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Ta b l e o f C o n t e n t s 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 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Fig. 1: Meta-analyses in medical, dental and nursing journals (Source: Pubmed, limited to publications of human studies in English) 60 50 40 30 20 10 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 0 1991 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 2500 2400 2300 2200 2100 2000 1900 1800 1700 1600 1500 1400 1300 1200 1100 1000 900 800 700 600 500 400 300 200 100 0 1990 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. 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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 Forthcoming Dental Meetings December 1-2/2008 2nd CAD/CAM & Computerized Dentistry International Conference Dubai, UAE www.cappmea.com October 28-31/2008 16th Alexandria International Dental Congress Alexandria, Egypt www.aidc-egypt.org October 29-November 1/2008 American College of Prosthodontics (ACP) Nashville, Tenessee, USA Fax: 00-1-312-573-1257 Email: [email protected] www.prosthodontics.org December 4-7/2008 American Association of Oral and Maxillofacial Surgeons (AAOMS) Dental Implant Conference Chicago, Illinois, USA Fax: 00-1-847-678-6286 www.aaoms.org October 29-November 2/2008 American Academy of Implant Dentistry (AAID) San Diego, California, USA Fax: 00-1-312-335-9090 Email: [email protected] www.aaid-implant.org January 23-24/2009 60th Anniversary Quintessenz Jubilee Meeting Berlin, Germany www.quintessenz.de November 3-7/2008 8th Asian Congress on Oral and Maxillofacial Surgery www.asianaoms.org Jan 28-Feb 1st /2009 Yankee Dental Congress Boston, USA www.yankeedental.com November 5-8/2008 World Orthodontic Congress Orthodontic Convention Mumbai, India www.bosq.org Feb 26-March 1/2009 Chicago Dental Society Midwinter Meeting Chicago, USA Fax: 00-1-312-836-7337 www.cds.org & 44th Indian November 19-21/2008 7th Arabic Congress of Pediatric Dentistry Dead Sea, Jordan www.jda_congress.com November 25-29/2008 ADF 2008 (Congrès de l’Association Dentaire Française) Paris, France www.adf.asso.fr November 30-Dec 1-3/2008 Greater New York Dental Meeting New York, USA gnydm.com Journal of the Lebanese Dental Association Volume 45 - Nº 1 - 2008 February 27-28/2009 American Academy of Fixed Prosthodontics (AAFP) Chicago, USA Fax: 00-1-707-875-2927 www.fixedprosthodontics.org Feb 26-28/2009 Academy of Osseointegration (AO) San Diego, USA Fax: 00-1-847-709-3029 www.osseo.org 71 Feb 28-March 1/2009 American Academy of Restorative Dentistry (AARD) Chicago, USA www.restorativeacademy.com March 5-8/2009 American Academy of Orofacial Pain (AAOP) Austin, USA Fax: 00-1-856-423-3420 www.aaop.org March 5-10/2009 33rd Australian Dental Congress and exhibition Perth, Australia www.adia.org.au March 10-12/2009 AEEDC 2009/Oral Health Progress UAE International Dental Conference and Arab Dental Exhibition, Dubai International Convention and Exhibition Centre, Dubai, UAE Tel: 00-971-4-362-4717 Fax: 00-971-4-362-4718 E-mail: [email protected] www.aeedc.com April 1-4/2009 International (IADR) / American (AADR) / Canadian (CADR) Associations for Dental Research Miami, USA Fax: 00-1-703-548-1883 www.iadr.org 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] LBP 3.000 x10 + $6 + $1 + $2 Only $5/month from IBL Bank offers you a wide range of products and services for only 5$/month: 'RPLFLOLDWLRQ of an XQOLPLWHGQXPEHURIELOOVZLWKRXWDQ\DGGLWLRQDOIHHV 'RPLFLOLDWLRQ of your VDODU\ WKDWDOORZV\RXWRJHWDQLQVWDQW&UHGLW)DFLOLW\RIWLPHV\RXU VDODU\YDOXH DGGLWLRQDOIUHHVHUYLFHVLQFOXGLQJ)UHH0DVWHU&DUGFDUG)UHHSHUVRQDODFFLGHQW inVXUDQFHXSWR)UHH606QRWLÀFDWLRQIRUHDFKELOOGRPLFLOLDWLRQSD\PHQWD )UHHFKHFNERRN)UHHRQOLQHEDQNLQJ)UHHVWDWHPHQWRIDFFRXQW)UHHLQFRPLQJWUDQVIHUV )RUPRUHLQIRUPDWLRQSOHDVHYLVLWDQ\RIRXU,%/%DQNEUDQFKHVRUFDOOXVRQ1284 IURPDQ\PRELOH SKRQHRUÀ[HGOLQH