Smile Volume 3 Issue 4

Calendar of Events 2009
Smile Dental Journal Volume 3, Issue 4 - 2008
Implantology
Immediate Loading of Implants Placed Into Fresh Extraction Sockets with Peri-Apical Lesions without Augmentation
Abstract
The objective of the present study was to evaluate the clinical and radiographic outcomes of immediately placed OsteoCare implants into fresh extraction sockets of maxillary central incisor teeth with periapical lesions, without raising a flap and loaded immediately with the final abutments. All implants were restored immediately with provisional unsplinted acrylic resin crowns above their immediately placed final abutments. The final restorations were placed after 3 to 6 months. The parameters were reported immediately after implant placement and after 3, 6 and 9 months. The described technique included 20 patients of young age, with 3 cases failure. The present results showed promising data for immediate implantation and provisionalization to replace teeth with periapical lesions in the anterior maxilla. The technique applied in this study shortens treatment time and simplifies implant restoration for the dentist, as well as, for the patient. It is evident that the success of this technique requires good case selection, atraumatic tooth extraction, achieving and maintaining primary stability.
Key words: Immediate implantation; marginal bone defect; periapical lesion; immediate loading.
Since Brnemark1 introduced the osseointegration concept in 1985, a healing period of at least six months has been recommended between tooth extraction and implant placement. In addition, the implant is placed after raising a full-thickness mucoperiosteal flap. It was also assumed that the implant should remain submerged in a load-free environment during the healing period, which is 3-4 months in the mandible and 6 months in the maxilla. After that, a surgical exposure of the implant can be made, the abutment connected and the restoration placed (Adell et al. 2, Brnemark et al. 1). This prolonged time after tooth extraction and full-thickness mucoperiosteal flap reflection result in buccal bone resorption and soft tissue loss. Thereby, the final esthetic results may be compromised. In the anterior maxilla, the labial plate of bone is thin and more prone to postextraction resorption.3 Since the maintenance of an existing anatomical structure is easier than its re-construction, immediate total replacement of failing teeth with dental implants was suggested. Immediate implantation has provided the opportunity to achieve better and faster functional and esthetic results. Numerous studies have reported predictable results for immediate implant placement into fresh extraction sockets, with and without bone grafting materials and barrier membranes.4-14 Immediate implant placement into fresh extraction sockets with a pathologic lesion is considered a contraindication by many authors including Saadoun3, Block & Kent 15 and Sclar. 16 The authors considered immediate implant placement following tooth extraction is indicated only when the extraction socket is intact and free from any pathologic lesions. Cavacchia & Bravi17 recommended that the extraction socket should be free from residual infection, but there is a chance of success if there is no active suppuration, pain or swelling. In other words, the granulation tissue associated with chronic infection does not contraindicate immediate implant placement. Nemcovsky et al.8 however recommended delayed/immediate implant placement; timing of implant placement can be delayed for 4-6 weeks after tooth extraction if there is a periapical infection. Immediate implant placement in the presence of active periapical infection has been reported by Novaes & Novaes18, Novaes et al.19, Rosenquist & Grenthe.20 Once the idea of immediate implant placement was accepted, the next logical question was whether this dental implant can be immediately restored, at least with a provisional restoration. The idea of immediate implantation, without raising a flap and immediate provisionalization has emerged as an alternate approach that can increase patients acceptance of implant treatment, shorten treatment time, reduce patient discomfort, and thereby providing patients with a simplified quick restoration. Recently, clinical studies have demonstrated that implants with rough surfaces can be loaded at earlier times, thus, reducing the period between surgery and restoration. Grit-blasted and acid-etched implants are in this category, and their early loading in patients with good bone quality and quantity has been proven to be successful. OsteoCare implants (OsteoCare TM International, Colnbrook, England)
6 Smile Dental Journal Volume 3, Issue 4 - 2008
Prof. Tarek Mahmoud Aly

BDS, MSc, PhD Oral and Maxillo-Facial Surgery Dean of Faculty of Dentistry, Pharos University , Alexandria drtarekmahmoud@yahoo.com
Dr. Sarah Mohamed Arafat

BDS, MSc Oral Surgery Faculty of Dentistry, Alexandria University sarah2000arafat@yahoo.com
Operative Dentistry Implantology
used in this study, are characterized by grit-blasted and acid etched surface. Implants with rough surfaces achieve faster and better osseointegration, greater bone implant contact (BIC), higher removal torque values and better primary stability than do implants with smooth surfaces. Therefore, they can be loaded at earlier times, thus, reducing the period between surgery and restoration. Grit-blasted and acid-etched implants are in this category and their early loading has been proven to be successful in previous studies3,21-26 that recommended using such implants with rough surfaces for immediate placement and provisionalization. The idea of immediate provisionalization of immediately placed dental implants was introduced and applied in some recent studies. At the beginning, most studies such as those by Balshi & Wolfinger7, Cooper et al.27, Petropoulos et al.28, involved implant placement in the interforamina area of the mandible; where the densest bone is located. Implants in these studies were bilaterally splinted and retained overdentures or fixed bridges. Later, other researchers applied immediate loading of immediately placed dental implants for single-tooth implant restorations. Provisional restorations for single tooth implants can be a modified denture tooth processed into the base of acrylic partial denture29, provisional Maryland bridge30, the crown of the extracted tooth itself if it is sound31 or simply a provisional acrylic single crown.3,32,33 Garber et al.34 reported excellent results with anterior single-tooth implants that were provisionalized after 3 weeks. The provisional restoration was kept nonfunctional out of occlusion for 6 to 8 weeks after which the final restoration was placed. The authors concluded that if woven bone begins to form in a matter of weeks and lamellar bone is preferred for better stress distribution, early loading may be beneficial to bone formation. Thus, immediate total tooth replacement allows maintenance of the bony housing and soft tissue that was present before extraction, while establishing root form anchorage in the bone for esthetic restoration. Locante35 in his study which was conducted on 55 patients, reported a success rate over 98%. In his study, Zimmer Spline Twist MP-1 implants were placed immediately after extraction to replace anterior teeth from the second premolar forward, using a flapless surgery, seating the final angled abuments and placing nonfunctional immediate provisionals for 6 months before the final restorations were placed. Jo et al.36 demonstrated a 98.9% success rate for implants placed in fresh extraction sockets and immediately loaded. However, the authors attributed this favorable result to the expandable implant 3 system used. Similar results were documented by Saadoun who performed immediate implant placement and temporization in extraction sites, with only a 4.48% failure rate. Similarly, Kan et al.37 evaluated immediate implant placement and provsiona lization of maxillary anterior single HA-coated threaded implants in 35 patients. The study suggested that favourable implant success rates can be achieved, with good peri-implant tissue responses and aesthetic outcomes. Moreover, Lorenzoni et al.38 reported 100% survival rate in a very similar study to the present study. The authors evaluated the clinical outcome of immediate loading of single-tooth implants placed immediately after extraction.38 Stepped-screw type grit-blasted acid etched Frialit-2 Synchro implants were placed into fresh extraction sockets in the incisal maxillary region. After implants were inserted, the angled abutments were seated and immediately restored with unsplinted acrylic provisional crowns. The final
crowns were inserted 4-6 months after implant placement. No implants failed up to 12 months after insertion, resulting in 100% survival rate and all implants maintained excellent peri-implant 38 soft tissue conditions. This study however included insertion of the implants with increasing the toque up to 45 N/cm and wearing an occlusal splint for 8 weeks. Similarly, Norton et al.39 demonstrated that immediate temporization of Astra Tech ST implants, placed immediately after extraction in the maxilla, can be safe, predictable and yield favourable soft tissue aesthetics. The survival rate in that study was 96.4%. On the other hand, Chaushu et al.40 in their study, reported that immediate loading of implants placed immediately into fresh extraction sites may carry a risk of failure in 20% of the fixtures. The survival rate was 82.4% for immediately loaded single-tooth implants placed into fresh extraction sockets compared to 100% survival rate for immediately loaded single-tooth implants placed in healed sites. Cavacchia & Bravi17 recommended that implants placed into fresh extraction sockets should not be loaded immediately. Similarly, Sclar16 in 2004 considered loading of the fragile buccal plate of bone and encroachment on the interproximal bone causes bone resorption, recession and blunting of the papillae. The rationale for recommending delayed loading is that immediate loading carries a risk for reduced BIC, fibrous encapsulation of the bony defect and apical epithelial migration. In addition, there are several case reports of immediate provisionalization of immediately placed different types of implants by; Kios & Kan29, Touati & Guez30 using Replace Nobel Biocare and Frialit-2 implants, Wohrle31 using Replace Steri-Oss implants, Park et al.32 using Osseotite 3i implants, Leary & Hirayama33 using Bicon implants, Baumgarten et al.41 using Certain Pervail 3i implants. Primary implant stability is in general a key factor to consider in implant success before attempting immediate loading. It becomes even more crucial in cases of immediate loading of implants immediately placed into fresh extraction sites, as was mentioned by Touati & Guez30 and Lorenzoni et al.38 The surgeon should consider that during the first 4-6 weeks after surgery, primary stability actually decreases due to the remodelling phase of necrotic bone, caused by surgical trauma.1 Therefore, the implant has to be firmly anchored to the bone immediately after its surgical placement, as was assured by Cavacchia & Bravi.17 Primary stability depends on the surgical technique of implant installation and proper implant selection. The objective of the present study was to evaluate the clinical and radiographic outcomes of immediately placed OsteoCare implants into fresh extraction sockets of maxillary central incisor teeth with periapical lesions, without raising a flap and loaded immediately with the final abutments.
Material & Methods
Twenty patients were selected from the Outpatient Clinic of the Oral Surgery Department, Faculty of Dentistry, Alexandria University. Patients were17-25 years old and were of both sexes. All patients were free from systemic and local health conditions that can compromise implant success. All patients were nonsmokers, had good oral hygiene, good periodontal status of all teeth, adequate posterior support, adequate inter-arch relationship and interocclusal space that could accommodate the implant abutment and the future crown restoration, had opposing natural teeth, and had no parafunctional habits. All patients signed an informed consent before starting the treatment.
Immediate implantation was performed to replace teeth with periapical lesions, such as; badly decayed teeth that can not be restored, teeth with failed endodontic treatment, fractured teeth after endodontic treatment and teeth with fractured roots after facial trauma. All extracted teeth were maxillary central incisor teeth, had no periodontal disease and no mobility.
(Figure 1)
OsteoCare implant fixture.
Implant System
OsteoCare endosseous root-form implants (OsteoCare TM International, Colnbrook, England), were used in this study. The advanced implant is formed of two-pieces; the implant body and the abutment, with an internal hex connection.
(Figure 2)
OsteoCare implant angulated abutments.
Advanced implants (Fig. 1) are made from Grade II Titanium, with internal hex connection, double-threaded, with grit-blasted and acid-etched surface and have a flared neck characterized by grooving and acid etching. The implant is available in two diameters; 3.75 mm and 4.50 mm, with a wide range of lengths; 8 mm to 18 mm, according to each case requirement.
Implant Body
Implant Abutment
OsteoCare abutments are made of Titanium alloy and can be prepared if needed (Fig. 2). They are available in different angulations from 0 to 45 degrees and in two lengths; 3 mm and 5 mm and in diameters 3.75 mm and 4.5 mm. Implant abument Trial Abutment is tried by engaging the internal hex in the implant fixture with the hex on the bottom of the trial abutment (Fig. 3). A hole also passes through each trial abutment to facilitate rotation with the hex tool situated in the base on the trial abutment stand. The selected abutment is seated and fixed to the implant internal hex by a retaining screw.
(Figure 3)
Trial abutments kit.
Clinical examination included evaluation of the condition, periodontal status and mobility of the tooth to be extracted and all adjacent and opposing teeth. Inter-arch relationship and interocclusal space that could accommodate the implant abutment and the future crown restoration was evaluated both clinically and by the aid of diagnostic study models. A distance of at least 8-10 mm was required. Alveolar ridge width was determined by direct measurement at 3 different points at the buccal side, using the penetrating bone caliber under local analgesia. Scaling of all teeth was performed and oral hygiene measures were re-enforced and explained to each patient. Then, the shade was selected and the acrylic resin provisional restoration -replacing the to be extracted tooth- was fabricated on the study model with a contour and dimension similar to that of the contralateral tooth. The provisional was free from occlusion in centric and eccentric relations (protrusive contact and lateral excursion) and was designed leaving a 1 mm space mesially and distally to avoid any micromotion caused by the physiologic tooth movement of adjacent teeth. The provisional crown used was either an acrylic denture tooth or an acrylic shell crown of appropriate size, shape and shade. Then, the tooth was removed from the cast, the cast was lubricated and the crown was adjusted by self-cure acrylic resin.
Pre-Operative Phase A- Clinical & Laboratory Procedures
an overall view of the maxilla and the mandible, existing teeth, amount of bone beyond the root apex, root length, root angulation, proximity to vital structures, i.e.; nasal floor and presence of any pathological conditions. Direct digital standardized peri-apical radiographs were taken using an x-ray machine (Heliodent Ds, Siemens Aktiengesellschaft, Germany ) to show the bone beyond the root apex, the mesial and distal bone surrounding the tooth to be extracted, root length and angulation, the distance and relation between the root of the tooth to be extracted to the roots of adjacent teeth, the corresponding tooth root in the adjacent quadrant and relation of the root to the nasal floor and presence of any periapical lesion. Direct digital standardized radiographs were taken using XCP (Extension Cone Paralleling technique) to keep a standard distance from the x-ray tube, as well as a fixed direction of the x-ray beam in relation to the implant. The distance was measured from the x-ray tube to the sensor holder to be applied every time. After, the exposure time was adjusted, the Sidexis sensor (Sidexis, Sirona, Germany) was connected to the XCP sensor holder and the angulation of the x-ray tube was adjusted and the tube was connected to the ring of XCP. Then, the sensor was placed into the patients mouth, parallel to the implant to be exposed to x-rays (Fig. 4). One day prior to the surgery, each patient was instructed to start the prophylactic broad-spectrum antibiotic therapy in the form of 500 mg of anhydrous Cephalexin tablets (CeporexTM tablets, GalaxoWellcome, Ireland) three times daily and the non-steroidal anti-inflammatory analgesic drug in the form of 20 mg Piroxican tablets(Feldene tablets, Pfizer Inc., USA), twice daily.
Smile Dental Journal Volume 3, Issue 4 - 2008 9
B-Radiographic Evaluation
Orthopantomogram (OPG) radiographs were taken to show
(Figure 4)
Sensor Connected to the XCP sensor holder inside the patients mouth.
the screw hole from being blocked with temporary cement. Then, the provisional crown was seated with a thin layer of temporary cement (Provy, Dentsply, Latin America) and the excess was removed with a dental floss.
Post-Operative Phase
The patients were operated upon under local infiltration anesthesia applied buccally at the surgical site and accompanied by nasopalatine nerve block anesthesia. The anaesthetic solution used was Mepevacaine Hcl 2% with vasoconstrictor as Levonordefrin 1:20,000. Each patient received 2-3 anaesthetic carpules. A periodontal probe was placed between the tooth root and bone to circumferentially cut the periodontal ligament fibers and facilitate extraction. The tooth was then gently extracted by extraction forceps, with minimum surgical trauma and without any damage to the adjacent soft or hard tissues. The bony socket was then carefully debrided with a sharp curette to remove any granulation or fibrous tissue present and irrigated with sterile saline. Integrity of the socket walls and socket depth from the alveolar crest of bone to the socket apex were checked with the osteotomy probe. Depth of the socket was measured to determine the drilling needed after the root apex. No incision or flap was performed. The osteotomy was prepared through the socket opening with copious sterile saline irrigation, using the socket walls as a guide. Osteotomy extended for at least 3-4 mm beyond the original root apex. Drills were used according to the manufacturers recommendations. The last drill was 0.5 mm less than the implant diameter. Drilling extended at least 3-5 mm beyond the root apex and extended 2 mm more than the implant length. Osteotomy probe was used to check the depth of the osteotomy after drilling. Then, the osteotomy was irrigated with tetracycline solution as Tetracycline Hydrochloride 500 mg capsule (Tetracid capsules, CID Co., Egypt) dissolved in saline solution, for detoxification of the osteotomy. OsteoCare implant was then manually screwed into the osteotomy, until there was resistance. The implant mount was removed and final seating of the implant was achieved by ratchet wrench until the implant shoulder was flushed with the level of alveolar crest of bone buccopalatally. It was placed 3-4 mm beyond the lowest point of adjacent labial gingival margin checked by the periodontal probe, to maintain a shallow sulcus. Then, the torque wrench was used to check the primary stability at 35 N/cm. After using the trial abutments kit (Fig. 3), implant abutment with suitable angulation was selected, adjusted outside the patients mouth and then seated and tightened to 35 N/cm by the torque wrench. Final preparation of the abutment was completed with carbide bur at high speed with profuse irrigation. The implant was immediately restored with a provisional crown over the implant abutment and kept out of occlusion as verified with an articulating paper. A small piece of cotton was placed into the abutment hole to protect
Operative Phase Surgical Technique
Post-operative instructions were given to the patients, which included extra-oral ice packs application for 2 hours on the first day to minimize oedema, oral hygiene instructions including warm 0.2% Chlorhexidine Hcl (Hexitol mouthwash, The Arab Drug Co., Egypt) as an antiseptic mouthwash twice daily from the day of implant placement and continued for the whole treatment period, using soft toothbrush and gentle cleaning with dental floss, to eat soft diet and to avoid biting on the provisional crown, to continue the use of the pre-operative broad-spectrum antibiotic and to take the non-steroidal anti-inflammatory analgesic twice daily for 7-10 days. Direct digital standardized peri-apical radiograph was taken immediately after implant placement to evaluate the implant position. After one week, each patient was recalled and examined for the presence of any pain, swelling or mobility. After 3 months, the final impressions were taken directly on the implant abutment, after blocking the abutment screw access hole with a temporary filling. Impressions were made using rubber base impression material (Speedex, Coltene/Whaledent Inc., USA). The shade was selected and the final restoration was cemented with temporary cement, so that it could be removed if necessary.
All patients were examined immediately after surgery and during the first week to check if there was pain, discomfort, swelling, or infection. Then, the following clinical parameters were used to clinically evaluate the cases after 3, 6 and 9 months after insertion of the final restoration. Assessment of the plaque was made according to 1964 Silness & Loe plaque index.42 The peri-implant mucosa was evaluated visually and by probing, according to the 1963 Loe & Silness43 classification. The probing pocket depth around the implant was measured at the four aspects of the implant; facial, palatal and proximal surfaces, using the probe graduation in mm, according to the 1978 Harvard conference.44 The integrity of the interproximal papillae was assessed by Papilla Index Score (PIS), which is an index evaluating the size of interproximal papillae adjacent to the single-implant restoration according to Jemt in 1997.45 Implant mobility was assessed manually according to the criteria by McKinney & Koth in 1982.46
Follow-up Phase A-Clinical Evaluation
B-Radiographic Evaluation
The digital radiography system and technique was as that used pre-operatively and applied immediately after implant placement, after 3, 6 and 9 months. The digital sensor connected to the XCP sensor holder, was placed into the patients mouth parallel to the implant to be exposed to x-rays (Fig. 4). The image appears on the computer screen immediately (Fig. 5).
Assessment of bone density
The peri-implant bone density was measured by a computerized
Implantology
(Figure 5)
Digital image appears immediately on the computer screen.
Clinical Case Reports Case No. 1
(Figure 6)
ROI selected to measure bone density.
A 21-year-old male patient was referred to extract a badly decayed non-vital maxillary central incisor tooth with a radiolucent peri-apical lesion (Fig. 8). There was no pain during surgery and there were no post-operative pain nor oedema. During the first week after implant placement, implant mobility grade 2 was detected because the patient had replaced a composite filling in the mandibular incisor that was high. After the composite filling was adjusted and the provisional restoration was splinted to adjacent teeth, there was no mobility of the implant. The final crown was placed three months after surgery. Apart from this, the periapical lesion healed successfully during the follow-up (Fig. 8-N, O, P, Q, R) and it can be observed that bone healing goes apically with a reduction of marginal bone defect. There was no mobility throughout the research; however, there was slight resorption of the buccal plate of bone (Fig. 8-K, L).
Case No. 2
(Figure 7)
Assessment of marginal bone level.
An 18-year-old female patient was referred to extract a maxillary central incisor tooth due to fracture of an endodontic file inside the tooth root during endodontic treatment (Fig. 9). The periapical radiograph revealed that the file has perforated the root apex and there was periapical radiolucency (Fig. 9-O, P). The patient felt very mild pain during surgery and in the first day of surgery. There was mild post-operative oedema on the day after surgery. The periapical lesion healed successfully during the study (Fig. 9-Q, R, S, T) and there was no mobility. After 3 months, healing of soft tissues around the implant abutment and the emergence profile (Fig. 9-M) can be observed due to the provisional restoration.
image J program. From ROI manager, Measure command was selected to give the mean gray value (mean density) of the ROI (Fig. 6). The ROI was selected mesially, distally and apically to the implant. The mean was calculated immediately postoperatively as the base line and after 3, 6 and 9 months. The Image J program translates the degree of darkness and lightness into a numerical value. The degree of blackening and whitening (radiolucency and radio-opacity) indicates the degree of bone density. In this program, the numerical values range from 0 (darkest) to 255 (lightest). Mean Gray Value (average gray value within the selection) is obtained by the sum of the gray values of all the pixels within the selection, divided by the number of pixels.
Results A-Clinical Results

Statistical Analysis
Of the total number of 20 implants placed, three implants were lost. The paired t test was used to compare the results pre-operatively, immediately after implant placement, after 3, 6 and 9 months, at 5% level of significance (P<0.05).
Pain & Swelling
All patients felt very minimal to no pain during surgery and on the first day. Post-operative discomfort and post-operative oedema were very minimal and unobserved.
Infection
Assessment of marginal bone level
The saved image was opened with Image J program. The scale was determined in reference to the known implant fixture length. From Analyze command, Set Scale command was selected to convert pixels dimension to millimeters. A line was drawn from the implant apex to the implant shoulder. The length of the implant fixture was measured and compared to the real fixture length to determine the magnification factor in the image (Fig. 7). The distance from the implant apex to the first seen point of Bone-Implant Contact was measured. The difference between it and the implant length represents vertical marginal bone defect. The measurements were noted mesially and distally and the mean was calculated in mm according to the magnification factor of the image immediately following implant placement (baseline) and after 3, 6 and 9 months.
In only one case the implant became mobile and was removed due to pus from around the implant. In the other cases, the periapical lesions healed successfully during the follow-up.
Plaque Index (PI)
The plaque index was reduced by time in all cases. This reduction was significant after 6 months, then, there was a non-significant reduction after 9 months, at 5% level (P<0.05), (Table 1). After 3 months, mean plaque index value was 1.00 0.35, after 6 months the mean plaque index value was 0.82 0.40 and after 9 months, mean plaque index value was 0.71 0.30.
Gingival Index (GI)
The GI after 3 months ranged between grade 2 and grade 1.
(Figure 8) Extraction, immediate implantation and provisionalization of case 1
a b c d a) Preoperatively; badly decayed root of maxillary left central incisor tooth. b) Atraumatic extraction. c) Curettage of the extraction socket. d) Drilling at least 3-4 mm beyond the original length of the extraction socket.
g e h f e) Manual placement of the implant into the osteotomy . f) Wrenching after feeling resistance to manual implant placement. g) Using the trial abutment to choose the proper angulated abutment. h) Placing the final angulated abutment.
i) Angulated abutment seated. j) Provisional crown placed. k) Final crown placed after 3 months. l) Resorption of the buccal bone.
m m) Pre-operative OPG.
n n) Pre-operative.
o o) Immediate Postoperative x-ray.
p p) After 3 months.
q q) After 6 months.
r r) After 9 months.
13
Implantology
(Figure 9) Extraction, immediate implantation and provisionalization of case 2
a b c d a) Preoperatively; an endodontic file broken inside the root of a maxillary right central incisor tooth. b) A periodontal probe is inserted between the root and the bone to cut the periodontal ligament fibers circumferentially around the root to facilitate its extraction. c) The file was unscrewed, then the remaining root was removed. d) Atraumatic extraction.
e) The socket immediately after extraction. f) Drilling at least 3-4 mm beyond the original length of the extraction socket. g) Irrigation of the osteotomy with tetracycline solution. h) Placing the implant manually into the osteotomy.
i) Seating with over hex driver. j) Wrenching. k) Placement of theangulated abutment. l) Provisional crown placed.
m) After 3 months, healing around the implant abutment with proper emergence profile. n) Final crown placed, with maintenance of soft and hard tissues contours. o) Pre-operative OPG.
p) Pre-operative. q) Immediately Post-operative. r) After 3 months. s) After 6 months. t) After 9 months.
14
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1275
Implantology
(Table 1): Mean Plaque Index
(Table 2): Mean Gingival Index
(Table3): Mean Probing Depth
(Table 4): Mean Bone Density
(Table 5): Mean Marginal Bone Level
Then, it was ranging between grade 1 and grade 0 in all cases. There was a significant reduction in the mean GI , at 5% level (P<0.05) after 6 months and after 9 months (Table 2). After 3 months, mean GI value was 1.21 0.76, after 6 months it was 1.04 0.78 and after 9 months it came down to 0.82 0.73.
Probing Depth (PD)
The PD started from 2 to 3 mm in labial and palatal sides, and 3 to 4 mm in proximal sides. Then, it was reduced to reach 1 mm in labial and palatal sides, and 2 to 3 mm in proximal sides. There was a significant reduction in the mean PD after 6 months, then, there was a non-significant reduction after 9 months, at 5% level (P<0.05) (Table 3). After 3 months, mean PD value was 2.32 mm 0.40 mm, after 6 months it was 2.04 mm 0.42 mm and after 9 months it was 1.86 mm 0.38 mm.
Papilla Index Score (PIS)
in the opposing mandibular incisor. After the composite filling was adjusted and the provisional restoration was splinted to adjacent teeth, there was no mobility of the implant. The final crown was placed three months after surgery. In another case, the implant became mobile during the first week and the implant was removed. In another case, mobility grade II occurred during the first month. The final crown was placed six months after surgery. Mobility grade II remained till the end of the follow-up period. No mobility was detected in the other cases throughout the study.
B-Radiographic Results
There was a significant increase in the mean bone density by time in all cases, at 5% level (P<0.05) (Table 4).
In all cases the interproximal papillae filled the entire interproximal space, and were in good harmony with the adjacent papillae; PIS 3. The interproximal papillae of all cases were intact during implant placement and maintained throughout the study.
Implant Mobility (IM)
Discussion
In the first case, mobility grade II was detected during the first week because the patient had placed a high composite filling
The technique applied in this study included an atraumatic tooth extraction without raising a flap, drilling at least 3-4 mm beyond the root apex, implant insertion, attaching the final abutment and placing a provisional restoration free from occlusion at the same visit. The final restoration was placed after 3-6 months. Such technique simplifies the classical sophisticated implant placement technique, saves a lot of time as well as eliminates the necessity for grafting materials or barrier
membranes around the immediately placed implants. In addition, drilling only 3-4mm beyond the root apex protects the bone from excessive heat generation. The atraumatic extraction preserves the walls of the extraction socket and improves primary stability. In contrast, drilling into healed sites results in more heat generation and more postoperative pain and oedema, because more amount of bone is being prepared. This was assured in the studies done by Saadoun3, Garber et al.34, Locante35 and Lorenzoni et al.38 The results of the present study indicate that immediately placed dental implants into fresh extraction sockets with periapical lesions, and immediate loading have favorable clinical and radiographic outcomes. All patients felt very mild to no pain during surgery and there was minimal to no postoperative pain or oedema. This is because drilling was performed only beyond the root apex, which minimizes heat generation and reduces the risk of overheating the bone. This was in agreement with the study of Schwartz-Arad & Chaushu47 who reported that reducing the surgical trauma at the time of implant placement results in obtaining more vital bone in contact with the implant interface and thereby improving primary implant stability. It should be also notified that flapless implant placement reduces postoperative discomfort, pain and oedema since the periosteum is left intact. Most patients were very keen to perform oral hygiene instructions after delivery of the final restoration. The plaque index and the gingival index decreased in all cases, revealing improved oral hygiene. The probing depth around the implants in all cases was reduced by time to reach 1mm in labial and palatal sides and 2 to 3 mm in proximal sides. Similar findings were reported 48 by Al-Ansari & Morris who demonstrated that placing dental implants without flap reflection resulted in probing depths of less than 2 mm around dental implants. The papilla index score (PIS), described by Jemt45, has been utilized in the present study as a simple technique for a more scientific evaluation of the integrity of the interproximal papillae mesial and distal to the single-implant restoration. This index was also used recently by Cardaropoli et al.49 as one of the parameters to assess clinical alterations of peri-implant mucosa. The interproximal papillae in all cases were preserved and filling the entire interproximal space and in good harmony with the adjacent papillae with a PIS = 3. There was minimal to no recession, which provided good esthetic results. Our explanation is that this occurred as a result of placing the implants without raising a flap and leaving the periosteum intact on the bone, which provides most of the blood supply to the bone. Besides, whenever the papilla is detached from bone, the interproximal bone is denuded from the periosteum. This affects the vascular supply to the papilla in varying amounts, depending on the type of surgery. Thereby, raising a flap eventually leads to gingival recession, papillae destruction and crestal bone resorption as was explained by Campelo & Camara50 and Covani et al.51. In addition, flapless implant placement offers other advantages such as, simplifying the procedure, reducing time of treatment, reducing or even eliminating post-operative discomfort, pain and oedema, allowing faster soft tissue healing around the implant, reducing possibility of contamination and infection and gaining excellent final aesthetics. According to Caradarpoli et al.49, the surgical trauma caused by flap elevation induces
remodeling of the surface layer of alveolar bone that was exposed during flap elevation. The labial bony wall in the anterior maxilla is thin, porous and more prone to resorption; when a flap is raised and the periosteum is detached, buccal resorption becomes very prominent. There are on the other hand some disadvantages of the flapless surgery. It prevents direct visualization of the bony configuration during drilling. Since flapless implant placement is a blind surgery, working blindly may lead to incorrect implant placement or perforation of the buccal plate of bone. Therefore, Campelo 50 & Camara considered preoperative CT scan a must before flapless implant surgery. Without raising a flap, it is more difficult to assess any bone defect during implantation. Besides, there is limited ability to augment the implant site, to place a barrier membrane and thus the ability to retain a grafting material is more complicated. The possibility of incorrect implant placement or perforation of the buccal plate of bone is however more likely to occur in delayed implant placement and less likely to happen during drilling into fresh extraction sockets. When the tooth is extracted due to caries or failure of endodontic treatment, the alveolar bone surrounding the root is usually not resorbed at the buccal side and the walls of the extraction socket guide the surgeon to the osteotomy direction. Besides, bone resorption and presence of bone concavities are much more likely to exist in case of placing implants into healed sites after extraction (late implantation). Preoperative clinical, radiographic evaluation and careful drilling into the extraction socket would definitely prevent such complications. In the case were implant mobility grade II was detected in this study, the patient had a new composite filling in the opposing incisor and the filling was high. After the composite filling was adjusted, the provisional restoration was splinted to the adjacent teeth with composite during the first month and the final restoration was placed three months after implant placement. Despite the fact that the preoperative periapical lesion healed gradually during the follow-up phase and marginal bone defect was reduced, there was however resorption of the buccal plate of bone that occurred during the first three months after implant placement probably due to excessive occlusal forces caused by the high composite filling placed on the opposing tooth during the healing phase. Therefore, it is recommended that the patient should not undergo any restorative treatment without consulting the treating dentist. In another case in this study, the implant became mobile during the first week after its placement and was removed. The tooth that was replaced with this implant, was extracted due to the fracture of the post and part of the root canal treated tooth after trauma. Although there was no peri-apical radiolucency in the preoperative peri-apical and panoramic radiographs, there was external resorption of the apical third of the root. The cause of implant failure of this case cannot be related to loading because the provisional restoration was not placed after implant placement. It is most likely because of the poor primary stability after attaching the abutment to the implant fixture and due to the weakness of the buccal plate of bone during extraction. Another possible explanation of failure is the possible presence of peri-apical infection that was not apparent in the preoperative periapical or
Implantology
panoramic radiographs and was not completely curetted after extraction. Although immediate implant placement into fresh etraction sockets with pathologic lesion was considered a contraindication3,15,17, Cavacchia & Bravi17 pointed out that there is a chance of success, if there is no active suppuration and the granulation tissue associated with the chronic infection does not contraindicate immediate implant placement. Presence of peri-apical lesions did not prevent success of the other cases in this research because there was no active infection. As we mentioned, immediate implant placement in the presence of active periapical infection has been reported by Novaes & Novaes18, Novaes et al.19, Rosenquist & Grenthe. 20 It has to be clarified that in the present study precautions were taken such as, good curettage of the socket after extraction, use of an antibacterial irrigant and prescription of a strong antibiotic pre and post operatively as was recommended by Gher et al.52. In addition, all patients who participated in this study were of young age and accordingly resolution of the periapical lesions with new bone formation is more likely to occur than in old patients who are more liable to infection and slow bone healing. In addition, since excessive occlusal forces would disturb bone healing and new bone formation, the provisional restoration that was free from occlusion gave the chance for the periapical lesion to heal with new bone formation. The three failed out of twenty implants had no mobility and were successful according to the success criteria mentioned by Albrektsson et al.53 The failure in these cases was due to an error in the preoperative evaluation and case selection not due to the technique itself (immediate implant placement and immediate non-functional loading). Again, primary implant stability is the key factor to consider for immediate loading of implants placed immediately into fresh extraction sites. Therefore, patients with periodontal disease and teeth with clinical mobility were excluded from the study to ensure presence of sufficient bone for primary stability. Primary stability depends on the surgical technique of implant placement, proper implant selection and bone quantity and quality. Regarding the surgical technique used, an absolute requirement of immediate implantation is that 3-4 mm of the implant fixture must be screwed into the bone. Drilling at least 3-4 mm beyond the root apex is mandatory to gain maximum degree of primary stability of the implant as was reported by many authors including Touati & Guez30, Schwartz-Arad & Chaushu54,55, Rosenquist & Ahmed56, Nemcovsky et al.57, Hmmerle et al.58 The authors recommended using the longest and widest implant whenever possible to increase the bone-implant interface and primary stability. The wider the implant, the greater is the contact with the alveolar socket wall because of the conical shape of the top of the alveolar socket. The implant surface area screwed into the bone is the most reliable index of primary implant stability. Despite that sometimes a part of the implant surface was not completely covered by bone, the implant was stable because it was screwed into the bone more than 3 mm. Similarly, in this research, although the implant in some cases was not completely surrounded by bone coronally, there was good primary stability and there was no mobility. In addition, vertical marginal defects decreased and although did not heal
with bone completely in some cases, there was no mobility 11 throughout the research. Aaccording to Juodzbalys , 30% is the minimal part of the implant surface area to be fixed in the bone and primary stability depends mainly on the implant length, implant width, as well as the depth of its insertion. It was calculated that the drilling must be more than 30% of the implant surface area taking into consideration that bone resorption occurs in the primary stage of osseointegration. In the present study, a provisional acrylic single crown, free from occlusion, was placed on the implant abutment immediately after tooth extraction, implant placement and abutment placement. The provisional acrylic single crown was used in the present study because it is more hygienic for the patient. Block et al.59 recommended that 1-2 mm of interocclusal space should exist between the provisional crown and the opposing teeth or restorations. The provisional restoration left 0.5-1 mm space at the mesial and distal margins to prevent micromotion on the implant due to physiologic movement of the adjacent natural teeth. Saadoun3 recommended using a provisional crown restoration that duplicates the contour of the contralateral tooth or the crown of the extracted tooth, if the crown is present. In the present research, immediate restoration with a provisional crown after tooth extraction had an excellent psychological effect on all patients. The provisional restoration role was not only to increase patients satisfaction by restoring esthetics and phonetics during the osseointegration period. It also guides soft tissue healing around the implant abutment to develop the emergence profile, supports and maintains the papillary height and gingival contour throughout the healing period, provides ideal gingival architecture and interproximal papillae that blend with the gingiva overlying the adjacent teeth without structural or esthetic defects. Furthermore, placing the provisional restoration on the implant abutment with no occlusal contact is different from the submerged approach, where the implant is not exposed to any occlusal forces. Thus, presence of the abutment and the provisional crown allows progressive loading of the implant. In addition, it maintains the position of adjacent and opposing teeth. Brunski60 considered micromovement amounting to 100 m as the threshold for smooth machined surface implants. More than 150 microns are sufficient to jeopardize healing and adversely affect osseointegration, resulting in fibrous tissue interface.60 Morris et al.61 explained that bone responses to clinical loading may be below, within, or exceeding physiological limits. Loading the bone below physiological limits may result in bone resorption, whereas loading above physiological limits may in addition to bone resorption cause fracture failures and eventual loss of the implant. Thus, loading within acceptable limits serves to stimulate bone surrounding the implant and increase bone density. Thus, progressive loading of the implant by a provisional restoration improves the implant ability to withstand functional stresses. Similarly, Touati & Guez30 explained that it is not early loading that cause fibrous tissue encapsulation, but the micromovement caused by insufficient primary stability or by excessive occlusal forces. In the present study, there was a decrease in vertical marginal bone defect observed radiographically implying an increase in BIC. This can be explained due to the fact that healing of the extraction socket proceeds in an apicocoronal direction around
Implantology
the implant as mentioned by Ten Cate et al.62 However, it has to be pointed out that the periapical radiograph reveals only the mesial and distal vertical marginal bone defects present around the implant. It does not show the depth of marginal defects present buccal and palatal to the implant. Besides, the BIC seen radiographically is not a direct bone-implant contact, because it is not histological data and it is not measured directly by a probe after raising a flap. In other words, radiographic examination displays the level of calcified bone located only mesial and distal to the implant. The marginal bone level at the buccal and palatal sides is not demonstrated radiographically. In the case of immediate implantation after extraction, blood, fibrous tissue or woven bone would be present, but not seen radiographically. In the present research, marginal defects decreased in depth, but did not heal completely with bone in all cases. Clinical examination of cases revealed that probing depth was not increased and there was no mobility. This means that these defects healed with fibrous connective tissue formation, instead of osseointegration. This was confirmed by Paolantonio et al.5, who reported in their study that when a screw type implant is placed into a fresh extraction socket, without using a barrier membrane or a bone grafting material, the clinical outcome does not differ from implants placed in healed, mature bone. Similar findings were reported by Botticelli et al.12, who demonstrated by direct measurement, at the re-entry after 4 months of healing, that even wide and deep marginal defects exceeding 3 mm around SLA-modified surface implants placed with a non-submerged (one-stage) surgical protocol, may predictably heal, but not completely, with new bone formation and defect resolution. Finally, proper patient/case selection is a very important factor to achieve success of this technique. The patient has to be in an ideal condition regarding any systemic health conditions that can affect the bone, performing good oral hygiene, has no parafunctional habits and with sufficient bone beyond the root apex of the tooth to be extracted. In addition, patient motivation and cooperation to follow instructions and the regular follow-up visits are crucial to achieve success. The patient has to be very understanding and willing to follow all instructions. Meanwhile, the patient should never undergo any restorative treatment without consulting the treating dentist, because any faulty restoration in the opposing dentition can cause excessive occlusal loads on the implant. The healing period after implant placement into fresh extraction socket is very critical. The bone should be left undisturbed to allow its normal healing. Therefore, any excessive functional or non-functional loading should be avoided.
The present results indicate that immediate loading of immediately placed dental implants replacing single-rooted teeth is a predictable treatment that depends mainly on; good patient/ case selection, achieving good primary stability and maintaining primary stability. Hence, from the present study we conclude that the success of this technique depends on: Good patient and case selection. Presence of sucient healthy bone beyond the peri-apical lesion. Surgical technique used; Atraumatic extraction, good curettage of the extraction socket, and drilling at least 3-4 mm beyond the root apex to gain maximum degree of primary stability. Implant selection; The implant has to be in length and diameter greater than that of the extraction socket, implants with a flared neck are better to be placed into fresh extraction sockets to increase bone-implant contact at the coronal part of the implant and implants with rough surface are recommended to be used for immediate loading. Patients motivation, patients cooperation to follow instructions and the follow-up program. Finally, it is important to note that the data of the present study do not imply that delayed or delayed-immediate implant placement or submerged approaches are no longer indicated. Additional research can be performed to investigate the possibility of immediate implant placement and provisionalization in the anterior mandible and in patients who are smokers, in old age, diabetics, osteoporotics or bruxers.
Acknowledgements
The authors declare no financial interest in any of the products used in this study.
References
1. Brnemark P-I. Introduction to osseointegration. In: Brnemark P-I, Zarb GA, Albrektsson T, editors. Tissue-integrated prosthesis: Osseointegration in clinical dentistry. Chicago: Quintessence Publishing; 1985. pp11-76. 2. Adell R, Lekholm U, Rockler B & Brnemark P-I. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981 Dec;10(6):387-416. 3. Saadoun AP. Immediate implants placement and temporization in extraction and healed sites. Compend Contin Educ Dent. 2002 Apr; 23(4): 309-24. 4. Gomez-Roman G, Kruppenbacher M, Weber H Schulte W. Immediate postextraction implant placement with root-analog stepped implants: surgical procedure and statistical outcome after 6 years. Int J Oral Maxillofac Implants. 2001 Jul-Aug;16(4):503-13. 5. Paolantonio M, Dolci M, Scarano A, dArchivio D, di Placido G, Tumini V, Piattelli A. Immediate implantation in fresh extraction sockets. A controlled clinical and histological study in man. J Periodontol. 2001 Nov;72(11):1560-71. 6. Fugazzotto P. Immediate implant placement following a modified trephine/ osteotome approach: success rates of 116 implants to 4 years in function Int J Oral Maxillofac Implants. 2002 Jan-Feb;17(1):113-20. 7. Balshi TJ, Wolfinger GJ. Immediate placement and implant loading for expedited patient care: a patient report. Int J Oral Maxillofac Implants. 2002 Jul-Aug;17(4):587-92. 8. Nemcovsky CE, Artzi Z, Moses O, Gelernter I. Healing of marginal defects at implants placed in fresh extraction sockets or after 4-6 weeks of healing. A comparative study. Clin Oral Implants Res. 2002 Aug;13(4):410-9. 9. Norton MR, Wilson J. Dental implants placed in extraction sites implanted with bioactive glass: human histology and clinical outcome. Int J Oral Maxillofac Implants. 2002 Mar-Apr;17(2):249-57. 10. Covani U, Cornelini R, Barone A. Bucco-lingual bone remodeling around implants placed into immediate extraction sockets: a case series. J Periodontol. 2003 Feb;74(2):268-73.
Conclusion
In conclusion, immediate provisionalization of immediately placed dental implants, without flap reflection, is within acceptable parameters a successful procedure and provides the following benefits: Preservation of peri-implant bone and soft tissue contour. Reduction of postoperative pain and oedema, which increases patients comfort. Improvement of aesthetics and phonetics during the healing period. Elimination of a second-stage surgery, thus shortening the treatment time and simplifying implant treatment. Improvement of the aesthetic results of the nal restoration and increasing patients satisfaction.
The Biologic Approach for Dental Procedures

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Implantology
11. Juodzbalys G. Instruments for extraction socket measurement in immediate implant installation. Clin Oral Implants Res. 2003 Apr;14(2):144-9. 12. Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol. 2004 Oct;31(10):820-8. 13. Akkocaoglu M, Uysal S, Tekdemir I, Akca K, Cehreli MC. Implant design and intraosseous stability of immediately placed implants: a human cadaver study. Clin Oral Implants Res. 2005 Apr;16(2):202-9. 14. Schropp L, Kostopoulos L, Wenzel A, Isidor F. Clinical and radiographic performance of delayed-immediate single-tooth implant placement associated with peri-implant bone defects. A 2-year prospective, controlled, randomized follow-up report. J Clin Periodontol. 2005 May;32(5):480-7. 15. Block MS, Kent JN. Placement of endosseous implants into tooth extraction sites. J Oral Maxillofac Surg. 1991 Dec;49(12):1269-76. 16. Sclar AG. Strategies for management of single-tooth extraction sites in aesthetic implant therapy. J Oral Maxillofac Surg. 2004 Sep;62(9 Suppl 2):90-105. 17. Cavicchia F, Bravi F. Case reports offer a challenge to treatment strategies for immediate implants. Int J Periodontics Restorative Dent. 1999 Feb;19(1):66-81. 18. Novaes AB Jr, Novaes AB. Immediate implants placed into infected sites: a clinical report. Int J Oral Maxillofac Implants. 1995 Sep-Oct;10(5):609-13. 19. Novaes AB Jr, Vidigal Jnior GM, Novaes AB, Grisi MF, Polloni S, Rosa A.. Immediate implants placed into infected sites: a histomorphometric study in dogs. Int J Oral Maxillofac Implants. 1998 May-Jun;13(3):422-7. 20. Rosenquist B, Grenthe B. Immediate placement of implants into extraction sockets: implant survival. Int J Oral Maxillofac Implants. 1996 Mar Apr;11(2):205-9. 21. Orsini G, Assenza B, Scarano A, Piatelli A, Piatelli M. Surface analysis of machined versus sandblasted and acid-etched titanium implants. Int J Oral Maxillofac Implants. 2000 Nov-Dec;15(6):779-84. 22. Roccuzzo M, Bunino M, Prioglio F, Bianchi SD. Early loading of sandblasted and acid-etched (SLA) implants: a prospective split-mouth comparative study. One-year results Clin Oral Implants Res. 2001 Dec;12(6):572-8. 23. Cochran DL, Buser D, ten Bruggenkate CM, Weingart D, Taylor TM, Bernard JP et al. The use of reduced healing times on ITI implants with a sandblasted and acid-etched (SLA) surface: early results from a clinical trial on ITI SLA implants. Clin Oral Implants Res. 2002 Apr;13(2):144-53. 24. Barone A, Covani U, Cornelini R, Gherlone E. Radiographic bone density around immediately loaded oral implants. Clin Oral Implants Res. 2003 Oct;14(5):610-5. 25. Marinho VC, Celletti R, Bracchetti G, Petrone G, Minkin C, Piattelli A. Sandblasted and acid-etched dental implants: a histologic study in rats. Int J Oral Maxillofac Implants. 2003 Jan-Feb;18(1):75-81. 26. Tortamano Neto P, Camargo LO. Prospective clinical evaluation of dental implants with sand-blasted, large-grit, acid-etched surfaces loaded 6 weeks after surgery. Quintessence Int. 2004 Oct;35(9):717-22. 27. Cooper LF, Rahman A, Moriarty J, Chaffee N, Sacco D. Immediate mandibular rehabilitation with endosseous implants: simultaneous extraction, implant placement, and loading. Int J Oral Maxillofac Implants. 2002 Jul-Aug;17(4):517-25. 28. Petropoulos VC, Balshi TJ, Balshi SF, Wolfinger GJ. Extractions, implant placement, and immediate loading of mandibular implants: a case report of a functional fixed prosthesis in 5 hours. Implant Dent. 2003;12(4):283-90. 29. Kois JC, Kan JY. Predictable peri-implant gingival aesthetics: surgical and prosthetic rationales. Pract Proced Aesthet Dent. 2001 Nov-Dec;13(9):691-8; quiz 700, 721-2. 30. Touati B, Guez G. Immediate implantation with provisionalization: from literature to clinical implications. Pract Proced Aesthet Dent. 2002 Nov-Dec;14(9):699-707; quiz 708. 31. Whrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: fourteen consecutive case reports. Pract Periodontics Aesthet Dent. 1998 Nov-Dec;10(9):1107-14; quiz 1116. 32. Park kB, Han TJ, Kenny B. Immediate implant placement with immediate provisional crown placement: Three case reports. Pract Proced Aesthet Dent. 2002 Mar;14: 147-54. 33. Leary JC, Hirayama M. Extraction, immediate-load implants, impresions and final restorations in two patient visits. J Am Dent Assoc. 2003 Jun;134(6):715-20. 34. Garber DA, Salama MA, Salama H. Immediate total tooth replacement. Compend Contin Educ Dent. 2001 Mar;22(3):210-6, 218. 35. Locante WM. The nonfunctional immediate provisional in immediate extraction sites: a technique to maximize esthetics. Implant Dent. 2001;10(4):254-8. 36. Jo HY, Hobo PK, Hobo S. Freestanding and multiunit immediate loading of the expandable implant: an up-to-40-month prospective survival study. J Prosthet Dent. 2001 Feb;85(2):148-55.
37. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and provisionalization of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxillofac Implants. 2003 Jan-Feb;18(1):31-9. 38. Lorenzoni M, Pertl C, Zhang K, Wimmer G, Wegscheider WA. Immediate loading of single-tooth implants in the anterior maxilla. Preliminary results after one year. Clin Oral Implants Res. 2003 Apr;14(2):180-7. 39. Norton MR. A short-term clinical evaluation of immediately restored maxillary TiOblast single-tooth implants. Int J Oral Maxillofac Implants. 2004 Mar-Apr;19(2):274-81. 40. Chaushu G, Chaushu S, Tzohar A, Dayan D. Immediate Loading of single-tooth implants: immediate vs. non-immediate implantation. A clinical report. Int J Oral Maxillofac Implants. 2001 Mar-Apr;16(2):267-72. 41. Baumgarten H, Cocchetto, Testori T, Meltzer A, Porter S. A new implant design for crestal bone preservation: initial observations and case report. Pract Proced Aesthet Dent. 2005 Nov-Dec;17(10):735-40. 42. Silness J, Loe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand. 1964 Feb;22:121-35 43. Loe H, Silness J. Periodontal disease in pregnancy. I Prevalence and severity. Acta Odontol Scand. 1963 Dec;21:533-51. 44. Schnitman PA, Shulman LB . Dental implants Benefits and risks. Proceedings of anNIH Harvard Consensus Development Conference, U.S. Department of Health and Human Services, December 1980, Publication No. 81-1531. 45. Jemt T. Regeneration of the gingival papillae after single-implant treatment. Int J Periodont Rest Dent. 1997 Aug;17(4):326-33. 46. Mckinney RV, Koth DL. The single-crystal sapphire endosteal dental implant: material characteristics and 18-month experimental animal trials. J. Prosthet Dent. 1982 Jan; 47(1):69-84. 47. Schwartz-Arad D, Chaushu G. Immediate implant placement: a procedure without incisions. J Periodontol. 1998 Jul;69(7):743-50. 48. Al-Ansari BH, Morris RR. Placement of dental implants without flap surgery: a clinical report. Int J Oral Maxillofac Implants. 1998 Nov-Dec;13(6):861-5. 49. Cardaropoli G, Lekholm U, Wennstrm JL. Tissue alterations at implantsupported single-tooth replacements: a 1-year prospective clinical study. Clin Oral Impl Res. 2006 Apr;17(2):165-71. 50. Campelo LD, Camara JR. Flapless implant surgery: a 10-year clinical retrospective analysis. Int J Oral Maxillofac Implants. 2002 Mar-Apr;17(2):271-6. 51. Covani U, Barone A, Cornelini R, Crespi R. Soft tissue healing around implants placed immediately after tooth extraction without incision: a clinical report. Int J oral Maxillofac Implants. 2004 Jul-Aug;19(4):549-53. 52. Gher ME, Quintero G, Sandifer JB., Tabacco M, Richardson AC. Combined dental implant and guided tissue regeneration therapy in humans. Int J Periodontics Restorative Dent. 1994 Aug; 14(4):33247. 53. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants. 1986 Summer;1(1): 1125. 54. Schwartz-Arad D, Chaushu G. The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review. J Periodontol 1997 Oct;68(10): 915-23. 55. Swardz-Arad D, Chaushu G. Placement of implants into fresh extraction Sites: 4-7 years retrospective evaluation of 95 immediate implants. J Periodontol 1997 Nov; 68(11):1110-6. 56. Rosenquist B, Ahmed M. The immediate replacement of teeth by dental implants using homologous bone membranes to seal the sockets: clinical and radiographic findings. Clin Oral Impl Res. 2000 Dec; 11(6): 57282. 57. Nemcovsky EC, Artzi Z, Moses O. Rotated palatal flap in immediate implant procedures. Clin Oral Impl Res. 2000 Feb;11(1):8390. 58. Hmmerle CH, Lang NP. Single stage surgery combining transmucosal implant placement with guided bone regeneration and bioresorbable materials. Clin Oral Impl Res. 2001 Feb;12: 918. 59. Block M, Finger I, Castellon P, Lirettle D. Single-tooth immediate provisional restoration of dental implants: technique and early results. J Oral Maxillofac Surg. 2004 Sep; 62(9):1131-8. 60. Brunski JE. In vivo bone response to biomechanical loading at the bone/ dental-implant interface. Adv Dent Res. 1999 Jun;13:99-119. 61. Morris HE, Ochi S, Crum P, Orenstein I, Plezia R. Bone density: Its influence on implant stability after uncovering. J Oral Implantol. 2003;29(6):263-9. 62. Ten Cate AR, Bartold PM, Squier CA, Nanci A. Repair and regeneration of oral tissues. In: Oral Histology: Development, Structure and Function. 6th ed. ST. Louis: Mosby Inc.; 2003, p. 408.
Clinical Evaluation of Bleaching Agents of Different Concentrations

Abstract
The purpose of this study was to evaluate the degree of color change of teeth, any rebound effect and sensitivities associated with using different concentrations of carbamide peroxide in an in vivo double blinded randomized prospective study. Twenty five subjects used 10% and 15% agents in trays for 14 days on different sides of their maxillary arches. Subjects returned in 3 days and at 1, 2, 3, and 6 weeks for evaluation. The use of 15% carbamide peroxide initially achieved significantly greater tooth lightness than the 10% carbamide peroxide. This difference was however insignificant by the end of the study, indicating that the use of either concentrations will eventually yield the same degree of tooth lightness, with comparable tooth and/or gum sensitivity.
Key words: Vital bleaching; carbamide peroxide; discolored teeth; color relapse.
The popularity of the night guard or home bleaching technique for vital teeth has stimulated manufacturers to produce a large number of products for this purpose.The first article on bleaching teeth using night guard vital bleaching (NGVB) technique was published in 19891 , but the technique can be traced back to 1968.2 The technique involves the use of a 10% carbamide peroxide material applied in a custom mouth guard for certain number of hours per day or night for a two-to-six week treatment regimen.3 A 10% carbamide peroxide material contains approximately three percent hydrogen peroxide (H2O2) and seven percent urea. The purpose of this study was to compare the effects of 10% and 15% fluoridated carbamide peroxide. It was hypothesized that there will be faster color change and more tooth and tissue sensitivity using the higher concentration of carbamide peroxide.
Dr. Hakam Al-Musa BDS, MSD Operative Dentistry
Adjunct Assistant professor University of Jordan
hmusa@musaclinics.com
Material and Methods
This randomized double blinded prospective clinical trial involved 25 patients who desired having their teeth whitened. After getting an ethical committee approval, seventeen non-pregnant nor lactating females and eight males, between 26 and 73 years of age participated in this study. All participants were medically healthy, didnt use in office nor mouth guard vital bleaching in the past three years, didnt use tobacco during the past 30 days and refrained from the use of tobacco products during the study period and had all maxillary anterior teeth without tetracycline staining. Ten and fifteen percent fluoridated carbamide peroxide from Opalescence (Ultradent products, South Jordan, UT, USA) (Fig. 1) were compared by evaluating the degree of color change of teeth, any postbleaching rebound effect associated with discontinued use of bleaching material, and any gum or tooth sensitivity associated with the use of different concentrations. A cast was fabricated after an impression was taken. The labial surfaces on the cast were blocked (Fig. 2) and a custom mouthguard was fabrcated (Fig. 3). The 25 maxillary arches were split into two halves for each concentration to be tested. The subjects were given a dental screening and prophylaxis prior to the beginning of the study. Bleaching of the lower jaw was performed at the end of the study. The operator evaluated the degree of color change in treated teeth by subjective shade matching using a shade guide (Fig. 4), by photographic means (Fig.5)and by measurements obtained with a lightness measuring device-Minolta Chroma Meter CR-321 (Minolta Corporation USA, Ramsey, NJ, USA). These tests were performed at baseline, at third day, at first, second, third and sixth week after bleaching. Gum and tooth sensitivities were evaluated by asking patients to daily record for three post-operative weeks any sensitivity they experienced. Subjects self-reported on scale of 1 (no sensitivity) to 5 (severe sensitivity). Patients who had more than moderate amount of sensitivity were given a potassium nitrate desensitizing gel-UltraEZ (Ultradent products, Inc., South Jordan, UT, USA).
24
Results
Twenty five patients completed this study. The color change and relapse effects were evaluated by using a colorimeter, shade guide, and by photographic means. During the 3, 7, 14 and 21 days, the Chroma Meter data for the 10% and 15% carbamide peroxide showed statistically significant differences. The differences were however statistically insignificant at the end of the study. The 15% concentrations demonstrated faster and greater color change compared with 10% during the active treatment period (first two weeks). Color relapse, measured using the three methods mentioned above, started when patients discontinued using the bleaching material. All concentrations showed fast rates of relapse during the third week of the study (one week post-bleaching), after which the 10% showed minimal change until the end of the study (4 weeks after the end of the active treatment). The 15% group continued to show color relapse at a higher rate compared with the 10% group until the end of the study. Subjective shade matching using the Trubyte Bioform Color Ordered Shade Guide was done. Twenty four shade units were arranged according to Value, Chroma, and hue as recommended by the American Dental Association. According to the results, change in shade guide rank was significantly different for the 10% and 15% products during the study period, but not at the end of the study. Sensitive photographic evaluation was done in this study by two calibrated restorative dental evaluators using slides. In this method of evaluation, the 15% group showed more lightness for days 7, 14, and 21. The products were not different in days 1, 3, and 45. Some patients experienced mild gum or tooth sensitivity that lasted for few days and then disappeared. There was no difference between the 10% group and the 15% group concerning the severity of the sensitivity.
Discussion
Bleaching has been accepted as one of the methods of treating discolored teeth. The increased popularity of home bleaching is related to the good aesthetic results that have been achieved by using night guard vital bleaching (NGVB) and to the safety of these dentist supervised products. Bleaching is considered a more conservative approach to obtain aesthetic or cosmetic results when compared with the more aggressive methods such as veneers, crowns, or bonding. It is important that NGVB be professionally supervised. A health professional must first diagnose the cause of discoloration4 and can take base line radiographs to determine if periapical pathology exists and to assess variation in pulp sizes. Logically, we would expect more sensitivity with larger pulp sizes. It is noteworthy that no clinical studies were done on children to evaluate the whitening effect on the pulp and accordingly the recommendation is to proceed with whitening treatment not earlier than 18 years of age, till more research is done on this age group.5 A health professional is able to evaluate any side effects a patient may experience and determine if bleaching is the most appropriate cosmetic therapy.6 A health professional should assess any composite restorations or crowns the patient may
(Figure 1)
Two concentrations of Opalescence bleaching material 10 and 15% carbamide peroxide with fluoride as supplied by the manufacturer.
Patients compliance with night time wear is generally better than that with day time wear, especially in extended treatment situations.8 Occasionally, patients may need to reduce treament duration to day time wear as a result of sensitivity, of life style changes, or because they prefer day treatment.5 Research has been accomplished to evaluate the safety and efficacy of bleaching agents.9-11 Repeated clinical trials have shown minimal significant adverse effect from using dentist monitored home bleaching agents. A review of the literature has shown that peroxide-containing bleaching agents have been used safely in oral application for years.10 The cases of mucosal irritation are generally caused by the tray and not the bleaching agent. Clinical and laboratory studies have shown that 10% carbamide peroxide tooth whitening lightens teeth effectively and causes noticeable changes in the shade of teeth.12-14 An in vitro study done by Jones f. showed that 20% carbamide peroxide Opalescence (Ultradent products Inc., South Jordan, UT, USA) caused greater perceptible change in color compared with 10% carbamide peroxide Opalescence.15 Studies have shown that bleaching procedures generally do 16 17 not affect the mechanical properties of enamel or dentin. Other studies demonstrate that there is no change in enamel morphology as a result of using bleaching agents.18 The effect of bleaching agents on bond strength to enamel has been studied. Bleaching by 35% H2O2 or 10% carbamide peroxide reduces the bond strength of composite to enamel and can reduce the bond strength of Glass Ionomer. The primary cause for reduced bond strength is probably the presence of residual peroxide or oxygen, which interferes with the polymerization of the resin bonding system and restorative material.9 Recommendation is to complete the restorative treatment after whitening in the aesthetic zone to match the new color of teeth. Whitening treatments will not change the shade of an existing restoration. Waiting for a period of two to four weeks before placing a restoration is recommended in order for the shade of the natural tooth to stabilize after whitening and to negate the effect of residual peroxide which interferes with the resin polymerization. The effect of carbamide peroxide on composite has little or no effect on color, surface roughness, strength, or hardness. The effect of carbamide peroxide on amalgam showed larger amounts of mercury release.9 Bleaching agents have no effect on color or physical properties of ceramics.9 Side effects from the bleaching procedure, such as tooth sensitivity, may be related to low water content of the bleaching agent, resulting in dehydration of the dental hard tissue.19 It is conceivable that protective or desensitizing varnishes applied prior to bleaching may prevent water loss from dentin by dehydrating bleaching agents.20 Varnishes, such as Vivasens (Ivovlar-Vivadent,Schaan,Liechtenstein), Seal & Protect (Dentsply DeTrey,Konstanz,Germany) or Bifluorid (Voco, Cuxhaven, Germany), did not compromise the bleaching effect of subsequently applied bleaching gels.21 Using varnishes, fluoride gel, or toothpaste for sensitive teeth, before and/or after whitening treatment will help in reducing the amount of sensitivity a patient might experience. Using fluoride gel in a tray for few days before treatment for three to four hours daily and
(Figure 2)
The labial surfaces were blocked out with LC Block-Out resin.
(Figure 3)
The custom maxillary mouthguard.
(Figure 4)
Trubyte bioform color ordered shade guide.
(Figure 5)
Slide photograph using Elite 100, 35-mm film (Kodak, Rochester, NY).
have on the teeth that are being considered for bleaching.7 Periodontal health should be evaluated and treated if needed before any final decision on whitening treatment. Finally, a health professional has access to the best bleaching and mouth guard materials available and can make a custom-fitted mouth guard.5 NGVB was so named because the patient wears the bleach during the night. Some companies advocate night time wear, whereas other companies propose one to two hours intervals of treatment during the day, because their products did not contain Carbopol. Carbopol makes the material thicker and stickier and slows the release of oxygen.5
applying topical fluoride treatment for two to four minutes immediately before and after whitening procedure will reduce the chances of sensitivity for office or home whitening procedures. The continuous use of toothpaste for sensitive teeth after treatment for a week or two would be ideal in controlling teeth sensitivity especially for patients already suffering from sensitive teeth before treatment. This clinical study compared two different concentrations of home whitening materials, (10% and 15% carbamide peroxide) in relation to 1) their ability to lighten teeth, 2) the relapse of color that occurs after discontinued use of the products, and 3) the amount of tooth and gum sensitivity that occurs with their use. The use of 15% carbamide peroxide initially achieved greater tooth lightness when compared to the 10% carbamide peroxide. Although this difference was initially significant, it however became insignificant by the end of the study (at 6 weeks). The greater achieved lightness during the active bleaching period was actually followed by a greater color relapse once the bleaching gel was not used. There was no significant difference in tooth or gum sensitivity with either concentration. Accordingly, it may be concluded that the use of either concentration will eventually yield the same degree of tooth lightness, with comparable tooth and/or gum sensitivity.
Natural. Biocompatible. Ormocer -based
References
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inorganic backbone polymerizable organic groups
1. Haywood VB, Heymann HO. Night guard vital bleaching. Quintessence Int. 1989 Mar;20(3):173-6. 2. Haywood VB. Night guard vital bleaching: a history and products update: Part 1. Esthet Dent Update 1991 Aug;2(4):63-6. 3. Haywood VB. History, safety, and effectiveness of current bleaching techniques and applications of the night guard vital bleaching technique. Quintessence Int. 1992 Jul;23(7):471-88. Review. 4. Haywood VB. Update on bleaching: an examination for night guard vital bleaching. Esthet Dent Update 1995;6(2):51-2. 5. Haywood VB. Night guard vital bleaching: current concepts and research. J Am Dent Assoc. 1997 Apr;128 Suppl:19S-25S. Review. 6. Haywood VB. Night guard vital bleaching: information and consent form. Esthet Dent Update 1995;6(5):130-2. 7. Haywood VB, Williams HA. Status and restorative options for dentist-prescribed home-applied bleaching. Esthet Dent Update 1994;5(3):65-7. 8. Haywood VB, Leonard RH, Dickinson GL. Efficacy of six months of nightguard vital bleaching of tetracycline-stained teeth. J Esthet Dent. 1997;9(1):13-9. 9. Swift EJ JR. Restorative considerations with vital tooth bleaching. J Am Dent Assoc. 1997 Apr;128 Suppl:60S-64S. 10. Li Y. Toxicological considerations of tooth bleaching using peroxide-containing agents. J Am Dent Assoc. 1997 Apr; 128 Suppl:31S-36S. 11. Fasanaro, TS. Bleaching teeth: history, chemicals, and methods used for common tooth discolorations. J Estht Dent. 1992 May-Jun;4(3):71-8. 12. Matis BA, Cochran MA, Heinonen L. Safety and effectiveness of bleaching agent in double blind study [Abstract]. J Dent Res.1997;76:323. 13. Bently C, Leonard RH, Garland G, Eagle JC, Phillips C. Crossover study of a 10 % carbamide peroxide solution [Abstract]. J Dent Res. 1998;77,804. 14. Kihn P, Barnes DM, Depaola L, George D, Romberg E, Medina E. Clinical evalation of carbamide peroxide tooth whitening agent [Abstract]. J Dent Res.1998;77:957. 15. Jones AH, Diaz-Arnold AM, Vargas MA, Cobb DS. Colorimetric assessment of laser and home bleaching techniques[Abstract]. J Dent Res. 1998;77:134. 16. Cadenaro M, Di Lenardo R. Effect of tooth whitening upon micro hardness of enamel and dentin [Abstract]. J Dent Res. 1998;77:134. 17. Nathoo SA, Chmielewski MB, Kakar A, Haxworth B, Rustogi K. Effect of tooth whitening upon microhardness of enamel and dentin [Abstract]. J Dent Res. 1998;77:144. 18. Settembrini L, Gultz J, Kaim J, Scherer W. Effect of two in-office bleaching systems on enamel morphology [Abstract]. J Dent Res. 1998;77:948. 19. Yarborough DK. The safety and efficacy of tooth bleaching: a review of literature 1988-1990. Compendium.1991 Mar;12(3):191-6.Review. 20. Betke H. Kahler E, Reitz A, Hartmann G, Lennon A, Attin T. Influence of bleaching agents and desensitizing varnishes on the water content of dentin. Oper Dent. 2006 Sep-Oct;31(5):536-42. 21. Betke H, Revas P, Attin R. [Einfluss von Desensibilisierungslacken auf die Zahnaufhellung in der Bleichtherapie] Quintessense 2005;6:589-97.
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Creative in research
Surgery
Ectopic Supernumerary Nasal Tooth: A Clinical Case Report

Abstract
The incidence of ectopically erupting teeth has increased in these days. Teeth erupting into the nasal cavity is however a rare phenomenon. This is a clinical case report of an ectopic supernumerary tooth which was found in the nasal cavity. The clinical and radiographic findings of this case, its possible etiology, complication, diagnosis and treatment were discussed.
Key words: Ectopic eruption; supernumerary teeth; nasal teeth.

The detection of ectopic teeth that appear in places other than that of the normal teeth is increasing. This may be due to the greater use of panoramics, CT scans, MRI and due to the increased awareness and public interest in their dentition and oral health. Ectopically erupting teeth may appear beside the orbit, chin, maxillary sinus, palate and the nose.1-7 There are several conditions that may lead to the ectopic eruption of teeth. These may include developmental disorders such as cleft palate cases, trauma causing displacement of the teeth, cysts, maxillary infection, crowding, genetic factors and high bone density.4,5,8 Theses ectopic teeth may be permanent, deciduous or supernumerary.4 Most cases of supernumerary teeth are asymptomatic and usually discovered with routine examination and radiographs.1 Sometimes ectopically erupted teeth cause epistaxis, rhinitis, septal abscess, septal perforation, pain in the philtrum area, discomfort during deglutition and speech.9 They can further cause delay in the eruption of teeth or future malalingment of teeth, external nasal deformities and nasolacrimal duct obstruction.8, 10 The nasal teeth are a rare form of supernumerary teeth.11 Smith et al.8 in 1979 identified 27 well documented cases of intranasal teeth. Pracy et al.3 , Spencer and Couldery5 and Johnson12 listed four instances of this abnormality. Chen et al.13 in 2002 reported two cases of intranasal teeth that were endoscopically removed. In 2008, Subramaniam et al.14 reported a case in which a patient with missing upper lateral incisor was found in the nasal cavity.
Dr. Khaled Mansour

BDS, MSc, LDP, PhD Director of Alexandria Dental Research Center (ADRC), Egypt Head of oral implantology department ADRC General Secretary of Alexandria Oral Implantology Association secretary@aoiaegypt.com
Case Report
A 27-year-old male attended the oral surgery department in Alexandria Dental Research Center complaining of pain in the nose, swelling and discomfort related to the area of the right canine eminence. On pressure, pain was referred to the nose with headache and the patient felt that there is something blocking his nose (an intranasal mass). Patients dental examination revealed a complete set of teeth without any oral disease nor history of maxillofacial trauma or surgery. Patients general medical status was reviewed and found adequate. Radiographic examination of the oral cavity including periapical, occlusal and panoramic films showed that there is an impacted supernumerary tooth like structure high above the apex of upper right canine (Figs. 1,2). It gave the image of an impacted tooth in the palate, but the patient with certain movements, clinically showed the tip of the supernumerary tooth in the floor of the nose (Fig. 3). The definitive treatment for the supernumerary tooth is the surgical removal of the tooth1,7, even if it were asymptomatic.8 A combination of infra orbital block anesthesia and infiltration were given to the patient. A blind dissection around the tooth like structure was performed to expose the whole crown (Fig. 4). No incisions were used during this procedure. The mass was held and extracted from the right nostril using a curved hemostat (Fig. 5). Local haemostatic was applied into the nose to stop bleeding. With visual examination, the mass appeared as a tooth having a crown and a root (Fig. 6). Microscopically, it was composed of dentine and covered by well organized enamel and the central region contained pulp tissue. The patient was asked for follow up after 3 days, where by then all preoperative signs and symptoms had completely disappeared. The patient was instructed to attend for follow up every 6 months.
Ectopic and supernumerary teeth may erupt in different sites.4 The incidence of supernumerary teeth usually affects 0.1-1% of the population.11 The prevalence is higher in male children and vegetarians. Heredity may play a role for the increased incidence in some families. Various theories have been proposed to explain the presence of supernumerary teeth. The first theory is the excessive growth of the dental lamina.11 The second theory is that the tooth germ may undergo dichotomy.15 The third theory states that these teeth are derived from clumps of epithelium that remained after the breaking up of the tooth band and became activated to tooth formation.15 The diagnosis of the nasal teeth depends on the clinical and radiographic examination. When an extra tooth is in the nasal cavity, the procedure is usually a minor operation. When a tooth has a bony socket in the floor of the nose, it may be extremely difficult to extract.16 If the patient is still in the mixed dentition period it is better to delay the surgical interference until the complete eruption of the permanent teeth and formation of their roots.17 Once these teeth are extracted, they appear as normal teeth in structure and appearance. The differential diagnosis of nasal teeth includes radiopaque foreign body, rhinolith, inflammatory lesions due to syphilis, tuberculosis, or fungal infection with calcification, benign tumors including hemangioma, osteoma, calcified polyps, enchondroma, dermoid cyst, and malignant tumors such as chondrosarcoma and osteosarcoma.13 More research with several investigations must be done to have statistical data about the actual percentage of ectopic teeth in the nose in Egypt. More research on ectopic teeth must be done to know the actual reason for their presence and to know why they appear in that specific place.
1. Elango S, Palaniappan SP. Ectopic tooth in the roof of the maxillary sinus. Ear Nose Throat J. 1991 Jun;70(6):365-6. 2. Dayal PK, Dewan SK, Bihani VK, Dave CJ. Eruption of a tooth into the nasal cavity due to osteomyelitis. J Laryngol Otol. 1981 May;95(5):509-12. 3. Pracy JP, Williams HO, Montgomery PQ. Nasal teeth. J Laryngol Otol. 1992 Apr;106(4):366-7. 4. Carver DD, Peterson S, Owens T. Intranasal teeth: a case report. Oral Surg Oral Med Oral Pathol. 1990 Dec;70(6):804-5. 5. Spencer MG, Couldery AD. Nasal tooth. J Laryngol Otol. 1985 Nov;99(11):1147-50. 6. Gadalla GH. Mandibular incisor and canine ectopia. A case of two teeth erupted in the chin. Br Dent J. 1987 Oct 10;163(7):236. 7. Di Felice R, Lombardi T. Ectopic third molar in the maxillary sinus. Case report. Aust Dent J. 1995 Aug;40(4):236-7. 8. Smith RA, Gordon NC, De Luchi SF. Intranasal Teeth. Report of two cases and review of the literature. Oral Surg Oral Med Oral Pathol. 1979 Feb;47(2):120-2. 9. Pradhan AC, Varma RK. Supernumerary tooth in palate--a case report. J Indian Dent Assoc. 1979 Mar;51(3):91. 10. Alexandrakis G, Hubbell RN, Aitken PA. Nasolacrimal duct obstruction secondary to ectopic teeth. Ophthalmology. 2000 Jan;107(1):189-92. 11. Thawley SE, LaFerriere KA. Supernumerary nasal tooth. Laryngoscope. 1977 Oct;87(10 Pt 1):1770-3. 12. Johnson AP . A case of an intranasal canine tooth. J Laryngol Otol. 1981 Dec;95(12):1277-9. 13. Chen A, Huang JK, Cheng SJ, Sheu CY. Nasal Teeth: Report of Three Cases. AJNR Am J Neuroradiol. 2002 Apr;23(4):671-3. 14. Subramaniam A, Sable D, Chavan M. Nasal Tooth: Report of a Rare Case and Radiographic Localization. International Journal of BioSciences and Technology 2008;1(1):22-4. 15. Farmer ED, Lawten FE. Anomalies in number size and form of the teeth. In: Stones Oral and Dental Diseases, 5th edn. Liverpool, E & S Livingstone Ltd, 1966, pp 161-164 16. Wurtele P, Dufour G. Radiology case of the month: a tooth in the nose. J Otolaryngol. 1994 Feb;23(1):67-8. 17. Martinson FD, Cockshott WP. Ectopic nasal dentition. Clin Radiol. 1972 Oct;23(4):451-4.
Discussion
(Figure 1)
Panoramic view showing a radio-opaque mass high above the apex of the upper right centrals.
(Figure 2)
Occlusal view suggestive of palatal imapction of the radioopaque mass.
(Figure 3)
The tooth was clinically apparent with certain movements of the nose.
(Figure 4)
Exposure of the tooth-like structure without incisions.
References
(Figure 5)
Extraction using a curved hemostat.
(Figure 6)
The extracted mass had a tooth like structure.
29
Endodontics
Tips for Endodontic Radiography

Abstract
Endodontic radiographs traditionally form the backbone of the diagnosis, treatment procedures and follow-up of endodontic cases. It is the only method whereby the dentist can visualize that which he cannot see or feel during the process of diagnosis and treatment. A radiograph is however a twodimensional image of an actually a three dimensional object. Some tips are outlined in this articles that have proved to be successful and predictable. If followed, they will greatly improve and simplify root canal treatment.
Key words: Endodontic radiographs; angled radiographs; diagnosis.

No single scientific advancement has contributed as greatly to improved dental health as the finding of the amazing properties of cathode rays by Professor Wilhelm Konrad Roentgen in November 1895. The possibilities of their application to dentistry were realized as soon as two weeks after this finding, when Dr. Otto Walkoff took the first dental radiograph in his own mouth.1 Three years later (1899), Dr. C. Edmund Kells used the x-ray during root canal therapy to determine the tooth length. One year later (1900), Dr. Weston A. Price called attention to incomplete root canal fillings as evidenced in radiographs and in 1901, he recommended using radiographs to check the adequacy of root canal fillings. 2 Radiography is nowadays considered a basic tool in the practice of endodontics. It would be almost impossible to obtain good results from treatment without the use of radiographs. One needs excellent diagnostic preoperative x-rays for evaluation of the case, x-rays during the treatment for verification of the procedures involved in the treatment, and postoperative x-rays to evaluate treatment outcome after completion of endodontic therapy. It is however important to mention that only by following certain criteria in capturing, reading and interpreting x-rays, one can make the best use of this important tool. The purpose of this paper is to discuss some tips in endodontic radiography and how to interpret findings in order to obtain the clearest true realistic picture. An x-ray may supply surprising information about the tooth, pulp chamber and contents, number, patency, curvature and length of the canals. In cases of retreatment, it may demonstrate canal perforations, broken instruments, failure to properly obdurate, ineffective endodontic surgery and a number of conditions well below the standard of care. In order to effectively use and understand x-rays one should go along with the following tips. The apices of the roots must be completely visible. Each radiograph must include the entire area of interest, and the apices of the teeth must be at least 3 mm away from the border of the radiograph.3 Figure 1, clearly demonstrates the importance of this rule. Take two or three radiographs at different angles. The long cone paralleling technique is the technique of choice for endodontic radiography. It projects an accurate radiograph with minimal distortion and a high level of reproducibility.4 A single radiograph may however show an apparently well accomplished treatment, which when retaken from a second or third viewpoint may demonstrate an important discrepancy relative to the first view. 5 An intentional shift of the x-ray beam from the orthoradial position may provide additional information compared to the zero degrees projection (Fig. 2). A straight-on diagnostic film should be taken such that the x-ray cone is aimed perpendicular to both the facial aspect and long axis of the tooth. A second, mesially angulated image is attained by horizontally aiming the x-ray cone up to 30mesial to the straight-on angle and perpendicular to the long axis of the tooth.6 A third, distally angulated image is attained by horizontally aiming the x-ray cone up to 30 distal to the straight on angle and perpendicular to the long axis of the tooth. This is to show a complete image of the root canal system that is as close to a three dimensional image as possible (Figs. 3, 4). It has been demonstrated that the recommended horizontal beam angulation for identification of two canals in one root is dependent on the amount of separation and divergence between canals and is reported to lie between 20 and 40. 7, 8, 9
Dr. Mohammad Hammo

BDS, DESE Endodontics Private Practice Amman, Jordan dentist_h@yahoo.com
(Figure 1)
a) Radiograph of the maxillary canine. The periapical area is not clear. b) Another x-ray extending beyond the full length of the same maxillary canine demonstrating a well defined radiolucency at the apex.
b (Figure 2)
a) Radiograph of the mandibular first molar shows apical radiolucency in spite of well performed endodontic treatment !! b) The angled x-ray shows incomplete endodontic treatment of mesial root accounting for the observed radiolucency.
b (Figure 3)
a) An x-ray of a mandibular first molar taken in a straight direction showed 2 canals. b) An x-ray taken in a distal direction showed 3 canals of the same tooth. c) An x-ray taken in a mesial direction showed 4 canals of the same tooth.
(Figure 4)
a) An x-ray of a maxillary first premolar taken in a straight direction showed 1 canal. b) An x-ray taken in a distal direction showed 2 canals of the same tooth. c) An x-ray taken in a mesial direction showed 3 canals of the same tooth.
c (Figure 5)
a) Preoperative X-ray of maxillary first and second premolars. Tracing periodontal ligament spaces (arrows) indicates the presence of three roots in each tooth. b, c) Postoperative x-rays clearly demonstrate what was pre-operatively traced.
c (Figure 6)
a) Preoperative X-ray of a mandibular first premolar. Tracing periodontal ligament spaces (arrows) indicates the presence of three canals. b) This can be readily seen in the post-operative x-ray.
b
Endodontics
(Figure 7)
a) Preoperative X-ray of a maxillary first premolar. Root canal filling is not centered in the canal (arrow) indicating the presence of a second untreated canal. b) Postoperative X-ray.
b (Figure 8)
a) Preoperative X-ray of mandibular first molar showing bone loss in the furcation area. b) Clinical examination shows mesialto-distal fracture line (arrow) running through the furcation floor.
b (Figure 9)
a) The teardrop radiolucency (arrow) present at the apex of this upper second premolar is highly suggestive of a vertically fractured root . b) Inserting gutta percha deep into the pocket to the point of resistance. c) Extension of the gutta percha till the apex confirms the diagnosis.
c long way towards allowing the dentist to see the often-elusive complete clinical picture.
Careful preoperative assessment of root canal anatomy obtained from a diagnostic radiograph is a key prerequisite for thorough canal preparation and, ultimately, successful therapy. One should always look for periodontal ligament spaces when evaluating x-rays (Figs. 5, 6). By tracing these spaces, one can diagnose multiple roots, bifurcated roots, or teeth with strange anatomy. 10 If the root canal filling is not centered in the canal, it is a virtual certainty that a second canal exists within the root that is untreated (Fig.7). An operator should always look at the position of radiolucencies. Lesions of endodontic origin can arise anywhere laterally along the periodontal ligament as often as they are present apically. An entire bone loss in the furcation area is a strong indication that either one of the roots is fractured or that there is a mesialto-distal fracture running through the furcal floor (Fig. 8). Similarly, a teardrop radiolucency that extends up a root, especially in the presence of a post and buildup, is most often associated with a vertical root fracture (Fig. 9). Probing to the apex of the affected root is virtually diagnostic. 11
References
1. Ennis LM, Berry HM. Dental roentgenology. 5th ed. Philadelphia: Lea and Febiger; 1959, p. 13. 2. Glenner RA. 80 years of dental radiography. J Am Dent Assoc. 1975 Mar;90(3):549-63. 3. van Aken J, Verhoeven JW. Factors influencing the design of aiming devices for intraoral radiography and their practical application. Oral Surg Oral Med Oral Pathol. 1979 Apr;47(4):378-88. 4. Fava LR, Dummer PM. Periapical radiographic techniques during endodontic diagnosis and treatment. Int Endod J. 1997 Jul;30(4):250-61. 5. Kaffe I, Gratt BM. Variations in the radiographic interpretation of the periapical dental region. J Endod. 1988 Jul;14(7):330-5. 6. Ruddle CJ. Endodontic Diagnosis. Dent Today. 2002 Oct;21(10):90-2, 94, 96-101; quiz 101, 178. 7. Walton RE. Endodontic radiographic technics. Dent Radiogr Photogr. 1973;46(3):51-9. 8. Klein RM, Blake SA, Nattress BR, Hirschmann PN. Evaluation of X-ray beam angulation for successful twin canal identification in mandibular incisors. Int Endod J. 1997 Jan;30(1):58-63. 9. Martnez-Lozano MA, Forner-Navarro L, Snchez-Corts JL. Analysis of radiologic factors in determining premolar root canal systems. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999 Dec;88(6):719-22. 10. Castellucci A. Diagnosis in Endodontics. In: Endodontics. Florence: IL Tridente; 2004, p. 44. 11. Mounce R. Interpreting endodontic radiographs. Take a trip to a Japanese rock garden. Dent Today. 2003 Dec;22(12):64-6, 68-70.
Conclusion
Radiographic examination is crucial for providing optimal dental care. In combination with a comprehensive objective and subjective clinical examination, such radiographic interpretation from multiple angles is made much more decisively when consideration is given to the tips presented above. This approach will go a
Events
Beirut, Lebanon / 16 18 October 2008

Under the High Patronage of His Excellency President of Republic of Lebanon; General Michel Sleiman, Beirut International Dental Meeting 2008 held its meeting in the congress palace Dbayeh, Beirut-Lebanon. The representative of the president, his Excellency Dr. M. Khaleefeh, Minister of Health, honored the opening ceremony by his presence. Dr. Antoine Karam, president of the Lebanese Dental Association (LDA) welcomed the guests and the participants, and mentioned that this annual congress is not held only to attend lectures, but it is more about meeting, helping and cooperating with each other. Dr. Antoine Berberi, scientific chairperson, stated Our program comprised more than 70 lectures, 5 live transmissions, 16 workshops and 13 posters, with the participation of 28 invited speakers from 14 countries. Dr. Nabeel Bou Habib, treasurer and head of committee, declared that this conference is the fruitful result of the hard work and coordination of all sections of the Lebanese Dental Association, and added that the meeting included a large exhibition with more than 60 exhibitors presenting and introducing the up-to-date dental armamentarium.
Opening ceremony
Miss Sfeir presenting a trophy to Dr. Antoine Karam; President of LDA
Egyptian delegates
ASA Dental
Cedra Levant
Tamer Group
Kavo
Pharmacol
Dr. Roland Arsan, Dr. Roger Rbeiz & Mr. Chawki Richa
Haddad Company
D.M.S.
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Events
Cairo, Egypt / 16 - 18 October 2008

The XIIth International Symposium on Dentofacial Development and Function was held in the historic hotel Cairo Marriott Hotel and Omar Khayyam Casino in Cairo in October 16-18, 2008. Abbas Zaher, professor of orthodontics at the University of Alexandria, Egypt and Vice-President of the WFO presided the meeting. The scientific program, orchestrated by Prof. Yehia Mostafa, Head of the Department of Orthodontics at Cairo University and successfully coordinated by Prof. Khaled Attiya from the same department, managed to attract an honorable slate of 21 invited speakers from the seven continents of the world, and thus tackling the most important topics discussed in the field of Orthodontics and Dentofacial orthopedics. The symposium was preceded by a continuing education course and followed by two, covering most up-to-date clinical arenas: Prof. Bjorn Zachrisson from Norway had a heavily attended pre-symposium course on finishing, adult orthodontics and multidisciplinary treatment. Following the symposium, Prof. Robert Vanarsdall, head of department of orthodontics in Pennsylvania University, presented the state-of-the art in orthodontic and periodontic conjunctive treatment modalities. This course attracted the participation of many periodontists and steered up most fruitful discussions. At the same time, Dr. Vitorrio Cacciafesta from Italy taught a large group of 50 orthodontists how to practice the lingual technique with 2D lingual bracket system in a theoretical and practical course. This esteemed group of world renowned lecturers, together with another 31 speakers whose oral presentation were accepted, attracted more than 400 participants from 34 countries from all over the world. Cairo offered a variety of touristic attraction; spouses and families of the participants took trips to the Pyramids and Sphinx and visited old Cairo and the Egyptian Museum. In the evening, the various cultural events were frequented by the participants. The morning following the post symposium courses, many participants took the legendary Nile Cruise from Luxor to Aswan for 4 days while the rest flew safely back home. Alongside the symposium, the presidents of the previous meetings, who attended the symposium, held a meeting to organize the coming event. Prof. Samir Bishara from USA, Prof. Athanasios E. Athanasiou from Greece, Prof. Hans Sergl from Germany, Prof. Kurt Faltin from Brazil, Prof. Nejat Erverdi from Turkey and Prof. Giuseppe Siciliani from Italy and Prof. Abbas Zaher, the president of this Symposium. The Board decided to elect Prof. Siciliani President of the XIIIth International Symposium to be held in Verona, Italy on October 8 10, 2010.
Prof. Yehia Mostafa, Khaled Attiya and Abbas Zaher with Dr. Maamoun Salhab at Smile Journal stand
The Symposiums organizers
Participants at the Symposium dinner
Events
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Events
Jordanian Endodontic Congress

Amman, Jordan / 22 - 24 October 2008
Under the patronage of his Excellency the Prime Minister,The first Jordanian Endodontic Congress was held in Hyatt Amman Hotel on the 22nd-24th of October 2008. During the opening ceremony, the representative of the Prime Minister, his Excellency the Minister of Health, Dr. Salah AlMawajdeh, gave a speech in which he brought the attention to the increasing incidence of oral and dental diseases in the Jordanian population. Furthermore, his Excellency emphasized the importance of the Endodontic specialty and its role in maintaining the health of dental tissues. In his speech, the president of the Jordanian Dental Association; Dr. Wasfi Al-Rashdan, praised the congress as one of many important efforts in the continuous education arena. The first two days of the congress were dedicated to scientific lectures given by 12 esteemed world wide lecturers, which were attended by 220 participants. Various concepts and techniques were discussed in the lectures. In the memorial lecture, presented by Professor Marwan Abu Rass, the use of Endodontics in preparation for immediate implants was discussed. In addition, about 110 participants attended the two hands-on courses held on the day following the congress. Each course was accredited six hours of continuous education. Alongside the congress, state of the art devices and materials were presented in the exhibition, in which twenty companies and representatives participated. Interestingly, the launch of the Arab Endodontic Association was announced during the congress. Dr. Ibrahim Abu Tahun, the president of the Jordanian Endodontic Society, was elected to be the first president of the Arab Endodontic Association. In addition, it was settled that Jordan will be the country where the first Arab Endodontic Congress will be held in November, 2009. As the congress was concluded, the speakers, congress organizers, and sponsors were handed the appreciation and honorary awards and trophies in a ceremonious Gala dinner. In conclusion, Smile team would like to pass on good wishes to Dr. Ibrahim Abu Tahun for his success in organizing the congress and his new post as the first president of the new Arab Endodontic Association.
Prof. Lamis Rajab, Dr. Wasfi Al-Rashdan, H.E. Dr. Salah Al-Mawajdeh, Prof. Ghazi Baqain, Dr. Maher jarbawi & Dr. Ibrahim Abu Tahun
Dr. Muna Al-Ali, Dr. Ehab Heikal & Solange Sfeir
Dr. Mohammad Hammo, Eng. Ziad Qwaider & Dr. Fadi Al-Khufash
DentaMed Company
During one of the lectures

Al-Shumukh Company
Events
Dubai, UAE / 24 - 25 October 2008
Teamwork For Excellent Dentistry
The 3rd CAD/CAM & Computerized Dentistry International Conference proved for the third time that this is an assembly for excellent network. This year the conference attracted more than 450 participants and visitors from 21 countries, 25% of whom were conference first-timers. Dr. Ali Bin Shakar, Director General of Ministry of Health and Dr. Ali Al Numairy, the Head of Emirates Medical Association, greeted the delegates and saluted for their desire for new knowledge in the era of computerized technology. Dr. Aisha Sultan Al Suwaidi, head of Dental Society in Emirates Medical Association and the President of the conference, welcomed the colleagues and motivated them to keep their knowledge continuously updated and improve their skills to insure that they are providing the best care for their patients. Dr. Munir Silwadi, Conference Chairman and Scientific Program Advisor said: In its third year, our conference is setting the standard for highly specialized conferences of our dental profession. With the outstanding success we enjoyed in the previous years, our conference is emerging to be the biggest CAD/CAM specialized event in the whole of the Middle East and probably beyond. The program covered topics in CAD/CAM in aesthetic and prosthetic dentistry, computerized Implantology, computerized scanning and imaging, CAD/CAM dental laboratories, CAD/CAM materials, computerized management and planning and computerized orthodontics. Workshops with Ivoclar Vivadent and Nobel Biocare were packed full and covered current topics and trends in the areas. SIRONA, the Gold sponsor of the conference surprised the delegates with live demonstration in the special designed area.
Dr. Nadim Abou-Jaoudi, Dr. Munir Silwadi & Dr. Philippe Tardieu
Opening ceremony
During one of the lectures
Dr. Dobrina Molova presenting a trophy for the iraqi group
Mr. Imad Kafity & Dr. Nadim Abou-Jaoudi
Sirona Company receiving the trophy

Mr. Elie Jurdak & Dr. Rodrigue Rizk
Events
DENTSPLY Centre of Excellence Dental Symposium 2008

Dead Sea, Jordan / 25 26 October 2008
DENTSPLY has a long-standing commitment to continuing education in the field of dentistry, working closely with international opinion leaders from around the globe to bring better dentistry to the widest possible audience. The DENTSPLY Centre of Excellence is a collaboration between different DENTSPLY Divisions. Contributions from DENTSPLY DeguDent, DENTSPLY Friadent and DENTSPLY Maillefer ensure a diverse and interesting program. World-renowned clinicians presented lectures, master classes and hands-on clinics that covered a variety of topics including aesthetic dentistry, implants, endodontics and prosthetics. DENTSPLY hosted this symposium in association with the Jordanian Dental Association at the Movenpick Hotel, Dead Sea, Jordan on the 25th-27th of October 2008 where more than 300 participants gathered. A Gala Dinner was held for all participants on the 25th providing an opportunity to meet fellow professionals from around the world in a relaxed atmosphere.
Dr. Mohammad Sartawi, Dr. Wasfi Al-Rashdan, Eng. Raid Shihadeh & Mr. Rolf Rothhammer
During one of the workshops
Prof. Dr. German Gomez-Roman
Prof. Pascal Zyman
Prof. Paul Dummer
Dr. Mohammad Sartawi, Miss Solange Sfeir & Eng. Raid Shihadeh
Mr. Rolf Rothhammer

Mr. Thomas Schuessler
Events
Alexandria, Egypt / 28 - 31 October 2008

Under the auspices of Prof. Hassan Nadeer Khairalla; president of Alexandria University, the 16th Alexandria International Dental Congress was held in Hilton Alexandria (Green Plaza) between the 28th and 31st of October 2008. Professor Ahmed Abdella; Dean of Faculty of Dentistry, Alexandria University & the congress President, together with the general secretary of the congress; Prof. Walid El-Kenany, in collaboration with the organizing committee succeeded to hold a well structured program that attracted more than two thousand local and regional participants. The 4 day-scientific-program handled general dental topics given by more than 80 local, regional and foreign speakers. In addition, the scientific program included 13 pre and post congress courses. Alongside the congress, state of the art devices and materials were presented in the exhibition, in which more than 45 companies and representatives participated.
Prof. Aly Sharaf, Prof. Tarek Mahmoud, Prof. Ahmed Abdella, Prof. Walid El-Kenany & Prof. Abbas Zaher
Mr. Benno Walter, Dr. Morad Naguib, Mr. Lazar Piro & Eng. Ziad Qwaider
Smile presenting a trophy for the AIDC Board
Oraltronics
Dr. Eduardo Mahn during a workshop
Dr. Mohamed Hassan lecturing
Mr. Stephen Lawry in A-dec booth
Dr. Ehab Heikal & Mr. Imad Najjar

Biomet 3i
SternWeber
Events
Doha, Qatar / 04 - 07 November 2008
&
Qatar International Medical Hospital Show Qmedic
The opening of Qmedicwas held under the auspices of H.E. Sheikha Dr. Ghalia Bint Mohammad Al Thani, Minister of Health with the official patronage of the National Health Authority & the partnership of Hamad Medical Corporation. H.E. Sheikha Dr. Ghalia, focused on the importance of holding such an exhibition in the State of Qatar especially that the Government is keen on providing the most advanced medical equipment, and introducing the latest technology in the medical equipment arena into the local markets of Qatar as she stated. On the other hand Mr. Khalifa Al Maslamani, Conex Chairman said that: The event gathered more than one hundred companies showcasing their latest products & services in the medical field and also international participations from various countries. The exhibition has reached its goal in highlighting on the health and medical sectors available in Qatar in terms of products, services. It has brought together the best in business of hospital diagnostic, pharmaceutical, dental, laboratory & medical rehabilitation, equipments and supplies for the future of healthy collaboration and success in the region. The number of visitors has reached 4000, among them health ministers from surrounding countries, ambassadors, as well as the first lady of the Dominican Republic and a number of international specialists. Participants pointed on the success of this exhibition in terms of organization and on the opportunity given for medical companies to showcase for the first time in Qatar their latest innovations and technologies in the health and medical sectors. Adding to this, the awareness campaigns and the presence of medical services has helped in producing a kind of public attention to the most common diseases. Ghassan Abou Touq, Project Manager stated: The strength of this exhibition lies in its international participants from Italy, Germany, Japan, Lebanon, Jordan, South Korea, UK, France, and Austria. The presence of the governmental sector, sponsors and local companies played a major role in attracting those international participations, noting that the marketing campaign and promotion for this exhibition reached through its media partners Europe, Asia, USA, Middle East and Gulf Area. Also a large number of online registrations as participants and visitors were listed on the Qmedic website: www.qmedic.net . Moreover, Maya Abou Rjeily, Senior Events Coordinator at Conex said that: A gala dinner honoring the sponsors, participants and media partners was held in the Intercontinental hotel were trophies and awards were distributed on the attendees to thank them for their support and their presence. This event will be organized biannually in Qatar and the next edition date and time will be announced shortly in the media and on the website.
H.E. Sheikha Dr. Ghalia Bint Mohammad Al Thani & Mr. Khalifa Al Maslamani
Mr. Zuhdi Jaouni General Manager of Ali Bin Ali Medical; official distributor of Smile in Qatar, visiting Smiles stand
Mr. Ghassan Abou Touq & Miss Maya Abou Rjeily

Solange Sfeir receiving Smiles trophy
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OptiBond AllInOne One component does it all.

Self-Etch Adhesive System
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OptiClean
Innovation for optimal dental care.

Easy and efficient handling:
Faster, easier and complete removal of temporary cement. Excellent access thanks to its specific design. Clear view of the working surface since no paste or pumice slurry is required. Low risk of abrasion on the preparation and adjacent teeth. Gentle to the soft tissue. Highly hygienic because its single use only.
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TempBond
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Provisional Cement
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Your practice is our inspiration.
Events
2nd Conference of the Syrian Society of Dental Implantology

Damascus, Syria / 12 - 14 November 2008
Under the patronage of His Excellency The Member of the Regional Leadership of Al-Baath Arab Socialist Party and Chairman of the Regional Trade Unions Bureau in Syria Dr. Bassam Janbieh, the Second Conference of the Syrian Society of Dental Implantology was held in Ebla Sham hotel, Damascus, Syria between the 12th and 19th of November 2008. Professor Safwan Jaber; president of the conference together with the conference vice president; Dr. Rifaat AlKubaissy, were able with the organizing committee to hold a well structured program that attracted hundreds of local and regional participants. Scientific lectures and workshops presented by local, regional and international pioneers discussed and covered the latest updates of dental implantology. Besides, an exhibition was held during the conference featuring the latest know-how in dentistry.
Xenon stand Official distributor of Smile; Chatta Dental Supplies Dr. Jihad Abdallah receiving the trophy after his lecture President of the Syrian Dental Implantology society; Prof. Safwan Jaber & members of the council
1st Jordanian & 7th Arabic Congress of Pediatric Dentistry

Dead Sea, Jordan / 19 - 21 November 2008
Under the patronage of His Excellency The Prime Minister, represented by His Excellency Dr. Salah Al Mawajdeh Minister of Health, the First Jordanian & Seventh Arabic Congress of Pediatric Dentistry held its meeting at the Marriott Hotel, Dead Sea, on the 19th-21st / November 2008. The number of participants exceeded 160 including general practitioners, orthodontists, oral surgeons, periodontists, oral histologists, endodontists, post graduate students, residents in pediatric dentistry in addition to specialists in pediatric dentistry from Jordan, Saudi Arabia, Kuwait, Bahrain, Oman, UAE, Lebanon, Syria, Egypt, Sudan, Tunisia, Libya, Iraq, and invited speakers from Sweden and England. Dr. Omima Gumaa the president of Sudanese Society of Pediatric Dentistry was elected as the president of the Arabic Societies Union of Pediatric Dentistry for the next two years, where Sudan will host the 8th Congress in 2010. The members of the executive committee were elected as follows: Dr. Othman Ajlouni from Jordan, Dr. Waleed Al-Saadi from Syria and Dr. Omima Gumaa from Sudan. The website of the union will be launched soon.
Dr. Raed Abutteen presenting future plans of Smile to the Arab delegates
During the opening ceremony
Dr. Omima Gumaa receiving a trophy from Dr. Othman Ajlouni
Miss Sfeir with H.E. Dr. Salah Al Mawajdeh
Participants from different Arab Countries
Colgate stand at the exhibition
Miscellaneous Events
Take the Full Control on Your Practice

Dubai, UAE / 05 - 07 November 2008
Doha, Qatar / 05 November 2008

The Straumann Institute and their representative partner, Ali Bin Ali Medical Group conducted an introductory workshop on the Straumann Dental System in Doha, Qatar. The event provided a platform of discussion and exchange for local dental professionals and an opportunity for further skills enhancement for those either starting an implant activity or wishing to enhance their existing experience by tackling more challenging indications.
Straumann Workshop
Business Administration for Dental Professional workshop, held for the third time in Dubai UAE, (organized by CAPP and conducted by Dr. Ehab Heikal) offered a comprehensive certification program for dental professionals. The program has been designed to assist and guide any member of the dental team in implementing the strategies for effectiveness and business principles specifically for dentistry. During the course, participants learned the concepts of management focusing on the four functions of management including human resources management and team building, marketing and how would one market services to the patients including pricing strategies and advertisement techniques. The course covered other topics including dentist patient relationship, accounting and finance for the non-financials and quality and standardization in a dental clinic to ensure good quality work and patients satisfaction.
25 clinicians and dental technicians responded to this invitation which took place at the Grand Regency Hotel. The main speaker of this event was Dr. Elie Kamel, who discussed the pre-surgical assessment of straight forward oral implant indications, basic surgical considerations and finally the most commonly used implant borne restorative solutions. Mr. David Dias, on behalf of the Straumann Institute for the Middle East region, conducted a workshop that focused on the clinical prosthetic procedures through hands-on exercises.
This was one of the many events which Straumann proposes as part of their extensive continuous training and education program in the Middle East region.
JDIG Monthly Meeting
Amman, Jordan / 29 November 2008

The monthly JDIG scientific meeting was held on the 29th of November at the Vendome Hotel, Amman - Jordan. More than 100 dentists attended the Surgical Implant Site Preparation and Implants in the Esthetic Zone lectures presented by Dr. Bishi Al-Garni and Dr. Abdullah Alkeraidis, respectively. Attendants by the end of the lectures enjoyed a coffee break in the meeting room overlooking Amman.
Hikma Pharmaceuticals Sponsors a Day at JUST
Irbid, Jordan / 27 November 2008
Hikma Pharmaceuticals opting to improve medical health care, has a long standing commitment to support medical educational programs. Working closely with this objective, Hikma Pharmaceuticals on the 27th of November, sponsored a day meeting at the Dental Faculty / Jordan University of Science and Technology (JUST). During the meeting, Hikma Pharmaceuticals presented Aloclair which is one of its unique products. Participants expressed their need to find a solution to manage the common and painful problem of ulcers. Aloclair was presented as a new efficient, nonstinging, fast acting and long lasting pain relief for the management of mouth ulcers.
1st Scienti c Annual Meeting Trans Jordan (ORALTRONICS Middle East)

Amman, Jordan / 29/11 - 01/12 2008
The first scientific annual meeting for Trans Jordan for Medical Tools and Supplies Company - ORALTRONICS Middle East was held at the International Dental Implantology Center in Amman, Jordan, during the period from 29th of November to the 1st of December. Dr. Bishi Al-Garni, Dr. Abdullah Al-Keraidis and Dr. Majdi Saadeh were the speakers in this event which was attended by many dentists from several Arab countries including Saudi Arabia, Egypt, Syria, UAE, Bahrain and Jordan.
Launching of CMA Rotary File

Beirut, Lebanon / 05 December 2008
Under the patronage of Dr. Antoine Karam, President of the Lebanese Dental Association, and in the presence of Dr. Roland Arsan representative of GADC Global Services, Mr. Chawki Richa, and more than 500 dentists, Dr. Roger Rbeiz introduced CMA, the new rotary endodontic files, at Beyt El Tabib, Beirut, Lebanon.
Flash News
The strength of the Anthos brand, other than the undeniable reliability of the equipment and stylish Italian design, has always been the vast assortment of treatment centres catering for just about any operating style. Dentists worldwide have had a chance to work on one of 25,000 Classe A units experiencing the flexibility of the product and enjoying the levels of performance Anthos customers have come to expect. The newest addition to the product range was presented this summer in Italy. Designed and built entirely in the Anthos plant in Imola (Italy), Classe R7 is a digital ambidextrous unit based on the Anthos quickswitch concept; total versatility and top performance. Classe R7 incorporates a powerful hydraulic patient chair with a triple-jointed pneumatic headrest. The seat provides the patient with secure yet comfortable anatomical support. The slender backrest enables the dentist to lower the chair while maintaining correct posture alongside the patient. Moreover, special backrest shaping ensures the patient access zone is free from parts that might hinder the work of the dental team. The Classe R7 patient chair also features extensive vertical travel, allowing the patient to be positioned at exactly the right height whatever the task at hand. The Classe R7 meets the needs of all dental surgeons by offering ergonomic solutions compatible with all work styles. Easily adapted to different operating modes, unbeatable versatility makes the Classe R7 the best all-inclusive unit on the market. Get it right, and left. Ambidextrous, but not only. Anthos belongs to Cefla Dental Group, a leading European manufacturer of dental equipments consisting of integrated treatment centres, multimedia devices and latest generation digital radiology systems.
For Further Information, Visit www.anthos.com / www.cefladentale.com
56
Introduces 3M ESPE Filtek Z350 Universal Restorative Material

3M introduced 3M ESPE Filtek Z350 that restores teeth for beautiful smiles. This composite with its patented nanotechnology combines the strength of a hybrid with the beauty of a microfill, meaning that excellent aesthetic properties, strength and wear characteristics are all met. Filtek Z350 Universal Restorative offers low polymerization shrinkage with less stress on the tooth and less sensitivity potential for patients. The combination of nanomer sized particles to the nanocluster formulations reduces the interstitial spacing of the filler particles. This allows for increased filler loading , superior handling, better physical strength and wear properties and improved polish retention when compared to composites containing only nanoclusters. Provided with eight of the most popular shades, this material can be used in direct anterior and posterior restorations, cusp and core build-ups and splinting. Besides, since the material has exceptional flow with ideal slump resistance, it can be used in indirect anterior and posterior restorations including inlays, onlays and veneers.

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Calendar of Events 2009

Smile Dental Journal Volume 3, Issue 4 - 2008

Prof. Tarek Mahmoud Aly

Dr. Sarah Mohamed Arafat

Operative Dentistry Implantology

Material & Methods

Pre-Operative Phase A- Clinical & Laboratory Procedures

Orthopantomogram (OPG) radiographs were taken to show

Operative Dentistry Implantology

Operative Phase Surgical Technique

Follow-up Phase A-Clinical Evaluation

Assessment of bone density

The peri-implant bone density was measured by a computerized

Clinical Case Reports Case No. 1

Results A-Clinical Results

Assessment of marginal bone level

The GI after 3 months ranged between grade 2 and grade 1.

(Figure 8) Extraction, immediate implantation and provisionalization of case 1

o o) Immediate Postoperative x-ray.

Smile Dental Journal Volume 3, Issue 4 - 2008

p) Pre-operative. q) Immediately Post-operative. r) After 3 months. s) After 6 months. t) After 9 months.

Smile Dental Journal Volume 3, Issue 4 - 2008

Absorbable collagen membrane for Guided Bone Regeneration (GBR)

Collagen fleece/cone with antibiotic protection for OMF surgery

Absorbable and non-absorbable sutures for OMF surgery

(Table 1): Mean Plaque Index

(Table 2): Mean Gingival Index

(Table3): Mean Probing Depth

(Table 4): Mean Bone Density

(Table 5): Mean Marginal Bone Level

The Biologic Approach for Dental Procedures

Demineralized Cortical Powder

125 May Street Edison, NJ 08837, USA www.mtf.org +1.732.661.0202

PLEASE VISIT US AT BOOTH #232 DURING THE AEEDC MEETING IN DUBAI.

Operative Dentistry Implantology

Clinical Evaluation of Bleaching Agents of Different Concentrations

Dr. Hakam Al-Musa BDS, MSD Operative Dentistry

Adjunct Assistant professor University of Jordan

Material and Methods

Smile Dental Journal Volume 3, Issue 4 - 2008

Operative Dentistry Implantology

Natural. Biocompatible. Ormocer -based

The innovation: three-dimentionally linked inorganic-organic co-polymers

Ectopic Supernumerary Nasal Tooth: A Clinical Case Report

Key words: Ectopic eruption; supernumerary teeth; nasal teeth.

Dr. Khaled Mansour

Smile Dental Journal Volume 3, Issue 4 - 2008

Tips for Endodontic Radiography

Key words: Endodontic radiographs; angled radiographs; diagnosis.

Dr. Mohammad Hammo

Beirut, Lebanon / 16 18 October 2008

Miss Sfeir presenting a trophy to Dr. Antoine Karam; President of LDA

home kit 30 min

AMT- MENA Regional Manager contact: Mr. Diaa Khreish at diaa.khreish@amt-mena.com

Looking for distributors in the rest of MENA countries

Cairo, Egypt / 16 - 18 October 2008

The Symposiums organizers

Participants at the Symposium dinner

Smile Dental Journal Volume 3, Issue 4 - 2008

Smile Dental Journal Volume 3, Issue 4 - 2008

Jordanian Endodontic Congress

Dr. Muna Al-Ali, Dr. Ehab Heikal & Solange Sfeir

During one of the lectures