Quintessence International, 05/2013

The decision-making process for the treatment of esthetic areas is based on the achievement of a healthy, harmonious, and pleasant smile. These conditions are directly associated with a solid knowledge of tooth anatomy and proportions, as well as the smile line, soft tissue morphology, and osseous architecture. To achieve these objectives, a multidisciplinary approach may be necessary to create long-term harmony between the final restoration and the adjacent teeth, and the health of the surrounding soft and hard tissues. This case report describes the application of a minimally invasive therapy on a 33-year-old woman seeking esthetic treatment. Minimally invasive periodontal plastic surgery associated with porcelain laminate veneers yielded satisfactory esthetics and minimal trauma to dental and periodontal tissues. Such a combined approach may be considered a viable option for the improvement of "white" and "red" esthetics. Keywords: esthetics, gingiva, porcelain laminate veneer, restorative dentistry, tooth root surgery

Objective: To investigate the two-body wear performance of monolithic dental ceramics with different surface treatments. Method and Materials: Standardized specimens (n = 8/ series) were fabricated from three monolithic dental ceramics (experimental translucent zirconia, experimental shaded zirconia, lithium disilicate). Four groups of each material were defined according to clinically relevant surface treatments: polished, polishedground, polished-ground-repolished, glazed. Two-body wear tests with steatite antagonists were performed in a chewing simulator. Surface roughness (Ra) was controlled, and wear depths of specimens and antagonistic wear areas were calculated in relation to human enamel as reference. Statistical analysis of wear data was carried out using one-way ANOVA and Bonferroni multiple comparison test for post hoc analysis (α = .05). Scanning electron microscopy was applied for evaluating wear performance of ceramics and antagonists. Results: Polished, ground, and repolished zirconia showed no wear, while glaze was abraded. Irrespective of the surface treatment, wear depth of lithium disilicate was significantly (P = .001) higher than for zirconia but only about half as high as for the enamel reference (274.14 µm). Mean relative wear areas of steatite antagonists (enamel reference: 1.25 mm2) ranged between 0.86 and 1.57 for zirconia, and between 1.79 and 2.28 for lithium disilicate, with the highest values found after grinding and glazing. Steatite surfaces were smooth when opposed to polished/ground/repolished zirconia, and ploughed when opposed to glaze and lithium disilicate. Conclusion: Translucent and shaded experimental zirconia yielded superior wear behavior and lower antagonistic wear compared to lithium disilicate. A trend to higher ceramic and antagonistic wear was shown after grinding and glazing. Keywords: CAD/CAM, monolithic, surface treatment, two-body wear, zirconia

Objective: When utilizing a single implant-supported crown to replace a central incisor, understanding the final shape of the implant restoration is an important factor to help achieve a successful esthetic outcome. In today's dentistry, tooth shape is a critical factor when dental implant prostheses are considered in the esthetic zone. The major esthetic goal for this type of restoration is to achieve the closest possible symmetry with the adjacent tooth, both at the soft and at the hard tissue levels. The goal of this study was to objectively analyze the significance of natural crown shape when replacing a central incisor with a single implant-supported crown. Method and Materials: In this study, we investigated the shape of the crowns of maxillary central incisors in 60 individuals who presented to our clinics with an untreatable central incisor. The presence of a dental diastema, "black triangle," presence or absence of gingival symmetry, and the presence or absence of dental symmetry were recorded in the pre- and postoperative photographs. Results: Out of 60 patients, 33.3% had triangular-shaped crowns, 16.6% square/tapered, and 50% square-shaped crown form. After treatment was rendered, 65% of the triangular group, 40% of the square/tapered group, and 13.3% of the square group required an additional restoration on the adjacent central incisor in order to fulfill the esthetic needs of the patients. Conclusion: Data analysis revealed that if there is a "black triangle," a diastema, or presence of dental or gingival asymmetry, an additional restoration on the adjacent central incisor is often required in order to fulfill esthetic goals. The additional restoration is highly recommended in situations with a triangular crown shape, while it is suggested in cases of square/tapered and square tooth shapes in the presence of a dental diastema. Keywords: biotype, black triangle, dental implant, esthetics, interproximal papilla, tooth shape

Objective: To assess the impact of local and systemic factors on additional peri-implant bone loss. Method and Materials: From a total of 253 patients, 193 were selected (126 women) and restored with 722 implants, in place for at least 1 year. Patients had previously attended the supportive periodontal/peri-implant therapy program at the Department of Implant Dentistry at the Federal University of Santa Catarina, Brazil. The study was divided according to physiologic (PBL 2 mm) or additional bone loss (ABL >= 2 mm) evaluated from the time of prosthesis placement to the reassessment visit. Data collection and analysis included evaluation of systemic factors, such as history of periodontal disease, heart disease, hypertension, diabetes mellitus, hyperthyroidism/hypothyroidism, osteoporosis, kidney disease, alcohol abuse, smoking habits, chemotherapy, radiation therapy, menopause, and hormone replacement. Analysis of local factors included implant platform, diameter, location, time in function, and type of prosthesis. Results: No systemic factors influenced ABL (P > .05). Considering local factors, only time in function and type of prosthesis influenced ABL (P .05). Conclusion: Fixed partial dental prostheses and full-arch fixed prostheses present higher rates of ABL. In addition, all types of prostheses showed greater ABL when in function for more than 4 years. Keywords: bone loss, dental implants, local factors, systemic factors

Objective: The detection of ferric ions in samples of black extrinsic dental stain led to the idea that it is comprised of insoluble ferric compounds. The present study examined the chemical composition of black extrinsic dental stain. Method and Materials: Plaque was collected from 17 children with black extrinsic dental stain (study group A) and from 15 children without black extrinsic stain (control group), using sterile graphite curettes; and from 4 children with black extrinsic stain (study group B), using a standard sterile metal curette. Samples were analyzed with a scanning electron microscope (SEM) and subjected to quantitative chemical analysis (energy dispersive spectrometry). Results: Except for calcium and phosphorus levels, no significant differences were found between the chemical composition of black extrinsic dental stain and dental plaque. Metallic ions were not detected in samples collected with a graphite curette (study group A), but were detected in samples collected with a metal curette (study group B). Conclusion: Metallic ions do not seem to be the origin of black extrinsic dental stain. Previous reports of the presence of metallic ions are probably due to contamination of the samples by the collection method. Keywords: black extrinsic dental stain, black pigmented teeth, microelemental composition of black stain

With increasing usage of Prasugrel (Effient), a new and highly efficient antiplatelet agent, in the management of cardiovascular events, the potential for bleeding complications has also increased. This is further compounded by the lack of a reversal agent, therefore poses a problem for clinicians engaged in oral invasive procedures. A case in which a patient taking daily Prasugrel suffered significantly prolonged bleeding following dental cleaning is reported. Local measures were used to achieve hemostasis. It is prudent to consult the prescribing physician about the risk of Prasugrel-induced bleeding, the potential for recurrence of cardiovascular events with disruption of medication, and the appropriate management strategy in advance of planned oral invasive procedures. Local measures are the first line of approach for management of hemostatic complications associated with Prasugrel, and patients should be referred to specialized centers if local approach fails. As more data become available, further evidence-based guidelines can be established. Keywords: antiplatelet, dental care, hemostasis, Prasugrel

Salivary gland impairment after radioiodine therapy (RIT) is a well-known iatrogenic artifact that includes recurrent episodes of sialadenitis, hyposalivation, dysgeusia, and dysphagia. Several therapy modalities have been suggested over the years to decrease these effects on the salivary glands. However, in cases where the salivary gland system is impaired prior to RIT, preserving its function becomes more challenging. We present three patients who underwent RIT with pre-existing insult to the salivary glands and discuss the treatment modality employed. A protocol for treating patients with pre-existing salivary gland impairment prior to RIT is proposed. The dental professional personnel should be aware of RIT insult to the salivary glands in order to preserve more maliciously the oral health in these patients. Management of impaired salivary glands subjected to additional RIT is mandatory to reduce further damage to the glands' function primarily by combining interventional sialoendoscopy for recurrent sialadenitis and sialogogues for hyposalivation. Keywords: iodine therapy, saliva, salivary glands, sialoendoscopy, Sjogren's syndrome

Periodontal treatment is based on tooth prognosis evaluation. Different approaches for determining tooth prognosis have been described in the literature. The vast majority are based on clinical and radiographic findings, as well as patient-related factors. The availability of various systems for assigning tooth prognosis complicates both the assignment process and the communication between clinicians regarding patient status and treatment plan. In addition, performance evaluation of several systems reveals that the accuracy of prediction differs between teeth of various conditions in most methods, as well as the factors providing significant predictive power. As a standardized prognostic classification system is still lacking, an overall evaluation based on a uniform dataset could provide an objective comparison of all methods, and help progress towards developing novel approaches. The main features of such approaches should include the selection of predictive factors, their assigned weights in accordance with different tooth conditions, and the estimated period of time applicable for reevaluation of prognosis. In this paper, we propose a different approach for prognosis evaluation, suggesting reevaluating tooth prognosis at several time points during the treatment plan, and taking into consideration some of the most important issues of patient compliance, oral hygiene, and plaque control. The suggested approach attempts to address prognosis from a different perspective, viewing the process as a dynamic and recurring evaluation embedded within each step of the treatment plan. Due to the fact that accurate tooth prognosis evaluation is still (and might forever be) unavailable, a more humble and less aggressive approach should be adopted, trying to preserve more and extract less. Keywords: hopeless teeth, periodontal disease, periodontitis, tooth extraction, tooth loss

Objectives: The aim of this systematic review is to investigate the effect of an additional lingual infiltration on the pulpal anesthesia of mandibular teeth. Method and Materials: Prospective clinical trials were searched from Medline, EMBASE, Cochrane Library, Pubmed, SCI, and the China National Knowledge Infrastructure. Papers that met the inclusion criteria were accepted. Data was extracted by two investigators using a designed extraction form. The anesthetic efficacy of an additional lingual infiltration on the pulpal anesthesia of mandibular teeth was analyzed. Results: Seven prospective randomized controlled trials were included. All subjects of these studies were volunteers with healthy pulps, without patients with pulpitis. Compared to buccal infiltration alone, an additional lingual infiltration following buccal infiltration is more likely to achieve a successful pulpal anesthesia in the mandibular incisor area, with a relative risk for success of 2.00 [1.08, 3.72] for 2% lidocaine and 1.32 [1.15, 1.51] for 4% articaine. For mandibular canines and premolars, the additional lingual infiltration following inferior alveolar nerve block did not enhance the anesthetic efficacy. In the mandibular molar area, no significant difference was found after an additional lingual infiltration with either 2% lidocaine or 4% articaine. Conclusion: An additional lingual infiltration following buccal infiltration can enhance the anesthetic efficacy compared with buccal infiltration alone in the mandibular incisor area. For mandibular canines, premolars, and molars, an additional lingual infiltration is not recommended, since no data exist to support such usage. Lingual infiltration of articaine in the mandibular teeth with pulpitis should be studied further. Keywords: articaine, lidocaine, lingual infiltration, local anesthesia, mandibular teeth

Objective: To compare the sealing ability of ProRoot mineral trioxide aggregate (MTA) to the sealing ability of EndoSequence Bioceramic Root Repair Material (ES-BCRR) putty using a bacterial leakage model. Method and Materials: Root canals of 60 single-rooted extracted teeth were enlarged to an apical diameter of 0.5 mm using EndoSequence files. The apical 3 mm of each root was sectioned at 90 degrees to the long axis of the root. An ultrasonic surgical tip was used to prepare a 3-mm deep root-end preparation in all teeth. Teeth were equally divided into four groups: Group 1, MTA; Group 2, ES-BCRR putty; Group 3, positive control, gutta-percha without sealer; Group 4, negative control, sealed with wax and nail varnish. Prepared teeth were kept moist for 48 hours to allow for initial setting of the materials. After ethylene oxide sterilization, the teeth were suspended in sterilized vials containing 3% phenol lactose broth and inoculated with Enterococcus faecalis through the occlusal access openings. The samples were observed daily for leakage to a maximum of 28 days. Chi-square and Fisher exact tests were used to compare the experimental groups and an alpha level of significance was set at P = .05. Results: In the ES-BCRR group 93% of samples leaked, compared to only 20% of samples in the MTA group. There was a significant difference in leakage between the experimental groups (P .0001). Also there were no significant differences between the negative control group and MTA group and between the positive control group and ES-BCRR group (P = 1.00). Conclusion: Samples in the ES-BCRR group leaked significantly more than samples in the MTA group. Keywords: bacteria, EndoSequence Root Repair Material, Enterococcus faecalis, leakage, MTA