Quintessence International, 06/2009

Cleft lip and palate (CLP) is a malformation of genetic derivation. For patients affected by CLP, procedures of guided bone regeneration by autologous bone grafting are recognized as the most effective to close oronasal communication. The residual gap of alveolar ridge, determined by the absence of 1 or more permanent teeth, can be completed by implant-prosthetic rehabilitation. This kind of rehabilitation for patients with CLP has the aim of completing dental reconstruction by avoiding sacrifice of adjacent teeth and preserving symmetric appearance. This article describes the rehabilitation of an 18-year-old patient affected by right unilateral CLP with use of a titanium implant supporting a single crown to replace the lateral incisor. The technique used was particularly helpful for this cleft case, in which a bone deficit subsisted after secondary bone grafting. An additional bone grafting procedure was performed at the time of implant placement to achieve the best functional and esthetic results. Keywords: alveolar ridge, cleft palate, grafting bone, single-tooth dental implant

An unusual case of an endodontic-periodontal lesion in a 29-year-old man resulting from a habit of opening beer bottle (metal) caps using his mandibular left molar is reported. The patient had been a chronic alcoholic with several emotional problems and was unaware of the injurious nature of his habit. Thus, the importance of a detailed case history and assessment of psychosocial aspects for an accurate diagnosis of such conditions is highlighted. Keywords: adventurous habit, bottle-cap opening, endodontic-periodontal, injurious habit, psychosocial, unusual

Endodontic treatment of third molars often becomes part of comprehensive treatment plans, as it represents a more conservative and less invasive approach than its therapeutic alternatives. The frequency of anatomic variations in mandibular molars, particularly root canal configuration, requires 2 periapical radiographs from different angles. Upon reading and interpretation of the radiographs, the clinician should consider the anatomy and level of difficulty of the endodontic procedure and refer the patient to an endodontist, if deemed necessary. The present article discusses the successful treatment and preservation of a mandibular third molar with 5 root canals, as well as methods for its clinical management. Keywords: anatomic variation, dental-operating microscope, root canal therapy, third molar

Patients who have experienced significant brain injury (such as hemorrhagic stroke or trauma) can suffer brain damage that leads to altered neurologic functioning. One such ill effect is the development of aberrant mandibular reflexes that may inflict serious trauma to oral and labial tissues. As primary oral health care providers, dental clinicians may be called upon to function as part of the medical team managing the patient. This case report reviews one such scenario in which the unique skills of trained specialists were used to provide a protective oral device to allow for tissue protection and healing. Keywords: bumper guard, cameo impression, decerebrate rigidity, hemorrhagic stroke, intracranial hemorrhage, Molt prop, orthodontic headgear

Predictable and optimal coverage of exposed root surfaces is an important goal in periodontal plastic surgery. In this report, recession coverage was performed as laterally sliding flap technique with the adjunctive use of enamel matrix derivative (EMD). The cases of 2 female patients with gingival recession on the maxillary canines are presented with 1-year follow-up observation. Initial vertical gingival recessions were 4.0 mm each, with a probing depth of 1.0 mm. The surgical procedure immediately produced a marked reduction in gingival recessions. In the course of healing, the soft tissue margin on the operated teeth showed some shrinkage in the first months. After 1 year, complete root coverage (100%) was observed, with a probing depth of 0.5 mm and 5.0-mm gain of clinical attachment in both cases, and there was 0.5-mm creeping tissue above the cementoenamel junction. Within the limits of these cases, the results demonstrated the possibility of treating human buccal recessions with EMD plus laterally sliding flap, with predictable root coverage and clinical attachment gain. Keywords: bioengineering, enamel matrix protein derivative, gingival recession, laterally sliding flap, mucogingival surgery, root coverage

Objective: To determine the effect of delayed start of light polymerization of a dual-cured composite base on the microleakage of Class 2 open-sandwich composite restorations. Method and Materials: Fifty extracted human molars were used to prepare Class 2 mesio-occlusal and disto-occlusal slot preparations. Teeth were randomly divided into 2 groups and restored with a base of dual-cured composite in the proximal box and a top layer of light-cured composite. Group I was restored with a 1-step dual-cured bonding agent; group II was restored with a 2-step dual-cured bonding agent. Five subgroups were created according to the method of polymerization of the dual-cured composite: (A) selfcured, (B) light-cured immediately, (C) light-cured 30 seconds after placement, (D) lightcured 60 seconds after placement, and (E) light-cured 120 seconds after placement. Restorations were stored for 1 week at 37°C and 100% relative humidity, thermocycled (2,000 times, 5°C to 55°C, 15-second dwell), and immersed in a 1% aqueous solution of methylene blue for 24 hours at 37°C. Samples were sectioned mesiodistally, and dye penetration at enamel, dentin, and cementum margins was scored under a stereomicroscope using an ordinal scoring system. Results: Statistical analysis using analysis of variance (ANOVA) on ranks showed that the dual-cured composite light polymerized 1 minute after placement exhibited the lowest microleakage (P .05) in both bonding agent groups. Conclusion: Delayed, rather than immediate, light polymerization of the dual-cured composite base reduced microleakage in Class 2 open-sandwich restorations. Keywords: Class 2, delayed curing, dual-cured, microleakage, open-sandwich restoration, polymerization shrinkage, posterior composite

Objective: The use of connective tissue grafts is a proven, effective treatment modality. This study examines whether harvesting connective tissue grafts from the palate causes persistent sensory dysfunction. Methods and Materials: Fourteen patients who had received at least 1 graft were included. Neurosensory tests at the palate performed postoperatively included minimal 2-point discrimination, soft-touch discrimination, pin-tactile discrimination, and thermal discrimination. Measurements were taken at 3 sites each: 5, 10, and 15 mm from the palatal tissue margin at canines, premolars, and first molars. Results: Eight patients had 1 graft, and 6 patients had 2 grafts harvested from their palate. Twelve patients had never noticed any dysfunction. Two patients reported a persistent numbness or a rough palatal surface. Statistically significant differences between donor sites and nondonor sites were shown by 2-point discrimination 5 mm from the margin of canines (6.57 mm ± 3.79 mm at donor sites and 4.71 mm ± 4.14 mm at nondonor sites, P = .01). Repeated-measures analysis of variance showed statistically significant differences between donor sites and nondonor sites for measurements taken 5 and 10 mm from the margin of all included teeth (P = .02). Conclusions: Some sensory changes can occur after graft harvesting from the palate. Keywords: connective tissue graft, harvesting, palate, patient-centered outcomes, root-coverage graft, sensory dysfunction

Objective: Restorative procedures of the dentin-pulp complex stimulate damages that, depending on the technique and materials used, may induce pulpal reactions. The purpose of this study was to evaluate immunochemistry, morphologic, and morphometric pulpal alterations of human teeth pulps capped with self-etching or total-etching adhesive systems. Method and Materials: Thirty human third molars were restored with a resinbased composite and adhesive system, either Clearfil (Kuraray; n = 10) or Scotchbond (3M ESPE; n = 10). After 7, 30, or 60 days, the teeth were extracted and longitudinally sectioned. The pulps were removed for histopathologic and immunochemistry evaluation for interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, and inducible nitric oxide synthase (iNOS). Results: The density of fibrous connective tissue was significantly higher after 30 days in both groups (P .001). Congestion, hemorrhage, calcification, and swelling of the odontoblasts were similar in both groups. The total capillary area was significantly higher after 7 and 30 days in both groups. Positive immunoreactions for iNOS were found in 1 case (20%) of the 30-day Scotchbond group. Immunoreactions for IFN-gamma were positive in a few cells in 1 case (20%) of the 7-day Clearfil group. There were no positive immunoreactions for TNF-alpha in any case. Conclusion: No inflammatory reactions, necrotic areas, or severe immunoreactions for proinflammatory cytokines were found, suggesting biocompatibility of self-etching or total-etching adhesive systems when placed directly on dentin. Keywords: adhesive systems, immunohistochemistry, marginal microleakage, morphology, morphometry, pulp reactions, teeth

Objective: The Volpe and Manhold Index (VMI) was used to evaluate the anticalculus efficacy of the dentifrice Fluor Kin antisarro, used on adults twice a day for 2 minutes over 3 months, in comparison with the dentifrice Lácer. Method and Materials: A clinical study in which 48 adults took part was designed. The presence of calculus was determined at baseline (VMI), a tartrectomy was performed, and the patients were instructed to brush their teeth twice a day for 2 minutes, using a medium-bristled toothbrush with a commercial dentifrice containing 0.2% aldioxa and 1.9% sodium monofluorophosphate. Three months later, VMI was determined again. After 2 weeks, a new tartrectomy was performed on the same patients, and the subjects were instructed to brush their teeth as before, this time with the study dentifrice based on 0.32% sodium fluoride, 4.1% tetrapotassium pyrophosphate, 2.0% PVM/MA (methylvinylether/maleic acid) copolymer (Gantrez S), 1.0% provitamin B5, and 0.2% vitamin B3. After an additional 3 months, dental calculus was determined again. Results: The study dentifrice showed a significant reduction in VMI in relation to the initial situation (P = .009). There were also significant differences in VMI values between the 2 dentifrices (P = .010). VMI differences were not significant for either dentifrice when analyzed by gender, tobacco use, and toothbrushing frequency before starting the study. Conclusions: Brushing twice a day for 2 minutes with Fluor Kin antisarro effectively reduces supragingival calculus. Keywords: anticalculus dentifrice, dental calculus, PVM/MA copolymer

A case of fibrosis in the cheek of a 42-year-old woman is presented. The panoramic radiograph showed a well-defined, round radiopacity in the maxillary right third molar region. Other techniques revealed that it was a superimposition. The lesion was hard and painless and associated with hypertrophic scarring secondary to a burn injury many years earlier. Clinicians must be aware of the radiologic image of this fibrosis, so as not to confuse it with other radiopaque lesions of hard tissue origin that occur in both arches. A differential diagnosis is described. Keywords: calcified tissue, fibrosis, hypertrophic scar

Objective: To determine whether embrasure morphology can affect the association between bone crest-contact point distance and central papilla height in esthetic dentistry. Method and Materials: The central papilla was visually assessed in 310 adults using standardized periapical radiographs of the maxillary central incisors. The following vertical distances were measured: bone crest to contact point, proximal cementoenamel junction to contact point, and papilla height. The horizontal distance measured was the interdental width. Subjects were divided into 4 groups according to interdental width and proximal cementoenamel junction-contact point distance: narrow-long, narrow-short, wide-long, and wide-short. Results: In subjects with papilla recession, the longer the bone crest-contact point distance, the greater the mean papilla height in all study groups except the narrow-long group. Significant correlations were found between papilla height and bone crest-contact point distance in subjects with recession. Conclusions: Various embrasure morphologies did not affect central papilla height in subjects with papilla recession. However, other factors may affect the central papilla height, and further study of these factors is necessary. Keywords: age factors, dental morphology, interdental papilla, radiography

Objective: To assess the accuracy of fit of frameworks on implants processed with electrical discharge machining (EDM) or the Cresco technique (Astra Tech). Method and Materials: On 12 identical master casts with implants at positions 9(21), 11(23), and 13(25), high-gold alloy frameworks were produced by standard casting procedure. Six frameworks were used for the Cresco technique (group CRE) by employing specific fixed partial denture supports. The remaining 6 frameworks were cast with prefabricated gold copings and served as control. The finished frameworks were screwed onto implant 25 of the corresponding master cast. Dimensions of the marginal gaps were measured at 4 locations on each implant under the scanning electron microscope, applying the replica technique. Subsequently, the control group was processed by EDM (SAE EDM 2000) (group EDM) and analyzed alike. Statistical analysis of the results was performed with Kruskal-Wallis and Mann-Whitney U tests. Results: The mean marginal gaps were measured as follows (CRE / EDM / control): position 25: 0.0 µm / 1.0 ± 1.6 µm / 1.5 ± 2.1 µm; position 23: 5.2 ± 5.6 µm / 18.7 ± 29.3 µm / 23.6 ± 30.7 µm; and position 21: 36.0 ± 21.6 µm/ 40.7 ± 31.0 µm / 46.0 ± 41.1 µm. The only statistically significant difference was found at location 23 between group CRE on one side and both group EDM and control on the other side. The strong increase of misfit for group CRE from location 23 to location 21 indicates that laser welding is the crucial parameter in this technique. Conclusion: The Cresco technique has a potential to reduce the marginal gap between implants and suprastructures. Keywords: Cresco, electrical discharge machining, fixed partial denture, implant, marginal fit, suprastructure

Objective: To learn about the use of various chewing substrates, such as areca nut and gutka, among subjects with oral submucosl fibrosis (OSMF) and controls with no oral mucosal lesions. Materials and Methods: In this hospital-based case-control study, 220 patients with OSMF were selected and compared with matched controls with regard to dietary habits, including spice use, smoking history, and preference for chewing substrates. Relative risk of various chewing habits was calculated using an odds ratio and logistic regression analysis to understand the influence of chewing habits, spices, and smoking on the development of OSMF. Discriminate analysis was employed to determine which risk factors were valid and reliable discriminators between individuals with or without OSMF. Results: The relative risk of developing oral submucosal fibrosis was highest with gutka-chewing habit (relative risk, 1,142.4), which was significant (P .01) at 95% confidence interval. The next highest relative risk for development of oral submucosal fibrosis was observed for the combination of gutka with other chewing habits. The relative risk of developing submucosl fibrosis increased with the frequency of chewing habit up to 15 times daily with a duration of habit up to 4 years. The relative risk decreased with chewing frequency beyond 15 times daily and 4 years in duration. Logistic regression and discriminative analysis show that chewing areca nut and gutka, especially daily, greatly influence the development of submucosl fibrosis. Conclusion: This study suggests that chewing commercially available areca-nut preparations such as gutka is strongly associated with the development of oral submucosl fibrosis. Keywords: areca nut, chewing habit, gutka, relative risk

Objectives: To evaluate the histopathological changes in mechanically exposed dog pulps capped with three self-etching adhesive systems. Material and Methods: Seventy-two Class V cavities were prepared under rubber dam isolation in dogs. The pulps were exposed and capped with Clearfil SE Bond (Kuraray), Imperva FluoroBond (Shofu), Prompt L-Pop (3M ESPE), and Dycal (Dentsply; control capping agent), respectively. Histopathological examination of the teeth was performed at 7, 14, and 30 days post-operatively. Hematoxylin-eosin staining was performed to assess the inflammatory cell response, tissue disorganization, and hard tissue formation. Brown & Brenn staining was used to detect the presence of bacteria. The data were analyzed by Kruskal-Wallis and Nemenyi tests. Results: Most pulps showed moderate to severe inflammatory response. Hard tissue formation appeared at 14 to 30 days. Positive bacterial staining was observed in most specimens in experimental groups. The histological changes in the pulps of the experimental groups were more pronounced than in the control group. Differences in inflammatory response, tissue disorganization, and hard tissue formation were observed among teeth treated with the three self-etching systems. Conclusion: Microleakage has a critical influence on pulpal repair. It is not beneficial to cap the pulp with self-etching adhesive systems. Diverse pulpal responses were observed to the self-etching adhesive systems, and the histological changes were more pronounced than in the control pulps treated with Dycal. The effects of the self-etching adhesive systems are such that these materials require further study to address issues of bacterial microleakage during placement of restorations. Keywords: adhesive system, direct pulp capping, self-etching