Quintessence International, 05/2009

This clinical case describes mandibular osteomyelitis in a healthy 31-year-old man as a severe complication following third molar removal. Recurrent abscess formations were treated with intensive therapy involving antibiotics, surgical debridement of the affected region, and hyperbaric oxygen. In the follow-up, despite microbiologic study to determine the indicated treatment approach, a severe osteomyelitis was present, clinically and radiographically. Finally, a partial resection of the mandible, including exarticulation, was indicated to manage this severe complication. Keywords: facial swelling, healthy man, hyperbaric oxygen, mandible, osteomyelitis, paramandibular abscess, third molar

Pathologically migrated teeth generally require orthodontic correction, as well as restorative options, as treatment. The term reactive positioning has been used to describe tooth movement that occurs without the use of appliances after periodontal treatment. This article describes the case of a young woman with periodontal attachment loss and distolabial pathologic migration of the maxillary central incisors, with midline diastema formation. Papilla preservation flap surgery was performed on the maxillary anterior segment, which spontaneously resolved the midline diastema without orthodontic treatment. This article also explores the possible mechanisms (hypotheses) for such an outcome of a simple periodontal surgery. Keywords: pathologic migration, periodontal surgery, reactive positioning

A 16-year-old girl presented with complaints of recurrent spontaneous pain in the mandibular second molar region. Treatment favored use of a simple uprighting technique involving orthodontic elastic separating rings. Keywords: impacted mandibular molars, orthodontic separating rings

Objective: To measure cuspal flexure of intact and restored maxillary premolars with different restorative materials and occlusal contacts. Method and Materials: Microcomputed tomography data were used to generate finite-element models with a mesioocclusodistal (MOD) cavity preparation and the corresponding restoration. The tooth parts were imported in finite-element software to create 3D volumetric models. Occlusal loading either in enamel, at restoration margin, or in restorative material was simulated by linear contact analysis. Cuspal widening was measured for the different contact locations and restorative conditions (unaltered tooth, MOD porcelain, and composite-inlay restorations). Results: For a given material property, contacts in restoration generated the least amount of cuspal deformation, followed by the enamel contacts and contacts at restoration margin. Models of the intact tooth and ceramic inlay behaved similarly (cuspal widening at 100 N ranging from 1.8 to 3.0 µm and 1.6 to 2.6 µm, respectively). Cuspal flexure was increased in the MOD composite resin restorations (3.4 to 5.7 µm at 100 N of axial force). The least amount of deformation was generated in the ceramic inlay with contacts in only restoration (1.6 µm at 100 N) and the largest in the composite inlay with contacts at restoration margins (5.7 µm at 100 N). For the composite restoration, antagonist contacts at restoration margins were less favorable compared to located on either enamel or the restoration itself. Conclusion: A relatively small cuspal deformation was observed in all models. There is an increased cusp-stabilizing effect of ceramic inlays compared to composite ones. Keywords: cuspal flexure, composite resins, finite element analysis, occlusion, porcelain inlays, restorative dentistry

A single-incision technique was introduced to minimize the size of the palatal wound and allow for primary closure of the donor site, which may result in reduced postoperative pain. It is sometimes necessary to repeatedly use the same area of a patient's palate for consecutive connective tissue grafts because of limitations caused by inadequate tissue or vascular anatomy. This case presentation describes the clinical results of 2 subepithelial grafts for root coverage from the same donor area at different times using the single-incision technique. The root coverage obtained with both the first and second connective tissue grafts from the same donor area using the single-incision technique at a 6-week interval showed predictable results, with reduction of dentin hypersensitivity without probing defect or significant complication. This approach may be an option when multiple connective tissue grafts are needed. The presented results need to be validated in further large case series or case-controlled studies. Keywords: connective tissue, multiple, palate, single incision, tissue graft

Following a complete evaluation of the patient, treatment planning requires the analysis of individual teeth, accurate diagnosis, and prognosis evaluation. Currently, there is no accepted comprehensive, standardized, and meaningful classification system for the evaluation of individual teeth that offers a common language for dental professionals. A search was conducted reviewing existing literature relating to classification and prognostication of individual teeth. The dimensions determined to be of importance to gain an overall perspective of the individual relative tooth prognosis were the periodontal, restorative, endodontic, and occlusal plane perspectives. The authors present a comprehensive classification system by conjugating the literature and currently accepted concepts in dentistry. This easy-to-use system assesses the condition of individual teeth and enables a relative prognostic value to be attached to those teeth based on tooth condition and patient-level factors. Keywords: classification, dental assessment, endodontic, diagnosis, occlusal plane, periodontic, prognosis, restorability, tooth, treatment planning

The 2004 American Dental Association (ADA)/US Food and Drug Administration (FDA) radiographic selection criteria and guidelines were reviewed and compared with the prior radiographic selection criteria and guidelines. The authors reviewed the publications from the US FDA, US Department of Health and Human Services, and National Council on Radiation Protection and Measurements. The positions outlined by the Canadian Dental Association and the European Commission were also reviewed and compared to US guidelines. The FDA guidelines were first published in 1987, and several changes have been made to them over the years. Recent literature reveals that the general compliance of these guidelines is very low, especially within dental schools in the United States and Canada. Little is known about the compliance outside of the dental school environment; however, it is expected to be low for various reasons. In 2007, the International Commission on Radiological Protection (ICRP) revised its estimates of tissue radiosensitivity, which resulted in effective doses of dental radiographs 32% to 422% higher than the 1990 ICRP guidelines. Flow charts summarizing the latest guidelines were developed to facilitate general compliance among practitioners. Based on the literature reviewed and the recent ICRP findings, it would be prudent for dental health care professionals to follow dental radiographic guidelines. Keywords: compliance, dental radiograph, radiation dose, radiographic guidelines

Objectives: Recurrent oral aphthous ulceration is a common condition treated with topical anti-inflammatory drugs, such as triamcinolone acetonide in Orabase (Kenalog in Orabase, Bristol-Myers Squibb). The aim of the study was to synthesize a novel dental paste containing dexamethasone and assess the therapeutic effect of this paste in comparison with a commonly used treatment, triamcinolone acetonide in Orabase, in oral aphthous ulceration. Method and Materials: The design was a case-control study. The setting was the laboratory of postgraduate students in the College of Pharmacy, University of Mosul, Iraq. Clinical evaluation of the paste was conducted in the outpatient clinic of the Oral Medicine Department, College of Dentistry, University of Baghdad, Iraq. The novel paste (named dexamucobase) was prepared under aseptic conditions and evaluated for its therapeutic effect in 53 patients with recurrent aphthous stomatitis, in comparison with 37 patients treated with triamcinolone acetonide in Orabase. Results: Healing of the ulcer was significantly faster (P .001), and adverse effects were significantly reduced (P .01) for the dexamucobase treatment compared to Kenalog in Orabase. There was no significant difference in the speed of pain reduction between the dexamucobase treatment compared to Kenalog in Orabase. Conclusions: The novel dexamucobase was found to be equally effective in treating oral aphthous ulceration, with some advantages, as the widely used preparation Kenalog in Orabase. Keywords: aphthous, Orabase, oral ulceration, topical formulation, triamcinolone

Objective: To evaluate the retention and the wear of different prefabricated precision ball attachments consecutively during long-term use. Method and Materials: Six commercially available ball attachment systems were selected. The balls were attached to stylized implants fixed in metal casts. The matrices were fixed in a stylized unilaterally removable partial denture (RPD). Using a chewing simulator with 8 units, 50,000 joining and separating cycles of the matrices were performed. After each joining movement, an eccentric load of 100 N was applied to the RPD at a distance of 12 mm from the ball attachment. The retention forces were measured at intervals. Results: Initially, median retentive forces varied between 8.2 N and 14.0 N. During the test, patterns in retention changes were identified. At the end of the test, one group with a matrix using precious alloy lamellae and a titanium ball showed significantly higher median retention forces (10.4 N) than the other ball attachments (1.0 N to 3.7 N). Also, the wear of the ball attachments varied considerably. Conclusion: Within the limitations of this study, the material combination of a precious gold alloy matrix and a titanium ball seems to be favorable for long-term retention. Keywords: ball attachment, implant, retention, wear

Objective: In the previous decade, several reports have been published regarding implants inserted in autografts, but none have analyzed implants inserted in fresh-frozen bone allografts. Thus, a retrospective study was planned to verify if 4-months' delay from grafting to implant insertion is a safe period before prosthetic rehabilitation of implants placed in fresh-frozen bone allografts. Method and Materials: Between December 2003 and December 2006, 22 patients (10 women and 12 men with a median age of 51 years) underwent grafting with horizontal augmentation without membrane and 88 implants inserted thereafter. The mean implant follow-up was 27 months. Implants used were 30 double etched (3i, Osseotite, Biomet), 10 SLA1 (Astratech), 26 anodic oxidized (Nobel Biocare), 12 CaPO4 ceramic-blasted (Lifecore Biomedical), 7 SLA2 (Sweden & Martina Spa), 2 ITI (Straumann), and 1 Biotec (Povolaro di Dueville). Implant diameter and length ranged from 3.25 to 5.0 mm and from 8.0 to 15.0 mm, respectively. Implants were inserted to replace 10 incisors, 7 canines, 36 premolars, and 35 molars. Results: No implants were lost (ie, survival rate = 100%). No difference was detected when comparing implants loaded after 4 months versus those loaded after 6 or more months (209 implants). Conclusion: Four-months' delay from grafting to implant insertion is a safe period to obtain a high survival rate and success rate for implants inserted in fresh-frozen bone. Keywords: allograft, Cox regression, homograft, iliac crest, implant, Kaplan-Meier algorithm

Objective: To evaluate intraexaminer reliability in measurement of basic tooth color by use of a clinically applicable spectrophotometer. Method and Materials: Three examiners determined the L* (lightness), C* (chroma), and h* (hue) values and tooth color according to the Vita 3D-Master shade guide system (Vident), twice for 161 anterior teeth of 19 subjects by use of a spectrophotometer (Vita Easyshade 1, Vita Zahnfabrik). Between the 2 measurements on each tooth, the investigators had to completely remove the probe tip from the mouth. The reliability of the measurements was observed, and deviations between the 2 L*C*h* measurements, as well as ΔEab for the measurements, were calculated. Results: Exact agreement of chosen shade tab according to the 3D-Master shade guide was achieved in 48% of cases. Mean ΔL*, ΔC*, and Δh* for all examiners were 1.9 (SD 1.7), 1.3 (SD 1.3), and 0.5 degrees (SD 0.7 degrees), respectively. The maximum deviation was 9 for ΔL*, 7 for ΔC*, and 3 degrees for Δh*. Mean ΔEab for the measurements was 2.7 (SD 1.8, range 0 to 9.5). Conclusion: Intraexaminer reliability was usually acceptable, although a clinically relevant difference between the 2 measurements of an examiner was occasionally observed. This uncertainty should be borne in mind in clinical routine and in studies reporting changes in color, eg, studies of tooth bleaching. Keywords: ΔEab value, reliability, shade guide, spectrophotometer, tooth color, tooth-color measurement

Aim: To examine the influence of the accuracy of fit on mouthguard retention in relation to mouthguard outline location. Materials and Methods: Mouthguards were fabricated on a fully dentate maxillary cast with 4-mm thick ethylene vinyl acetate sheets using a well-dried cast (VD) and on a wet cast (VW) with a vacuum-forming machine. Mouthguards were also made with a pressure-forming machine (P). The mouthguard outline was set at 4 mm from the cervical margin (control, C), the palatal outline was set at the cervical margin (Pa), and the buccal outline was extended to the buccal fold (Bu). A dislodging force perpendicular to the occlusal plane was applied at the first molar on the universal testing machine. Results were analyzed using ANOVA with Scheffe's test (P .05). Results: Using the VW, the retentive forces were statistically smaller at Pa compared to Ca or Bu (C: 58 ± 17 gf, Pa: 36 ± 7 gf , Bu: 50±8gf) (P .05). There were no statistical differences between VD (C: 116±27gf, Pa: 86±15gf, Bu: 92±7gf) and group P (C: 133±31gf, Pa: 139±24gf, Bu: 136±17gf). Conclusions: The results indicate that mouthguard retention is closely related to the accuracy of fit at the cervical undercut area rather than the outline location. Keywords: accuracy of fit, cast, design, mouthguard, outline, retention