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This literature-based OPINION PAPER reflects in an introductory historical perspective on the rapid advancement of dental adhesive technology. Past and current techniques to bond to tooth tissue, in particular to dentin as the most challenging bonding substrate, are critically appraised. Including the historical perspective in (1), this paper focuses on fourteen items thought to be of primary importance with regard to the current status of dental adhesive technology. In (2) the primary mechanisms involved in adhesion to enamel and especially dentin are dealt with having (3) also revisited the previously introduced adhesion-decalcification concept (AD concept) as basis of biomaterial-hard tissue interaction; the worldwide accepted classification of today's adhesives into etch&rinse (E&R) and self-etch (SE) adhesives are presented in (4), along with presentation of their respective PLUS-MINUS balances in (5) and (6); nomination of the GOLD-STANDARD E&R (7) and SE (8) adhesives is based on evidence of successful laboratory and long-term clinical performance, resulting in a recommended 3-step full E&R bonding route in (9) and the preferred 3-step combined selective enamel E&R with 2-SE bonding route in (10); (11) description of the main bond-degradation pathways and eight strategies to preserve bond stability; (12) coverage of the PROS and CONS of the newest generation of UNIVERSAL adhesives. Looking into the future, some expected future developments in dental adhesive technology have been suggested in (13), along with (14) a first status determination of the latest research-and-development towards self-adhesive restorative materials that no longer require any pre-treatment. Keywords: review, bonding, dentin, adhesion, self-adhesive

Purpose: The goals of this review are (1) to describe the evidence behind the use of ceramics vs composite resin to restore teeth with anterior veneers using a minimally-invasive strategy; and (2) to discuss the choice of materials and techniques for anterior veneer restorations. Overview: In recent years new adhesive restorative materials and techniques have been introduced in dentistry, including nanofilled composite resins for direct restorations, new ceramic materials that combine esthetics and strength, and polymer/ceramic materials for indirect restorations that are fabricated chairside using CAD/CAM technology, allowing the dentist to design, mill, and cement the restoration in one session. In spite of the novelty and new technology behind the introduction of new materials, the available evidence that backs some of these materials does not justify their use over similar materials or techniques that have been used by dentists for some years. Notwithstanding the success of laminate veneers and the popularity of new materials and digital techniques, the classical direct composite resin veneer is still very popular among clinicians and taught in dental schools and continuing education courses. Direct composite resin veneers are usually more affordable than indirect veneers, less invasive of the tooth structure, and easier to repair. Current composite resin materials can be finished to a tooth-like appearance, but they are susceptible to alterations of the surface gloss and potential discoloration of the composite resin. On the other hand, the preparation for indirect veneers is generally more invasive and the respective restorations are more difficult to repair. In addition, the esthetic outcome of bonded ceramic restorations still depends on the clinical behavior of the dentin adhesive and resin luting cement used to bond the restoration to the tooth structure. Conclusions: The ultimate goals of any restorative treatment are to restore function and esthetics, prevent recurrent caries lesions and bacterial leakage into the pulp space, save tooth structure, and promote the well-being of our patients. The armamentarium of new dental materials for esthetic clinical procedures has increased exponentially in the last few years. The use of different materials and techniques for anterior veneer restorations must be based on sound evidence rather than on the marketing hype or testimonials. Keywords: adhesion, ceramics, clinical, composite resin, MID, restorative materials, veneers

Purpose: The present study aimed to investigate the resistance and failure mode of broken-down endodontically treated incisors without ferrule restored with CAD/CAM endocrowns. Materials and methods: Endodontically treated bovine incisors (N = 30) without ferrule were divided into two groups and restored with two types of CAD/CAM endocrowns: lithium disilicate (Eld) or resin nanoceramics (Erc). The preparations included a 4-mm–deep ‘internal ferrule’ and immediate dentin sealing. The samples were subjected to accelerated fatigue testing. Cyclic isometric loading was applied to the incisal edge at a 30-degree angle at a frequency of 5 Hz, beginning with a load of 100 N (5,000 cycles). A 100 N load increase was applied every 15,000 cycles. Specimens were loaded until failure or to a maximum of 140,000 cycles. Previously published data from the same authors regarding lithium disilicate crowns over post-and-core buildups without ferrule (NfPf), core buildups without post without ferrule (NfNpFR), and with a 2-mm ferrule (FNp) using the same experimental setup were included for comparison. Groups were compared using the Kaplan Meier survival analysis for cycles (log rank pairwise post hoc test comparisons at P = 0.05) and Life Table survival analysis for load at failure, followed by the Wilcoxon pairwise comparison at P = 0.05. Results: All specimens failed before 140,000 load cycles. There was no statistically significant difference between the endocrown materials (Eld: 53,448 mean endured cycles; Erc: 52,397 mean endured cycles; P = 0.844). Endocrowns outperformed the group with lithium disilicate crowns on incisors without ferrule and post-and-core buildup (NfPf with mean endured 35,025 cycles), showed no statistical difference compared with the group with no-post fiber-reinforced composite resin core buildup (NfNpFR with 45,557 mean endured cycles), and had a lower survival rate compared with the group with ferrule (FNp with mean endured 73,244 cycles). Endocrowns generated a majority of non-catastrophic failures (with an advantage for Erc), while 100% of catastrophic failures were found in the group with a post. Conclusions: CAD/CAM endocrowns of nonvital incisors without ferrule improved the resistance and optimized the failure mode when compared with traditional bonded crowns with adhesive post-and-core and no-post buildups.

The present article describes a treatment planning clinical strategy based on a flowchart developed to facilitate the treatment of teeth with severely compromised clinical crowns. The study comprised a group of 978 patients presenting with 2327 teeth needing clinical crown reconstruction. The patients were screened, diagnosed, and treated with a multidisciplinary approach according to a flowchart structure. A subgroup of 75 teeth in 62 patients was considered irrational to treat when a composite risk-evaluation model was applied. Another subgroup of 168 teeth in 126 patients required periodontal surgery and received a minimally invasive crown lengthening (MICL) procedure. Endodontic treatment was necessary for 73 teeth, and retreatment for 51. Most of the teeth (124 in 94 patients) received a full crown, while the remaining 44 teeth received a direct (24 teeth) or an indirect (20 teeth) reconstruction. Six teeth were orthodontically extruded before surgery. The 1-year average probing depth and clinical attachment level at the treated teeth was 2.5 ± 0.5 mm and 2.7 ± 0.6 mm, respectively. Bleeding on probing was detected in 19 sites (11.3%). No side effects or short-term recurrences were detected in 168 treated sites. Patients described function and esthetics as extremely satisfactory, very satisfactory, or satisfactory. In conclusion, an accurate screening based on a flowchart supported the clinical decision to treat 168 teeth with MICL and to replace 75 out of 2327 teeth presented at our clinic for restorations. The use of MICL and the high-quality restorations resulted in a healthy periodontal and dental condition of all the treated teeth as well as patient satisfaction at the 1-year follow-up.

Purpose: The aim of this study was to describe oral health knowledge, attitudes and behaviours of parents and caregivers of preschool children in order to inform an oral health promotion strategy. Materials and Methods: A sample of parents and caregivers of children attending nine randomly selected preschools in central Trinidad were invited to complete a self-administered questionnaire on early childhood oral health. Results: A total of 309 parents and caregivers participated: 88% were female, 74.4% were of Indian ethnicity, with 50.4% in manual employment, and 50.2% educated to secondary level. 59.1% felt a child's first dental visit should be when all primary teeth are present. 64% had not taken their child for a dental visit. 81.6% rated their child's oral health as good or better and 28% would want an asymptomatic, decayed primary tooth extracted rather than filled. Over 80% used fluoride toothpaste. 52.8% always supervised their child's toothbrushing, and 44% claimed to be using the recommended pea-size amount. 26.2% reported having used a sweetened feeding bottle or infant feeder at night. Conclusion: Parents and caregivers of preschool children in this sample had reasonable oral health knowledge. However, despite generally positive attitudes towards preventive oral healthcare, confusion regarding dental attendance, supervised toothbrushing, fluoride use and sugar intake suggests that these items require particular emphasis in oral health promotion programmes aimed at improving early childhood oral health. Keywords: early childhood caries, parents, caregivers, oral health promotion

Background: The characteristics of the periodontium in anterior teeth influence the outcomes and prognosis of different periodontal, implant, and restorative procedures. In the present study, CBCT images were used to determine alveolar bone thickness and, to a lesser extent, gingival thickness. The aim was to evaluate the use of CBCT to measure the dentogingival complex in the anterior maxilla. Materials and methods: CBCT scans from 25 healthy patients were taken and the maxillary anterior teeth (n = 138) analyzed in the radial plane. The study provided descriptive data on gingival thickness, alveolar bone thickness (horizontal measurements), and vertical measurements related to biologic width. Results: The mean distance from gingival margin to bone crest (BC) was 3.4 ± 0.7 mm, and that between the cementoenamel junction and BC was 2.6 ± 1.0 mm. The average mid-labial gingival thickness 1 mm apical of the gingival margin was 1.0 ± 0.3 mm; a thinner gingiva was observed in females (P = 0.01) and canines (P < 0.001). The average crestal labial bone thickness was 0.8 ± 0.3 mm. In total, 62% of the tooth sites had a thin gingiva (< 1 mm), and 72% had thin labial bone plates; a moderate positive correlation was found between these parameters (P < 0.001). Conclusions: CBCT was effective in providing data on the thickness of the labial plate and gingiva as well as on the relationship among BC, CEJ, and gingival margin. The majority of tooth sites had thin labial bone and thin gingiva, with thinner gingiva observed in females and at canine sites.

Background: The palatal surface of the maxillary anterior teeth in conjunction with the incisal edge represents the mechanical area, which is of great importance for lateral and anterior guidance. Therefore, in terms of restorative dentistry, it is crucial for the clinician to have a detailed knowledge of the palatal surface anatomy (PSA) of the different maxillary anterior teeth in order to reestablish a definitive correlation between form, function, and esthetics. The aim of the present study was to analyze the variations in the PSA of the maxillary central incisors (CIs) and their correlation with tooth form and gender. Materials and methods: Impressions of the maxillary arch of 500 study participants were taken and then classified according to PSA and tooth form. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) software. The chi-square test was utilized for comparisons among PSA, tooth form, and gender of the participants. Results: The results showed Type 5 to be the most common PSA in maxillary CIs and the square tooth form to be the most common tooth form among both genders; Type 5 was also found to be the most common PSA within the square tooth form.

Purpose: Currently, there is no consensus on recommendations for manual toothbrushing techniques between dentists, oral health therapists and dental companies. The aim of this systematic review is to identify and assess the quality of evidence of the effectiveness of manual toothbrushing techniques in the existing literature. Methods: A broad search was conducted on the electronic databases Medline via Ovid, PubMed and EBSCO Dentistry & Oral Sciences. Included studies examined manual toothbrushing technique efficiency. Articles were assessed utilising the Cochrane Collaboration's tool for assessing risk of bias. Thirteen studies met the inclusion criteria and were included in this review. These included five randomised controlled trials (RCT), seven experimental non-randomised control studies and one in vitro study. Results: Of the 3190 articles identified, 40 were relevant to manual toothbrushing and 13 were included in the final review. Studies indicating statistically significantly superior plaque removal for a given technique were Bass (one), modified Bass (one), Charter's (two), Fones (two), scrub (two), roll (one), modified Stillman (one), toothpick method (one). Four studies exhibited no statistically significant difference in effectiveness of plaque removal. Unfortunately, considerable variation was found between studies, making a definitive conclusion impossible in terms of an ideal manual toothbrushing technique that would promote plaque removal and reduce gingivitis. Conclusion: There is still insufficient evidence for suggesting that one toothbrushing method is more effective than another in plaque removal and reduction of gingivitis. Excessive variability in many aspects of the design and methodology of the selected studies hinder conclusions on an ideal manual toothbrushing technique. Experimental randomised controlled trials that follow the CONSORT guidelines are required to provide adequate-quality evidence and make any definitive conclusions on the relative effectiveness of manual toothbrushing techniques. Keywords: evidence-based medicine, oral hygiene, systematic review, toothbrushing

Since the first introduction of the Cerec system (Sirona) in the early 1980s, the use of computer-aided design/computer-aided manufacture (CAD/CAM) technology has spread widely in modern adhesive dentistry. Thanks to this innovative technology, it has been possible to carry out chairside restorations fully managed by the clinician, with the advantages of lower costs for the patient, more rapid execution of the restorations, and the exclusion of the provisional phase. With further improvements in chairside technologies and materials, specifically in the field of composite resin blocks, it is now possible to fabricate multiple ultrathin, minimally invasive or even noninvasive restorations in one single appointment. The clinical case presented here was solved using an innovative approach: It was entirely studied and realized chairside by a dentist on a computer, without any plaster cast or classic articulator. Vertical dimension of occlusion (VDO) augmentation was projected with the 'Incisal Tip' tool on the virtual articulator of the Cerec system. Eight composite resin overlays were designed on the non-prepared posterior teeth of a patient suffering from generalized tooth loss principally caused by a history of bulimia nervosa. The maxillary anterior teeth were restored with six palatal veneers modified with direct composites from the vestibular side, in order to improve the esthetic integration of the restorations. The mandibular posterior teeth were built up with direct composites.

Anterior open bites can cause both aesthetic and functional issues in patients. Previous research has demonstrated stable results with counterclockwise rotation of the mandible following maxillary molar intrusion, thereby leading to closure of open bites. In this case, a modified transpalatal arch (TPA) was chosen, as the patient declined the use of temporary anchorage devices (TADs). A 15-year-old patient presented with a Class III skeletal profile, an anterior open bite, steep mandibular plane, increased lower facial height, obtuse gonial angle, mandibular anterior spacing and a mild tongue thrust. The use of a fixed TPA was decided since the appliance would help to intrude the maxillary molars, thereby bringing about improved positioning of the chin, increased overbite and a more favourable lower facial height. Utilising a diagnostic modality such as finite element analysis (FEA) for treatment planning can aid in the specific design and placement strategies of appliances for optimal results. The result of the present patient case demonstrates the essential role played by FEA in studying the effects of the placement of a TPA at different positions and using various designs to lead to a successful outcome. Keywords: open bite, transpalatal arch (TPA), finite element analysis (FEA), counterclockwise rotation, molar intrusion

Purpose: To the assess whole salivary cotinine and interleukin 1β (IL-1β) levels among individuals involuntarily exposed to vapor from electronic nicotine delivery systems (ENDS) (test group) and unexposed individuals (control group). Materials and Methods: Demographic data and information related to ENDS vapor exposure were collected using a questionnaire. Unstimulated whole saliva samples were collected, unstimulated whole-saliva flow rate (UWSFR) was calculated, and cotinine and IL-1β levels were determined using enzyme-linked immunosorbent assay. Sample-size estimation and statistical analysis were performed. Regression analysis was performed to determine the correlation between whole salivary cotinine and IL-1β levels. Statistical significance was set at p < 0.05. Results: Forty-eight individuals (24 and 24 in test and control groups, respectively) were included. Mean ages of individuals in the test and control groups were comparable. In the test group, the mean duration for which the individuals inhaled vapor from ENDS in each session was 22.3 ± 9.5 min and they were exposed to ENDS vapor 12.2 ± 2.4 times daily. There was no difference in the UWSFR between patients in the test (0.21 ± 0.02 ml/min) and control (0.22 ± 0.04 ml/min) groups. Whole salivary cotinine (p < 0.001) and IL-1β (p < 0.001) levels were significantly higher in the test than control group. Conclusion: Young adults involuntarily exposed to vapor from ENDS express elevated whole salivary cotinine and IL-1β levels. Long-term exposure to ENDS vapor may potentially predispose vulnerable populations to oral and systemic inflammatory diseases. Keywords: cotinine, electronic nicotine delivery systems, interleukin 1 beta, unstimulated whole saliva, vaping

Dental plaque is an archetypical biofilm composed of a complex microbial community. It is the aetiological agent for major dental diseases such as dental caries and periodontal disease. The clinical picture of these dental diseases is a net result of the cross-talk between the pathogenic dental plaque biofilm and the host tissue response. In the healthy state, both plaque biofilm and adjacent tissues maintain a delicate balance, establishing a harmonious relationship between the two. However, changes occur during the disease process that transform this 'healthy' dental plaque into a 'pathogenic' biofilm. Recent advances in molecular microbiology have improved the understanding of dental plaque biofilm and produced numerous clinical benefits. Therefore, it is imperative that clinicians keep abreast with these new developments in the field of dentistry. Better understanding of the molecular mechanisms behind dental diseases will facilitate the development of novel therapeutic strategies to establish a 'healthy dental plaque biofilm' by modulating both host and microbial factors. In this review, the present authors aim to summarise the current knowledge on dental plaque as a microbial biofilm and its properties in oral health and disease. Keywords: dental plaque biofilm, health and disease, properties

The injectable composite resin technique is an indirect/direct method that uses a transparent silicone index for accurate and predictable translation of a diagnostic wax-up into composite restorations without the need for tooth preparation. This case report involves a 22-year-old man who presented with esthetic and functional problems associated with diastemas and insufficient tooth visibility. Clinical examination revealed inadequate canine guidance in lateral excursion. The treatment plan included the fabrication of composite veneers for the maxillary incisors and canines. A wax-up was prepared by simulation of functional movements on an articulator, and a transparent silicone index was prepared after checking a mock-up in the oral cavity. The teeth were restored with flowable composite injected and polymerized through the transparent silicone index. The conventional technique was modified by cutting the silicone index at the gingival margin, using individual mock-ups as space holders, and the use of gingival retraction cords. The final outcomes were elongated teeth for increased visibility, closed diastemas, and reshaped canines for adequate guidance in lateral excursion. A protective splint for night-time wear was fabricated and delivered to ensure long-term stability. The patient did not exhibit any soft tissue inflammation or significant wear during a 24-month follow-up period. The technique described is minimally invasive and inexpensive, and it can be used for definitive as well as translational restorations. The treatment goals are to establish adequate function and esthetics, with advantages including minimal tooth structure loss and cost-effectiveness. Stable and predictable results can be achieved with proper planning and a careful workflow. Keywords: composite resin injection, composite veneer, esthetic rehabilitation, functional rehabilitation, transparent silicone index

Die Bedeutung qualifizierter Mitarbeiter/-innen für die Prophylaxe in der Zahnarztpraxis ist unbestritten. Zahnärztinnen und Zahnärzte arbeiten sehr eng mit ihrem nichtzahnärztlichen Team zusammen. Dabei können sie nicht jede Aufgabe in ihrer Praxis selbst erledigen und haben deshalb die Möglichkeit, bestimmte Tätigkeiten an dafür qualifizierte Mitarbeiter/-innen − mit einer abgeschlossenen Ausbildung zur Zahnarzthelferin/zum Zahnarzthelfer (ZAH) oder zur/zum Zahnmedizinischen Fachangestellten (ZFA) als Voraussetzung − zu übertragen. Die Delegation zahnärztlicher Leistungen wird durch das Zahnheilkundegesetz (ZHG) eröffnet. Der Delegationsrahmen der Bundeszahnärztekammer (BZÄK) für ZFA erläutert die Grundsätze der Delegation und interpretiert das ZHG exemplarisch. Dieser Artikel gibt einführend einen kurzen Überblick über die Karrierewege nach der Ausbildung zur/zum ZFA und beschränkt sich dabei auf die Aufstiegsfortbildungen, für welche die BZÄK bundeseinheitliche Muster-Fortbildungs- und Prüfungsordnungen formuliert hat. Ebenso informiert der Beitrag auf Grundlage des ZHG über Grundsätze, Möglichkeiten und juristische Grenzen der Delegation zahnärztlicher (Teil-)Leistungen an dafür qualifizierte Mitarbeiter/-innen. Die juristische Grenzziehung erfolgt im Wesentlichen über die Normierungen des ZHG, welche für Zahnärztinnen und Zahnärzte und ihr Team in einem Rahmen Rechtssicherheit bei der Delegation von (Teil-)Leistungen bieten. Es werden auch die professionelle Zahnreinigung (PZR) sowie in Teilen die neue Behandlungsstrecke bei der Parodontitistherapie unter den Bedingungen der seit dem 1. Juli 2021 geltenden Richtlinie zur systematischen Behandlung von Parodontitis und anderer Parodontalerkrankungen (PAR-Richtlinie) berücksichtigt. Ein Ausblick schließt den Beitrag ab. Manuskripteingang: 05.08.2021, Annahme: 28.10.2021 Keywords: Aufstiegsfortbildung, Zahnheilkundegesetz, Delegation, professionelle Zahnreinigung (PZR), antiinfektiöse Therapie (AIT), subgingivale Instrumentierung, geschlossene mechanische Therapie (GMT), unterstützende Parodontitistherapie (UPT), langfristiger Zahnerhalt, Parodontitis

Eine funktionierende und somit nachhaltige parodontale Therapie hängt von vielen verschiedenen Parametern ab. Neben den patientenseitigen Faktoren spielen auch die behandlerspezifischen Fähigkeiten und Techniken eine entscheidende Rolle. Ziel dieses Fallberichts soll es sein, anhand eines Patientenfalles mögliche Synergien auf der Seite des Praxisteams aufzuzeigen und diese möglichst nutzbar einzubringen, um eine nachhaltige Therapie durchführen zu können und den Patienten in diesem Kompetenzgefüge richtig einzubinden. Dies schafft eine gute Basis für die Behandlungsqualität und bringt die parodontale Therapie als Teamleistung zum Ausdruck – entsprechend unserem Ziel, die Nachsorge als wichtige Stütze der gesamten Therapie sichtbar zu machen, sodass diese auch eingefordert wird. Manuskripteingang: 14.09.2021, Annahme: 01.11.2021 Keywords: Dentalhygienikerin, Dentalhygieniker, parodontaler Screening-Index (PSI), systematische Parodontitistherapie, parodontale Befundung, unterstützende Parodontitistherapie (UPT)

Purpose: To identify and assess differences in oral hygiene parameters in patients undergoing orthodontic treatment with clear aligners compared to fixed appliances. Materials and Methods: Published and unpublished literature was searched in seven databases until May 31st 2021. Representative keywords included ‘orthodontic aligner’, ‘fixed appliance’, ‘oral hygiene’, ‘plaque index’, ‘caries’. Study selection, data extraction, risk of bias and certainty of evidence assessment were undertaken independently by three reviewers. Random effects meta-analyses with respective confidence intervals (95% CI) were conducted, where applicable. Results: A total of 882 unique records were screened, with a final number of 21 articles being eligible for qualitative synthesis, while 4 of those contributed to meta-analyses. Risk of bias was rated within the range of low to high or serious overall, while certainty of evidence was low to very low according to GRADE. For periodontal parameters, adults undergoing aligner orthodontic treatment presented summary plaque scores 0.58 lower than those treated with fixed appliances, within the first 6 to 12 weeks (4 studies: mean difference: -0.58; 95%CI: -0.82, -0.34; p < 0.001; I2 squared: 71.3%), while no evidence of difference was recorded for inflammation indices. Microbiologic parameters such as presence of S. mutans and lactobacilli were more pronounced in patients with fixed appliances for the first 3 to 6 months (synthesised data from 2 studies). Conclusions: In the short-term after initiation of orthodontic treatment, patients treated with aligners and no additional attachments/adjuncts presented potentially higher levels of oral health overall. However, the evidence is supported by low to very low certainty. Keywords: fixed appliances, oral hygiene, orthodontic aligners, systematic review

Nach dem heutigem Stand der Wissenschaft ist der Orale Lichen ruber planus (OLP) eine chronische Erkrankung unklarer Genese, wobei jedoch vermutet wird, dass es sich um eine Autoimmunerkrankung handelt, bei der die spezifische Immunabwehr eine wichtige Rolle spielt. Außerdem werden folgende Triggerfaktoren, die zum Ausbrechen des multifaktoriellen Geschehens führen, diskutiert: mechanische Reizung, elektrochemische Ursachen, schlechte Ernährungsgewohnheiten, Stress, traumatisierte Psyche, hormonelle Entgleisungen, Speicheldrüsenfehlfunktionen, genetische Vorbelastung, Infektionskrankheiten und Diabetes mellitus bzw. Hepatitis B- oder C-Vorerkrankungen.

Artificial intelligence (AI) encompasses a broad spectrum of emerging technologies that continue to influence daily life. The evolution of AI makes the analysis of big data possible, which provides reliable information and improves the decision-making process. This article introduces the principles of AI and reviews the development of AI and how it is currently being used. AI technology has influenced the health care field because of the need for accurate diagnosis and superior patient care. In order to understand the trend of AI in dentistry, electronic searching was carried out, combined with approaching individual companies to obtain the details of AI-based services. The current applications of AI in clinical dentistry were introduced and summarized. In the future, the AI-based comprehensive care system is expected to establish high-quality patient care and innovative research and development, facilitating advanced decision support tools. The authors believe that an innovative inter-professional coordination among clinicians, researchers, and engineers will be the key to AI development in the field of dentistry. Despite the potential misinterpretations and the concern of patient privacy, AI will continue to connect with dentistry from a comprehensive perspective due to the need for precise treatment procedures and instant information exchange. Moreover, such developments will enable professionals to share health-related big data and deliver insights that improve patient care through hospitals, providers, researchers, and patients. Keywords: artificial intelligence, big data, caries detection, future dentistry, machine learning

An orthodontic extraction technique with a ramus mini-screw was used to remove a deeply impacted mandibular third molar contacting the inferior alveolar nerve, avoiding damage to the inferior alveolar nerve and relieving postsurgery inflammation. Case presentation: A 24-year-old man was required to extract impacted third molars for orthodontic treatment. Panoramic radiographs and CBCT images showed that his mandibular left third molar penetrated into the inferior alveolar nerve canal and a distomolar was inverted and impacted distally to the third molar. The distomolar was directly removed and the impacted third molar was extruded with the aid of a ramus mini-screw. After 4 months of traction, the mandibular left third molar was successfully moved away from the inferior alveolar nerve canal. No nerve injury occurred after the surgical extraction and the patient was very satisfied with the treatment outcome. Conclusion: Orthodontic extraction, with the aid of ramus mini-screws, is a safe, effective, and efficient technique for the removal of high-risk impacted molars contacting the inferior alveolar nerve. (Quintessence Int 2021;52:538–546; doi: 10.3290/j.qi.b1244345) Keywords: impacted tooth, nerve injury, orthodontic extraction, ramus mini-screw, third molar, traction

Objective: To analyse factors associated with the susceptibility of early childhood caries (ECC), populations with a high risk of ECC were screened and guidance for ECC prevention was proposed. Methods: A total of 392 children aged 24 to 71 months were selected for oral examination in Qingdao. Parents or guardians of the participants completed the questionnaires and decayed missing filled surface (dmfs) were recorded. Differences in caries condition and oral health behaviour in different families were compared. Risk factors related to ECC were screened. The subjects were finally grouped based on the obtained dmfs into three groups: caries-free, ECC and S-ECC (severe ECC). Association of risk factors with the caries status was analysed using the Kruskal-Wallis test, the chi-square test and logistic regression analysis. Results: There were significant differences among the caries-free, ECC and S-ECC groups in three parameters: eating too many sweets each day, brushing before and after sleeping, and whether parents helped to brush (P 0.01). Combined factors such as the parents' level of education, oral health knowledge, attitudes, the family's annual income, the age of children when they start to brush and not brushing regularly were also significantly related to ECC (P 0.05). No significant differences were observed among the three groups for these factors, including birth condition and nursing state, physical condition of the mother during pregnancy, feeding situation, if a pacifier was used during sleep, duration of brushing, frequency of mouth rinsing after meals each day and brushing with fluoride toothpaste (P > 0.05). Conclusion: Eating a lot of sweets, an incorrect brushing method, starting brushing at a later stage and not brushing regularly are susceptible factors for ECC. Emphasising oral health knowledge to parents and guardians, conducting proper brushing methods, limiting the frequency of sweets being eaten and avoiding an inappropriate habit of eating sweets are very important factors in the prevention of ECC. Keywords: children, decayed missing filled surface (dmfs), early childhood caries (ECC), prevalence, susceptibility

Adjusted occlusal splints (AOS) have a wide range of indications in the treatment of functional disorders of the craniomandibular system. Simulation splints add a fully anatomically modeled occlusal appliance to the armamentarium of AOS that enables clinical testing of proposed changes in vertical dimension of occlusion and/or jaw position in complex cases, even during mastication, without the need for invasive tooth preparation. As such, they fill a gap at the decision crossroads between functional therapy and more far-reaching restorative treatment. The present case report describes the integration of simulation splints in treatment based on the example of a temporomandibular dysfunction patient with myopathy, arthropathy, and occlusopathy. The special feature of this case was that 2 years after the successful initial treatment, the patient had a recurrence of temporomandibular joint arthrosis that no longer responded to treatment with conventional equilibration splints. Only the daytime use of a fully anatomical simulation splint, in addition to wearing the positioning splint at night, was able to stabilize this situation and improve the patient’s well-being in the long term. Hence, this approach achieved the goals of pain reduction, improvement of mandibular mobility, and rehabilitation of restricted masticatory function without invasive procedures. Adjuvant physiotherapy had a supportive effect. The present case report demonstrates the use of a fully anatomical simulation splint at the crossroads between classical functional therapy and irreversible restorative treatment. Keywords: Simulation splint, functional therapy, arthritis, chewing function

Aim: The goal of the present study was to determine both distances and spatial relationships between centric relation (CR) and maximal intercuspal position (MIP) in the condylar area, and to demonstrate their implications for dental practice. Materials and methods: Eighty-one subjects were assigned to one of four licensed dentists, who recorded their CR by six different checkbite registration methods. Maxillary casts were mounted after transferring the individual hinge axes to Dentatus articulators by facebow transfer, and mandibular casts were mounted in precise alignment with the apex of a Gothic arch tracing. A fifth colleague took measurements in the condylar area after transferring the casts to a special measuring articulator. Distances and spatial relationships were calculated as the means of triplicate measurements with casts mounted in CR and of duplicate measurements with casts articulated in MIP for each bite registration method. Results: Overall, the spatial mean distance between CR and MIP for all methods combined was 0.86 ± 0.52 mm (min 0.05 mm; max 3.14 mm). The corresponding mean distance was 0.47 mm on the purely sagittal plane. The mean position of the condyles in CR was only slightly dorsal and cranial to that in MIP but with considerable variation in all spatial directions. Conclusions: MIP moves the condyles out of CR to a position that deviates from CR by an average of 0.8 to 0.9 mm spatially and by approximately 0.5 mm on the sagittal plane, with slightly anterior and caudal deviation as well. Hence, the spatial position of the condyles in MIP varies considerably from that in CR. This has substantial implications for dental practice, eg, when performing terminal molar tooth preparation or interpreting condylar position indicator device readings. Keywords: static occlusion, maximal intercuspal position, centric relation, reproducibility, condylar position indicator device, temporomandibular joint compression, temporomandibular joint distraction, freedom in centric relation

Abstract: Tooth-cavity preparation contributes to a large extent to the quality of the direct posterior composite restoration, the so-called hidden quality of the restoration. Indeed, the effect of a poor cavity design is not immediately visible after placement of the restoration. To correctly prepare a cavity for a posterior composite restoration, the tooth to be restored should first be profoundly biomechanically analyzed. Here, the forces that work on the tooth during occlusion and articulation, and the amount and quality of the remaining tooth structure determine the cavity form. In addition, the dental tissues must be prepared in order to receive the best possible bond of the adhesive and subsequent restorative composite. A well-finished cavity preparation enables the restorative composite to adapt well, providing a good marginal ?seal to the direct benefit of the clinical lifetime of the posterior composite restoration. Finally, it is highly recommendable to isolate the teeth with rubber-dam before starting with the cavity preparation, as this increases the visibility of the operating field and allows the operator to work in a more precise way.

Objective: To determine the association of high occlusal force (HOF) with the signs of occlusal trauma and periodontal conditions in periodontitis patients, and elaborate the relevant clinical implications. Methods: Periodontal parameters and signs of occlusal trauma were recorded for 807 teeth in 30 subjects with untreated chronic periodontitis. The T-scan II occlusal analysis system determined the HOF during maximum intercuspation, lateral excursion and protrusive excursion. The correlation of HOF with periodontal parameters and signs of occlusal trauma was analysed. Results: Overall, the teeth with HOF existed mainly in molars and presented with deeper probing depth (PD) and higher frequency of bleeding on probing (BOP) than those without HOF. The fixed-effect analysis showed that HOF was positively correlated with PD and BOP (P 0.05) in posterior teeth; widened periodontal ligament space on radiographs in upper (r = 0.179, P 0.01) and lower posterior teeth (r = 0.205; P 0.05); as well as functional mobility in upper posterior teeth (r = 0.168; P 0.05). Conclusion: This study suggests that the posterior teeth with HOF in subjects with chronic periodontitis may reflect occlusal trauma-associated periodontal conditions that could probably increase the risk of further periodontal destruction. These findings may improve the clinical assessment of occlusal trauma and related periodontal conditions for better patient management and treatment outcomes. Keywords: chronic periodontitis, occlusal trauma, T-scan occlusal analysis system

Introduction: This article reports the results of a comprehensive systematic review and meta-analysis of the effect of occlusal splints (OSs) on active maximum mouth opening (AMMO) in patients with temporomandibular disorders (TMD). Methods: Multiple databases (PubMed/MEDLINE, EMBASE, Cochrane Library, LIVIVO, OpenGrey, DRKS, and ClinicalTrials.gov) plus additional literature were searched for relevant randomized clinical trials (RCTs) using OSs to treat adults with painful TMD. AMMO was assessed after 6 and 12 months of treatment, and OS therapy was compared with no treatment, other active treatments (OATs), and/or placebo splints. The Cochrane Collaboration’s tool for assessing risk of bias was used to assess study quality. The threshold for statistical significance of correlations detected by meta-analysis was P ≤ 0.05. Results: The use of OSs did not increase AMMO significantly more than no treatment (P = 0.28) or placebo splints (P = 0.76). OS therapy was significantly inferior to OATs (P = 0.02 for short-term effect, P = 0.01 for medium-term effect). In 18 of the 21 included studies, OSs increased AMMO slightly but not significantly more than no treatment (P = 0.28) or placebo splints (P = 0.76). Conclusions: OSs made no significant contribution to improving AMMO. Therefore, OATs should be used in patients with limited jaw opening.Registration: This study was registered in the PROSPERO database under ID number CRD42019123169. Keywords: temporomandibular disorders (TMD), systematic review, meta-analysis, adults, pain propagation, occlusal splints, pain chronification

Purpose: This study aimed to investigate whether treatment of gingivitis in pregnant women affects pregnancy outcomes. Materials and Methods: This was a systematic review and meta-analysis of clinical trials using PRISMA guidelines to appraise the treatment of gingivitis on pregnancy outcomes, including preterm birth (less than 37 weeks), low birth weight (less than 2,500 g), gestational age and birth weight. Pooled odds ratios (OR), mean difference, and 95% confidence intervals (CI) were calculated using the random effect model. A search was conducted in databases including Medline, Pubmed, Web of Science, Google Scholar and Embase without restrictions regarding language or date of publication. Results: Three clinical trials comprising 1,031 participants were included in this review. Treatment of gingivitis during pregnancy was associated with a decreased risk of preterm birth (OR = 0.44, 95% CI [0.20–0.98], P = 0.045) and higher birth weight (weighted mean difference (WMD) =105.36 g, 95% CI [36.72–174.01], P = 0.003). Gestational age at birth in the treatment group (WMD = 0.31 weeks, 95% CI [–0.02–0.64], P = 0.64) as well as likelihood of low birth weight (OR = 0.92, 95% CI [0.38–2.21], P = 0.851) did not reach statistical significance. Conclusion: The results of this meta-analysis indicate that treatment of gingivitis in pregnancy may improve pregnancy outcomes including increased infants birth weight and reduced preterm births. Future trials are warranted to validate the true effect size of gingivitis treatment on pregnancy outcomes. Keywords: birth weight, gingivitis, gingivitis treatment, preterm, randomised controlled trials

Aim: The aim of the present study was to evaluate the number, strength, and position of occlusal contacts shown using an intraoral scanner (IOS) and a digital occlusal analysis system (T-Scan) compared with the current gold standard using occlusal foil (OF). Materials and methods: Occlusal contacts were analyzed for 75 volunteers using OF in maximum intercuspation (MI). The contact points obtained using the IOS were evaluated using a screenshot from Zirkonzahn.Modellier CAD software. Finally, the volunteers were asked to bite on the sensor sheet of the T-Scan system. For the evaluation of these data, the contact points of the OF and the IOS were graded as light, medium, and strong. Furthermore, the positions of the contact points were analyzed for the anterior region (premolars and molars). Parametric statistical tests were applied to analyze the differences among the three methods. Results: The mean number of all contact points was similar: 29 ± 8 with the OF, 30 ± 12 with the IOS, and 24 ± 10 with the T-Scan. However, results were different in terms of the grading of the strength of contact points: mean number of light contacts: 8 ± 4 OF vs 17 ± 8 IOS and 17 ± 6 T-Scan; medium contacts: 12 ± 5 OF vs 8 ± 4 IOS and 5 ± 4 T-Scan; and strong contacts: 9 ± 5 OF vs 6 ± 6 IOS and 4 ± 2 T-Scan. The positions of the occlusal contact points were also different. Conclusion: The data sets showed that there were differences in the distribution of occlusal contact points evaluated using the OF, the IOS, and the T-Scan system. Although the number of detected occlusal contacts was similar, different occlusal contact protocols were determined by the three different methods.(Original article published in Int J Comput Dent 2020;23:
245–255.) Keywords: occlusal contacts, intraoral scanner, T-Scan, occlusal foil, contact strength

The injectable composite resin technique is a minimally invasive and purely additive procedure that uses a transparent silicone index and flowable composite resin to translate the restorative plan from the wax-up to the final restoration. Its minimally invasive nature means that it can preserve tooth structure as it may not require hard tissue reduction. It is also an indirect/direct molding technique that allows the clinician to perform a direct restoration based on a proper analysis and planning. This case report describes a simple case of reshaping the maxillary lateral incisor and maxillary first premolar of a 25-year-old female patient to close the buccal corridor and restore smile symmetry. Digital planning was used to make a biocopy of the contralateral incisor to mimic the restoration. A printed model was prepared based on the design of the digital wax-up, followed by an analog protocol. Shade selection was challenging due to the high translucency of the incisal edges. This article is a step-by-step description of the injectable composite resin technique. It also compares this technique with other treatment options such as ceramic veneers, prefabricated composite veneers, different molding techniques, and freehand bonding. The significant advantages of the injectable composite resin technique include its predictability, repeatability, simplicity, minimal invasiveness, and financial affordability for patients. Recent studies demonstrate significant improvements in physical, mechanical, and optical properties of specific flowable composite resins, which reinforces the justification for implementing them in different restorative procedures.

Aim: To evaluate the impact of localized and widespread pain on the outcome of oral appliance treatment of headache frequency and intensity in patients with temporomandibular disorders (TMD). Materials and methods: The present multicenter study comprised 65 myofascial TMD patients diagnosed according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Pain site drawings were completed at baseline. All patients received oral appliance treatment. Treatment outcome was followed up and analyzed (chi-square test, Mann-Whitney U test, Wilcoxon signed-rank test) for two pain profiles, being localized pain (face and head, n = 26) and widespread pain (pain sites also outside face and head, n = 39) at 6 and 10 weeks, and 6 and 12 months. Results: At baseline, there were no differences in frequency of headache between the pain profile groups. Headache frequency decreased significantly within both groups (localized pain P = 0.008, widespread pain P < 0.001) during follow-up, with no differences between the groups. The intensity of headache differed significantly between the groups at baseline (P = 0.002). During follow-up, the decrease of headache intensity was statistically significant within both groups (localized pain P = 0.007, widespread pain P < 0.001), with no difference shown between groups at 6 weeks and 12 months. At the 6-week follow-up, 52% of all patients showed a 30% reduction of headache intensity; at the 12-month follow up, a 30% reduction was observed in 54% of the patients. Conclusion: The present study indicates that oral appliance treatment has a similar positive effect on headache frequency and intensity, regardless of whether the myofascial TMD pain is localized or widespread. Keywords: TMD, headache, localized pain, widespread pain, oral appliance treatment

Ziel dieser Studie war es, die Auswirkungen von kieferorthopädischen Attachments der Marke Forestadent (Pforzheim) auf die diagnostische Qualität im 1,5 Tesla-Magnetresonanztomografen von vier kraniofazialen Regionen zu untersuchen. Die Unterschiede der diagnostischen Qualität bei Verwendung der Attachments verschiedenster Materialien sollten dabei in vivo bewertet werden. Ziel sollte es sein, sowohl dem Radiologen als auch dem Kieferorthopäden eine Richtlinie an die Hand zu geben, wann die Entfernung festsitzender kieferorthopädischer Attachments vor einer MRT-Untersuchung empfohlen werden sollte und wann die Apparatur belassen werden kann. Zunächst erfolgte die Herstellung von acht Trägerschienen mithilfe eines 3-D-gedruckten Oberkiefermodells einer 24-jährigen Probandin. Sieben dieser Schienen wurden mit jeweils verschiedenen Bracketsets bestückt und anschließend in vivo im 1,5 Tesla-MRT untersucht. Zu Vergleichszwecken wurden zusätzlich MRT-Untersuchungen ohne Trägerschiene und mit unbestückter Trägerschiene angefertigt. Im Anschluss wurde das Ausmaß der Artefakte und die damit einhergehende Beeinflussung durch einen erfahrenen Radiologen anhand von Screenshots der einzelnen MRT-Untersuchungen bestimmt. Um Brackets aus Kunststoff entstanden die geringsten Artefakte, gefolgt von Attachments aus Vollkeramik. Die Artefakte um Keramikbrackets mit Metallslot stellten sich als moderat dar. Die signifikantesten Artefakte entstanden um die verschiedenen Stahlbrackets. Darüber hinaus konnte eine Korrelation zwischen dem Ausmaß der Artefakte und der Größe der Brackets beobachtet werden. Alle festgestellten Artefakte beschränkten sich auf den Bereich der Mundhöhle. Eine prophylaktische Entfernung der Brackets vor dem Hintergrund der Artefaktentstehung ist bei Untersuchungen im 1,5 Tesla-MRT mit Zielregion jenseits der Kopf-Hals-Region nicht angezeigt. Keywords: Kieferorthopädische Brackets, kieferorthopädische Geräte, 1, 5 Tesla-MRT, Magnetresonanztomografie, Artefakte, diagnostische Qualität

Purpose: To assess the association of various factors including education level and oral health with type 2 diabetics’ awareness of periodontitis and periodontitis/diabetes relationship, and to evaluate the importance of integrated healthcare in this association. Materials and Methods: 288 type 2 diabetics were evaluated through a validated structured questionnaire about oral hygiene habits, access and attendance to dental treatment, the presence of periodontitis and previously received information of periodontitis and periodontitis/diabetes relationship. Descriptive data were explored and both simple and multiple logistic regressions were performed. Results: The average age of participants was 62.24 (±10.93) years, 81.6% were previously treated for periodontitis and approximately 70% have never received information on periodontitis and its relationship with diabetes. A higher chance of participants having previously received information regarding periodontitis was associated with more than 8 years of schooling, daily flossing habit, presence of periodontitis and prior treatment for periodontitis (p 0.005). Regarding previously received information about periodontitis/diabetes relationship, statistically significant associations were observed for more than 12 years of schooling and diabetes diagnosed more than 8 years ago (p 0.05). Conclusion: The vast majority of participants were previously treated for periodontitis without receiving proper oral health education, which means that access to costly dental treatment is provided while patient education is neglected. It was shown the influence of habits and living conditions on the previously received information about diseases, and therefore, particular attention to the population characteristics is important to make the information accessible to everyone. Keywords: diabetes mellitus, periodontal diseases, health promotion, public health/community dentistry, primary healthcare

Purpose: Recent data indicate that gene polymorphisms, e.g. those of vitamin D-receptor (VDR), are associated with an increased susceptibility to chronic periodontitis (CP). This study investigated whether VDR gene polymorphism is associated with chronic periodontitis in a population in Western Romania, by determining the prevalence of the BsmI (rs1544410), ApaI (rs7975232), TaqI (rs731236) and FokI (rs2228570) genotypes and comparing the CP group with a periodontally healthy group. Materials and Methods: This case-control study included 53 patients with CP and 47 healthy patients. VDR polymorphisms were genotyped using real-time polymerase chain reaction (PCR). The associations between VDR polymorphisms and CP were determined using logistic regression models, adjusted for patient age and serum level of Vitamin D. Results: We found a statistically significant association between the single nucleotide polymorphism (SNP) rs2228570 (FokI) and CP. Compared with subjects having the Thymine-Thymine (TT) genotype, those with the Cytosine-Cytosine (CC) variant were 19 times more likely to have the disease (adjusted odd ratio [OR]: 19.58; 95% confidence interval [CI]: 2.67 - 198.92) and with the Thymine-Cytosine (TC) variant, 8 times more likely (adjusted OR: 7.86; 95% CI: 1.29 - 61.56). Also, for the SNP rs1544410 (BsmI), compared with the Adenine-Adenine (AA) genotype, the Adenine-Guanine (AG) variant had an increased risk of periodontal disease (crude OR: 3.76; 95% CI: 1.15 - 13.80). Conclusion: This case-control study of a Western Romanian population shows an association between vitamin D receptor (VDR) polymorphisms (FokI and BsmI) and CP susceptibility. Keywords: chronic periodontitis, vitamin D receptor, polymorphism, susceptibility

The present case report sheds light on the treatment of a skeletal Class III malocclusion with severe tetracycline stains and associated enamel hypoplasia. Contrary to popular belief, premolar extraction is a viable alternative to orthognathic surgery in certain patients. A patient’s final expectations may need to be lowered in case of associated extensive staining and enamel hypoplasia. Fixed orthodontic therapy may require specific bonding processes to reduce bracket ‘pop outs’ and to achieve optimal treatment durations. Keywords: Class III malocclusion, tetracycline stains, orthodontic management, enamel hypoplasia, bonding

Objectives: The aim of this retrospective case series was to report the performance up to 5 years of an innovative surgical design (the apically incised coronally advanced surgical technique [AICAST]) for the regenerative treatment of one- or two-walled intrabony periodontal lesions. Method and materials: After completion of standard step I to II periodontal therapy, nine isolated periodontal defects were treated through AICAST. The following clinical outcome measurements were collected before the surgical intervention and at the last available follow-up: probing pocket depth (PPD), recession depth (REC), and clinical attachment level (CAL). Periapical radiographs of the treated teeth were also taken at baseline and at the last available follow-up (18 months or 5 years postoperatively). Results: A mean (± standard deviation) PPD reduction of 6.05 ± 1.76 mm (P < .01), REC reduction of 1.15 ± 1.97 mm (P = .119), and CAL gain of 7.20 ± 2.13 mm (P < .01) were attained when comparing preoperative results with the last follow-up visit. CAL gain of 6 mm or more was reached in eight out of nine treated cases (88.9%), with a residual PPD of 2 to 3 mm in all the cases. Complete radiographic fill of the intrabony component was present in all the defects, while detectable suprabony radiographic filling was identified in two cases. Conclusion: AICAST represents an innovative surgical design for the treatment of deep intrabony defects and the eventual reduction of the associated gingival recessions. Preliminary results show good performance in terms of clinical attachment gains and maintenance of the marginal tissues. Keywords: coronally advanced flap, enamel matrix derivatives (EMD), papilla preservation flap, periodontal regeneration, periodontitis

Aims: To investigate whether a shortened dental arch (SDA), as identified by reduced posterior occlusal contacts, is a risk factor for the progression of temporomandibular joint (TMJ) intra-articular disorders (ID), as identified using imaging techniques. Methods: This multisite, prospective observational study with a mean follow-up period of 7.9 years had a sample of 345 participants with at least one temporomandibular disorder (TMD) diagnosis at baseline. SDA was defined as reduced occlusal posterior support due to lack of occlusal intercuspal contacts in the molar region on the left and/or right side. SDA was assessed at baseline and at follow-up with metalized Mylar Tape. The presence or absence of a TMJ ID and the specific TMJ ID diagnoses for baseline and follow-up images were established by a calibrated, blinded radiologist at each of three sites by using bilateral magnetic resonance imaging for soft tissue imaging for disc displacement and by bilateral multidetector computed tomography or cone beam computed tomography for hard tissue imaging for degenerative joint diseases. Wilcoxon rank sum test and linear regression analyses were used to test for an impact of SDA on TMJ ID status. Results: At baseline, TMJ ID status of either side was not significantly affected by the presence of SDA on the ipsilateral or contralateral side of the jaw (all P > 0.05). Furthermore, the presence or absence of SDA at baseline was also not a significant predictor for progression of the TMJ ID status between baseline and follow-up (all P > 0.05). Conclusion: The findings of this study suggest that there is no significant effect of SDA on progression of TMJ ID. (Original article published in J Oral Facial Pain Headache 2018;32:329–337. doi: 10.11607/ofph.1910) Keywords: intra-articular disorders, observational study, risk factor, shortened dental arch, temporomandibular joint

Purpose: The aim of this study was to review the literature and chart the clinical studies that have focused on periodontal diseases and adverse pregnancy outcomes since 1996. Materials and Methods: Medline, Cinahl, and Cochrane databases were searched for original studies focused on pregnancy outcomes and periodontal status in humans. The most recent search was conducted on April 30, 2020. Results: Of the 633 articles identified, 232 articles (n = 119,774 participants) were selected for analysis. The majority of studies highlighted a statistically significant association between periodontal diseases and preterm birth (71 of 111 articles; 63.96%), low birth weight (46 of 64 articles; 71.87%), preterm low birth weight (29 of 49 articles; 59.18%), preeclampsia (31 of 45 articles; 68.89%) and other pregnancy complications, such as preterm, prelabor rupture of membranes (17 of 26 articles; 65.38%). Geographical analysis revealed that clinical studies were conducted in 51 countries, primarily in the United States (42 studies, 18.10%), Brazil (33 studies, 14.22%) and India (25 studies, 10.78%). Irrespective of geographical location, analysis showed various degrees of evidence of a relationship between periodontal diseases and adverse pregnancy outcomes. Conclusion: The majority of the studies found a statistically significant link between periodontal diseases and some complications of pregnancy. The strength of such a link varies according to type of study, type of variable and outcome measure selected. Keywords: periodontal diseases, pregnancy, adverse pregnancy outcomes, mapping

Aim: To investigate whether different restoration designs, overlay types, and full crowns in posterior teeth have similarly acceptable marginal sealing and quality. Materials and methods: For Part 1 of the present study (investigation of fracture resistance), 70 extracted molars were divided into five groups (N = 14), prepared with four different posterior indirect adhesive restoration (PIAR) overlay design types, according to the adhesthetics classification. The groups were: 1. Butt Joint; 2. Full Bevel; 3. Shoulder; 4. Full Crown; 5. Sound Tooth. For Part 2 of the study (present article; marginal quality), there was no group 5, and only 56 of the 70 extracted molars were used. Seven expert dentists performed all the preparation and cementation phases with codified protocols. A CAD/CAM workflow was used to realize the 56 monolithic lithium disilicate restorations. The samples were tested with thermomechanical loading (TML) and the marginal quality evaluated. The data relating to fracture resistance are presented in Part 1 of this study (Int J Esthet Dent 2021;16:2–17). Results and conclusions: In terms of marginal quality after TML, within the limitations of the present study, in molar teeth (without endodontic treatments) restored with different monolithic ceramic lithium disilicate PIAR designs, it is possible to present the following conclusions:

Background and aim: The coronally advanced flap (CAF) and the tunnel technique (TUN) are the most performed surgical approaches for treating gingival recessions (GRs). Nonetheless, these two approaches have commonly been regarded as substitutes for one another, and clinicians are often faced with the choice of performing only one during root coverage procedures. The aim of the present article is to describe a surgical design in which the benefits of both the CAF and the TUN are combined for the treatment of isolated type 2 (RT2) GRs with deficient papilla. Materials and methods: Ten patients with isolated RT2 GRs were treated using the tunneled coronally advanced flap (TCAF) + connective tissue graft (CTG) technique. Results: The healing was uneventful, and patients consistently reported minimal discomfort. After 6 months, the TCAF + CTG resulted in an average mean root coverage of 86.5%, with six sites showing complete root coverage (60%). The mean increases in keratinized tissue width and gingival thickness were 1.40 and 0.92 mm, respectively. All the treated GRs showed an increased soft tissue phenotype. No significant changes were observed for midfacial probing depth, while a mean midfacial clinical attachment level gain of 3.05 mm was obtained after 6 months. The professional esthetic evaluation, according to the root coverage esthetic score, was 7.90 ± 1.66. Conclusions: The present article suggests that the TCAF + CTG is a suitable technique for treating isolated RT2 GRs. The newly introduced technique may have the potential to enhance flap blood supply and graft vascularization and improve clinical-, esthetic-, and patient-reported outcomes of RT2 GRs with deficient papilla. Future studies with larger sample sizes and comparative groups are needed to support these preliminary results.

Within the framework of treatment planning for missing teeth, the fundamental question is how to offer long-term solutions. One option is to close the space with a prosthetic restoration such as a dental implant or fixed or removable partial denture. Another option is orthodontic space closure, which makes it possible to avoid further tooth preparation, thus reducing the tooth substance required, or even generate new bone through the tooth movement into the gap due to the interdental fibres. Compared to space opening, however, space closure has far greater requirements in terms of anchorage. Preservation of the sagittal vertical overlap and adjustment of the dental midlines often necessitates use of skeletal anchorage, especially in cases of dental asymmetry. The present case report demonstrates a complex treatment using aligner orthodontics in combination with the Mesialslider (TADMAN, Gunningen, Germany) after loss of a maxillary molar, including a mandibular incisor extraction approach, closure of anterior open bite and solving of unilateral reverse articulation. Keywords: aligner orthodontics, anterior open bite, incisor extraction, Invisalign, Mesialslider, mini-implants, molar extraction, reverse articulation, skeletal anchorage, space closure

Objective: The present study aimed to assess the cephalometric changes in patients with a clinically proven anterior open bite after clear aligner treatment (Invisalign, Align Technology, San Jose, CA, USA). The amount of planned movement was also compared with the amount of movement that actually occurred, as measured on the radiographs. Materials and methods: This retrospective study included 30 patients (11 women, 19 men; mean age 20 years) with anterior open bite (bite depth < 0 mm) treated using Invisalign clear aligners in both arches. The patients received non-extraction treatment with a mean duration of 20 months. Twenty-one parameters (eight linear, twelve angular and one ratio) were evaluated on cephalometric radiographs taken prior to (T1) and after treatment (T2). The amount of planned movement and the actual movement that resulted from the treatment were also compared. Results: Statistically significant molar intrusion occurred in the maxilla (0.66 to 0.83 mm) during treatment. Bite deepening was also statistically significant (mean 2.7 mm), but this was not the case for mandibular autorotation. Significant extrusions were recorded in the incisors (0.95 to 1.06 mm in the maxilla and 0.38 mm in the mandible). Significant changes in the interincisal angle (mean increase 10.84 degrees) were also recorded due to the significant oral inclination of both the maxillary (mean 4.73 degrees) and mandibular (mean 
5.53 degrees) incisors. No significant changes to the occlusal plane were noted during treatment. For most movements, the difference between the planned and measured amount was not significant. Conclusion: Clear aligners can be used to treat less severe cases of open bite. The clinical effect of bite deepening is achieved through a combination of intrusion of the lateral segments and extrusion and oral inclination of the frontal segments. In particular, the resulting oral inclination was greater than planned; in general, however, significant changes to sagittal relationships due to mandibular autorotation probably cannot be expected, and significant improvement of facial aesthetics is therefore also unlikely. Keywords: autorotation, clear aligners, extrusion, intrusion, open bite

Eine Schwangerschaft stellt eine ganz besondere Situation für den Körper dar und geht mit zahlreichen Veränderungen einher. Hiervon ist auch die Zahn- und Mundgesundheit betroffen. Es handelt sich dabei jedoch um einen wechselseitigen Einfluss. Das heißt: Nicht nur schwangerschaftsbedingte Veränderungen können sich auf die Zahn- und Mundgesundheit auswirken, sondern diese kann ebenfalls einen Einfluss auf den Schwangerschaftsverlauf bzw. auf das noch ungeborene Kind haben. Eine zahnärztliche Prävention in der Schwangerschaft im Sinne einer zahnärztlichen Gesundheitsfrühförderung sollte somit als wichtiger Bestandteil in der Schwangerenvorsorge angesehen werden. Keywords: Zahnärztliche Gesundheitsförderung, Schwangerschaft, zahnärztliche Behandlung

Thermoplastic sheets have become extremely popular for fabricating clear vacuum-formed orthodontic aligners and retainers. These appliances are preferred by patients due to their excellent aesthetics, ease of use and minimal discomfort. Although a single thermoplastic sheet is normally used to fabricate a single clear aligner or retainer, this clinical tip illustrates a judicious way to fabricate two retainers using a single, 1-mm-thick Duran thermoplastic sheet (Scheu Dental, Iserlohn, Germany). The two dental casts, either maxillary or mandibular, are orientated in a BIOSTAR model cup (Scheu Dental) in such a manner as to provide adequate distance between them, which results in stability of the casts along with uniform distribution of pressure during the pressure moulding process, both of which are required for optimal adaptation and accuracy. This modification to the manufacture of aligners and retainers is useful for fabricating any kind of clear thermoplastic appliance. This two-in-one approach to the fabrication of clear appliances optimises time, energy and effort, facilitates prudent use of resources and minimises waste, and thus can help to protect the environment by reducing use of plastic and laboratory costs. Keywords: aligner orthodontics, aligners, clear retainers, thermoplastic sheet

Purpose: Several studies demonstrated compromised oral health and periodontal diseases as risk factors for adverse pregnancy outcomes. However, consideration of oral health by pregnant women remains elusive. The aim of this study was to evaluate knowledge and behaviour of French pregnant women towards relationship between oral conditions and pregnancy outcomes and to evaluate influencing factors. Materials and Methods: A self-reported questionnaire was given to women between 1 and 3 days after delivery in three specialised clinics in France. The questionnaire aimed to evaluate demographic characteristics, self-perceived oral health, type of pregnancy follow-up and knowledge regarding oral conditions during pregnancy and risk of adverse pregnancy outcomes. A multivariate analysis was performed to evaluate correlation between knowledge and behaviour. Results: The questionnaire was completed by 212 women. Among them, 92% considered prevention of oral diseases during pregnancy important. Despite knowledge of potential negative influence of periodontal diseases on pregnancy outcomes, only 47% of pregnant women received dental diagnosis or treatment during pregnancy. Only 18% of the women discussed oral health consideration during pregnancy with health professional in charge of pregnancy follow-up. Interestingly, absence of dental consultation during pregnancy was associated with low rate of dental consultation prior to pregnancy (p < 0.01). Conclusions: Pregnant women were aware of the association between oral health and pregnancy and of need of prevention. However, consideration of importance of oral health was not adequate to the rate of dental consultation and seems to be influenced by individual dental follow-up habits prior to pregnancy. Clinical Relevance: Dental evaluation should be considered systematically during pregnancy follow-up. Keywords: oral health, questionnaire, prevention, risk factor

Präventive Betreuung von Kindern und Heranwachsenden ist eng verknüpft mit kieferorthopädischen Fragestellungen. Zahndurchbruchsstörungen beeinflussen nicht nur die Entwicklung eines eugnathen Gebisses, die betroffenen Zähne unterliegen einem erhöhten Kariesrisiko. Zudem können die während kieferorthopädischer Behandlungsmaßnahmen eingebrachten Apparaturen das ökologische Gleichgewicht ungünstig beeinflussen. Gleichzeitig wirken patientenindividuelle Verhaltensweisen wie z. B. Ernährung, Hygiene und das regelmäßige Einhalten von vereinbarten Prophylaxeterminen auf das Biotop in der Mundhöhle ein. Gerade bei lang andauernden kieferorthopädischen Behandlungen kann sich die Patientencompliance immer wieder verändern und damit ein höheres Kariesrisiko zur Folge haben. Da aber zwischen der Veränderung der kariogenen Bedingungen bis zum Auftreten einer kariösen Läsion Jahre vergehen, sollte zur korrekten Einschätzung der klinisch beurteilbaren Situation immer auch eine Analyse subklinischer Risikoparameter wie Streptococcus mutans und Lactobacillus erfolgen. Keywords: Ektopischer Zahndurchbruch, Speicheltest, Kariesrisiko, Streptococcus mutans, Lactobacillus, Chlorhexidin (CHX), myofunktionelle Störung, Nasenatmung

Purpose: Orthodontic treatment may introduce a risk to the integrity of enamel due to plaque accumulation and colonisation by oral microbes. This prospective cohort study observed the effect of fixed, self-ligating orthodontic appliances on saliva properties and oral microbial flora. Materials and Methods: Thirty adolescent patients were recruited (13 female, 17 male, mean age 13.97 ± 2.07 years). Saliva samples were collected before placement of fixed orthodontic appliances (T0), and 4 (T1) and 12 (T2) weeks later. Salivary pH, flow rate and buffering capacity were recorded. All saliva samples were cultured on agar plates for 2 days. Salivary prevalence of Neisseria spp., streptococci, Staphylococcus aureus, coagulase-negative staphylococci and Candida albicans were assessed. Results: High buffering capacity was reported in 21 patients at T0, 22 patients at T1 and in 28 patients at T2. Saliva flow rate also increased over time (7.08 ml/5 min at T0, 7.93 ml/5 min at T1 and 8.35 ml/5min at T2). Mean pH was 7.63 at T0, 7.67 at T1 and 7.78 at T2. There was no evidence that either pH or the number of colonies of any of the microbial species changed over time. Conclusion: The increased buffering capacity of saliva as well as the salivary flow rate after initial bonding might be protective against the development of dental caries. Current microbial findings indicate that initiation of orthodontic treatment may not be associated with significant changes in oral microbial flora. Keywords: microbial flora, orthodontics, saliva

Purpose: The aim of the present research was to analyse the effects of two bleaching agents, on the enamel crystallography by means of X-ray diffraction. Material and Methods: Twelve human sound posterior teeth, were collected for the present study (n = 12) and from each tooth two enamel slabs were obtained and randomly assigned to one of two different bleaching protocols. The first protocol involved an in-office bleaching agent (hydrogen peroxide 37.5%/ SDI Polaoffice+), and the second an at-home whitening product (carbamide peroxide 16%/ PHILIPS Zoom! NiteWhite). X-ray diffraction readings were made before and after applying the treatments in order to analyse the peak intensity and crystal domain size. Additionally, scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDX) were carried out to identify the composition correctly. Statistical analysis included repeated measures analysis of variance (p ≤ 0.05). Results: Peak intensity in spectra obtained by X-ray diffraction had a tendency to diminish, mostly in the at-home bleaching group. The analysed data approximate a decrease in the crystal domain size among the samples treated for longer periods of time. Statistical analysis depicted no statistically significant differences among the experimental groups (p ≥ 0.05). Conclusions: Crystal domain size had a tendency to decrease, mostly when the enamel was treated by bleaching gels that had to be applied by prolonged periods of time. Keywords: bleaching agent, enamel crystallography, X-ray diffraction

Ideally, orthognathic surgery is indicated to treat skeletal Class III malocclusion with severe open bite in adults. In this borderline case, however, camouflage treatment without any skeletal anchorage was chosen. This report describes the orthodontic treatment of a 23-year-old man who presented with multiple orthodontic problems including severe open bite of the anterior and posterior teeth up to the first molars, bilateral posterior crossbite, bilateral Class III molar relationship, severe crowding, increased vertical dimension, and dental and facial midline deviation. The treatment included the extraction of four wisdom teeth, uprighting and distalisation of the mandibular arch with molar intrusion using curved NiTi wires with intermaxillary elastics. After 36 months of treatment, satisfactory improvements in the vertical overlap, horizontal overlap and sagittal malocclusion were achieved. The design of the mechanical system used in this case confirmed stable results at the 4-year follow-up. Keywords: anchorage, molar distalisation, open bite, skeletal class III malocclusion

Purpose: This study aimed to evaluate the impact of oral care and use of chlorhexidine gluconate on the prevention of ventilator-associated pneumonia (VAP) in patients admitted to an intensive care unit (ICU). Materials and Methods: An evaluation was performed on 229 patients admitted to ICU in 2012 (before implementation of oral care protocol) and 329 in 2013 (after the protocol). Oral care was based on the removal of secretions from the oral cavity with 0.12% chlorhexidine solution for brushing and sterile gauze for cleaning before a new aspiration. The cases of VAP were evaluated by observing respiratory signs, radiological changes, and culture and laboratory results. The following data were also analysed: gender, length hospital of stay, mechanical ventilation, use of antibiotics and aetiological agent of infection. Results: There was a tendency towards lower risk of development of VAP after application of oral care protocol (odds ratio = 0.64–95% CI: 0.39–1.04). There was also a reduction in the incidence of early pneumonia (up to 72 h of hospitalisation). With regard to the aetiological agent of infections, although Gram-negative bacteria predominated in the two periods studied, there was a decrease in the cases of Staphylococcus aureus infection. Conclusion: Oral care protocol has statistically significantly reduced the risk of developing early VAP in ICU patients, thus demonstrating the importance of multidisciplinary teamwork for hospitalised patients. Keywords: chlorhexidine, mechanical ventilation, oral care, pneumonia