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Volume 45 - Nº1 - September 2008
3
Guest Editorial
Daniel van Steenberghe
5
Meet the Editors and the Editorial Board
Adhesive Dentistry Research
15
Shear bond strength to sclerotic dentin using self-ecthing and total etching techniques:
an in vitro study.
Karim Corbani, Joseph Hobeiche, Nasser Al Moflehi, Alaa’ El Araby
Evidence-based dentistry
19
Evidence-based dentistry: reality and dilemmas.
Joseph Ghafari, Nada Souccar, Maria Saadeh
Oral and Maxillofacial Medicine
31
Dental management of patients under clopidogrel (Plavix®) treatment:
realities and current recommendations.
Rima Abou Tayeh, Elie Sidnaoui, Waêl Khalil, Ziad Noujeim
Questions and Answers
39
Periodontology Update: the questions.
Maroun Dagher, Cynthia Chemaly
Endodontology
41
Apexification with Mineral Trioxide Aggregate: a case report.
Salwa Yammine, Edgard Jabbour
Questions and Answers
45
Endodontology Update: the questions.
Fadl Khaled
Orthodontics and Dentofacial Orthopaedics
47
Non surgical treatment of skeletal Class III malocclusion:
report of two adult cases.
Mona Sayegh Ghoussoub, Saro Ghougassian, Chadi Kassir
Questions and Answers
57
Periodontology Update: the answers.
Maroun Dagher, Cynthia Chemaly
Temporo-Mandibular Disorders
59
Characteristics of temporo-mandibular joint pain: a prospective tunisian study.
L. Oualha, H. Hentati, A. Salma, M. Dhidah, F. Ben Amor, J. Selmi
Questions and Answers
63
Endodontology Update: the answers.
Fadl Khaled
Orthodontics and Dentofacial Orthopaedics
65
Conditions and techniques for clinical application of orthodontic miniscrews.
Ghada Al Asmar, Antoine Saadé
71
73
Forthcoming Dental Meetings
Instructions for authors
The LDA is a regular member of the FDI
Cited in the WHO Eastern
Mediterranean Index Medicus
ISSN 1810-9632
ISSN 1810-9632
Editor-in-Chief
Philippe E. Aramouni, DCD, DEA, M.Sc.D, FICD,
Lecturer and Assistant Professor,
Department of Fixed Prosthodontics and Occlusion,
St. Joseph University Faculty of Dental Medicine,
Beirut, Lebanon
[email protected]
Associate Editor-in-Chief
Ziad E.F. Noujeim, DCD, CES Odont. Chir.,
Dipl. Oral Med., DU Cell. Therapy, FICD, FACOMS,
Chairperson, Department of Basic Science, and
Senior Lecturer, Departments of Oral and
Maxillofacial Surgery, Oral Pathology and Diagnosis,
Lebanese University School of Dentistry,
Beirut, Lebanon,
Lecturer, Department of Restorative Dentistry,
Loma Linda University School of Dentistry, USA
[email protected]
Chairperson, LDA Scientific Committee
Antoine N. Berbéri, BDS, CES Odont. Chir.,
DU Perio., Dr. d’Université, Dip. EBOS,
Associate Professor and Chairperson,
Department of Oral and Maxillofacial Surgery,
Lebanese University School of Dentistry, Beirut, Lebanon,
[email protected]
Editorial Board
Joseph M. Sabbagh, DCD, CES Odont. Conserv.,
DES Endo., Dr. Sciences Dentaires,
Lecturer,
Department of Restorative Dentistry,
Lebanese University School of Dentistry,
Beirut, Lebanon
[email protected]
Faouzi F. Riachi, DCD, DEA, CES Odont. Chir.,
DU Perio., MBA,
Assistant Professor and Chairperson,
Department of Oral Surgery,
St. Joseph University Faculty of Dental Medicine,
Beirut, Lebanon
[email protected]
Maroun F. Dagher, DCD, M.Sc.D, Dip. ABP,
Clinical Associate,
Department of Periodontology,
St. Joseph University Faculty of Dental Medicine,
Beirut, Lebanon
[email protected]
Ziad A. Salameh, DCD, DES Fixed Prostho., MSD,
FICD, Ph.D,
Assistant Professor,
Prosthodontics, Biomaterials and Research,
Lebanese University School of Dentistry,
Beirut, Lebanon
[email protected]
Cynthia H. Chemaly, BDS, CES Perio., DU Perio.,
DU Implant., DU Oral Mucosal Pathol.,
Clinical Associate, Department of Periodontology,
St. Joseph University Faculty of Dental Medicine
Beirut, Lebanon
[email protected]
Fadl H. Khaled, BDS, DES Endo,
Clinical Instructor,
Department of Restorative Dentistry,
Beirut Arab University Faculty of Dentistry,
Chief of Clinical Services,
Department of Endodontics,
Lebanese University School of Dentistry,
Beirut, Lebanon
[email protected]
English Reviewer
Tala Sabbagh Yaghi, BA (Transl./Interpret.)
[email protected]
Nada A. El-Osta, DCD, DES Prostho.,
MS (Biol. Med. Sc.), DIU Biostat.,
Consultant in Biostatitics / Epidemiology,
St. Joseph University Faculties of Medicine and Dental
Medicine, Beirut, Lebanon
[email protected]
Editorial Consultants
Assem Soueidan, France
Bernard Giumelli, France
Tony Daher, USA
Mounir Doumit, Lebanon
Nada Naaman, Lebanon
Nadim Baba, USA
Hervé Reychler, Belgium
Dan Nathanson, USA
Fadi Atiyeh, Lebanon
Hani Ounsi, Kuwait
Jaafar Mouh’yi, Morocco / Sweden
Hani Abdul Salam, UAE
Joseph Bou Serhal, Lebanon
Maria Saadeh, Lebanon
Ghada Ayyash, Lebanon
Joseph Hobeiche, Lebanon
Mohammad Itani, Lebanon
Philippe Souaïd, Lebanon
Bassel Doughan, Lebanon
Gabriel Menassa, Lebanon
Farès Abou Obeid, Lebanon
Rafif Tayara, Lebanon
José Johann Chidiac, Lebanon
Fady Faddoul, USA
The Journal of the Lebanese Dental Association is the official organ of the Lebanese Dental Association. The Editorial Board is responsible for the
scientific policy of the journal. Its members may also participate as reviewers.
Statements and opinions in the papers and communications herein are those of the author(s) and not necessarily those of the Editor(s) and the
Editorial Board. The Editor(s) and Editorial Board disclaim any responsibilities or liability for such material and do not guarantee, warrant, or
endorse any product advertised in this publication, nor do they guarantee any claim made by the manufacturer of such product or service.
Address: The Lebanese Dental Association,Victoria Tower, 2nd floor, Corniche du Fleuve, Beirut, Lebanon
Tel. / Fax: 961-1- 611222, www.LDA.org.lb .
Layout and Printing: Metni Printing Press 961.1.283631 Beirut, Lebanon.
“I have a dream...”
Daniel van Steenberghe**, MD, PhD, Dr.h.c.
Emeritus Professor,
Throughout centuries, oral health has been entrusted to surgeons, barbers, itinerant charlatans, doctors, and finally to
dentists, thus varying from culture to culture. This abrupt transition of a part of the human body, regarding treatment and
training, is explained through several aspects. There is the accessibility of the oral cavity and the relative harmlessness of minor
surgical operations, especially dental extractions, that take place according to the partticular immunologic condition. However,
the epidemic of dental caries was, above all, the element that rendered a briefer training indispensable, in order to meet the huge
needs emerging suddenly at the beginning of the 20th century in a number of countries, due to industrialization.
Inspired by Anglo-Saxon countries where research in oral medicine was a permanent floweret, all countries chose to
distinguish, almost totally, between training of “dentists” and that of doctors. The term “dentist” is, unfortunately, reductionist
when we acknowledge the numerous oral pathologies lying within. One should admit that many types of academic training are
simplistic too and highly focused on both manual skills and teeth, thus resulting in not very well trained dentists on other than
fillings or dentures, just to restore dentition. Eventually, they are not very much interested in oral dryness, herpetic gingivitis or
mouth ulcers, three common oral complaints. For many, those are even “terra incognita” (unknown land). Dentition is, for many,
an aim in itself, given it is part of oropharynx that makes up a whole and knowing it belongs to a person. Tooth is an object of
fixation in the psychological meaning of the word. We talk about “dental” hygiene, whereas hygiene necessarily encompasses
tongue and other mucous membranes, we also talk about “dental” implants whereas those are not inserted in teeth. In fact, it is
about endosseous implants that hold up a denture just as a femoral implant holds up a hip prosthesis. An ad, a professional
journal, a writing paper, an appointment card rarely escapes fixation: the tooth as a logo. We even sport it on the buttonhold!
What a piece of luck that all those who do so aren’t in gynecology. If a patient comes with a chronic periodontitis, we motivate
him/her by talking about the risk of losing teeth, whereas the main argument should be to inform him/her that with a chronic
inflammation implicating several square centimeters, cardiovascular risk is high. For a woman ready to carry a baby, risk of
premature birth should be the main worry and not the maintenance of dentition. Those arguments interest patients and public
health authorities, not teeth themselves.
At the beginning of 21st century, we find ourselves at crossroads regarding oral health. Science proves, as well, that oral
cavity constitutes an integral part of human body, a fact anatomically proven. A revolution in mentalities is thus required. Just
like when Galileo claimed what the world had knew a long time ago, but pretended to ignore: the sun is the center of our
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
3
planetary system, not earth. The patient, not dentition, is the center of our medical concerns. Many oral therapies prolong
patient’s life which is much more important than dentition’s longevity. Hence, the latter is obviously worth all treatment and
preventive efforts. Dentists should become oral physicians and this not only on the level of semantics, but also on that of
thinking.
The considerable decrease of tooth decay in many industrial countries should, moreover, free dentists from highly repeated
tasks, such as fillings and dentures. Some countries have even involved dental auxiliaries in doing those tasks. Unfortunately,
few are reoriented towards other oral complaints like those previously mentioned or for example periodontitis or oral malodor.
Yet, if this reorientation exists, it is unfortunately rather towards aesthetics or even cosmetics, which are not part of medicine,
except for some rare practices. Thus, it is logical that social security is not involved in reimbursing the patients. Easy money in
medicine has always caused damage. It is hence urgent to legislate on deontological level, in order to avoid ads and internet
sites, unworthy of medicine.
In dental medicine, and due to the advent of oral implants, we encounter many dentists without any true surgical training,
suddenly devoted to surgery. Although they continue to refer patients needing other surgical practices (cystectomy,
frenectomy…) to periodontists or oral surgeons, they still oddly practice both surgery and prosthetics when it comes to implants.
The term “implantologist” should conceal the absence of specialization among the public. Can we imagine an orthopaedist or
an ENT specialist, who continuously places implants, to be called implantologist? Similarly, there is no cardiologist assuming
the right to practice surgery of placing a coronary stent, though not very invasive. Moreover, a general practitioner who has
attended, throughout his studies, several full-time months of surgery, prefers to entrust the paracentesis of the eardrum to the
ENT specialist. Herodotus reported that doctors in ancient Egypt were specialized.Yet, the main argument lies within the
scientific studies that indicate that quality of care and side-effects decrease when it comes to specialists, especially working as
a team.
Paraphrasing Martin Luther King, I conclude by quoting “I have a dream”. After having devoted several decades of my
professional life to oral health and above all to dentists, I have a dream of a dental medicine that preserves a specificity of
training, when necessary, yet embracing the mentality of medicine and continuing to constitute an integral part of it: devotion
to patients, absolute discretion, fraternal respect, scientific rigour, fair pay, yet refusal of mercenary mentality and publicity,
respect of wishes for harmony, yet refusal of cosmetics.
**Professor van Steenberghe taught human anatomy, medical ethics and periodontal therapy at the Faculty of Medicine of
Leuven in Belgium. He is a big friend of Lebanon that he has visited since the sixties.
Translated (from french to english) by Tala Sabbagh Yaghi
4
Volume 45 - Nº 1 - 2008
Meet the Editors
and the
Editorial Board
is a graduate of
Medicine, Editor–in-Chief
Saint-Joseph University Faculty of Dental
of the Journal of Lebanese
Medicine in Beirut, Lebanon. He specialized
Dental Association (JLDA),
in Prosthodontics, with a Certificate of
and
Advanced Graduate Studies (CAGS) and a
International
Masters of Science in Dentistry (MSc.D) from
Dentists (FICD), Middle
Boston University Henry M. Goldman School
East Section. He is involved in teaching and
of Graduate Dentistry, in Boston, USA. In
clinical practice, in Beirut, Lebanon and
2004, he furthered his research background by
Doha,
earning an advanced studies diploma (DEA)
impression materials and techniques, implant
in Biology and Materials of Oral Milieu at St.
abutment connections, Zirconium abutments
Joseph
Dental
for implants, implant-supported overdentures,
Medicine, and his Doctorate degree is now in
and restoration of endodontically treated teeth
progress (at the same institution), to be
by fiber posts.
Philippe Aramouni
University
Faculty
of
Currently, Dr. Aramouni is Assistant
(at
Qatar.
of
the
College
of
His
main
interests
are
He is the author and co-author of several
defended soon.
Professor
Fellow
undergraduate
and
postgraduate levels) in the Department of
scientific papers and has lectured in USA,
Morocco, Kuwait, Jordan, Syria, Egypt, UAE
(AEEDC), KSA, and FDI conventions.
Fixed Prosthodontics and Occlusion at St.
Joseph
University
Faculty
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
of
Dental
5
Meet the Editors and the Editorial Board
Ziad Noujeim is Chairperson of Basic
Science Department, Director of Oral Biology
Graduate Diploma (DU), and Senior Lecturer
in the Departments of Oral and Maxillofacial
Surgery, and Oral Pathology and Diagnosis at
the Lebanese University School of Dentistry in
Beirut, Lebanon. He is also Lecturer in
Implant Dentistry with the Department of
Restorative Dentistry (Implant Graduate
Program) at Loma Linda University School of
Dentistry, in California, USA.
Dr. Noujeim received his dental degree
from Saint-Joseph University Faculty of
Dental Medicine, in Beirut, Lebanon. He
completed a postgraduate training in Paris
(France), attaining an advanced certificate
(CES) in Oral Surgery at the University of
Paris VI Institute of Stomatology and
Maxillofacial Surgery, and a Clinical
Fellowship in Oral Surgery and Dental
Implants at the Massachussets General
Hospital/Harvard School of Dental Medicine,
in Boston, USA. He also pursued an advanced
education
in
oral
medicine
and
histopathology by completing the Pindborg’s
Course with the University of Copenhagen
Department of Oral Pathology/Medicine at
the School of Dentistry, in Denmark, and he
lately earned the University Diploma (DU) in
Regenerative Medicine and Cell Therapy at
the University of Montpellier I Faculty of
Medicine, in France.
Former Chairperson of the Lebanese
Dental
Association
(LDA)
Scientific
6
Committee (2001 to 2003),
he is now member of this
Committee and Associate
Editor-in-Chief
of
the
Journal of LDA.
Dr. Noujeim is a Fellow
of the American College of
Oral and Maxillofacial Surgeons (FACOMS)
and the International College of Dentists
(FICD), Middle East Section, and a life
Fellow of the International Association of
Oral and Maxillofacial Surgeons (FIAOMS).
He is one of the rare recipients of the Gold
Medal of the LDA (2003) for his achievements
in organized dentistry and dental education.
He has lectured in Lebanon, KSA, Egypt,
Kuwait, Syria, UAE, France, Germany,
Belgium, Australia, Canada, and USA. He is
the author and co-author of several
publications cited on PubMed, Medline,
Bibliodent, and WHO Eastern Mediterranean
Index Medicus.
Dr. Noujeim’s main interests are dental
education, oral odontogenic tumors, oral
medicine, oral mucosal pre-cancerous lesions,
stem cells, tissue engineering, regenerative
dentistry, wisdom teeth, oral lesions, and
applied oral anatomy.
He maintains a private practice (in Beirut
and Bahrain) devoted to Surgical Dentistry,
Oral Surgery, Oral Medicine, and Dental
Implants.
Volume 45 - Nº 1 - 2008
Meet the Editors and the Editorial Board
Antoine Berberi is a graduate of the
Currently, Dr. Berberi is
Lebanese University School of Dentistry in
Associate
Beirut, Lebanon. He specialized, in France, in
Chairperson
Oral Surgery, graduating with an advanced
Department of Oral and
certificate (CES), and in Periodontology,
Maxillofacial Surgery at the
graduating with a University Diploma (DU).
Lebanese University School of Dentistry in
He also attended a doctoral course in Reims,
Beirut, President of the Lebanese Society of
France, leading to a “Doctorat d’Université”
Oral Surgery, and Scientific Chairperson of
in Dentistry. He is Diplomate of the European
the Lebanese Dental Association. He has
Board of Oral Surgery (EBOS) and maintains
published more than 35 scientific papers in
a private practice (in Beirut and Doha, Qatar)
several refereed journals, including IJOMI,
limited to Surgical Dentistry, Oral Surgery,
Oral Surg Oral Med Oral Pathol Oral Radiol
Surgical Implantology, and Periodontology.
Endod,
His main interests are HIV impact in dental
practice, Astra Tech® implant, immediate
implantation, oral tumors, and single-tooth
replacement in implantology.
Professor
of
GIRSO,
Periodontology,
and
the
French
Journal
of
and
Quintessence
International.
Dr Berberi has lectured in USA, Norway,
Spain, France, Russia, Sweden, Switzerland,
Lebanon, and most Arab countries.
Journal of the Lebanese Dental Association
7
Meet the Editors and the Editorial Board
Joseph Sabbagh is a graduate of St.
and co-authored numerous
Dental
refereed articles (Journal of
Medicine, in Beirut, Lebanon. He specialized,
Dental Research, Dental
in
Materials, Journal of Oral
Joseph
University
Paris,
in
Faculty
of
Conservative
Dentistry,
graduating with an advanced certificate
Rehabilitation,
(CES).
postgraduate
Cliniques...) on endodontics, restorative,
education at the Catholic University of
aesthetic, and cosmetic dentistry, and has
Louvain (UCL), in Belgium, earning an
extensively lectured in Belgium, France, UK,
advanced
USA, Egypt, UAE, Iran, KSA, Bulgaria, and
He
furthered
studies
his
diploma
(DES)
in
Conservative Dentistry and Endodontics and
a “Doctorat en Sciences Dentaires” in
Réalités
Jordan.
His research and clinical interests are
dynamic and static modulus of elasticity of
Biomaterials.
Currently, Dr. Sabbagh is a Lecturer in the
resin composites and resin-based materials,
Department of Restorative and Aesthetic
physical and mechanical characterization of
Dentistry at the Lebanese University School of
resin-based materials, polymerization of resin
Dentistry
Visiting
composites, improvement of aesthetic outcome
Lecturer (at postgraduate level) at St. Joseph
of composite restorations, hypersensitivity in
University Faculty of Dental Medicine, and
composite restorations, layering technique
Fellow Researcher at the Catholic University
concept, and posterior restorations.
in
Beirut,
Lebanon,
of Louvain (Cribio Division), in Belgium. He
Dr. Sabbagh is currently in private practice
is an active member of the Academy of
(limited
to
Cosmetic
Dentistry
Operative Dentistry and the Academy of
Endodontics) in Beirut, Lebanon.
and
Dental Materials, in USA. He has authored
8
Volume 45 - Nº 1 - 2008
Meet the Editors and the Editorial Board
Ziad Salameh is a graduate of St. Joseph
published in many indexed
University Faculty of Dental Medicine in
journals with high impact
Beirut, Lebanon. He specialized (at the same
factor, and has extensively
institution)
lectured
in
Fixed
Prosthodontics,
graduating with an advanced diploma (DES).
After achieving his clinical specialty in
(AEEDC,
Beirut,
in
KSA,
FDI),
Syria,
UAE
Egypt,
Germany,
Beirut, he worked as Lecturer, Clinical
Switzerland, Spain, and Italy. He is a Fellow
Associate, and researcher (for seven years)
of International College of Dentists (FICD),
with the Department of Prosthetic Dental
Middle East Section and European Society of
Sciences at King Saud University College of
Restorative Dentistry.
Dentistry, in Riyadh, Kingdom of Saudi
Dr. Salameh’s research interests include
Arabia. During this period, he earned a
bonding, CAD-CAM technology, fiber post,
Masters Degree in Dental Biomaterials at
Zirconia dental applications, and restoration
Siena University Faculty of Dental Medicine
of endodontically treated teeth.
in Italy, and he lately graduated (at the same
Lately, he has received (in Seefeld,
Italian institution) with a Ph.D degree in
Germany) the European Talent Award of
Biomaterials and their clinical applications.
Dental Scientists for his research on Zirconia
Currently,
Dr.
Salameh
is
Assistant
dental applications.
Professor and researcher at the Research
Dr. Salameh is currently involved in
Department of the Lebanese University
research and teaching, both in Lebanon and
School of Dentistry, in Beirut. He has
Saudi Arabia.
Journal of the Lebanese Dental Association
9
Meet the Editors and the Editorial Board
Cynthia Chemaly is a graduate of the
University
Faculty
of
Lebanese University School of Dentistry in
Dental Medicine in Beirut,
Beirut, Lebanon.
Lebanon.
She specialized in Periodontology in Paris,
France,
graduating
with
an
advanced
Her
main
interests are periodontal
medicine, bone grafts, bone
certificate (CES) and a University Diploma
substitutes,
(DU). She also graduated in Implant
factors.
and
growth
Dentistry with a University Diploma (DU)
Dr. Chemaly runs a private practice (in
and earned another Diploma (DU) in Oral
Beirut) devoted to Periodontology, Implants,
Mucosal Pathology, both from the Institute of
and Restorative Dentistry.
Stomatology of Paris VI University.
She is a Clinical Associate in the
Department of Periodontology of St. Joseph
10
Volume 45 - Nº 1 - 2008
Meet the Editors and the Editorial Board
Maroun Dagher is Clinical Associate
Academy of Periodontology
of
(AAP) and the Academy of
Periodontology at Saint-Joseph University
Osseointegration (AO). He
Faculty of Dental Medicine in Beirut,
has lectured in Lebanon,
Lebanon, and a Diplomate of the American
Jordan, Syria, Morocco,
Board of Periodontology (DABP).
and USA (IADR).
and
Lecturer
in
the
Department
After earning his dental degree from St.
Joseph
University
Faculty
of
Dental
His main clinical and research interests are
bone grafting materials and techniques,
Medicine, in Beirut, he specialized in
periodontal
immunity,
maxillary
sinus
Periodontology at Boston University Henry
grafting, and aesthetic periodontal surgery.
M. Goldman School of Graduate Dentistry, in
Apart his active academic career, Dr.
USA, attaining both a Certificate of Advanced
Dagher maintains a private practice (in
Graduate Studies (CAGS) and a Masters of
Beirut) exclusively devoted to Periodontology
Science (MSc.D) in Oral Biology.
and Dental Implants.
Dr. Dagher is a member of the American
11
Volume 45 - Nº 1 - 2008
Meet the Editors and the Editorial Board
Faouzi Riachi is a graduate of St. Joseph
and
Paris
I
Panthéon
University Faculty of Dental Medicine, in
Sorbonne. He has authored
Beirut, Lebanon. He specialized, in Paris, in
and co-authored several oral
Oral Surgery, graduating with an advanced
surgery, periodontology, and
certificate (CES), and in periodontology,
implant articles, in Lebanon
graduating with a Universiy Diploma (DU)
and France, and has lectured
and an advanced certificate (CES); and apart
in Lebanon, Syria, Sudan, France, Belgium,
this formal education, he furthered his
Iran, and Jordan.
training with a private Clinical Fellowship in
His main interests are oral reconstructive
oral implantology and reconstructive surgery.
surgery, implants, and mucogingival surgery.
Lately, he earned an advanced studies
Currently, he is Assistant Professor and
diploma (DEA) in Biology and Materials of
Chairperson of Oral Surgery Department at
Oral Milieu, at St. Joseph University Faculty
St. Joseph University Faculty of Dental
of Dental Medicine, and his Doctorate degree
Medicine and Clinical Associate in Oral
is now in progress (at the same institution).
Surgery at the Central Military Hospital of
Dr. Riachi has also widened his educational
Lebanese Army, in Beirut. He maintains (in
horizons and background by earning an MBA
Beirut) a private practice limited to Oral
degree in Health Management from St. Joseph
Surgery,
University and Universities of Paris Dauphine
Periodontology.
Journal of the Lebanese Dental Association
Dental
Implants,
and
12
Meet the Editors and the Editorial Board
is a graduate of the
Lebanese University School
Lebanese University School of Dentistry in
of Dentistry, in Beirut. He
Beirut,
has published in Lebanese,
Fadl Khaled
Lebanon.
He
specialized
in
Endodontics at the St. Joseph University
British,
Faculty of Dental Medicine in Beirut,
Canadian literature.
graduating with an advanced diploma (DES).
Italian,
and
His main interests are
He is a former member of the Board of
endodontic techniques, endodontic rotary
Lebanese Society of Endodontology (LSE) and
instruments, endodontic bacteriology, and
the Scientific Committee of the Lebanese
cleaning of the endodontic system.
Dental Assocation (LDA).
Dr. Khaled is Clinical Instructor in the
Department of Restorative Dentistry at Beirut
He maintains a private practice (in Beirut)
devoted
to
Restorative
Dentistry
and
Endodontics.
Arab University (BAU) Faculty of Dentistry,
and Chief of Clinical Services (Chef de
Clinique) in the Department of Endodontics at
Journal of the Lebanese Dental Association
13
Adhesive Dentistry Research
Shear bond strength to sclerotic dentin using self-ecthing and total
etching techniques: an in vitro study.
Karim Corbani1, Dr. Chir. Dent., DES Endo., Joseph Hobeiche2, Dr. Chir. Dent., DU (Occluso), DEA, MBA (Public
Health), DU (Remov. Prostho.), Nasser Al Moflehi3, BS, MS, Alaa’ El Araby4, BDS, MS, Ph.D
INTRODUCTION
Bonding to dentin is more difficult to achieve when
compared to enamel due to its variable histological
features1; in some situations, physiological and
pathological post-eruption changes may further result
in sclerotic dentin2 that is less receptive to bonding
protocols designed for sound dentin3. These lesions are
well known to respond to etching and bonding
differently from normal dentin, leading to
complications during clinical treatment4,5.
Studies have shown that the sclerotic casts which
obliterated the dentinal tubules were still present after
acid conditioning the sclerotic dentin, resulting in
minimal or no resin tag formation. Furthermore the
zone of resin-impregnated sclerotic dentin was found
to be much thinner than the one observed in normal
dentin6,7,8. The bonding scenario may further be
complicated by the presence of bacteria overgrowth9,
and their entrapment within the surface
hypermineralized layer of these lesions10.
Contemporary self-etching primers have been
developed by replacing the separate acid-conditioning
step with increased concentration of acidic resin
monomers11. When self-etching primers were used on
sound dentin, a thin hybrid layer was observed, but
1 Lecturer and Assistant Professor, Department of
Restorative and Aesthetic Dentistry, St. Joseph University
Faculty of Dental Medicine, Beirut, Lebanon
2 Lecturer and Assistant Professor, Department of Fixed
Prosthodontics and Occlusion, St. Joseph University
Faculty of Dental Medicine, Beirut, Lebanon
3 Lecturer, Department of Preventive Dental Sciences, King
Saud University College of Dentistry, Riyadh, KSA
4 Associate Professor, Department of Restorative Dental
Sciences, King Saud University College of Dentistry,
Riyadh, KSA
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
high bond strength was obtained12. However, bond
strengths were compromised when self-etching
primers were used on sclerotic dentin13. Kwong et al14
showed that there was no significant difference in
microtensile bond strengths to sclerotic dentin using a
self-etching and a total-etching technique, but results
were lower than those obtained on sound dentin.
The aim of this study was to compare the shear
bond strength to sclerotic dentin of a self-etching to a
total-etching technique. The null hypothesis tested was
that there was no difference in bond strength between
the two techniques tested.
MATERIALS AND METHODS
Study sample
Thirty premolars with deep, noncarious cervical
sclerotic wedge-shaped lesions that were extracted for
periodontal reason were used for the study. The lesions
were glossy, hard, with a deep yellow to brown color.
The teeth were stored in 0.5% chloramines T solution
at 4ºC, and used within 1 month following extraction.
Interventions (treatment groups)
The teeth were first cleaned first with an ultrasonic
scaler to remove all signs of calculus, and then cleaned
with pumice and rubber cup in a low speed handpiece.
The roots were cut off and the crowns were sectioned
mesiodistally using a low speed diamond saw (Isomet
2000, Buehler Ltd, Lake Bluff, NY, USA) under
copious water cooling.
The sectioned crowns were placed in a silicon mold
and embedded in a self-curing acrylic resin with the
buccal or lingual surfaces positioned for surface
treatment and composite bonding. The crown surfaces
were ground flat with 600-grit silicon carbide (SiC)
15
Corbani K, Hobeiche J, Al Moflehi N, El Araby A
paper, under running tap water, to obtain flat sclerotic
dentin (n=30) surfaces. For each surface type, the
specimens were randomly divided into two groups of
15 specimens each. In group 1, an aceton-based total
etching adhesive was used (Prime & Bond NT,
Caulk/Dentsply) and in group 2, a self-etching
adhesive (Prompt L-Pop, 3M-ESPE, St Paul, MN,
USA).
The adhesives were applied to sclerotic dentin
surfaces according to the manufacturer’s instructions.
In group 1, each specimen was first conditioned with
34% phosphoric acid gel (Caulk/Dentsply) for 15s.
The acid was rinsed with distilled water for 20s and the
etched surface was left moist before bonding with
Prime & bond NT (Caulk/Dentsply). The primer
mixture was gently evaporated after application to
evaporate the solvent. Two coats of adhesive were
added and light cured for 20s, as before. In the “selfetch” protocol (group 2), Prompt L-Pop (3M-ESPE)
was applied; prior to placement, a blister pack was
activated by squeezing and emptying the liquid out of
the red cushion into the yellow cushion. The activated
liquid mixture was then emptied into the green section
of the blister pack and then applied to the dentin
specimens using pre-pack-aged, disposable applicator.
A new blister pack was used for each specimen. The
all-in-one adhesive was applied and agitated for 15s.
The liquid was then air-dried and spread into
homogenous shiny film, then light cured for 20s.
After the application of the bonding system, a
cylindrical Teflon mold was placed on each sample
(internal diameter = 3mm; height = 5mm). Nanocomposite restorative material (Filtek Supreme, 3MESPE) was condensed into the mold and then lightcured using a halogen light-curing unit (Astralis 10,
Ivoclar-Vivadent, Schaan, Liechtenstein) with an
intensity of 1200 mW/cm2 for 40 seconds (Fig.1). The
bonded specimens were stored in distilled water at
37ºC for 24 hours prior to testing.
Outcome measurement
The specimen cylinders were loaded by a
chisel- like metal rod parallel to the bonding
interface in a shear mode until rupture occurred
(Fig.2). The shear bond strengths were determined by
means of a mechanical testing machine (Instron testing
machine, USA) at a cross head speed of 1mm/min.
Shear bond strength was calculated as the ratio of
fracture load and the cross-sectional area of the bonded
composite cylinder.
Statistical analysis
The statistical analysis was performed using a
software program SPSS for Windows version 11.0
(SPSS Inc., Chicago, IL, USA). The study was
designed for testing equivalence between the two
techniques. The main outcome variable of the study,
“shear bond strength” (MPa*), was tested for normal
distribution using the Kolmogorov Smirnov test. As
this variable was not normally distributed, the nonparametric Mann-Whitney test was conducted to
compare the shear bond strength for prime and Bond
NT and Prompt L-Pop groups. Values were considered
as statistically different at P ≤ 0.05.
RESULTS
Descriptive statistics (table 1) revealed that mean
and standard deviation for the Prime & Bond NT and
Prompt L-Pop groups were respectively 18.91±3.59
MPa* and 13.53±2.31MPa*.
Independent t-test showed significant difference in
bond strength (MPa) between group 1 and group 2
(P=0.000038) (Fig.3). However, as the data failed the
Kolmogorov-Smirnov test, a Mann-Whitney rank sum
test was performed, showing statistical difference
between the 2 groups (P=0.0022).
DISCUSSION
Current dentin bonding methods depend on the
development of micromechanical retention. The
application of an acid superficially demineralizes
dentin, exposing a collagen network, the interfibrillar
microporosities, which become available for
subsequent infiltration by resin. Polymerization of the
infiltrated resin stabilizes the collagene network,
forming a micromechanical bond through the
formation of an intertubular hybrid layer15.
Dentinal tubules in sclerotic dentin are obliterated
with mineral casts that consist of rhombohedral,
whitelockite crystallites13,6 resistant to acid
demineralization, resulting in minimal resin tag
formation. The presence of a surface of
* MPa = Mega Pascal
16
Volume 45 - Nº 1 - 2008
Corbani K, Hobeiche J, Al Moflehi N, El Araby A
Table 1: Descriptive statistics of the Prime & Bond NT and
Prompt-L-Pop groups. Means and Standard Deviations (SD)
are given in MPa (Mega Pascal).
Group
n
Mean (SD)
Prime & Bond NT
15
18.91 (3.59)
Prompt L-Pop
15
13.53 (2.31)
Fig. 1: Composite disc bonded on sclerotic dentin specimen.
Fig. 2: Specimen mounted on the Instrom testing machine.
Fig. 3: Bond strengths of group 1 (Prime and Bond NT)
and group 2 (Prompt L-Pop).
24.00
Shear Bond Strength (in MPa)
hypermineralized layer was described in natural
sclerotic wedge-shaped lesions2,10,16,17. This layer of
variable thickness can be a substitute to the surface
smear layer found in polished sound dentin. The
surface hypermineralized layer may also be colonized
with bacteria9, and this zone of mineralized bacteria
may be comparable to the presence of smear layer on
sound abraded dentin.
In this study, the mean bond strength obtained for
both total-etch and self-etch technique to sclerotic
dentin were lower than the corresponding values to
sound dentin as reported by previous study18.
Yoshiyama and co-workers19 also showed significant
difference in bond strength between total-etch and
self-etch which is not in agreement with another
study14. This can be explained by the presence of a
hybridized intermicrobial matrix together with
entrapped bacteria that may have weakened the bond;
on the other hand, the inability of a self-etching primer
to etch through the surface hypermineralized layer,
especially when it is thicker than 1µm10, and the
inability of the same self-etching primer to remove
sclerotic casts that obliterate tubular lumina and the
lack of effective resin tag formation. As reported by
Prati and co-workers6, Prime & Bond is more acidic
(pH-1.6) than other primers, and this may have helped
to produce a second demineralization of dentin, thus
allowing a deeper penetration of the primer into
demineralized dentin matrix and dentinal tubules.
Grinding might be expected to increase bond strength
by removal of the microbial deposits and the
hypermineralized layer that will allow a better resin
infiltration, as suggested by Gwinnett and Kanca20.
Another important factor is the test used in this
study to evaluate the bond strength. The conventional
shear test had become the object of criticism for some
researchers21–23. The limitations of these methods
include the heavy dependence of recorded strengths
upon experimental conditions, such as materialsubstrate misalignments, possibly affecting stress
uniformity. Anyway, stress distribution was likely to
be non-uniform anyway over a large bonded surface,
in relation to the density of intrinsic faults within the
substrates or at their interface, functioning as crack
propagating areas. Yet, the most critical shortcoming
of conventional shear and tensile tests that emerged
with the advent of adhesive systems able to achieve
22.00
20.00
18.00
16.00
14.00
12.00
10.00
P&B NT
Prompt L-Pop
Techniques
Journal of the Lebanese Dental Association
17
Corbani K, Hobeiche J, Al Moflehi N, El Araby A
dentine bond strengths over 20 MPa, was the frequent
occurrence of cohesive dentine fractures that
prevented assessment of interfacial strength24.
The microtensile technique for bond strength
testing was thus introduced25 and credited with the
potential to more closely reflect the true interfacial
bond strength, the ability to measure adhesion to small
surfaces, the capacity to assess local variations over
the bonding substrate, and the convenience of
obtaining multiple specimens from a single tooth26.
Within the limitations of our study, the results led to
reject the null hypothesis. Further in vivo researches
should be conducted to validate these in vitro results.
13. Yoshiyama M, Matsuo T, Ebisu S, Pashley DH. Regional bond
strength of self-etching/self-priming adhesive systems. J dent
1998;26:609-16.
REFERENCES
18. Yoshiyama M, Carvalho RM, Sano H, Horner JA, Brewer PD,
Pashley DH. Regional strengths of bonding agents to cervical
sclerotic root dentin. J Dent Res 1996;75:1404-1413.
1. Swift EJ, Perdigao J, Heymann HO. Bonding to enamel and
dentin: a brief history and state of the art, 1995. Quintessence Int
1995;26:95-110.
2. Weber DF. Human dentine sclerosis: a microradiographic
survey. Arch Oral Biol 1974;19:163-9.
3. Levitch LC, Bader JD, Shugars DA, Heymann HO. Non-carious
cervical lesions. J Dent 1994;22:195-207.
4. Duke ES, Robbins JW, Snyder DS. Clinical evaluation of a
dentinal adhesive system: Three-year results. Quintessence Int
1991;22:889-895.
5. Harnirattisai C, Inokoshi S, Shimada Y, Hosada H. Adhesive
interface between resin and etched dentin of cervical
erosion/abrasion lesions. Oper Dent 1993;18:138-143.
6. Prati C, Chersoni S, Mongiorgi R, Montanari G, Pashley DH.
Thickness and morphology of resin-infiltrated dentin layer in
young, old, and sclerotic dentin. Oper Dent 1999;24:66-72.
7. Van Meerbeck B, Braem M, Lambrechts P, Vanherle G.
Morphological characterization of the interface between resin
and sclerotic dentine. J Dent 1994;22:141-146.
8. Yoshiyama M, Sano H, Ebisu S, Tagami J, Ciucchi B, Carvalho
RM, Johson MH, Pashley DH. Regional strengths of bonding
agents to cervical sclerotic root dentin. J Dent Res
1996;75:1404-1413.
9. Spranger H. Investigation into the genesis of angular lesions at
the cervical region of teeth. Quintessence Int 1995;26:149-54.
10. Tay FR, Kowng SM, Itthagarun A, King NM, Yip HK,
Moulding KM, Pashley DH. Bonding of a self-etching primer
to noncarious cervical sclerotic dentin:interfacial ultrastructure
and micro-tensile bond strength evaluation. J Adh Dent
2000;1:9-28.
11. Watanabe I, Nakabayashi N. Bonding durability of photo-cured
phenyl-P in TEGDMA to smear layer-retained dentin.
Quintessence Int 1993;24:335-342.
12. Yoshiyama M, Carvalho RM, Sano H, Horner JA, Brewer PD,
Pashley DH. Regional bond strengths to resins to human root
dentine. J Dent 1996;24:435-42.
18
14. Kowng SM, Cheung GSP, Kei LH, Itthagarun A, Smales RJ,
Tay FR, Pashley DH. Micro-tensile bond strengths to sclerotic
dentin using a self-etching and a total-etching technique. Dent
Mater 2002;18:359-369.
15. Nour El-Din AK, Miller BH, Griggs JA. Resin bonding to
sclerotic, noncarious, cervical lesions. Quintessence Int
2004;35:529-540.
16. Daculsi G, LeGeros RZ, Jean A, Kerebel B. Possible physicochemical processes in human dentin caries. J Dent Res
1987;66:1356-1359.
17. Schupbach P, Lutz F, Guggenheim B. Human root caries:
histopathology of arrested lesions. Caries Res 1992;26:153164.
19. Yoshiyama M, Masada J, Uchida A, Ishida H. Scanning
electron microscopic characterization of sensitive versus
insensitive human radicular dentin. J Dent Res 1989;68:14981502.
20. Gwinnet AJ, Kanca J. Interfacial morphology of resin
composite and shiny erosion lesions. Am J Dent 1992;5:315-7.
21. Goracci C, Grandini S, Bossu M, Bertelli E, Ferrari M.
Laboratory assessment of the retentive potential of adhesive
posts: A review. J Dent 2008; In Press
22. Van Noort R, Cardew GE, Howard IC, Noroozi S. The effect of
local interfacial geometry on the measurement of the tensile
bond strength to dentin. J Dent Res 1991;70:889–93.
23. Sudsangiam S, Van Noort R. Do dentin bond strength tests
serve a useful purpose? J Adh Dent 1999;1:57–67.
24. Versluis A, Tantbirojn D, Douglas WH. Why do shear bond
tests pull-out dentin? J Den Res 1997;76:1298– 307.
25. Sano H, Shono T, Sonoda H, Takatsu T, Ciucchi B, Horner JA,
et al. Relationship between surface area for adhesion and
tensile bond strength—evaluation of a microtensile bond test.
Dent Mater 1994;10:236–40.
26. Pashley DH, Carvalho RM, Sano H, Nakajima M, Yoshiyama
M, Shono Y, et al. The microtensile bond test: a review. J Adh
Dent 1999;1:299–309.
Correspond with:
Karim Corbani
[email protected]
Acknowledgment: The authors express special
thanks to Assistant Professor Ziad Salameh for his
valuable contribution to this article.
Volume 45 - Nº 1 - 2008
Evidence-Based Dentistry
Evidence-based dentistry: reality and dilemmas.
Joseph G. Ghafari, DMD1, 2, 3, Nada M. Souccar, DCD, MS1, Maria E. Saadeh, BDS, MS1, 2
Abstract
The concept of evidence-based practice (EBP) relies on rendering treatment, the effectiveness is solidly demonstrated by
rigorous research, not just empirical experience. The aim of this paper is to review the foudation of EBP and the reality of its
application. Evidence is commonly ordered up in a “hierarchy” from expert opinion to case report, case series, case-control
study, cohort study, randomized controlled trial, and systematic review/meta-analysis. We stratify this hierarchy into 3
categories ascending from perspective, to investigation then synthesis. Depending on the type and feasibility of research, the
higher levels of evidence do not negate the value of lower strata. The application of evidence is illustrated in two representative
areas of dentistry: timing of early orthodontic treatment and immediate loading of osseointegrated implants. The clinician
faces dilemmas in the need to ground treatment into unquestionable basis and the difficulty of relating this basis to the
individual treatment. Reasons for this dichotomy include the scale of variation around mean results delivered by the most
sophisticated research and the potential for new more encompassing research to deviate from prior findings. While research
sets central tendencies, individual variation favors interpretation of the evidence. In the face of viewpoints on EBP ranging
from support to rejection, the clinician should not indict a needed process, but rather use judgment to apply the average
response shown in investigations to the individual circumstances of patients.
INTRODUCTION
In the last decades of the 20th century, dental
specialties departed at different paces from the era of
“an opinion-driven specialty”1 to enter the age of
“evidence-based” practice (EBP), which has
permeated all medical fields and stirred arguments for
or against the trend2-9. The goal of the EBP process is
to promote sound and informed clinical decisionmaking by consistently determining the most effective
treatment. Reliance on expert opinion carries serious
limitations, since recommendations by recognized
authorities (e.g. 19th century William Osler’s use of
opium to treat diabetes), initially sanctioned by current
clinical knowledge and practice, may be proven
inappropriate or harmful through judicious research2,3.
Consequently, the nature and quality of studies testing
treatment regimens are assessed for scientific validity
and generalizability. Our aim is to review the basic
premise and components of evidence-based practice
Orthodontics and Dentofacial Orthopedics units at:
1 American University of Beirut
2 Lebanese University School of Dentistry, Beirut
3 New York University School of Dentistry, NY, USA
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
and assess its relevance and the reality of its clinical
application. As the scope of knowledge and practice in
dental disciplines is immense, we limit the discussion
of EBP to two specific areas: timing orthodontic
treatment in growing children and immediate loading
of osseointegrated implants.
Definitions
Sackett et al2,3 defined evidence-based medicine
(EBM) as “the conscientious, explicit and judicious
use of current best evidence in making decisions about
the care of individual patients. The practice of
evidence-based medicine means integrating individual
clinical expertise with the best available external
clinical evidence from systematic research.” Critical
to this integration is the patient’s preference in
decision-making10. The definition combines “best
available” evidence with “judgment”, elements that
introduce the need to objectively stratify a voluminous
amount of information entering the stream of medicine
on a daily basis, and use reason to logically apply the
evidence in individual patients.
Applying EBM principles to dentistry, the
American Dental Association defined evidence-based
19
Ghafari JG, Souccar NM, Saadeh ME
dentistry as “an approach to oral health care that
requires the judicious integration of systematic
assessments of clinically relevant scientific evidence,
relating to the patient’s oral and medical condition and
history, with the dentist’s clinical expertise and the
patient’s treatment needs and preferences”11.
Given that even peer reviewed articles are not
always reliable, a “hierarchy of evidence” was sought,
ranging from the least scientific to more rigorous
evidence, organized and graded according to their
scientific strength as per specific guidelines (Table 1).
While
several
authors
suggested
various
categorizations of the evidence, raters agree on the
following general scale (from highest to lowest)12: 1systematic reviews of randomized controlled trials
(RCT), often using meta-analysis, 2- RCT, 3- cohort
studies (also known as prospective studies), 4- casecontrol studies, 5- case studies, 6- expert opinion, 7anecdotal evidence. We describe this hierarchy
according to 3 categories: synthesis (reviews and
meta-analysis), investigation (all types of studies), and
perspective (analysis and opinion). Studies are
classified on the type of research design. An RCT best
answers questions related to intervention and therapy;
cohort or case control studies are more appropriate for
diagnosis, prognosis or causation13-15.
Detailed definitions are presented in a hierarchy of
data adapted, synthesized and restructured from
several sources (Table 2)12-17. In Table 3, a separate
classification, developed by the Agency for Healthcare
Research and Quality (AHRQ, http://www.ahrq.gov)18,
applies specifically to studies only.
Criteria
Because the level of evidence influences the
strength of recommendations for the performance of a
specific treatment, ratings have been developed not
only to indicate scientific grades (A to C, Table 1), but
also acceptability (Table 4). The criteria for rating
evidence may differ for studies of treatment efficacy,
effectiveness, diagnosis, prognosis, or other
characteristics. Criteria relevant to types of clinical
information have been delineated19. In all instances,
basic themes are respected: independent confirmation
and converging evidence (well-designed metaanalyses summarize results across a number of
scientifically rigorous studies); experimental control
(prospective randomized designs); avoidance of
Table 1: Hierarchy of evidence
Grade
Type of evidence: OBTAINED FROM
( Level or Rank)
Ia meta-analysis, systematic reviews based
A
on more than one RCT
Ib well designed randomized controlled trial
IIa at least one well-designed controlled
study without randomization
IIb at least one other type of well-designed
B
quasi-experimental study
III well-designed non experimental
descriptive studies such as comparative,
correlation, and case control studies
IV expert committee reports or opinions
C
20
and/or clinical experience of respected
authorities
Category
S
Y
N
T
H
E
S
I
S
I
N
V
E
S
T
I
G
A
T
I
O
N
P
E
R
S
P
E
C
T
I
V
E
1- meta-analysis
2- systematic review
Definition
Rigorous selection of studies:
combined/pooled statistical results
Rigorous selection and appraisal of
individual studies
3- randomized
controlled trial-RCT
Prospective study: random assignment
to treatment group (+ control)
4- cohort study
Observational study: interventions
compared in similar groups
5- case-control study
Retrospective study with comparison
of “treated” and “untreated” patients
Prospective / retrospective series of
patients studied for particular
intervention
Communication of
diagnostic/treatment records
6- case
series
7- case
report -if
Uncontrolled
cohort
study
more than 1
8- expert opinion
9- personal
communication
Consensus conference, authorities
opinion
Editorial/interview
Volume 45 - Nº 1 - 2008
Ghafari JG, Souccar NM, Saadeh ME
Table 2: Design features in hierarchy of evidence
Research method
KEY FEATURES
SURVEY
Describes how things are now. May include all or a random sample of the population of
interest. Do not usually have separate control groups but internal comparisons can be made
Data collected from sample members on one occasion
Data collected from sample members on two or more occasions
Describes what happens to patients without actively intervening with their treatment.
Can be prospective or retrospective. May have a separate control group or be uncontrolled
Small case series describing the treatment outcome of a few (<5–10) cases or reporting
potential problems with treatment
Uncontrolled cohort study describing outcome of treatment for a group of patients
Comparison made to information on patients in a published paper or growth study
Prone to chronological and/or geographical bias
Comparison made with patients treated previously in the same unit/place.
Prone to chronological bias
Comparison made with patients who are similar in respect to one or two specific criteria.
Prone to allocation bias
Control group treated at the same time as the study group. Prone to allocation bias
Asks what makes a group of individuals different with respect to treatment received or
environmental factors. Retrospective and look back in time
Identify factors that have a significant influence on the outcome of interest
Assess whether one intervention is better than another, a placebo or no treatment.
PROSPECTIVE and controlled. Allocation to test/control groups is predetermined
Allocation to patient/quadrant/tooth according to a sequence generated from a table of
random numbers or its electronic equivalent. Minimizes risk of all forms of bias
Allocation to alternate patients or according to date of birth, case note number, day of week,
side of mouth, quadrant. Prone to allocation bias
A group of patients is divided into groups. Prone to allocation bias
Summarizes information from several previously published papers on a specific topic
Based on haphazard selection of papers related to the subject of the review
Papers are identified, critically appraised and results synthesized according to a defined
protocol
Combines the results from several different clinical trials to obtain an overall estimate of the
effectiveness of a particular intervention
Cross-sectional
Longitudinal
COHORT STUDY
Uncontrolled
Case Report
Controlled
Case Series
Literature
Historical
Matched
Concurrent
CASE CONTROL STUDY
Multi-variant methods
CLINICAL TRIAL
Random
Quasi-random
Haphazard
REVIEW ARTICLE
Narrative review
Systematic review
Meta-analysis
Table 3: Classification of evidence by AHRQ*
LEVEL
1
2
3
4
5
CLASSIFICATION
Large randomized trials with clear-cut results
(low risk of error)
Small, randomized trials with uncertain results
(moderate to high risk of error)
Nonrandomized, contemporaneous controls
Nonrandomized, historical controls and expert opinion
Uncontrolled studies, case series, and expert opinion
*Agency for Healthcare Research and Quality, US Department of
Health and Human Service
Color scheme of 3 tiers as in tables 1 and 2
subjectivity and bias (particularly the bias of clinicians
that their efforts are beneficial); statistical power;
relevance (patients investigated typical of subjects in
clinical practice); and feasibility (investigated
procedure reasonably applied in known clinical
settings).
The quality of each study is assessed for strengths
Journal of the Lebanese Dental Association
Table 4: Strength of recommendation on treatment
based on level of available evidence**
LEVEL
I
IIa
IIb
III
STRENGTH OF RECOMMENDATION
Always acceptable and considered useful and effective
Usually indicated
Acceptable, of uncertain efficacy and may be controversial.
Weight of evidence in favor of usefulness/efficacy
Acceptable, of uncertain efficacy and may be controversial.
May be helpful, not likely harmful
Not acceptable, of uncertain efficacy and may be harmful
*** Source: Agency for Healthcare Research and Quality, US Department of
Health and Human Service
and weaknesses using recognized techniques of
critical appraisal. Publications at all levels may be
deficient. Even at the highest level of evidence, if
performed on clinical trials with faulty designs, a
meta-analysis may provide a weaker evidence than a
lower-level but strictly designed trial. Nevertheless,
contemporary clinical practice is increasingly equated
21
Ghafari JG, Souccar NM, Saadeh ME
22
1980
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1999
2000
2001
2002
2003
2004
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Fig. 1: Meta-analyses in medical, dental and nursing
journals (Source: Pubmed, limited to publications of human
studies in English)
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Resources
Medline and the Cochrane Collaboration are the
most commonly searched databases in the English
language, which is used in the vast majority of the top
rated scientific journals. Medline is the standard
English-language database for biomedical information
and is accessed through several gateways such as
PubMed and Embase. The Cochrane collaboration is
one of the most credible organisms for evidence-based
medicine. Its reviews are acknowledged for reflecting
a scrutiny of the highest levels of evidence. A
systematic review in the Cochrane Database of
Systematic Review (available on the Cochrane Library
website and considered as a benchmark for evaluation)
is first appraised in a “protocol” that rises to the level
of a “publication” when specific guidelines are met.
In addition, various specialty groups have
developed their own databases and reviews of
evidence to facilitate evaluation of the literature on
pertinent clinical issues. The Oral Health Group
(OHG) produces systematic reviews of all randomized
controlled trials in different oral health topics
including the prevention, treatment and rehabilitation
of oral, dental and craniofacial diseases and disorders.
Other sources include Internet data sites such as The
Centre for Evidence-Based Dentistry, an Oxford-based
reference source for training in EBP, and Bandolier, a
synthesis of bullet-point headings from primary health
journals using evidence-based methods. The US
Department of Health and Human Service’s Agency
for
Health-care
Research
and
Quality
(http://www.ahrq.gov) allows researchers and
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2200
2100
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with evidence-based practice. To gauge this trend, we
conducted a Pubmed search limited to journals
published in English and to meta-analysis type of
articles in humans. By the end of 2007, these articles
in all areas of medicine have increased by nearly 8
folds since 1990 (Fig. 1). Of a total 344 articles
published in dental journals over the same time period,
68% were published after 2001, representing a surge
that peaked in 2003 with 48 articles (Fig. 2). The
highest number of published meta-analyses was in
dental public health and periodontics, followed at
nearly half the rate by oral and maxillofacial
pathology, orthodontics, and prosthodontics (Fig. 3).
Fig. 2: Meta-analyses in dental journals (Source: Pubmed,
limited to publications of human studies in English)
Fig. 3: Distribution of meta-analyses published in dental
journals among the different dental specialties.
DPH: dental public health; Perio: periodontics; Patho: oral
and maxillofacial pathology; Ortho: orthodontics; Prostho:
prosthodontics; Resto: restorative dentistry; Implant:
implantology; Multi: multidisciplinary (general denstistry);
Surg: oral/maxillofacial surgery; Ped: pediatric dentistry;
TMJ: temporomandibular joint disorders; Endo:
endodontics; Radio: oral and maxillofacial radiology.
Volume 45 - Nº 1 - 2008
Ghafari JG, Souccar NM, Saadeh ME
clinicians to search for evidence about a great number
of health conditions, providing links to studies,
summary statements and funding opportunities. The
expansion of the evidence-based culture led to the
development of dedicated journals (Journal of
Evidence Dental Practice, Evidence Based Dentistry)
and a focused society (International Society of
Evidence Based Dentistry) that serve the needs of
research and practice in evidence-based dentistry.
molars (incisors, canines and premolars) (Fig. 4)23.
This finding was gathered in a nonrandomized study,
but the evidence is strong and a higher level of
evidence does not appear necessary. Loss of the E not
only indicates the potential for arch length decrease
from the mesial shift of the permanent first molars but
also modification in molar occlusion consequent to the
shift, or if the space is maintained, to the inhibition of
this shift (Fig. 5)21.
EVIDENCE-BASED PRACTICE IN TIMING
EARLY ORTHODONTIC TREATMENT
The debate on this issue can be traced back to the
early 20th century when Edward H. Angle20 advocated
early treatment, “as near the beginning of the variation
from the normal in the process of the development of
the dental apparatus as possible”, opposing the
argument of the “old school that this is a most
unpromising age for treatment,” mostly because of
cooperation. With the benefit of studies rated at the
highest levels of evidence, including a number of
randomized clinical trials and systematic reviews,
more refined conclusions can be made at present. The
controversy has shifted away from waiting to treat in
the permanent dentition because the benefits of earlier
treatment have been documented. They include taking
advantage of opportunities that normal growth
provides at specific times during the patient’s
development, most notably the time of loss of the
primary second molar and the adolescent growth spurt
as the key events in dental and skeletal development,
respectively. Practical implications of these critical
growth considerations find support from studies at the
various scales of the evidence tree.
Emerging general trend: treat in late childhood
1- Space management
The primary second molar (E) contributes the most
to the leeway space, which is the differential space
between the widths of the primary molars and the
narrower succedaneous premolars. Loss of the E (at
the dental age of 10.5-11.5 years) could be the most
important missed opportunity regarding dental
development21,22. If the E space is entirely preserved,
nearly 70% of mandibular arches have enough space
for alignment of all permanent teeth mesial to the first
Journal of the Lebanese Dental Association
A
B
C
D
Fig. 4: A- Space analysis projected sufficient space for
alignment of crowded mandibular incisors if leeway
space was maintained.
B- Loss of the primary second molars led to mesial
drift of the permanent first molars and uncorrected
crowding.
C- Placement of a lower lingual holding arch
maintains the larger space of the second primary
molars (D).
2- Treatment of occlusal problems
Modalities are employed that presume to affect or
profit from growth mostly when discrepancies
between the jaws, such as mandibular or maxillary
prognathism or retrognathism, underlay severe Class II
or Class III malocclusions. The orthodontist tries to
benefit from the adolescent growth spurt to maximize
the skeletal response (e.g. favoring mandibular growth
in a Class II malocclusion) or anticipates the spurt to
minimize its effect (e.g. favoring maxillary growth or
mandibular rotation to counteract additional
mandibular growth in a Class III malocclusion). The
complexity of the issue, including the variables of
treatment modality, timing, and growth contribution
over sustained periods of time, renders the randomized
23
Ghafari JG, Souccar NM, Saadeh ME
A
6
6
E
E
B
6
6
E
E
C
6
6
E
E
E
Fig. 5: In the average occlusion during the early mixed
dentition, the primary teeth are in Class 1, but the
permanent first molars may be in mesial step (A),
commonly referred to as “short” Class I occlusion with
mandibular molar ahead of maxillary molar but not in ideal
interdigitation, or in an end to end relation. The reason for
these possibilities is the wider mandibular primary second
molar -E- relative to the maxillary E. Although these teeth
meet in neutroclusion at their mesial aspects, the
mandibular E extends farther posteriorly to line up with the
distal surface of the maxillary E in a straight or “flush”
terminal plane.
B-D- Consequences of saving the E space with a space
maintainer (lingual holding arch) on the occlusion between
maxillary and mandibular permanent first molars. When the
latter are in Class II (B), the maxillary first molars would
need to be moved distally in Class I. If not, and absent
adequate differential growth between the jaws whereby
mandibular growth would exceed maxillary growth and
carry the entire mandibular arch forward, a distoclusion
would persist. If the first molars are in end-on relationship
(C), the maxillary molars may require distal movement. In
all instances, and even when the permanent molars are in
Class I (D), saving the mandibular E space would require
maintenance of the maxillary E space to achieve or preserve
neutroclusion. E- Loss of the maxillary E disturbed the
molar occlusion with a mesial drift of the first permanent
molar.
24
D
clinical trial the best suited to answer specific
questions on modality and timing of treatment.
Randomization eliminates known and even
unaccounted for variables. Evidence from a
randomized trial of Class II malocclusion,24-26 also
supported by studies and reports at a lower level,27,28
demonstrated that treatment in the late mixed dentition
can be as effective as that in the early or mid-mixed
dentition21,24,25. The findings favor intervention in the
late mixed dentition for an early start of a “one-stage
treatment” with two consecutive phases.
The initial phase would take advantage of the
above-mentioned leeway space and concurrent
growth, and the second phase continues when all
remaining permanent teeth emerge, without an
interruption between phases 1 and 2. This continuous
one-stage approach reduces the length of time a child
is seen by the orthodontist, is more cost effective,
avoids the need for a retention period between phases
1 and 2, and may avoid the extraction of permanent
teeth
(usually
premolars)
to
correct
the
malocclusion21,28,29. Treatment with two distinct stages
does not guarantee a shorter second phase or better
long term results30,31.
Therefore, the optimal treatment time would be in
the late mixed dentition, or the early permanent
dentition if preservation of the leeway space is not
needed. Treatment in the late mixed dentition, closer to
the time of onset of the adolescent growth, particularly
in girls, would combine the advantages of dental and
skeletal growth (when needed) within a period of 2
years, the average orthodontic treatment time. This
practicality does not apply (on average) to boys
because of the longer intermediate span between the
loss of the E’s and onset of growth spurt21,22.
Earlier intervention
Excluding the required early orthodontic stages in
craniofacial anomalies (e.g. cleft lip/palate32), a
number of occlusal and developmental conditions
would warrant intervention in early-mid mixed
dentition (or possibly the primary dentition)21,22,25. As
also recommended, with some variation, by the
American Association of Orthodontists33, the
conditions include:
a- Removal of primary etiological factors such as
Volume 45 - Nº 1 - 2008
Ghafari JG, Souccar NM, Saadeh ME
habits, or mechanical obstructions (e.g. enlarged
adenoids and/or tonsils), whenever possible.
b- Correction of skeletal dysplasia and occlusal
deviations such as unilateral and bilateral
posterior
crossbites,
anterior
crossbite
(particularly related to Class III malocclusion).
c- Space management, preserving the integrity of
the dental arch through maintenance of the
leeway space or interception of developmental
problems (e.g. ectopic eruption of permanent
teeth)34,35.
d- Risk of trauma to maxillary incisors because of a
severe overjet36.
e- Malocclusions associated with psychological
conditions36,37 such as severe anterior crossbite or
overjet.
The above strategies are not all supported with
definitive evidence, but based on statistics available
for American children on incidence of malocclusion in
the mixed dentition prior to age 11 years38-40, and
excluding crowding and deep overbite, nearly one
third of these children would need early intervention.
The statistics combine early and late mixed dentition
periods prior to age 11 years. Thus, the working
hypothesis of intervention in the late mixed dentition
would apply in the majority (nearly two thirds) of
children between 6 or 8 years and 11 years.
These conclusions indicate that early orthodontic
treatment should not be overdone, but also that growth
opportunities should not be missed36. The premise that
orthodontic treatment should be left until all
permanent teeth have erupted has been proven false by
available high-ranking evidence.
EVIDENCE-BASED PRACTICE IN
IMMEDIATE LOADING OF OSSEOINTEGRATED IMPLANTS
Immediate restoration following the placement of
oral osseointegrated implants is the ideal approach for
partially or totally edentulous patients. Beside the
avoidance of a long healing period, a more important
advantage is foregoing provisional removable
prosthesis that sometimes impairs function and
negatively affects esthetics (mostly anteriorly)41,42. At
issue is the effect of immediate functional loading on
the stability of the implant.
Journal of the Lebanese Dental Association
Definitions
Standardized definitions43 differentiate between an
“immediate restoration”, inserted within 48 hours of
implant placement but not in occlusion with opposing
teeth, and “immediate loading”, when the restoration,
also placed within 48 hours, is in occlusion. On the
other hand, loading is “conventional” when the
prosthesis is attached in a second procedure after a
healing period of 3-6 months, “delayed” if affixed
some time later than 3-6 months, and “early” if an
occluding restoration is placed at least 48 hours but no
later than 3 months after implant placement.
Indications for immediate loading/restoration
Criteria that must be considered for successful
immediate loading concern: the inserted implants
(number, distribution, length, diameter, and
macroscopic stabilizing characteristics); constitutional
components (patient bone quality and density); the
implant surgery (precision of surgical technique); and
the quality of the restoration (stiffness of the
reconstruction and occlusal force application through
function and parafunction)44. Primary stability of the
implant is probably the most important condition45.
Most publications have targeted the edentulous
mandible to test immediate implantation/restoration,
as bone quality is usually best between the mental
foramina45-48. In a literature review, Castellon et al46
concluded that the mandible appears to be a safe site
for immediate loading of implants and that limited
evidence for the edentulous maxilla and the partially
edentulous patient are available.
Conditions for success include a healthy site of
implantation and the implant’s design49,50, i.e. shape
and surface. To increase primary stability, some
authors advocated implant splinting as stress levels in
the surrounding bone is decreased. Bergkvist et al51
determined through a finite element analysis that stress
distribution in bone surrounding splinted implants was
lower by a factor of nearly 9 compared to uncoupled
implants. Another concern pertains to loading time and
osseointegration. A recent study by Vandamme et al52
in an in vitro model suggests that well-controlled early
loading would actually accelerate tissue mineralization
at the interface. However, Susarla et al53 report a 2.7
higher risk of failure with immediately loaded
25
Ghafari JG, Souccar NM, Saadeh ME
implants when compared to the delayed protocol.
A systematic review published in the Cochrane
library aimed at evaluating success, function,
complications and patient satisfaction between
different implant loading procedures54. The
conclusions indicate that immediate loading could be a
successful alternative for both clinicians and patients.
However, the data were derived from only two
randomized clinical trials with a relatively short
follow-up period. Although initial trends are supported
by present evidence, immediate implant loading
remains largely based on the practitioner’s clinical
experience. More focused and controlled research
should help understand the healing process and the
optimal loading time, to establish scientific bases for
the various surgical/prosthetic procedures and
corresponding individual applications.
CONTROVERSIES
Viewpoints and reasons
The advent of EBP concepts has generated
opposing views, ranging from negating the value of
any treatment without high evidence to attacking the
evidence ladder as “dangerous innovation”, even
caricaturing meta-analysis as “shmeta-analysis”55.
Most clinicians accept the tenet of research to buttress
their treatment. Yet, clinicians whose experience
supports the success of specific treatment regimens
question the practicality of “evidence” provided by the
upper tier of the scientific hierarchy when it does not
support “their way” of practice6,7,9. In the orthodontic
literature, several specific issues of modality and
timing of treatment have been cited6. One example
relates to the effect of extraction (of premolars) on
facial esthetics in patients whose malocclusion
combines crowding and protrusion of maxillary teeth.
The evidence indicates a higher probability of
improving the profile than with non extraction, and
that more than 50% of adolescents require profile
reduction. However, non extraction approaches are
prevalent in 70% of all orthodontic treatments23.
Duration and type of evidence-gathering, as well as
the unpredictability of patient cooperation and growth,
confound the success of orthodontic and other longterm clinical studies, particularly if prospective.
Several reasons may be listed why the evidence is
26
often neglected in practice, even by proponents of
evidence-based dentistry. We discuss only three of
them that apply to orthodontics and all other dental
specialties:
1- Individual variation. Variations are ill-defined
around the means determined in research. Individual
responses can outlie prevailing average trends.
Patients may opt for or certain conditions may be more
amenable to compromised alternative treatment rather
than the well-supported comprehensive option. In
addition, sources of variation are not defined
completely, particularly constitutional limitations
(specific deviant morphology such as a deficient chin
that maintains the convexity of the face despite
occlusal correction, Fig. 6)56.
2- Potential and limitations of research. The
potential exists for present evidence to be different in
future research that is more appropriately conducted,
particularly with the improvement in research tools.
New evidence on the effect of airway blockage on
facial morphology revealed that the compensatory
dysmorphology starts setting as early as 2 or 3 years of
age57, favoring removal of the hypertrophic lymphoid
tissues to clear the air pathway earlier than now
practiced.
Ioannidis58 determined that highly cited (>1000
times) research of clinical interventions and their
outcomes are later contradicted (16%) or have stronger
effects (16%) than subsequent studies of comparable
or larger sample size and similar or better controlled
designs. Controversies are most common with highly
cited nonrandomized studies, but even the most highly
A
B
C
D
Fig. 6: Correction of a Class II occlusion (A) to Class I (B)
with a headgear. Despite the correction, the initially
malformed chin (C) remained deficient after treatment (D).
Volume 45 - Nº 1 - 2008
Ghafari JG, Souccar NM, Saadeh ME
cited randomized trials may be challenged and refuted
over time, especially small ones. Issues of bias and
heterogeneity between original studies are
incriminated for such differences59.
Although recognized as the golden standard in
research, the RCT is limited on ethical grounds to
compare certain irreversible treatment strategies
(extraction vs. non extraction, orthognathic surgery vs.
orthodontic treatment). On the other hand, lower level
evidence is appropriate to answer certain questions
(e.g. loss of E space), foregoing the need for RCTs.
3- Technological developments may shift
treatment paradigms in directions that make recent
research questions benign or even obsolete. Temporary
implanted anchorage (mini-screws or plates) have
resolved issues of anchorage earlier requiring different
mechanical set-ups and patient compliance. Tissue
engineering’s impact on periodontics and orthodontics
reflects on treatment goals and modalities, as well as
mechanotherapy.
Realistic outlook
A resolution of the controversy must be based in the
common goal of providing justified treatment to
individual patients. A priori rejection or blind
adherence to the evidence ladder is not a sound
approach. While the randomized trial is highly rated,
encountered difficulties, such as high cost and ethical
consideration related to randomization and the
treatment endpoints, preclude the RCT from being a
common model in dentistry and orthodontics60. The
ethical limitation is commonly illustrated by the
prospect of randomizing the provision of parachutes to
people about to jump from airplanes61. On the other
hand, reliance on retrospective studies of only
successfully treated patients with or without
nontreated comparable cohorts often contain bias of
various types (e.g. patient selection, choice of
treatment modality)60. Problems detected in the
execution of meta-analyses and in the interpretation
and clinical application of results have further
sharpened controversies58. Therefore, in systematic
reviews, the inclusion of appropriate studies is the
ultimate discerning task. Reviews may not be based on
RCT’s if they are sparse or of low value; yet,
methodological
quality
of
nonrandomized
Journal of the Lebanese Dental Association
investigations may warrant inclusion in such reviews.
Facing two opposing “camps”, the skeptical
unwilling to accept the primacy of systematic research
and review, and the enthusiastic lacking prudence to
discern the substance from the process, Huang62
cautions against accepting any systematic review and
meta-analysis as valid, stressing the responsibility of
every clinician to understand the hierarchy of
evidence, the principles of rigorous research, and the
proper conduct of systematic review. He sums up the
charge of the health care provider to be “informed
consumers” of scientific information. The basic goal
must be to factor out bias in research and systematic
reviews.
CONCLUSION
Evidence-based practice involves searching the
literature on a specific topic, assessing its validity then
using the scrutinized evidence to make decisions
concerning a particular patient’s treatment. The
clinician’s responsibility is to adhere to the scientific
basis of treatment, weigh the evidence for more
“effective, efficient, stable and predictable treatment”4,
and interpret the evidence for a favorable application
in the individual patient.
27
Ghafari JG, Souccar NM, Saadeh ME
REFERENCES
1. Proffit W. The evolution of orthodontics to a data-based
specialty. Am J Orthod Dentofacial Orthop 2000;117:545-7.
2. Sackett D, Haynes R, Guyatt G, Tugwell P. Clinical
epidemiology: A basic science for clinical medicine (2nd ed.).
Boston: Little, Brown. 1991.
3. Sackett D, Rosenberg W, Gray J, Haynes R. Evidence-based
medicine: what it is and what it isn’t. Br Med J 1996; 312:71-2.
4. Huang G. Making the case for evidence-based orthodontics, Am
J Orthod Dentofacial Orthop 2004; 125:105-6.
5. Huang G. Bigfoot Lives? Am J Orthod Dentofacial Orthop
2006; 129:323-4
6. Gianelly A. Evidence-based therapy: An orthodontic dilemma.
Am J Orthod Dentofacial Orthop 2006; 129:596-8.
7. Ackerman J, Kean M, Ackerman M, Evidence-bolstered
orthodontics. Austr Orthod J 2006; 22:69-70.
18. Helfand M, Thompson D, Davis R, McPhillips H, Lieu T,
Homer C (2001, October). Newborn hearing screening: a
summary of the evidence for the U. S. Preventive Services Task
Force. Rockville, MD: Agency for Healthcare Research and
Quality. Accessed at http:// www.ahcpr.gov/clinic/3rduspstf/
newbornsum1.htm.
19. Oxford
Centre
for
Evidence-based
http://cebm.jr2.ox.ac.uk/docs/levels.
Medicine;
20. Angle E. Treatment- preliminary considerations. In:
Malocclusion of the Teeth, EH Angle (editor). 7th edition.
Philadelphia: The S.S. White Dental Manufacturing Co. 1907;
309-13.
21. Ghafari J. Timing the early treatment of Class II, Division 1
Malocclusion: Clinical and research considerations. Clin
Orthod Res 1998;1:118-29.
22. Ghafari J. The role of developmental and occlusal conditions in
timing orthodontic treatment. Alpha Omegan 1999; 92:28-35.
8. Sutherland S. Evidence-based dentistry: Part IV. Research design
and levels of evidence. J Can Dent Assoc 2001; 67:375-8.
23. Brennan M, Gianelly A. The use of the lingual arch in the
mixed dentition to resolve incisor crowding. Am J Orthod
Dentofacial Orthop 2000;117:81-5.
9. Darendeliler M. Validity of randomized clinical trials in
evaluating the outcome of Class II treatment. Semin Orthod
2006; 12:69-79.
24. Ghafari J, Shofer F, Laster L, Markowitz D, Shofer F, Silverton
S, Katz S. Monitoring growth during orthodontic treatment.
Semin Orthod 1995; 1:165-75.
10. American Speech-Language Hearing Association. Evidencebased practice in communication disorders: An introduction
(Technical report). 2004:1-7. Available at: http://www.asha.org
25. Ghafari J, Shofer F, Jacobsson-Hunt U, Markowitz D, Laster L.
Headgear versus function regulator in the early treatment of
Class II, Division 1 malocclusion. Am J Orthod Dentofacial
Orthop 1998; 113:51-61.
11. Ballini A, Capodiferro S, Toia M, Cantore S, Favia G, De
Frenza G, Grassi FR. Evidence-based dentistry: What’s new?
Int J Med Sci 2007; 4:174-8.
12. American Dental Association policy statement on evidencebased dentistry. Available at: www.ada.org/prof/resources/
positions/statements/evidencebased.asp”. Accessed Feb 08,
2007.
13. Woolf S, Battista R, Anderson G, Logan A, Wang E. Assessing
the clinical effectiveness of preventive maneuvers: analytic
principles and systematic methods in reviewing evidence and
developing clinical practice recommendations. A report by the
Canadian Task Force on the Periodic Health Examination. J
Clin Epidemiol 1990; 43:891-905.
14. Oxman A, Sackett D, Guyatt G. Users’ guide to medical
literature: I. How to get started? J Am Med Assoc 1993; 270:
2093-5.
15. Greenhaulgh T. How to read a paper: The basis for evidencebased medicine. British Medical Group Publishing London,
1997.
16. Harrison J. Evidence-based Orthodontics-How do I assess the
evidence? Brit J Orthod 2000;27:189-197.
17. Flores-Mir C, Major M, Major P. Search and selection
methodology of systematic reviews in orthodontics (20002004). Am J Orthod Dentofacial Orthop 2006;130:213-7.
28
26. Efstratiadis S, Baumrind S, Shofer F, Jacobsson-Hunt U, Laster
L, Ghafari J. Evaluation of Class II treatment by cephalometric
regional superimpositions versus conventional measurements.
Am J Orthod Dentofacial Orthop 2005; 128: 607-18.
27. Livieratos F, Johnston L Jr. A comparison of one-stage and
two-stage nonextraction alternatives in matched Class II
samples. Am J Orthod Dentofacial Orthop 1995;108:118-31.
28. Gianelly A. One-phase versus two-phase treatment. Am J
Orthod Dentofacial Orthop 1995; 108:556-9.
29. Proffit W. The timing of early treatment: An overview. Am J
Orthod Dentofacial Orthop 2006;129:S47-9.
30. Tulloch J, Proffit W, Phillips C. Influences on outcome of early
treatment for Class II malocclusion. Am J Orthod Dentofacial
Orthop 1997;11: 533-42.
31. Tulloch C, Proffit W, Phillips C. Outcomes in a 2-phase
randomized clinical trial of early Class II treatment. Am J
Orthod Dentofacial Orthop 2004;125:657-67.
32. Haddad R, Abou Chebel N, Ghafari J. Sequencing cleft lip and
palate treatment. J Lebanese Dent Assoc 2006; 43:9-20.
33. American Association of Orthodontists, Early check-up
information. Recommendation For Early Orthodontic CheckUp. http://www.braces.org, [Accessed 2008].
Volume 45 - Nº 1 - 2008
Ghafari JG, Souccar NM, Saadeh ME
34. Ghafari J. Early treatment of dental arch problems. I. Space
maintenance, space gaining. Quintessence Int 1986; 17:423-32.
49. Misch C. Implant design considerations for the posterior
regions of the mouth. Implant Dentistry 1999;8:376-86.
35. Ghafari J. Early treatment of dental arch problems: II.
Guidance in alignment and occlusion. Quintessence Int
1986;17:489-95.
50. Batenburg R, Meijer H, Raghoebar G, Van Oort R, Boering G.
Mandibular overdentures supported by two Branemark, IMZ or
ITI implants. A prospective comparative preliminary study:
one-year results. Clin Oral Impl Res 1998;9:374-83.
36. Ghafari J. Early Treatment in Orthodontics. Progress in
Orthodontics 2007;8:174-190.
37. Tung A, Kiyak A. Psychological influences on the timing of
orthodontic treatment. Am J Orthod Dentofacial Orthop
1998;113:29-39.
38. Kelly J, Sanchex M, Van Kirk L. An assessment of the
occlusion of the teeth of children 6-11 years. Washington, DC:
National Center for Health Statistics, Public Health Service,
USDHEW publication no. (HRA) 74-1612 (Vital and Health
Statistics; series 11, no. 130); 1973.
39. Brunelle J, Bhat M, Lipton J. Prevalence and distribution of
selected occlusal characteristics in the US population, 19881991. J Dent Res 1996;75:706-13.
40. Proffit W, Fields H Jr, Moray L. Prevalence of malocclusion
and orthodontic treatment need in the United States: estimates
from the NHANES III survey. Int J Adult Orthod Orthognath
Surg 1998;13:97-106.
41. Lekholm U. Immediate/early loading of oral implants in
compromised patients. Periodontology 2000,2003;33:194-203.
42. Kinsel R, Lamb R. Development of gingival esthetics in the
edentulous patient with immediately loaded, singlestage,
implant-supported fixed prostheses: a clinical report. Int J Oral
Maxillofac Implants 2000;15:711-21.
43. Aparicio C, Rangert B, Seennerby L. Immediate/early loading
of dental implants: A report from the Sociedad Espanola de
implantes World Congress consensus meeting in Barcelona,
Spain 2002. Clin Implant Dent Relat Res 2003;5:57-60.
51. Bergkvist G, Simonsson K, Rydberg K, Johansson F, Dérand T,
A finite element analysis of stress distribution in bone tissue
surrounding uncoupled or splinted dental implants, Clin
Implant Dent Relat Res 2008;10:40-6.
52. Vandamme K, Naert I, Geris L, Vander Sloten J, Puers R,
Duyck J. Influence of controlled immediate loading and
implant design on peri-implant bone formation. J Clin
Periodontol 2007;34:172-81.
53. Susarla S, Chuang S, Dodson T. Delayed versus immediate
loading of implants: survival analysis and risk factors for
dental implant failure. J Oral Maxillofac Surg 2008;66: 251-5.
54. Esposito M, Koukoulopoulou A, Coulthard P, Worthington H.
Interventions for replacing missing teeth: dental implants in
fresh extraction sockets (immediate, immediate-delayed and
delayed implants). Cochrane Database of Systematic Reviews
2006, Issue 4. Art. No.:CD005968.DOI:10.1002/14651858.
CD005968. pub2.
55. Shapiro S. Meta-analysis/shmeta-analysis. Am J Epidemiol
1994;140:771-8.
56. Ghafari J, Baumrind S, Macari A, Shofer F, Markowitz D,
Ashmore J, Ramsay D, Laster L, Efstratiadis S. Profile
characteristics related to the anatomy of the chin in a Class II
treatment population J Dental Res 2003;82:3020 (abstract).
57. Macari A, Ghafari J. Effect of compromised nasal breathing on
craniofacial development. J Lebanese Dent Assoc 2006; 43:2936.
44. Ganeles J, Rosenberg M, Holt R, Reichman L. Immediate
loading of implants with fixed restorations in the completely
edentulous mandible: report of 27 patients from a private
practice. Int J Oral Maxillofac Implants 2002;16: 418-26.
58. Ioannidis J. Contradicted and initially stronger effects in highly
cited clinical research. J Am Med Assoc 2005;294:218-28.
45. Hall J, Miranda-Burgos P, Sennerby L. Stimulation of directed
bone growth at oxidized titanium implants by macroscopic
grooves: an in vivo study. Clinical Implant Dentistry and
Related Research 2005;7:S76-82.
60. Flores-Mir C. Can we extract useful and scientifically sound
information from retrospective nonrandomized trials to be
applied in orthodontic evidence-based practice treatments? Am
J Orthod Dentofacial Orthop 2007; 131:707-8.
46. Castellon P, Blatz M, Block M, Finger I, Rogers B. Immediate
loading of dental implants in the edentulous mandible. J Am
Dent Assoc 2004;135:1543-9.
61. Vig K. Commentary. Am J Orthod Dentofacial Orthop 2007;
131:708-9.
47. Schnitman P, Wohrle P, Rubenstein J, DaSilva J, Wand N. Tenyear results for Branemark implants immediately loaded with
fixed prostheses at implant placement. Int J Oral Maxillofac
Implants 1997;12:495-503.
48. Randow K, Ericsson I, Nilner K, Petersson A, Glantz PO.
Immediate functional loading of Branemark dental implants.
An 18-month clinical follow-up study. Clin Oral Implant Res
1999;10:8-15.
Journal of the Lebanese Dental Association
59. Rasmussen L, Dahl J. Meta-analysis: a valuable but easily
misused tool. Acta Anaesthesiol Scand 2001;45:657-8.
62. Huang G. Things that make me nervous. Am J Orthod
Dentofacial Orthop 2007; 131:579-80.
Correspond with:
Joseph Ghafari
[email protected]
29
Oral and Maxillofacial Medicine
Dental management of patients under clopidogrel (Plavix®)
treatment: realities and current recommendations.
Rima Abou Tayeh1, DCD, DU Chir.Bucc., Elie Sidnaoui2, BDS, CES Odont.Chir.2, Waêl Khalil3, DCD, DU Chir.Bucc.,
DU Pathol. Orale, Ziad Noujeim4, Dr. Chir. Dent., CES Odont. Chir., Dipl. Oral Med., DU Cell. Therapy, FICD,
FACOMS, FIAOMS.
INTRODUCTION
Cardio-vascular diseases currently represent the
primary cause of mortality and morbidity, worldwide1-2.
Much progress has been made recently in the
management of acute coronary syndromes, heart
failure, and other kinds of cardiac and vascular
accidents, with anticoagulants (antivitamine K and
antiplatelet drugs).
Antivitamine K (AVK) drugs are frequently
prescribed in curative or preventive treatment of
arterial or venous thromboembolic accidents. The
major complication of this kind of medicines is
haemorrhage, consequently, before any oral or
periodontal surgical procedure, dental practitioners
have to figure out how and when to prevent any
possible per-operative or post-operative bleeding by
discontinuing (on a temporary basis) AVK-with or
without shifting to heparin-, or pursuing the same
medicine (AVK) – with or without decreasing its
posology (dosage) as determined by the treating
medical doctor.
Regarding AVK treatment, any modification of
treatment (interruption or dosage decrease) may
threaten patients and make them an easy target for
increased thromboembolic risk (Balderston, 2003 –
Yoshimura et al.; 1987) and no major consequence
(including death) has been noticed in case of postoperative bleeding occurring in oral surgical patients
whose AVK regimes were not modified52.
Department of Oral & Maxillo-Facial Surgery,
Lebanese University School of Dentistry, Beirut, Lebanon.
1 Associate Clinical Instructor,
2 Associate Chief of Clinical Services,
3 Associate Chief of Clinical Services,
4 Senior Lecturer, Department of Oral and Maxillofacial
Surgery, and Chairperson, Department of Basic Science,
Lebanese University School of Dentistry,
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
AVK include:
- Warfarin (Coumadine*)
- Acenocoumarol (Sintrom*, Minisintrom*)
- Fluindione (Previscan*).
Platelet anti-agregants (or antiplatelet drugs)
(APDs) constitute another kind of anticoagulants, they
are capable of inhibiting platelet functions, and, more
specifically, activation and aggregation of platelets.
They are prescribed in order to prevent ischemic
accidents linked to atherosclerosis.
Since platelets are a very important contributor to
arterial thrombi, antiplatelet treatment was reported to
reduce overall mortality from vascular disease by
≈15% and reduce nonfatal vascular complications by
≈30%.
APDs include:
a- Aspirin
b- Dipyridamole, and
c- Thienopyridines (which include ticlopidine and
clopidogrel)
d- Abciximab
e- Integrelin, tyrafiban, and lamifiban
Aspirin is the universal prototypical APD, it exerts
its antithrombotic action by irreversibly inhibiting
platelet cyclooxygenase (COX), impairing platelet
secretion and aggregation, and preventing synthesis of
thromboxane A2.
Dipyridamole
increases
cyclicademosine
monophosphate, abciximab is a monoclonal antibody
(C7E3-Fab), and integrelin, tyrafiban and lamifiban
are peptide disintegrin inhibitors (platelet fibrinogen
receptor inhibitors).
Ticlopidine and Clopidogrel inhibit the fibrinogren
receptor glycoprotein IIb-IIIa (GPIIb – IIIa)
Patients undergoing APD treatment display
31
Abou Tayeh R, Sidnaoui E, Khalil W, Noujeim Z
alterations in their primary hemostasis5, which
interferes directly with nonsurgical dental treatment or
oral surgical procedures (exodontia, surgical dentistry,
periodontology, surgical implantology, or oral
surgery). Hence, two treatment modalities arise (as for
AVK): either interruption of APDs – with or without
alternative treatment – or continuation of APDs, with
absolutely no modification.
USE OF CLOPIDOGREL
Antithrombotic
and
anticoagulant
therapy
minimizes
thrombotic
complications
after
percutaneous coronary intervention (PCI)2-7. Aspirin
plus a thienopyridine (clopidogrel or ticlopidine) are
more effective than aspirin plus heparin and extended
warfarin therapy in preventing periprocedural
ischemic events6-7. Dual antiplatelet therapy with
aspirin and clopidogrel (the preferred thienopyridine
because of its superior hematologic safety) is
recommended1-2 for at least 4 weeks to prevent
subacute stent thrombosis with bare-metal stents, and
3 to 6 months to prevent late stent thrombosis with
drug-eluting stents8. Coronary atherothrombosis is a
diffuse vascular disease and reduction of the risk of
future ischemic events requires dual therapy (aspirin
and clopidogrel) for at least 12 months after PCI for
prophylaxis of future atherothrombotic events7,6.
Clopidogrel is a specific antagonist for the
recapture of adenosine diphosphate (ADP). This
molecule inhibits platelet activation induced by ADP9.
As for aspirin, inhibition of platelet aggregation is not
complete and its action is equally irreversible.
Standard posology of Plavix® is 75 mg per day (one
tablet) for an ambulatory treatment10, to be taken orally
with or without food. A dose of 300mg/day (4 tablets)
is recommended for patients who have experienced
severe chest pain.
Clopidogrel can cause many side effects:
a- Bleeding is the most common side effect
reported, and it can manifest as bruising,
haematoma, epistaxis, hematuria, or gastrointestinal (GI) bleeding (stomach, bowels…),
rarely, in eyes, head, lungs, or joints.
b- Gastro-intestinal upset (diarrhea, abdominal pain,
constipation, nausea, vomiting, heartburn…).
c- Nervous system side effects (vertigo, headache,
32
hypotension, confusion, hallucinations…).
d- Skin disorders (itching, rashes…).
e- Arthralgia (pain in joints).
f- Fever.
g- Taste disorders.
PLATELET FUNCTION TESTS
Platelets have been understood traditionally within
the context of hemostasis and hemorrhagic disorders11.
All APDs affect clotting by inhibiting platelet
aggregation and they do so by a variety of different
mechanisms12.
Clopidogrel alone, or aspirin alone, significantly
increases bleeding time, but cilostazol (an agent
proven to increases exercise capacity and enhance
quality of life on cardiovascular patients) alone did
not. Combination of aspirin and clopidogrel had a
greater effect on increasing bleeding time than either
monotherapy, and no further bleeding time
prolongation was observed when cilostazol was added
to any aspirin/ clopidogrel regimen13.
Clopidogrel is a potent inhibitor of platelet
aggregation. Its favorable effects on preventing
thrombus formation may have deleterious effects on
hemostasis14.
Platelet function is commonly assessed using the
cutaneous bleeding time test (CBT). When platelet
function is normal, bleeding time ranges from 2 to 10
minutes15. This range varies between institutions and
depending on method of measurement used (Duke or
Ivy bleeding time)16. Bleeding times may be longer in
women than men17. However, a correlation between
bleeding time test results and the rate of surgical
bleeding complications has not been established18.
A study in 30 healthy patients found no relationship
between CBT and oral bleeding time following a
single tooth extraction15.
The arguments against use of CBT as a diagnostic
and screening examination are strong16:
• Subject age, body temperature, hormonal levels,
underlying disease, and operator techniques may
influence CBT, regardless of platelet number or
function.
• CBT does not reflect in vivo platelet function.
Other parameters, including components of
coagulation, blood viscosity, haemoglobin, and
Volume 45 - Nº 1 - 2008
Abou Tayeh R, Sidnaoui E, Khalil W, Noujeim Z
haematocrit levels, as well as local tissue and
vessel factors, all influence bleeding time.
• Abnormal CBT has been reported in various
disorders like amyloidosis, congenital heart
disease, and trisomy 21 (Down’s syndrome).
CBT should not be used to estimate hemorrhagic
risk in a patient on platelet medication19-20, also it is no
longer recommended even to monitor effects of APDs
in cardiovascular diseases14-16.
Platelet Count (PC) tests platelet phase of blood
coagulation: normal range is 140,000 to 400,000/mm3
of blood, and clinical bleeding problem will normally
occur if PC is less than 50,000/mm3.
Platelet function analyser 100 (PFA-100) tests
platelet function, and this test is normal (60-120
seconds) if adequate number of platelets of good
quality are present. And if PFA-100 is not available,
the Ivy Bleeding time (BT) is suggested to test platelet
function and vascular phase of blood coagulation, it is
considered normal if 1 to 6 minutes (BT is most
helpful in cases of congenital bleeding disorders).
International Normalized Ratio (INR)56 is a test
calculated by the formula, INR = PTR(ISI)*, the
pothrombin time (PT) ratio corresponding to patient’s
PT divided by that of reference control plasma. INR
index helps medical and dental practitioners in the
interpretation of PT with respect to other laboratories
(Steinberg and Moores, 1995 - Helft, Vacheron and
Samama, 1995 – Hirsh and Poller, 1994). The PT test
is used to measure the status of extrinsic and common
pathways of blood coagulation and reflects the ability
of blood lost from vessels in the area of injury to
coagulate: PT normal range is 11 to 15 seconds,
depending on laboratory, and goal for anticoagulation
is 16 to 20 seconds. Unfortunately, PT is imprecise and
variable and little comparability of PT values taken in
different laboratories is seen (these differences are
caused by the source of thromboplastin: human brain,
rabbit brain…- the brand of thromboplastin - and the
type of instrumentation used). INR system is now
internationally accepted and its normal value is 1.01.3, and most anticoagulated patients are held at a PT
ratio of about 1.5 to 2 times normal or an INR of about
*ISI= international sensitivity index = establishes the reference
standard of 1.0 to human brain – derived thromboplastin (ISI>1
=> a less sensitive thromboplastin, and ISI<1 => a more sensitive
thromboplastin)
Journal of the Lebanese Dental Association
2.0 to 3.0 (INR > 3.0 requires to consult the patient’s
physician).
Discontinuation of APDs before oral surgical
procedures:
Aspirin and clopidogrel irreversibly inhibit platelet
aggregation within one hour of ingestion and this lasts
for the life of platelets (7-10 days)12,21. The effect is
only overcome by the manufacture of new platelets 22
and there is no known antidote. The only way to
overcome antiplatelet effect of clopidogrel is with
platelet transfusion23. Despite the common practice of
clopidogrel loading for coronary stenting, time
dependence and degree of platelet inhibition after this
therapy are not yet well defined24. A point of care assay
can identify subjects who may recover platelet
function before five days after discontinuation or, in
contrast, have persistent platelet inhibition despite
discontinuation25. An interruption of APD treatment
five days before surgery seems enough, and since 1/ 10
of the pool of circulating platelets is renewed each day,
this period of five days enables renewal of 50% of
circulating platelets, which is sufficient to ensure a
correct functional primary hemostasis26.
Unfortunately, this procedure does not guarantee an
optimal security against a thromboembolic risk.
In a recent study, depicting the danger of
thrombosis of coronary stent after clopidogrel
discontinuation, a drug-eluting stent was implanted in
4 patients, a man aged 67 and a woman aged 42 with
acute myocardial infarction, a woman aged 41 with
unstable angina pectoris and a man aged 41 with stable
angina pectoris. All suffered coronary stent thrombosis
after discontinuation of clopidogrel therapy. Reasons
for discontinuation included allergic reaction, a dental
procedure and other. Stent thrombosis after drugeluting stent implantation usually occurs within 1-4
weeks following discontinuation of APD27.
In a retrospective analysis of 475 patients admitted
to hospital with a myocardial infarction, 11 (2,3 %)
had discontinued APD within 15 days prior to
admission; 9 patients discontinued APD prior to
planned surgical procedures, one of which was dental.
The dental patient sustained a myocardial infarction 10
days after stopping APD28.
Discontinuation of APD therapy even years after
implantation of a drug-eluting coronary stent,
33
Abou Tayeh R, Sidnaoui E, Khalil W, Noujeim Z
increases the risk of a late stent thrombosis. This
should be taken into account, especially before any
procedure, even with a low bleeding risk such as single
tooth extraction.
Antiplatelet treatment should be continued, even if
there is an increased risk of minor bleeding
complications, in order to avoid life threatening
complications such as acute myocardial infarction29.
Discontinuation of APD and substitutive treatment:
Should alternative therapies be recommended
during withdrawal of oral antiplatelet therapy? This is
a critical and controversial question, especially for
patients with high risk of recurrent thrombotic events,
facing situations with a high risk of bleeding . The aim
is to continue APD treatment to a time very close to
dental procedure and to minimize thromboembolic
risk, at the same time privilege bleeding control related
to actual dental procedure.
A variety of non-selective NSAIDs* can inhibit
Thromboxane A2-dependent platelet activation
through competitive reversible inhibition of COX1**
activity by 70-90%9. NSAIDs other than aspirin (e.g.
ibuprofen, diclofenac) also have antiplatelet activity
and may increase bleeding time. However, this rarely
exceeds normal limits. Even major surgery is not
usually complicated by taking NSAIDs and they
should not be discontinued prior to dental surgical
procedures11. NSAIDs with a short half-life or a low
molecular
weight
heparin
(LMWH)
could
theoretically be prescribed in order to replace aspirin
or clopidogrel. Only flurbiprofen has the market
authorization for this role12. The procedure is the
following: interruption of APD 8 to 10 days before
surgery, substitution by flurbiprofen (50 mg bid) along
with withdrawal during surgery, interruption of
flurbiprofen, and then, as soon as possible, APD
postoperatively. According to several authors, it’s not
necessary to wait till all platelets are renewed in order
to obtain good hemostasis30-31-35-36.
Unfortunately, this procedure does not guarantee an
optimal security against a thromboembolic risk. Death
risk is greater in patients who stopped APD treatment
than those who didn’t37.
* NSAIDs = Non Steroidal Anti-Inflammatory Drugs
** COX1 = Cyclooxygenase 1
34
In a recent study, and due to the persistent
antiplatelet effect complicating surgery, Vilahur and
Choi33 suggested that preoperative transfusion of 10
platelet concentrate units after 300 mg of clopidogrel
loading may adequately reverse clopidogrel-induced
platelet disaggregation to facilitate postoperative
hemostasis. This included hospitalization and reduced
bleeding complications. But these observations should
be fully explored in an in vivo clinical setting with
clopidogrel-treated patients before and after surgery33.
Risks related to the continuation of APDs:
Continuation of APD treatment before surgery
ensures prevention of thromboembolic risk associated
with cardiovascular pathology. This therapeutic attitude
overrides per and postoperative bleeding risks30-35-36-37.
Clinically significant postoperative bleeding has
been defined as that which20:
• Continues beyond 12 hours (after surgey).
• Causes the patient to call or return to the dental
office or / and emergency unit.
• Results in the development of a large haematoma
or ecchymosis within oral, perioral, and neck soft
tissues38-39.
• Requires a blood transfusion.
Clopidogrel reduces the rate of arterial thrombosis,
but the average bleeding time is prolonged40.
There are a few published studies on the relative
risks of perioperative bleeding with clopidogrel. The
pharmacological mechanisms underlying AP action of
clopidogrel suggest that patients taking these
medications will be at no greater risk of excessive
bleeding than those taking aspirin37. There is
insufficient evidence to comment on the bleeding risk
if patients take both aspirin and clopidogrel. Patients
under APD treatment and requiring dental treatment, or
oral, periodontal or implant surgery, have a higher
potential risk of bleeding, but this risk is not significant
if local haemostatic measures are implemented.
Management modalities of patients under APD
treatment when undergoing dental treatments or
oral, or periodontal or implant surgery
1. Evaluation of operative risk:
Patients taking APD with the following problems
should be referred to a dental or general hospital:
* Liver impairment and / or alcoholism.
Volume 45 - Nº 1 - 2008
Abou Tayeh R, Sidnaoui E, Khalil W, Noujeim Z
* Renal failure.
* Thrombocytopenia, hemophilia, or other disorder
of haemostasis.
* Those currently receiving course of cytotoxic
drug20-41-42.
2. Evaluation of bleeding risk:
There are three plausible scenarios regarding
temporary interruption of dual oral antiplatelet therapy
for planned surgery according to bleeding risk
following certain surgical procedures:
1. Low bleeding risk: interruption of oral
antiplatelet therapy is not necessary, irrespective
of ischemic risk profile: simple (non surgical)
extraction of up to three teeth, gingival surgery,
crown and bridge procedures, and dental
scaling9.
2. Intermediate bleeding risk: when more than
three teeth need to be extracted, then multiple
sessions will be required20. Interruption of oral
antiplatelet therapy should be decided after
assessing ischemic risk. In low ischemic risk
patients, interruption of clopidogrel 5 days
before surgery with reintroduction as soon as
possible is an option. In high ischemic risk
patients, surgery should be postponed. If surgery
cannot be postponed, interruption of clopidogrel
5 days before surgery with reintroduction as
soon as possible is an option, with or without
alternative therapies9. Surgical operations where
the risk of bleeding has shown to be highest are:
multiple dental extractions and implant
placement in mandibular symphyseal region38-39.
3. High bleeding risk: The first option is to
postpone surgery, if possible. Otherwise, it
should be possible either to stop aspirin and
clopidogrel 5 days before planned surgery3,
without alternative therapy, or stop aspirin and
clopidogrel 10 days before surgery with
alternative therapy. These recommendations are
not based on evidence, but rather emanate from a
consensus document on the management of this
particular situation (published by three
professional
organizations
in
France9).
Therefore, it is recommended to undertake no
surgical periodontal treatments before every oral
Journal of the Lebanese Dental Association
surgical operation, in order to limit preoperative
inflammation.
Some authors recommend a cautious approach by
deferring elective dental care for the first 6 months
following a stroke and in patients experiencing
transient ischemic attacks or reversible ischemic
neurologic defects2.
3. Operative period :
It is important to be aware of the increased risk of
bleeding while maintaining APD treatment during oral
surgical procedures:
* Timing: planning surgery should ideally be done:
- at the beginning of the day (this allows more time
to deal with bleeding).
- early in the week, (bleeding problem will be dealt
during working days42).
* Analgesia: the risk of haemorrhage associated to
analgesia is confined to a haematoma at the point of
injection43. These haematomas cause some discomfort,
but do not represent a clinical threat. The
haemorrhagic risk associated with the use of a
locoregional analgesia (LRA) results in a higher
bleeding secondary to tissue or vascular trauma, thus
causing extensive and / or compressive haematoma.
Not one single case has been reported in the literature
where a hemorrhagic incident and an APD treatment
are put in parallel, when performing a peripheral
analgesic block. Despite the absence of significant
argumentation suggesting that the risk of
lateropharyngeal haematoma increases with the intake
of APD when performing LRA of inferior alveolar
nerve, several authors do not recommend it44-45. The
choice of a needle with a maximum diameter of 27
gauge or 0.4 mm, along with a slow injection, ensures
limitation of tissue trauma. In case of general
anesthesia, tracheal intubation could be the cause of
per and / or post operative bleeding, due to direct
trauma by the probe. Intake of APD could result in an
important epistaxis47.
Efforts should be made to make the procedure as
atraumatic as possible and any bleeding should be
prevented or treated by using local haemostatic
measures (pressure, splint, suturing, electrocautery,
and topical haemostatic agents2 like gelfoam* with
thrombin, microfibrillar collagen, fibrin glue,
surgicel*, or a gauze soacked with tranexamic acid).
35
Abou Tayeh R, Sidnaoui E, Khalil W, Noujeim Z
4. Post-operative period:
It represents one of the most important steps in the
management of APDs patients. It includes monitoring
and post-operative advices:
- look after the initial clot while local analgesia
wears off and the clot fully forms (2- 3h).
- avoid mouthrinsing for 24-48 hours.
- avoid disturbing socket with the tongue or any
foreign object.
- avoid hot liquids and hard food for the rest of the
day.
- avoid chewing on the operated side for one week.
- apply pressure packs (or pre-operatively made
splints) over the socket if bleeding continues or
restarts.
- contact treating dentist in case of excessive or
prolonged bleeding48.
CONCLUSION AND RECOMMENDATIONS
Management of patients under APDs treatment has
considerably evolved in a very short period of time.
Until the year 2000, most of authors have recommended
interruption of APDs prior to a surgical operation in
order to limit bleeding risk. The truth is that there was a
tendency to underestimate thromboembolic risk when
compared to haemorrhagic risk9. Unluckily,
retrospective studies have illustrated occurrence of
serious complications in the post-operative period (1-3
weeks) resulting from progressive platelet function
recovery. On the other hand, not a single study could
provide evidence for a greater relative risk of
haemorrhagic complication in case of continuation of
APD treatment. The advantages of stopping or
reducing antithrombotic therapy should always be
weighed out against the disadvantage of the enlarged
risk of thromboembolic complication49. Ignorance of
risks incurred by interrupting oral antiplatelet therapy
is the clinician’s worst enemy. Insufficient scientific
evidence in this field makes it impossible to issue clear
guidelines. The first question that should always be
asked is whether interruption is really appropriate and
whether it can be avoided. Then, evaluation of the
bleeding-associated risk is a key step in the decisionmaking of interruption. Difficult situations arise when
high-risk features for both ischemic and bleeding
events are present simultaneously. Fortunately, this is a
36
rare scenario. There is an urgent need for dedicated
studies to assess the real magnitude of the problem,
which could lead to firm recommendations issued by
specialized scientific societies9.
Nowadays, the most accepted recommendations
are the following:36,51-52-53-54-55-57
1- Transient withdrawal of clopidogrel may
minimize bleeding risk, but it definitely increases
thromboembolic risk.
2- The thromboembolic risk linked to withdrawal
of clopidogrel is much more prejudicial than
haemorrhagic risk linked to oral surgical procedures.
3- INR (in clopidogrel patients) = 2-3, and the last
INR test should be preferably performed immediately
(or hours) before oral surgical procedure.
It is of utmost importance that INR in such patients
remains stable, and if the value exceeds 3, patient
should immediately consult his/her treating physician.
4- Clopidogrel dose shouldn’t be modified and
clopidogrel shouldn’t be stopped if INR is stable and
lower than 4.
5- Surgical technique should be atraumatic and
gentle with mandatory local haemostatic measures
(compression, sutures, gelatine and collagen sponges,
surgicel®, thrombin, fibrin glue, gauze soaked with
tranexamic acid, ...). Soft tissue crushing and alveolar
fractures should be avoided.
6- If INR exceeds 3, patient should be treated in
hospital, in presence of his/her treating physician.
REFERENCES
1. Caprie Steering Committee. A randomized blinded trial of
clopidogrel versus aspirin in patients at risk of ischemic events.
Lancet 1996; 348: 1329-1339.
2. Fatahzadeh M, Glick M. Stroke: epidemiology, classification,
risk factors, complications, diagnosis, prevention, and medical
and dental management. Oral Surg Oral Med Oral Pathol Endod
2006; 102: 180-191.
3. Fox KAA , Mehta SR, Peters R, Zhao F, Lakkis N, Gersh BJ,
Yusuf S. Benefits and risks of the combination of clopidogrel
and aspirin in patients undergoing surgical revascularization for
non-ST-Elevation acute coronary syndrome. The Clopidogrel in
unstable angina to prevent recurrent ischemic events (CURE)
trial. Circulation 2004; September 7:110.
4. Brugemann J, Van Gelder IC. Cardiological therapy and dental
practice. Ned Tijdschr Tandheelkd.. 2006 Feb; 113(2):75-81.
Volume 45 - Nº 1 - 2008
Abou Tayeh R, Sidnaoui E, Khalil W, Noujeim Z
5. Agarwal S, Coakley M. Quantifying the effect of antiplatelet
therapy: a comparison of the platelet function analyzer (PFA100) and modified thromboelastography (m TEG) with light
transmission platelet aggregometry. Anesthesiology. 2006 Oct;
105(4): 676-683.
6. Stone GW, Aronow HD. Long-term care after percutaneous
coronary intervention: focus on the role of antiplatelet therapy.
Mayo Clin Proc. 2006 May; 81(5):641-652.
7. Khurram Z, Chou E. Combination therapy with aspirin,
clopidogrel and warfarin following coronary stenting is
associated with a significant risk of bleeding. J Invasive Cardiol.
2006 Apr; 188(4):162-164.
8. Carrozza J. Duration of clopidogrel therapy with drug-eluting
stents. J Interven Cardiol 2006; 19: S40-46.
9. Collet JP, Montalescot G. Premature withdrawal and alternative
therapies to dual oral antiplatelet therapy. European Heart
Journal Supplements 2006 Oct; 8: G 46-52.
21. Alstrom U, Tyden H, Oldgren J, Siegbahn A, Stahle E. The
platelet inhibiting effect of a clopidogrel bolus dose in patients
on long-term acetylsalicylic acid treatment. Thromb Res. 2007;
120(3):353-359.
22. Schafer A. Effects of nonsteroidal antiinfammatory drugs on
platelet function and systemic hemostasis. J Clin Pharmacol
1995; 35: 209-219.
23. Eikelboom J, Hirsh J. Bleeding and management of bleeding.
European Heart Journal Supplements 2006; 8:G38-G45.
24. Gurbel PA et al. Onset and extent of platelet inhibition by
clopidogrel loading in patients undergoing elective coronary
stenting. Am Heart J 2003; 145(2):239-247.
25. Price MJ, Coleman JL. Onset and offset of platelet inhibition
after high-dose clopidogrel loading and standard daily therapy
measured by a point-of-care assay in healthy volunteers. Am J
Cardiol. 2006 Sep 1; 98(5):681-684.
10. Vidal 2005. Le dictionnaire, 81ème édition. Edition Vidal,
Issy-les-Moulineaux, France, 2005.
26. Boneu B, Sampol J. Traitements antithrombotiques (p. 541). In
Hématologie clinique et biologique, Sébahoun G ed. Arnette
Initiatives Santé, Paris 1998, p. 541.
11. Chaer RA, Graham JA. Platelet function and pharmacologic
inhibition. Vasc Endovascular Surg. 2006 Aug-Sep; 40(4): 261267.
27. Van Werkum JW, Heestermans AA. Thrombosis of a coronary
stent after discontinuing treatment with clopidogrel. Ned
Tijdschr Geneeskd. 2006 Apr 15; 150(15):863-868.
12. Merrit JC and Bhatt DL. The efficacy and safety of
perioperative antiplatelet therapy. J Thromb Thrombolysis
2002; 13: 97-103.
28. Collet J-P, Himbert D and Steg PG. Myocardial infarction after
aspirin cessation in stable coronary artery disease patients. Int
J Cardiol 2000; 76: 257-258.
13. Comerota AJ. Effect on platelet function of cilosatzol,
clopidogrel and asprin, each alone or in combination.
Atheroscler Suppl. 2005, Dec. 15;6(4): 13-19.
14. Chu MW, Wilson SR. Does clopidogrel increase blood loss
following coronary artery bypass surgery? Ann Thorac Surg.
2004 Nov ; 78(5): 1536-1541.
15. Brennan MT, Schariff G, Kent ML. Relationship between
bleeding time test and postextraction bleeding in a healthy
control population. Oral Surg Oral Path Oral Radiol Endod
2002; 94:439-443.
16. De Rossi SS. Bleeding time: an unreliable predictor of clinical
hemostasis. J Oral and Maxillofacial Surg 1996;54:1119-1120.
17. Wallach J. Interpretation of diagnostic tests. 7th ed.
Philadelphia: Lippincott Williams; 2000. p. 452-454.
29. Kruth P, Heer T. Acute myocardial infarction after
discontinuing aspirin two years after implantation of a drugeluting coronary stent. Dtsch Med Wochenschr 2007 Feb 2;
132(5):201-204.
30. Patrono C, Coller B. Platelet active drugs: the relationship
among dose, effectiveness, and side effects. Chest 2001; 119:
39S-63S.
31. Sonken JR, Kong KL. Magnitude and time course of impaired
primary hemostasis after stopping chronic low and medium
dose aspirin in healthy volunteers. Br J Anaaesth 1999; 82:
360-365.
32. Collet J-P, Himbert D and Steg PG. Myocardial infarction after
aspirin cessation in stable coronary artery disease patients. Int
J Cardiol 2000; 76: 257-258.
18. Shalom A and Wong L. Outcome of aspirin use during excision
of cutaneous lesions. Ann Plast Surg 2003; 50: 296-298.
33. Vilahur G, Choi BG. Normalization of platelet reactivity in
clopidogrel-treated subjects. J Thromb Haemost. 2007 Jan;
5(1): 82-90.
19. Samama CM et al. Antiplatelelet agents in the perioperative
period: Expert recommendations of the French Society of
Anesthesiology and Intensive Care (SFAR) 2001 - Summary.
Can J Anesth 2002; 49:S26-35.
34. Altman R, Scazziota A. Recombinant factor VIIa reverses the
inhibitory effect of aspirin and clopidogrel on in vitro thrombin
generation. J Thromb Haemost. 2006 Sep; 4(9):2022-2027.
20. Lockhart PB, Gibson J, Pond SH and Leitch J. Dental
management considerations for the patient with an aquired
coagulopathy. Part 1: coagulopathies from systemic disease. Br
Dent J 2003; 195:439-445.
Journal of the Lebanese Dental Association
35. Ardekian L, Gaspar L, Peled M. Does low-dose aspirin therapy
complicate oral surgical procedures? J Am Dent Assoc 2000;
131:331-335
36. Levesque H, Peron JM. Anti-agrégants plaquettaires et antivitamines K en stomatologie et chirurgie maxillofaciale. Rev
Stomatol Chir Maxillofac 2003;104:80-90.
37
Abou Tayeh R, Sidnaoui E, Khalil W, Noujeim Z
37. Little JW, Miller CS. Antithrombotic agents: implications in
dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2002; 93:544-551.
55. Campbell JH, Alvarado F, Murray RA. Anticoagulation and
minor oral surgery: should the anticoagulation regimen be
altered? J Oral Maxillofac Surg 2000;58:131-135.
38. Darriba MA, Mendonca JJ. Profuse bleeding and lifethreatening airway obstruction after placement of mandibular
dental implants. J Oral Maxillofac Surg 1997; 55: 1328-1330
56. Wahl MJ. INR and PTR anticoagulation values. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 1996; 81: 377-378.
39. Niamtu III J. Near-fatal airway obstruction after routine
implant placement. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2001; 92(6):597-600.
40. Nayak VK, Deschler DG. Clopidogrel use for reducing the rate
of thrombosis in a rat model of microarterial anastomosis. Arch
Otolaryngol Head Neck Surg. 2005 Sep; 131(9):800-803
41. Daniel NG, Goulet J. Les antiplaquettaires: y a-t-il un risque
opératoire? J Can Dent Assoc 2002;68:683-687.
42. Scully C and Wolff A. Oral surgery in patients on anticoagulant
therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2002; 94: 57-64.
57. Dia Tine S, Seck O, Kébé NF, Dieng NF, Cissé I, Kane A,
Diallo B. Arrêt des anticoagulants avant un acte de chirurgie
buccale: mythes et réalités (Anticoagulant withdrawal before
oral surgery: mythis and realities). Médecine Buccale
Chirurgie Buccale 2008; 14(2): 103-109.
Correspond with:
Ziad Noujeim
[email protected]
43. Malamed SF. Handbook of local anesthesia. 4th ed. Mosby, St
Louis 1997.
44. Jonhson WT, Leary JM. Management of dental patients with
bleeding disorders: review and update. Oral Surg Oral Med
Oral Pathol 1998; 66: 297-303.
45. Mullingan R, Weitzel RG. Pretreatment management of the
patient receiving anticoagulant drugs. J Am Dent Ass 1988;
197: 479-483.
46. Collet JP, Montalescot G. Impact of prior use or recent
withdrawing of oral antiplatelet agents on acute coronary
syndromes. Circulation 2004; 110: 2361-2367.
47. Eurin B, Fischer M. Intubation trachéale. Collection
d’Anesthésiologie et de Réanimation. Masson, Paris 1993.
48. Scully C and Cawson RA. Medical Problems in Dentistry. 4th
ed. Oxford, London, and Boston: Wright; ButterworthHeinemann; 1998. p. 49-50
49. Allard RH, Baart JA. Antithrombotic therapy and dental
surgery with bleeding. Ned Tijdschr Tandheelkd. 2004 (Dec);
111(12):482-485.
50.Samama MM. Hémorragies et thromboses. Du diagnostic au
traitement. Masson, Paris, 2004.
51. De Mello G, Andrieu G, et coll. Prise en charges des patients
sous traitement anti-vitamines K en chirurgie bucco-dentaire.
Recommendations. Médecine buccale Chirurgie Buccale 2006;
12(4): 187-212.
52. Evans BE, Irving SP, Aledort LM. Can anticoagulant be
continued during dental extraction? Results of a randomized
controlled trial. Br J Oral Maxillofac Surg 2002;40:248-252.
53. Troulis MJ, Head TW, Leclerc JR. Dental extraction in patients
on oral anticoagulant: a survey of practice in North America. J
Oral Maxillofac Surg 1998; 56: 914-917.
54. Wahl MJ. Myths of dental surgery in patients receiving
anticoagulant therapy. J Am Dent Assoc 2000;131:77-81.
38
Volume 45 - Nº 1 - 2008
Q’s and A’s
Periodontology Update: the QUESTIONS.
Prepared by* Maroun Dagher1, DCD, CAGS, MSc.D, Dip. ABP,
Cynthia Chemaly2, BDS, CES Perio., DU Perio., DU Implant., DU Oral Mucosal Pathol.
Answers : page 57
1- What are the main features of chronic
periodontitis?
11- How does smoking
periodontal therapy?
2- What are the main features of generalized
aggressive periodontitis?
12- What are bisphosphonates?
(tobacco)
affect
13- How can bisphosphonates affect oral health?
3- What is biological width?
14- What does “LASER” stand for?
4- What are the signs/symptoms of a dental
restoration impinging on biological width?
15- What are the advantages of LASERs?
5- How can we prevent encroaching on biological
width?
16- What are the (possible) side-effects of dental
LASERs?
6- What damages can be caused by electrosurgery
on periodontal tissues?
17- Should we use a LASER in periodontal
therapy?
7- Can periodontal disease affect general health?
18- What are the pharmacological agents used
locally (as antimicrobial agents) in
periodontal therapy?
8- Is there a relationship between stress and
periodontal disease?
9- How can stress possibly affect gum disease?
10- How does smoking
periodontal tissues?
(tobacco)
affect
* Department of Periodontology, St. Joseph University
Faculty of Dental Medicine, Beirut, Lebanon.
1 Clinical Associate
2 Clinical Associate
Journal of the Lebanese Dental Association
39
Endodontology
Apexification with Mineral Trioxide Aggregate: a case report.
Salwa Yammine1, MD / Stomatologist, DES (Pediat. Dent.), DES Endo., Edgard Jabbour2, BDS, DESS Oral Surg.
Traumatic injuries affecting dentition of young
patients can result in the interruption of development
of incompletely formed roots.
A permanent immature tooth can loose pulpal
vitality subsequently to trauma, halting radicular
growth. Necrotic pulp acts as an irritant to periapical
tissues. Apical foramen remains open in a tubular or
blunted form. In teeth with incomplete root-end
formation associated with necrotic pulp, root canals
must be completely shaped using intra-canal
instruments and irrigation with 2.5% NaClO solution12.
Apexification in these teeth is mandatory due to
presence of thin and fragile walls and lack of apical
barrier6.
Various procedures and materials have been
recommended by different authors to induce
apexification in teeth with immature apices10. These
include: no treatment11, infection control4, induction of
a blood clot in the periradicular tissues7, antibiotic
pastes2 and calcium hydroxide mixed with various
materials6. Bouchon utilized Walkoff’s paste to
achieve apical closure3, and Kaiser obtained
apexification with calcium hydroxide paste (in 9).
An alternative treatment to long-term apexification
procedure is the use of an artificial apical barrier that
allows immediate obturation of the canal. Mineral
Trioxide Aggregate (ProRoot MTA®,Tulsa Dental,
Tulsa, USA) is a potential apical barrier material with
good sealing ability10. It is a cement composed of
tricalcium silicate, dicalcium silicate, tricalcium
aluminate, tetracalcium aluminoferrite, calcium sulfate
Department of Endodontics, Lebanese University School of
Dentistry, Beirut, Lebanon
1 Voluntary Associate Clinical Instructor
2 Chief of Clinical Services
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
and bismuth oxide similar to Portland’s cement except
for the addition of bismuthoxide9. MTA is very
alkaline (pH = 12.4), has a high degree of
biocompatibility16, and a potential ability to induce
hard tissue formation19.
The material is mixed with sterile water to provide
a grainy, sandy mixture. Once the material has
acquired this consistency, it can be applied by using a
small gun. At this point, it is gently packed into the
desired area. MTA being hydrophilic requires moisture
to set, making absolute dryness not only unnecessary
but contraindicated. MTA has different clinical
applications, mainly in endodontics.
A case of two traumatized permanent young teeth
in which apexification was induced by means of
endodontic treatment is reported. It illustrates how an
immature tooth that has sustained pulp necrosis and
periapical inflammation could progress to complete
apical formation after apexification with MTA®.
The purpose of this report is to show the potential
ability of MTA® to induce formation of apical hard
tissue in immature human roots.
CASE REPORT
A 14-year old girl suffering from painful symptoms
caused by her central incisors was examined in the
department of endodontics (Lebanese University) for
evaluation and treatment.
Investigation revealed a trauma (six years ago)
associated with an enamel/dentin fracture. No
treatment was performed at that time. Approximately
two years later, a fluctuant swelling developed in the
apical area of the teeth. Symptoms also included
41
Yammine S, Jabbour E
tenderness to percussion. Drainage was established by
lingual access in the pulp chamber. Treatment was
interrupted by the patient for no reason, and four years
later, an attempt of apexification using calcium
hydroxide paste was carried out for six months by
another dentist, but no apexification was observed on
either tooth.
When patient was referred to our department, extra
and intra-oral examinations (including radiology) were
performed: they revealed central left and right incisors
in normal position with enamel/dentin fracture. Root
canals were wide, roots incompletely formed with
open apices and periapical lesions (fig.1).
Cleaning and shaping of root canals system was
achieved under rubber dam isolation. The solution
used for irrigation was 2.5% sodium hypochlorite.
Root canal length was determined using an apex
locator and confirmed radiographically. Calcium
hydroxide paste was placed in the canals for 1 week
for disinfection. During the second appointment,
calcium hydroxide was eliminated by mechanical
instrumentation and rinsed out of root canals by means
of sterile water irrigation. The canals were dried using
sterile paper points. MTA® was prepared immediately
before use, placed into the canals with an MTA®
carrier and compacted with a hand plugger to create an
apical plug of 3 to 4 mm as described by the
manufacturer. Radiography was taken to check if no
Fig.1. Radiographic examination Fig. 2. First attempt to place
shows implication of pulpal MTA® in the right maxillary
tissues and presence of periapical central incisor (11)
lesions due to dental trauma.
* IRM: Intermediate Restorative Material.
42
apical extension occured.
The apical plug failed in the first attempt on the
right maxillary central incisor (fig. 2), MTA® was
rinsed out with sterile water and the procedure was
repeated (fig. 3). Moist paper points were placed in the
canals and access cavities were closed with a
temporary restorative material, IRM® (Dentsply,
Caulk, USA)*.
Two days later, coronal and middle thirds of the
canals were filled with gutta-percha by a vertical warm
compaction technique and access cavities were sealed
in conjunction with the final restoration (fig. 4).
Periradicular healing was assessed clinically and
radiographically at 6, 8 (fig. 5) and 12 months (fig. 6).
The use of MTA® (as a barrier in the apical region)
completed with a conventional endodontic treatment
resulted in apical formation of the two central incisors
(fig. 6).
DISCUSSION
Compared to conventional techniques used for
apexification, MTA® has the advantage of achieving
treatment in a single visit. MTA® was chosen as the
material of choice for apexification for its reported
biocompatibility16, superior sealing ability9, and
absence of neurotoxicity1. MTA® has been also shown
to be a suitable material for one step obturation of open
apices in many studies14,17,18,4,13,21.
Fig. 3. Apical plug of MTA® in
the apical third of the canal.
Fig. 4. Conventional obturation
with gutta-percha.
Volume 45 - Nº 1 - 2008
Yammine S, Jabbour E
Indeed, consistent hard
tissue formation in roots
treated with MTA® may
also be attributed to its
sealing capacity and its
ability to induce hard
tissue formation.
This case showed two
traumatized teeth with
immature root apices in
which apical barrier was
induced
by
MTA®.
According
to
other
authors, this phenomenon Fig. 5. Radiographic follow-up
is more related to growth at 6 and 8 months.
of osseous tissue into
apical portion of the canal than the deposit of hard
dental tissues. It is possible that mechanisms of
apexification could be related to both hypotheses20,22,4.
This material, applicable in one step apexification,
shows good results with either type of powder: grey or
white8. In the present case, grey powder was used.
Figure 8 shows a follow-up of 5 years with two crowns
performed on the two incisors after healing of the
infection.
Fig. 6. Radiographic follow-up
after 12 months.
Fig. 7. Radiographic follow-up
after 5 years, with two porcelain
fused to metal crowns placed on
both incisors.
REFERENCES
1. Asrari M, Lobner D. In vitro neurotoxic evaluation of root-end
filling materials. J Endod 2003; 29 (11): 743-746.
10. Ingle J, Beveridge E. Endodontics. 2nd ed. Philadelphia:, 1976:
66.
2. Ball JS. Apical root formation in a non-vital immature
permanent incisor. Br Dent J 1964; 116: 166-167.
11. Liberman J, Trowbridge H. Apical closure of nonvital
permanent incisor teeth where no treatment was performed:
case report. J Endod 1983; 9: 257-260.
3. Bouchon F. Apex formation following treatment of necrotized
immature permanent incisor. J Dent Child 1966; 33: 378-380.
4. Claisse-Crinquette A, Claisse D. Hydroxide de calcium ou MTA
en traumatologie. Réalités Cliniques 2002 ; 13 (1) : 53-73.
5. Das S. Apexification in a nonvital tooth by control of infection.
J Am Dent Assoc 1980; 100: 880-881.
6. Frank A. Therapy for the divergent pulpless tooth by continued
apical formation. J Am Dent Assoc 1966; 72: 87-93.
7. Ham J et al. Induced apical closure of immature pulpless teeth
in monkeys. Oral Surg 1972; 33: 438-448.
8. Holland R, De Souza V, Nery M. Reaction of rat connective
tissue to implanted dentin tubes filled with a white mineral
trioxide aggregate. Braz Dent J 2002; 13 (1): 23-26.
9. Kaiser JH. Oral presentation, American Association of
Endodontics. Washington, DC, USA, 1994.
43
12. Seltzer S. The root apex. In, Endodontology. 2nd ed.
Philadelphia. WB Saunders, USA 1988: 1-30.
13. Sjögren U, Fidgor D, Pangberg L, Sundqvist G. The
antimicrobial effect of calcium hydroxide as a short-term
intracanal dressing. Int Endod J 1991; 24:119-125.
14. Tittle KW, Farley J, Linkhardt T, Torabinejad M. Apical closure
induction using bone growth factors and mineral trioxide
aggregate. J Endod 1996; 22:198.
15. Torabinejad M, Watson TF, Pitt Ford TR. The sealing ability of
mineral trioxide aggregate as a retrograde root filling material.
J Endod 1993; 19: 591-595.
16. Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD.
Cytotoxicity of four root end filling materials. J Endod 1995;
21:427-430.
Volume 45 - Nº 1 - 2008
Yammine S, Jabbour E
17. Torabinejad M, Chivian N. Clinical applications of mineral
trioxide aggregate. J Endod 1999; 25 : 197-205.
18. Torabinejad M, Hong CU, Pitt Ford TR. Physical properties of
a new root end filling material. J Endod 1995; 21: 349-353.
19. Tronstad L. PH changes in dental tissues after root canal filling
with calcium hydroxide. J Endod 1981; 7: 17-21.
20. Torneck CD, Smith JS, Grindall F. Biological effects of
endodontic procedures on development incisor teeth, Part III.
Effect of debridement and disinfection procedures in the
treatment of experimentally induced pulp and periapical
disease. Oral Surg 1973, 35: 532-540.
21. Yammine S. Les nouvelles alternatives du traitement
d’apexification des dents permanentes à apex immatures.
Mémoire de DES, Faculté de Médecine Dentaire, Université
Saint-Joseph, Beirut, Lebanon, 2001.
22. Witherspoon D, Small J, Harris G. Mineral trioxide aggregate
pulpotomies: a case series outcome assessment. J Am Dent
Assoc 2006; 137:610-618.
Correspond with:
Salwa Yammine
[email protected]
44
Volume 45 - Nº 1 - 2008
Q’s and A’s
Endodontology Update: the QUESTIONS.
Prepared by Fadl Khaled*, BDS, DES Endo.
Answers : page 63
1- What are the reasons to use a sealer in
endodontics?
10- What are the possible causes of tooth mobility
after trauma?
2- Why is moderate extrusion of obturating
materials beyond apex undesirable?
11- What is the concept of crown-down?
3- What are the main functions of macrophages?
4- What is the best combined treatment for
actinomycosis israelii?
5- How are polyamines produced? And where are
they mostly concentrated?
6- Why is incision and drainage of cellulitis
effective?
7- When is antibiotic prophylaxis recommended
by the American Heart Association (AHA) in
endodontic therapy?
8- Who formulated the theory of focal infection?
To what infections and diseases is it related and
what is its result?
12- What are some of the symptoms of pulp
abnormalities in primary teeth?
13- What are some of the possible causes that lead
a dentist to miss a canal during root canal
treatment?
14- What facilitates removal of objects from
within a root canal?
15- What are the common
obturation techniques?
conventional
16- What are the most used solutions for root
canal irrigation?
17- Is there any medical conditions
contraindicate endodontic treatment?
that
18- What are the main signs of root fracture?
9- What are the properties of the best apex
locators?
* Chief of Clinical Services, Department of Endodontics,
Lebanese University School of Dentistry, Beirut, Lebanon,
and
Clinical Instructor, Department of Restorative Dentistry,
Beirut Arab University, Faculty of Dentistry,
Beirut, Lebanon
Journal of the Lebanese Dental Association
45
Orthodontics and Dentofacial Orthopaedics
Non surgical treatment of skeletal Class III malocclusion: report of
two adult cases.
Mona Sayegh Ghoussouba, DCD, CECSMO, Saro Ghougassianb, DCD, DU Oral Biol.,
Chadi Kassirb, BDS, DU Oral Biol.
Abstract
This article describes orthodontic treatment of two adult patients presenting with a skeletal Class III malocclusion. A
camouflage treatment procedure was implemented for each one of them in order to resolve the dental problems; For the first
patient, we extracted two mandibular second premolars, and for the second one, the decayed first permanent mandibular
molars. The aim of this paper is to show that treatment of borderline skeletal Class III malocclusions by dentoalveolar
compensation is possible and can assure occlusal improvement and favorable effect on facial esthetics, if indications are
initially well established.
INTRODUCION
Historically, skeletal Class III malocclusion was
viewed as a problem of the mandible. Until the 1970s,
Class III and mandibular prognathism were virtually
synonymous. Many studies since then have found that
the maxilla was also incriminated, and its hypoplastic
aspect was often the primary etiology of Class III
malocclusion1.
Skeletal Class III malocclusions can result from
any combinations of deficient maxillary growth and
excessive mandibular growth. Vertically, they can be
divided into two basic types, depending on the vertical
disproportions: long face and short face. It is important
to diagnose the etiology in order to adequately treat the
underlying cause (or causes) of the problem2.
Intraorally, it is generally characterized by an
anterior crossbite or, in less severe cases, an edge-toedge incisal relationship and Class III molar3. Common
dental compensations are maxillary dentoalveolar
proclination
and
mandibular
dentoalveolar
retroclination to compensate for the underlying skeletal
discrepancy.
a Chief of Clinical Services / Clinical Instructor, Department of
Orthodontics, Lebanese University School of Dentistry, Beirut,
Lebanon .
b Postgraduate Residents, Department of Orthodontics, Lebanese
University School of Dentistry, Beirut, Lebanon .
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
Knowledge of craniofacial growth in Class III
individuals is fundamental to treatment timing and
mechanics: currently, early management of Class III
malocclusions has become common in the orthodontic
community. According to McNamara4 and Turley5,
rapid maxillary expansion may enhance protraction
effect of the face mask by disrupting the maxillary
suture system.
In non-growing patients, treatment of skeletal Class
III malocclusions is more challenging. For the
orthodontic (non-surgical) option in patients with mild
skeletal Class III problems, camouflage is a
therapeutic option that often masks skeletal
discrepancy through extractions. In such cases, dental
movements are opposite to those prior to surgery
where dentoalveolar decompensation is mandatory.
“camouflaging” can also be used in growing patients
but should take into account the remaining growth
difficult to predict accurately9.
In the following case reports, orthodontic
camouflage treatment was performed in Class III adult
patients in order to achieve an optimal occlusion and
less apparent underlying skeletal discrepancy.
Presentation of these two cases will show that different
treatment alternatives are possible if one takes into
account the diagnosis, treatment plan and mechanics,
in addition to the personal opinion and the patient’s
chief complaint.
47
Sayegh Ghoussoub M, Ghougassian S, Kassir C
CASE 1:
HISTORY
A 21-year old woman consulted us with a chief
complaint of “backward position of maxillary teeth
and crowded mandibular anterior ones”. Her medical
history revealed respiratory problems caused by a
deviation of her nasal septum to the left. Her dental
history showed regular dental care. The family history
revealed no relevant data concerning Class III
malocclusion. No signs of temporomandibular
dysfunction were noticed.
DIAGNOSIS AND ETIOLOGY
Pretreatment facial examination showed a straight
profile with unstrained lip closure. Soft tissue
characteristics included thin lips, orthogonal
nasolabial angle, and shallow mentolabial sulcus.
Skeletally, midface at the level of cheeks was deficient
and the chin increased in height and was slightly
prominent. The smile showed laterally excessive
buccal corridors due to constriction of maxilla, and the
lower lip curvature was not consonant to the smile arc
of maxillary teeth. The maxillary dental midline was
on with the facial midline and the lower deviated 2 mm
to the right (Fig.1).
Analysis of pretreatment intraoral photographs and
dental casts showed a Class III molar relationship on
both sides, a Class III canine on the left side and a
Class I canine on the right side. Anteriorly, an edge-toedge relationship was observed with a cross-bite
between right maxillary central incisor and mandibular
left central incisor. Laterally, a cross-bite was noticed
due to maxillary transverse deficiency. Maxillary arch
was constricted and mandibular arch form was
irregular due to teeth malposition, especially in the
anterior region where 8 mm of dental crowding were
measured. Gingival recession was noticed in the
mandibular anterior region with prominence of roots
obvious through the gum (Fig.2).
Panoramic radiograph showed that all permanent
teeth were present and completely erupted including
the third molars. Cephalometric analysis indicated a
Class III skeletal tendency with a slight vertical excess
(Fig.3; Table I).
48
Malocclusion was probably due to nasal septum
deviation and deficiency in nasal permeability, thus
decreasing expansion and growth of maxilla, and
leading to Class III and dental compensation.
TREATMENT OBJECTIVES
They included the following main objectives:
Facial esthetics: procline upper lip to normalize
nasolabial angle, assure a harmonious labial profile
and decrease consequently the appearance of the
prognathic mandible. The smile would be improved by
reducing excessive buccal corridors and aligning the
teeth.
Maxillary and mandibular dentitions: resolve
crowding, align teeth and reshape the dental arches.
For maxilla, rapid palatal expansion might resolve
crowding, whereas for mandible, extraction of teeth
(second premolars) was considered not to retrocline
excessively anterior teeth which were already upright.
Occlusion: establish a functional occlusion with
optimal overjet and overbite.
TREATMENT ALTERNATIVES
Three treatment alternatives were presented to the
patient and her parents at the consultation
appointment.
First option: a combination of orthodontics and
orthognathic surgery, including an orthodontic
treatment to achieve a dental decompensation in
preparation for a maxillary advancement procedure
and genioplasty in order to resolve skeletal, cosmetic
and dental problems.
Second option: an orthodontic nonsurgical
approach with dentoalveolar compensation to hide or
“camouflage” the skeletal discrepancy, involving
maxillary expansion to widen the arch, extraction of
the mandibular second premolars in order to relieve
the crowding and not to reposition the already
retroclined mandibular incisors. The final occlusion
would be Class I canine and therapeutic Class III
molar.
Third option: A maxillary expansion with
extraction of the restored mandibular first molars to
relieve crowding, correct the dental Class III
malocclusion and finish with Class I molar and canine
Volume 45 - Nº 1 - 2008
Sayegh Ghoussoub M, Ghougassian S, Kassir C
Fig. 1. Pre-treatment facial photographs.
Fig. 2. Pre-treatment intraoral photographs.
Fig. 3. Panoramic and lateral cephalometric radiographs
Journal of the Lebanese Dental Association
49
Sayegh Ghoussoub M, Ghougassian S, Kassir C
relationship.
It was explained to the patient and her parents why
a more esthetic outcome could be expected with the
surgical option, and the patient chose the nonsurgical
option based on inconvenience of greater cost and
additional risks of the orthognathic surgery; the second
option was adopted because the purpose of the
extraction in mandibular arch was to relieve crowding
and correct Class III canine.
TREATMENT PROGRESS
The maxilla was expanded with a hyrax. Split of
the suture occurred after one week and the space
created by the expansion was used to relieve anterior
crowding.
Second mandibular premolars were extracted.
Maxillary and mandibular first and second molars
were banded, and maxillary and mandibular remaining
teeth were bonded except for the mandibular incisors
(.022 x .028-in straight wire appliance) to permit their
spontaneous alignment and retraction while closing
extraction sites. Levelling of both arches was
performed and light Class III intermaxillary elastics
were used to avoid mandibular anterior teeth
proclination. After the first phase of treatment,
retraction of mandibular canines was achieved using
sliding mechanics with power chains. Once a Class I
canine was achieved, retraction of mandibular incisors
was done with closing loops mechanics. After the
extraction space closure, occlusion was detailed and
finished. Stripping of maxillary anterior teeth was
performed to eliminate black triangles created after
the alignment of maxillary incisors. At debonding
appointment, patient had four bonded twist flex
retainers: from canine to canine in the maxilla and
mandible to prevent relapse of rotations, and other
two on buccal side going from mandibular canines to
mandibular first molars to prevent extraction space
re-opening. In addition, patient was provided with a
Hawley retainer for full-time wear the first 6 months
and at night time only after this period, but with
regular follow-up.
TREATMENT RESULTS
Post-treatment records showed that facial esthetics
improved. Mandible appeared less prognathic, and
50
patient was pleased with her appearance. Midlines
coincided with each other and the midsagittal plane
(Fig.4).
Intraoral examination showed a therapeutic Class
III molar and a Class I canine relationship with normal
overjet and overbite. Final occlusion had acceptable
interdigitation and canine guidance (Fig.5).
Final radiographs and superimpositions are shown
in figure 6 and table I.
Table I. Pre-treatment
cephalometric measurements.
Measurements
LFH/TFH (%)
SNA ()
SNB ()
ANB ()
PP/MP ()
PP/H ()
MP/H ()
MP/SN ()
I/NA ()
I-NA (mm)
I/PP ()
I/SN ()
i/NB ()
i-NB (mm)
i/A-Pog ()
i-A-Pog (mm)
i/MP ()
i/I ()
Norm
55
82
80
2
27
0
25
32
22
4
110
104
25
4
22
2
90
131
and
Preatreatment
57.70
79.5
81.5
-2
19.5
3
23
31.5
24
4
116
103.5
14
0
18.5
0
80
145
post-treatment
Posttreatment
57.48
83
83
0
23
1.5
24
34.5
26
5
118
105.5
10.5
1.5
15
-1
76
145
CASE 2:
HISTORY
A 19-years and a half old man consulted us with an
anterior crossbite as chief complaint. He is a mouth
breather and his tonsils are enlarged. Dental and family
history revealed no contributory data.
DIAGNOSIS AND ETIOLOGY
Extraoral examination revealed a concave profile
due to a retruded maxilla that is reflected by the
midface deficiency, a normal nasolabial angle, a
retruded upper lip, and a prominent chin. Lower facial
was increased. Smile examination showed insufficient
incisor display with the maxillary midline being
Volume 45 - Nº 1 - 2008
Sayegh Ghoussoub M, Ghougassian S, Kassir C
Fig. 4. Post-treatment facial photographs.
Fig. 5. Post-treatment intraoral photographs.
Fig. 6. Final radiographs and superimpositions (
Journal of the Lebanese Dental Association
Pre-treatment
Post-treatment)
51
Sayegh Ghoussoub M, Ghougassian S, Kassir C
deviated 1mm to the right relative to facial midline. No
consonancy of the lip arc with maxillary anterior teeth
was observed, and dark buccal corridors were present
due to maxillary transverse constriction (Fig.7).
Intraoral examination showed bilateral crossbite
and coincident upper and lower midlines. Sagittally,
occlusion was a Class III molar and Class III canine on
both sides with an anterior crossbite. Maxillary arch
was tapered and presented a mild dental crowding.
Large restorations on mandibular first molars were
observed. Periodontium appeared healthy with
adequate attached gingival height and width (Fig.8).
Panoramic radiograph revealed the presence of a
full complement of teeth, but unerupted maxillary
third molars. Endodontic treatment was performed on
maxillary and mandibular right first molars (Fig.9).
Cephalometrically, patient had a Class III skeletal
relationship, an increased lower third of the face,
proclined maxillary and retroclined mandibular
incisors (Fig.9; Table II).
Malocclusion was probably due to mouth
breathing, leading to a deficient growth of the maxilla
transversally and sagittally.
TREATMENT OBJECTIVES
They included the following:
- Facial esthetics: decrease concavity of profile and
correct maxillary deficiency. A more forward position
of maxilla and maxillary incisors would eliminate
midface deficiency and lead to more lip protrusion,
thus improving profile. Reach a pleasant smile by
maxillary expansion and extrusion of maxillary
incisors.
- Dentition: align teeth in an ideal arch form and an
adequate coordination in the three dimensions.
- Occlusion: achieve a functional occlusion with
ideal overjet and overbite.
TREATMENT ALTERNATIVES
Three treatment options were proposed. The first
option consisted of a sagittal correction of the skeletal
discrepancy in conjunction with orthodontic treatment,
including a maxillary Lefort I for posterior impaction
and advancement of the maxilla, thus resolving
vertical excess and midface deficiency; a mandibular
bilateral sagittal split osteotomy to set back the
52
mandible, and a genioplasty to reduce chin
prominence. The second option consisted of an
orthodontic camouflage of skeletal problem by
extracting mandibular first premolars to achieve a
Class I canine occlusion and proper overjet. Because
of the poor prognosis of mandibular first molars and
the presence of mandibular third molars, their
extraction instead of first premolars was suggested as
a third treatment option.
TREATMENT PROGRESS
Patient was not willing to undergo orthognathic
surgery and wanted only a dental correction. For this
reason, extraction of mandibular first molars was
chosen as a treatment plan.
A maxillary expansion appliance was used to
correct maxillary constriction and was kept for 5
months. Extraction of mandibular first molars was
performed after banding and bonding of mandibular
arch (.022 x .028-in straight wire appliance). A
succession of arch wires was used to achieve
alignment and leveling, resulting in a proclination of
mandibular incisors. Similar appliances were placed in
maxillary arch, after removal of the expander, and
alignment was achieved by a progression of arch
wires. Class III elastics in conjunction with vertical
elastics were used while retracting mandibular incisors
with control of their torque. Seating of the occlusion
and achieving proper root parallelism were
accomplished as last phase of active treatment. Fixed
lingual retainers were bonded on maxillary and
mandibular anterior teeth, in conjunction with a
maxillary Hawley appliance to retain maxillary
expansion (Fig.11). Patient was reevaluated for a
genioplasty.
TREATMENT RESULTS
Esthetically, an improvement of the patient’s
profile was observed. Proclination of maxillary
incisors lead to a more forward position of lips,
resulting in reduction of concavity of the profile and
“camouflaging” prominence of the chin. A more
pleasant smile was achieved due to a wider maxillary
arch and further incisor display (Fig.10).
Functionally and occlusally, a Class I molar and
canine occlusion was achieved with proper overbite
Volume 45 - Nº 1 - 2008
Sayegh Ghoussoub M, Ghougassian S, Kassir C
Fig. 7. Pre-treatment facial photographs.
Fig. 8. Pre-treatment intraoral photographs.
Fig. 9. Panoramic and lateral cephalometric radiographs
Journal of the Lebanese Dental Association
53
Sayegh Ghoussoub M, Ghougassian S, Kassir C
and overjet, resulting in a normal function in
protrusion and laterality (Fig.11). Final radiographs
and superimpositions are shown in figure 12 and table
II.
Table II. Pre-treatment
cephalometric measurements.
Measurements
LFH/TFH (%)
SNA ()
SNB ()
ANB ()
PP/MP ()
PP/H ()
MP/H ()
MP/SN ()
I/NA ()
I-NA (mm)
I/PP ()
I/SN ()
i/NB ()
i-NB (mm)
i/A-Pog ()
i-A-Pog (mm)
i/MP ()
i/I ()
Norm
55
82
80
2
27
0
25
32
22
4
110
104
25
4
22
2
90
131
and
Preatreatment
56.42
76
80
-4
23
0.5
22
32
31
4
115
107
9
-1.5
20.5
0
78
145
post-treatment
Posttreatment
57.43
76.5
78
-1.5
23
0
24
28
31
3.5
116
109
3
-2
12
-3.5
72
150
DISCUSSION
Ideal treatment plan for patients presenting a
skeletal Class III is a combination of orthodontics and
orthognathic surgery. However, in some cases, where
skeletal discrepancy is moderate, a camouflage
treatment consisting in a dental compensation of
skeletal discrepancy can be considered. For the
motivation of patients, and in borderline cases,
camouflage treatment is a good compromise10. Within
the context of camouflage treatments, many options
are possible after reevaluation of the entire case, its
dental and facial components11. Dental evaluation
consists of assessing dental crowding, repositioning of
incisors, occlusion, periodontal considerations that
may limit the envelope of dental movements, dental
health influencing prognosis of some teeth,
permanence of the achieved results, and the extraction
decision. Facial and aesthetic considerations combine
the impact of treatment on profile and smile.
Both patients fulfilled aesthetic and functional
requirements. A more harmonious profile and a wider
smile were achieved. In terms of occlusion, both
54
patients had a functional occlusion, with the second
one having the advantage of finishing the treatment in
a Class I molar and canine relationship. Patient 1
ended in a Class I canine and Class III molar relation,
but it ended with a good function as revealed by proper
seating of occlusion at mandibular first molar level.
Patient 2 ended in a Class I molar and canine
occlusion, but presented the disadvantage of having
the maxillary first molar occluding with mandibular
second molar (which is smaller than a first molar).
This may disturb posterior intercuspation. In the
presence of these factors, a careful assessment of
occlusion is required at the finishing stage of
treatment. On the long term, occlusion must be
revisited and stabilized. Selective grinding may still be
needed during retention phase. From the retention
standpoint, it is believed that a proper intercuspation
and a stable occlusion increase long-term stability of
treatment.
A major disadvantage of “camouflage” treatment is
the occurence of compensatory dental movements. In
fact, in both patients, mandibular incisors were
retroclined, thus impinging on the tongue space.
Stability of such an incisor position is questionable
over time, and retention requirements become more
critical. It has been recommended that overcorrection
is indicated to minimize future relapse, finishing in a
slight Class II occlusion in a Class III “camouflage”
treatment as it was performed in both treatments.
Another contributing factor in post-treatment relapse in
Class III patients is residual growth. Late mandibular
growth is less likely to occur at both patients age.
CONCLUSION
In their study12 on Class III patients, StellzigEisenhauer, Lux, and Schuster stated: “ Because not all
Class III patients are candidates for surgical
correction, patient assessment and selection remain
main issues in diagnosis and treatment planning”.
In this report, both patients benefited from
treatment results that satisfied their aesthetic and
functional needs, and most importantly their chief
complaint. More than one treatment alternative can be
available for such borderline cases, and a specialist’s
second opinion is mandatory in these circumstances.
This emphasizes on the role of the dental general
Volume 45 - Nº 1 - 2008
Sayegh Ghoussoub M, Ghougassian S, Kassir C
Fig. 10. Post-treatment facial photographs.
Fig. 11. Post-treatment intraoral photographs.
Fig. 12. Final radiographs and superimpositions (
Journal of the Lebanese Dental Association
Pre-treatment
Post-treatment)
55
Sayegh Ghoussoub M, Ghougassian S, Kassir C
practitioner in orienting patients to seek orthodontic
consultation, offering them options not only limited to
treatments involving orthognathic surgery.
Correspond with:
Mona Sayegh Ghoussoub
[email protected]
REFERENCES
1. Proffit WR, Fields HW. Contemporary orthodontics, 3rd ed. St.
Louis: Mosby; 2000. p. 270, 276, 98–106, 185, 186.
2. Ngan P. Treatment of Class III malocclusion in the primary and
mixed dentitions. In: Bishara SE, editor. Texbook of
orthodontics. Philadelphia: W. B. Saunders; 2001. p.375.
3. Delaire J. Maxillary development revisited: relevance to the
orthopaedic treatment of Class III malocclusion. Eur J Orthod
1997;19:289–311.
4. McNamara J. An orthopedic approach to the treatment of Class
III malocclusion in young patients. J Clin Orthop 1990;21:598608.
5. Turley P. Orthopedic correction of Class III malocclusion with
palatal expansion and custom protraction headgear. J Clin
Orthod 1988;22:314-25.
6. Bacetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I.
Skeletal effects of early treatment of Class III malocclusion with
maxillary expansion and face mask therapy. Am J Orthod
Dentofacial Orthop 1998;113:333-43.
7. Tortop T, Keykubat A, Yuksel S. Facemask therapy with and
without expansion. Am J Orthod Dentofacial Orthop 2007;
132:467-74.
8. Williams M, Sarver D, Sadowsky L, Bradley E. Combined
Rapid maxillary expansion and protraction facemask in the
treatment of Class III malocclusions in growing children: A
prospective long-term study. Semin Orthod 1997;3:265-274.
9. Daher W, Caron J, Wechslerc MH. Non surgical treatment of an
adult with a Class III malocclusion. Am J Orthod Dentofacial
Orthop 2007;132:243-51.
10. Graber T, Vanarsdall Jr R, Vig K. Orthodontics: current
principles and techniques, 4th ed., St. Louis: Mosby; 2005.
p.1024-1025.
11. Moullas A, Palomo J, Gass J, Amberman B, White J,
Gustoviche D. Nonsurgical treatment of a patient with Class III
malocclusion. Am J Orthod Dentofacial Orthop
2006;129:S111-8.
12. Stellzig-Eisenhauer A, Lux CJ, Schuster G. Treatment decision
in adult patients with Class III malocclusion: orthodontic
therapy or orthognathic surgery? Am J Orthod Dentofacial
Orthop 2002;122(1):27-37.
56
Volume 45 - Nº 1 - 2008
Q’s and A’s
Periodontology Update: the ANSWERS.
Prepared by* Maroun Dagher1, DCD, CAGS, MSc.D, Dip. ABP,
Cynthia Chemaly2, BDS, CES Perio., DU Perio., DU Implant., DU Oral Mucosal Pathol.
1- • Most prevalent in adults but can occur in
children and adolescents.
• Amount of destruction is consistent with the
presence of local factors.
• Presence of subgingival calculus is frequent.
• Association with a variable microbial pattern.
• It is aggravated by other factors (smoking,
diabetes...).
• Slow to moderate rate of progression, but may
have periods of rapid progression.
5- A crown lengthening procedure that creates a
minimal 3 to 4 mm distance between margin of a
restoration and crestal bone can prevent a BW
violation; this procedure becomes necessary to
maintain a good periodontal health around future
restorations. Other procedure such as orthodontic
extrusion can also help manage certain cases.
2- • More prevalent in people under 30 years, but can
occur in older patients.
• Rapid rate of progression.
• Subgingival calculus may or may not be present.
• Amount of microbial deposits sometimes /or not
consistent with severity of destruction.
7- Yes. Inflammation due to periodontal disease can
affect parts of body and it has been linked to
several medical conditions such as:
• Coronary heart disease.
• Pre-term low-weight childbirth.
• Pre-eclampsia in pregnant women.
• Diabetes.
• Respiratory diseases.
• Rheumatoid arthritis.
3- Biological Width (BW) is the distance established
by "the junctional epithelium and connective
tissue attachment to the root surface". The mean
measures of the connective tissue (CT) attachment
and the junctional epithelium (JE) are respectively
1.07mm and 0.97 mm. A healthy, non-invaded
biological width is essential for the preservation
of periodontal health.
4- • Chronic pain.
• Chronic inflammation of gingiva.
• Loss of attachment.
• Unpredictable loss of alveolar bone.
* Department of Periodontology, St. Joseph University
Faculty of Dental Medicine, Beirut, Lebanon.
1 Clinical Associate
2 Clinical Associate
57
6- • Osseous necrosis.
• Loss of epithelial attachment.
• Gingival recessions.
8- Yes. A recent literature review showed a strong
relationship between stress and periodontal
disease; Also, a positive relationship between
periodontal disease and psychological factors
such as stress, distress, anxiety, depression, and
loneliness were found.
9- The specific role stress plays in periodontal
diseases remain unclear, but it is speculated that
(the hormone) cortisol may play a role. When
experiencing stress, the body releases increased
amounts of cortisol, which can be harmful to the
gums and surrounding bone tissue.
Volume 45 - Nº 1 - 2008
10- Smoking-related substances lead to increased
periodontal
breakdown
by
inducing
vasoconstriction and deleterious effects on
various neutrophil and fibroblast functions and
altering host response to plaque.
decrease swelling and edema, and increased
patient acceptance. But there are little data
concerning the faster healing response or
decreased scarring.
16- Most dental LASERs can be damaging to bone.
11- Smokers have a diminished response to
They also may induce root surface modifications
periodontal therapy and show approximately half
(cracking) and thermal damage to dental pulp.
as much improvement in probing depths and
clinical attachment levels following non-surgical 17- There is still controversy regarding the application
and various surgical modalities. Thus, tobacco
of dental LASERs in Periodontology. There is
cessation should be included as a part of
insufficient evidence to suggest that any specific
periodontal therapy.
LASER is superior to the traditional modalities of
the treatment of periodontitis or for crown
12- Known as bone-sparing drugs, bisphosphonates
lengthening and there is still a great need to
are commonly used in tablet form to prevent and
develop an evidence-based approach to the use of
treat osteoporosis in post-menopausal women.
LASERs in periodontology.
When used in IV form, Bisphosphonate are used
in the management of advanced cancers that have 18- • Chlorhexidine disks.
metastatic cancers.
• Tetracycline fibers.
• Gels containing doxycycline, metronidazole, or
13- In very rare instances, some people being treated
minocycline.
with IV bisphosphonates have developed an
osteonecrosis of the jaw (ONJ). This condition
Correspond with:
can worsen by invasive dental procedures such as
Maroun Dagher
dental implants or tooth extractions.
[email protected]
What are the recommendations?
First make sure that every patient fills a complete
medical history form. Second, and in the case of
bisphosphonate intake, and if the patient will
undergo periodontal surgery or other procedures,
the dental professional may recommend the
interruption of Bisphosphonate prior to, during
and after surgery.
14- Light Amplification by Stimulated Emission of
Radiation.
15- Advantages of LASERs range from increased
coagulation that yields a dry surgical field and
better visualization, to tissue surface sterilization,
Journal of the Lebanese Dental Association
58
Temporo-Mandibular Disorders
Characteristics of temporo-mandibular joint pain:
a prospective tunisian study.
L Oualha1, H Hentati2, A Salma3, M Dhidah4, F Ben Amor5, J Selmi6
INTRODUCTION
Within the context of temporo-mandibular joint
pathology, pain is considered the most frequent cause
of consultation. Indeed, and given the multi-factorial
character of the articular structure deteriorations, they
often come along with symptoms and varied clinical
signs, while pain remains the most important, frequent,
and constraining symptom.
The purpose of this study was to investigate the
following factors :
- determine the different etiologies of periarticular
pains.
- determine the frequencies and characteristics of
periarticular pains.
- evaluate and quantify pain intensity according to
two kinds of scales: simple verbal scale (VS) and
visual analog scale (VAS).
- check the concomitance between symptoms and
signs found during clinical examination.
MATERIALS AND METHODS
Fifty persons, aged between 20 and 40, were
randomly selected among patients presenting at
occlusal exam, in the oral medicine and oral surgery
service of the Odontological Clinic of Monastir and in
1 Oral Medicine and Oral Surgery Department,
Odontological clinic of Monastir, TUNISIA
2 Oral Medicine and Oral Surgery Department,
Odontological Clinic of Monastir, TUNISIA
3 Maxillo-Facial Surgery Department, University Hospital
of Sahloul Sousse, TUNISIA
4 Professor of Physiology, Faculty of Dental Medicine,
Monastir, TUNISIA
5 Professor of Anatomy, Faculty of Dental Medicine,
Monastir, TUNISIA
6 Professor, Oral Medicine and Oral Surgery Department,
Odontological Clinic of Monastir, TUNISIA
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
the maxillo-facial surgery service of Tahar Star
hospital of Mahdia, Tunisia.
A specific questionnaire was filled by each patient
during the clinical interview; it included, besides the
status of the patient (age, sex, consultation, address,
job…), a clinical index card evoking pain
characteristics: presence or absence of pain, location
and frequency of pain, provoking factors, pain onset.
Pain intensity was evaluated using two scales (VAS
and VS), as well as the patient’s painful antecedents
and
seniority.
Questionnaire
also
included
psychological status of the patient, possible
parafunctions or disturbances of masticatory functions
and signs observed during clinical examination as
follows:
1. functional signs such as articular rumors and
reduction or abnormal mandibular movements.
2. sensitivity to articular and muscular structure
population in closed and open mouth.
3. occlusal abnormalities.
From this investigation, a positive diagnosis was
established for each clinical situation. Results were
statistically organized using Excel software 2003.
RESULTS
Age and sex of patients had a significant influence
on pain incidence. Percentage of patients complaining
about periarticular pain was more important among
women (86%) than men (14%).
Regarding the extent of periarticular pain evaluated
by patients, it varied according to the incriminated
pathology. An attack limited only to joint resulted in
painful symptoms (40%) in specific points. On the
other hand, adjacent structures lesions were
responsible for genesis of locoregional irradiated pain
(52%), and diffuse pain displayed by some patients
59
Oualha L, Hentati H, Salma A, Dhidah M, Ben Amor F, Selmi J
(8%) was a source of anxiety. This duality resulted
from a phenomenon of convergence of noxious and
non noxious information that characterizes myofascial
pain.
According to the results of this study, different
trigger factors were responsible for pain: 48.8% were
due to prolonged chewing, 18.7% to yawning, and
16.2% to prolonged mouth opening.
The fourth and fifth trigger factors were stress
(14%) and cold (2.5%), respectively.
Pain intensity
Evaluation of temporomandibular articular pain
intensity with the simple verbal scale and the visual
analog scale showed a certain correspondence in this
subjective measure. For 80 to 86% of patients, it was
uncomfortable to distressing pain (corresponding to
the intervals 2-4 and 4-6 on the visual analog scale).
Unbearable pain was left only in 8% of patients
equivalent to the value found in the interval 6-8 of the
VAS, while the excruciating pain corresponding to the
interval 8-10 was not found in our sample.
Psychological profile of patients
Results showed that 86% of our patients displayed
psychological disturbances contributing to modulation
of pain experience. It was mostly related to anxiety
(49%).
Sensibility to palpation
Sensibility to joint palpation:
Palpation of the external aspect of TMJ* and retro
condylar area asserted presence of sensibility in only
70% of patients complaining of pain. In the remaining
30%, we noticed the existence of pathology without
painful signs, but dysfunction generated by pathology
distorted patient’s psychology and incited them to
complain about pain.
Sensibility to muscular palpation:
Examination of masticatory muscles showed that
80% of patients complaining about pain were sensitive
to muscular palpation, especially areas of masseter and
temporal muscles.
Parafunctions
In patients complaining about articular pain,
several parafunctions seem to be well correlated with
these signs. 44% of these patients displayed a dental
grinding, 18% to 22% suffered from bad habits or
bruxism. Occlusal examination revealed the presence
of interferences in 72% of the sample.
Etiologic diagnosis of periarticular pains
Articular pathologies were the most important
source of periarticular pains. Only displacements of
discs (86%), inflammatory and degenerative
phenomena (2% capsulitis, 2% osteoarthritis) were
noticed in study.
DISCUSSION
According to our study, percentage of patients
complaining from periarticular pains was more
important among women (86%) than men (14%). Those
findings are in accordance with several authors1-4.
Indeed, Chossegros confirmed the female prevalence
(85%) at an age ranging between 20 and 401. Woda and
Pionchon2 also found a strong female prevalence (ratio
1/3 to 1/10) regarding demand of care during orofacial pain management. According to Laplanche and
co-workers5, periarticular pain appears more in the age
range of 15-45, with always a female prevalence of 1/7
to 1/9 ratio.
These pathologies are responsible for this
periarticular pain as well as the amplification of the
degree of their irritability. Also, the role of female
hormones in pain genesis was incriminated: indeed,
the role of female sex hormones lies within the scope
of biochemical and physiological differences between
the two sexes regarding pain sensitivity (Fillingin and
Maxiner 1995; Riley and co-workers, 1998)2.
Other studies showed that the link between
algogenic activity and hormonal balances was due to
the presence of oestrogenes receptors in the concerned
tissues. The issue of their presence and possible
function under normal or pathological conditions is
applicable for temporo-mandibular joint (LeResche
and co-workers, 1997, in 2).
Triggering factors intervene by brutally disturbing
the so-called masticatory «homeostasis».
An imbalance which has been tolerated for a long
time because of its slow and progressive installation in
a young individual, becomes symptomatic in case of a
*Temporo-Mandibular Joint
60
Volume 45 - Nº 1 - 2008
Oualha L, Hentati H, Salma A, Dhidah M, Ben Amor F, Selmi J
rough and structural or behavioral modification, of the
masticatory device7. According to Fleiter8, the first
three factors analyzed (in his study) were the cause of
a loss of mandibular micro movements and rise of
macro movements. Thus , muscular tiredness
(hyperactivity) involves muscular and articular painful
symptoms.
Recently, certain neurobiological mechanisms were
described: they help in understanding these symptoms.
Important stimulations of tissues are likely to support
the release of endogenous inflammatory substances
which can activate the oversensitiveness phenomenon
of nociceptors. The clinical effects result in
spontaneous pains and localized hyperalgesia with
hypersensitivity to palpation. As for cold, some
authors classify it as a factor that worsens pain.
Mood, somatization disorders, and anxiety
contribute to overcome initial pain in chronic pain
episodes. Time allows psychological components to
dominate somatic component9. These various factors
play a considerable role, disrupting neurosensory
regulation and exaggerating symptoms.
Indeed, according to the “bio-psycho-social” model
of pain described by Okesson in 1995, life and
stressful events alter the functioning mechanisms of
the central nervous system and put it out of order.
Bioactive molecules (such as adrenalin) released
during stress, pain, on particular or sensitized grounds,
can worsen it.
Regarding the sensibility in muscular pain, in fact
the TMJ cannot withstand an excessive pressure
because of the nature of its fibro cartilage, which is
induced by phenomenon of adjacency, and causes
sensibility in muscular palpation11.
Gasma (in 2) (1994) noticed that in many cases,
psychological disoders would be the result and not the
cause of pain. But longitudinal studies proved that
scales of depression were only slightly predictive of
appearance of this type of musculo-articular pain of
the face (Von Koff et al., 1990). Thus, and as Okesson
underlined (in 2) (1996), psycho-social factors can
predispose
certain
individuals
to
develop
temporomandibular pain. They can also constitute
factors of maintenance of already established pain.
According to Molina (in 12), more than half of
patients sustaining an articular pathology suffer from a
bruxism. Electromyographic studies, such as those
carried out by Reding (1969) (in 12) in patients
suffering from bruxim,showed that protective reflexes
which avoid setting in forced and frequent contact of
the dental arches are disturbed or deleted.
Indeed, several authors11 think that in case of
parafunctions, the whole of the very powerful
masticatory muscles will be in hyperactivity. However,
the protective muscle of temporo-mandibular joint is
fragile
and
cannot
compensate
for
this
hypercontraction from where the expression of the
articular pain. In fact, Krief13 noticed that the contact of
bruxism facets generates a prolonged contraction
which entails a greater demand for ATP*, leading to its
exhaustion and thus to an impossibility of the
relaxation of the muscle, and finally to spasm; the fall
in ATP* involves vasoconstriction, accumulation of
metabolites of catabolism from where the activation of
nociceptives fibers at the origin of pain. Other
parafonctions such as atypical deglutition, and oral
breath, seem also well correlated with articular
dysfunctions, and studies carried out couldn’t explain
their pathogeneses, (Vanders, 1995; Widmalm, 1995;
Moss,1995; Miller, 1998; Israel, 1999; Gavish, 2000 in
12).
Finally, when analyzing all the elements of clinical
examination, we noticed that articular pathologies
were the most important source of periarticular pain
(displacements of discs 86%, 2% capsulitis, 2%
osteoarthritis). Thus, patients complaining about
articular pain consulted only when articular and/or
muscular attacks generated a dysfunction.
CONCLUSION
According
to
our
population
study,
temporomandibular pain is:
- mainly related to articular pathologies.
- most frequently found among women.
- occuring in presence of articular pathology.
- irradiating to neighbouring structures.
*ATP: Adenosine Triphosphate
Journal of the Lebanese Dental Association
61
Oualha L, Hentati H, Salma A, Dhidah M, Ben Amor F, Selmi J.
REFERENCES
1. Chossergros C, Cheynet F, Guyot L, Ferrara JJ Uyot L, SansomBellot V, Blanc JL. SADAM (syndrome algie et
dysfonctionnement de l’appareil manducateur): danger! Rev
Stomatol Chir Maxillofac 2002; 103 (1): 33-34.
2. Woda A, Pionchon P. Algies oro-faciales idiopathiques :
sémiologie, causes et mécanismes. Rev. Neurol 2001 ;
157(3):265-283.
3. Guillaumat G. Epidémiologie descriptive des troubles temporomandibulaires. French Society of Dentofacial Orthopedics
SFODF, September 1996.
4. Kuttila M, Niemi PM, Kuttila S, Alanen P, Lebell Y:TMD
treatment need in relation to age, gender, stress and diagnostic
subgroup. J Orofac Pain 1988, 125 (1): 67-74.
5. Laplanche O, Peudeutour P, Duminil G, Mahler P, Bolla M.
Dysfonctionnements de l’appareil manducateur. Encyclo Méd
Chir (EMC), Odontologie, 23-435-E-20, 2001, p 15.
6. Reychler H, Piette E. Traité de pathologie buccale et maxillofaciale: Pathologie articulaire temporo-mandibulaire. Edition
Deboeck Université, 1991.
8. Fleiter B. Rééducation de l’appareil manducateur : optimiser la
fonction. Information Dentaire 2005 ; 6 : 301-388.
9. Hue O. Diagnostic des algies et dysfonctions oro-faciales.
Information Dentaire 2005;13-22.
10. Boucher Y, Godefroy JN Expression et évaluation de la
douleur. Information Dentaire 2000; 24 :1807-1825
11. Gola R, Cheynet F, Chossegros C, Orthlieb JD. Les
dysfonctions de l’appareil manducateur (D.A.M). Rev.
Stomatol Chir Maxillofac 1995; 96(4): 177-292.
12. Chassagne JF, Chassagne S, Deblock L, Gillet P, Kahn JP,
Bussienne JE, Pierucci F, Fyad JP, Simon E. Encycl Méd Chir
(EMC), Stomatologie, 22-056-R-10, 2002, p 46.
13. Krief A. Le bruxisme, un défi permanent à nos traitements.
Information Dentaire 2002 ; 38 : 2893-2898.
Correspond with:
Faten Ben Amor
[email protected]
7. Goupille P, Fouquet B, Coutty P, Gogo D, Valat JP. Articulation
temporo-mandibulaire et polyarthrite rhumatoïde. Rev Rhum
Mal Ostéoartic 1992; 59 (3) : 213-218.
Journal of the Lebanese Dental Association
62
Q’s and A’s
Endodontology Update: the ANSWERS.
Prepared by Fadl Khaled*, BDS, DES Endo.
1- • Achievement of an impervious seal.
• Canal disinfection.
• Lubrication of the master cone.
• Adhesion to dentin.
7- • Surgery.
• Instrumentation beyond apex.
• Periodontal-ligament injection.
• High risk of infective endocarditis (IE).
2- Because:
• There is more likelihood of post-operative
discomfort.
• Sealer and gutta-percha cause a severe,
inflammatory reaction in periradicular tissue.
• Prognosis is poorer.
8- The theory of focal infection was propounded by
Dr. William Hunter in 1910. It was referred to
infections found around poorly made restorations,
and was used to explain diseases for which there
was no cure. It finally results in needless tooth
extraction.
3- • Phagocytosis of microorganisms.
• Removal of small foreign particles.
• Antigen processing and presentation.
9- • They require training with the instrument to
become proficient.
• They are sensitive to canal contents.
• They measure impedance between the file and
mucosa.
• On average, they are accurate to within 0.5mm
of the apex.
4- • Root canal treatment.
• Root end surgery.
• Antibiotics (penicillin for 3 weeks).
5- Polyamines are produced by bacteria and host 10- • Displacement.
cells. They may be found in infected root canals,
• Alveolar fracture.
and they are more concentrated in teeth with
• Root fracture.
spontaneous pain.
• Crown fracture.
11- It is a technique used in the preparation of root
6- Because:
• It provides a pathway for drainage to prevent
canals. The main goal is to enlarge the coronal
spread of infection.
part of the canal, in order to ensure a passive
• It relieves increased tissue pressure.
access to the apex.
• It provides relief of pain.
• It increases circulation to the area and improves 12- • Pain to percussion.
delivery of antibiotics.
• History of spontaneous pain.
• Variations in mobility.
* Chief of Clinical Services, Department of Endodontics,
Lebanese University School of Dentistry, Beirut, Lebanon,
and
Clinical Instructor, Department of Restorative Dentistry,
Beirut Arab University, Faculty of Dentistry, Beirut,
Lebanon
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
13- • Calcification.
• Anomalous location.
• Inadequate access cavity.
63
Q’s and A’s
14- • Straight-line access.
• Good light source.
• Magnification.
15- • Laterally condensed cold gutta-percha.
• Vertically condensed warm gutta-percha
(Schilder’s technique).
• Hybrid technique.
• Thermomechanical compaction of gutta-percha.
• Thermoplasticised gutta-percha.
16- • Sodium hypochlorite (NaOCl 2.5%).
• EDTA (Ethylene Diamine Tetraacetic Acid)
17%.
• Chlorhexidine 2%.
• Citric acid 10%.
17- There are no medical conditions that
contraindicate endodontic treatment. However,
some situations require special care, such as
allergies, bleeding tendencies, or cardiac disease.
18- • Presence of sinus tract.
• Localised deep periodontal probing.
• Lateral radiolucency.
Correrspond with:
Fadl Khaled
[email protected]
64
Volume 45 - Nº 1 - 2008
Orthodontics and Dentofacial Orthopaedics
Conditions and techniques for clinical application of orthodontic
miniscrews.
Ghada Al Asmar1, BDS, CES Ortho., Antoine Saadé2, DCD, CES Ortho., DU Ortho., CECSMO
Abstract
The incorporation of miniscrews into orthodontic treatment planning has allowed for predictable anchorage control and has
increased the ability to correct severe skeletal and dental discrepancies. Various minicsrews systems are now available for
clinical use and abundant reports and studies are being published, dealing with different aspects of their applications (biology,
surgical procedures, placement sites, complications, success rate…). The aim of this article is to review the actual
considerations regarding their mechanical properties, surgical considerations, risks and complications as well as their success
rate and failure reasons.
A- HISTORY26
Achieving absolute anchorage has always been a
very important objective in orthodontic treatment.
After the success in implant osseointegration, the use
of endosseous implants as an absolute anchorage
system has been reported and evaluated in different
studies.
In 1945, and following the failure of Higley and
Gainsforth to orthodontic anchorage, using implants as
anchorage in orthodontics was not common. But after
Brånemark and co-workers reports (1970) on
successful osseointegration of implants in bone,
orthodontists took an interest in using implants for
orthodontic anchorage.
In 1978, Sherman3 placed six vitreous dental
implants into the extraction sites of mandibular third
premolars in dogs and loaded them with orthodontic
forces. Only two of the six implants were considered
successful.
Later on, Roberts and co-workers4 investigated
the osseous adaptation of rigid endosseous implants
to continuous loading: titanium implants with an
acid-etched surface were screwed into the femur of
rabbits and were found to be useful as a source of
firm osseous anchorage for orthodontics and
dentofacial orthopaedics. They concluded that
Lebanese University School of Dentistry, Department of
Orthodontics, Beirut, Lebanon,
1 Clinical Instructor
2 Chief of Clinical Services and Postgraduate Faculty
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
endosseous implants could be used as a firm osseous
anchorage for orthodontics and dentofacial
orthopaedics.
The endosseous implants used in previously
mentioned studies were mostly blade-type or
conventional prosthodontic fixtures, which were
difficult to use clinically by orthodontists because of
the complex procedure involved and their relatively
high cost1. Consequently, Kanomi5, and Costa and coworkers6 introduced the mini-implant procedure using
endosseous implants that were more suitable for
orthodontic purposes.
B- ADVANTAGES
Contrary to conventional implants, miniscrews can
be placed in an area that would not accept an
endosseous implant such as the cortical bone, the
zygomatic bone, the mid-suture the maxilla, and interalveolar and inter-radicular bone7,5,8. Furthermore, the
surgical procedure is simplified, discomfort after
placement is reduced and early loading is also
possible.
From a mechanical point of view, miniscrews
deliver rigid anchorage against orthodontic load,
adverse reciprocal effects are eliminated and their
removal is easier after orthodontic treatment. Finally,
since patient compliance is not necessary (such as for
extra-oral appliances), treatment time might be
significantly reduced.
65
Al Asmar G, Saadé A
A
B
Fig. 1. Minisrew placed between right maxillary first molar and second premolar to support distalizing the posterior segment.
A. Before distalization. B. After distalization: Class I molar and canine achieved.
and effectively bring them on dental arch.
Miniscrew anchorage allows force vectors that
are otherwise hardly attainable.
4- Uprighting of mesially tipped molars.
5- Correction of canted occlusal planes: these cases
have conventionally been accepted, ignored, or
referred for correction with orthognathic
surgery. Miniscrew anchorage can now be
effectively used to correct asymmetries and
canting of occlusal plane.
D- MECHANICAL AND BEHAVIORAL
PROPERTIES
Fig. 2. Protraction of a left mandibular second molar using
a miniscrew placed between premolars.
C- CLINICAL APPLICATIONS25
Miniscrews might be used in different steps of
orthodontic treatment and in different dental and occlusal
situations. Although their use cannot be theoretically
limited, typical applications include the following:
1- Anchorage control in space closure: whether
closing space is present from extracted or
missing teeth or created as a result of molar
distalization, the use of miniscrew anchorage
provides a good control.
2- Intrusion of over-erupted teeth: in the past,
intrusion of such teeth was virtually impossible.
The use of miniscrew anchorage allows troublefree intrusion of these problematic teeth.
3- Traction of impacted teeth: in many instances,
the precarious position of an impacted teeth,
especially canines, can limit the ability to safely
66
Miniscrews are either stainless steel or titanium.
Their mechanical and behavioral properties affect their
failure mode and, consequently, have to be taken into
consideration in clinical applications.
Mechanical properties:
The failure of both materials depends on the
following mechanical properties: flexural, torsional,
and pull-out strengths.
- Flexural strength: the type of the alloy is not only
important to avoid the breakage but also the bending
during the use of an orthodontic screw. In fact, it could
be difficult for the screw to complete its self-tapping
and its removal whenever it bends during insertion9.
Carano and colleagues9 foud out that, stainless steel
screws reached the load at failure (fracture) in bending
at values twice as high as titanium at lower levels of
forces; however, the yield point (permanent
deformation) occurred at lower levels.
Volume 45 - Nº 1 - 2008
Al Asmar G, Saadé A
Fig. 3. Minisrew displacement after applying orthodontic force.
- Torsional strength and insertion moments
(torsional moments required for the insertion):
Moments greater than 40 Ncm were found to fracture
the screws in torsion. Stainless steel screws were
shown to sustain higher torsional moments than the
titanium screws9.
The torsional moments required for the insertion of
different screws (maximum 11 Ncm) were
significantly lower than those required to break them
(40 Ncm)9. However, it is possible that the torsional
force leading to fracture could be higher than 40 Ncm.
This could be a serious issue with the titanium
implants where torsional fracture is closer to 40 Ncm
(compared to approximately 110 Ncm for the stainless
steel screws). Therefore, the use of a specifically
designed screwdriver, held by the fingertips, was
recommended to reduce this torsional force. Also, a
0.2 mm diameter reduction of the screw would reduce
the resistance to torsional stress by approximately
50%; consequently, the authors suggested using
screws at least 1.5 mm wide9.
- Pull-out strength: Materials used in orthopaedics
screws are significantly stronger than bone; thus, pull-out
failure usually occurs by shearing the bone material
around the screws5. The shear strength of the bone
adjacent to the screw and the screw geometry (major
and minor diameters, and the thread pitch) were found
to be critical factors with respect to the failure during
pull-out9,10.
Miniscrews behavior does not depend on the
material but on the thread design, shape of the screw,
and the drill / screw diameter ratio9.
- Design: the asymmetric profile of the threads was
shown to be better than the symmetrical cut9.
- Shape: a cylindrical shape behaved better than the
Journal of the Lebanese Dental Association
Fig. 4. Miniscrew placement for left mandibular molar
distalization.
conic one (inter- radicular site is between 2.5 and 3.5
mm)9.
- Drill/screw diameter ratio: the ratio between the
drill and the miniscrew diameters is crucial for the
successful implantation and resistance of the
miniscrew. A difference of 0.3 mm (or a ratio of 0.3)
between the drill and the screws was found to be ideal9.
Behavioral properties:
According to Carano and Melsen12, only an
ankylosed tooth is considered as a reliable absolute
anchorage.
Liou and colleagues13 found that miniscrews are a
stable anchorage and remain clinically stable, but not
absolutely stationary throughout orthodontic loading;
they might be extruded from -1.0 to +1.5 mm, and
tipped forward up to 0.4 mm, depending on the
orthodontic force. To prevent possible complications,
authors recommended to place miniscrews in an
edentulous area that has no foramen, major nerves, or
blood vessels pathways, or in a tooth-bearing area
allowing a 2 mm safety clearance between roots.
67
Al Asmar G, Saadé A
The displacement of miniscrews was attributed to
several factors: fixture size, orthodontic force
magnitude, bone quality and quantity at the miniscrew
site, primary fixation and the waiting period-the latter
playing a relatively determinant role13.
1-Fixture size: a larger implant size and light
orthodontic forces do not guarantee the miniscrew
retention13.
The success keys are the following12,14,15:
• Diameter: If the diameter is reduced, the
stationary is less and the risk of fracture increases
(the ideal diameter should be approximately 1.3 1.5 mm)13. In addition, the miniscrew is more
fragile (if the diameter decreases from 2 mm to
1.5 mm, the maximum bending and torsion stress
on the screw increases more than two-folds). On
the other hand, an increase in the diameter is
rarely suitable because of lack of space in the
inter-radicular bone zone (2.5 to 3.5 mm).
• Length: Stability was found to depend more on
the length than on the diameter of the
miniscrew; however, based on anatomic studies
and mechanical tests, the optimal length was set
to 6 – 8 mm13.
2- Orthodontic force magnitude: Asikainen and
colleagues17 showed in an animal experiment that titanium
implants could resist lateral forces up to 250-350 mg
without losing osseointegration over a three month
loading period. In addition, Kyung and co-workers18 stated
that microimplants with a diameter as small as 1.2–1.3mm
could withstand a 450g force.
3- Bone quality and quantity: This factor
determines the center of screws rotation. Bone
trabeculations add a little to the miniscrew anchorage
in the bone12,21.
4- Waiting period: Liou and co-workers13 showed
that a two-weeks waiting period is not necessary if
primary stability is achieved (i.e. mechanical
retention). Immediate loading with controlled force
(50 N) can be done without damage, risk of failure, or
decrease of success rate.
68
E- COMPLICATIONS21,25,26
Accurate miniscrews placement should be
performed with a thorough understanding of soft and
hard tissue anatomy, surgical response, and healing to
reduce per and post-operative complications. Only few
were reported in the literature:
- Injury of anatomic structures such as nerves,
blood vessels, roots and maxillary sinus23. Some
regions in both jaws do not allow a safe insertion for
miniscrews like around sinus region or in the maxillary
tuberosity basal bone in the mandible close to the
dental nerve2. In some situations, required width of
inter-radicular bone is not enough and presence of
permanent dental germs close to placement site will
create surgical challenge to avoid teeth damage12,14.
Finally, the majority of authors agree that screws in
the midpalatal area are not suitable for growing
patients and have a low rate of success in adults. This
is where a dental implant works better than screws12.
- Infection of the insertion site if it is not kept
absolutely clean; the infection is also associated with
repeated drilling during placement12.
- Inflammation around the implant. Screws placed
in the attached gingiva without incisions are less likely
to develop infection and inflammation. A mild
swelling occurs with screws placed without a flap10.
- Heat generation during drilling.
- Screw breakage because of an increased bone
density or a decreased miniscrew diameter.
F- PAIN AND DISCOMFORT OF
PATIENTS21,22,23
Kuroda and co-workers23 evaluated pain and
discomfort after the placement of miniscrews and
miniplates by using retrospective questionnaires based
on a visual analog scale (VAS); The majority of
patients who received titanium screws or miniplates
with muccoperiostal flap surgery reported a severe
pain for a week. On the other hand, only half of the
patients who had miniscrews without muccoperiostal
flap reported mild pain which peaked one hour after
surgery and was less than the pain occurring one day
after starting an orthodontic treatment (19.5 versus 40
on 100 points visual analog scale)21,22. The other half
of the patients with miniscrews had no pain and did not
need any medication after the procedure. It was
Volume 45 - Nº 1 - 2008
Al Asmar G, Saadé A
consequently concluded that flap reflection is closely
related to pain caused by the surgical procedure21.
In addition, incidence of swelling, speech and
chewing difficulty after placement surgery was higher
in flap surgery in comparison to flapless surgery.
G- SUCCESS RATE
Different factors such as age, dental arch, drilling
and loading protocols, and the miniscrew shape were
found to affect the success and failure rate of
miniscrews were thoroughly evaluated2,21,25,26.
Woo et and co-workers (2003) found no statistically
significant differences between placing the miniscrews
in the mandible (11%) and the maxilla (16%).
In 2001, Kim and Choi found a higher success rate
with self tapping (34% failure) when compared with
the self-drilling method (63% failure)
Costa and co-workers24 stated that miniscrews can
be loaded immediately after insertion, and that
stability decreased after loading with torsion, whereas
for Kuroda and colleagues23, there was no significant
correlation between the rate of success and time of
loading, whether immediate or delayed.
And in 2005, Jang compared clinical success rate
between cylindrical and tapered screws: the study
showed no statistically significant difference between
the two shapes, although tapered shape had a higher
success rate (95%) than the cylindrical one (88%).
H- CONCLUSION
Achieving absolute anchorage is critical in the field
of orthodontics. Miniscrews offer orthodontists a new
and wide therapeutic solution in critical cases where
absolute anchorage is needed or when the patient is
poorly compliant.
After reviewing many reports, we found that the
level of 100% success rate in miniscrews clinical use
has not been reached yet. Many factors and criteria
should be considered for their success i.e. choice of the
mini-implants and their site, general health of the
patient, age, mechanical factors.. etc...
Well-designed and evidence-based trials are still
warranted for further knowledge in this field27.
Journal of the Lebanese Dental Association
REFERENCES
1. Lee JS, Kim DH, Park YC, Kyung SH, Kim TK. The efficient
use midpalatal miniscrew implants. Angle Orthod 2004;74:7114.
2. Sung J-H, Kyung H-M, Bae S-M, Park H-S, Kwon O-W,
McNamara Jr.J. Microimplants in Orthodontics. Ed. Dentos Inc.,
Daegu, Korea, 2006 (www.dentos.co.kr).
3. Sherman AJ. Bone reaction to orthodontic forces on vitreous
carbon dental implants. Am J Orthod 1978;74:79-87.
4. Roberts WE, Smith RK, Zilberman Y, Mozsary PG, Smith RS.
Osseous adaptation to continuous loading of rigid endosseous
implants. Am J Orthod 1984;86:95-111.
5. Kanomi R. Mini-implant for orthodontic anchorage. J Clin
Orthod 1997:11:763-7.
6. Costa A, Raffaini M, Melsen B. Miniscrews as orthodontic
anchorage: a preliminary report. Int J Adult Orthod Orthognath
Surg 1998;13:201-9.
7. Park H-S, Kwon T-G, Sung J-H. Non extraction treatment with
microscrew implants. Angle Orthod 2004;74:539-49.
8. Lee JS, Park HS, Kyung HM. Micro–implant anchorage in
lingual orthodontic treatment for a skeletal Class 2
malocclusion. J Clin Orthod 2001;35:643-7.
9. Carano A, Lonardo P, Velo S, Incorvati C. Mechanical properties
of three different commercially available miniscrews for skeletal
anchorage. Prog Orthod 2005;6:82-97.
10. Chapman JR, Harrington RM, Lee KM. Factors affecting
pullout strength of cancellous bone screws. J Biomech
1996;118:391-8.
11. Hearn TC, Schatzker J, Wolfson N. Extraction strength of
cancellous bone screws. J Orthop Trauma 1993;7:138-41.
12. Carano A, Melsen B. Implants in orthodontics. Prog Orthod
2005;6:62-9.
13. Liou EJW, Pai BCJ, Lin JCY. Do miniscrews remain stationary
under orthodontic forces? Am J Orthod Dentofacial Orthop
2004;126:42-7.
14. Degushi T, Nasu M, Murakami K, Yabuuchi T, Kamioka H,
Takano-Yamamoto T. Quantitative evaluation of cortical bone
thickness with computed tomographic scanning for orthodontic
implants. Am J Orthod Dentofacial Orthop 2006;129:7-12.
15. Chen YJ, Chen YH, Lin LD, Yao CC. Removal torque of
miniscrews used for orthodontic anchorage-a preliminary
report. Int J Oral Maxillofac Implants 2006;21:283-9.
16. Chung KR, Kim SH, Kook YA. The C-Orthodontic MicroImplant. J Clin Orthod 2004;38:478-86.
17. Asikainen P, Klemett E, Vuillemin T, Sutter F, Rainio V,
Kotilainen R. Titanium implants and lateral forces: An
experimental study with sheep. Clin Oral Implants Res
1997;8:465-8.
69
Al Asmar G, Saadé A
18. Kyung H-M, Park H-S, Bae S-M, Sung J-H, Kim I-B.
Development of orthodontic micro-implants for intraoral
anchorage. J Clin Orthod 2003;37:321-8.
19. Kim H-J, Yun H-S, Park H-D, Kim D-H, Park Y-C. Soft-tissue
and cortical-bone thickness at orthodontic implant sites. Am J
Orthod Dentofacial Orthop 2006;130:177-82.
20. Sugawara J, Nishimura M. Minibone plates: The skeletal
anchorage system. Semin Orthod 2005;11:47-56.
21. Kuroda S, Sugawara Y, Degushi T, Kyung H-M, TakanoYamamoto T. Clinical use of miniscrew implants as
orthodontic anchorage: Success rates and postoperative
discomfort. Am J Orthod Dentofacial Orthop 2007;131:9-15.
22. Bergius M, Berggren U, Kiliaridis S. Experience of pain during
an orthodontic procedure. Eur J Oral Sci 2002;110:92-8.
23. Kuroda S, Deguchi T, Hashimoto T, Kyung HM, TakanoYamamoto T. Root proximity is a major factor for screw failure
in orthodontic anchorage. Am J Orthod Dentofacial Orthop
2007;131:S68-73.
24. Costa A, Raffaine M, Melsen B. Miniscrews as orthodontic
anchorage: a preliminary report. Int J Adult Orthod Orthognath
Surg 1998;13:201-9.
25. Introduction of innovative orthodontic concepts using
microimplant anchorage. Adjunctive prerestorative tooth
movement without bracket appliances. Hayashi H. Edit.
Dentos, 2006.
26. Applications of orthodontic mini-implants. Lee JS, Kim JK,
Park Y-C, Vanarsdall, Jr RL. Quintessence, 2007.
27. Mini-implants in orthodontics: Innovative anchorage concepts.
Edit. Björn Ludwig. Quintessence, 2008.
Correspond with:
Antoine Saadé
[email protected]
70
Volume 45 - Nº 1 - 2008
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72
Volume 45 - Nº 1 - 2008
Instructions for authors
ISSN 1810-9632
AIM AND SCOPE
The Journal of the Lebanese Dental
Association “JLDA” is the official organ of the
Lebanese Dental Association. It is a
multidisciplinary dental journal addressed to
dental general practitioners.
Manuscripts are considered for publication if
they have not been published or submitted for
publication elsewhere. Clinical case reports,
literature reviews, technical reports, and research
studies are welcomed.
REVIEWING AND EDITING PROCESS
Manuscripts will be reviewed by the editor-inchief, editorial board, and at least two reviewers. In
case of conflict of opinion, an additional reviewer
or special consultant will be asked to act as an
adjudicator. Reviews are double-blind (for authors
and reviewers). Manuscripts accepted for
publication will be edited, in consultation with the
author, to fit the space available and ensure
conciseness, clarity and stylistic consistency.
Studies that draw conclusions from statistical
evidence will have the statistical analysis reviewed
by a qualified statistician.
Manuscripts that are not prepared in
accordance with these guidelines will be returned
to the author before review.
Manuscripts will be addressed to the editor in - chief of the journal, at the following address:
[email protected].
When accepted for publication, manuscripts
will be edited, in consultation with the author, to
fit the space available and ensure conciseness,
clarity, and stylistic consistency.
Authors must refrain from using articles to
sell or advertise for a particular trade name or
product.
GUIDELINES
• The journal follows recommendations of the
International Committee of Medical Journal
Editors (Vancouver Group) in regard to
preparation of manuscripts and authorship
(Uniform requirements for manuscripts
submitted to biomedical journals. Ann Intern
Med 1997;126:36-47).
• Manuscript should be submitted in English
according to the Oxford English Dictionary
or Websters, in three copies typed on one side
of a plain white paper, size ISO A4 (210x297
mm or 8.5x11 inches), double-spaced with at
least a margin of 25mm (1 inch).
• We welcome and encourage electronic
submission (upload manuscripts as a PC
Word file with tables and figures included at
the end of the document).
• Manuscript should not exceed 10 to 12 pages
(excluding references, figures, figure legends
and tables). All pages must be numbered
starting with the title page.
1. Title page:
• Must include the title of the article, name(s)
middle initial(s) and first name(s) of the
author(s),
title,
academic
degrees,
institutional affiliations, and locations.
• Should indicate if the manuscript was
Journal of the Lebanese Dental Association
Volume 45 - Nº 1 - 2008
presented before any organization (date and
location).
• Should indicate if author(s) received any
financial support or grant.
• Must list mailing address, business and
telephone number, fax number, and e-mail
address of the corresponding author.
2. Abstract/ keywords
• Must be submitted on a separate sheet of
paper and not exceed 250 words.
• Must be structured as follow: a- statement of
the problem, b- purpose of the study, cmaterials and methods, d- results, and econclusion.
• Abstracts for case reports and literature
reviews need not to be structured.
• Keywords: up to 10 keywords should be
supplied.
3. Text:
• Clinical reports: should describe the
author’s methods for meeting a patient
treatment challenge, and be no longer than 4
to 5 pages, with no more than 10 quality
descriptive illustrations.
• Literature review: should be an accurate
record of the sequence of development of a
particular phase of dentistry. It should be
complete and provide documentation by
references.
• Technical procedures: should state the
objective of the technique, provide a
description of the procedure with no more
than 8 quality descriptive illustrations, make
appropriate reference to alternate techniques,
discuss advantages and disadvantages, and
should be written in a step-by-step manner.
• Research studies: (a) state clearly the
problem and objective of the research (the
working hypothesis), (b) describe material
and methods to allow confirmation of the
observations, and indicate the statistical
methods used, if applicable, (c) report the
results briefly and accurately, (d) provide a
discussion that summarizes findings without
repeating in detail the data given in the result
section, (e) list the conclusion that may be
drawn from the research, (f) provide, under
separate heading, a statement of the
research’s clinical implications.
4. References
• All listed references must be cited in the text.
• Citations in the body of the text should be
identified by the superscript Arabic
numerals, and numbered in order of
appearance.
• The format should conform to that set forth
in “Uniform requirements for manuscripts
submitted to biomedical journal” (Ann Intern
Med 1997;126:36-47). Journal titles should
conform to the abbreviations in the
Cumulative Index Medicus.
Journal reference style:
1. Trabert KC, Caputo AA, Abou-Rass M.
Tooth
fracture-a
comparison
of
endodontic and restorative treatments. J
Endodont 1978; 3:341-5.
Book reference style:
2. Misch CE, editor. Occlusal considerations
for implant supported prosthetics. In:
Contemporary implant dentistry. St.
Louis, MO: Mosby-year Book; 1993. p.
705-33.
5. Illustrations
• All illustrations must be numbered and cited
in order of appearance.
• The figure number should be indicated on the
back of each photograph or on the mount of
each slide. Also indicate with an arrow the
top edge in pencil.
• All illustrations are returned after
publication.
• Radiographs: submit the original radiograph
as well as two sets of prints.
• Black and white: submit three sets of high
quality glossy prints. Should the quality
prove inadequate, negatives will be
requested as well. Photographs should be
unmounted and untrimmed.
• Color: color is used at the discretion of the
publisher. Original slides must be submitted
in addition to two sets of prints made from
them (3x4 inches).
• Drawings: figures, charts, and graphs should
be professionally drawn and lettered large
enough to be read after reduction. A good
quality laser-printed arts is acceptable (no
photocopies) for reviewing and electronic
files must be provided upon acceptance.
• Legends: figure legends should be grouped
on a separate sheet and typed double-spaced.
6. Tables
• Each table should be logically organized, on
a
separate
sheet,
and
numbered
consecutively with arabic numerals.
• The title and footnotes should be typed on
the same sheet as the table.
COPYRIGHT RELEASE
The following statement, signed by all
authors, must accompany submitted manuscripts
before they can be reviewed for publication:
The undersigned author(s) transfer all
copyright ownership of the manuscript (title of
the article) to the Editorial Board of the Journal
of the Lebanese Dental Association, in the event
the work is published. The undersigned author(s)
warrant(s) the article is original, is not under
consideration for publication by any other
journal, and has not been published previously.
The author(s) confirm that they have reviewed
and approved the final version of the manuscript.
PERMISSION AND WAIVER
• Permission of author and publisher must be
obtained for the direct use of material (text,
photos, drawings) under copyright that is not
the property of the authors.
• Waivers must be obtained for photographs
showing persons. When such waivers are not
supplied, faces will be masked to prevent
identification.
73
Hazmieh - Sayyad
Phone: 05/452555
Email: [email protected]
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