ma- sticatory muscles and TMJ (23-25). In the examined subjects, 17 cases were found to be an- gle class I, 4 were class II, and 2 were class III. te Interincisive line symmetry was observed in 56.5% of ca- ses and in all cases was present dental crowding with an irregularity index of >5. The presence of rotations of different dentition was ob- In served in 56,5% of cases. Increased overbite was observed in 15 patient and was di- minished in 4. Increased overjet was observed in 7 cases, and reduced in 4 cases. ni In all cases the position of the upper arches was distally derotated and there was absence of the curve of Spee and loss the curve of Monson. io During excentrum movements, such as during the move- as zero (5,14); ment of lower jaw protrusion, wherein the anterior contacts B6. Dental anomalies and/or malpositioning; are also supported by posterior contacts, a group function iz B7. Overbite/openbite (15); relationship was observed in all cases. B8. Overjet (16); Absence of verticalization of movements was observed in B9. Position of the first upper molars. Evaluation of the pa- all patients, everyone exhibited a masticatory angle <25º. Ed rallelism between the median raphe of the palate and the Analysis of Jarabak tracings, modified Bondi, showed that mesiodistal diameter of the upper arches, taking the trian- in all cases the indexes present point to a brachyfacial ty- gular fossettes into consideration; pology. B10. Occlusal plane state observed on the sagittal plane Dental wear was found in 78.3% of cases. In 14 of these, (absence/presence curve of Spee) and on the frontal pla- the dental wear was observed on both arches, which is a ne (absence/presence of curve of Monson); sign of adaptation. B11. Evaluation of the characteristics of the contacts bet- In 12 cases was present gum inflammation while in 6 ca- IC ween structures of antagonistic arches during lower-jaw ses receding gums. movements. We evaluated whether a group function or a To summarize the results of our study, the following cha- canine guidance was present during right and left lateral racteristics were observed in all of the cases: dental crow- movements (15,17); ding, brachyfacial typology, the absence of lingual dy- C B12. Absence or presence of verticalization in lower jaw sfunctions, the presence of group function during lateral movements (masticatory functional angle) (18,19); movements from the working side and malocclusion on the Radiographic assessment of facial typology. X-ray eva- nonworking side, absence of the curve of Spee, loss of the luation was performed on the basis of Jarabak-Bondi’s ce- curve of Monson, and derotation of the upper arches. © phalometric tracing; this was interpreted “dynamically” to obtain an understanding of the mutual relationships bet- ween the more important functional units of the face in the Discussion anteroposterior and vertical spatial planes. In particular, the following values were consider: We were able to observe 23 patients aged at least 75 ye- C1. Sum of S+ar+Go angles; ars with dental arches that were complete in both the an- C2. Jarabak’s ratio of posterior face height (PFH, S-Go) terior and posterior sectors. This study focused on the struc- to anterior face height (AFH, N-Me); tural characteristics of these patients’ mouths; we asses- 20 Annali di Stomatologia 2011; II (3-4): 19-24  Investigation of complete dental arches of 23 patients aged at least 75 years sed them according to the existing diagnosis and data col- Table 2 - Results. lection systems, as well as in the light of current gnatho- logic, orthodontic, and periodontic thinking. To gain a better appreciation of how correct function af- fects the structure of the masticatory organ, we assessed the presence or absence of labiolingual dysfunctions, ab- li sence of any TMD and absence of pain on palpation of the craniomandibular muscles. In other words, if it is true that na the function affects the structure of the organ, throughout their lives these patients have somehow maintained fun- ctioning that has allowed them in turn to maintain the struc- tures of the masticatory organ in a good condition, since io they all displayed the absence of the edentulous condition and prosthetic reconstructions in the posterior sectors. Even allowing for the existence of favorable genetic and envi- ronmental components, we investigated whether observing az the characteristics of these mouths provides any useful in- formation. Our aim was to define a preliminary theoreti- cal model that takes into account the integration of the fun- ctional and structural aspects, which would allow us to pre- rn dict more accurately the consequences of an altered fun- ction on the structure of the masticatory organ. For instance, by assessing the presence or absence of crowding of den- tition, this factor may be considered as a physiological con- te sequence of the normal development and adaptive pro- cesses involving the mouth. It is likewise possible to view the distinction into angle classes not as a functional clas- sification, or indeed as a primary objective to be attained, but rather a certain kind of evolution that is not necessa- In rily pathological or pathogenetic. The mechanistic theories of occlusion suggest that the dif- ference between ideal occlusion and malocclusion should be assessed on the basis of the morphological variations ni inferred from a comparison with the normal population. Once the predefined morphological objectives have been attained, a correct system functionality may be conside- io red to have been reached. According to functionalist phi- losophy, occlusal rehabilitation is defined as the therapy aimed at achieving an excellent morphology integrated with iz the overall equilibrium of the masticatory apparatus. On the strength of these concepts, the requirements of an ideal occlusion are set out in Table 3 (26-28). Nevertheless, 95% Ed of the population display significant morphological varia- tions of occlusion (1,4,29). It is possible for even a serious malocclusion to exist without having any significant effect on the health of the stomatognathic apparatus (19,30). These reflections were made with reference to and consi- dering all of the stomatognathic factors, and this leads us to believe that strictly speaking, not all of the results can be con- IC sidered as predictive of a pathological condition of the ma- sticatory organ, but rather as the consequence of an adap- tive physiological process, at least in a general sense. With reference to the principles of occlusion contained in C Table 4, the alignment of teeth in the arches is related to the mutual relationship between the teeth within the den- tal arch, and the resulting imaginary plane is referred to as the occlusal plane. This plane is curved, as the teeth © are situated in the dental arch according to different in- clinations: the curves of Spee and Monson. With reference to the occlusal plane, we found that all of the patients had a flat, straight occlusion plane (anti-Spee and anti-Monson), mesial inclination of the anterior and po- sterior teeth, and vestibular dental cusps, the upper ones of which were conserved and the lower ones worn (Figu- re 1). Annali di Stomatologia 2011; II (3-4): 19-24 21  B. Volpato et al. Table 3 - Ideal occlusion requirements (Okeson JP 1983)(27). 1. With the mouth closed the condyles are in their maximum superior position against the curve of the articular hemiarches 2. Dental contacts determine an axial loading of occlusal forces. 3. In laterality dental contacts are formed (canine guidance) on the working side and disclusion on the non working side. li 4. In protrusion suitable contacts of the anterior teeth guide the disclusion of the posterior teeth. 5. In a position of food alert waking feeding the posterior contacts are stronger than the anterior contacts. na Table 4 - Occlusal evaluation criteria according to NHANES III (7). io 1. Maximal opening capacity was measured as the distance between the incisal edges of the maxillary and mandibular right central incisors. 2. Relationship between RP and IP. The distance between the retruded contact position and the intercuspal position was az measured as the horizontal, vertical, and lateral distance between the two positions to the nearest half-millimetre. 3. The side of the first contact on guided hinge closure. 4. Mediotrusion contacts were recorded during habitual lateral gliding from the intercuspal position up to 3 mm. The presence of contact was verified with thin strips for occlusal registration. Mediotrusion contacts inhibiting contact on the laterotrusion side were considered to be interferences. rn 5. Protrusion contact. The location of the protrusion contact was recorded and then verified with occlusal strips in cases of doubt. Contacts of posterior teeth during protrusive movement were considered to be interferences. 6. The muscles palpated were the insertion of the temporal muscle and the lateral pterigoid muscle. The palpation index was te the sum of sites tender to palpation, the maximum thus being 4. 7. Pain on maximal active opening. 8. Pain and stiffness on guided hinge closure. In addition, the following variables were recorded at the age of 15: In 9. TMJ-sounds. Clicking and crepitation during mandibular movements were recorded with a stethoscope. 10. Tenderness to palpation of the TMJs. The joints were palpated laterally and posteriorly. 11. Deviation of the mandible during the opening movement was recorded with the aid of a transparent acrylic sheet having parallel lines to facilitate recording of lower jaw deviation. Deviation of > 3 mm from the imaginary midline of the upper and middle face was recorded. ni 12. Occlusal interferences were used to calculate the interference score (horizontal and vertical distance RP-IP > 1.5 mm, lat- eral deviation >0.5 mm, and mediotrusion contact on one side were given 1 point each; horizontal and vertical distance RP -IP>2 mm, lateral deviation > 1.0 mm, and mediotrusion contact on both sides were given 2 points each). io 13. The clinical CMD index was calculated for statistical testing at the age of 12 as follows: tenderness to palpation of the mus- cles of mastication was given 1 point, interincisal distance < 40 mm 1 point, and pain on maximal opening 1 point. At the age of 15 some additional variables were included in the index: pain on guided hinge closure 1 point, TMJ-sounds 1 point, iz tenderness to palpation of the TMJs 1 point, and deviation of the mandible during the opening movement >3 mm 1 point. Ed As far as the alignment of cusps and upper arch fossae eth, intercuspal groove of the teeth parallel to the median are concerned, the following observations were made: non- axis of the palate, and staggered alignment of the vesti- linear alignment of cusps and lateroposterior maxillary te- bular surfaces between molars and premolars (Figure 2). IC C © Figure 1 - A) Anti Spee and anti Monson; B) Vestibular cusps: su- Figure 1 - B) Intercuspal groove of the teeth parallel to the me- perior kept and inferior worn. dian axis of the palate, staggered alignment of the vestibular sur- faces between molars and premolars. 22 Annali di Stomatologia 2011; II (3-4): 19-24  Investigation of complete dental arches of 23 patients aged at least 75 years li na io Figure 2 - Intercuspal groove of the teeth parallel to the median Figure 3 - Important role in stabilizing a group function on the axis of the palate, staggered alignment of the vestibular surfaces working side is the disto-vestibular cusp of the first upper molar, between molars and premolars. az which was found to be mesio-inclined (case studies). rn te In A B Figure 4 - Extensive group contacts in the course of mandibular protrusion (A: right side; B: left side). ni The maxillary and mandibular canines are the teeth best io suited to absorbing and distributing horizontal forces whi- le the posterior teeth are in malocclusion. Patients with the- se conditions are said to have a canine guidance. The most iz preferable alternative to canine guidance is the so-called group function (17,31). Any laterotrusive contact posterior to the mesial position of the first molar is counterproduc- tive as a result of the increased force that leads to a clo- Ed ser approach to the fulcrum and the vector forces (32). In 96% of the patients in our study (22 out of 23), an im- portant role in stabilizing a group function on the working side was the distovestibular cusp of the first upper molar, Figure 5 - Important role in stabilizing a group function on the which was found to be mesioinclined (Figure 3). In order working side is the disto-vestibular cusp of the first upper molar, for this cusp to become involved in the group function, the which was found to be mesio-inclined (case studies). IC upper molar must be perfectly positioned with its median axis parallel to the palatine raphe with respect to the me- dian line of the palate, and the intercuspal groove must be parallel to the median line of the palate. To achieve ex- sent in all mouths, decisively contribute to the health of the C tensive group contacts in the course of mandibular pro- masticatory apparatus in ways and in terms that remain trusion (Figure 4), wear of the front teeth must allow po- to be elucidated. Among the constant contributory factors, sterior malocclusion (Figure 5).(33) it was noted that all of our patients are of the brachyfacial Angle classes, median line asymmetry, tooth rotation and/or type, which is a genetic rather than an adaptive factor. This © malpositioning, overbite, overjet, tooth wear and inflamed factor ensures a certain stability as regards the health of and receding gums are all factors that contribute to the gre- the stomatognathic apparatus. at variability in the results observed. Crowding and disa- It may be concluded that it is impossible to label the fol- lignment, derotated positioning of the upper arches, ab- lowing models that were found to be non predictive as pa- sence of the curve of Spee, occlusal plane trend contra- thological in the strict sense: angle classes, median-line ry to spherical theory, presence of group function on the asymmetry, tooth rotation and/or malpositioning, overbi- working side, and malocclusion on the nonworking side te, overjet, tooth wear, and inflamed and receding gums. seem to suggest that these factors, which are always pre- In other words, the results seem to indicate that these fac- Annali di Stomatologia 2011; II (3-4): 19-24 23  B. 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