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Peer-Reviewed Journal of the Academy of General Dentistry

DENTISTRYJanuary/February 2015 ~ Volume 63 Number 1


6 Editorial Top traits 14 Endodontics Achieving and
maintaining apical patency in
7 To the editor Outdated endodontics: optimizing canal
information? shaping procedures

10 Restorative Dentistry 80 Answers Self-Instruction exercises

The crown to implant ratio in No. 343, 344, and 345
fixed prosthodontics

Clinical articles
16 Diagnosis and Treatment SELF -INSTRUCTION

Planning Why the general dentist 48 Anesthesia and Pain Control

needs to know how to manage Local anesthetic calculations:
oral lichen planus avoiding trouble with pediatric
Stephanie M. Price, DDS patients
Valerie A. Murrah, DMD, MS Mana Saraghi, DMD
Paul A. Moore, DMD, PhD, MPH
Continuing Dental 23 Microbiology Investigation
Education (CDE) of antibacterial efficacy of 53 Self-Instruction Exercise No. 362
Opportunities Acacia nilotica against salivary
Earn 2 hours of CDE mutans streptococci: a randomized 54 Forensic Dentistry The role of the
credit by signing up control trial dentist in identifying missing and
for and completing the Devanand Gupta, BDS, MDS unidentified persons
SELF-INSTRUCTION exercises Rajendra Kumar Gupta, PhD Amber D. Riley, RDH, MS
based on various subjects.
28 Self-Instruction Exercise No. 361 58 Non-Surgical Endodontics
Nonsurgical endodontic treatment
30 Diagnosis and Treatment of permanent maxillary incisors
Planning Clinical considerations with immature apex and a large
for selecting implant abutments periapical lesion: a case report
for fixed prosthodontics Gautam P. Badole, MDS
Roger A. Solow, DDS M.M. Warhadpande, MDS
Rakesh N. Bahadure, MDS
37 Dental Materials Surgical repair Shital G. Badole, BDS
of invasive cervical root resorption
with calcium enriched mixture SELF -INSTRUCTION

General Dentistry cement: a case report 61 Fixed Removable Hybrid

Index of Articles Saeed Asgary, DDS, MS Prosthesis Stress analysis of
available online. Mahta Fazlyab, DDS, MS mandibular implant-retained
Please visit www.agd.org/ overdenture with independent
gdindex to peruse 41 Office Design Evaluation of attachment system: effect of
our Index of Articles. 3 dental unit waterline restoration space and attachment
Arranged by topic, contamination testing methods height
this index provides a Nuala Porteous, BDS, MPH Behnaz Ebadian, DDS, MSc
comprehensive list of Yuyu Sun, PhD Saeid Talebi, MSc
articles published on a John Schoolfield, MS Niloufar Khodaeian, DDS, MSc
particular topic in past Mahmoud Farzin, PhD
issues and includes
PubMed citation 68 Self-Instruction Exercise No. 363

www.agd.org General Dentistry January/February 2015 1

69 Oral Medicine, Oral Diagnosis, e9 Dental Materials Impact of
Oral Pathology p53 expression toothbrushing with a dentifrice
in oral lichenoid lesions and oral containing calcium peroxide on
lichen planus enamel color and roughness
A. Arreaza, MSc Diala Aretha de Sousa Feitosa, DDS, MSc
H. Rivera, MSc Boniek Castillo Dutra Borges, PhD
M. Correnti, PhD Fabio Henrique de Sa Leitao Pinheiro, PhD
Rosangela Marques Duarte, PhD
73 Dental Materials Effect of imaging Renato Evangelista de Araujo, PhD
powders on the bond strength of Rodivan Braz, PhD
resin cement Maria do Carmo Moreira da Silva Santos, PhD
Christopher R. Jordan, DMD, MS Marcos Antonio Japiassu Resende Montes, PhD
Clifton W. Bailey, DDS
Deborah L. Ashcraft-Olmscheid, DMD, MS e12 Obturation Techniques Apical
Kraig S. Vandewalle, DDS, MS plug technique in a calcified
immature tooth: a case report
78 Implant Maintenance Crestal Kumar Raghav Gujjar, MDS
approach for removing a migrated Ratika Sharma, MDS
dental implant from the maxillary Amith H. V., MDS
sinus: a case report Smitha Amith, MDS
Raid Sadda, DDS, MS, MFDRCSI Indushekar K. R., MDS

e1 Cancer Screening Ameloblastic e16 Diagnosis and Treatment

carcinoma of the mandible Planning Central giant cell lesion:
manifesting as an infected diagnosis to rehabilitation
odontogenic cyst Ana Carolina Amorim Pellicioli, DDS
Adepitan A. Owosho, BChD Thieni Kaefer, DDS
Anitha Potluri, DMD Marco Antonio Trevizani Martins, DDS, PhD
Richard E. Bauer III, DMD, MD Vinicius Coelho Carrard, DDS, PhD
Elizabeth A. Bilodeau, DMD, MD, MSEd Manoela Domingues Martins, DDS, PhD

e5 Surgical Orthodontics A large e20 Diagnosis and Treatment

dentigerous cyst treated with Planning Alveolar ridge splitting for
decompression and orthosurgical implant placement: a review of the
traction: a case report procedure and report of 3 cases
Rodrigo Dias Nascimento, PhD Prakash S. Talreja, MDS
Fernando Vagner Raldi, PhD Chandrashekhar R. Suvarna, BDS
Michelle Bianchi de Moraes, PhD Preeti P. Talreja, MDS
Paula Elaine Cardoso, PhD
Deborah Holleben, DDS

Instructions for
For information on
submitting a manuscript
for publication in General
Dentistry, please visit

2 January/February 2015 General Dentistry www.agd.org

Advisory Board e24 Prosthodontics/Removable e32 Diagnosis and Treatment
Management of severe mandibular Planning Atypical presentation of
For Advisory Board members deviation following partial salivary mucocele: diagnosis and
biographies, visit www.agd.org/ mandibular resection: a case report management
gdadvisoryboard. Husain Harianawala, BDS, MDS Kumar Nilesh, MDS
Mohit Kheur, BDS, MDS Jagadish Chandra, MDS
Dental Materials
Supriya Kheur, BDS, MDS
Howard S. Glazer, DDS, FAGD
Jay Matani, BDS, MDS
Dental Public Health
Larry Williams, DDS, ABGD, MAGD e28 Diagnosis of Oral Pathology Rare
oral cartilaginous choristoma: a case
Esthetic Dentistry report and review of the literature
Wynn H. Okuda, DMD Marina Lara de Carli, DDS, PhD
Endodontics Felipe Fornias Sperandio, DDS, PhD
Gerald N. Glickman, MS, DDS, Fernanda Rafaelly de Oliveira Pedreira, DDS
MBA, JD Alessandro Antonio Costa Pereira, DDS, PhD
Joao Adolfo Costa Hanemann, DDS, PhD
Geriatric Dentistry
Eric Zane Shapira, DDS, MAGD,

Wesley Blakeslee, DMD, FAGD
Coming next issue
Oral and Maxillofacial In the March/April issue of General Dentistry In the February issue
Pathology Comparison of the effectiveness of Endo-eze, Navitip, and of AGD Impact
John Svirsky, DDS, MEd Navitip FX irrigation devices in the cleansing of root canal Career transitions for
walls instrumented with oscillatory and rotary techniques dental students and
Oral and Maxillofacial Surface characteristics of resin composite materials after new dentists
Radiology finishing and polishing Treating bruxism
Dale A. Miles, BA, DDS, MS, The effect of specially designed and managed occlusal
FRCD(C) devices on patient symptoms and pain: a cohort study
Oral and Maxillofacial Surgery
Karl Koerner, DDS, FAGD

Yosh Jefferson, DMD, FAGD

Pain Management
Henry A. Gremillion, DDS, MAGD

Jane Soxman, DDS

Samuel B. Low, DDS, MS, MEd

Thomas Viola, RPh, CCP

Practice Management
Mert N. Aksu, DDS, JD, MHSA, FAGD

Joseph Massad, DDS
Jack Piermatti, DMD

4 January/February 2015 General Dentistry www.agd.org

General Dentistry General Dentistry (ISSN 0363-6771) is published Editor
560 W. Lake St., Sixth Floor bimonthly in 2015 by the AGD, 560 W. Lake Roger D. Winland, DDS, MS, MAGD
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Top traits

s a dentist, you studied hard new things, ultimately figuring out what works best for your
in dental school, and you now patients. An anonymous sage once said, Getting something
continue learning through done is an accomplishment; getting something done right
advanced certification and CE is an achievement.
classes, as well as by reading articles
in General Dentistry. You are a Modesty
seasoned and trusted dentist at the Another good trait to develop is professional modesty. It is more
top of your profession with years of rewarding to have your patients and staff recognize your abilities
experience. But how will you stay than to point them out yourself. While psychologists have long-
there? Perhaps the following traits considered self-esteem an essential element of a healthy personal-
which I have observed in dentists I ity, this is not achieved by self-promotion.2 Train your staff to take
respectwill help guide you as you pride in their work and in every successful outcome and interac-
navigate the coming years. tion with patients, but be careful not to constantly pat yourselves
on the back about a job well done. Doing so may detract from the
Positive attitude cultivation of new skills and potentially lead to missteps. Traits
Great dentists maintain a positive attitude and avoid slipping into of successful dentists include both professional excellence and a
negativity. Maintaining a positive outlook, even when confronted healthy dose of modestyeven when everything is going well.
with difficult situations, is a start on the road to success. A nega-
tive outlook will severely diminish your opportunities. Style
Your style is not about your clothes, but about who you are as a
Tenacity dentist in your clothes. Whether you are an introvert or an extra-
Tenacity is a trait worth developing. Little is ever accomplished vert by nature, try to develop a loving, caring, professional style to
with just one letter, e-mail, telephone call, request, or CE course. complement your interactions with your staff and patients.
There is a slogan in the safety industry that Triumph is just an
umph added to try.1 In my experience, the most successful den- Loyalty
tists embody a tenacious spirit. They are undaunted by adversity Develop downward loyalty. Great dentists protect their staff and
and frequently persist with their goals long after others might provide the training and attention needed to develop a good
have given up. It is this trait that tends to propel practitioners rapport. Along the way, your staff will appreciate your straightfor-
into professional successes. wardness and support that is simple and direct. A cohesive staff is
bound by this loyalty, and the power of this trait is evident to all
Honesty who enter your practice.
Always practice honesty in your practice, as carelessness with facts
can destroy your credibility. Some patients present at our practices Will Rogers once said that The road to success is dotted with
after having experienced dishonesty with medical or dental provid- many tempting parking places. As you move forward in your
ers. Many have found that promises made by so-called professionals experience as a dentist, you will inevitably be met with challenges.
did not live up to their expectations. To avoid disappointing your However, continuously adapting the traits mentioned above will
patients, always carefully discuss with them their diagnoses and all help secure your success for many years to come.
available treatment options, including the costs and possible out-
comes of each treatment. Dentists who run honest practices tend
to have happier patients. Happy patients return for many years,
which is always the objective in running a successful practice.

Innovation Roger D. Winland, DDS, MS, MAGD

Patients like to sense that their dentist is breaking ground with Editor
new technology that they have personally researched or pos-
sibly originated. Are you the type of dentist who is stuck in old References
ways of doing things? Do you refuse to explore new technol- 1. SAFTENG.net. Safety Slogans. Available at: http://www.safteng.net/index.php?option=
com_content&view=article&id=2702&Itemid=178. Accessed November 13, 2014.
ogy, even when it has proven successful? Successful dentists
2. About Education. What is Self-Esteem? Available at: http://psychology.about.com/od/
have a way of finding new ways of doing things even as they sindex/f/what-is-self-esteem.htm. Accessed November 13, 2014.
continue to maximize proven techniques. Be open to trying

6 January/February 2015 General Dentistry www.agd.org

To the editor

Outdated information?

have just completed reading the November/December 2014 This type of disinformation will do nothing to add clarity to the
issue of General Dentistry, which I look forward to every already confusing topic of medically complex patients and their
month as a benefit of my AGD membership over the last management in the dental realm. I cannot emphasize enough that
10 years. Unfortunately, you have chosen to publish an article the rest of the article continues the theme of using these terms
(Perspective of cardiologists on the continuation or discon- interchangeably and worse, makes recommendations on how to
tinuation of antiplatelet therapy before dental treatment: a manage these patients based on VERY OUTDATED informa-
questionnaire-based study, pp. 64-68) with so many egregious tionsomething that I see as a patient safety issue.
fallacies and outdated information, that under advisement from
the Editor, Dr. Roger Winland, I have put the proverbial pen Main article
to paper. For full disclosure, I have been a licensed pharmacist The authors miss an important opportunity to clearly define the
for 24 years and hold a specialty in dental pharmacology. I am issue and offer a review of the recent literature in order to help
a reviewer for a number of peer-reviewed journals (including guide modern dental practice. The 4 drugs mentioned in the very
General Dentistry), am on the Editorial Board for the Journal of first paragraph (aspirin, clopidogrel, dipyridamole, and warfarin)
the American Dental Association, and have numerous publica- comprise an incomplete and outdated list of both anticoagulant
tions in the peer reviewed literature including book chapters. I and antiplatelet medications, but nowhere in this article is any ref-
teach, perform original research, and am on faculty at 2 universi- erence made to the more common and currently used medications:
ties which include the Oregon Health & Sciences University prasugrel and ticagrelor (antiplatelet agents) and rivaroxaban, dabi-
in Portland, where I am the only non-dentist in the Faculty of gatran, apixaban, vorapaxar, and edoxaban (anticoagulant agents).
Dentistry. Many recommendations are cited, such as the American College
While I typically applaud original research, this article is far of Chest Physicians in 2006, even though this does not appear as
below the standards of General Dentistry and the conclusions a referenced citation, and this 2006 reference does NOT represent
reported may not be in support of the current standard of care or the most recent guidelines supported by the American College
published guidelines and could in fact result in patient harm. I of Chest Physicians Evidence-Based Clinical Practice Guidelines.
cannot believe that through the usually rigorous editorial process, These types of statements are rampant throughout the text and
this manuscript was allowed to make it to print, and from the in almost every case refer to outdated information: with
outset, I may even suggest that the Editor consider a possible increasing concern over the thromboembolic risk, this is no longer
retraction. I have included just a few of my comments in the recommended.7 (Jaya Kumar A, Kumari MM, Arora N, Haritha
highlighted sections of the attached document. I will try to be A. Is anti-platelet therapy interruption a real clinical issue? Its
succinct in my concerns. implications in dentistry and particularly in periodontics. J Ind
Soc Periodontol. 2009;13(3):121-125.)
References To further add to the confusion and misinformation, the middle
This article has 49 references of which 42 are over 5 years section on monitoring and blood tests has very little to do with
old. Four of the remaining 7 references refer to website antiplatelet therapy (on which this study focused), and everything
addresses on the internet, 1 reference (No. 9) cites an entire to with anticoagulant treatment. It is therefore possible that oral
textbook (Sweetman SC, ed. Martindale: The Complete Drug healthcare professionals, based on this article, will begin to use
Reference. 34th ed. London: Pharmaceutical Press; 2013), INR measurements to gauge a patients antiplatelet capacity which
and the remaining 2 articles were published in 2009 and are is NOT recommended. Furthermore, statements such as, An
based on 2008 data (again more than 5 years old). Many of INR is advised for all patients on warfarin or heparin therapy,31
the citations refer to articles published in journals which are are entirely incorrect, misleading, and NOT even supported by
not listed in the Index Medicus (such as The Journal of Indian the reference that is cited (No. 31). INR is not a measurement of
Society of Periodontology). heparin efficacy and SHOULD NOT be ordered. The appropriate
test is a PTT. The article also states that, before dental therapy,
Abstract patients with antiplatelet regimens should have bleeding time,
The abstract does NOT accurately reflect the title and, there- clotting time, ECG, routine investigations, blood sugar level, and
fore, purpose of the article, which immediately gave me pause. blood pressure tests. This is definitely not the type of informa-
Perspective of cardiologists on the continuation or discontinuation tion we should encourage general practitioners to follow.
of antiplatelet therapy before dental treatment: a questionnaire- My intention is certainly not to rewrite this manuscript nor
based study is very different than what the Abstract reports as, point out every error of fact, but I will close with just a few addi-
a survey of 50 cardiologists was conducted regarding suggested tional conclusions the authors suggest:
guidelines for dentists in the management of patients who are If a patient is on a dual therapy of aspirin and clopidogrel, it
taking anticoagulant medication. Antiplatelet medications is recommended that the dental procedure be performed in a
and anticoagulant medications are NOT the same drug class. hospital setting.

www.agd.org General Dentistry January/February 2015 7

Thomason et al reported severe bleeding following a gingivectomy by the authors]. We deeply regret this error. The title does not
in a patient taking 150 mg aspirin qd, which was resolved by mention the term anticoagulant therapy, as our survey focused
platelet transfusion.27 This was a single case published in 1999. on antiplatelet therapy, as reflected by our questionnaire.
Shalom & Wong concluded that cutaneous bleeding tests
should not be used to estimate the hemorrhagic risk in patients Incomplete and outdated information
on anticoagulant therapy.36 This was not their conclusion The reader claims that we provided an incomplete and outdated
and this study in plastic surgery cases from 2003 looked at list of antiplatelet and anticoagulant medications with no men-
aspirin (an antiplatelet agent, NOT an anticoagulant). tion of more common and currently used medications.
Oral surgical procedures must be done at the beginning of We must EMPHASIZE that the drugs mentioned by us were
the day, as it allows more time to deal with any bleeding epi- based on the responses of practicing cardiologists regarding drugs
sode.41 Reference is from 2002. most frequently used in Indore, India. No leading questions were
Patients with the following medical problems taking anti- put forth, and no bias was incorporated by the authors.
platelet medications should not be treated in primary care
without medical advice or should be referred to a hospital- Standard of care varies temporally and
based dental clinic: liver impairment and/or alcoholism; renal geographically
failure; hemostasis disorders; and patients currently receiving We have focused on drugs most frequently used in our geographic
cytotoxic medication or dual antiplatelet therapy. location. The newer drugs mentioned by our esteemed reader
Medical consent is mandatory in cardiac patients taking were not frequently used in Indore, India at the time of submis-
antiplatelet therapy. sion of our article. After receiving the letter from our reader, we
These few statements alone, if followed, may limit many of our extensively researched these drugs and found that many of them
medically complex patients with oral pathologies from getting the are highly potent medications. However, we feel that discussion
oral healthcare they require. My phone has not stopped ringing about the merits of usage of newer drugs and their protocols is
with concerned dental colleagues and AGD members who are beyond the scope of our article.
confused by this recent publication.
I look forward to hearing from you on this matter. Why was INR mentioned in a study focusing
Mark Donaldson, BSP, RPH, PHARMD, FASHP, FACHE on antiplatelet therapy?
Kalispell, Montana As mentioned earlier, the surveyed cardiologists mentioned the
(with enclosures) practice of checking INR when a patient is on anticoagulants. We
have clearly stated that it is a test of coagulation. Earlier in the
same paragraph, we mentioned that there is no suitable test to
assess the increased risk of bleeding in patients taking antiplatelet
therapy; platelet function is normally assessed using the cutaneous
Response from Dr. Singh et al bleeding time test.
At the outset, we must congratulate your journal for having such
an enlightened and knowledgeable readership. We appreciate the Only an ignorant oral health care professional will
points raised by our pharmacist friend as we genuinely believe start using INR to gauge antiplatelet capacity
that healthy criticism is a sure shot way forward towards academic The reader claims that we are recommending bleeding time,
growth. In fact, our rigorous preparation to answer the various clotting time, ECG, routine investigations, blood sugar level,
queries raised by the reader has improved our understanding of and blood pressure tests in all patients on antiplatelet regimen
the subject manifold. We would like to thank you for sharing the before dental therapy. This however is MISCONSTRUED, as
concerns of the reader and for providing us with an opportunity we were merely reporting the opinions of surveyed cardiologists
to respond to each one of them. when asked for medical consent.
The reader has pointed out that many conclusions attrib-
Antiplatelet and anticoagulant medications uted to us or cited by us are outdated and would limit many
We agree with the readers view that antiplatelet and antico- medically complex patients with oral pathologies from getting
agulant medications are NOT the same drug class. In our requisite oral health care. This could not be further from the
questionnaire, the questions were targeted at antiplatelet agents truth as we strongly believe in the idiom, Discretion is the
only. However, the responses given by the cardiologists were not better part of valor.
regarding patients on antiplatelet therapy alone. They pointed Nowhere in the article have we recommended not to provide
toward a growing number of patients on combined antiplatelet care to the patient, but have only advised caution and necessary
and anticoagulant therapy. INR has been added when cardiolo- preparedness for any untoward eventuality (however rare) that can
gists mentioned its use in patients under anticoagulant therapy. happen in a surgical procedure. The reader claims that dentists
To maintain the transparency and authenticity of the survey, might be alarmed and therefore refuse cases requiring treatment.
we mentioned both the terms in our Discussion. In fact, our This is a dangerous fallacy. By this account, Ignorance is bliss.
Abstract begins with these terms. However, a typographical There seems to be a difference of perception between the
error in the last line of the Abstract fails to mention antiplatelet authors and the reader owing to the difference in healthcare
medication also. [Editors note: the typographical error was made standards and facilities in the developing and developed

8 January/February 2015 General Dentistry www.agd.org

world. Average dental clinics in India are probably not as The Journal of Indian Society of Periodontology may not be
equipped to handle emergencies as those in the Western world. listed in the Index Medicus. However, it is listed in many other
Hence, we would always lean towards caution as opposed to indices, most notably PubMed.
blind overconfidence. Standard textbooks and credible websites are an important
source of information and knowledge for clinicians. Not
Medical consent and physician referral all general dental practitioners read journals or articles. The
The reader has objected to our statement regarding medical nuances of web research are mostly developed at the post-
consent being mandatory for cardiac patients on antiplatelet graduate level.
therapy. We steadfastly stand by our opinion based on our clini-
cal experience that the medical referral should be mandatory for Clarifications and addendum
cardiac patients on antiplatelet medication. Dental practitioners Some respondents mentioned INR as an investigation when
lack the clinical acumen of judging cardiac status of patients. the patient was on anticoagulant therapy. To avoid the confu-
Our opinion is substantiated in a 2012 article by Can et al, sion in the minds of readers, we have clearly mentioned that
who reported only 30% of the surveyed dentists had knowl- INR and partial thromboplastin time have been used to evalu-
edge about the consequence of interrupting treatment with ate anticoagulant levels.
clopidogrel, and only 30% were aware of the high mortality Due to a typographical error, lines cited to reference No. 34
rates associated with stent thrombosis.1 All of the respondents have erroneously mentioned antiplatelet instead of anticoagu-
were cautious and expressed willingness to consult a cardiolo- lant. [Editors note: the typographical error was made by the
gist before interrupting aspirin and/or clopidogrel. None of authors.] We would also like to clarify that a PTT is a test to
the respondents knew the names of new generation antiplatelet evaluate anticoagulant status in patients on heparin, and INR
agents such as prasugrel or ticagrelor. is to be considered in patients on warfarin.
More importantly, the educational awareness and level of In lines cited to reference No. 36, cutaneous bleeding tests
understanding of the patients in our geographic area mandate should not be used to estimate the hemorrhagic risk in patients
extra precautions to prevent any untoward sequelae and medi- on antiplatelet therapy. It has been erroneously mentioned as
colegal complications. Many times, patients are noncompliant anticoagulant therapy.
with their regimens. We are not depriving patients of dental care
as claimed by our esteemed reader; rather, we are making their Concluding remarks
dental management safer. We had no intention to confuse or alarm general dental practitio-
ners but only to sensitize them to a controversial topic.
References Each specialist or person looks at the same situation from a dif-
The reader points out that most of the references cited by us are ferent perspective. Wisdom lies in accepting these differences in
old and outdated. We would like to share a few facts: perception and cultural traits with an open mind. The knowledge
While this article is based on a study conducted nearly 3 years domains of a dental surgeon, a cardiologist, and an eminent phar-
ago, the article itself was in the process of publication for macist shall be very different, and we have no qualms in admit-
almost 1.5 years. ting that a pharmacist will have a final word on drugs and their
Most of the drugs mentioned by our respondents have been merits. In the same vein, we would humbly like to profess that
used for a long period of time. Hence, their references are not prescribing a drug is a physicians prerogative, and dental manage-
as recent as those of the drugs mentioned by our reader. ment of patients as well as seeking physician referral and medical
Forty of the 49 references cited by us are of the current cen- consent comes under the jurisdiction of dental surgeons.
tury, hence they are not archaic as claimed. We hope we have been able to clarify our position and satis-
Old data need not need be written off. In fact, we have factorily answer the queries raised by our esteemed reader. We
seen (as in the case of focal infection theory) old theories wholeheartedly appreciate the concern and efforts on the part of
being rejuvenated on account of newer understanding. our reader. We look forward to any further correspondence in this
Hence we should not demean what is old, but look at it in matter, if required.
a better light.
Many times, adverse events are not reported in the literature. Reference
Therefore, case report references which have done so need to Can MM, Biteker M, Babur G, Ozveren O, Serebruany VL. Knowledge, attitude and percep-
tion of antiplatelet therapy among dentists in Central Eastern Turkey. World J Cardiol. 2012;
be given meritorious consideration. As the idiom states, One
swallow does not a summer make.

General Dentistry welcomes correspondence from its readers. You can send letters to General Dentistry Editor, AGD, 560 W. Lake St., 6th Floor, Chicago, IL 60661-6600,
or email us at generaldentistry@agd.org. The editors reserve the right to edit all submissions. We cannot print letters that have been submitted to other publications.

www.agd.org General Dentistry January/February 2015 9

Restorative Dentistry

The crown to implant ratio in fixed prosthodontics

Roger A. Solow, DDS

rior to the advent of osseointegrated implants, a periodontal on teeth that the implants dont have. The posterior occlusion
prosthesis was the preferred treatment for a patient with should be refined so that implants receive a delayed initial contact
significant periodontal bone loss and altered crown to root and a lighter final contact than teeth.11 Implant canine guidance
ratios (C/Rs). The C/R is the radiographic amount of tooth out avoids the increased stress to prosthetic components and support-
of alveolar bone compared to the amount within alveolar bone.1 ing bone from group function excursive contacts.12
These patients have missing, mobile, or malposed teeth with To prevent force overload at the buccal crestal bone, it is cru-
open gingival embrasures that pose functional and esthetic prob- cial that anterior implant-supported restorations do not contact
lems. Drifted, over-erupted, and flared teeth are repositioned heavier than adjacent teeth during closure. Any loss of bone may
and then restored with fixed partial prostheses. Splinting the create gingival recession with abutment exposure or asymmetric
remaining teeth and creating a therapeutic occlusion improves levels of the gingival margins. This region typically has minimal
force distribution and preserves the compromised teeth.2 This bone thickness and is often augmented prior to or at implant
type of restoration and occlusal adjustment can be used to placement. The dentist should place a gloved fingernail on the
decrease mobility in teeth with attachment loss. Additionally, facial surface of the crown to detect heavy contact on firm or light
implant-supported restorations can predictably replace lost teeth closure. Lateral and protrusive excursion contacts should be on the
or teeth with a hopeless prognosis. strongest anterior tooth or implant to separate the posterior teeth.
A dentist may encounter a normal, reduced, or amplified In cases of anticipated excess force, such as patients with a history
restorative space when treating these areas; such changes result in of bruxism and attrition, multiple anterior teeth can contact in
altered crown to implant ratios (C/Is). The C/I is the radiographic concert during the excursion to distribute the force over a greater
amount of the crown-abutment-implant complex out of alveolar surface area. A reduced C/I typically occurs when there is minimal
bone compared to the amount within alveolar bone.3 Altered C/R interocclusal space due to over-eruption of the opposing tooth,
and C/I are not equivalent; this is important to understand when or severe attrition with compensatory eruption of many teeth
treatment planning for implant-supported restorations. Teeth (Fig. 2 and 3). Most posterior teeth have a crown height of 7.0-
undergo a 2-phase displacement on loading as the periodontal 8.5 mm.5 A reduced restorative space could be defined as <5 mm,
ligament (PDL) is initially compressed prior to engaging the where the dentist does not have a choice to use either cement or
alveolar bone.4 The PDL creates stress distribution along the root screw retention but is restricted to using screw retention. Cemented
length as well as a protective neuromuscular response. In contrast, restorations need 5 mm space, consisting of 2 mm for material and
implants when loaded undergo a 1-phase linear deformation with 3 mm for minimal abutment height to resist dislodgement.
stress concentrated at the bone crest without a protective response. Treatment planning for a reduced C/I involves evaluating the
The C/I affects the periodontium for all implant designs: esthetics and functional occlusion to determine the patients
1-piece implant with a pre-established restorative margin, 2-piece most appropriate procedure. Alternatives include occlusal adjust-
implant with the implant shoulder as the restorative margin, or ment of the opposing tooth, restoration of the opposing tooth
bone-level implant with the restorative margin on the abutment.
This column reviews the clinical considerations of C/I in fixed
prosthodontics. A normal C/I is similar to the C/R for natural
teeth (Fig. 1). The C/R of maxillary and mandibular first premo-
lars have been measured at 0.57 and 0.61, respectively, and for
maxillary and mandibular first molars at 0.63 and 0.54, respec-
tively.5 A 13 mm length tissue-level implant with a typical size
crown would approximate a normal C/R. Although the intent of
implant restoration is to achieve a biomimetic replacement of lost
structure, there is no reason to use the root length as the implant
length, since width is more important than length to minimize
crestal cortical bone stress.6-8
The occlusal design for posterior teeth implant-supported res-
torations is similar to natural teeth and should allow only vertical
force during closure or chewing excursions.9,10 Contact on closure
should be centered over the implant to maintain vertical force and
minimize shear stress. In mixed tooth and implant restorations,
implants should not contact at the same time or heavier than Fig. 1. Normal crown to implant ratio (C/I). The gold crown was placed at the
teeth on firm closure. The PDL creates an intrusion displacement gingival margin similar to the adjacent gold crowns on natural teeth.

10 January/February 2015 General Dentistry www.agd.org

Fig. 2. Reduced C/I indicating the need for a screw-retained crown. The Fig. 3. Screw-retained gold crown with intracrevicular margins for predictable
distance from the implant platform to the opposing tooth is 4 mm. cement clearance. Note the crown height compared to the adjacent tooth.

Fig. 4. Tissue-level implant placed subcrestal near the adjacent tooth apex. Fig. 5. Ten-year soft tissue reaction to excellent patient hygiene. The distal
The surgeon achieved bicortical engagement and stability but compromised papilla of tooth No. 5 was lost due to the absence of bone on the mesial of
vertical position. tooth No. 4.

with occlusal reduction to compensate for the over-eruption, height may create an esthetic problem. A deep implant platform
orthodontic intrusion with temporary anchorage devices, and requires a stock mesostructure or a custom abutment to avoid a
segmented osteotomy with repositioning. The restorative dentist restoration margin >1 mm subgingival with unpredictable cement
always needs 2 measurements from the surgeon for the implant clearance. Alternatively, a screw-retained crown can be used.
restoration treatment plan: sulcus depth and restorative space. A titanium stock mesostructure or titanium custom abutment
Sulcus depth (gingival margin to implant shoulder) determines would provide better soft tissue adhesion than porcelain or gold.13
the abutment collar dimension. Restorative space (gingival margin C/I problems also occur in concert with porous posterior bone
to the opposing cusp) determines whether a screw-retained crown and increased forces on molar sites. This is especially true with
or an abutment with cemented crown are indicated. The surgeon maxillary sinus grafting cases, where pneumatized sinuses and min-
can use a periodontal probe and communicate these measure- imal native bone further challenge the dentist to manage occlusal
ments at the implant integration verification appointment. The force (Fig. 6 and 7). The increased height of restorative material
restorative dentist can then plan for a screw-retained crown with above the implant platform creates a vertical cantilever that magni-
provisional abutment or order the appropriate definitive abut- fies torque stresses on the crestal bone from lateral loading. Also,
ment, precluding the need to maintain a large inventory of pros- the lost posterior bone resorbs preferentially from the buccal side,
thetic components. An amplified C/I may result from lost bone creating a horizontal cantilever in the restoration. It is critical to
from periodontal destruction or trauma, failed osseous grafting, remove all excursive interferences so force is aligned with the long
or submerged implant placement. The surgeon should place the axis of the implant. The increased restorative space and a short
implant to avoid problems in the vertical axis that compromise implant (<10 mm), dictated by a limited amount of available bone,
oral hygiene and papilla support (Fig. 4 and 5). However, deep synergistically increase the C/I. Amplified C/I >2.0 are well-tol-
placement may be needed to engage bone, or reducing gingival erated and again show how implant-supported restorations differ

www.agd.org General Dentistry January/February 2015 11

Fig. 6. Multiple parallel implants with stock abutment at site Fig. 7. Cement-retained composite-acrylic provisional restoration No. 11 and
No. 11 and custom abutments at sites No. 12-14. Note the splinted screw-retained composite provisional restoration No. 12-14 with
amplified restorative space of the posterior implants. amplified C/I.

from natural teeth with compromised bone support in the peri- deflect on pressure, whereas this same contact with implant sup-
odontal prosthesis paradigm. Short implants may allow implant port would not permit floss to pass. Assiduous refinement of these
placement in nongrafted atrophic ridges and avoid invasion of the contacts should be done with thin marking ribbon in the contacts
maxillary sinus, mandibular canal, or angled adjacent roots. Short to show the exact area to be adjusted. Implant-supported crowns
implants have been shown to be as successful as standard length require a very small space in the contact area so that floss can
implants (>10 mm).14-16 Studies on short, single implants with pass but food wont get trapped. Heavy interproximal contacts
amplified C/I showed no increased marginal bone loss compared can create a nonpassive cementation with increased bone strain,
to normal C/I.17-20 Studies on multiple short implants support- which magnifies the deleterious effects of occlusal loading.26
ing a fixed prosthesis also found no effect of increased in C/I on The current literature supports the use of single and multiple
marginal bone loss.21,22 Two systematic reviews concluded that short implants to restore edentulous spaces with normal, reduced,
amplified C/I resulted in less marginal bone loss than lower C/I.3,23 and amplified C/I. Short implants expand the treatment planning
This result is contrary to the assumption that greater anchorage is options for the dental team, especially in atrophic posterior jaw
beneficial to stability and force distribution, and should result in sites with an amplified C/I. This option may allow a fixed prosth-
less harmful stress to crestal bone. Blanes attributed the improved odontic solution for the patient where grafting, time, or financial
marginal bone levels to the stimulatory effect of higher but not concerns previously restricted treatment to a movable prosthesis.
excessive stress to the supporting bone.23 Alveolar bone tolerance
of amplified C/I may also be due to rough or porous implant Author information
surfaces and tapered, threaded, macroretentive design features that Dr. Solow is in private practice in Mill Valley, California, and a vis-
contribute to high initial torque and stability.24,25 iting faculty member at the Pankey Institute, Key Biscayne, Florida.
Splinting should be considered when restoring multiple
implants with amplified C/I to improve stress distribution in References
crestal bone. Splinting concentrates stress in the prosthesis con- 1. Grossmann Y, Sadan A. The prosthodontic concept of crown-to-root ratio: a review of
the literature. J Prosthet Dent. 2005;93(60:559-562.
nectors, reducing force to the peridontium.26 Splinting has been
2. Keough B. Occlusal considerations in periodontal prosthetics. Int J Periodontics Restor-
recommended for implants in poor quality bone to resist destruc- ative Dent. 1992;12(5):359-371.
tive horizontal forces.27,28 Splinting can also minimize the gin- 3. Garaicoa-Pazmino C, Suarez-Lopez del Amo F, Monje A, et al. Influence of crown/implant
gival embrasures by enlarging the interproximal contact height, ratio on marginal bone loss: a systematic review. J Periodontol. 2014;85(9):1214-1221.
whereas normal interproximal contacts would leave large gingival 4. Kim Y, Oh TJ, Misch CE, Wang HL. Occlusal considerations in implant therapy: clinical
guidelines with biomechanical rationale. Clin Oral Implants Res. 2005;16(1):26-35.
embrasures that trap food. 5. Kraus BS, Jordan RE, Abrams L. A Study of the Masticatory System: Dental Anatomy
Splinting is not required for normal C/I multiple implant- and Occlusion. Baltimore, MD: The Williams and Wilkins Company; 1969.
supported restorations.29 Nonsplinted posterior teeth crowns 6. Baggi L, Cappelloni I, Di Girolamo M, Maceri F, Vairo G. The influence of implant diameter
create a biomimetic restoration that allows normal access to and length on stress distribution of osseointegrated implants related to crestal bone geom-
etry: a three-dimensional finite element analysis. J Prosthet Dent. 2008; 100(6):422-431.
flossing. They restrict prosthetic problemssuch as porcelain
7. Chang SH, Lin CL, Lin YS, Hsue SS, Huang SR. Biomechanical comparison of a single
fracturethat occur on a single tooth to just that tooth, whereas short and wide implant with monocortical or bicortical engagement in the atrophic
multiple splinted crowns are affected by a single problem tooth. posterior maxilla and a long implant in the augmented sinus. Int J Oral Maxillofac Im-
Interproximal contact adjustment for these crowns is complicated plants. 2012;27(6):e102-e111.
by the ankylotic implant support compared to the PDL resiliency 8. Schulte J, Flores AM, Weed M, Crown-to-implant ratios of single tooth implant-sup-
ported restorations. J Prosthet Dent. 2007;98(1):1-5.
of teeth. A very tight contact may pass floss as the natural teeth

12 January/February 2015 General Dentistry www.agd.org

9. Misch CE, Steignga J, Barboza E, Misch-Dietsh F, Cianciola LJ, Kazor C. Short dental im- 20. Lai HC, Si MS, Zhuang LF, Shen H, Liu YL, Wismeijer D. Long-term outcomes of short
plants in posterior partial edentulism: a multicenter retrospective 6-year case series dental implants supporting single crowns in posterior region: a clinical retrospective
study. J Periodontol. 2006;77(8):1340-1347. study of 5-10 years. Clin Oral Implants Res. 2013;24(2):230-237.
10. Merin RL. Repair of peri-implant bone loss after occlusal adjustment: a case report. 21. Anitua E, Alkhraist MH, Pinas L, Begona L, Orive G. Implant survival and crestal
J Am Dent Assoc. 2014;145(10):1058-1062. bone loss around extra-short implants supporting a fixed denture: the effect of
11. Kerstein RB. Nonsimultaneous tooth contact in combined implant and natural tooth crown height space, crown-to-implant ratio, and offset placement of the prosthesis.
occlusal schemes. Pract Proced Aesthet Dent. 2001;13(9):751-755. Int J Oral Maxillofac Implants. 2014;29(3):682-689.
12. Gore E, Evlioglu G. Assessment of the effect of two occlusal concepts for implant-sup- 22. Pistilli R, Felice P, Cannizzaro G, Piatelli M, et al. Posterior atrophic jaws rehabilitated
ported fixed prostheses by finite element analysis in patients with bruxism. J Oral Im- with prostheses supported by 6 mm long 4 mm wide implants or by longer implants in
plantol. 2014;40(1):68-75. augmented bone. One-year post-loading results from a pilot randomised controlled
13. Rompen E, Domken O, Degidi M, Pontes AE, Piattelli A. The effect of material character- trial. Eur J Oral Implantol. 2013;6(4):359-372.
istics, of surface topography and of implant components and connections on soft tis- 23. Blanes RJ. To what extent does the crown-implant ratio affect the survival and compli-
sue integration: a literature review. Clin Oral Implants Res. 2006;17(Suppl 2):55-67. cations of implant-supported reconstructions? A systematic review. Clin Oral Implants
14. Anitua E, Pinas L, Begona L, Orive G. Long-term retrospective evaluation of short im- Res. 2009;20(Suppl 4):67-72.
plants in the posterior areas: clinical results after 10-12 years. J Clin Periodontol. 2014; 24. Sohn DS, Lee JM, Park IS, Jung HS, Park DY, Shin IH. Retrospective study of sintered po-
41(4):404-411. rous-surfaced dental implants placed in the augmented sinus. Int J Periodontics Restor-
15. Al-Hashedi AA, Taiyeb Ali TB, Yunus N. Short dental implants: an emerging concept in ative Dent. 2014;34(4):565-571.
implant treatment. Quintessence Int. 2014;45(6):499-514. 25. Steigenga J, Al-Shammari K, Misch C, Nociti FH Jr, Wang HL. Effects of implant thread
16. Fugazzotto PA, Beagle JR, Ganeles J, Jaffin R, Vlassis J, Kumar A. Success and failure geometry on percentage of osseointegration and resistance to reverse torque in the
rates of 9 mm or shorter implants in the replacement of missing maxillary molars when tibia of rabbits. J Periodontol. 2004;75(9):1233-1241.
restored with individual crowns: preliminary results 0 to 84 months in function. A ret- 26. Guichet DL, Yoshinobu D, Caputo AA. Effect of splinting and interproximal contact tight-
rospective study. J Periodontol. 2004;75(2):327-332. ness on load transfer by implant restorations. J Prosthet Dent. 2002;87(5):528-535.
17. Birdi H, Schulte J, Kovacs A, DDS, Weed M, Chuang SK. Crown-to-implant ratios of 27. Tiossi R, Lin L, Rodrigues RC, et al. Digital image correlation analysis of the load trans-
short-length implants. J Oral Implantol. 2010;36(6):425-433. fer by implant-supported restorations. J Biomech. 2011;44(6):1008-1013.
18. Schneider D, Witt L, Hammerle CH. Influence of the crown-to-implant length ratio on the 28. Wang TM, Leu LJ, Wang JS, Lin LD. Effects of prosthesis materials and prosthesis splint-
clinical performance of implants supporting single crown restorations: a cross-sectional ing on peri-implant bone stress around implants in poor-quality bone: a numeric analy-
retrospective 5-year investigation. Clin Oral Implants Res. 2012;23(2):169-174. sis. Int J Oral Maxillofac Implants. 2002;17(2):231-237.
19. Rossi F, Lang NP, Ricci E, Ferraioli L, Marchetti C, Botticelli D. Early loading of 6-mm 29. Simon RL. Single implant-supported molar and premolar crowns: a ten-year retrospec-
short implants with a moderately rough surface supporting single crowns - a prospec- tive clinical report. J Prosthet Dent. 2003;90(6):517-521.
tive 5-year cohort study. Clin Oral Implants Res. 2014 [Epub ahead of print].

www.agd.org General Dentistry January/February 2015 13


Achieving and maintaining apical patency in

endodontics: optimizing canal shaping procedures
Rich Mounce, DDS

chieving and maintaining apical patency is a prerequisite narrowing cross sectional diameters moving from orifice to
for predictable clinical results in endodontic treatment. apex. For practical purposes, the MC is the anatomic landmark
After endodontic access, cleaning and shaping of root delineated by a 0.0 reading on electronic apex locators.
canal systems is made possible by negotiation of canals to their Location of the MC and maintenance of apical patency
apical terminus followed by the creation of a glide path and provides the clinician a reproducible landmark for all cleaning,
nickel titanium instrumentation. Leaving untreated canal space shaping, and obturation procedures. Should the true working
due to a lack of apical patency is the harbinger of iatrogenic length (TWL) change in treatment for any reason (especially
misadventure (canal transportation) as well as long-term end- electronically), the clinician should immediately troubleshoot
odontic failure. the source of the differential. Any loss of TWL during a clini-
The benefits of achieving and maintaining apical patency cal procedure should alert the clinician both to the need for
include improved removal of organic and inorganic debris regaining the lost length and reconfirmation of the TWL before
from the root canal system. It is axiomatic that optimal debris moving forward. An increase in TWL should alert the clinician
removal from the canal system increases postoperative comfort to the possibility that the TWL was inaccurately determined
relative to the alternatives (such as loss of working length, initially. Once apical patency is obtained and reproducible, the
uncleaned and unfilled canal space, and iatrogenic canal canal can be predictably enlarged to prepare a glide path before
transportation). the introduction of nickel titanium instruments for bulk canal
The minor constriction (MC) of the apical foramen is the shaping. A glide path is prepared when a No. 15 hand K file
ideal end point of instrumentation, irrigation, and obturation spins freely in the canal.
during clinical endodontic treatment. Anatomically, the MC is Not all canals are negotiable to the MC. Severe 3-dimen-
the narrowest diameter of the canal before it exits to the apical sional (3D) curvature, blockage, previous canal transportation,
tissues. While apical anatomy can vary, and some canals do not and calcification are natural barriers to the attainment of apical
have a true narrowest diameter, there is an optimal endpoint patency. An incorrectly and improperly used hand file (wrong
to which canal systems should be cleaned and obturatedmost file type, size, and/or pre-curvature) and inadequate coronal
often, the MC. Leaving the MC at its original position and access, along with a lack of irrigation and viscous chelating
size is central to fulfilling the various objectives of endodontic agents can all leave otherwise negotiable canals without proper
cleaning and shaping goals, which include keeping the canal exploration and enlargement. Alternatively, using the cor-
in its original position and creating a tapered funnel with rect hand file with optimal technique, access, irrigation, and

Fig. 1. Radiograph showing tooth No. 18 at severe Fig. 2. Tooth No. 18 post-treatment.
risk for canal blockage and nickel titanium instrument
fracture if canal negotiation is not carried out
appropriately. Note that tooth No. 19 has untreated
canal space and coronal leakage present from the
previous root canal treatment.

14 January/February 2015 General Dentistry www.agd.org

Fig. 3. A clinical case treated using the concepts utilized Fig. 4. A clinical case treated using the concepts utilized
in this column. in this column.

sequencing improve the possibilities for canal negotiation. Clinical technique

In general terms, the more curved and calcified a canal, the Clinically, a precurved No. 6 hand K file is used first to the
greater the time and attention to detail required for negotia- TWL followed by No. 8, 10, 12, and 15 files. Once a hand K
tion. Simpler anatomy is generally more forgiving, in that small file reaches the MC, it can be safely and efficiently reciprocated
errors in clinical judgment may not lead to severe iatrogenic with a reciprocating handpiece that replicates the watch wind-
issues (Fig. 1 and 2). ing motion of the manual hand file technique while saving
While a comprehensive review of all canal anatomy requiring time and hand fatigue. If a more stiff file is required for canal
preoperative evaluation prior to treatment is beyond the scope negotiation, several marketplace options are available.
of this column, it is important to note that special care should Once apical patency is obtained, the importance of frequent
be taken to obtain a comprehensive radiographic assessment of recapitulation cannot be overstated. Frequent recapitulation is
the tooth prior to making treatment-planning decisions. For critical in apical irrigation and cleansing. It involves the insertion
clinicians using 2-dimensional (2D) radiographic technology, of a small hand file to assure the clinician that the canal is open
this means having multiple radiographic angles to guide the and negotiable. Clinically, after every insertion of a nickel titanium
assessment of calcification and curvature. Cone beam computed file, a small hand file should be inserted to ensure the canal is open
tomography assessment is the gold standard for radiographic and negotiable to the MC. As the recapitulating hand file moves
anatomic evaluation. Regardless of whether the clinician is using out of the canal, fresh irrigant should move apically (Fig. 3 and 4).
2D or 3D imaging, the true anatomy of the canal cannot be This column has discussed the importance of achieving and
fully known until the canal is being negotiated with hand files. maintaining apical patency. Emphasis has been placed on assess-
Aside from obvious calcification and curvature, many clini- ing the anatomy of the clinical case preoperatively and moving
cal entities, including high furcations, crowns obscuring the sequentially to determine the position of the minor constriction
furcation, rotated and tipped teeth, atypical root numbers and of the apical foramen.1-3 Future columns may address specific
canal morphologysuch as C-shaped lower second molar canal techniques for hand file negotiation and achieving apical patency
configurations and lower molars with either a third or fused in curved and calcified canals.
rootshould inspire caution in the clinician with regard to the
complexity of the canal space being explored. Author information
Hand files give the clinician strong clues to the complexity of Dr. Mounce is in endodontic practice in Rapid City, South
the root canal system. For example, if a hand file emerges from Dakota. He has written and lectured globally on endodontics.
a root with a 3D curve imparted onto it, the clinician liter-
ally has an impression of the canal shape. This knowledge has Disclaimer
ramifications for the clinician with regard to glide path size, the Dr. Mounce owns MounceEndo, LLC, which markets the
means for creating the glide path, and nickel titanium sequenc- rotary nickel titanium MounceFile in Controlled Memory and
ing, among others. Standard NiTi.
Aside from optimal visualization and magnification (surgical
microscope and/or loupes), removal of the cervical dentinal References
triangle, restrictive dentin in the coronal third, and pulp chamber 1. Dummer PM, McGinn JJ, Rees DG. The position and topography of the apical constric-
tion and apical foramen. Int Endod J. 1984;17(4):192-198.
debris all set the stage for hand file negotiation. It is advisable
2. Meder-Cowherd L, Williamson AE, Johnson WT, Vasilescu D, Walton R, Quian F. Apical
during evacuation of the pulp chamber and coronal third to morphology of the palatal roots of maxillary molars by using micro-computed tomog-
apply a viscous EDTA gel to emulsify pulp tissue and hold it in raphy. J Endod. 2011;37(8):1162-1165.
suspension while the aforementioned removal of pulp tissue is 3. Burch JG, Hulen S. The relationship of the apical foramen to the anatomic apex of the
taking place in the coronal third prior to apical negotiation. tooth root. Oral Surg Oral Med Oral Pathol. 1972;34(2):262-268.

www.agd.org General Dentistry January/February 2015 15

Diagnosis and Treatment Planning

Why the general dentist needs to know

how to manage oral lichen planus
Stephanie M. Price, DDS n Valerie A. Murrah, DMD, MS

Oral lichen planus (OLP) is a frequently mismanaged chronic disease the myriad signs, symptoms, and complications associated with this
that requires care throughout a patients life, and therefore a condition disease, as well as educational approaches and legal considerations. A
the general dentist must know how to manage. Patients with OLP often rationale is provided to place the responsibility for the management of
suffer considerable physical discomfort and an inability to perform these patients under the person best positioned to coordinate care for
proper oral hygiene, eventually resulting in poor periodontal health. In this conditionthe general dentist. A general dentist can contribute to
addition, these patients are confronted with the psychological stress of the overall oral health of an OLP patient with timely diagnosis, effective
knowing that OLP is not curable. This is accompanied by a fear of other treatment, thorough patient education, and the orchestration of efforts
negative health developments, particularly oral cancer. The objective of by a team of health care providers.
this study was to identify major issues surrounding the management of Received: June 24, 2013
OLP by the general dentist. Accepted: August 13, 2013
A literature review of over 1100 articles was performed. An eclectic
compilation of the issues revealed 12 major areas of concern. This Key words: lichen planus, dental management,
article reviews those concerns and presents strategies for coping with malignant transformation, general dentist

ince Erasmus Wilson first described compelling reasons for the general dentist Results
oral lichen planus (OLP) in 1869, to become thoroughly knowledgeable Twelve broad areas of concern for the
much has been written about the about this uncommon disease and to keep general dentist were identified in an effort
condition.1 Oral lichen planus affects current on the latest issues regarding OLP to promote a proactive approach in the
0.5%-2% of the population, with a throughout his/her professional life. The management of this disease. These are
predominance in women 30-70 years of dentist who is able to diagnose, treat, listed in Table 1.
age.2-7 Clinically, OLP manifests most and manage an OLP patient may not
frequently bilaterally, with the most only improve the quality of, but may also Discussion
common sites being the buccal mucosa, potentially prolong, the patients life. Clinical presentation and
tongue, and gingiva.8-14 It has several identification
forms; the most commonly described are Materials and methods The dentist may identify signs and symp-
reticular (containing Wickhams striae) Citations and abstracts of over 1100 toms suggestive of OLP upon meeting a
and erosive (Fig. 1 and 2).9,11,14-17 While articles were reviewed regarding all aspects new patient or during routine follow-up
the etiology of OLP is unknown, it is of lichen planus to identify critical issues examinations. Occasionally, a new patient
thought to be a T-cell-mediated autoim- pertinent to the management of the OLP may present with signs and symptoms of
mune response.10,18-23 The authors present patient by the general dentist. OLP as his or her chief complaint. OLP can

Fig. 1. Reticular lichen planus with intersecting white net-like Fig. 2. Erosive lichen planus in addition to significant plaque accumulation.
lines (Wickhams striae) with focal ulceration showing an
erosive component.

16 January/February 2015 General Dentistry www.agd.org

Table 1. Twelve areas of concern for the general
dentist in the treatment of an oral lichen planus
(OLP) patient.

1. Recognition of clinical signs and symptoms

2. Optimal objective diagnosis
3. Disease management and concomitant reduction of the
patients pain and suffering
Table 2. Partial list of
4. Reduction in risk of increased periodontal disease or
exacerbation of existing periodontal disease medications linked to
lichenoid reactions.39-42
5. Education of the patient concerning his/her disease and
management of his/her expectations
6. Appropriate referral of patient to other health care
providers for skin, nail, or genital lesions Diuretics
7. Identification of correlated systemic diseases (hepatitis C Methyldopa
or graft versus host disease) -blocking agent
8. Avoiding the misfortune of mistakenly treating a ACE inhibitor Fig. 3. Photomicrograph of an
patient as though he/she has OLP when he/she NSAIDs epithelial rete ridge showing attenu-
has oral cancer
Antimalarials ation, interface change (lyphocytic
9. Identification of malignant transformation early, when it migration into the epithelium), and
can be managed with minimal morbidity and mortality Oral hypoglycemic drugs
florid lymphocytic infiltrate in the
10. Dentist versus physician management Phenothiazines
upper connective tissue (H&E,
11. Reduction of susceptibility to litigation Gold salts magnification 400X).
12. Orchestrating the coordination of care HIV antivirals

be asymptomatic; this is usually associated basal cell layer liquefaction, and a band- Differential diagnoses
with the reticular type. It may also present like T-cell lymphocytic infiltrate localized Lichenoid drug reactions may be more
with a burning sensation; this is typically to the lamina propria proximal to the difficult to manage since the removal
associated with the erosive type. The presen- epithelium.35,36 Other features often pres- of a given medication may threaten the
tation can change within one patient over ent are interface change characterized by patients overall health. In addition, these
time and these changes could be associated the movement of inflammatory cells into reactions are more difficult to recognize
with increased stress, thus making successful the epithelium, Civatte (colloid) bodies, because manifestations may be delayed
symptom management challenging.9,10,14,24-29 and saw-toothed (attenuated) rete ridges for weeks to months, both at the start
(Fig. 3).10,35-37 The findings of the clinician of medication and/or after the medica-
Diagnosis and pathologist should always be corre- tion has been stopped.39-42 The clinician
OLP can present with clinical and his- lated when making a diagnosis. A clinical should take a detailed health history and
tologic presentations similar to many photograph should ideally be sent with the inquire about allergies and medications
other conditions, such as lichenoid drug biopsy to the lab, and the clinician should commonly associated with lichenoid drug
reactions (also known as lichenoid drug consult the pathologist if the diagnosis reactions (Table 2).
eruptions), lichenoid contact mucositis, does not fit the clinical context. Specimens A potential lichenoid drug reaction
cinnamon stomatitis, lupus erythematosus, should be submitted in formalin for rou- that merits further investigation is the
dysplasia, carcinoma, and graft versus tine microscopy and in Michels solution use of hydrochlorothiazide in patients
host diseaseall of which require dif- for direct immunofluorescence (DIF). The who have experienced sulfa allergies.
ferent treatments.9,10,15,30-32 Because OLP DIF specimen may be critical in differen- Hydrochlorothiazide is the most com-
does not have a pathognomonic appear- tiating OLP from other vesiculo-ulcerative monly prescribed antihypertensive, and
anceexcept for classical Wickhams diseases such as benign mucous membrane treatment with this drug is commonly
striaediagnosis by biopsy is necessary. pemphigoid, lupus erythematosus, pem- associated with lichenoid mucositis.43
Additionally, the practitioner must keep in phigus vulgaris, chronic ulcerative stoma- Patients with sulfa allergies often have
mind that multiple pathologies can exist titis, and lichenoid reactions. Under DIF, a history of a hypersensitivity response
simultaneously in the same or in different OLP lesions often show fluorescence at to the sulfonamide antibiotic, sulfa-
locations, thus complicating both diagno- the level of the basement membrane zone methoxazole-trimethoprim.44-46 Although
sis and treatment.9,33,34 Histopathological with antibodies to fibrinogen and, less there is little evidence that antimicrobial
criteria include variable keratinization, frequently, to IgG and IgM.10,23,38 sulfonamides cross-react with other sulfur

www.agd.org General Dentistry January/February 2015 17

Diagnosis and Treatment Planning Why the general dentist needs to know how to manage oral lichen planus

Table 3. Steroid treatment for OLP.

Systemic Topical
Methylprednisolone 0.1% Triamcinolone-mild potency
Prednisone 0.05% Fluocinonide-moderate potency
0.05% Clobetasol-high potency
Fig. 4. An example of a focal lichenoid reaction to
Topical steroids could be applied in a custom tray worn at night.
amalgam. The lesion resolved following replacement
of the amalgam with a gold crown.

Table 4. Recommended care sequence for an OLP patient.

containing moieties, patients with sulfa
allergies may be predisposed to lichenoid 1. Health history 8. Treatment (to include topical and/or
reactions from medications containing 2. Clinical exam systemic steroids and increased frequency
sulfur groups such as hydrochlorothiazide of dental prophylaxis)
3. Working diagnosis
and sulfonylureas (non-antimicrobial sul- 9. Re-evaluation of treatment
fonamides).44,45,47,48 Alternatively, patients 4. Biopsy (for light microscopy and DIF)
10. Treatment modification and additional
who have a sulfa allergy may simply have 5. Definitive diagnosis biopsy as needed
a predilection to other allergic responses 6. Patient education 11. Periodic follow-up to check for malignant
even with chemically dissimilar drugs.48 7. Referral to primary care physician, transformation
This is not surprising given the great if applicable
number of medications associated with
oral lichenoid reactions.
Unlike a lichenoid drug reaction, lichen-
oid contact mucositis can be differentiated of the use of the product or food contain- particularly at nighttime, as the drug will
clinically by the position of the lesion next ing cinnamon should result in resolution of leak out of the tray and bathe the oral
to the offending agent (e.g., amalgam, the lesions in a matter of days. tissues. Treatment of symptoms can be
gold, composite, or cast alloy restora- accomplished with viscous lidocaine or
tions).10,31,49-56 The dental material most Treatment other topical anesthetics. A recommended
often cited as the cause of a hypersensitivity Following the determination of the diagno- care sequence for an OLP patient is illus-
reaction is amalgam (Fig. 4).51,52,54-56 Some sis, management can be accomplished in a trated in Table 4.
authors advocate removing restorations for number of ways depending on the severity
resolution of this hypersensitivity, while of disease. The usual first line of treatment Associated candidiasis
other authors do not.49,51,57 Although not a for symptomatic OLP is topical steroids Since steroid treatment suppresses the
dental material, cinnamon is an even more (Table 3). Approaches to treatment could immune system, it may also promote the
frequent cause of a mucositis resembling also include an initial systemic steroid development of a Candida infection that
lichen planus.32,58 There is controversy burst, such as a methylprednisolone or a will exacerbate the patients discomfort.
with both amalgam and cinnamonover high potency topical corticosteroid, such It is also possible that a Candida infec-
the benefit of allergy patch testing.31,32,49 as clobetasol propionate. Maintenance tion was already present prior to steroid
Points of contention include which mercu- treatment during symptomatic periods treatment for OLP.13,59 If candidiasis is sus-
rial or amalgam material to use for the could be a moderate topical steroid, such pected, clinicians should obtain a cytologic
testing, the clinical similarity between as fluocinonide. Triamcinolone, a mild smear, and patients with positive results
sensitivity and irritant responses, the length topical steroid, is occasionally used but should be given appropriate antifungal
of time that the material should be in often does not result in significant resolu- treatment, such as fluconazole, clotrima-
contact with the skin, and the relevance of tion in adults. Treatment of more severe zole, or nystatin (Table 5). In addition to
cutaneous testing to mucosal allergies.31,32 cases consists of systemic steroids or other alleviating additional patient symptoms, it
Complicating the diagnosis regarding amal- immunosuppressant agents. Topical drug is helpful to have possible Candida infec-
gam are other factors such as the contour of delivery via a custom tray or mouth- tions cleared prior to performing a biopsy
a restoration or the position of its margin. guardeven if lesions extend beyond the so that only the inflammation specific to
With respect to cinnamon, discontinuation gingivahas been shown to be efficacious, OLP is evident in the specimen.

18 January/February 2015 General Dentistry www.agd.org

dentists may potentially learn more about
Table 5. Antifungal treatment for associated candidiasis in OLP patients. patients individual clinical presentations
and can make appropriate referrals.
Systemic Topical
Presentation in areas outside of
Fluconazole 100-200 mg Clotrimazole 10 mg troches
the oral cavity
Nystatin 100,000-200,000 units Lichen planus not only presents in the
Topical antifungals could be administered as troches or as lozenges. oral cavity, but also can be found in the
mucous membranes of the genitalia,
esophagus, skin, nails, and eyes.3,66-73
Approximately 19%-25% of OLP patients
Chart. Network of providers for management of oral lichen planus. have genital lesions.70 In these patients,
OLP tends to present primarily on the
gingiva.66,68,70 Most of the literature
Periodontist describes women with vulvovaginal-gin-
Oral Surgeon
Gynecologist gival lichen planus, however there are also
Urologist a few reports of male patients, for whom
the lesions are referred to as penogingival
General lichen planus.66,70 Ten percent to 20% of
Oral Pathologist
Dentist OLP patients have cutaneous lesions, and
it has been found that patients with cuta-
Primary Care
Physican neous lesions either already have or are
likely to develop OLP.3,70,74 The sequence
of presentation between OLP and lichen
planus in other locations is not predict-
able, and presentations may be separated
by months or years.3,69,70 Lichen planus
presenting in the fingernails, toenails,
Relationship to periodontal health Education esophagus, and eyes is uncommon; in a
One of the most significant reasons for the Educating OLP patients is essential to study of 584 lichen planus patients, 11
general dentist to be knowledgeable about both short- and long-term treatment showed clinical signs of nail involvement,
OLP is that it can have a negative impact success. A 1997 survey conducted to 6 presented with esophageal involvement,
on periodontal health. It is estimated that determine patient awareness of OLP and 1 had biopsy-proven ocular lichen
approximately 38%-48% of OLP patients etiology, treatment, and malignancy planus.70 Because any given clinician does
have gingival lesions, and 7%-10% have resulted in a wide variety of responses.65 not investigate all potential anatomic
gingival lesions as their only clinical The authors found a significant number sites of lichen planus, the condition is
manifestation.11,14,60,61 It is thought that of patients reporting the treatment strat- frequently misdiagnosed, particularly in
plaque and calculus exacerbate the clinical egy of learn to live with the disease, the genitalia.69,70 Therefore, the general
presentation of OLP.11,60,62-64 All OLP types and only 7% of the respondents stating dentist must be able to provide effective
are associated with increased bleeding that they received additional education referrals to gynecologists, urologists, and
on probing, which is expected given the after the initial diagnosis.65 By provid- dermatologists (Chart). If these alternate
inflammatory nature of the disease.11,62,64 ing education to their OLP patients, presentations are missed during the health
OLP patients with symptomatic lesions dentists make them aware of potentially history, the general dentist could discuss
often have difficulty with oral hygiene exacerbating factors, help them under- the possibility of other lichen planus
and have more plaque and calculus pres- stand the need for increased visits to the lesions as part of patient education.
ent, putting them at increased risk for dental office and improved home care,
poor periodontal health.60,63 Patients with and raise awareness of other associated Associated conditions
erosive lichen planus have more clinical health concerns. According to Burkhart Oral lichen planus may signal the clinician
attachment loss.63 Avoiding certain types et al, it is important that dentists inform to look for hepatitis C, as it is another
of foods, such as those that are acidic, their patients about all the pertinent systemic condition found to be associated
spicy, and/or rough textured; using a non- information regarding this disease, and with the disease.75-77 A previous worldwide
alcoholic chlorhexidine rinse; and placing provide them with a comprehensive treat- estimate found that 170 million people
patients on a more frequent recall schedule ment strategy.65 By doing so, dentists have chronic hepatitis C, although its
may be helpful.31,63 Trauma, heat, irritants can reduce OLP patients inherent stress prevalence is regionally variable.78 Many
from smoking, and oral habits have also of uncertainty and empower them to hepatitis C patients may be asymptom-
been found to exacerbate the clinical be part of their own health success.65 In atic.79 Chronic hepatitis C can lead to
symptoms of OLP.10,31 addition, during the educational process, hepatocellular carcinoma and to cirrhosis,

www.agd.org General Dentistry January/February 2015 19

Diagnosis and Treatment Planning Why the general dentist needs to know how to manage oral lichen planus

which itself could be an independent risk asymmetric appearance of the lesion, and cancer exams.95 A similar 2009 survey in
factor for oral cancer.30,80 A person with lack of response to treatment.30,60 Treatment Massachusetts found that dentists per-
hepatitis C is 2.8-5.4 times more likely to of patients with a diagnosis of OLP should formed double the number of oral cancer
have OLP than the control population.57 include a clinical examination every 3-6 exams compared to physicians.94 This study
Therefore, it makes good sense to ensure months for a minimum of 5 years, ideally also found that 24% of dentists reported
that ones health history includes questions with regular photographic documentation finding suspicious lesions in >10 patients,
that address hepatitis C risk factors and to of the lesion.30 Several studies have found compared to no physicians finding such
refer patients to their primary care provid- that the tongue is the preferred site for lesions in >10 patients.94 The study further
ers as indicated.57 In the United States, risk malignant transformation, although all reported that both dentists and physicians
factors for hepatitis C include blood trans- areas should be observed with suspicion.30,87 are more confident that dentists are quali-
fusions, intravenous drug use, or high risk One review article found that the reported fied to perform oral cancer exams when
sexual practices; worldwide practitioners interval between a diagnosis of OLP and compared to physicians.94 The hypothetical
should look for risk factors specific to their oral squamous cell carcinoma ranges correlation is that OLP would be found
region.31,78 Several authors postulate that from 20.8 months to 10.1 years.30 Recent in the same exam conducted to detect oral
it is not economically advantageous for research hypothesizes that malignant trans- cancer, and that physicians may be even
everyone who has OLP to be screened for formation of OLP is related to long-term less aware of specific uncommon diseases
hepatitis C.31,57 Regional areas that tend to chronic inflammation.89 In addition to of the oral cavitysuch as OLPthan
have strong associations between OLP and the increased rate of cellular turnover, the they are of oral cancer.
hepatitis C are the Mediterranean region thought is that the nitric oxide produced by If physicians are less likely to perform
of Europe (especially Spain and Italy) and inflammatory cells can promote carcinogen- oral exams, they are consequently less
East Asia (especially Japan).10,57,75,76 esis.90 Some researchers have hypothesized likely to manage oral lesions. In addition,
Lichenoid reactions as a manifestation of that steroid and/or immunosuppressive because of the association between OLP
graft versus host disease may be the easiest treatment contributes to the potential for and periodontal disease, dentists are in
of systemic conditions to identify due to carcinogenesis in OLP, although there is no the best position to manage the entire
their presentation after bone marrow or current evidence to support this.30,38,87 oral health picture. Dentists are also more
stem cell transplants.81,82 Oral complica- Late diagnosis of oral cancer will likely likely to fabricate a custom tray for drug
tions are common and associated with result in a patients increased morbidity delivery. This is not to suggest, however,
donor-generated T cells attacking host and mortality. The ideal period from that physicians or other primary care pro-
tissues.31,82-84 The reaction can be found diagnosis to treatment of oral cancer is viders should not conduct comprehensive
in more severe cases of acute graft versus the sooner the better. A 10-year analysis oral exams, with the goal of identifying
host disease (<100 days), but historically is of new cases of oral squamous cell carci- lesions, as it is well-recognized that some
a frequent finding in chronic disease.84-86 noma showed that there was a significant patients visit their primary care provid-
Dentists should notify the patients trans- difference in the stage of the tumor, ers more frequently than their dentist or
plant physician should these lesions mani- and therefore prognosis, between those do not visit a dentist at all. Therefore, it
fest in the oral cavity so as to integrate oral referred earlier than 6 weeks and those is essential that a comprehensive exami-
symptom management with overall disease later.93 In 2000, the United Kingdom nation of the mouth be taught in the
treatment. As with other symptomatic placed a 2-week rule for all suspected medical school clinical curriculum. A
lichenoid reactions, these patients can be cancers as a time limit for referral from survey of 86 US medical schools found
treated with topical corticosteroids and/or primary care to a specialist.93 that such training is currently brief
topical anesthetics.84 and incomplete.96,97 The Association of
Respective roles of dentists and American Medical Colleges recommends
Malignant transformation physicians in oral examination that additional training be added to the
Officially, OLP has been designated as Dentists are in the best position to identify medical curriculum in its Medical Schools
a premalignant condition by the World and diagnose all diseases of the oral cavity. Objective Project.98
Health Organization; however the rates As specialists of the oral cavity, dental
and mechanisms of transformation are practitioners spend more time observing Litigation
subject to debate.30,87-91 Researchers who this area and thus would be more likely to Litigation involving oral cancer and OLP
theorize that OLP is not a premalignant observe a soft tissue irregularity or to diag- is not openly discussed. Consequently,
condition propose that cases diagnosed nose a chief complaint associated with an there is a dearth of information published
as malignant transformation of OLP oral mucosal lesion. While physicians are in the medical literature. However,
were actually instances of misdiagnosed often aware of oral diseases and understand selected publications on the subject merit
epithelial dysplasia.9,91,92 Published rates their implications to overall health, they the general dentists attention. Given that
of malignant transformation vary from are less likely to perform oral exams than OLP is a disease that is relatively uncom-
0%-12.5%.30,87,91 Clinicians should become dentists.94 In a 1995 survey conducted in mon, it is frequently misdiagnosed, result-
particularly suspicious of malignant trans- Maryland of dentists and physicians, more ing in a number of lawsuits for failure to
formation when there are specific sites with physicians than dentists felt that they did diagnose oral cancer as the health care
a loss of homogeneity, increased size or not feel adequately trained to conduct oral provider makes the unfortunate mistake

20 January/February 2015 General Dentistry www.agd.org

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Pathol Oral Radiol Endod. 2004;98(5):553-565. nail, esophageal, and ocular involvement in patients 91. Position paper: oral features of mucocutaneous disor-
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52. Jameson MW, Kardos TB, Kirk EE, Ferguson MM. Mu- tients. J Am Acad Dermatol. 1993;28(5 Pt 1):724-730. relates with a more advanced stage at presentation,
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11(4):236-239. with oral lesions and a systematic review. Br J Derma- and dentists oral cancer knowledge, opinions and
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Urban legends series: lichen planus. Oral Dis. 2013; of a WHO consultation organized in collaboration at: https://www.mededportal.org/download/
19(2):128-143. with the Viral Hepatitis Prevention Board, Antwerp, 258678/data/oralhealthmsop.pdf. Accessed Novem-
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59. Lundstrom IM, Anneroth GB, Holmberg K. Candida in 80. Lekholm U, Stenman G. Induction of oral cancer by 100. Lydiatt DD. Cancer of the oral cavity and medical mal-
patients with oral lichen planus. Int J Oral Surg. 1984; 7,12-dimethylbenz[a]anthracene in rats with liver cir- practice. Laryngoscope. 2002;112(5):816-819.
13(3):226-238. rhosis. Acta Odontol Scand. 1989;47(5):265-269. 101. Lydiatt DD. Medical malpractice and head and neck
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tients. J Clin Periodontol. 2005;32(10):1029-1033. 82. Vogelsang GB, Lee L, Bensen-Kennedy DM. Pathogenesis 102. Rice PJ, Hamburger J. Oral lichenoid drug eruptions:
61. Scully C, Beyli M, Ferreiro MC, et al. Update on oral and treatment of graft-versus-host disease after bone their recognition and management. Dent Update.
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Barjas-Castro ML. Oral involvement in chronic graft

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Investigation of antibacterial efficacy of Acacia

nilotica against salivary mutans streptococci :
a randomized control trial
Devanand Gupta, BDS, MDS n Rajendra Kumar Gupta, PhD

This double-blind, randomized control trial sought to evaluate the clinical of error was fixed at 5%. ANOVA and post hoc least significant differ-
effects of 3 mouthrinses against salivary mutans streptococci (MS). Ninety ence tests were performed. There were significant decreases in the MS
high-caries risk volunteers were randomly assigned to 3 groups, each colony count in the A. nilotica and chlorhexidine groups at 30 days (85%
group using a selected mouthrinse BID for 30 days. Subjects in Group 1 and 83%, respectively) and at 60 days (65% and 63%, respectively)
rinsed with 10 ml of 50% Acacia nilotica, Group 2 subjects rinsed with (P < 0.0001). The antibacterial action of A. nilotica against MS was
10 ml of 0.2% chlorhexidine (active control), and subjects in Group 3 similar to that of chlorhexidine.
rinsed with saline water (passive control). Unstimulated saliva samples Received: November 12, 2013
were collected at baseline, 30, and 60 days. MS were cultured on mitis Revised: April 2, 2014
salivarius bacitracin agar, and colony counts were obtained. The margin Accepted: May 7, 2014

ental caries is one of the most prev- Acacia speciescommonly known Considerable efforts have been made to
alent infectious diseases in humans as Babool (or babul), Egyptian mimosa, find an active agent against Streptococcus
worldwide.1 Caries is defined as a Egyptian thorn, kikar, Indian gum, and mutans, as it is found to be resistant to
localized, progressive demineralization of red thornhave long been used for the many antibacterial agents, such as penicil-
the hard tissues of the crown and/or root treatment of various ailments and for lin, amoxicillin, cefuroxime, and erythro-
surfaces of teeth. This demineralization other practical uses. The wood of A. mycin.7 Thus, there is a growing need to
is caused by acids produced by bacteria, nilotica was used by ancient Egyptians investigate natural antimicrobial agents
particularly mutans streptococci (MS), to make statues and furniture. Its use that are effective and safe for patients.
which ferment dietary carbohydrates. has been reported since early Egyptian A. nilotica mouthrinses have dem-
This occurs within dental plaque, a dynasties. Dioscorides, the Greek physi- onstrated effective antibacterial effects
bacteria-laden gelatinous material that cian considered to be the father of botany, against halitosis-inducing bacteria on
adheres to tooth surfaces and becomes described the use of A. nilotica (as a the tongue, and has also been used in
colonized by bacteria. Thus, caries preparation extracted from the leaves and the treatment of gingival bleeding and
results from the interplay of 3 factors fruit pods) in his De Materia Medica.5 mouth ulcers.8 The antimicrobial effi-
over time: dietary carbohydrates, car- He named it akakia, and it is from this cacy of A. nilotica against MS has been
iogenic bacteria within dental plaque, word that the modern name, acacia, is ascertained in previous in vitro studies.9,10
and susceptible hard tooth surfaces.1 If derived. The origin of the word, acacia, However, no in vivo studies have been
left untreated, caries may lead to pain, is spiny, which is a typical feature of carried out to assess the antibacterial
infection, and tooth loss. During the the species. The species is widely spread efficacy of A. nilotica against MS in com-
past few decades, changes have been in Africa, with a range extending from parison with chlorhexidine. Hence, the
observed in the prevalence and epidemi- Egypt to Mauritania southwards to South current study was conducted.
ology of dental caries.1 Africa, and also in Asia, ranging east-
Mouthrinses are adjuncts to mechanical wards to Pakistan and India. It has been Materials and methods
plaque control and serve as delivery vehi- introduced in China, Australia (where it This double-blind, randomized control
cles for antimicrobial agents. For decades, is considered to be a pest plant of national trial was conducted on undergraduate
chlorhexidine has been considered the importance), Caribbean and Indian student volunteers in the Department of
gold standard among the different anti- Ocean islands, United States, Central Public Health Dentistry, Teerthankar
microbial mouthrinsees commercially America, and South America. It has been Mahaveer Dental College and Research
available.2 Although chlorhexidine is introduced as a medicinal, forage, and Centre, India. The protocol was approved
effective in reducing the number of MS, fuel wood plant in many parts of world. by the Institutional Review Board (IRB)
it has inherent side effects, such as stain- A. nilotica has been proven as an effective of Teerthankar Mahaveer University.
ing of teeth and composite restorations, medicine in the treatment of malaria, sore All subjects signed an IRB-approved
altered taste perception, metallic taste, and throat (aerial part), toothache (bark), acute consent form. A pilot study was done on
burning sensation.3 Plant compounds can diarrhea, colds, bronchitis, diarrhea, bleed- 10 patients from each of 3 test groups to
be therapeutic substitutes for synthetically ing hemorrhoids, and leucoderma.6 A. nilot- check the feasibility of the study; those
created antimicrobial agents.4 ica twigs have been used as toothbrushes.6 results are not included in the study.

www.agd.org General Dentistry January/February 2015 23

Microbiology Investigation of antibacterial efficacy of Acacia nilotica against salivary mutans streptococci

Table 1. Baseline background of the subjects.

A. nilotica Chlorhexidine Placebo control

Baseline characteristics n = 30 n = 30 n = 30 P value
No. of men/women 15/15 10/20 12/18 0.698
Range of age (years); mean (SD) 20-24; 22.16 (2.01) 19-25; 21.42 (2.07) 20-25; 22.74 (2.28) 0.362
Number of times toothbrushing Once25, Twice5 Once24, Twice6 Once25, Twice5 0.897
Additional oral hygiene aids None None None
DMFT, mean (SD) 3.52 (3.39) 3.67 (2.43) 3.18 (2.85) 0.759
Incipient lesions, mean (SD) 5.58 (3.48) 5.42 (4.08) 5.63 (4.64) 1.098
Abbreviations: A. nilotica, Acacia nilotica ; DMFT, decayed/missing/filled teeth; SD, standard deviation.

Table 2. ANOVA results for the 3 study groups.

Sum of squares df Mean square F value P value

MS (baseline) Between groups 21709.972 2 10854.986 0.542 1.3120
Within groups 1589356.737 54 29432.532
MS (Day 30) Between groups 468912.035 2 234456.017 15.825 0.0001
Within groups 789459.474 54 14619.619
MS (Day 60) Between groups 389590.877 2 194795.438 9.361 0.0001
Within groups 929856.000 54 17219.555
Abbreviations: df, degree of freedom; MS, mutans streptococci.

Preparation of extract plaque score >2 and a baseline DMFT The volunteers were randomly allocated
A water-washed section of A. nilotica index of 2-5 were included in the study. into 3 study groups through computer-
bark was subjected to coarse grating Volunteers who had used antibiotics or generated numbers. Individuals were
(sieve No. 44) to produce a coarse powder any mouthrinse for 7 consecutive days, or identified by code numbers throughout
of uniform texture. A hot solid-liquid taken corticosteroids in the past 15 days the study. The clinical trial was con-
(Kumagawa) extraction procedure was were excluded from the study. Subjects ducted according to American Dental
applied to obtain the extract of A. nilot- with a history of sensitivity to any mouth- Associations Adjunctive Dental Therapies
ica. The powder was subjected to 50% rinse, and those who had used removable for the Reduction of Plaque and Gingivitis
ethanol for 48 hours at 60C-65C. The prostheses or an orthodontic appliance, guidelines.11 All eligible subjects partici-
resulting separate 50% extract was then were excluded from the study. pated in the study.
concentrated and the ethanol solvent was All volunteers were subjected to clinical For the study, all subjects were asked
completely removed under reduced pres- examination, and a sampling frame (n = 90) to rinse with 10 ml of their designated
sure by a Lyotrap dryer (LTE Scientific was prepared of those who fulfilled the mouthrinse BID for 30 days. Group 1
Ltd.). The extract was stored at 4C in a inclusion and exclusion criteria. Subjects subjects were given a 50% A. nilotica
tightly closed container to preserve it from were instructed to refrain from any drug mouthrinse, Group 2 subjects were given
any contamination, deterioration, and/or and alcohol consumption for the study a 0.2% chlorhexidine mouthrinse, and
decomposition. period of 60 days and to report any con- Group 3 (control) was given a saline water
sumption of these products. The subjects mouthrinse (placebo).
Inclusion and exclusion criteria were divided into 3 groups (n = 30). This
Volunteers who had 1 or more active sample size was chosen as the minimum size Methodology
incipient lesions and/or frank carious required due to the calculations for error DMF scores and incipient lesion scores
lesions were considered to be at high risk used in this study: error <5% (P < 0.05), were recorded at baseline. The unstimu-
for dental caries and were included in error 20%, expected mean difference lated salivary samples were collected from
the study. Participants having a baseline 3.257, and standard deviation 2.715. the participants and inoculated onto mitis

24 January/February 2015 General Dentistry www.agd.org

Table 3. Post hoc significant difference test for multiple comparisons.

95% confidence interval

Dependent variable Group (I) Group (J) Standard error P value Lower limit Upper limit
MS (baseline) A. nilotica Chlorhexidine 52.68 0.4220 -149.90 47.80
A. nilotica Placebo control 52.68 0.6980 -138.12 62.17
Chlorhexidine Placebo control 52.68 0.8970 -69.28 114.01
MS (Day 30) A. nilotica Chlorhexidine 33.23 0.9810 -69.23 53.23
A. nilotica Placebo control 33.23 0.0001 -212.18 -99.72
Chlorhexidine Placebo control 33.23 0.0001 -211.18 -98.72
MS (Day 60) A. nilotica Chlorhexidine 40.18 0.8560 -87.64 79.69
A. nilotica Placebo control 40.18 0.0001 -224.33 -79.99
Chlorhexidine Placebo control 40.18 0.0001 -216.85 -66.52
(I) and (J) designations according to post hoc analysis.
Abbreviations: A. nilotica, Acacia nilotica ; MS, mutans streptococci.

salivarius bacitracin (MSB) agar (M259, samples were collected again, inoculated compliance in the A. nilotica group was
HiMedia Laboratories). The MS colony onto MSB agar (MS3), and colony counts 90.1% (range 87% to 95%), while that
counts were obtained by a microbiologist were obtained after incubation. of the chlorhexidine group was 86.3%
who was blinded to the groups. Each par- (range 82% to 96%). ANOVA was used
ticipant was given the same brand of tooth- Collection of saliva sample to analyze the reduction in colony counts
brush and toothpaste to minimize bias. The unstimulated saliva samples were col- in the 3 groups. There was a significant
All 3 solutions were made in the uni- lected during the study in the mornings decrease in the MS colony count in both
versitys pharmacy department. Each after the use of mouthrinse. The study the A. nilotica and chlorhexidine groups at
mouthrinse was the same color, and kept subjects were asked not to swallow for Day 30 (85% and 83%, respectively) and
in a coded container. Study subjects were 60 seconds, after which time the pooled at Day 60 (65% and 63%, respectively)
instructed to rinse with 10 ml of mouth- saliva on the floor of the mouth was aspi- (P < 0.0001). The colony counts obtained
rinse for 60 seconds BID, post-breakfast rated with a syringe. The syringes were at Day 60 showed a slight increase com-
and post-lunch, for 30 days. They were not coded and the saliva samples were diluted pared to counts obtained at Day 30, but
to rinse with water afterward. They were in distilled water. The sample was inocu- an overall reduction to the baseline colony
also instructed not to consume any solid or lated within 30 minutes after collection. count was seen (P < 0.0001). The control
liquid for a half hour following mouthrinse All the microbiological procedures were group showed a slight decrease at Day 30
use. Except for the BID mouth rinsing, carried out in the microbiology lab of the and a slight increase at Day 60 (3% and
the volunteers were asked to maintain their universitys medical college. 7%, respectively). This variation, however,
normal oral hygiene practices. All subjects was not statistically significant (P = 0.201).
lived in the same student housing, so they Statistical analysis ANOVA was carried out to assess the
all shared the same diet. A compliance SPSS version 21 (SPSS, Inc.) was used intra- and intergroup variations (Table 2).
diary was given to each study participant; for data analysis. Repeated ANOVA and There was no significant difference in
they were asked to make an entry of each ANOVA followed by post hoc least sig- the baseline colony count between the
usage and side effects experienced, if any. nificant difference (LSD) tests were used 3 groups (P = 1.312), while the difference
Unstimulated saliva samples were collected for analysis. A P value of 0.05 was taken at Day 30 and Day 60 was statistically
and inoculated on MSB agar (MS1) before to be significant. significant (P = 0.0001). Post-hoc LSD was
the study began (baseline). Unstimulated performed to obtain multiple comparisons
saliva samples were collected from subjects Results (Table 3). The difference in the decrease
of all 3 groups at the end of 30 days and All 90 participants completed the study. in colony counts between A. nilotica and
inoculated onto MSB agar (MS2); colony Descriptive statistics are presented in chlorhexidine groups was not statistically
counts were obtained after 48 hours Table 1. No statistically significant differ- significant (P = 0.981 and P = 0.856 at
incubation. On Day 31, the subjects were ence was found in the baseline data between Days 30 and 60, respectively). However,
instructed to stop using the mouthrinse and the 3 groups. Compliance with mouthrinse the differences between both Group 1
continue with their routine oral hygiene use was determined to be acceptable for and Group 2 vs Group 3 (control) were
care. At Day 60, unstimulated saliva both the experimental groups. Mean highly significant (P < 0.0001).

www.agd.org General Dentistry January/February 2015 25

Microbiology Investigation of antibacterial efficacy of Acacia nilotica against salivary mutans streptococci

Adverse events of chlorhexidine. In contrast, Group 3 to simmer until the water is reduced by
The most common adverse event reported showed a slight variation in MS colony 75%. The extract can then be used as a
was a mild burning sensation in both the count. For both Groups 1 and 2, there mouthrinse. This method is the prevail-
A. nilotica and chlorhexidine groups. The was a slight decrease in colony counts ing oral hygiene practice in rural parts of
chlorhexidine group reported altered taste at Day 30 and a slight increase at Day India. Alternatively, purified A. nilotica is
and brown staining of the teeth (50% and 60. This variation was not statistically commercially available in powder form.
67%, respectively). Such side effects were significant and it was possibly due to At 50 rupees (0.82 USD) for 500 g, the
not recorded in the A. nilotica group. physiological changes. powder is very cost efficient and can be
A. nilotica stem bark extracts contain used instead of bark. For a family of 4,
Discussion alkaloids, saponins, cardiac glycosides, 10 mg of powder can be used to make
The present study was conducted to tannins, flavonoids, and anthraquinones 100 ml of mouthrinseenough for the
assess the antibacterial action of a 50% which might be responsible for its anti- entire family to use for 4 days. The cost
A. nilotica mouthrinse against salivary bacterial properties.9 A review of the avail- per 10 ml of mouthrinse use is estimated
MS in comparison with the gold stan- able literature revealed that some authors to be approximately 1 rupee (0.02 USD).
dard 0.2% chlorhexidine mouthrinse and have reported in vivo antibacterial activity Our data show that a mouthrinse made
a placebo (saline water). of herbs such as Terminalia chebula and from A. nilotica is just as effective in com-
Research has been focused in recent Triphala against salivary MS, and Aloe bating caries as chlorhexidine. A. nilotica
years on herbal medicines as alternatives to vera against dental plaque, but to date, no can be considered a viable substitute for
synthetically created antimicrobial agents, studies have been conducted to assess the chlorhexidine, especially among popula-
due to their wide range of biological and effect of A. nilotica on salivary MS.16-20 tions of lower socioeconomic means.
medicinal activities, potentially higher The results of 50% A. nilotica extract
safety margins, and lower costs. Several mouthrinse on salivary MS could not be Conclusion
antibacterial agentssuch as chlorhexi- compared with other studies, as no in vivo As S. mutans is generally considered the
dine, fluorides, and various antibiotics studies that have tried to assess the same main oral pathogen responsible for dental
are commercially available that can be used effect have been reported in the literature. caries, the fact that A. nilotica inhibited
to prevent dental caries. However, some of However, studies have been reported the growth of S. mutans provides some
these have been reported to have undesir- that suggest that A. nilotica possesses scientific rationale for the use of this plant
able side effects, including nausea, vomit- other beneficial properties for general for the treatment of dental caries. The
ing, tooth staining, and metallic taste.4 A. and oral health.21 results of the present study clearly indicate
nilotica is considered safe for human use.12 Compliance with mouthrinse use was the use of A. nilotica as a viable mouth-
Research on A. nilotica-containing acceptable in both Groups 1 and 2. Mean rinse among rural communities of lower
products has demonstrated its oral health compliance in the A. nilotica group was economic means, where it is easily acces-
benefits. Acacia gum has the potential to 93.6% while that in the chlorhexidine sible. However, as this is the first attempt
inhibit early plaque formation, although group was 91.2%. The taste of A. nilotica to assess the effects of A. nilotica on
there is no proven long-term benefit. mouthrinse was acceptable to all the sub- salivary S. mutans, a clinical trial of longer
For centuries, A. nilotica gum has been jects of the group. The astringent action of duration with a larger sample size is neces-
used for oral hygiene in the Middle East A. nilotica resulted in the drying of the oral sary in the consideration of a commercially
and North Africa.13 In a 2010 study, a cavity, and subjects reported that it acted available A. nilotica mouthrinse.
gel containing A. nilotica significantly as a breath freshener. Side effect profiles
improved clinical gingival and plaque were also checked at the end of the trial. Author information
index scores over a period of 6 weeks.14 No staining of the teeth or altered taste Dr. D. Gupta is an assistant professor,
In a comparison study of other herbal perception was reported by the volunteers Department of Public Health Dentistry,
remedies, Dhanya Kumar & Sidhu in the A. nilotica group. Volunteers using Institute of Dental Sciences, Bareilly, Uttar
indicated that an A. nilotica extract chlorhexidine reported a yellowish discol- Pradesh, India. Dr. R. Gupta is a principal,
(concentration 50%) showed the highest ouration of the teeth and a metallic taste. Government Degree College, Banbasa,
antimicrobial activity against S. mutans.15 Uttrakhand, India.
Thus, a 50% extract concentration was Cost effectiveness
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Streptococcus mutans to chlorohexidine and six other 18(1):75-77. 109-116.
antimicrobial agents. Antimicrob Agents Chemother. 14. Pradeep AR, Happy D, Garg G. Short-term clinical 21. Pradeep AR, Happy D, Garg G. Short-term clinical ef-
1993;37(5):1158-1159. effects of commercially available gel containing fects of commercially available gel containing Acacia
8. Dhinahar S, Lakshmi T. Role of botanicals as antimicro- Acacia arabica: a randomized controlled clinical trial. arabica: a randomized controlled clinical trial. Aust
bial agents in management of dental infections a Aust Dent J. 2010;55(1):65-69. Dent J. 2010;55(1):65-69.
review. Int J Pharm Biosci. 2011;2(4):8690-8704. 15. Dhanya Kumar NM, Sidhu P. The antimicrobial activi-
9. Deshpande SN, Kadam DG. Phytochemical analysis ty of Azardirachta Indica, Glycyrrhiza glabra, Cinna-
and antibacterial activity of Acacia nilotica against mum zeylanicum, Syzygium aromaticum, Accacia Manufacturers
Streptococcus mutans. Int J Pharm Biosci. 2013;5(1): nilotica on Streptococcus mutans and Enterococcus HiMedia Laboratories, Mumbai, India
236-238. faecalis: an in vitro study. Endodontology. 2011;23: 91.22.6147.1919, www.himedialabs.com
10. Xavier TF, Vijayalakshmi P. Screening of antibiotic resis- 18-25. LTE Scientific Ltd., Greenfield, England
tant inhibitors from Indian traditional medicinal plants 16. Jagtap AG, Karkera SG. Potential of the aqueous 44.1457.876221, www.lte-scientifc.co.uk
against Streptococcus mutans. J Plant Sci. 2007. Avail- extract of Terminalia chebula as an anticaries agent. SPSS, Inc., Quarry Bay, Hong Kong
able at: http://www.docsdrive.com/pdfs/academicjour- J Ethnopharmacol. 1999;68(1-3):299-306. 852.2811.9662, www.spss.com
nals/jps/2007/370-373.pdf. Accessed September 30, 17. Nayak SS, Kumar BR, Ankola AV, Hebbal M. The effica-
2014. cy of Terminalia chebula rinse on Streptococcus

www.agd.org General Dentistry January/February 2015 27

Exercise No. 361 Microbiology Subject Code 013

The 15 questions for this exercise are based on the article, Reading the article and successfully completing this exercise will enable you to:
Investigation of antibacterial efficacy of Acacia nilotica identify the physical properties of Acacia nilotica (AN);
against salivary mutans streptococci: a randomized recognize the action of AN against mutans streptococci (MS); and
control trial, on pages 23-27. This exercise was developed understand the efficacy of chlorhexidine mouthrinses compared with
by Jean Carlson, DDS, FAGD, in association with the AN mouthrinses.
General Dentistry Self-Instruction committee.

1. Dental caries results from the interplay 6. In subjects using the AN mouthrinse, 10. Mean compliance of mouthrinse use in
of all the following factors except one. the MS colony count was decreased the AN group was ____%.
Which is the exception? by _____% at 30 days. A. 91.2
A. bacteria in dental plaque A. 85 B. 93.6
B. dietary carbohydrates B. 83 C. 95.2
C. physiologic age C. 65 D. 97.6
D. susceptible tooth surfaces D. 63
11. Mean compliance of mouthrinse use in
2. Chlorhexidine has all of the following 7. The most common adverse reaction the chlorhexidine group was _____%.
inherent side effects except one. Which reported was altered taste sensation in A. 81.2
is the exception? both the AN and chlorhexidine groups. B. 83.6
A. burning sensation Brown staining was not observed in the C. 91.2
B. altered taste AN group. D. 93.6
C. staining of teeth A. Both statements are true.
D. mucosal sloughing B. The first statement is true; 12. The cost for 100 ml 0.2% chlorhexidine
the second is false. mouthrinse ranges between ____ Indian
3. An AN mouthrinse exhibits C. The first statement is false; rupees.
antibacterial effects against halitosis- the second is true. A. 55-100
inducing bacteria on the tongue. The D. Both statements are false. B. 105-150
efficacy of AN against MS remains C. 155-200
unproven in in vitro studies. 8. In the placebo control group, a slight D. 205-250
A. Both statements are true. variation in MS colony count was
B. The first statement is true; reported. There was a slight increase 13. A quantity of 500 g AN powder is
the second is false. in colony count at 30 days with a slight priced at _____ Indian rupees.
C. The first statement is false; decrease at 60 days. A. 20
the second is true. A. Both statements are true. B. 30
D. Both statements are false. B. The first statement is true; C. 40
the second is false. D. 50
4. Volunteers in Group 1 were given C. The first statement is false;
_____% AN mouthrinse for use in the second is true. 14. The average age of participants
the study. D. Both statements are false. in the placebo control group
A. 40 was ______ years.
B. 50 9. AN stem bark extracts contain all of A. 21.16
C. 60 the following components except one. B. 21.42
D. 70 Which is the exception? C. 22.16
A. free radicals D. 22.74
5. Study participants were instructed B. tannins
to rinse their mouths with ____ ml of C. saponins 15. The placebo group was given _______
solution for ____ seconds. D. flavonoids to use as a mouthrinse.
A. 5; 30 A. ethanol
B. 10; 30 B. saline water
C. 5; 60 C. hydrogen peroxide
D. 10; 60 D. chlorhexidine

Answer form is on the inside back cover. Answers for this exercise must be received by December 31, 2015.

28 January/February 2015 General Dentistry www.agd.org


The AGD Podcast series features interviews with some of the professions most highly
regarded speakers. To access, simply use your smartphone to scan each podcasts QR code,
download, and enjoy!

Marketing Your Practice New Vistas in Periodontics Insurance Coding Updates

with Kim McQueen with Sam Low, DDS, MS, MEd with Charles Blair, DDS

Effective Web Marketing Profiting with PPO Dental Embezzlement in the Dental
with Colin Receveur Insurance with Dana Moss Office with David Harris

Dr. Blakeslee discusses

the latest news and
emerging trends with
prominent dental
professionals to keep
you in the know.

Wes Blakeslee,
Diagnosis and Treatment Planning

Clinical considerations for selecting implant

abutments for fixed prosthodontics
Roger A. Solow, DDS

There is an overwhelming number of designs and components for occur in concert. This article addresses the principles that guide implant
dentists to choose from when treatment planning implant-supported abutment selection when treatment planning for fixed prosthodontics.
restorations. The selection process can be simplified by establishing Received: December 16, 2013
priorities on a site-by-site basis to facilitate a predictable, esthetic, Revised: May 28, 2014
and stable final result. Clinical considerations should include prosthetic Accepted: September 3, 2014
support, periodontal stability, reparability, and oral hygiene, which often

reatment planning for any case that alteration.1 Anterior teeth experience less and crestal bone. In order to keep occlusal
includes implant-supported restora- masticatory and bruxing forces compared forces aligned with the long axis of the
tions may involve a complex series of to posterior teeth.2 When using implants implant, the crown must be centered over
decisions about a multifactorial problem to restore anterior teeth, the main priority the implant platform and only contact
list. The restorative dentist, who typically of treatment is to preserve the topogra- the opposing tooth during closure, not
finishes the case, must be able to explain to phy of the dentogingival interface via mandibular excursions. The crestal bone
the patient why the proposed treatment is periodontal reconstruction and prosthetic tolerates vertical, compressive force better
the optimal approach, and communicate to contours for stability and esthetics. By than shear forces induced by lateral torque
the surgeon the necessary steps for achiev- contrast, the priority for implant restora- on the crown.6
ing the desired result. One way to organize tion of posterior teeth is force manage- The fracture of porcelain and implant
the treatment planning is to decide on the ment, in order to avoid damage to the components can be caused by mechani-
priorities for each site and the overall goal implant, abutment, prosthesis, or crestal cal stress related to cantilevered restora-
of the comprehensive restoration. These bone. However, some anterior sites are tions (Fig. 2). Proper implant position
priorities are based on the clinical consid- not visible due to the marginal gingiva-lip in the center of the restorative space
erations of prosthetic support, periodontal relationship or low lip activity, while some and improved prosthetic support with
stability, reparability, and oral hygiene. posterior sites may be quite visible due to a wide diameter implant minimizes the
This article discusses how these concerns high lip mobility, requiring tissue augmen- cantilever problem that is most noticeable
influence treatment planning and the tation for acceptable esthetics. in molar sites. An average maxillary first
selection of implant abutments for fixed molar is 11 mm buccolingual and 10 mm
prosthodontics. Dentists must understand Prosthetic support and posterior mesiodistal, while an average mandibular
the relationship between implant and abut- tooth sites first molar is 10.5 mm buccolingual and
ment for optimal clinical application. Many posterior tooth restorations have 11 mm mesiodistal.7 Regular diameter
It is not possible to discuss all implant sys- low esthetic exposure, and the priority
tems in a single article, and any mention of with implant-supported restorations is to
a specific manufacturer is intended to show avoid adverse forces on the prosthesis and
a design or concept, not to make a recom- the supporting periodontium.3 Placing
mendation. This article illustrates clinical the implant in the center of the restorative
decisions based on this authors preferences, space is the first step toward accomplishing
clinical experience, and the literature. these goals. Ridge augmentation may be
Anterior and posterior tooth restora- necessary to create the proper dimensions
tions are placed in different environments. for ideal implant positioning. When mul-
Anterior teeth are highly visible and have tiroot extraction sites are involved, imme-
a scalloped periodontium, with the facial diate implant placement may be facilitated
and oral bone distinctly apical to the by engaging the septal bone to provide
interproximal bone level. Posterior teeth proper orientation.4,5 Placing an implant
are less visible and have flatter periodontal into the socket of a multirooted tooth
architecture with less disparity between creates a cantilevered restoration (Fig. 1).
the facial and oral bone and the inter- With single crowns, off-center implant
proximal bone levels. Anterior teeth have placement forms a cantilever on 1 side of Fig. 1. Implant-supported crown No. 31 with a
thin bundle bone that is lost after tooth the implant that increases stress on the mesial cantilever. Abutment screw loosening was
removal, inducing significant alveolar ridge restorative material, abutment, implant, attributed to magnified force by the cantilever.

30 January/February 2015 General Dentistry www.agd.org

Fig 2. Top. Fractured fragment of Fig. 3. Top. Soft-tissue level implant with a 6.5 mm Fig. 4. Top. Subcrestal placement of a soft-tissue
implant neck due to force overload. platform for enhanced prosthetic support, centered level implant, complicating impressions and cement
Bottom. Distal view of crown on in the edentulous space. Bottom. Regular diameter clearance. Bottom. A good restoration fit was
abutment with significant palatal implant supporting a molar crown with large achieved, but a nonhygienic, deep, subgingival
horizontal cantilever. horizontal cantilever and gingival embrasures. margin persists.

implant platforms typically are 3.75-5 mm, thus decreasing the crestal bone stress per A regular diameter soft-tissue level
while wide diameter implant platforms unit area.9 The implant should be placed implant can be used in premolar sites
typically are >5 mm. A mandibular molar at the level of the gingiva or 0.5 mm similar to molars. The implant must
crown with ideal implant position and intracrevicularly for esthetics, cement be placed accurately, as there is less
average tooth dimension would have a clearance, and patient hygiene. These margin for error in the smaller sites,
mesial horizontal cantilever of 3.25 mm design features, combined with a rough and an implant malposition can result
with a 4.5 diameter platform and only surface, minimize crestal bone loss. These in deficient papilla size or the need to
2.25 mm with a 6.5 diameter platform. implants need to be placed in the correct recontour adjacent teeth. A bone level
Unfortunately, not all ridges are thick relationship with the rough-smooth border implant with a platform-switch abutment
enough buccolingually to accommodate at the crestal bone, to prevent any vertical is also appropriate for these sites. The
a wide diameter implant. A flared soft- position errors that would require a meso- platform-switch abutment has a smaller
tissue level implant with a 6.5 mm plat- structure component or preparation of the diameter compared to the implant plat-
form and a 4.8 mm body can be placed implant platform (Fig. 4). form that shifts the IAJ away from the
within a 7 mm ridge (Standard Plus WN, Premolar teeth occupy a smaller space bone and toward the implant center.10
Straumann) (Fig. 3). than molars and encounter less force. The bacterial-mediated inflammatory
The larger platform increases the linear Providing prosthetic support is less of a infiltrate is displaced from the bone,
prosthetic support by 2 mm (44% of a priority, as the horizontal cantilever (the preserving higher osseous levels in com-
4.5 mm implant) and normalizes the gin- crown minus the crown margin dimen- parison to symmetrical abutments, where
gival embrasure by the same amount. This sion) is reduced. An average maxillary bone loss to the first implant thread is
abutment is torqued into the implant with first premolar is 9 mm buccolingual typical. Platform-switch abutments have
a tapered interference fit, so it is internally and 7 mm mesiodistal, while an average been shown to preserve crestal bone with
connected to the implant platform edge mandibular first premolar is 7.5 mm buc- bone growth onto the implant shoulder.11
that forms the margin for the restoration, colingual and 7 mm mesiodistal.7 The Reducing the 360-degree bone loss seen
eliminating the external implant-abutment main concern with premolars is maintain- adjacent to symmetrical IAJs allows den-
junction (IAJ) microgap.8 The wide diam- ing periodontal stability for esthetics and tists to place the implants closer to natural
eter distributes force through more bone, implant longevity. teeth or implants without losing the bone

www.agd.org General Dentistry January/February 2015 31

Diagnosis and Treatment Planning Clinical considerations for selecting implant abutments for fixed prosthodontics

that supports the interproximal papilla

height.12,13 The platform-switch design is
indicated for all bone level abutments.
In premolar implant sites, a stock tita-
nium or zirconia abutment can be ordered
after the surgeon communicates the sulcus
depth (implant platform to marginal
gingiva) and the restorative space (mar-
ginal gingiva to opposing tooth occlusal
surface). These measurements are recorded
with a periodontal probe and minimize
the need for the restorative dentist to
maintain a large array of components. The
facial margin of the abutment should be
placed 0.5 mm intracrevicularly and the
oral margin should be placed at the level of
the marginal gingiva to visualize complete
crown seating (Fig. 5).14
If the interproximal margin is >1 mm Fig. 5. Top. A premolar implant with a platform- Fig. 6. Top. The dentogingival junction of the central
deep, compromising thorough cement switch abutment. Bottom. The flat gingiva permitted incisors is apical to the lip during function. Bottom. The
clearance, then a stock abutment with a the use of an unaltered stock abutment. long contact ensured that the papilla filled the gingival
taller gingival collar should be customized. embrasure avoiding food accumulation and air passage.
This abutment should be seated and the
gingival margins marked intraorally with
a bur or ink. The abutment should be
shaped extraorally with diamond burs and
checked repeatedly by reseating it on the instead of laying parallel as with polished If esthetics are not a concern because
implant until the margin is correct. titanium. This attachment was broken and the dentogingival junction is hidden by an
Alternatively, an implant level impres- reformed on detachment and replacement apical position beneath the lip or from an
sion is obtained and the laboratory of healing abutments with definitive abut- inactive lip, restoration of the implant can
technician creates a custom abutment ments.18 These microgrooves are a positive proceed as described above with bicuspid
while a temporary abutment supports the design feature to maintain crestal bone and sites. A stock abutment can be placed and
provisional restoration. This approach marginal gingiva levels. modified extraorally to create an intracre-
involves additional time and cost, and vicular margin prior to seating, impres-
precludes the use of the 1 abutment at Periodontal stability and anterior sions, and provisionalization (Fig. 6).
1 time protocol. Research has shown tooth sites In most situations, anterior implant-
that placement of the permanent abut- Tomographic studies show that the buccal supported restorations are placed in
ment at the time of surgery helps to plate of bone adjacent to anterior teeth highly visible areas where both white and
preserve alveolar bone levels, as repetitive is often <1 mm thick or absent entirely, pink esthetics are apparent. Forces in the
detachment and attachment of titanium which results in dehiscence and fenestra- anterior region are low, and the disparity
abutments induces minor bone loss.15,16 tions.19,20 This bone is categorized as between crown dimension and prosthetic
The dentist must be assured of the stabil- bundle bone, a hybrid of osseous and support is small. The priority in anterior
ity of the facial periodontium to place the fibrous tissues. During root extraction, site restoration is periodontal tissue stabil-
permanent abutment at the time of sur- this bone is resorbed after the periodontal ity and esthetics. The restorative dentist
gery or healing abutment removal, since ligament ruptures.21 This loss of the socket must create a prosthetic contourfrom
gingival recession may require abutment wall subsequently deforms the residual the orally positioned implant platform to
removal or intraoral preparation. This alveolar ridge and complicates placement the incisal edgethat molds the gingiva
technique is appropriate for thick peri- of anterior implants. Implants placed in into the correct position and replicates
odontal biotypes and sites where esthetics the center of the resorbed ridge will be natural tooth esthetics. Platform-switch
are not a concern. toward the oral side of the original tooth bone level implants are recommended in
Laser-etched 8-12 channels have been position. Intentional placement of the anterior esthetic sites to preserve crestal
shown to create an enhanced attachment implant further toward the oral side will bone and give the restorative dentist
of bone and connective tissue to both maximize buccal bone dimension. Most control over the entire prosthetic con-
implants and abutments (Laser-Lok, anterior implant-supported restorations tour. The restorative margin position for
BioHorizons IPH, Inc.).17 Connective require tissue augmentation to restore tissue level implants is determined by the
tissue fibers inserted perpendicular to the topography of the periodontium and surgeon and leaves little room for adjust-
these grooves are similar to natural teeth, achieve stable esthetics.22 ment if the position is not correct. In ideal

32 January/February 2015 General Dentistry www.agd.org



Fig. 7. A. One-piece implant with good mesiodistal placement and 2 mm of titanium from the restorative margin to the bone crest.
B. Provisional restoration with healthy tissue but asymmetric length with tooth No. 10. C. Gingival sculpting with retraction cord and
electrosurgery to elongate the facial length of the restoration. D. All-porcelain restoration with a facial and apical emergence profile.

circumstances, the biologic width of the positioned so that the screw access channel facial gingiva is less than 3 mm thick or has
prosthetically molded and supported gin- exits through the cingulum of the crown. a thin biotype where a periodontal probe is
giva is allowed to mature for 3-6 months; When the implant is more facially posi- visible when introduced into the sulcus. A
at that point, its contours are recorded tioned the abutment acts as a mesostruc- 2009 systematic review showed that zirco-
immediately after the provisional restora- ture to correct the position or angulation nia abutments met or exceeded the perfor-
tion is removed.23,24 A cement-retained that would result in the screw access chan- mance of titanium abutments in terms of
provisional on a permanent abutment nel exiting at, or facial to the incisal edge. survivability and technical complications.31
can be used for anterior restorations with A conventional crown can be cemented on One-piece implants are indicated for
the 1 abutment at 1 time protocol, the properly aligned abutment. anterior sites with a restricted mesiodistal
if the abutment properly supports the Custom abutments allow dentists to dimension. The small cervical width
facial tissue and a 0.5 mm intracrevicular control the cervical dimension and margin of the implant would be reduced and
margin is present for cement clearance. location. They are indicated to either elim- weakened if a screw channel was used
In this scenario, only interproximal tissue inate the access defect of screw retention or to attach an abutment. This system has
modification would be necessary, as pres- compensate for the vertical and horizontal no IAJ or micromobility; however, the
sure from the provisional contour could implant position. A circumferential 0.5 surgeon must place the implant precisely
improve papillae shape. However, in most mm intracrevicular margin creates good in 3 dimensions for an optimal restora-
anterior site cases, the need to modify the esthetics with predictable cement removal. tion. The restorative dentist can customize
facial contour sequentially, alter a perma- The most coronal subgingival aspect of the coronal aspect of the implant, but
nent abutment margin intraorally, remove a custom abutment or a screw-retained cannot substitute another abutment (in
the cement completely, or avoid cement crown has the greatest influence on the case of over-reduction) or compensate for
deterioration/re-cementation during the gingival support and level.27 problems with vertical position by using a
maturation period make screw-retained For predictable pink esthetics, the facial different abutment collar or switching to a
provisionals more practical.25,26 Screw- gingival thickness should be 3 mm; at screw-retained crown (Fig. 7).
retained provisional restorations facilitate this thickness, abutment color is not an
tissue molding for papillae and pontic sites issue.28 A 2007 in vitro study by Jung et al Reparability of cement vs
by maintaining constant gentle pressure, reported that titanium perceptibly altered screw retention
inducing gingival blanching that dissipates abutment color when gingival thickness Historically, a high incidence of abutment
within 10 minutes.25,26 was 2 mm but not when it was 3 mm, screw loosening and the need to access and
Anterior tooth restoration using an abut- while white zirconia did not alter color for retorque them favored screw retention for
ment and crown versus a screw-retained either thickness.29 More recently, Happe fixed prostheses.32,33 According to a 2008
crown is determined by the position and et al found that titanium induced a visible study by Theoharidu et al, abutment screw
angulation of the implant. A screw-retained change in gingival 1.5 mm thick while loosening occurs in approximately 2.5%
crown that attaches directly to the implant white or dyed zirconia did not.30 A zirconia of single implant restorations when proper
platform requires the implant to be orally abutment should be considered when the antirotational features and torque are

www.agd.org General Dentistry January/February 2015 33

Diagnosis and Treatment Planning Clinical considerations for selecting implant abutments for fixed prosthodontics

used.34 The decision to use cement or screw any excess polymerize past the margin.37
retention is based on the need to contour Residual cement removal is increasingly
periodontal tissues, interocclusal space, difficult with deeper subgingival margins,
subgingival implant platform location, or and this excess cement is directly related
anticipated need to repair a prosthesis. to peri-implantitis. Screw retention avoids
Limited interocclusal space (<5 mm) this problem and is indicated for patients
makes cement retention difficult. with deep subgingival margins.38
Restorative material 2 mm thick would Bruxers and patients who consume hard
leave an abutment height of only 3 mm or abrasive foods may experience a higher
for frictional crown retention. In such incidence of repair. The anticipated need
cases, screw-retained crowns are recom- for future repairs may be determined by
mended, as inadequate abutment height a patients history of repeated restora-
compromises the ability of cement- tion, noncompliance with occlusal splint
retained restorations to resist dislodge- therapy, or damage to high quality
ment, especially in posterior tooth sites.35 provisional restorations. Large cases with
Cement retention permits the same multiple, splinted, implant-supported
clinical protocol as restorative dentistry on crowns or multiple-abutment implant-
natural teeth. Cement may act as a stress- supported bridges may be more difficult
breaker for splinted crowns and bridges, to repair. In these cases, damage to 1 area Fig. 8. Top. Parallel placement of implant determined
with no occlusal access restorations to could require accessing and disassembling by the surgical guide derived from a diagnostic
compromise esthetics or occlusal contacts. the cemented structure or the fabrica- wax-up. Bottom. Individual gold castings on implants
When necessary, crown retrieval can be tion of an overcasting. Screw retention No. 29 and 30, and tooth No. 31.
performed via occlusal access to create a facilitates removing the entire structure
screw-retained design. and replacing it with a screw-retained
It is crucial to avoid excessive provisional provisional restoration during labora-
or permanent cement in the sulcus, which tory repair. Repair may also be necessary
could cause peri-implantitis. The following in the provisional phase of restoration. natural teeth for predictable maintenance.
protocol is the same for both provisional Screw retention is recommended in cases Cantilevered restorations can create
and permanent cements. The axial wall of long-term provisionalization, when gingival embrasures that trap food and
of the abutment is roughened with a dia- removal of the prosthesis is needed for may compromise the ability to maintain
mond bur, or a slot undercut is placed in specialist procedures, or for patients who hygiene on the adjacent tooth (Fig. 1).40
the gingival third of the axial wall to resist risk decementation while traveling. Posterior crowns on contiguous
crown decementation due to smooth- Multi-unit abutments are titanium com- implants can be restored as nonsplinted
walled abutments. Next, retraction cord is ponents that compensate for soft tissue single units that have the same longevity
placed in the sulcus. A slightly undersized thickness and implant angulation prob- as splinted restorations.41,42 However,
die, to create cement space, is fabricated lems relative to the occlusal surfaces of a adjusting the interproximal contacts
from the intaglio of the crown with a fast- screw-retained prosthesis. They function as can be a challenge since the ankylosed
set polyvinyl siloxane (PVS) (Blu-Mousse, a mesostructure that allows the prosthesis implant does not move. The resilient
Parkell, Inc.).36 A thin, slow-setting layer to seat at the abutment level instead of periodontal ligament of a natural tooth
of cement is placed inside the crown and the implant platform level, with screw allows for a slight separation of the inter-
the crown is seated on the PVS die to retention channels at favorable locations proximal contact. The contacts must be
remove excess. The crown is then seated through the occlusal surfaces adjusted to allow thin floss to pass with-
on the abutment and removed. The cord out creating an open contact that collects
and any excess cement are removed and Oral hygiene and prosthesis food. This adjustment involves marking
the crown is immediately reseated. This design the interproximal contact repeatedly by
technique minimizes cement excess and Oral hygiene requirements influence pros- seating the crown (with marking ribbon
avoids cord entrapment under crowns. thesis design, with regard to access for rou- between it and the adjacent tooth) and
A moderately strong provisional cement tine frictional cleaning, minimizing food polishing the marked area. This treat-
(IRM, DENTSPLY Caulk) can retain a entrapment in the gingival embrasure, ment allows patients to brush and floss
relined provisional crown with a precise and creating optimal interproximal con- normally; however, it requires a normal
fit for several months. Zinc phospate tacts. Over-contoured implant-supported gingival embrasure dimension to create
cement is used for permanent cementation crowns inhibit access for proper hygiene, an ideal contact area (approximately 3 x
since it is radiopaque and water soluble. resulting in plaque accumulation that may 2 mm) with the papilla, which fills the
Radiotransparent, water insoluble, resin lead to peri-implantitis.39 A proper gingival embrasure and precludes lateral food
cement should not be used for implant- embrasure form is just as important for impaction (Fig. 8). If proper contacts
supported crowns since it is the most implant restorations as it is with orth- cannot be developed, the crowns should
difficult type to detect and remove should odontic repositioning or the restoration of be splinted to avoid food entrapment.

34 January/February 2015 General Dentistry www.agd.org

this process by analyzing the problem list 15. Degidi M, Nardi D, Piattelli A. One abutment at one
and designating priorities for each implant time: non-removal of an immediate abutment and its
effect on bone healing around subcrestal tapered im-
site that support the total restorative plan.
plants. Clin Oral Implants Res. 2011;22(11):1303-
Author information 16. Abrahamsson I, Berglundh T, Lindhe J. The mucosal
Dr. Solow is in private practice in Mill barrier following abutment dis/reconnection. An ex-
Valley, California, and a visiting faculty perimental study in dogs. J Clin Periodontol. 1997:
member at the Pankey Institute, Key 17. Nevins M, Nevins ML, Camelo M, Boyesen JL, Kim DM.
Biscayne, Florida. Human histologic evidence of a connective tissue at-
tachment to a dental implant. Int J Periodontics Re-
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thet Dent. 1981;45(4):389-391. cal alveolar bone dimension of maxillary anterior and
4. Fugazzotto PA. Implant placement at the time of man- premolar teeth: a cone beam computed tomography
dibular molar extraction: description of technique and investigation. Int J Oral Maxillofac Implants. 2012;
preliminary results of 341 cases. J Periodontol. 2008; 27(6):1514-1519.
79(4):737-747. 21. Cardaropoli D, Cardaropoli G. Preservation of the
Fig. 9. Top. Four posterior tooth implants supporting 5. Fugazzotto PA. Implant placement at the time of max- postextraction alveolar ridge: a clinical and histologic
a cemented, splinted prosthesis. The pronounced illary molar extraction: treatment protocols and report study. Int J Periodontics Restorative Dent. 2008;28(5):
of results. J Periodontol. 2008;79(2):216-223. 469-477.
interproximal contacts normalize the gingival
6. Kim Y, Oh TJ, Misch CE, Wang HL. Occlusal consider- 22. Buser D, Halbritter S, Hart C, et al. Early implant place-
embrasures. Bottom. Provisional restoration with ment with simultaneous guided bone regeneration
ations in implant therapy: clinical guidelines with bio-
a large crown-to-implant ratio, large interproximal mechanical rationale. Clin Oral Implants Res. 2005; following single-tooth extraction in the esthetic zone:
contacts, and normal gingival embrasures. 16(1):26-35. 12-month results of a prospective study with 20 con-
7. Kraus BS, Jordan RE, Abrams L. Dental Anatomy and secutive patients. J Periodontol. 2009;80(1):152-162.
Occlusion. Baltimore, MD: Williams and Wilkins Co.; 23. Wilson RD, Maynard G. Intracrevicular restorative den-
1973:48-94. tistry. Int J Periodontics Restorative Dent. 1981;1(4):
8. Bozkaya D, Muftu S. Mechanics of the tapered inter- 34-49.
ference fit in dental implants. J Biomech. 2003;36(11): 24. Priest G. Developing optimal tissue profiles implant-
Implants often are placed after traumatic 1649-1658. level provisional restorations. Dent Today. 2005;
9. Anitua E, Tapia R, Luzuriaga F, Orive G. Influence of 24(11):96, 98, 100.
tooth loss or advanced periodontal disease 25. Potashnick SR. Soft tissue modeling for the esthetic
implant length, diameter, and geometry on stress dis-
that results in significant bone loss and tribution: a finite element analysis. Int J Periodontics single-tooth implant restoration. J Esthet Dent. 1998;
a large restorative space (Fig. 9). When Restorative Dent. 2010;30(1):89-95. 10(3):121-131.
these contiguous implants are restored, 10. Lazzara RJ, Porter SS. Platform switching: a new con- 26. Issarayangkul C, Schoenbaum TR, McLaren EA. Pros-
cept in implant dentistry for controlling postrestorative thetic soft tissue management following two periim-
they should be splinted together to bring
crestal bone levels. Int J Periodontics Restorative Dent. plant graft failures: a clinical report. J Prosthet Dent.
the restorative contours in contact with 2013;110(3):155-160.
the gingival tissue and avoid exaggerated 11. Degidi M, Perrotti V, Shibli JA, Novaes AB, Piattelli A, 27. Su H, Gonzalez-Martin O, Weisgold A, Lee E. Consid-
gingival embrasures and food entrapment. Iezzi G. Equicrestal and subcrestal dental implants: a erations of implant abutment and contour: critical
Nonsplinted crowns would either require histologic and histomorphometric evaluation of nine contour and subcritical contour. Int J Periodontics
retrieved human implants. J Periodontol. 2011;82(5): Restorative Dent. 2010;30(4):335-343.
perfecting large contact areas with normal 28. Gamborena I, Blatz MB. The gray zone around dental
gingival embrasures or accept the normal 12. Vela X, Mendez V, Rodriguez X, Segala M, Tarnow DP. implants: keys to esthetic success. Am J Esthet Dent.
contact areas with open gingival embra- Crestal bone changes on platform-switched implants 2011;1(1):26-46.
sures that can trap food. and adjacent teeth when the tooth-implant distance is 29. Jung RE, Sailer I, Hammerle CH, Attin T, Schmidlin P. In
less than 1.5 mm. Int J Periodontics Restorative Dent. vitro color changes of soft tissues caused by restor-
2012;32(2):149-155. ative materials. Int J Periodontics Restorative Dent.
Summary 13. Nevins M, Nevins ML, Gobbato L, Lee HJ, Wang CW, 2007;27(3):251-257.
Treatment planning for implant-supported Kim DM. Maintaining interimplant crestal bone height 30. Happe A, Schulte-Mattler V, Strassert C, et al. In vitro
restorations requires a thorough under- via a combined platform-switched, Laser-Lok implant/ color changes of soft tissues caused by dyed fluores-
standing of the periodontal requirements abutment system: a proof-of-principle canine study. Int cent zirconia and nondyed, nonfluorescent zirconia in
J Periodontics Restorative Dent. 2013;33(3):261-267. thin mucosa. Int J Periodontics Restorative Dent. 2013;
for a stable and esthetic foundation. 33(1):e1-e8.
14. Nevins M, Skurow HM. The intracrevicular restorative
Choices for the abutment and the implant- margin, the biologic width, and the maintenance of 31. Sailer I, Philipp A, Zembic A, Pjetursson BE, Hammer-
abutment interface should be based on the the gingival margin. Int J Periodontics Restorative le CH, Zwahlen M. A systematic review of the perfor-
anatomy and the clinical considerations of Dent. 1984;4(3):30-49. mance of ceramic and metal implant abutments
each particular site. Dentists can simplify

www.agd.org General Dentistry January/February 2015 35

Diagnosis and Treatment Planning Clinical considerations for selecting implant abutments for fixed prosthodontics

supporting fixed implant reconstructions. Clin Oral 39. Chaves ES, Lovell JS, Tahmasebi S. Implant-supported There are more articles on
Implants Res. 2009;20(Suppl 4):4-31. crown design and the risk for peri-implantitis. Clin Adv DIAGNOSIS AND TREATMENT
32. Becker W, Becker BE. Replacement of maxillary and Periodont. 2014;4(2):118-126. PLANNING in the online edition.
mandibular molars with single endosseous implant 40. Chiche G. Pinault A. Considerations for fabrication of
restorations: a retrospective study. J Prosthet Dent. implant-supported posterior restorations. Int J Prosth-
1995;74(1):51-55. odont.1991;4(1):37-44.
33. Kallus T, Bessing C. Loose gold screws frequently occur 41. Simon RL. Single implant-supported molar and pre-
in full-arch fixed prostheses supported by osseointe- molar crowns: a ten-year retrospective clinical report.
grated implants after 5 years. Int J Oral Maxillofac Im- J Prosthet Dent. 2003;90(6):517-521.
plants. 1994;9(2):169-178. 42. Mendonca JA, Francischone CE, Senna PM, Matos de
34. Theoharidu A, Petridis HP, Tazannas K, Garefis P. Abut- Oliveira AE, Sotto-Maior BS. A retrospective evaluation
ment screw loosening in single-implant restorations: of the survival rates of splinted and non-splinted short
a systematic review. Int J Oral Maxillofac Implants. dental implants in posterior partially edentulous jaws.
2008;23(4):681-690. J Periodontol. 2014;85(6):787-794.
35. Taylor TD, Belser U, Mericske-Stern R. Prosthodontic
considerations. Clin Oral Implants Res. 2000;
11(Suppl 1):101-107. Manufacturers
36. Wadhwani C, Pineyro A. Technique for controlling the BioHorizons IPH, Inc., Birmingham, AL Central giant cell lesion: diagnosis
cement for an implant crown. J Prosthet Dent. 2009; 888.246.8338, www.biohorizons.com to rehabilitation
102(1):57-58. DENTSPLY Caulk, Milford, DE
37. Wadhwani C, Hess T, Faber T, Pineyro A, Chen CS. A 800.532.2855, www,caulk.com Alveolar ridge splitting for implant
descriptive study of the radiographic density of im- Parkell, Inc., Edgewood, NY placement: a review of the
plant restorative cements. J Prosthet Dent. 2010; procedure and report of 3 cases
800.243.7446, www.parkell.com
Straumann, Andover, MA
38. Wilson TG Jr. The positive relationship between excess Atypical presentation of
cement and peri-implant disease: a prospective clinical 978.747.2500, www.straumann.com
salivary mucocele: diagnosis
endoscopic study. J Periodontol. 2009;80(9):1388-1392.
and management
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36 January/February 2015 General Dentistry www.agd.org

Dental Materials

Surgical repair of invasive cervical root resorption

with calcium-enriched mixture cement: a case report
Saeed Asgary, DDS, MS n Mahta Fazlyab, DDS, MS

Invasive cervical resorption (ICR) occurs in the cervical area of the teeth from >3 mm to 1 mm, showing attachment gain. As a biocompatible
due to the formation of a soft tissue that progressively resorbs dentin. material, CEM has proven its ability in dentinogenesis, cementogenesis,
The disease is asymptomatic unless the pulp is exposed. This article and osteogenesis; it may prove to be a suitable biomaterial for treating
presents a case involving a mandibular canine that was treated with a ICR cases.
calcium-enriched mixture (CEM) cement. After a full mucoperiosteal flap Received: June 6, 2013
was performed, the soft tissue was curetted away and the cavity filled Accepted: September 3, 2013
with CEM biomaterial. One week later, the supragingival surface of the
CEM was polished and covered with composite resin. At a 1-year follow- Key words: calcium-enriched mixture, CEM cement, cervical
up visit, the pulp was healthy and the gingival probing depth decreased resorption, endodontic, invasive cervical root resorption

rritation of the periodontal ligament the periodontium (due to a defect in the tissue, followed by curettage, andwhen
or pulp can lead to internal or external cementum layer) is necessary for such necessaryendodontic treatment.6 The
resorption.1 Invasive cervical resorption an invasion.3-5,10,16 Several potential pre- defect can be restored using glass ionomer
(ICR) refers to a type of external root disposing factors have been identified, cement, resin-modified glass ionomer, or
resorption, defined as a resorptive process including trauma, orthodontic treatment, mineral trioxide aggregate (MTA).3,6,19-23
in the cervical area that involves the dentoalveolar surgery, and periodontal The material needs to be placed close to
root surface in the junctional epithelium treatment; in addition, feline herpes the pulp; thus, it must be nontoxic and
zone.2,3 Other terms used to describe virus type 1 is suspected as an etiologic biocompatible, provide a perfect seal to
this process include odontoclastoma, cofactor.5,17 Heithersay developed a clini- prevent leakage of environmental irritants
peripheral cervical resorption, extracanal cal classification system for such lesions: through the cavity walls, induce dentino-
invasive resorption, supraosseous extraca- Class 1, a small lesion near the cervical genesis, demonstrate antibacterial behavior,
nal invasive resorption, and subepithelial area with shallow penetration into the and cause minimal pulp inflammation.24
external root resorption.3,4 The term inva- dentine; Class 2, a well-defined lesion The selected treatment must also provide
sive describes the aggressive nature of this that has penetrated close to the coronal an appropriate environment for osteogen-
lesion.3,5,6 Although early diagnosis may pulp with little or no extension into the esis and cementogenesis, which is followed
be difficult, some clinical signs can indi- radicular dentine; Class 3, a deeper inva- by soft tissue attachment gain.23
cate the presence of an ICR lesion, such as sion of dentine that not only involves the Recently, a new endodontic cement
a pinkish hue in the crown (as a result of coronal dentine but also extends into the composed of a calcium-enriched mixture
the thinning resorbed dentin), the trans- coronal third of the root (the majority of (CEM) was introduced.25 It has the same
lucency of enamel that makes the vascular patients present at this stage); and Class clinical indications as MTA but a different
resorptive tissue visible, and contour 4, a large resorptive process that extends chemical formulation.25 CEM cement is
irregularities.3,7-10 The condition usually beyond the coronal third of the root.5 The biocompatible, nontoxic, and antibacte-
is painless due to a predentin layer that author also recommended that dentists rial, while also providing a good seal.8,24,25
protects the pulp.4,7,11-14 Symptoms develop only treat defects categorized as Class 1, CEM material is hard tissue inductive,
when the resorption penetrates through 2, or 3, as the extensive nature of Class 4 dentinogenic, cementogenic, and osteo-
this barrier and the pulp is invaded sec- lesions makes treatment difficult.5,18,19 genicproperties that make CEM an
ondarily by oral bacteria.11,13 Most lesions The basic goal of ICR treatment is the appropriate biomaterial for treating ICR.26
seen on periapical radiographs are poorly inactivation of all resorbing tissue and the This article presents a case in which
defined with irregular borders, with what reconstitution of the tooth structure so that CEM cement was used to treat a Class 3
has been referred to as a moth-eaten the tooth may be retained for health and ICR in a mandibular canine.
appearance.1,5,14 The outline of the root esthetics.9-11,15 In a 2004 article, Heithersay
canal can be seen as a radiopaque line recommended a treatment regimen that Case report
through the lesion.1,5,14 included mechanical/chemical debride- A man in his early thirties had the
The etiology of ICR is poorly under- ment of the resorptive lesions, followed chief complaint of a carious-like lesion
stood; however, it has been suggested that by restoration.6 That same article also on his mandibular left canine. A brief
a type of fibrovascular tissue and clastic offered a nonsurgical technique involving examination of the dental and gingival
resorbing cells may be responsible.3,4,10,15 a 90% aqueous solution of trichloracetic tissues revealed that the patient had
Direct contact between the dentin and acid applied topically to the resorptive normal hygiene and no carious lesions,

www.agd.org General Dentistry January/February 2015 37

Dental Materials Surgical repair of invasive cervical root resorption with calcium-enriched mixture cement: a case report

Fig. 1. A photograph of a periodontal Fig. 2. A radiograph of the lesion in Fig. 3. Local anesthesia is injected into Fig. 4. A full mucoperiosteal flap is
probe assessing the lesion depth of the affected tooth. Note the moth- the soft tissue prior to flap resection. resected and the soft tissue is curetted
the patients left mandibular canine. eaten margins and lesion extending away. Note the absence of pulp exposure
beyond the crestal bone. and the irregularity of the margins.

Fig. 5. The cavity is filled with calcium- Fig. 6. A radiograph taken of the tooth Fig. 7. Histological views of the soft tissue specimen (H&E). A. Granulation tissue
enriched mixture (CEM) cement prior after the CEM cement restoration was with chronic inflammatory cell infiltrate (magnification 100X). B. Same view at higher
to flap replacement. placed. magnification (400X). Note the dense collagen matrix and lymphocytic infiltration.

although he had some amalgam restora- beneath the bone crest. The root canal tissue was removed from the inner side
tions on his molars and premolars. His could be seen through the radiolucency of the flap. The cavity was evacuated
most recent dental visit had taken place (Fig. 2). The patient did not report any without any exposure of the pulp space
7 months earlier. sensitivity to cold or heat, and vitality (Fig. 4). CEM cement powder and liquid
A cavity was visible on the buccal cervi- pulp testing revealed normal responses (BioniqueDent) were mixed according
cal area of the mandibular left canine; the compared to the mandibular right canine. to the manufacturers instructions, and
contour was irregular and extended api- Given the nature of the lesion, a diagnosis placed into the cavity until it was filled
cally beyond the gingival margin (Fig. 1). of ICR was made. completely (Fig. 5). Another radiograph
An explorer revealed the tissue that filled After an antibacterial mouth rinse, local was taken to confirm the quality of the
the defect was extremely hyperemic and anesthesia was injected into the resorptive CEM restoration (Fig. 6). The flap was
the dentin beyond the tissue on the pulpal soft tissue (Fig. 3), and an intrasulcular sutured and the patient was given post-
side appeared stiff and sound. The probing full thickness flap was raised to disclose operative instructions. The patient made
depth on the midbuccal area was >3 mm. the margin of the lesion. Crestal bone a follow-up appointment to remove the
Orthoradial periapical radiographs showed had recessed to the most apical margin sutures 1 week postsurgery. The curetted
a radiolucent lesion on the cervical area. of the cavity. The resorptive tissue that soft tissue was placed in a 10% forma-
The margins had a moth-eaten pattern, replaced the dentin was curetted by using lin solution for common histological
and the most apical margin had extended an excavator; in addition, all granulated evaluation with H&E staining (Fig. 7).

38 January/February 2015 General Dentistry www.agd.org

Fig. 8. An anterior view of the treated Fig. 9. An anterior view of the tooth Fig. 10. The tooth 10 days post- Fig. 11. The tooth at a 3-month
tooth 7 days postsurgery. 10 days post-treatment. Note the treatment, after the surface was follow-up. Note the healthy gingival
supragingival portion of the CEM covered with flowable composite resin. tissues.
cement is polished.

remains unknown. The present case was

a Heithersay Class 3 type.6 Without
treatment, the resorption would have
proceeded progressively, involving the
dental pulp or causing cervical fracture of
the tooth.6 The patient had no signs or
symptoms; the color of his tooth led him
to seek treatment.
Subgingival caries was listed in the dif-
ferential diagnosis. These have a sticky
feeling on probing in cases of ICR. By
contrast, the remaining hard dentin on
Fig. 12. The tooth at a 1-year follow- Fig. 13. A radiograph of the tooth taken at the 1-year follow-up visit. the pulpal side made a scraping sound on
up, with a gingival depth of 1 mm. probing. In the present case, the dentin
overlying the pulp was completely sound
and stiff. According to Patel et al, the
radiolucent band across the entire neck
of the tooth on periapical radiographs
Examination of the tissue showed a patient at 3 months and 1 year, respec- (known as the cervical burnout) needs to
chronic infiltration with lymphocytes tively. At the 1-year follow-up, the probing be ruled out as well.3 Recently, cone beam
dominating in a dense collagen matrix. depth on the midbuccal area was 1 mm. computed tomography (CBCT) has been
The CEM filling was tested clinically A radiograph taken at that follow-up visit used to assess the position and the true
at the follow-up appointment.27 The showed that the tooth had remained com- extent of ICR lesions.13,21 However, CBCT
filling remained intact, except for some pletely asymptomatic with normal peri- is a costly and time-consuming diagnostic
stains and debris covering the surface radicular and periapical tissues (Fig. 13). tool, and it was determined that the clini-
(due to the porous surface of the material) During all the scheduled follow-up visits, cal and radiographic examinations taken in
(Fig. 8). Ten days postsurgery, the patient the patient reported no problems with this the present case revealed sufficient infor-
returned for the next treatment step. The tooth, and vitality testing confirmed the mation about the lesion.
surface of the CEM cement was polished pulps normal condition. As mentioned previously, histological
to make a clean surface (Fig. 9). After assessment of the lesion revealed a chronic
etching and placement of the bonding Discussion infiltration with lymphocytes dominat-
resin (Margin Bond, Coltene/Whaledent, An ICR in a mandibular canine was ing in a dense collagen matrix, which is
Inc.), the supragingival portion of the exposed surgically and treated successfully how granulomatous tissue appears, and is
cavity was filled with composite (Synergy with CEM cement with no endodontic the common histological finding in ICR
Nano Formula, Coltene/Whaledent, Inc.) co-intervention. In the present case, the cases.3 Early defects usually do not contain
(Fig. 10). Figures 11 and 12 show the contributing factor to cervical resorption acute inflammatory cells, which suggests a

www.agd.org General Dentistry January/February 2015 39

Dental Materials Surgical repair of invasive cervical root resorption with calcium-enriched mixture cement: a case report

nonbacterial etiology.3 However, it is possi- significantly different) when compared subsequent arrest of the resorption. Dent Traumatol.
ble that a secondary bacterial colonization to MTA.26 Advantages of this studys 2008; 24(5):556-559.
13. Gunst V, Mavridou A, Huybrechts B, Van Gorp G, Berg-
of dentinal tubules at a later stage might treatment plan include biocompatibility,
mans L, Lambrechts P. External cervical resorption: an
induce an acute inflammatory response. induction of dentinogenesis, cemento- analysis using cone beam and microfocus computed
Treatment regimens for ICR include genesis, and perfect seal. CEM cement tomography and scanning electron microscopy. Int En-
debridement of the resorptive lesions fol- offers a high alkalinity, which can be a dod J. 2013;46(9):877-887.
lowed by restoration.5,6,18,19 In the present mechanism of osteoclast inactivation; it 14. Trope M. Cervical root resorption. J Am Dent Assoc.
case, the granulated tissue was curetted also did not result in tooth discoloration, 15. Yu VS, Messer HH, Tan KB. Multiple idiopathic cervical
completely after flap reflection. The a drawback of MTA.26,28 resorption: case report and discussion of management
proposed nonsurgical treatment plan by options. Int Endod J. 2011;44(1):77-85.
Heithersay & Wilson, which uses 90% tri- Conclusion 16. Lin YP, Love RM, Friedlander LT, Shang HF, Pai MH.
Expression of Toll-like receptors 2 and 4 and the
chloracetic acid, was rejected in this case, Given the biological properties of CEM
OPG-RANKL-RANK system in inflammatory external
as the authors believe that there would be cement, it may be an appropriate biomate- root resorption and external cervical resorption. Int
a risk of incomplete tissue removal and rial in cases of ICR. Further research is Endod J. 2013;46(10):971-981.
restoration of the cavity, due to the apical recommended concerning the mechanisms 17. von Arx T, Schawalder P, Ackermann M, Bosshardt DD.
extension of the defect.19 According to by which CEM cement stimulates regen- Human and feline invasive cervical resorptions: the
missing link?Presentation of four cases. J Endod.
Patel et al, treating ICR and decreasing the eration and interferes with periodontal 2009;35(6):904-913.
chance of recurrence requires reflecting ligament inflammation. 18. Heithersay GS, Dahlstrom SW, Marin PD. Incidence of
a full-thickness periosteal flap, curetting invasive cervical resorption in bleached root-filled
away the granulation tissue, and severing Author information teeth. Aust Dent J. 1994;39(2):82-87.
19. Heithersay GS, Wilson DF. Tissue responses in the rat
the blood supply to the resorbing cells.3 Dr. Asgary is a professor and dean, Iranian
to trichloracetic acidan agent used in the treatment
The surgical technique used in the present Center for Endodontic Research, Research of invasive cervical resorption. Aust Dent J. 1988;
case eliminated the chance that trichlor- Institute of Dental Sciences, Shahid 33(6):451-461.
acetic acid (a cytotoxic material) would get Beheshti University of Medical Sciences, 20. Hiremath H, Yakub SS, Metgud S, Bhagwat SV, Kulkarni
close to the vital pulp. Tehran, Iran, where Dr. Fazlyab is an S. Invasive cervical resorption: a case report. J Endod.
The drawbacks of MTAincluding endodontist, Dental Research Center. 21. Estevez R, Aranguren J, Escorial A, et al. Invasive cervi-
its high cost, long setting time, difficult cal resorption Class III in a maxillary central incisor:
handling properties, limited antibacterial References diagnosis and follow-up by means of cone-beam com-
effects against some endodontic pathogens, 1. Ne RF, Witherspoon DE, Gutmann JL. Tooth resorption. puted tomography. J Endod. 2010;36(12):2012-2014.
and potential for discolorationprevent Quintessence Int. 1999;30(1):9-25. 22. Park JB, Lee JH. Use of mineral trioxide aggregrate in
2. Vinothkumar TS, Tamilselvi R, Kandaswamy D. Reverse the non-surgical repair of perforating invasive cervical
it from being an ideal biomaterial for sandwich restoration for the management of invasive resorption. Med Oral Patol Oral Cir Bucal. 2008;
treating ICR in anterior teeth.22,23 CEM cervical resorption: a case report. J Endod. 2011;37(5): 13(10):E678-E680.
cement and MTA have similar clinical 706-710. 23. Yilmaz HG, Kalender A, Cengiz E. Use of mineral triox-
uses; however, the water-based CEM 3. Patel S, Kanagasingam S, Pitt Ford T. External cervical ide aggregate in the treatment of invasive cervical re-
resorption: a review. J Endod. 2009;35(5):616-625. sorption: a case report. J Endod. 2010;36(1):160-163.
cement offers a shorter setting time, 4. Thonen A, Peltomaki T, Patcas R, Zehnder M. Occur- 24. Zarrabi MH, Javidi M, Jafarian AH, Joushan B. Histo-
increased flow, and decreased film thick- rence of cervical invasive root resorption in first and logic assessment of human pulp response to capping
ness.26 In addition, CEM cement has the second molar teeth of orthodontic patients eight years with mineral trioxide aggregate and a novel endodon-
ability to release indigenous calcium and after bracket removal. J Endod. 2013;39(1):27-30. tic cement. J Endod. 2010;36(11):1778-1781.
5. Heithersay GS. Invasive cervical resorption: an analysis 25. Asgary S, Nosrat A. Concurrent intentional replanta-
phosphorus ions to form hydroxyapatite,
of potential predisposing factors. Quintessence Int. tion of maxillary molars using a novel root-end filling
which ensures an effective bioseal after 1999;30(2):83-95. biomaterial: a case report. Gen Dent. 2013;62(3):30-
settinga prerequisite for any biomaterial 6. Heithersay GS. Invasive cervical resorption. Endod Top- 33.
used in proximity to pulp.24 ics. 2004;7(1):73-92. 26. Asgary S, Ahmadyar M. Vital pulp therapy using cal-
In the present case, the cavity was 7. Silveira LF, Silveira CF, Martos J, Piovesan EM, Cesar cium-enriched mixture: an evidence-based review.
Neto JB. Clinical technique for invasive cervical root J Conserv Dent. 2013;16(2):92-98.
restored with CEM cement; at a follow-up resorption. J Conserv Dent. 2011;14(4):440-444. 27. Parirokh M, Torabinejad M. Mineral trioxide aggre-
visit, the CEM cement bulk was polished 8. Asgary S, Ahmadyar M. One-visit endodontic retreat- gate: a comprehensive literature reviewPart III:
to remove the stains and leave a flat white ment of combined external/internal root resorption clinical applications, drawbacks, and mechanism of
surface. Next, the supragingival part of using a calcium-enriched mixture. Gen Dent. 2012; action. J Endod. 2010;36(3):400-413.
60(4):e244-e248. 28. Marao HF, Panzarini SR, Aranega AM, et al. Periapical
the CEM cement was covered with a
9. Kim Y, Lee CY, Kim E, Roh BD. Invasive cervical resorp- tissue reactions to calcium hydroxide and MTA after
composite restoration for esthetics. CEM tion: treatment challenges. Restor Dent Endod. 2012; external root resorption as a sequela of delayed tooth
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this cementum layer acts as a biologic 10. Fuss Z, Tsesis I, Lin S. Root resorptiondiagnosis,
barrier.26 In the present case, a 2 mm classification and treatment choices based on stimula- Manufacturers
tion factors. Dent Traumatol. 2003;19(4):175-182. BioniqueDent, Tehran, Iran
reduction in probing depth revealed the 11. Smidt A, Nuni E, Keinan D. Invasive cervical root re- www.bioniquedent.com (website suspended)
attachment gain, offering additional proof sorption: treatment rationale with an interdisciplinary
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12. Mattar R, Pereira SA, Rodor RC, Rodrigues DB. Exter- 330.916.8800, www.coltene.com
had higher antimicrobial activity, and
nal multiple invasive cervical resorption with
caused less inflammation (although not

40 January/February 2015 General Dentistry www.agd.org

Office Design

Evaluation of 3 dental unit waterline

contamination testing methods
Nuala Porteous, BDS, MPH n Yuyu Sun, PhD n John Schoolfield, MS

Previous studies have found inconsistent results from testing methods detection of limited numbers of heterotrophic organisms at the required
used to measure heterotrophic plate count (HPC) bacteria in dental unit 35C incubation temperature. The results also confirm that while the
waterline (DUWL) samples. This study used 63 samples to compare in-office chairside method is useful for DUWL quality monitoring, the
the results obtained from an in-office chairside method and 2 currently Standard Method 9215C provided the most accurate results.
used commercial laboratory HPC methods (Standard Methods 9215C Received: May 27, 2014
and 9215E). The results suggest that the Standard Method 9215E is Accepted: September 17, 2014
not suitable for application to DUWL quality monitoring, due to the

he water that is supplied via dental Currently, there is only 1 in-office, Standard Method 9215C (a spread plate
unit waterline (DUWL) tubing to chairside kit available: the HPC Sampler method on R2A medium) has long been
air/water syringes, handpieces, and (EMD Millipore), consisting of a remov- considered the gold standard for analysis
ultrasonic scalers in a typical dental unit is able dip paddle contained in a plastic of DUWL quality.12 This procedure, using
fed directly from the main water supply or sampler. The dip paddle contains a 0.45 a low nutrient R2A formulation (Becton,
via a self-contained reservoir on the dental filter and an absorbent pad with dehy- Dickson & Company) and room tempera-
unit itself. DUWL tubing typically is 2 drated agar medium which absorbs 1 ml of ture incubation for 7 days, was designed
mm in diameter and made of either poly- the liquid sample, facilitating the recovery for the detection of common water organ-
vinyl chloride or polyurethane. This tubing of stressed (that is, partially sanitized or isms. The disadvantages of this method
forms a complex network inside a dental nutritionally starved) aerobic bacteria in are that it is time-consuming to prepare
unit, resulting in a high ratio of tubing 7 days. According to the manufacturer, the R2A and it relies on a small volume of
surface area to water volume.1 These fac- this method can produce accurate readings liquid (0.1 ml), which can become quickly
tors, along with the periodic pooling of up to 300 CFU/ml; all counts >300 CFU/ absorbed if the agar dries out.11
stagnant water inside the tubing, facilitate ml are considered too numerous to count Standard Method 9215E (SimPlate
an ideal environment for bacterial growth (TNTC).7 There is evidence from previous for HPC, IDEXX Laboratories, Inc.)
and biofilm formation (up to 50 thick) studies to show that, although the HPC is a user-friendly method that has been
comprised of a heterogeneous population Sampler underestimates bacterial counts included in the list of Standard Methods
of organisms.2,3 Microorganisms from compared with other methods, it is useful in recent years.11 A proprietary enzyme
the biofilm are continuously shed as the as a screening tool for regular DUWL substrate is mixed with the water sample,
water flows through the DUWL tubing, quality monitoring in dental offices to and as bacteria metabolize the substrate
resulting in microbial contamination of the ensure the water used in the treatment of they fluoresce after 48 hours of incuba-
patient treatment water.4 patients meets the CDC/EPA recommen- tion at 35C. The number of fluorescent
The Centers for Disease Control and dation of <500 CFU/ml.8-10 wells are counted and converted to the
Prevention (CDC) recommends that the Dental offices can also utilize services most probable number (MPN), using a
water used in dental offices should meet offered by commercial laboratories for a table provided by the manufacturers. The
the drinking water standard established more accurate assessment of water quality. maximum MPN/ml recorded from an
by the US Environmental Protection Waterline samples are collected and mailed undiluted sample is 73.8; for more highly
Agency (EPA) of <500 colony forming using kits that are supplied to offices contaminated water samples, 10-fold serial
units per milliliter (CFU/ml) for routine by the commercial entities. Standard dilutions can be used.13 Since its introduc-
dental treatment output water.5,6 In order laboratory methods, as published in the tion as a Standard Method, SimPlate for
for dental practitioners to comply with Standard Methods for the Examination HPC has become widely used in commer-
these guidelines, DUWL monitoring of Water and Wastewater(hereafter cial laboratories, and dental offices that use
should be performed as recommended by referred to as Standard Methods), are a mail-in laboratory service may be obtain-
the dental unit manufacturers.5 Waterline recommended by the American Public ing their results from this method.
monitoring can be done in-office with Health Association, American Water Works A previous study by the authors found
chairside kits or via commercial labora- Association, and Water Environment that bacterial counts were underestimated
tories. The purpose of monitoring is to Federation.11 The list includes 4 standard on the SimPlate for HPC compared to
measure the heterotrophic (organisms methods and 5 types of media for use in R2A agar.14 The purpose of this experi-
that use a carbon source for survival) plate different combinations as appropriate for ment was to expand on those findings and
count (HPC) of DUWL samples. testing purposes.11 to compare bacterial counts and genera

www.agd.org General Dentistry January/February 2015 41

Office Design Evaluation of 3 dental unit waterline contamination testing methods

from all 3 currently available monitoring discarded and the Sampler was incubated at Sequencing
methods: the spread plate R2A (Method room temperature for 7 days, at which point DNA obtained from the PCR reac-
9215C), the SimPlate for HPC (Method CFU/ml were recorded using the compari- tion was prepared for sequencing by
9215E), and the in-office HPC Sampler. son chart provided by the manufacturer.7 cleaning with a Qiaprep Spin Miniprep
Kit (Qiagen Sciences, Inc.) according
Materials and methods Molecular identification to manufacturers instructions. The
The experiment was designed to collect A selection of HPC Samplers and R2A purified DNA was sequenced at the
an approximately uniform distribution of plates with the largest bacterial colonies UTHSCSA Advanced Nucleic Acids
water sample contamination based on 3 was transported to the Department of Core facility. Sequences were then
source types and 7 exposure durations yield- Microbiology at the University of Texas used to perform individual nucleotide-
ing a total of 63 waterline samples. Sterile Health Science Center at San Antonio nucleotide searches of the ribosomal 16s
collection bottles (100 ml), each containing (UTHSCSA) for molecular identifica- region using the BLASTn algorithm at
sodium thiosulfate to neutralize residual tion, and a sequence-based approach the National Center for Biotechnology
chlorine (IDEXX Laboratories, Inc.) were using the 16s ribosomal DNA regions as Information website.18 Identifications
used to collect samples from the handpiece targets for the molecular identification were calculated based on a percent-
lines, the air/water syringe lines, and the isolates was performed.17 age made from the alignment matches
source tap water in 21 randomly selected obtained from the top 3 BLAST searches
dental operatories in a teaching institution. DNA isolation for the 16s region to yield a variety level
Each sample was cultured on HPC Isolates were suspended in 600 l cell lysis identification. The 3 highest percent
Sampler, R2A agar (Method 9215C), buffer (blood Maxwell LEV kit, Promega identities for each isolate were analyzed
and SimPlate for HPC (Method 9215E) Corporation) in a 0.5 ml microfuge tube. for bacterial identification.
according to manufacturer-recommended The suspension was bead-beaten for
methods. The pH of the source tap water 45 seconds to 1 minute to aid in cell wall Statistical analysis
and the residual free chlorine level (mg/l) breakdown. The suspension was then pel- For the 3 types of detection methods,
were tested before the experiment and leted for 3 minutes at maximum speed in a all possible pairwise Pearson and/or
were found to be 7.2 and 0.5mg/l, respec- microfuge according to the manufacturers Spearman correlation coefficients with
tively. These levels were assumed to remain instructions. The supernatant was trans- corresponding 95% confidence intervals
constant as previous readings in the insti- ferred to the Maxwell LEV cartridge and were performed to determine if any sig-
tution had shown this to be the norm.15 then mounted on the automated Maxwell nificant association was observed among
system, resulting in 150 ng/l of purified the 3 measurement methods, with log
Sample cultures bacterial DNA after a 45-minute run. transformations performed if appropri-
All laboratory procedures were conducted ate. Correlations were performed for all
by 1 laboratory technician. A 10-fold serial Polymerase chain reaction waterline samples and, if appropriate,
dilution of each sample was made with Polymerase chain reactions (PCR) were separately for each waterline sample
phosphate buffer solution. performed directly on 3 l of the DNA source type. Statistical analyses and
For Method 9215C, 0.1 ml of each supernatant in a 50 l reaction using a graphics were performed using Stata 13.0
sample was spread on R2A plates in tripli- 5 prime PCR Extender system (Thermo (StataCorp LP).
cate, incubated at room temperature, and Fisher Scientific, Inc.), according to the
the microbial CFU/ml was recorded after manufacturers instructions. 16s amplicons Results
7 days.11 were obtained using primers 27F and As expected, the R2A measures approxi-
For Method 9215E, 10 ml of each 1525R. Amplifications were performed in a mated an exponential distribution;
solution were placed in the center of the PTC-100 thermocycler (MJ Research, Inc.) however, the SimPlate for HPC values
SimPlates and the manufacturers instruc- using the preprogrammed, 3-step protocol approximated a uniform distribution
tions were followed. Plates were incubated as the standard program for all reactions, ranging from a minimum of 0.4 MPN/ml
for 48 hrs at 35C, and the MPN/ml was consisting of 35 cycles using an anneal- to the maximum 73.8 MPN/ml, followed
calculated.16 Following the calculation ing temperature of 55C and 1 minute by 12 (19%) samples with unspecified
of MPN/ml, liquid was collected (using extension time. A 5 l aliquot of the PCR values >73.8 MPN/ml, as the correspond-
an inoculating loop) from randomly reaction was run on a 0.7% agarose gel and ing 110 dilution plates did not provide
selected fluorescent wells, then spread on stained with ethidium bromide to confirm any results. There were also 4 samples
R2A plates and incubated at room tem- amplification. The remaining PCR reac- based on a 110 dilution that had values
perature for 7 days to prepare isolates for tion (45 l) was run on a gel as described ranging from 112 to 440 MPN/ml and
molecular identification. above, then purified using the Wizard SV 1 handpiece sample that could not be
For HPC Sampler cultures, an undiluted Gel and PCR Clean-Up System (Promega assayed due to technical error. For the
10 ml sample was placed in the outer Corporation), eluted in 30 l sterile water purposes of graphs and correlations, an
sheath, and the dip paddle was replaced according to the manufacturers instruc- arbitrary value of 80 MPN/ml was used
for 30 seconds until 1 ml was absorbed. tions, and incubated with proteinase K at to represent all SimPlate for HPC values
The remainder of the DUWL sample was 56C for 15 minutes. >73.8 MPN/ml.

42 January/February 2015 General Dentistry www.agd.org

Table 1. HPC from DUWL samples

R2A agar SimPlate HPC sampler R2A agar SimPlate HPC sampler
Dental Dental
unit Sample source CFU/ml MPN/ml CFU/ml unit Sample source CFU/ml MPN/ml CFU/ml
a b
1 Handpiece 61,300 26.6 1000 12 Handpiece 543,000 80.0 0
Air/water 87,000 23.9 1000 Air/water 47,300 80.0 b 1000
Source water 1,130 23.1 59 Source water 133 15.1 39
2 Handpiece 494,000 23.1 1000 13 Handpiece 411,000 55.5 1000
Air/water 102,000 37.2 1000 Air/water 244,000 80.0 b 1000
Source water 293 2.1 12 Source water 387 0.2 86
3 Handpiece 142,000 41.4 1000 14 Handpiece 795,000 257.0 1000
Air/water 6,570 26.6 1000 Air/water 722,000 37.2 1000
Source water 8,430 29.9 1000 Source water 213 1.0 151
4 Handpiece 138,000 31.1 1000 15 Handpiece 233,000 73.8 1000
Air/water 392,000 47.0 1000 Air/water 362,000 62.3 1000
Source water 86.7 0.4 33 Source water 417 2.6 73
5 Handpiece 341,000 55.5 1000 16 Handpiece 8,370 62.3 1000
Air/water 235,000 44.0 1000 Air/water 139,000 80.0 b 1000
Source water 1,470 1.9 360 Source water 76.7 47.0 39
6 Handpiece 252,000 68.0 1000 17 Handpiece 115,000 80.0 b 1000
Air/water 284,000 50.7 1000 Air/water 101,000 80.0 b 1000
Source water 1,850 27.6 1000 Source water 2,390 73.8 600
7 Handpiece 642,000 62.3 0 18 Handpiece 33,400 NA 1000
Air/water 573,000 73.8 1000 Air/water 70,700 112.0 1000
Source water 327 73.8 1000 Source water 283 37.2 216
8 Handpiece 361,000 239.0 1000 19 Handpiece 42,300 80.0 b 1000
Air/water 535,000 62.3 1000 Air/water 13,100 80.0 b 1000
Source water 73.3 1.0 20 Source water 527 73.8 116
9 Handpiece 178,000 47.0 1000 20 Handpiece 343,000 440.0 1000
Air/water 39,900 80.0 b
1000 Air/water 226,000 80.0 b 1000
Source water 10 0.6 1 Source water 367 13.2 36
10 Handpiece 151,000 80.0 1000 21 Handpiece 91,300 55.5 1000
Air/water 323,000 55.5 1000 Air/water 57,700 80.0 b 1000
Source water 24,600 33.9 1000 Source water 51,300 73.8 1000
11 Handpiece 243,000 41.4 1000 a
1000 CFU/ml
Air/water 176,000 39.2 1000 MPN >73.8/ml
Abbreviations: CFU, colony forming units; DUWL, dental unit waterline;
Source water 27,700 47.0 1000 HPCs, heterotrophic plate counts; MPN, most probable number; NA, not available.

Results for each of the methods can counts were detected; otherwise, all samples for which the HPC Sampler
be seen in Table 1. The HPC Sampler handpiece and air/water samples counts failed to detect CFUs were excluded as
detection method showed that 46 (73%) were TNTC. For the purposes of graphs having implausible results. Specific HPC
of the dip paddle surfaces were entirely and correlations, an arbitrary value of counts were detected for 14 of 21 source
covered with TNTC small microbial col- 1,000 CFU/ml was used to represent water samples. Due to the characteristics
onies. For 2 handpiece samples, no HPC TNTC results, and the 2 handpiece of the distribution of HPC measures,

www.agd.org General Dentistry January/February 2015 43

Office Design Evaluation of 3 dental unit waterline contamination testing methods

correlations were performed for all

samples and for source water samples Table 2. Correlation coefficients (95% confidence interval).
only (Table 2).
For the R2A with SimPlate for HPC, Pearson Spearman
the overall Pearson correlation coef-
Sample source R2A with SimPlate for HPC
ficient of 0.607 was moderate, while
the corresponding Spearman rank cor- All 0.607 (0.421, 0.744) 0.475(0.256, 0.648)
relation coefficient of 0.475 was lower. Handpiece 0.103 (-0.356, 0.522) 0.174 (-0.291, 0.572)
Correlations for each source type showed Air/water -0.068 (-0.486, 0.375) -0.268 (-0.627, 0.185)
similar results for source water samples
Source water 0.481 (0.062, 0.756) 0.521 (0.115, 0.778)
and poorer results for handpiece and air/
water samples. To depict the pairwise Millipore with SimPlate for HPC
association, a scatterplot was generated All 0.650 (0.474, 0.776) 0.598 (0.406, 0.740)
displaying the paired results for each
Source water 0.573 (0.188, 0.805) 0.624 (0.263, 0.832)
sample with symbols indicating the
source type (Chart). R2A with Millipore
For the HPC Sampler with SimPlate for All 0.871 (0.793, 0.921) 0.734 (0.592, 0.832)
HPC, the overall Pearson correlation coeffi- Source water 0.795 (0.554, 0.913) 0.797 (0.557, 0.914)
cient of 0.650 was significantly lower than
the overall Pearson correlation coefficient
of 0.871 for SimPlate for HPC with R2A.
Similarly, the corresponding Spearman cor-
relation for HPC Sampler with R2A was Chart. R2A with SimPlate for HPC method scatterplot, displaying legend markers
higher than that for SimPlate with R2A, indicating the range of the corresponding HPC Sampler value for each sample.
but the 2 Spearman correlations were not
significantly different. 1,000,000
When restricted to the source water
samples, the HPC Sampler with SimPlate
for HPC Pearson correlation coefficient 100,000
of 0.573 was significantly lower than
the HPC sampler with R2A coefficient
of 0.795, while the corresponding 10,000
Spearman correlations were not signifi-
R2A (CFU/ml)

cantly different.
Recovered microorganisms
As seen in Table 3, 16 genera of bacteria HPC sampler
were recovered. The most commonly 100 (CFU/ml)
occurring genus was Sphingomonas, >500
and only 2 speciesCupriavidus metal- 100-500
lidurans and Sphingomonas parapauci- 10 50-99
mobiliswere found on all 3 culture 1-49
media. Micrococcus luteus was the only
gram-positive species found. All other 0 0 10 20 30 40 50 60 70 80
recovered bacteria were gram-negative. SimPlate for HPC (MPN/ml)
Note that 2 handpiece samples for which no CFUs were detected by HPC Sampler were excluded. All samples with
Discussion R2A >1500 CFU/ml had HPC Sampler values >500 CFU/ml, while only 1 sample with R2A <1500 CFU/ml had an
This article describes an evaluation HPC Sampler value >500 CFU/ml.
of 3 currently available methods for
monitoring HPC bacteria in DUWLs.
The SimPlate for HPC (Method 9215E)
recovered the lowest numbers of micro- sample and no single method will recover Statistical analysis showed moderate
organisms and the highest readings were all genera.19 The overall results are not correlations between Method 9215E
found on spread plate R2A (Method altogether unexpected, since the media and the other 2 methods, while Method
9215C), although it must be noted that composition and incubation parameters 9215C and HPC Samplers had high cor-
all HPC methods enumerate only a were specifically designed to recover dif- relations. Correlations based on source
fraction of microorganisms in any water ferent microbial populations. tap water samples involved fewer arbitrary

44 January/February 2015 General Dentistry www.agd.org

recovered organisms represents a mere
Table 3. Bacteria recovered from DUWL samples. snapshot of the total bacterial popula-
tion. Not surprisingly, due to the limited
Acidovorax sp.a Methylobacterium radiotolerans Sphingomonas sanguinis number of microorganisms isolated on
Acidovoraxcitrulli Methylobacterium rhodesianum Sphingomonas trueperi SimPlate for HPC, only 2 bacterial spe-
Acidovoraxtemperans Methylobacterium thiocyanatum Sphingomonas yunnanensis cies were identified. However, it must also
be noted that this method is not designed
Afipia sp. Micrococcus luteus Sphingopyxis alaskensis
for recovering particular organisms, as
Blastomonas natatoria Novosphingobium stygium Sphingopyxis chilensis stated in the Standard Methods.11
Bradyrhizobium sp. Pseudomonas koreen c Xenophilus aerolatus One gram-positive organism was identi-
Bradyrhizobium yuanmingens Pseudomonas libane c Xulophilus ampelinus fied on R2A: M. luteus, which is ubiqui-
Caulobacter segnis Ralstonia sp. a
tously found in soil, dust, air, and water.
Grown on R2A and Millipore
Cases of infective endocarditis due to M.
Cupriavidus basilensis Sphingobium sp. HPC Samplers
luteus have been reported in the literature.23
Cupriavidus metallidurans b Sphingobium amiense Grown on all 3 media
All other microorganisms were gram-
Methylobacterium extorquens Sphingomonas sp. Grown on Millipore HPC negative, which are known to have lipo-
Samplers only
Methylobacterium oryzae Sphingomonas adhaesiva polysaccharide molecules (endotoxins) in
No symbol: grown on R2A
Methylobacterium populi Sphingomonas parapaucimobilis b their cell wall that can trigger inflammatory
agar only
responses in humans. Several studies have
reported a significant association between
the presence and severity of asthma and
approximation values, resulting in a The inclusion of SimPlate for HPC a raised concentration of airborne gram-
decrease in Pearson correlations and an (Method 9215E) in the list of the negative bacteria in the indoor environ-
increase in Spearman correlations. Standard Methods endorses its use for ment.24 A significant correlation between
Unlike the other 2 laboratory methods, analysis of drinking water and source water endotoxin levels and high bacterial load in
serial dilutions of samples were not done sampes.11 It is recommended as an alterna- DUWLs has also been reported.25
prior to culturing on HPC Samplers due tive to the pour plate method (9215A), Two species of Pseudomonas isolated
to its purposeful design as an in-office, which uses high nutrient plate count agar on the HPC Samplers in this study have
chairside monitoring device. As stated to test for general EPA compliance moni- previously been recovered from DUWLs
earlier, previous studies have shown that toring; studies have demonstrated good and reported as the causative organisms
HPC Samplers underestimate bacterial correlation between the 2 methods.11,13,16 of postoperative dental infections and
counts when compared to the spread Both 9215A and 9215E methods require respiratory infections in immunocompro-
plate R2A agar method, and some have incubation periods of 48 hours at mam- mised patients.26,27
attributed this to its failure to grow malian physiological incubation tem- Only 2 bacterial types were common
certain phenotypes.20,21 The results of perature (35C), favoring the growth of to the 3 culture methods tested in the
this study concur with those findings. bacteria from human and animal wastes.22 study: Cupriavidus metallidurans and
However, this study also confirms the However, a previous study showed that Sphingomonas parapaucimobilis; these
high sensitivity of the HPC Samplers, Method 9215E showed lower microbial were the only bacterial species recov-
as microbial counts on the majority of counts when compared to the membrane ered on SimPlate for HPC, verifying
the paddles were TNTC and 5 different filter method (9215D), which utilizes low the limitations of this culture method
species of bacteria were detected. For nutrient R2A agar and incubation periods for detection of common water organ-
the 2 handpiece samples in which zero of 48 hours at 22C-28C.13 Lower incu- isms. C. metallidurans belongs to the
bacterial growth was recovered on HPC bation temperature (22C-28C), along -Proteobacteria group, known to be
Samplers, a plausible explanation may be with a longer incubation time favor the the predominant survivor in chlorinated
variation among kits, as it was unlikely growth of indigenous aquatic bacteria.22 water distribution systems.28,29
due to laboratory error (based on the SimPlate for HPC was a method designed The most frequently isolated genera
reliability of the standard laboratory for higher incubation temperatures, and in this study were Sphingomonas, also
methods employed). the results of this study add to the body of closely aligned with the phylogenic
The spread plate R2A agar (Method existing scientific evidence showing that group -Proteobacteria, and previously
9215C) has long been considered the gold Method 9215E underestimates microbial found in DUWL samples and ultrapure
standard for application to DUWL moni- contamination at 22C-28C.13,14,16 water.2,15,29,30 A review of nosocomial
toring with the advantage of producing a infections concluded that the species S.
true assessment of HPC contamination Significance of microorganisms parapaucimobilis has emerged in recent
levels. In this study, accurate counts were recovered years as an opportunistic pathogen as it
obtained using serial dilutions, and 14 Culture plates that were selected for has been associated with many cases of
different genera of bacteria were detected organism identification were based on bacteremia and other systemic infections
on R2A plates. recovered colony size, so the number of in immunocompromised patients.31

www.agd.org General Dentistry January/February 2015 45

Office Design Evaluation of 3 dental unit waterline contamination testing methods

Conclusion & Craniofacial Research of the National Detection of Heterotrophic Plate Count Bacteria in
The variety of potentially pathogenic Institutes of Health (NIH) under Award Ozone-Treated Drinking Water. International Ozone
Association Conference, October 1998. Available at:
organisms recovered from waterlines in this Number R01 DE018707-05. The content
study reinforces the need for monitoring is solely the responsibility of the authors reg-article8B.pdf. Accessed November 10, 2014.
DUWL quality to ensure the delivery of and does not necessarily represent the offi- 14. Porteous N, Sun Y, Dang S, Schoolfield J. A comparison
high quality dental patient treatment water. cial views of the NIH. Drs. Porteous and of 2 laboratory methods to test dental unit waterline
The study confirmed that Millipore Sun are co-principal investigators and Mr. water quality. Diag Microbiol Infect Dis. 2013;77(3):
HPC Samplers are useful for routine Schoolfield is a co-investigator. 15. Porteous N, Luo J, Hererra M, Schoolfield J, Sun Y.
in-office, chairside DUWL quality moni- The authors wish to thank Monica Growth and identification of bacteria in N-halamine
toring when the benchmark CDC recom- Herrera, MD, research associate, dental unit waterline tubing using an ultrapure water
mended level of <500 CFU/ml is used. The Department of Microbiology, UTHSCSA, source. Int J Microbiol. 2011;767314.
16. Jackson RW, Osborne K, Barnes G, et al. Multiregional
study also confirmed that the spread plate for her work on molecular analysis of
evaluation of the SimPlate heterotrophic plate count
R2A agar method (9215C) provides the organisms at the time of this study. method compared to the standard plate count agar
most accurate analysis of DUWL quality. pour plate method in water. Appl Environ Microbiol.
The laboratory SimPlate for HPC Disclaimer 2000;66(1):453-454.
method (9215E) failed to detect micro- The authors have no financial, economic, 17. Frank JA, Reich CI, Sharma S, Weisbaum JS, Wilson BA,
Olsen GJ. Critical evaluation of two primers commonly
bial contamination of DUWL samples commercial, and/or professional interests used for amplification of bacterial 16S rRNA genes.
to the same extent as Method 9215C, related to topics presented in this article. Appl Environ Microbiol. 2008;74(8):2461-2470.
most likely due to the specific design of 18. National Center for Biotechnology Information. Blast:
SimPlate for HPC for the recovery of References Basic Local Alignment Search Tool. Available at: http://
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Acknowledgments 13. Stillings A, Herzig D, Roll B. Comparative Assessment ination of sterile water used in Japanese hospitals.
Research reported in this article was sup- of the Newly-Developed SimplateTM Method With the J Hosp Infect. 1998;38(1):61-65.
ported by the National Institute of Dental Existing EPA-Approved Pour Plate Method for the

46 January/February 2015 General Dentistry www.agd.org

31. Ryan MP, Adley CC. Sphingomonas paucimobilis: a
persistent Gram-negative nosocomial infectious or-
ganism. J Hosp Infect. 2010;75(3):153-157.

Becton, Dickson & Company, Franklin Lakes, NJ
888.237.2862, www.bd.com
EMD Millipore, Billerica MA
781.533.6000, www.emdmillipore.com
IDEXX Laboratories, Inc., Westbrook, ME
800.548.6733, www.idexx.com
MJ Research, Inc., St. Bruno, Quebec, Canada
450.461.6245, mj-research.com
Promega Corporation, Madison, WI
608.274.4330, www.promega.com
Qiagen Sciences, Inc., Germantown, MD
240.686.7700, www.qiagen.com
StataCorp LP, College Station, TX
800.782.8272, www.stata.com
Thermo Fisher Scientific, Inc., Waltham, MA
800.678.5599, www.thermofisher.com

www.agd.org General Dentistry January/February 2015 47

Anesthesia and Pain Control

Local anesthetic calculations: avoiding trouble

with pediatric patients
Mana Saraghi, DMD n Paul A. Moore, DMD, PhD, MPH n Elliot V. Hersh, DMD, MS, PhD

Local anesthetic systemic toxicity (LAST) is a rare but avoidable will also be reviewed, as well as the appropriate treatment procedures
consequence of local anesthetic overdose. This article will review for a local anesthetic overdose.
the mechanism of action of local anesthetic toxicity and the signs Received: July 17, 2013
and symptoms of LAST. Due to physiologic and anatomic differences Revised: October 30, 2013
between children and adults, LAST occurs more frequently in Accepted: February 10, 2014
children; particularly when 3% mepivacaine is administered. The
calculation of the maximum recommended dose based on mg/lb body Key words: local anesthetic toxicity, systemic toxicity, maximum
weight, Clarks rule, and the Rule of 25 in order to prevent LAST recommended dose, Clarks rule, lidocaine, mepivacaine

pproximately 1 million cartridges shorter duration of soft tissue anesthesia neurons are blocked to such a profound
of local anesthetic are used each and prevent postoperative self-inflicted level that CNS and respiratory depression,
day in the United States.1 Local lip and cheek trauma.10,11 unconsciousness, and respiratory arrest
anesthetic systemic toxicity (LAST) is can occur. At even higher plasma concen-
dose-related and although rare, occurs Local anesthesia: mechanism trations, systemic vasodilation results in
more frequently in small children than of action and toxicity significant hypotension and cardiovascular
adults. LAST occurs more frequently Local anesthetics are essential for intra- depression. Local anesthetics also block
when the patient is administered con- operative dental analgesia; they work by sodium channels in the myocardium,
comitant central nervous system (CNS) blocking sodium channels in neurons resulting in bradycardia. Bradycardia is a
depressants, such as opioid/sedative so that pain signals from the periphery major cause of concern when bupivacaine
medications.2-9 cannot be transmitted to the CNS. LAST is used, as it can induce a use-dependent
The following case serves as a reminder is mediated by the same mechanism when blockade at normal heart rates.12,13 Because
to proceed cautiously when administering the maximum recommended dose (MRD) of its extended duration of action, bupiva-
routine local anesthetic, always keeping is exceeded. This dose-related toxicity caine is rarely indicated for children. The
weight-based dosing in mind. A 50-lb, is especially important as the sodium sequelae of depressed cardiac conduction
8-year-old girl with a history of extensive channels in the cardiovascular system are include atrioventricular block, ventricular
caries and dental fearbut otherwise blocked along with those in the CNS.12,13 arrhythmias, cardiac arrest, and ultimately,
no medical problems, diseases, or aller- Regardless of which local anesthetic death. A local anesthetic overdose can
giespresented for multiple extractions. is administered, the same progression of result in significant morbidity and mor-
For the initial sedation, the patient effects on the CNS and cardiovascular tality unless life support interventions
received oral promethazine, as well as system occur with increasing plasma levels can be initiated following standard basic
nitrous oxide-oxygen inhalational seda- of local anesthetic.12,13 Symptoms of early and advanced cardiac life support guide-
tion. A half hour later, the sedation was toxicity consist of numbness and tingling lines.12,13 Concomitant opioid sedative
supplemented with an intramuscular dose of the mouth and lips, metallic taste, administration will augment respiratory
of meperidine. After another half hour diplopia, tinnitus, nausea, dizziness, and depression and decrease the seizure thresh-
had elapsed, the child received injections drowsiness.12,13 These reactions are usually old of local anesthetics.3,5,6,12-15
of 6 cartridges of 3% mepivacaine plain self-limiting and often are due to a mild
(without a vasoconstrictor). Seizures and overdose or an inadvertent intravascular LAST: a greater tendency in
respiratory distress followed 5 minutes injection. As the plasma concentrations pediatric patients
later. Resuscitation efforts followed, but of local anesthetic increase, the inhibitory There are some important physiological
were unsuccessful, and the patient died of neurons in the CNS are blocked, leaving differences between children and adults
anoxic encephalopathy.5 excitatory neurons unopposed. Clinically, that play a role in the greater tendency
The most common cause of morbidity this manifests as tremors and tonic-clonic for LAST to be reported in the pediatric
and mortality due to LAST is respira- (also known as grand mal) seizures. CNS population. Seated in the dental chair, a
tory depression or apnea.10 LAST occurs arousal may stimulate the cardiovascular child may appear deceptively large. The
more frequently in children when 3% system, possibly resulting in hyperten- reason that the child appears to be larger
mepivacaine is administered, with the sion, tachycardia, and increased cardiac is that in the dental chairwith a bib,
false presumption that a local anesthetic output.12,13 At higher plasma levels of local napkin, or blanketonly the childs dis-
without a vasoconstrictor will have a anesthetic, both excitatory and inhibitory proportionately large head is visible.4 This

48 January/February 2015 General Dentistry www.agd.org

6 6 3 than a local anesthetic with a vasoconstric-
1.00 Head size 0.75 tor, such as 2% lidocaine with 1:100,000
epinephrine.11,12 Mepivacaine does offer
5 shorter pulpal anesthesia (20-40 minutes)
as compared to lidocaine with epinephrine
(60-90 minutes), but soft tissue anesthe-
4 sia is similar between the 2 anesthetics:
120-180 minutes and 120-240 minutes
for mepivacaine plain and lidocaine with

3 epinephrine, respectively.11 Hersh et al

found that the onset of soft tissue numb-
ness, peak numbness effects, and numb-
2 ness duration were quite similar when
comparing 3% mepivacaine plain and 2%
lidocaine with epinephrine.11
1 Using 3% mepivacaine plain instead of
2% lidocaine with epinephrine does not
provide any benefit with respect to the
prevention of postoperative lip/mouth
trauma, but the higher concentration of
Figure. Diagram comparing the relative proportions in height vs head size between a 3.5-year-old child local anesthetic in the 3% mepivacaine
and an adult. solution makes it easier to reach or exceed
the MRD.3,4,11,16,17 A brief review of local
anesthetic calculations illustrates this
point: a 2% formulation of a drug means
Table 1. Local anesthetic calculation: amount of local anesthetic in cartridges. that there is 2 grams of drug in 100 ml
volume. If 2 grams are in 100 ml, then
2% anesthetic = 2 grams/100 ml in volume = 2000 mg/100 ml = 20 mg/ml 2000 mg are in 100 ml, which means
3% anesthetic = 3 grams/100 ml in volume = 3000 mg/100 ml = 30 mg/ml that 20 mg are in each ml. Since a dental
cartridge contains approximately 1.8 ml
1 cartridge of local anesthetic is 1.8 ml in volume (exception: 4% articaine has 1.7 ml)
volume, then there are 36 mg drug per
Therefore cartridge (Table 1). Similarly, when a drug
2% cartridge: 20 mg/ml x 1.8 ml/cartridge = 36 mg/cartridge is in a 3% formulation, there are 30 mg
3% cartridge: 30 mg/ml x 1.8 ml/cartridge = 54 mg/cartridge per ml, thus there are 54 mg per 1.8 ml
dental cartridge. Therefore, a cartridge
of 3% mepivacaine contains 50% more
local anesthetic than a cartridge of 2%
makes it more critical to determine the tongues, tonsils, and adenoids than adults. lidocaine; thus it would take less volume
maximum dose and number of cartridges These anatomic differencescoupled with (or fewer cartridges) of the more concen-
based on the childs actual weight. the heightened susceptibility to CNS and trated drug (3% mepivacaine) to reach its
The following example of a 3.5-year-old respiratory depressantsrender children respective MRD.11
child illustrates the point that children more vulnerable to losing airway patency.4
often appear deceptively large and how Preventing local anesthetic
this may prompt the dentist to overes- Local anesthetic selection: toxicity: calculating appropriate
timate the childs size based solely on misconceptions about prolonged weight-based dose
appearances.4 Because the head develops soft tissue numbness Respecting weight-based dosing limits
quickly during early childhood, children When treating children, it is important is essential, as previous cases of LAST
have disproportionately large heads; at the to inform parents or caregivers that close have resulted in significant morbidity
age of 3.5, a childs head is nearly 75% postoperative supervision is needed to and mortality when dosing limits were
of the size of his/her adult counterpart.4,5 prevent the child from biting their lips, exceeded.3,4,12,16,17 In a 1983 retrospec-
However, the same child has only 50% cheeks, and tongue. While the soft tissues tive study, pediatric dental patients that
of the height, 25% of the blood volume, are still numb, significant trauma from received local anesthesia and opioid
and 20% of the weight compared to lip and cheek biting can occur. There sedationeither local alone or local plus
his/her adult counterpart (Figure).4 The is a misconception that using a local narcotic doseexceeded their combined
childs airway is also different, with nar- anesthetic without a vasoconstrictor, such MRDs by a factor of 3; the result was
rower nasal passages, larynx, and trachea. as mepivacaine 3% plain, will provide a either permanent brain damage or death.6
Meanwhile, children have relatively larger shorter duration of soft tissue anesthesia In a 1992 survey of local anesthetic use

www.agd.org General Dentistry January/February 2015 49

Anesthesia and Pain Control Local anesthetic calculations: avoiding trouble with pediatric patients

Table 3. Local anesthetic calculation for a 50 lb child based

on Clarks rule.

1. Calculate the MRD from each drug for a 50 lb child.

Patients weight/150 lb adult x adult MRD = patients MRD
Table 2. Local anesthetic calculations for a 50 lb child
based on mg/lb. Adult MRD:
2% lidocaine with 1:100,000 epinephrine: 500 mg
1. Calculate the MRD for each drug for a 50 lb child. 3% mepivacaine plain: 400 mg
2% lidocaine with 1:100,000 epinephrine = 3.2 mg/lb x 50 lb = 160 mg Lidocaine with 1:100,000 epinephrine: 50/150 x 500 mg = 166 mg
3% mepivacaine plain = 2.6 mg/lb x 50 lb = 130 mg Mepivacaine plain: 50/150 x 400 mg = 133 mg
2. Determine the maximum number of cartridges based on the MRD. 2. Determine the maximum number of cartridges based on the MRD.
2% lidocaine with 1:100,000 epinephrine: 160 mg 36 mg/cartridge = 2% lidocaine with 1:100,000 epinephrine: 166 mg 36 mg/cartridge =
4.4a cartridges 4.62a cartridges
3% mepivacaine plain: 130 mg 54 mg/cartridge = 2.4b cartridges 3% mepivacaine plain: 133 mg 54 mg/cartridge = 2.46b cartridges
In clinical terms, 4.5 cartridges.
In clinical terms, 4.5 cartridges.

In clinical terms, 2.5 cartridges.

In clinical terms, 2.5 cartridges.

Abbreviation: MRD, maximum recommended dose. Abbreviation: MRD, maximum recommended dose.

among Florida dentists who routinely

treated pediatric patients, a majority of Table 4. Local anesthetic calculation for a 50 lb child based on the Rule of 25.
the respondents used an absolute number
of cartridges without accounting for the 1 cartridge/25 lb weight
childs age or weight.2 A clinician can 1 cartridge/25 lb weight x 50 lb child = 2 cartridges of any local anesthetic or combination
prevent a local anesthetic overdose by of local anesthetics for a 50 lb patient.
calculating the MRD and the maximum
number of cartridges by weight to appro-
priately administer local anesthetic in chil-
dren; this dose per weight is contingent on Clarks rule is another weight-based administered, the patient cannot receive
calculations of a weight that is consistent method for calculating the MRD.12 any other local anesthetics, including topi-
with normal growth and development and According to Clarks rule, the dose of local cal applications.22
normal lean body mass.18 anesthetic should be reduced by the ratio Moore & Hersh describe a simplified
Based on these calculations, the MRD of of the childs weight to an adult weight alternative for calculating safe maximum
2% lidocaine with 1:100,000 epinephrine is of 150 lb.5 Thus, if a child weighs 50 lb, doses using a conservative guideline.12
3.2 mg/lb; for a patient 150 lbs, the adult then he/she is 33% of the established adult Described as the Rule of 25, this alterna-
MRD is 500 mg. The MRD of 3% mepi- weight. Therefore, the childs MRD for any tive calculation can be applied to all US
vacaine plain is 2.6 mg/lb; for a patient local would be 33% of the 150 lb adult dental local anesthetic formulations for
>150 lbs, the adult MRD is 400 mg.18,19 MRD for a given local anesthetic. As stated healthy patients. The Rule of 25 states
Table 2 illustrates the calculation needed to before, the MRD for 2% lidocaine with that 1 cartridge of any formulation mar-
derive the absolute maximum number of epinephrine for a 150 lb adult is 500 mg, keted in the US may be used per 25 lb of
cartridges of 2% lidocaine with epineph- and the MRD for 3% mepivacaine plain is weight. Therefore, 1 cartridge for a 25 lb
rine and 3% mepivacaine plain that can 400 mg. Therefore, the MRD for a 50 lb patient, 2 cartridges for a 50 lb patient,
be given to a child weighing 50 lb. This patient is 33% of the adult MRD, which 3 cartridges for a 75 lb patient, up to a
number is approximately 33% of the adult calculates as 166 mg of 2% lidocaine with maximum of 6 cartridges for patients
maximum number of cartridges. A vaso- epinephrine (approximately 4.5 cartridges) 150 lbs (Table 4).12 The end result of the
constrictor (such as epinephrine) reduces or 133 mg of 3% mepivacaine plain Rule of 25 is a lower number of cartridges
the systemic absorption of a local anes- (approximately 2.5 cartridges.) (Table 3).12 administered to the child in comparison to
thetic, and several pharmacokinetic studies It is important to note that the effects other weight-based calculations (Table 5).
have demonstrated that the average peak of all local anesthetics, including toxic- Since the vast majority of local anesthetic
blood levels following maxillary infiltration ity, are mediated at the sodium channel morbidity and mortality reports involve
injections were 3 times higher with 3% in a dose-dependent fashion. The effects children 8 years of age, the Rule of 25
mepivacaine plain in comparison to 2% of various local anesthetics are additive. may be more appropriate in this popula-
lidocaine with epinephrine.12,20,21 Once the MRD for 1 local anesthetic is tion than in calculations used for adults.12

50 January/February 2015 General Dentistry www.agd.org

Table 5. Summary of dosing calculations in a 50 lb child.

Adult MRD Weight-based calculations Clarks rule Rule of 25

MRD 2% lidocaine with 1:100,000 epinephrine 500 mg 160 mg 166 mg N/A
Maximum cartridges with 2% lidocaine with 1:100,000 epinephrine 13.5 4.5 4.5 2.0
MRD 3% mepivacaine plain 400 mg 130 mg 133 mg N/A
Maximum cartridges with 3% mepivacaine plain 7.5 2.5 2.5 2.0
Abbreviation: MRD, maximum recommended dose.

When treating small children, it is advis- or absence of lip numbness.2,24 A pos- patient has no pulse, apply chest compres-
able to determine the maximum number sible alternative to mandibular blocks for sions so that oxygenated blood can reach
of local anesthetic cartridges needed for procedures in young children is to utilize the brain and heart.4
that appointment. Keep only this amount a buccal mandibular infiltration tech- Basic life support skills are essential until
of cartridges on the tray, and do not dis- nique with 4% articaine plus 1:100,000 the patient can be transferred to a hospital.4
card any used cartridges until the appoint- epinephrine, which appears to produce Someone on the dental team should call for
ment is over. This will precisely track the a high success rate of mandibular pulpal medical assistance; another should manage
number of cartridges administered. anesthesia.25,26 If the injections fail and seizures and respiratory depression.5 The
Aspiration and slow injection will allow the predetermined maximum amount of patient should be positioned on the left
for recognition of inadvertent intravascular local anesthetic has been administered, it lateral side to facilitate suction, which
injection before the entire cartridge is is recommended to not attempt to supple- should be applied to the pharynx to remove
injected into a vessel.22 Profound anesthesia ment with more local anesthetic.2,22 The any saliva and foreign bodies, such as dis-
can often be achieved in children with less best approach would be to reschedule the lodged stainless steel crowns, rubber dam
than a full cartridge of anesthetic. Injecting treatment appointment. clamps, or pieces of gauze. An oxygen tank
slowlyapproximately 30-60 seconds per should be available to provide supplemental
cartridgewill minimize discomfort and Local anesthetic systemic toxicity: oxygen either by nasal cannula or nasal
allow retention of the local anesthetic at the warning signs and management hood for a patient who is able to breathe,
target site rather than being flushed farther When providing emergency care, a dentist or by a bag-valve-mask if there is significant
away.22 Rather than giving the entire prede- needs to immediately recognize signs and respiratory depression. According to Moore,
termined amount of local anesthetic at the symptoms of LAST (such as tremors or positive pressure oxygen ventilation is
beginning of a procedure, it is preferable to convulsions). The dental procedure should the most important element in managing
reserve 25% of the predetermined amount be stopped as soon as any neurological, local anesthetic overdose.5 Although rarely
of local anesthetic in case an injection fails respiratory, or cardiovascular signs or required, advanced management of seizures
or if supplemental anesthesia is needed symptoms of local anesthetic overdose may include the intravenous administration
later.5 With a reported 15%-20% failure become apparent.5 The dentist should of a benzodiazepine such as diazepam or
rate for inferior alveolar nerve blocks, it is monitor vital signs (such as pulse and midazolam.5,12 Following any convulsion,
critical to use the proper technique in order blood pressure), watch for coloration if serious respiratory depression can occur,
to reduce the need for supplemental injec- pulse oximetry is not available, and assess so it is critical to continue to monitor the
tions.2,22 On average, a childs mandibular breathing by looking for chest rise and patient and support the airway.5,12
foramen is near the occlusal plane; by movement of air. If necessary, initiate basic
adulthood, the mandibular foramen moves life support in the form of chest compres- Conclusions
posteriorly and is approximately 7 mm sions and positive pressure ventilation with While local anesthetics possess a wide
above the occlusal plane.2,23 Therefore, if oxygen until medical assistance arrives.5 In margin of safety in adult patients, MRDs
the inferior alveolar nerve block is missed the event of an emergency, any delay may of these drugs can be easily exceeded in
in the treatment of a child but the MRD result in the patients reserves of oxygen pediatric dental patients. The preven-
has not been exceeded, one can attempt to being consumed leading to poor oxygen- tion of LAST in young children is best
inject vertically higher.2 While lip numb- ation of key organs such as the brain and achieved by strictly adhering to weight-
ness is usually considered a sign of an heart, and irreversible damage may occur. based MRD dosing guidelines. The more
adequate inferior alveolar nerve block, the Three key interventions are necessary: conservative Rule of 25, which states that
lack of gingival response to stimulation is 1) clear the airway of any obstructions no more than 1 cartridge of local anes-
considered to be a more rapid and reliable including the tongue or foreign bodies thetic should be given for each 25 lb of
indicator of anesthesia in young children such as gauze; 2) provide supplemental patient body weight, will impart an added
than asking the patient about the presence positive pressure oxygen; and 3) if the safety layer in children 8 years of age.

www.agd.org General Dentistry January/February 2015 51

Anesthesia and Pain Control Local anesthetic calculations: avoiding trouble with pediatric patients

Author information narcotic, local anesthetic, and antiemetic drug inter- 19. Novocol Pharmaceutical of Canada, Inc. Isocaine
Dr. Saraghi is in private practice in New action. J Am Dent Assoc. 1983;107(2):239-245. (Mepivacaine 3% Injection) [package insert]. Available
7. McAuliffe MS, Hartshorn EA. Anesthetic drug interac- at: http://www.novocol.com/our-products/injectable-
York, New York. Dr. Moore is a professor
tions. Quarterly update. CRNA. 1998;9(4):172-176. anesthetics/isocaine/. Accessed October 8, 2014.
of Dental Anesthesiology, Pharmacology, 8. Kohli K, Ngan P, Crout R, Linscott CC. A survey of local 20. Goebel WM, Allen G, Randall F. The effect of commer-
and Public Health, University of Pittsburg and topical anesthesia use by pediatric dentists in the cial vasoconstrictor preparations on the circulating ve-
School of Dental Medicine, Philadelphia. United States. Pediatr Dent. 2001;23(3):265-269. nous serum level of mepivacaine and lidocaine. J Oral
Dr. Hersh is a professor of Pharmacology, 9. Zinman EJ. Letter: toxicity and mepivacaine. J Am Dent Med. 1980;35(4):91-96.
Assoc. 92(5):858. 21. Goebel WM, Allen G, Randall F. Comparative circulato-
Department of Oral and Maxillofacial 10. Zinman EJ. More on mepivacaine. J Calif Dent Assoc. ry serum levels of 2 per cent mepivacaine and 2 per
Surgery and Pharmacology, and the direc- 1976;4(4):50. cent lignocaine. Br Dent J. 1980;148(11-12):261-264.
tor of the Division of Pharmacology, 11. Hersh EV, Hermann DG, Lamp CJ, Johnson PD, 22. Meechan J. How to avoid local anaesthetic toxicity. Br
University of Pennsylvania School of MacAfee KA. Assessing the duration of mandibular Dent J. 1998;184(7):334-335.
soft tissue anesthesia. J Am Dent Assoc. 1995;126(11): 23. Berberich G, Reader A, Drum M, Nusstein J, Beck M. A
Dental Medicine, Philadelphia.
1531-1536. prospective, randomized, double-blind comparison of
12. Moore PA, Hersh EV. Local anesthetics: pharmacology the anesthetic efficacy of two percent lidocaine with
References and toxicity. Dent Clin North Am. 2010;54(4):587-599. 1:100,000 and 1:50,000 epinephrine and three per-
1. Personal communication with Paul Mondock, senior 13. Fonseca RJ. Oral and Maxillofacial Surgery. Vol 1. 1st cent mepivacaine in the intraoral, infraorbital nerve
vice president, Sales and Marketing, Septodont, Inc. ed. Philadelphia: W.B. Saunders Company; 2000. block. J Endod. 2009;35(11):1498-1504.
June 7, 2013. 14. Malamed SF. Morbidity, mortality, and local anesthe- 24. Ellis RK, Berg JH, Raj PP. Subjective signs of efficacious
2. Cheatham BD, Primosch RE, Courts FJ. A survey of lo- sia. Prim Dent Care. 1999;6(1):11-15. inferior alveolar nerve block in children. ASDC J Dent
cal anesthetic usage in pediatric patients by Florida 15. Meechan J. How to avoid local toxicity. Br Dent J. Child. 1990;57(5):361-365.
dentists. ASDC J Dent Child. 1992;59(6):401-407. 1998;184(7):334-335. 25. Robertson D, Nusstein J, Reader A, Beck M, McCart-
3. Hersh EV, Helpin ML, Evans OB. Local anesthetic mor- 16. Berquist HC. The danger of mepivacaine 3% toxicity in ney M. The anesthetic efficacy of articaine in buccal
tality: report of case. ASDC J Dent Child. 1991;58(6): children. Can Dent Assoc J. 1975;3:13. infiltration of mandibular posterior teeth. J Am Dent
489-491. 17. Zinman EJ. Letter: Toxicity and mepivacaine. J Am Dent Assoc. 2007;138(8):1104-1112.
4. Tarsitano JJ. Children, drugs, and local anesthesia. Assoc. 1976;92(5):858. 26. Haase A, Reader A, Nusstein J, Beck M, Drum M.
J Am Dent Assoc. 1965;70:1153-1158. 18. Novocol Pharmaceutical of Canada, Inc. Octocaine Comparing anesthetic efficacy of articaine versus li-
5. Moore PA. Preventing local anesthesia toxicity. J Am (Lidocaine HCl 2% and Epinephrine 1:100,000 Injec- docaine as a supplemental buccal infiltration of the
Dent Assoc. 1992;123(9):60-64. tion) [package insert]. Available at: http://staging.test. mandibular first molar after an inferior alveolar nerve
6. Goodson JM, Moore PA. Life-threatening reactions novocol.com/docs/product-insert/Octocaine.pdf. block. J Am Dent Assoc. 2008;139(9):1228-1235.
after pedodontic sedation: an assessment of Accessed October 8, 2014.


52 January/February 2015 General Dentistry www.agd.org


Exercise No. 362 Anesthesia and Pain Control Subject Code 132
The 15 questions for this exercise are based on Reading the article and successfully completing this exercise will enable you to:
the article, Local anesthetic calculations: avoiding describe the signs and symptoms of local anesthesia systemic toxicity (LAST);
trouble with pediatric patients, on pages 48-52. understand the mechanism of action of local anesthetic toxicity (LAO); and
This exercise was developed by Riki Gottlieb, DMD, learn how to calculate the maximum recommended dose (MRD) to prevent local
FAGD, in association with the General Dentistry Self- anesthesia toxicity.
Instruction committee.

1. LAST can be described using all of the 7. Use of ______ makes it easier to reach mediated at the sodium channel in a
following terms except one. Which is or exceed the MRD. dose-dependent fashion.
the exception? A. 2% lidocaine, 1:100,000 epinephrine A. Both statements are true.
A. rare consequence of LAO B. 3% mepivacaine, no epinephrine B. The first statement is true;
B. avoidable consequence of LAO C. 4% articaine,1:100,000 epinephrine the second is false.
C. allergic reaction to LAO D. 5% bupivacaine, no epinephrine C. The first statement is false;
D. occurs more frequently in children the second is true.
8. A 4% formulation of a drug means that D. Both statements are false.
2. According to the article, the there are _____ mg/ml, and in a 1.8 ml
most common cause of morbidity dental cartridge there are _____ mg/ 13. All of the following are correct about
and mortality due to LAST is cartridge. the Rule of 25 except one. Which is the
_______________________. A. 30; 36 exception?
A. respiratory depression B. 30; 42 A. It can be applied to all US dental local
B. cardiovascular stimulation C. 40; 54 anesthetic formulations for healthy
C. central nervous system (CNS) excitation D. 40; 72 patients.
D. nerve damage B. The Rule of 25 states that 1 cartridge
9. The MRD of 3% mepivacaine is 2.6 mg/ of any formulation marketed in the US
3. Symptoms of early toxicity consist of all lb. What is the maximum number of may be used per 25 lb.
of the following CNS symptoms except cartridges one can give a 45 lb child? C. Using the Rule of 25 may be more
one. Which is the exception? A. 1 appropriate in children 8 years than
A. metallic taste B. 2 weight-based calculations.
B. tinnitus C. 3 D. The Rule of 25 indicates the use of
C. dry mouth D. 4 3 cartridges of local anesthetic for a
D. dizziness 50 lb child.
10. Clarks rule is another weight-based
4. Concomitant opioid sedative method for calculating the MRD. 14. To prevent local anesthetic overdose,
administration will _______ respiratory According to Clarks rule, the dose of all of the following should be followed
depression and ________ the seizure local anesthetic should be reduced by except one. Which is the exception?
threshold of local anesthetics. the ratio of the childs weight to an A. Determine the maximum amount of
A. reduce; increase adult weight of 200 lb. local anesthetic at the beginning of the
B. enhance; increase A. Both statements are true. appointment.
C. reduce; decrease B. The first statement is true; B. Keep all used local anesthetic cartridges
D. enhance; decrease the second is false. until the end of the appointment.
C. The first statement is false; C. Inject the local anesthetic quickly, at
5. All of the following are relatively larger the second is true. a rate of approximately 10-15 seconds
in children than adults except one. D. Both statements are false. per cartridge.
Which is the exception? D. Use aspiration technique to determine
A. tongue 11. Using Clarks rule, what would be a intravascular injection.
B. tonsil 60 lb childs MRD for the use of 2%
C. airway lidocaine with 1:100,000 epi? 15. All of the following actions are to be
D. adenoid A. 3.5 cartridges performed immediately in the event of
B. 4.5 cartridges local anesthetic overdose, except one.
6. A local anesthetic without a C. 5.5 cartridges Which is the exception?
vasoconstrictor offers ______ minutes of D. 6.5 cartridges A. stop dental procedure
pulpal anesthesia. B. administer nitrous oxide
A. 20-40 12. The effects of various local anesthetics C. position patient on left lateral side
B. 60-80 used in conjunction with each other D. begin basic life support and call 911
C. 100-120 are unrelated. The effects of all local
D. 140-160 anesthetics, including toxicity, are

Answer form is on the inside back cover. Answers for this exercise must be received by December 31, 2015.

www.agd.org General Dentistry January/February 2015 53

Forensic Dentistry

The role of the dentist in identifying missing

and unidentified persons
Amber D. Riley, RDH, MS

The longer a person is missing, the more profound the need for dental re- for cross-matching with unidentified person records created by medical
cords becomes. In 2013, there were >84,000 missing persons and >8,000 examiner and coroner departments across the United States and Canada.
unidentified persons registered in the National Crime Information Center Received: March 24, 2014
(NCIC) database. Tens of thousands of families are left without answers or Revised: July 24, 2014
closure, always maintaining hope that their relative will be located. Law en- Accepted: September 17, 2014
forcement needs the cooperation of organized dentistry to procure dental
records, translate their findings, and upload them into the NCIC database Key words: missing persons, unidentified persons, HIPAA, dental records

ny single eventbe it a natural for 2013, there were >84,000 missing informationsuch as height and weight,
disaster, terrorism act, or mass persons (MPs) and >8,000 unidentified eye and hair color, and where they were last
transit accidentthat produced persons (UPs) in the United States seenbut will also include information
thousands of fatalities and tens of thou- and Canada that year, leaving many that is not made available to the public
sands of missing persons would cause families without closure for their missing in order to assist in law enforcements
concerned citizens and outraged family loved ones.1 search and investigation. This information
members to descend upon Capitol Hill, In response to these daily numbers includes the names and addresses of the
demanding that law enforcement and the of MPs and UPs, the US has set very MPs dentist and medical doctor, as well as
government take immediate action to high standards for the identification of any referral information, such as orthodon-
answer questions and show what they are our nations deceased. The scientifically tic or endodontic specialists. This informa-
doing to bring justice to the victims and supported methods of human identifica- tion is used in order to retrieve the MPs
closure to the victims families. However, tion are fingerprints, dental records, and antemortem medical and dental records.
even in the absence of cataclysmic events, DNA.2,3 Each method is accurate and each When a person is reported as missing,
there are still people being reported requires comparison analysis. it is not automatically assumed by law
missing and unidentified bodies being When a person is reported missing, a enforcement that the MP is deceased;
found every day. The statistics are stag- series of actions takes place. The first is the gathering of medical and dental data
gering. According to the National Crime the filing of a missing person (MP) report. specific to the MP is a critical part of
Information Centers NCIC Missing This report is a detailed intake of the MPs any investigation.2,3 A dentist (or auxil-
Person and Unidentified Person Statistics information that will include not only basic iary) who has been specially trained as

Fig 1. An example of a National Crime Information Center $.M. report. Fig 2. Postmortem dental record creation.

54 January/February 2015 General Dentistry www.agd.org

Fig 3. Picture of a decedents hand showing unusable fingerprints due to decomposition in water. Fig 4. Facial photograph of a decedents head showing how despite
surrounding tissue decomposition, the dental evidence is preserved.

The reports are then reviewed by the immediately after death, and usable
originating agency for their actual friction ridges (fingerprints) may rapidly
relevance to the case. If dental records deteriorate if the body is outdoors and
need to be reviewed, it will be done by certainly if the body is in water for several
an FBI-trained dental coder, who will hours to a few days (Fig. 3 and 4).2,3 If
determine if the cross-match is valid the body (including the hands) has fourth
and therefore requires a follow-up by the or fifth degree burns, fingerprints will
originating agency. not be retrievable, and the recovery of
When a body is recovered and the usable DNA is highly compromised due
identity of the decedent is unknown, to heat-related denaturation of proteins in
a postmortem dental record will be the body.2,3 What will remain usable for
created as part of the autopsy (Fig. 2). identification in all of these scenarios are
This record will contain radiographs, the decedents teeth (Fig. 5).
photographs, and an odontogram. For a The role of the dentist in helping law
Fig 5. A decedents head with fourth degree UP, the data will be coded and uploaded enforcement identify MPs or UPs involves
postmortem burns, still showing the preserved into the NCIC system for constant cross- both recordkeeping and the retention of
dental evidence. referencing with all MP reports. It is records. The American Dental Association
from these UP files that the originating recommends full dental record retention
agencies investigating MPs get some of of active and inactive patients, as well as
their hits. There is a national repository keeping the record of a deceased patient
of radiographic and photographic images for 2 years beyond their death.4 However,
a dental coder by the Federal Bureau of that can be accessed by authorized per- this is only a recommendation. There are
Investigation (FBI) translates the dental sonnel for rapid record comparison when many states in the US and provinces in
data into the NCIC system in order to a strong hit from a $.M. report is received. Canada that have no minimum standard
cross-reference on a continual basis all Every dental professional understands set for dental record retention whatsoever
unidentified bodies found in the US and how incredibly resistant to destruction (although there are some exceptions for
Canada that have been entered into the the human dentition is. From a forensic the records of children and the disabled).
system.1 Possible matches are marked, and standpoint, human teeth can withstand Death investigations have been severely
daily reports of any hits are generated blunt force trauma; fires at profoundly compromised due to the destruction of
and remitted to the originating agen- high temperatures; natural decomposi- patients dental records. Loss of dental
cies (such as local police departments, tion; chemical erosions that destroy records can be caused by overstringent
county sheriffs, or highway patrol) that other tissues; and various environmental housekeeping in the dental officeespe-
initially filed the MP reports.1 These changes in climate, humidity, and expo- cially with inactive patientsor during
reports are called $.M. reports (Fig. 1). sure.2,3 Human skin begins to decompose changes in ownership of the practice when

www.agd.org General Dentistry January/February 2015 55

Forensic Dentistry The role of the dentist in identifying missing and unidentified persons

a new owner may purge old records. The

problem of dental record destruction has
become such a profound obstacle in the
endeavor to find MPs and identify UPs
that the American Society of Forensic
Odontology (ASFO) published an official
position paper on record retention directed
toward general dentistry practitioners.5
The guidelines in this paper state that if,
for good reason, a full record of a patient
cannot be retained, then the dentist should
retainat a minimumthe most recent
bitewing, full mouth, or panoramic X-rays
for patients who have been inactivated,
as well as a patient information form that
includes the patients date of birth and
social security or drivers license number.5
If a photo of the patient is available, the
dentist is advised to keep that, as well.5
If file space is at a premium, as it is in
many dental offices even though practices
are moving toward fully digitized record
keeping, the aforementioned files can be
scanned and saved onto an external drive
to free up needed physical space. Taking
this step not only maintains a record in
case it is ever requested by law enforce-
ment, it also allows the general dentist to
organize and prioritize records for day-to-
day practice.
To address questions that a dentist may Fig 6. Sample record request from the Department of the Medical Examiner, San Diego, CA.
have about patient privacy and the legal
ramifications for releasing a dental record
without a patients permission, the Health
Insurance Portability and Accountability
Act (HIPAA) has a specific provision for in their patients record and give the The author of this article serves as a
this very scenario. This is stated in 45 CFR entire original record to the investigator. forensic dental autopsy technician. As
Section 164.512(g)(1), which reads in part: Making a duplicate of the entire record is an FBI-trained dental coder, the author
very important since the original record is extremely aware of the importance of
A covered entity (e.g., a hospital or doctor) will likely be retained by the authorities, dental records in identifying UPs and
may disclose protected health information logged as evidence, and retained with the MPs. No dental record is ever purged in
to a coroner or medical examiner for the case material. the authors office, radiographs are current
purpose of identifying a deceased person, A warrant is not needed for a dentist to and properly exposed, dental charting
determining a cause of death, or other release records to assist in an investigation. (digital) is updated to include existing as
duties as authorized by law.6 However, if a dentist chooses not to release well as completed dentistry, and therapy
dental records, a warrant will be issued, records are detailed to include not only
Dentists and their practices are indem- and the requested record will be legally the procedure performed, but also the
nified from violation if they relinquish confiscated in order to collect the needed materials used in the treatment. Numerous
records to a law enforcement agent. A information. As such, it is advisable to intraoral and extraoral photographs
dentist will be given a written request cooperate with law enforcement. are collected; these images are strongly
on official letterhead of the law enforce- Law enforcement agencies not only need recommended not just from a forensic
ment agency that contains the name dental records, they also need experienced standpoint (such as unusual tori or tooth
of the patient, the case number of the dental professionals trained by the FBI as anomalies), but also from the standpoint
investigation, and the name and contact dental coders. A dental coder can directly of impairing any illegitimate attempts of
information of the requesting agency create the postmortem dental records for civil litigation against a dental practicea
and requesting officer (Fig. 6). A dentist the cases that enter the NCIC system from dentist should take many photos, and take
should make duplicates of everything their assigned jurisdictions.1 them often (Fig. 7 and 8).

56 January/February 2015 General Dentistry www.agd.org

of human identification. A dentists
responsibility to his/her patients does
not end when records are archived. For
the thousands of UPs, and the tens of
thousands of MPs, the dental profession
is obligated to retain the integrity of their
dental records.

Author information
Ms. Riley is a registered dental hygien-
ist, San Diego, California. She is a
member of the American Academy of
Forensic Sciences, the American Society
of Forensic Odontology, the American
Fig 7. A sample photograph from a patients file showing unique Fig 8. A sample photograph from a Dental Hygienists Association, the
and clinically significant intraoral anatomy (large, lobulated patients file showing unique dental California Dental Identification Team,
maxillary torus). anatomy (accessory cusp on the buccal and the Disaster Mortuary Operational
of tooth No. 2). Response Team.

The author would like to acknowledge
Gary Bell, DDS, DABFO, Anthony
A general dentist can contribute to the reports which have been entered by law Cardoza, DDS, DABFO, Stephanie
effort of identifying the thousands of enforcement agencies.7,8 The NamUs Kavanaugh, DDS, DABFO, Craig Nelson,
MPs and UPs reported across the US and site is managed by the US Department MD, American Academy of Forensic
Canada. The first step is to stop destroy- of Justice and was designed explicitly to Sciences, American Board of Forensic
ing dental records. There is always a pos- solicit the publics help in solving cases.8 Odontology, and the American Society of
sibility that a patient has become inactive There is access to names, filtered search Forensic Odontology.
because they are missing or deceased. results by state and city, and information
The colder an MP case becomes, the on how to contact the investigator manag- References
more important that persons dental ing a specific case.7,8 1. National Crime Information Center. NCIC Missing
record becomes, since teeth withstand the Unlike televised depictions of forensic Person and Unidentified Person Statistics for 2013.
Available at http://www.fbi.gov/about-us/cjis/ncic/
processes of decomposition and elemen- technologies that routinely locate evidence ncic-missing-person-and-unidentified-person-
tal exposure long after other sources of such as usable DNA samples from objects statistics-for-2013. Accessed November 14, 2014.
identification have disappeared.2,3 For found at crime scenes or fingerprints 2. Senn DR, Weems RA, eds. Manual of Forensic Odon-
a general dentist who is selling their from rough textiles, complex cases in real tology. 5th ed. Boca Raton, FL: CRC Press; 201:78-81.
3. Senn DR, Stimson PG. Forensic Dentistry, 2nd ed. Boca
practice, a provision can be added that life are not quickly solved. The reality is Raton, FL: CRC Press; 2010:163-183.
the new owner must retain at least the that it takes teamwork and cooperation 4. American Dental Association. Dental Records. Avail-
minimal patient recordsas outlined by between law enforcement, healthcare able at: http://raedentalmanagement.com/wp-content/
the ASFOof the old practice.5 providers, the public, and families of the uploads/2014/03/ADA-Dental-Records.pdf. Accessed
November 14, 2014.
At least once (and often twice) a year, missing to help identify and, if possible,
5. American Society of Forensic Odontology. ASFO Dental
the FBI will fund 2-day training work- bring home MPs and UPs. The identifica- Record Retention Position Paper. Available at: http://
shops on NCIC coding for dentists and tion of MPs and UPs aids in investiga- asfo.org/asfo-dental-record-retention-position-paper/.
auxiliaries.1,7 Space is extremely limited, tions that will hopefully provide answers Accessed November 7, 2014.
and positions are filled on a first-come, as well as a sense of closure, and in some 6. U.S. Department of Health and Human Services Office
for Civil Rights. HIPAA Administrative Simplification,
first-served registration basis. After the cases, mete out justice to the person or Regulation Text 45 CFR Parts 160, 162, and 164.
successful completion of this course, a persons responsible for a victims demise. Available at: http://www.hhs.gov/ocr/privacy/hipaa/
dentist may be asked by his/her local or administrative/privacyrule/adminsimpregtext.pdf. Ac-
state bureaus to translate procured dental Conclusion cessed November 7, 2014.
7. Silver WE, Souviron RR. Dental Autopsy. Boca Raton,
records for entry into the NCIC system, Dentists should consider record retention
FL: CRC Press; 2009:125-126.
or to create postmortem records for UPs.7 as their professional duty. The dental 8. US Department of Justice. National Missing and Un-
The National Missing and Unidentified profession serves as custodians of one of identified Persons System (NamUs). Available at:
Persons System (NamUs) has a website the most reliable, cost-effective, expedi- http://www.namus.gov/. Accessed November 10,
on which anyone can view MP and UP ent, and scientifically supported methods 2014.

www.agd.org General Dentistry January/February 2015 57

Non-Surgical Endodontics

Nonsurgical endodontic treatment of permanent

maxillary incisors with immature apex and a large
periapical lesion: a case report
Gautam P. Badole, MDS n M.M. Warhadpande, MDS n Rakesh N. Bahadure, MDS n Shital G. Badole, BDS

Immature teeth with necrotic pulp and large periapical lesions are post-treatment showed a decrease in the periapical lesion; at 1 year,
difficult to treat via conventional endodontic therapy. However, complete healing was visible.
they can be treated with calcium hydroxide and mineral trioxide Received: October 21, 2013
aggregate (MTA). This article reports the case of a nonvital tooth Accepted: November 24, 2013
with a periapical lesion and an open apex that was treated with a
single-visit MTA apical plug. A radiographic evaluation taken 6 months Key words: MTA, open apex, periapical lesion

uccessful endodontic treatment water, or an anesthetic solution.5 The does not weaken the root canal dentin, and
requires cleaning and shaping to usual time required to form a calcific it sets in a wet environment. Satisfactory
obtain a fluid-tight seal in apical barrier is 6-24 months.5 Determining the compaction of filling material can be
areas.1 When teeth have incompletely extent of apical closure can be difficult, as achieved as MTA forms a hard and nonre-
formed apices (known as blunderbuss analyzing a 3-dimensional apical closure sorbable apical barrier.10 MTA also is used
canals) and/or a root canal with abnor- via a 2-dimensional radiograph can lead for single-step apexification in open apex
mal apical constriction, it is difficult to misinterpretation.6 The disadvantages cases, producing less inflammatory reactions
to control the obturating material of long-term use of Ca(OH)2 include the in the periapical area and favoring bone
within the canal during condensation.2,3 need for multiple appointments, possible formation. This case report used the MTA
Apexification with calcium hydroxide recontamination of the root canal, and apical plug technique for successful nonsur-
[Ca(OH)2] has been the treatment of increased brittleness of the root dentin.7,8 gical management of a tooth with a large
choice for necrotic teeth with open A 1975 study by Roberts & Brilliant periapical lesion and blunderbuss canal.
apices in recent years.3,4 Ca(OH)2 can be reported the use of tricalcium phosphate as
used alone or mixed with camphorated an apical barrier.9 Mineral trioxide aggregate Case report
monochlorophenol (CMCP), metacresyl (MTA) was developed as a root-end filling A 24-year-old woman complained of mild,
acetate (with or without CMCP), physi- material. Apexification using MTA has intermittent pain in the maxillary anterior
ologic saline, Ringers solution, distilled several advantages, as it is not resorbed, it region. Patient history revealed that she

Fig. 1. A preoperative radiograph Fig. 2. A radiograph taken after Fig. 3. A radiograph of teeth No. 7, 8,
showing open apices on teeth No. 8 placement of MTA apical plugs in and 9 taken postobturation.
and 9, with a large periapical lesion teeth No. 8 and 9.
extending across teeth No. 7 and 8.

58 January/February 2015 General Dentistry www.agd.org

The diagnosis of chronic apical periodon-
titis and immature apex was confirmed.
A large periapical radiolucency was pres-
ent, suggesting periapical granuloma or
periapical/radicular cysts. Although there
are histological differences between these
conditions, they cannot be differentiated
clinically as their clinical and radiographic
appearances are identical. The borders of
the radiolucency cannot be used as diag-
nostic criteria.11,12
It is now accepted that a well-defined
border indicates a long-standing lesion
Fig. 4. A radiograph taken 6 months Fig. 5. A radiograph taken 1 year that is slowly increasing in size, whereas
post-treatment. Note the decrease in post-treatment. Note that the periapical a diffuse border is more likely to indicate
size of the periapical lesion. lesion is completely healed. a rapidly expanding lesion.13 The size of
the radiolucency is irrelevant to the his-
tological state of the tissue, as both small
and large lesions could be granulomas,
abscesses, or cysts. Since granulomas and
had suffered a trauma 15 years earlier. canal as an intracanal medicament. After radicular cysts are difficult to diagnose
Clinical examination showed loss of placing a sterile cotton pellet, the access differentially, they are classified clini-
enamel translucency in teeth No. 7, 8, and cavities were closed with cement (IRM, cally by the general term chronic apical
9. Tooth mobility within the physiologic DENTSPLY International). periodontitis.11-13
limit was present. Teeth No. 7 and 9 One week later, the patient was When performing root canal treatment
demonstrated mild pain on percussion. A asymptomatic and the Ca(OH)2 was in teeth with necrotic pulps and wide-open
periapical radiograph revealed a large peri- removed. Root canals were irrigated with apices, the main challenge is obtaining an
apical lesion (5 x 5 cm) extending across 0.5% sodium hypochlorite, 17% EDTA optimal apical seal. According to a 2005
teeth No. 7 and 8. The lesion showed a (Pulpdent Corporation), and a final rinse prospective clinical study, Ca(OH)2 apexi-
well-defined nonsclerotic border. Open of 2% chlorhexidine gluconate. Canals fication therapy had a 100% success rate,
apices were found in both teeth No. 8 and were dried with paper points, and MTA with a mean of approximately 12 months
9 (Fig. 1). Soft tissue examination showed (ProRoot MTA, DENSTPLY Tulsa) was to form an apical barrier.14 Disadvantages
that gingival and mucogingival tissue were placed in the apical portion of teeth No. of Ca(OH)2 apexification include failure
normal. None of the teeth responded to 8 and 9. Subsequent increments were to control infection, recurrence of infec-
electric and thermal pulp vitality tests. condensed with a hand plugger until tion, and cervical fracture.15
There was no history of discharge or a thickness of 4-5 mm was achieved Creating an MTA apical plug in a
swelling, and the patients medical history (Fig. 2). A wet cotton pellet was placed single visit has been suggested for nonvital
was noncontributory. into the canals and the access cavity immature permanent teeth as an alterna-
Based on clinical and radiographic was sealed with IRM. Using the lateral tive to long-term apexification treatment,
findings, a diagnosis of chronic apical peri- condensation technique, tooth No. 12 offering good apical seal, biocompatibility,
odontitis with immature apex was made was obturated with gutta percha and and pulpal and periodontal regenerating
for teeth No. 7, 8, and 9. A treatment plan root canal sealer (AH Plus, DENTSPLY capabilities.16 MTA has the potential to
was proposed involving root canal therapy Tulsa Dental Specialties) at the same provide an effective seal (even in the pres-
for all 3 teeth, with an MTA apical plug appointment. On the following day, the ence of blood and moisture) and form a
for teeth No. 8 and 9. remaining canals in teeth No. 8 and 9 primary monoblock.2 A 5 mm barrier is
After rubber dam isolation, access were obturated by applying gutta percha significantly stronger and demonstrates
cavities were prepared for the 3 teeth. with AH Plus and using the lateral con- less leakage than a 2 mm barrier.17
Working length was established with densation technique (Fig. 3). The access The major problem in cases of a wide-
both radiographic and electronic apex cavity was sealed with resin-modified open apex is the need to limit the material
locators (Root ZX, J. Morita USA, Inc). glass ionomer cement (GC Fuji PLUS, to the periapical area, thus avoiding the
Root canals were cleaned mechanically GC America, Inc.). extrusion of a large amount of material
using H-files (DENTSPLY International) At a follow-up visit 6 months post- into the periodontal tissue. A large volume
and gentle but copious irrigation with treatment, a radiograph revealed a marked of the extruded material may set before it
0.5% sodium hypochlorite and saline. decrease in the size of the periapical lesion disintegrates and is resorbed. This might
After drying the canals with paper points, (Fig. 4). At 1 year, the periapical radiolu- result in the persistence of the inflam-
Ca(OH)2 paste was placed into the root cency had healed completely (Fig. 5). matory process, which may complicate

www.agd.org General Dentistry January/February 2015 59

Non-Surgical Endodontics Nonsurgical endodontic treatment of permanent maxillary incisors

repair of the tissue. The use of a matrix is VSPMs Dental College and Research trioxide aggregate) cement. J Mater Sci Mater Med.
advisable since its placement in the area Center, Nagpur, India, where Dr. S. 2004;15(2):167-173.
18. Al-Daafas A, Al-Nazhan S. Histological evaluation of
of bone destruction provides a base for a Badole is an intern. Dr. Warhadpande
contaminated furcal perforation in dogs teeth re-
sealing material (such as MTA). In cases of is an associate professor, Government paired by MTA with or without internal matrix. Oral
teeth with incomplete formation of apex, Dental College and Hospital, Nagpur, Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;
several materials have been recommended India, where Dr. Bahadure is a lecturer, 103(3):92-99.
to create a matrix. These materials include Department of Pedodontics. 19. Jantarat J, Dashper SG, Messer HH. Effect of matrix
placement on furcation perforation repair. J Endod.
calcium hydroxide, hydroxyapatite, resorb- 1999;25(3):192-196.
able collagen, and calcium sulfate.18-21 References 20. Bargholz C. Perforation repair with mineral trioxide
In the present case, the MTA plug 1. Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K. aggregate: A modified matrix concept. Int Endod J.
Outcome of primary root canal treatment: systematic 2005;38(1):59-69.
technique was used successfully for
review of the literaturepart 2. Influence of clinical 21. Zou L, Liu J, Yin SH, Tan J, Wang FM, Li W, et al. Ef-
the endodontic treatment of an open factors. Int Endod J. 2008;41(1):6-31. fect of placement of calcium sulphate when used for
apex with a periapical lesion. Six- and 2. Park JB, Lee JH. Use of mineral trioxide aggregate in repair of furcation perforation on seal produced by a
12-month follow-up radiographs showed the open apex of a maxillary first premolar. J Oral Sci. resin-based material. Int Endod J. 2007;40(2):100-
complete healing for the apical lesion and 2008;50(3):355-358. 105.
3. Raldi DP, Mello I, Habitante SM, Lage-Marques JL, Coil 22. Dogra S, Mukunda KS, Arun A, Rao SM. Apexification.
the regeneration of periradicular tissues. J. Treatment options for teeth with open apices and J Dental Sci Res. 2012;3(1):1-4.
Three hours after mixing, the pH of the apical periodontitis. J Can Dent Assoc. 2009;75(8): 23. Tait CM, Ricketts DN, Higgins AJ. Weakened anterior
MTA increased from 10 to 12.5. It is 591-596. roots-intraradicular rehabilitation. Br Dent J. 2005;
assumed that in a high pH environment, 4. Huang GT. Apexification: the beginning of its end. Int 198(10):609-617.
calcium ions that are released from MTA Endod J. 2009;42(10):855-866. 24. Perinpanayagam H, Al-Rabeah E. Osteoblasts interact
5. Frank AL. Therapy for the divergent pulpless tooth by with MTA surfaces and express Runx2. Oral Surg Oral
react with phosphates in the tissue fluid to continued apical formation. J Am Dent Assoc. 1966; Med Oral Pathol Oral Radiol Endod. 2009;107(4):590-
form hydroxyapatite, which would explain 72(1):87-93. 596.
its favorable sealing ability and biocom- 6. Rafter M. Apexification: a review. Dent Traumatol. 25. Cintra LT, de Moraes IG, Estrada BP, et al. Evaluation of
patibility.4,22 MTA stimulates interleukin 2005;21(1):1-8. the tissue response to MTA and MBPC: microscopic
7. Asgary S, Ehsani S. MTA resorption and periradicular analysis of implants in alveolar bone of rats. J Endod.
production and cytokine release; it also healing in an open-apex incisor: a case report. Saudi 2006;32(6):556-559.
promotes hard tissue formation.23 Dent J. 2012;24(1):55-59. 26. Moretton TR, Brown CE Jr, Legan JJ, Kafrawy AH. Tis-
A 2009 cell culture study on human 8. Sharma R, Dhingra A, Nayar R. Delayed MTA apical sue reactions after subcutaneous and intraosseous
alveolar osteoblasts reported the expression plug in immature open apexa case report. implantation of mineral trioxide aggregate and eth-
of runt-related transcription factor 2 (which Endodontol. 2008;20:49-52. oxybenzoic acid cement. J Biomed Mater Res. 2000;
9. Roberts SC Jr, Brilliant JD. Tricalcium phosphate as an 52(3):528-533.
is essential for osteoblast differentiation and adjunct to apical closure in pulpless permanent teeth. 27. Tani-Ishii, Hamada N, Watanabe K, Tujimoto Y, Ter-
bone formation) in the presence of MTA J Endod. 1975;1(8):263-269. anaka T, Umemoto T. Expression of bone extracellu-
mixed with either sterile water or an anes- 10. Trope M. Treatment of immature teeth with non-vital lar matrix proteins on osteoblast cells in the
thetic solution.24 Studies have reported that pulps and apical periodontitis. Endod Topics. 2007; presence of mineral trioxide. J Endod. 2007;33(7):
14(1):51-59. 836-839.
MTA is both osteoconductive and osteoin- 11. Ramachandran Nair PN, Pajarola G, Schroeder HE. 28. Ham KA, Witherspoon DE, Gutmann JL, Ravindra-
ductive; thus it favors bone formation.25-27 Types and incidence of human periapical lesions ob- nath S, Gait TC, Opperman LA. Preliminary evalua-
According to the literature, MTA showed tained with extracted teeth. Oral Surg Oral Med Oral tion of BMP-2 expression and histological
the highest amount of hard tissue formation Pathol Oral Radiol Endod. 1996;81(1):93-102. characteristics during apexification with calcium
12. Ramachandran Nair PN. Apical periodontitis: a dy- hydroxide and mineral trioxide aggregate. J Endod.
and the lowest level of periapical inflamma-
namic encounter between root canal infection and 2005;31(4):275-279.
tion in open apex cases.28-29 The single-visit host response. Periodontol 2000. 1997;13:121-148. 29. Felippe WT, Felippe MC, Rocha MJ. The effect of miner-
MTA apical plug technique saves time 13. Abbott PV. Classification, diagnosis and clinical mani- al trioxide aggregate on the apexification and periapi-
compared to Ca(OH)2 apexification, and festations of apical periodontitis. Endod Topics. 2004; cal healing of teeth with incomplete root formation.
offers predictable apical barriers that favor 8(1):36-54. Int Endod J. 2006;39(1):2-9.
14. Dominguez Reyes A, Munoz Munoz L, Aznar Martin T.
periapical tissue regeneration. Study of calcium hydroxide apexification in 26 young
permanent incisors. Dent Traumatol. 2005;21(3):141- Manufacturers
Conclusion 145. DENTSPLY International, York, PA
15. Maroto M, Barbera E, Planells P, Vera V. Treatment 800.877.0020, www.dentsply.com
A single-visit MTA apical plug is an effec-
of a non-vital immature incisor with mineral trioxide DENTSPLY Tulsa Dental Specialties, Tulsa, OK
tive method to provide a good apical seal
aggregate (MTA). Dent Traumatol. 2003;19(3):165- 800.662.1202, www.tulsadentalspecialties.com
in open apex cases. It also offers the advan- 169. GC America, Inc., Alsip, IL
tages of biocompatibility, predictability, less 16. Torabinejad M, Watson TF, Pitt Ford TR. Sealing abili- 800.323.7063, www.gcamerica.com
treatment time, and fewer appointments. ty of a mineral trioxide aggregate when used as a
J. Morita USA, Inc., Irvine, CA
root end filling material. J Endod. 1993;19(12):591-
595. 800.831.3222, www.morita.com/usa
Author information 17. Pelliccioni GA, Ciapetti G, Cenni E et al. Evaluation of Pulpdent Corporation, Watertown, MA
Dr. G. Badole is a lecturer, Department of osteoblast-like cell response to Proroot MTA (mineral 800.343.4342, www.pulpdent.com
Conservative Dentistry & Endodontics,

60 January/February 2015 General Dentistry www.agd.org

Fixed Removable Hybrid Prosthesis

Stress analysis of mandibular implant-retained

overdenture with independent attachment system:
effect of restoration space and attachment height
Behnaz Ebadian, DDS, MSc n Saeid Talebi, MSc n Niloufar Khodaeian, DDS, MSc n Mahmoud Farzin, PhD

In this in vitro study, 2 implants were embedded in the interforaminal in maximum stress values around implants correlated with the ball
region of an acrylic model. Two kinds of retention mechanisms were attachment collar height. The Locator attachment with a 1 mm cuff height
used to construct complete overdentures: ball type and direct abutment and 9 mm occlusal plane height demonstrated 6.147 and 3.914 MPa in
(Locator). The ball-type retention mechanism models included 3 differ- unilateral and bilateral loading conditions, respectively. While a reduction
ent collar heights (1, 2, and 3 mm) with 15 mm occlusal plane height, in the collar height of a ball-type retention mechanism and an increase in
and 3 different occlusal plane heights (9, 12, and 15 mm) with 1 mm the vertical restorative space in direct abutment retention mechanisms are
collar height. The direct abutment models included 3 different occlusal both biomechanically favorable, and may result in reduced stress in peri-
plane heights (9, 12, and 15 mm) with 1 mm cuff height. Vertical uni- implant bone, a ball attachment seems to be more favorable in the stress
lateral and bilateral loads of 150 N were applied to the central fossa of distribution around an implant than a Locator attachment.
the first molar. The stress of the bone around the implant was analyzed Received: April 11, 2013
by finite element analysis. Accepted: July 10, 2013
The results showed that by increasing vertical restorative space, the
maximum stress values around implants were decreased in both unilateral Key words: overdenture, stress, finite element analysis,
and bilateral loading models. The results also showed that the increase independent attachment, occlusal plane

he restoration of an edentulous various vertical heights, and its resiliency, a lateral moment which proportionally
mandible with an overdenture sup- retention, and durability are favorable.12 increases with increased CHS; this results
ported or retained by 2 implants is The effect of a resilient or rigid attachment in stress concentration at the bone sur-
considered to be the primary prosthetic system on retention and stress distribution rounding the implant neck.22 Increasing the
treatment approach.1 The retention and is a subject of controversy in the litera- CHS by 1 mm results in a 20% increase in
stability of prostheses are provided primar- ture.12-16 Biomechanically, the advantages the cervical load on a fixed-implant pros-
ily by implants through attachments.2,3 of implant splinting are unclear. The thesis. Implant splinting has been suggested
Various types of attachments have been rationale of implant splinting was that it to overcome the biomechanical overload in
suggested for implant-supported over- would decrease stresses due to increased this situation. However, implant splinting
dentures. Independent or dependent con- prosthesis stability.17,18 in fixed-implant supported prostheses has
nection of implants through ball, O-ring, Adequate restorative space is another not been proven to significantly improve
Locator, and bar attachments are the most important factor in successful implant- implant success rates.23
common approaches.2-5 Some studies have retained overdenture treatment.19 In Fabricating an implant-supported
reported implant support via ball-type edentulous patients, available restorative overdenture requires an adequate space
attachments as a reliable treatment.3,6-10 space is bounded by the supporting tissues for restorative components.19 Evaluation
The freedom of rotation within the ball of the edentulous jaw, cheeks, lips, tongue, of space limitation after implant surgery
attachment allows for stress release. The and the occlusal plane. Other factors must allows for appropriate attachment selection.
method of retaining overdentures by 1 or also be considered when defining available Inappropriate treatment planning before
2 implants using resilient attachments is a restorative space, such as interocclusal dis- placing a removable implant-supported
relatively simple and inexpensive method tance, phonetics, and esthetics.20 prosthesis can lead to problems such as
to reconstruct an edentulous mandible.11 The minimum vertical restorative space overcontoured or fractured prostheses. Two
Selection of the optimal attachment is required for an implant-supported overden- height levels should be considered in any
dependent upon the required retention, ture is 8.5 mm for Locator attachments, removable prosthesis with mobility and
jaw morphology and anatomy, oral func- 10-12 mm for ball and O-ring attachments, soft tissue support: the first is the height of
tion, and patient compliance for recall.12 and 13-14 mm for bar-clip attachments.20 the attachment system to the crest of the
The ball attachment places less stress on The distance from the crest of the bone, and the second is the distance from
implants and produces less bending move- alveolar bone to the plane of occlusion in the attachment to the occlusal plane.21
ment in comparison to the bar-clip attach- implant-supported prostheses is defined In a finite element analysis (FEA) study,
ment.3 The Locator, which is self-aligning as the crown height space (CHS). The Ebadian et al evaluated different vertical
and has dual retention, is another type of biomechanics of CHS is related to lever restorative spaces and different bar heights
independent attachment. It is available in arm mechanics.21 Nonaxial loading creates of mandibular overdentures, and showed

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Fixed Removable Hybrid Prosthesis Stress analysis of mandibular implant-retained overdenture attachments

Overdenture Metal housing

Metal housing
Plastic cap Plastic cap
Ball abutment
Locator abutment

Fig. 1. Computerized mesh modeling showing jaw and overdenture with ball attachment.24 Fig. 2. Computerized mesh modeling showing Locator system.24

Fig. 3. Modeling of 3 different occlusal plane heights.24

that increasing the vertical restorative abutment platform (Biohorizons Internal, ATOS II (Triple Scan) scanning technology
space and decreasing the bar height led to BioHorizons IPH, Inc.), were embedded (GOM mbH) and viewer software (ATOS
a decrease in the maximum stress value in the interforaminal region of the acrylic version 6.3.0, GOM mbH). Implants were
around the implants when a unilateral model using a surveyor (Ney Surveyor, assumed to be completely osseointegrated,
load was applied.24 DENTSPLY International). The implants so that a mechanically perfect interfaceto
Since the use of independent attach- were vertically oriented, perpendicular to ensure the continuity of displacement and
ments in different occlusal plane heights is the occlusal plane, and parallel to each traction vectorswas pressured between
not well-defined, the purpose of this study other. The crestal bone position of the implants and bone. Other contacts existing
was to evaluate the effect of different verti- implants was on the top of the ridge. between the elements were also assumed
cal restorative spaces (that is, occlusal plane The interimplant distance was 20 mm. to be perfect. The resultant dense point
distance to gingival level) and different Two types of retention mechanisms were cloud was transferred to CATIA model-
ball attachment collar heights on the stress used in this study: a ball attachment ing software (Dassault Systemes Americas
distribution around implants by 3-dimen- with plastic matrix and metal housing Corp.). The geometry was then meshed by
sional (3D) finite element analysis. (BioHorizons IPH, Inc.), and a direct tetrahedral linear elements.
abutment attachment with plastic matrix The mucosa and cortical bone were
Materials and methods and metal housing (Locator attachments, reproduced as a 2 mm and 2.5 mm
In this in vitro study, the experimental 4.5 mm with a 1.0 mm cuff, BioHorizons layer, respectively. Three different collar
design included the fabrication of a IPH, Inc.) (Fig. 1 and 2).24 heights (1, 2, and 3 mm) with a 15 mm
simulated 2-implant-retained mandibular Based on the laboratory design used by occlusal plane height, and 3 different
overdenture. For this purpose, an acrylic Ebadian et al, a complete overdenture was occlusal plane heights (9, 12, and 15 mm)
model of an edentulous mandible was fabricated on these attachment models.24 with a 1 mm collar height were modeled
fabricated with a clear acrylic resin The plastic model, acrylic denture, implants, for the ball attachment system (Fig. 3).
(Meliodent Multicryl, Heraeus Kulzer). Locator and ball attachments were used for Three different occlusal plane heights (9,
The configuration of the bone was dupli- computerized reproduction. To improve 12, and 15 mm) with a 1 mm cuff height
cated from an edentulous mandibular analysis, the implants were considered as flat were modeled for the Locator system.
skeleton. Two screw-type implants, 4 cylinders. The 3D geometry of the entire Thus, 9 models were obtained. The value
x 10.5 mm with a 4.5-mm-diameter system was scanned and digitized using of friction coefficient was fixed to 0.02.25

62 January/February 2015 General Dentistry www.agd.org

Table 1. Mechanical properties of
the prosthesis, implant, and bone Table 2. The number of
materials used in this study.13,27-30 elements and nodes in the
ball attachment models.
Young Poisson Table 3. The number of
Material modulus (Pa) ratio Occlusal Collar Number elements and nodes in the
plane height height of Number Locator attachment models.
Cortical bone 1.371010 0.30
(mm) (mm) elements of nodes
Trabecular bone 1.37109 0.30
9 1 147,640 40,898 Occlusal Cuff Number
Mucosa 1.0107 0.40 plane height height of Number
12 1 155,058 42,095
Acrylic resin 2.7109 0.35 (mm) (mm) elements of nodes
15 1 161,329 43,240
Titanium 1.171011 0.33 9 1 176,967 50,772
15 2 164,140 43,828
Gold 1.010 11
0.30 12 1 184,234 51,957
15 3 166,287 44,355
Rubber 510 6
0.45 15 1 190,533 53,181

Table 4. Stress values generated in the bone in the ball attachment model with different occlusal plane
and collar heights by unilateral and bilateral loading.

Distal side force (MPa) Mesial side force (MPa) Maximum force (MPa)
Occlusal plane
height (mm) Collar height (mm) Unilateral Bilateral Unilateral Bilateral Unilateral Bilateral
9 1 5.249 2.811 4.224 0.870 5.249 3.263
12 1 4.695 2.557 3.685 0.754 4.695 3.365
15 1 4.438 2.455 3.407 0.726 4.438 3.428
15 2 4.920 2.429 3.863 0.722 4.920 3.443
15 3 5.357 2.493 4.262 0.751 5.357 3.439

Table 5. Stress values generated in the bone in the Locator attachment models with different occlusal plane
heights by unilateral and bilateral loading.

Distal side force (MPa) Mesial side force (MPa) Maximum force (MPa)
Occlusal plane
height (mm) Cuff height (mm) Unilateral Bilateral Unilateral Bilateral Unilateral Bilateral
9 1 6.147 3.914 4.143 1.063 6.147 3.914
12 1 5.702 3.450 3.823 1.008 5.702 3.450
15 1 5.378 3.103 3.606 0.855 5.378 3.422

Stress analysis was performed using FEA and bone are shown in Table 1.13,27-30 The Maximum stresses were found in the
software (ABAQUS version 6.11, Abaqus, number of elements and nodes are sum- Locator model with 1 mm cuff height
Inc.). Linear static analysis was used marized in Tables 2 and 3. and 9 mm occlusal plane height. The
in this study. Arbitrary 150 N vertical stresses were 6.147 and 3.914 MPa in
unilateral and bilateral loads representing Results unilateral and bilateral loading condi-
the masticatory force were applied to the Maximum stress values on the bone in the tions, respectively.
central occlusal fossa of the first molar of bilateral and unilateral loading models of In the ball attachment models, maxi-
the prosthesis.26 Mechancial properties ball attachment and Locator systems are mum stress values of bone were observed
for the prosthesis and all implant parts shown in Tables 4 and 5. mostly in the distal bone adjacent to the

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Fixed Removable Hybrid Prosthesis Stress analysis of mandibular implant-retained overdenture attachments

Fig. 4. Stress distribution pattern in ball attachment model when Fig. 5. Stress distribution pattern in Locator attachment model
load applied. Top. Unilateral. Bottom. Bilateral.24 when load is applied. Top. Unilateral. Bottom. Bilateral.24

ipsilateral implant when a unilateral load Comparisons of ball attachment vs bar- Maximum stresses of ball and Locator
was applied, and more distal to the bone clip attachments have been conducted attachments in unilateral loading models
adjacent to the implants when a bilateral in other studies with varying results in in this study were 4.438 and 5.378 MPa,
load was applied (Fig. 4). terms of retention and maintenance.36,37 respectively; and in bilateral loading condi-
The maximum stresses in the Locator Kleis et al reported a higher rate of main- tions, the maximum stresses were 3.428
attachment system were observed in tenance for Locator systems in compari- and 3.422 MPa, respectively. Ebadian et
the distal side of the ipsilateral implant son to ball attachments in mandibular al found the maximum stresses of a bar-
when unilateral and bilateral loads were 2-implant overdentures.38 clip attachment system modelwith 1
applied (Fig. 5).24 Cakarer et al reported no difference mm bar height and 15 mm occlusal plane
between ball attachment and Locator sys- heightwere 4.753 and 3.482 MPa in
Discussion tems regarding implant failure, replacement unilateral and bilateral loading conditions,
Dependent and independent attachment of attachments, and fracture of overden- respectively.24 Comparing the result of
systems have been used in implant-sup- tures.11 However, they found that overall, these 2 studies showed that the Locator
ported overdentures. Many researchers have the Locator system had more advantages attachment transferred more stress than
evaluated either ball or bar-clip attachment than the ball or bar-clip systems.11 Celik & the bar clip, and the ball attachment
systems in overdentures.8,31-34 The present Uludag used a photoelastic model to evalu- transferred the least stress of all 3 attach-
study evaluated stress distributions of an ate the stress transfer of various types of ment systems when a unilateral load was
overdenture retained by either a ball attach- attachments in a mandibular implant over- applied. In bilateral loading conditions, all
ment or Locator system on 2 implants in denture.39 They reported that the Locator 3 attachments transferred almost the same
a mandibular jaw model. Various occlusal system showed greater stresses as compared stress to the peri-implant bone.24 These
plane heights were studied in these models. to ball, bar-clip, and bar-ball attachment findings are in agreement with previous
The selection and application of differ- systems.39 Kenney & Richards reported studies that used unilateral loading.3,39,40
ent attachment systems for implant over- less stress was transferred to implants by a In the current study, the maximum
dentures depend on many factors, such ball/O-ring attachment system than a bar- stress was found in bone adjacent to the
as retention, stress, restorative space, and clip attachment.40 Tokuhisa et al compared implant in unilateral loading models;
maintenance.3,20 Fractures of implants, the transferred stresses of O-ring/ball and however, in bilateral loading conditions,
attachments and prostheses can occur due bar-clip attachment systems and concluded the maximum stress of the ball attach-
to biomechanical stresses. Misch showed that, the ball/O-ring system minimized the ment was observed more distal from the
how stress management in implant pros- stress transferred to the bone surrounding bone adjacent to the implant than the
theses is important in order to reduce implant-supported overdentures in com- Locator attachment. This may be due
fracture rates.35 parison to the bar-clip system.3 to the more rigid behavior of a Locator

64 January/February 2015 General Dentistry www.agd.org

system, which restricts the movement of A meta-analyses study on mandibular So it could be concluded that in abundant
the overdenture and thus increases the overdentures by Cehreli et al reported no vertical space, even low height attachments
stress in the bone around the implant differences in marginal bone loss around are biomechanically advantageous.
while decreasing the stress in the posterior implants in various attachment designs.42 It has been recommended that a
residual ridge. The maximum stress loca- The level of stress correlated to bone minimum of approximately 12 mm
tions in these models were similar to the resorption has not been clearly defined vertical restorative space is necessary to
study by Ebadian et al which evaluated in the literature.43 Since an FEA can only consider a mandibular implant-supported
bar-clip attachments of mandibular over- produce theoretical conclusions, the aim overdenture.45,46 The minimum space
dentures.24 It is evident in Figures 4 and 5 of this study was not to report absolute required for an implant-retained over-
that the stress distribution in the ball values of stresses but to compare stress denture with a Locator system is 8.5 mm
attachment model was more uniform values between different models.28,44 It is (vertical) x 9 mm (horizontal).47 Based
than that of the Locator model, which very important to choose the appropriate on the authors findings and from a bio-
was concentrated around the implants. attachment system according to patient mechanical and stress-generated aspect,
The stress obtained from applying a characterization in terms of bone quality in a restricted vertical space, ball attach-
mastication load both unilaterally and and quantity, stress conditions, desired ments with minimum collar heights are
bilaterally is distributed into 2 segments: retention and stability, available restorative preferred to Locator attachments.
the posterior ridge and the bone around space, and patient maintenance. The roles of crown/implant ratio and
the implants, both of which are influ- By increasing the occlusal plane height CHS in fixed-implant prostheses are con-
enced by the retention mechanism of the in this study from 9 to 15 mm, the troversial in the literature.48-50 The role of
attachment system. Therefore, whenever maximum stress in the bone around the CHS and its biomechanical effect is related
the attachment system is more resilient, implant was decreased in the unilateral to lever mechanics.51 A CHS 15 mm can
the stress in the bone around the implant and bilateral loading models of the ball be biomechanically unfavorable, resulting
is subsequently lessened and a part of attachment and Locator systems, but the in increased stress at the bone around the
the stress is transferred to the posterior maximum stress in the posterior residual implant.52 It appears that the CHS role in
ridge; this results in better stress distri- ridge was slightly increased in the bilat- fixed-implant prostheses is not completely
bution and thus reduces the maximum eral loading models of ball attachments, applicable in implant overdentures. Our
stress level. The ball attachment is more which tolerated the maximum stress in findings indicate that by increasing the
resilient than the Locator system, thus it these models. The study by Ebadian et CHS (via occlusal plane height), the stress
causes more uniform and less maximum al on bar-clip attachments showed the generated in the bone was decreased. This
stress. Resiliency in these 2 attachment same results when a unilateral load was may be related to the different support,
systems is closely related to the plastic appliedthe stress with a bilateral load movement, and leverage mechanisms of
caps that are used. Therefore, because the slightly decreased when the occlusal plane the 2 tested prostheses.
plastic volume in the cap of a ball attach- height was increased.24 There are some unavoidable limita-
ment is greater than the plastic volume By increasing the collar height of the tions in an FEA study, mainly in biologic
in a Locator attachment, and because ball abutment from 1 to 3 mm, the maxi- simulations, which compelled the authors
the ball attachment has a single retention mum stress was increased. This was also to assume some simplifications. Bone is a
mechanism while the Locator has dual in agreement with the study by Ebadian complex living structure without a defined
retention, the ball attachment is more et al.24 Therefore, it can be concluded that pattern; its characteristics vary among
resilient and transfers less stress than the by increasing the first lever arm (distance individuals, and its actual mechanical
Locator system. from crest of bone to attachment level), properties are not precisely established.
Takeshita et al reported that the reten- stresses in the bone around the implants Furthermore, the use of FEA in a study
tive forces of an attachment system affect increase. By increasing the second lever of an extremely accurate anatomy of a
stresses generated in the peri-implant arm (distance of occlusal plane of denture bone structure may limit the results to
bone during loading.41 This finding could to attachment), the stress values were that particular structure. As such, certain
explain why more stresses are generated decreased in both the Locator and ball- simplifications were adopted in this study
in the bone by the Locator attachment in attachment systems. to generalize the results and facilitate the
comparison with the ball attachment. The According to Cehreli et al, when severe study without compromising the valid-
Locator system used in this study has a vertical bone loss is present, vertically can- ity of the findings. The implants were
dual retention mechanism, therefore it is tilevered occlusal loading will increase.42 modeled without threads, as the aim of
more retentive than the ball attachment. However, the results of the present study the study was to analyze the stresses on
Chen et al observed that the least retentive are not in agreement with that claim. This implants and not the mechanical interac-
attachments offer greater rotation than the study found that increasing the occlusal tions within the bone.28 It has been said
more retentive ones.10 The authors com- plane height decreased the stress generated that this assumption results in an under-
pared Locator, ERA, and O-ring systems in bone, especially with the Locator attach- estimation of stress patterns in bone, as
and reported that the O-ring system was ment system. Increasing the collar height reported in previous studies.53,54 In addi-
the least retentive system.10 Their findings of abutment, or decreasing the second tion, the connecting screws at the implant-
are in agreement with the present study. lever arm could result in increased stress. abutment interface were not modeled,

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Fixed Removable Hybrid Prosthesis Stress analysis of mandibular implant-retained overdenture attachments

although some studies have shown that 6. Heckmann SM, Winter W, Meyer M, Weber HP, Wich- supporting restorations. J Oral Maxillofac Surg. 2011;
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Author information and extension base contact on load transfer with tion of bone resorption beneath a complete denture.
Dr. Ebadian is an associate professor, mandibular implant-retained overdentures. J Prosthet J Dent Res. 1989;68(9):1370-1373.
Dent. 2000;84(3):327-334. 31. Porter JA Jr, Petropoulos VC, Brunski JB. Comparison of
Dental Implant Research Center and 13. Chun HJ, Park DN, Han CH, Heo SJ, Heo MS, Koak JY. load distribution for implant overdenture attachments.
Department of Prosthodontics, School of Stress distributions in maxillary bone surrounding Int J Oral Maxillofac Implants. 2002;17(5):651-662.
Dentistry, Isfahan University of Medical overdenture implants with different overdenture at- 32. Sadowsky SJ. Mandibular implant-retained overden-
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66 January/February 2015 General Dentistry www.agd.org

40. Kenney R, Richards MW. Photoelastic stress patterns 50. Schulte J, Flores AM, Weed M. Crown-to-implant ratios There is an article on
produced by implant-retained overdentures. J Prosthet of single tooth implant-supported restorations. J Pros- PROSTHODONTICS/REMOVABLE
Dent. 1998;80(5):559-564. thet Dent. 2007;98(1):1-5. in the online edition.
41. Takeshita S, Kanazawa M, Minakuchi S. Stress analysis 51. Nissan J, Gross O, Ghelfan O, Priel I, Gross M, Chaushu
of mandibular two-implant overdenture with different G. The effect of splinting implant-supported restora- Management of severe
attachment systems. Dent Mater J. 2011. Available at: tions on stress distribution of different crown-implant
https://www.jstage.jst.go.jp/article/dmj/30/6/30_ ratios and crown height spaces. J Oral Maxillofac Surg. mandibular deviation following
2011-134/_article. Accessed Ocotber 6, 2014. 2011;69(12):2990-2994. partial
42. Cehreli MC, Karasoy D, Kokat AM, Akca K, Eckert S. A 52. Misch CE, Steignga J, Barboza E, Misch-Dietsh F, Cian- mandibular
systematic review of marginal bone loss around im- ciola LJ, Kazor C. Short dental implants in posterior par- resection:
plants retaining or supporting overdentures. Int J Oral tial edentulism: a multicenter retrospective 6-year case
Maxillofac Implants. 2010;25(2):266-277. series study. J Periodontol. 2006;77(8):1340-1347.
a case
43. Ciftci Y, Canay S. The effect of veneering materials on 53. Natali AN, Pavan PG, Ruggero AL. Evaluation of stress report
stress distribution in implant-supported fixed prosthet- induced in peri-implant bone tissue by misfit in multi-
ic restorations. Int J Oral Maxillofac Implants. 2000; implant prosthesis. Dent Mater. 2006;22(4):388-395.
15(4):571-582. 54. Bellini CM, Romeo D, Galbusera F, et al. Comparison
44. Satoh T, Maeda Y, Komiyama Y. Biomechanical ratio- of tilted versus nontilted implant-supported prosthetic
nale for intentionally inclined implants in the posterior designs for the restoration of the edentuous mandible:
mandible using 3D finite element analysis. Int J Oral a biomechanical study. Int J Oral Maxillofac Implants.
Maxillofac Implants. 2005;20(4):533-539. 2009;24(3):511-517.
45. Misch C. The edentulous mandible: an organized ap- 55. Silva GC, Mendonca JA, Lopes LR, Landre J Jr. Stress Visit www.agd.org/GeneralDentistry
proach to implant supported overdentures. In: Misch patterns on implants in prostheses supported by four
CE, ed.. Contemporary Implant Dentistry. 3rd ed. St. or six implants: a three-dimensional finite element
Louis: Mosby; 2007:297-298. analysis. Int J Oral Maxillofac Implants. 2010;25(2):
46. Pasciuta M, Grossmann Y, Finger IM. A prosthetic solu- 239-246.
tion to restoring the edentulous mandible with limited AGDPODCAST
interarch space using an implant-tissue-supported Controversies in
overdenture: a clinical report. J Prosthet Dent. 2005; Manufacturers Implant Dentistry
93(2):116-120. Abaqus, Inc., Pawtucket, RI
47. Lee CK, Agar JR. Surgical and prosthetic planning for a 415.496.9436, www.abaqus.net
two-implant-retained mandibular overdenture: a clini- BioHorizons IPH, Inc., Birmingham, AL
cal report. J Prosthet Dent. 2006;95(2):102-105. 888.246.8338, www.biohorizons.com
48. Wang TM, Leu LJ, Wang J, Lin LD. Effects of prosthesis Dassault Systemes Americas Corp., Waltham, MA
materials and prosthesis splinting on peri-implant 781.810.3000, www.3ds.com
bone stress around implants in poor-quality bone: a
numeric analysis. Int J Oral Maxillofac Implants. 2002; DENTSPLY International, York, PA
17(2):231-237. 800.877.0020, www.dentsply.com
49. Guichet DL, Yoshinobu D, Caputo AA. Effect of splint- GOM mbH, Braunschweig, Germany
ing and interproximal contact tightness on load trans- 49.531.390290, www.gom.com
fer by implant restorations. J Prosthet Dent. 2002; Heraeus Kulzer, South Bend, IN
87(5):528-535. 800.435.1785, www.heraeus-dental-us.com

www.agd.org General Dentistry January/February 2015 67

Exercise No. 363 Fixed Removable Hybrid Prosthesis Subject Code 674
The 15 questions for this exercise are based on the article, Stress Reading the article and successfully completing the exercise will
analysis of mandibular implant-retained overdenture with enable you to understand the:
independent attachment system: effect of restoration space and theoretical force distribution on implants and surrounding bone;
attachment height, on pages 61-67. This exercise was developed by differences between ball and Locator attachments; and
Robert A. Busto, DMD, MBA, FAGD, in association with the General unfavorable biomechanical scenarios for implant overdenture
Dentistry Self-Instruction committee. treatment.

1. All of the following are factors for 6. If the vertical restorative space is 12 mm, 12. The level of stress correlated to
selecting the optimal mandibular which implant-supported overdenture bone resorption has not been clearly
overdenture attachment except one. attachment(s) is/are acceptable? defined in the literature. Finite
Which is the exception? A. Locators only element analysis studies can produce
A. required retention B. Locators and balls clinical conclusions to determine how
B. patient finances C. Locators and bar clips much stress an implant can take before
C. patient compliance D. Locators, balls, and bar clips bone resorption.
D. jaw morphology A. Both statements are true.
7. How were the implants in this study B. The first statement is true;
2. The ball attachment places_______ placed in relation to the occlusal plane? the second is false.
stress on implants and produces ______ A. Angled 30 degrees C. The first statement is false;
bending movement than the bar-clip B. Angled 45 degrees the second is true.
attachment. C. Angled 75 degrees D. Both statements are false.
A. less; less D. Angled 90 degrees
B. more; less 13. In a restricted vertical space, this study
C. less; more 8. The implants in this study were placed recommends using a _____ attachment
D. more; more with an interimplant distance of ___ mm. system with minimum collars to address
A. 14 stress concerns.
3. What is the minimum vertical B. 16 A. Locator
restorative space (mm) required for C. 18 B. ball
using Locator attachments on an D. 20 C. Dalbo
implant-supported overdenture? D. bar clip
A. 12.5 9. Which combination of implant collar
B. 10.5 height and occlusal plane height (mm) 14. Increasing the crown height space
C. 8.5 resulted in maximum stress? in removable implant overdentures
D. 6.5 A. 1; 9 decreases the stress generated in the
B. 1; 15 bone. Increasing the crown height
4. The crown height space is the distance C. 2; 9 space in fixed implant prostheses
from the ______ to the ______ in D. 2; 15 increases the stress in the bone.
implant-supported prostheses. A. Both statements are true.
A. mandibular crest of alveolar bone; 10. Cakarer et al reported that the Locator B. The first statement is true;
maxillary crest of alveolar bone attachments receive greater stress the second is false.
B. most superior point of the implant than ball attachments. Celik & Uludag C. The first statement is false;
attachment; plane of occlusion reported that Locator attachments the second is true.
C. crest of the alveolar bone; most superior have a higher implant failure rate. D. Both statements are false.
point of the implant attachment A. Both statements are true.
D. crest of the alveolar bone; plane of B. The first statement is true; 15. In unsplinted implants, decreasing the
occlusion the second is false. distance from the crest of the bone
C. The first statement is false; to the __________ will decrease the
5. Increasing the crown height space by the second is true. stresses generated in the bone.
1 mm results in a _____% increase in D. Both statements are false. A. abutment
the cervical load on a fixed implant B. plane of occlusion
prosthesis. 11. The Locator implant is ______ retentive C. apex of the implant
A. 10 and ______ resilient than the ball D. facial midline
B. 15 attachment.
C. 20 A. equally; less
D. 25 B. more; equally
C. more; less
D. less; more

Answer form is on the inside back cover. Answers for this exercise must be received by December 31, 2015.

68 January/February 2015 General Dentistry www.agd.org

Oral Medicine, Oral Diagnosis, Oral Pathology

p53 expression in oral lichenoid lesions

and oral lichen planus
A. Arreaza, MSc n H. Rivera, MSc n M. Correnti, PhD

The aim of this article was to compare the expression of p53 pro- was observed at the basal cell layer. Due to the chance of potential future
tein in oral lichen planus (OLP) and oral lichenoid reaction (OLR). malignancy, follow-up for all cases is recommended.
The study population consisted of 65 patients31 diagnosed with Received: May 22, 2013
OLP and 34 with OLR. Revised: September 7, 2013
The results showed more p53 positive cases in the OLP group than in Accepted: October 2, 2013
the OLR group. However, the difference between the 2 groups was not
statistically significant (P = 0.114). The most common immunolocalization Key words: p53, oral lichen planus, lichenoid lesions

ral lichen planus (OLP) is a migration to these sites leads to the expres- but the putative mechanism remains
chronic inflammatory condi- sion of other molecules at the basal cell unknown1,2,4,7-10 Some studies have shown
tion that involves the skin and layer, resulting in lymphocyte linkage to that OLR lesions may have an increased
oral mucosa.1,2 It mainly affects women the epithelium. This linkage triggers an risk of malignant transformation.1,4,6 The
between 30 and 50 years of age, and it is intense production of IFN- and TNF-, annual rate of OLP malignant transfor-
not common in children.1 The prevalence leading to matrix metalloproteinases and mation has been estimated to be 0.2%-
of this condition represents 1%-4% of p53 overexpression, ending in apoptosis.1-3 1% worldwide.1,4
the global population with no apparent
ethnic predisposition.1 Oral lichenoid reaction p53 expression
OLP has a variety of clinical manifesta- Oral lichenoid reaction (OLR) presents p53 is an oncoprotein involved in the
tions: papuloreticular, linear, plaque, erosive as lesions that are clinically and histo- suppression of the proliferation of DNA-
or ulcerative, and macular or pigmented. logically identical to OLP, but with an damaged cells via cell cycle regulation
Reticular or plaque forms frequently occur identifiable etiologic factor.1,5,6 They may that results in the apoptosis of these
with single, asymptomatic lesions being the be classified as oral lichenoid lesions as a cells.11 Impaired function of the p53 gene
only manifestation of the disease. However, result of contact with dental materials has been implicated in the development
erythematous or ulcerative clinical presen- particularly amalgamdue to both an and progression of oral epithelial dysplasia
tations may also occur.1-4 adverse reaction to medications or graft- and oral SCC.11,12 Therefore, detection of
OLP is caused by an immune T cell versus-host disease (GVHD).1-3 p53 changes may help in the identifica-
response to an unidentified antigen in the Clinically, OLR may be observed as tion of high risk lesions or potentially
skin or oral mucosa of patients who have erosive lesions that occur unilaterally. malignant OLP cases.12
a genetic predisposition to the disease. Histologically, OLR presents similarly to Due to its established role as a genomic
The initial response is an increased pro- OLP, with a larger proportion of diffuse guardian, the wild p53 protein has been
duction of cytokines produced by TH1 lymphocytic infiltrate, plasma cells, and connected to a low potential for malig-
lymphocytes with gene polymorphism citoid bodies.1-3,5,6 nant transformation in OLP cells.13 In
in molecules such as IFN- and TNF- Both OLP and OLR may exhibit a addition, it has been recently shown that
in oral and skin lesions. Another indica- band-like lymphocytic infiltrate that is the human TP53 gene encodes at least
tor of OLP pathogenesis is the presence not patognomonic, which is similar to 9 different isoforms; while the function
of dendritic cells (stromal plasmacytoids other autoimmune diseases such as lupus of these novel isoforms is still not clearly
and Langerhans), triggered by chemo- erythematous.1,5,6 The 2 conditions differ understood, they have been amplified
tactic agonists expressed in the vascular mainly in their outcome and the treatment (via a quantitative real-time polymerase
endothelium.1-3 modality: OLP lesions become chronic, reaction) in samples of SCC in the head
The INF-/TNF- cytokine production while OLR lesions tend to disappear as and neck.14 This could indicate a tumor-
induces cytotoxicity against keratinocytes, soon as the etiologic cause is eliminated.1,5,6 related role for these isoforms. Evaluating
by activating natural killer cells and cyto- The malignant potential of OLP the oncogenic potential by using different
toxic T lymphocytes, eventually resulting remains controversial. Some retro- markers could help researchers to analyze
in apoptosis via the Fas ligand pathway. spective studies and case reports have the ethiopathogenesis and potentially
This is caused by adhesion molecules documented OLP transforming into oral serve as a carcinogenic prognosticator for
such as VCAM and ICAM-1which squamous cell carcinoma (SCC), and these conditions. This study sought to
enable the activated T cells to migrate there are other studies on OLR malig- compare the expression of p53 protein in
to the oral epithelia or skin. The T cell nant transformation related to GVHD, OLP and OLR.

www.agd.org General Dentistry January/February 2015 69

Oral Medicine, Oral Diagnosis, Oral Pathology p53 expression in oral lichenoid lesions and oral lichen planus

Table 1. Anatomical locations of oral lichen planus (OLP) Table 2. Incidence of histological features found in the
and oral lichenoid reaction (OLR) in this study. OLP and OLR groups.

Anatomical location OLP (n = 31) OLR (n = 34) Histological feature OLP (n = 31) OLR (n = 34)
Buccal mucosa (bilateral occurrence) 14 0 Inflammatory band-like infiltrate 31 34
Buccal mucosa (unilateral occurrence) 1 9 Acanthosis 19 21
Internal lip 3 6 Basal cell degeneration 17 14
Maxillary alveolar ridge mucosa 1 5 Parakeratosis 3 15
Hard palate 3 3 Cytoid bodies 10 6
Dorsum of tongue 3 1 Orthokeratosis 9 5
Attached gingiva 2 2 Ulceration 4 7
Buccal vestibule mucosa 1 5 Epithelial atrophy 3 3
Others (retromolar area, soft palate, 3 3 Others (amalgam remnants, basal 4 7
floor of the mouth, ventral tongue, cell shedding, sialadenitis, vasculitis,
mandibular ridge mucosa) glandular fibrosis, ductal ectasia)

Materials and methods were made of the total cells and of the
The study population consisted of 65 marked cells in each field, and the mean Table 3. Histological location
biopsy cases31 diagnosed with OLP percentages of expression were calculated of p53 expression in the OLP
and 34 with OLR at the Oral Pathology for each case. Brown-stained cells were and OLR groups.
Laboratory, Faculty of Dentistry, Central considered positive, regardless of the
University of Venezuela. These cases were intensity of staining. Immunoreaction OLP OLR
analyzed and histologically classified intensity was recorded as mild, moderate, Histological location (n = 31) (n = 34)
according to Van der Meij et al.10 or strong. Basal cell layer 13 11
Paraffin embedded sections (3 m) The Ethics Committee of the Faculty of
Basal cell/infiltrate 9 2
were deparaffinized and subjected to Dentistry, Central University of Venezuela,
an antigen retrieval solution (pH = 6) approved the study. All patients signed a Inflammatory infiltrate 0 3
(Dako North America, Inc.) for 1 hour. written informed consent form. Basal/suprabasal 1 2
Endogenous peroxidase was blocked by Suprabasal/basal/ 1 0
immersing the sections in methanol and Statistical analysis infiltrate
3% hydrogen peroxide for 30 minutes. The p53 immunoreactivity was correlated
Submucosa 0 1
Next, a primary antibody p53 clone in the OLP and OLR groups, while vari-
in a 1:50 dilution (DO7, Dako North ablesincluding gender, age group, and
America, Inc.) was applied to the sec- anatomical sitewere analyzed separately.
tions for 30 minutes. A detection system A Fisher exact test was performed to assess
(EnVision, Dako North America, Inc.) the correlation between variables. The mucosa occurrence was bilateral in the
was utilized using diaminobenzidine for level of significance was determined to OLP group and unilateral in the OLR
10 minutes. Positive and negative controls be P < 0.05. The statistical analysis was group (Table 1).
were performed. performed using SPSS statistical software According to histological analysis, all
The slides were observed under light (version 16.0; SPSS, Inc.). cases of OLP and OLR showed similar
microscopy. Expression of the proteins findings of an inflammatory band-like
was studied by cell count in 4 high Results infiltrate and acanthosis. Basal cell liquefac-
magnification fields (40X). The immu- The distribution of OLP and OLR tion was evidenced in both groups. Citoid
noreactivity in each section was graded according to age was 59.5 (11.7) years bodies were present in 32.2% of the OLP
according to the number of positively and 57.0 (15.1) years in the OLP and cases, while parakeratosis was present in
stained nuclei in a field and grouped in OLR groups, respectively. Gender dis- 44.1% of the OLR cases (Table 2).
order from the least (-) to most (+++) tribution in the OLP group was 84.6% In terms of immunohistochemical analy-
positive reaction: <1% nuclei (-), up to female and 19.3% male; the distribution sis, p53 expression was observed in 77.4%
30% nuclei (+), 30%-70% nuclei (++), in the OLR group was 79.4% female and of the OLP cases and 55.9% of the OLR
and >70% (+++). Separate counts were 20.6% male. The buccal mucosa was the cases. However, the difference between the
made in the basal layer, suprabasal layers, most common anatomical site in both 2 groups was not statistically significant
and inflammatory infiltrate. Counts groups. With 1 exception, the buccal (P = 0.114).

70 January/February 2015 General Dentistry www.agd.org

Fig. 1. A sample of oral lichen planus (OLP) with p53 expression at Fig. 2. A sample of oral lichenoid reaction (OLR) with p53
the basal cell layer and an inflammatory infiltrate (immunostain, expression at the basal cell layer and inflammatory infiltrate
magnification 20X). (immunostain, magnification 20X).

Fig. 3. A sample of OLP with nuclear immunolocalization of p53 at Fig. 4. A sample of OLR with nuclear immunolocalization of p53
the basal cell layer (immunostain, magnification 40X). at the basal cell layer and inflammatory infiltrate (immunostain,
magnification 40X).

For both groups, nuclear p53 immuno- These positively stained nuclei were data were consistent with the OLP and
localization was most common at the basal located mainly in the basal cell layer OLR epidemiology previously documented
cell layer. Basal cell/infiltrate locations were (Fig. 3 and 4). in the literature.1 In terms of anatomical
seen in 29.0% and 5.9% in the OLP and The intensity of the stain was mild to location, the buccal mucosa was the most
OLR groups, respectively (Table 3). It is moderate in the majority of cases: mild common site in both groups, in agreement
noteworthy that p53 positivity was found staining was found in 25.8% and 20.6% with the literature.1-4 Bilateral occurrence
both alone and in combination with other of the OLP and OLR groups, respectively; was a common feature among the OLP
histological localizations (Fig. 1 and 2). moderate staining was found in 29.0% cases in this study, as it is in the literature.1
Immunostaining at 40X magnification and 20.5% of the OLP and OLR groups, White striations were observed in
revealed that p53 was similarly expressed respectively. There was strong intensity both groups. The appearance of these
in both groups. The results showed that staining in 22.6% and 14.7% of the OLP asymptomatic striations are considered
38.7% and 26.5% were graded (+) in and OLR cases, respectively. to be a good clinical prognostic for
the OLP and OLR groups, respectively; malignant transformation.1-5 Lesions
25.8% and 20.6% were graded (++) in Discussion symptomatic of erosion/ulcers were more
the OLP and OLR groups, respectively; Regarding the age group and gender distri- regularly observed in the OLR goup in
12.9% and 8.8% were graded (+++) in bution in the present study, women were comparison to the OLP group; the OLP
the OLP and OLR cases, respectively. more affected in the fifth decade. These cases presented nonpainful white plaque

www.agd.org General Dentistry January/February 2015 71

Oral Medicine, Oral Diagnosis, Oral Pathology p53 expression in oral lichenoid lesions and oral lichen planus

as a primary clinical sign. Based on similar The role of p53 as a prognostic marker 6. Cortes-Ramirez DA, Rodrguez-Tojo MJ, Gainza-Cirau-
studies, the presence of the erosive lesions for SCC, as well as other malignant qui ML, Martinez-Conde R, Aguirre-Urizar JM. Overex-
pression of cyclooxygenase-2 as a biomarker in
in the OLR group indicate a potential for disorders, has been widely documented.17
different subtypes of the oral lichenoid disease. Oral
malignant transformation.1,4 p53 positivity Sadafi et al reported a higher incidence Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;
was observed in the majority of the lesions of p53 and p21 in OLP patients, suggest- 110(6):738-743.
in both groups. While the OLP group ing a need for follow-up inspection on 7. Accurso BT, Warner BM, Knobloch TJ, et al. Allelic im-
had a higher percentage of p53 positivity, these cases.18 Although previous studies balance in oral lichen planus and assessment of its
classification as a premalignant condition. Oral Surg
the difference between the 2 groups was have indicated that OLR is more likely Oral Med Oral Pathol Oral Radiol Endod. 2011;112(3):
deemed not to be statistically significant. to become malignant than OLP, the 359-366.
The data in this study suggests an anti- follow-up of OLP patients should not be 8. Kumagai K, Horikawa T, Gotoh A, et al. Up-regulation
apoptotic potential at the basal cell layer. dismissed readily, since these cases may of EGF receptor and its ligands, AREG, EREG, and HB-
EGF in oral lichen planus. Oral Surg Oral Med Oral
Under normal conditions, the epithelia also present an oncogenic potential.18,19
Pathol Oral Radiol Endod. 2010;110(6):748-754.
does not show apoptotic basal cells, but in The anti-p53 antibody, pAb240, recog- 9. Ramos-e-Silva M, Jacques CD, Carneiro SD. Premalig-
OLP and OLR, the lymphocytic stimula- nizes an evolutive preserved epitope that is nant nature of oral and vulval lichen planus: facts and
tion should lead to an apoptotic state in present on the p53 protein. This antibody controversies. Clin Dermatol. 2010;28(5):563-567.
these cells that produces an apoptotic uses inmmunoblots with denaturated 10. Van der Meij E, Schepman K, Van der Waal I. The pos-
sible premalignant character of oral lichen planus and
response as evidenced by the presence of extracts from human and animal models. oral lichenoid lesions: a prospective study. Oral Surg
Civatte bodies (cytoid bodies) and the Gonzalez-Moles et al found fewer positive Oral Med Oral Pathol Oral Radiol Endod. 2003;96(2):
hydropic degeneration of the epithelial OLP cases with pAb240 compared to the 164-171.
cells layer. The maintenance of a chronic p53 DO7 clone.13 Future studies may be 11. Agha-Hosseini F, Mirzaii-Dizgah I. p53 as a neoplas-
tic biomarker in patients with erosive and plaque like
inflammatory response at this level can necessary to verify these results.
forms of oral lichen planus. J Contemp Dent Pract.
result in cellular genome mutations that 2013;14(1):1-3.
lead to an alteration of this apoptotic Conclusion 12. Ebrahimi M, Nylander K, Van der Waal I. Oral lichen
response. One of these mutations may In this study, the OLP group showed more planus and the p53 family: what do we know? J Oral
be evidenced by the expression of altered positive p53 cases compared to the OLR Pathol Med. 2011;40(4):281-285.
13. Gonzales-Moles MA, Gil-Montoya JA, Ruiz-Avila I, Es-
p53 in the basal layer of the epithelium in group. Dentists should follow-up all OLP teban F, Bascones-Martinez A. Differences in the ex-
both diseases. This mutation can alter the and OLR cases, due to the possibility of pression of p53 protein in oral lichen planus based on
balance between the rate of epithelial cell malignant transformation. the use of monoclonal antibodies DO7 and pAb 240.
replication and apoptosis, resulting in the Oral Oncol. 2008;44(5):496-503.
14. Ebrahimi M, Boldrup L, Coates PJ, Wahlin YB, Bour-
emergence of malignancies.11 Author information don JC, Nylander K. Expression of novel p53 isoforms
Despite the small sample size in this Dr. Arreaza is an aggregate professor, in oral lichen planus. Oral Oncol. 2008;44(2):156-
study, the resultsin consideration of the Pharmacology Department, Faculty of 161.
widely accepted belief that the presence of Dentistry, Central University of Venezuela, 15. Gorsky M, Epstein JB. Oral lichen planus: malignant
white striations is a good prognostic for Caracas, where Drs. Rivera and Correnti transformation and human papilloma virus: a review
of potential clinical implications. Oral Surg Oral Med
malignant transformationindicate the are professors. Oral Pathol Oral Radiol Endod. 2011;111(4):461-464.
need for clinicians to follow-up on any inci- 16. Arreaza A, Correnti M, Avila M. Deteccion del virus
dence of white striations in OLP patients, Disclaimer Epstein-Barr en lesiones de liquen plano bucal. Acta
and consider a new biopsy when any clini- The authors have no financial, economic, Odontol Vzla. 2010;48(3):1-9.
17. Georgakopoulou EA, Troupis TG, Troupis G, Gorgou-
cal changes appear or when erosive symp- commercial, and/or professional interests
lis VG. Update of the cancer-associated molecular
tomatic cases do not respond to therapy.1-5 related to topics presented in this article. mechanisms in oral lichen planus, a disease with pos-
Parakeratosis was a common histologic sible premalignant nature. J BUON. 2011;16(4):613-
characteristic in the OLR group (44%) References 616.
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2. Farhi D, Dupin N. Pathophysiology, etiologic factors,
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SCC.4,8,9,12 The etiology of this process dinal cohort study. Oral Surg Oral Med Oral Pathol Manufacturers
remains unknown, however protein Oral Radiol Endod. 2011;112(3):328-334. Dako North America, Inc., Carpinteria, CA
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72 January/February 2015 General Dentistry www.agd.org

Dental Materials

Effect of imaging powders on the bond strength

of resin cement
Christopher R. Jordan, DMD, MS n Clifton W. Bailey, DDS n Deborah L. Ashcraft-Olmscheid, DMD, MS n Kraig S. Vandewalle, DDS, MS

The application and incomplete removal of a computer-aided design/ A self-adhesive resin cement was bonded to the surfaces and loaded to
computer-aided manufacture imaging powder may affect the dentin failure in a universal testing machine after 24 hours of storage. Data was
surface prior to bonding a ceramic restoration. The purpose of this study analyzed with Kruskal-Wallis and Mann-Whitney nonparametric tests.
was to compare the effect of imaging powder residue on the shear bond The bonding to dentin surfaces of the powder groups that were rinsed for
strength of a self-adhesive resin cement to dentin. Mounted human third 1 or 10 seconds were not significantly different from each other or the
molars were sectioned coronally with a diamond saw to expose the den- nonpowdered control. The type of imaging powder did not significantly
tin, which was then prepared with a diamond bur mounted in a custom affect the bond strength. The nonrinsed powdered dentin surface had a
jig. The dentin surface was sprayed with 3 different imaging powders. significant reduction in bond strength compared to both the control and
The 3 powder groups were then divided into 3 subgroups based on the the rinsed powdered surfaces.
method of powder removal: no rinse, 1-second rinse, and 10-second rinse. Received: April 18, 2013
A control group was created that had no application of imaging powder. Accepted: July 17, 2013

he notion of computer-aided design/ longevity of posterior dental restorations In order for the CEREC camera to
computer-aided manufacture (CAD/ was dependent upon many factors related capture an accurate image, the surface or
CAM) dentistry was first introduced to the chosen materials, the patient, and object to be scanned must be as uniform
in the late 1970s by Duret.1 In 1987, the dentist. According to a 2001 study, as possible in its reflectivity. To accom-
Sirona Dental Systems, Inc. released the annual failure rates in posterior stress- plish this, a titanium dioxide powder is
first version of a chairside economical bearing restorations were: 0% to 7.0% typically used to coat the area. The E4D
restoration of esthetic ceramics (CEREC) for amalgam restorations, 0% to 9.0% (Planmeca E4D Technologies) is a chair-
technology.2 Since then, this all-ceramic for direct composites, 1.4% to 14.4% for side imaging and milling system that cre-
restoration treatment has been simplified glass ionomers and derivatives, 0% to ates a digital impression from an intraoral
and improved, and numerous systems 11.8% for composite inlays, 0% to 7.5% scan without the use of reflective powder.
have been developed and marketed.2 for ceramic restorations, 0% to 4.4% for The new CEREC Omnicam (Sirona
The most advantageous aspect of this CAD/CAM ceramic restorations, and 0% Dental Systems, Inc.) also functions
technology is the capability to create and to 5.9% for cast gold inlays and onlays.20 without application of imaging powder.
mill a restoration in the dental office, The principle reasons for failure were sec- Other systems, such as iTero (Align
thus reducing costs and streamlining ondary caries, fracture, marginal deficien- Technology, Inc.) and Lava C.O.S. (3M
treatment. As of 2009, there were approx- cies, wear, and postoperative sensitivity.20 ESPE), are used exclusively for digital
imately 25,000 CEREC users world- The type of luting agent is considered to impressions. Whereas the iTero system
wide.2,3 CAD/CAM is also being used to be one of the key factors in determining a does not require powder, the Lava C.O.S.
restore endodontically treated teeth with restorations longevity.26,27 requires a light dusting.
endocrowns and in conjunction with cone A critical step in any indirect restora- The improper use of imaging powder is
beam volumetric tomography to plan and tion is the capture of the preparation in a possible source of error when fabricat-
restore dental implants.4,5 an impression. When using a CAD/CAM ing a CEREC 3D restoration.29 The coat-
Very little research, however, has been system to mill a restoration, the impres- ing can be sprayed on with a delivery unit
done to support specific methods and sion is made by using a camera to digitally such as PowderPro (Advanced Dental
standard processes for the restorative den- scan the tooth (or a cast), then using a Instruments LLC), painted on using
tist. Additionally, manufacturers produce computer program to virtually design the a liquid such as Scan Film (Dentaco
a variety of materials that can be used at restoration. The CEREC 3D AC (Sirona As), or sprayed on with a self-contained
different steps. The practitioner is tasked Dental Systems, Inc.) system uses a camera propellant and powder system such
with selecting the imaging powder and that projects blue wavelength light over as Optispray (Sirona Dental Systems,
cement that have the best performance the area to capture all of the dimensions of Inc.).30 Cameras record an over-powdered
properties. The majority of the research the preparation and surrounding teeth and surface as uneven, whereas one with too
to date has been focused on the proper- tissues. The blue wavelength light report- little powder does not adequately reflect
ties of the restoration itself, as well as the edly provides a higher resolution image light. The CEREC 3D camera must be
marginal adaptation, retention, or dura- than the infrared camera used in earlier positioned appropriately as well. If the
bility of a particular cement.6-26 A review systems, such as the CEREC 3D AU camera is not properly oriented in the
of these clinical studies found that the (Sirona Dental Systems, Inc.).28 path of insertion to allow capturing all

www.agd.org General Dentistry January/February 2015 73

Dental Materials Effect of imaging powders on the bond strength of resin cement

margins, without undercuts, the scan for the use of imaging powder and resin to be tested were that there would be no
will not capture the necessary data to cements with a milled all-ceramic restora- significant differences in the bond strength
accurately allow the restoration to be tion using CEREC 3D. of the self-adhesive resin cement to dentin
properly designed. RelyX Unicem (3M ESPE) is a dual- based on the amount of rinsing, or the
As an alternative to intraoral scanning, curing, self-adhesive resin luting cement type of imaging powder.
the practitioner can make a conventional for adhesive cementation of indirect
impression and scan the impression, composite, metal, or ceramic restora- Materials and methods
thereby designing the prosthesis from an tions.36 Self-adhesive resin cements do Extracted human third molars stored
image captured indirectly. A cast may be not require a separate adhesive or etchant, in 0.5% chloramine-T were used within
fabricated using a scannable stone mate- which can be considered a major benefit 6 months following extraction. The teeth
rialthat is made specifically for indirect due to their simplicity of application com- were mounted in dental stone in plastic
optical imagingsuch as Diamond Die pared to more traditional resin cements. pipe with the crown exposed and acces-
(Hi-Tec Dental Products)which allows Relatively little information exists about sible. A diamond saw (Isomet, Buehler)
the clinician to eliminate the intraoral the composition and adhesive mechanism was used to remove 2 mm coronal tooth
use of a powder spray and scanning. of these materials. The current self- structure to ensure dentin exposure and
However, the impression and cast fabrica- adhesive cements are 2-part materials that the proper orientation of the surface
tion requires an additional step, which require hand mixing, capsule trituration, relative to the direction of shear force
adds time to the procedure but may result or auto-mixing with a dispenser.37 Bond applied. Each specimen was examined
in a more precise scan. A study by da strengths vary among self-adhesive resin under a stereomicroscope (SMZ-1B,
Costa et al compared the marginal gap cements. Etch-and-rinse cements generally Nikon USA) at 10X magnification to
created with a direct intraoral scan with provide the greatest retention.37,38 Self- ensure complete exposure of the dentin
that of an indirect scan of a model and etching cements provide an intermediate surface with no residual enamel. To sim-
found no significant difference.31 Another level, while self-adhesive cements are the ulate a prepared surface, the flat dentin
study, however, found that extraoral least retentive.37 The vast majority of the was roughened with a fine diamond bur
optical scanning methods provided the published literature describes one cement, (No. 837, Brasseler USA) under water
highest precision.32 Rely-X Unicem, which was the first com- spray with a jig that was used to support
When using powder, Sirona Dental mercially available self-adhesive resin the height of the handpiece head with the
Systems, Inc. recommends their product, cement.36,38 Rely-X Unicem has 2 compo- surface of the tooth specimen.
CEREC Optispray, but there are powders nents: a powder composed of glass, silica, The mounted specimens were then
on the market that contain a reflective calcium hydroxide, pyrimidine, peroxy divided into 4 groups: 3 powder groups
compound other than titanium dioxide. compound, and initiator; and a liquid VITA CEREC Powder, CEREC Optispray,
Possible alternatives include an economi- composed of methacrylated phosphoric and Occludeand 1 group that was
cal magnesium stearate spray (Occlude, ester, dimethacrylate, acetate, stabilizer, not powdered and served as a control.
Pascal International, Inc.) marketed and initiator.36,38 Studies have suggested Manufacturers directions were followed
specifically as an aid for seating castings.33 that Unicem shows nearly equivalent in the application of the powder. For the
However, no research has been published results to other resin cements in terms CEREC Powder application, the glycerin
evaluating the use of Occlude as an alter- of marginal sealing and adaptation.38 coating was first placed with a brush and
native intraoral imaging powder for use However, a separate phosphoric-acid gently air-thinned. Next, the VITA CEREC
with a CEREC 3D system. etch of enamel margins has been shown Powder was applied using a PowderPro
The application and incomplete removal to improve bond strength.39 A review of system (Advanced Dental Instruments
of an imaging powder may affect the studies evaluating the physical properties LLC). The PowderPro system was attached
bonding of the restoration to the dentin of self-adhesive resin cements suggest that to the handpiece hose of a dental delivery
surface. CEREC manufacturers instruct these materials may be expected to show unit and the VITA CEREC Powder was
the dentist to clean the surface with air/ similar clinical performance as other dental delivered through a nozzle on the hand-
water spray, but do not provide detailed cements, but clinical studies are lacking, so piece with the use of a foot pedal. CEREC
directions. There is no current literature long-term conclusions are not possible.38 Optispray and Occlude are self-contained
that shows whether an air/water rinse Self-adhesive resin cements have a signifi- canister systems, and therefore did not
adequately removes the powder residue cant reduction in dentin bond strength require an adhesive-type first coating or use
and whether any remaining residue will when the dentin is etched with phosphoric of the PowderPro system.33,35 All powders
affect the cement bond. Some systems, acid and a bonding agent is applied.37 were applied according to the manufactur-
such as VITA CEREC Powder (Vident), The effect of imaging powder and its ers instructions with the applicator tip at a
rely on the application of glycerin to coat effective removal on the bond strength of standardized distance of 1 inch.
the surface prior to applying the powder.34 resin cement to dentin is unknown. The The 3 powder groups were then divided
Most other self-contained systems, such as purpose of this study was to compare the into 3 subgroups (n = 10) based on the
CEREC Optispray, do not require the sep- effects of imaging powder residue on the method of powder removal: no rinse,
arate application of a coating.35 The intent shear bond strength of a self-adhesive resin 1-second rinse, and 10-second rinse. The
of this study was to provide guidance cement to dentin. The null hypotheses teeth were rinsed with distilled water

74 January/February 2015 General Dentistry www.agd.org

Chart 1. Shear bond strength (MPa) and standard deviation (SD) of self- Shear bond strength values (MPa) were
adhesive resin cement (RelyX Unicem) to dentin after treatment with calculated from the peak load of failure
3 imaging powders (VITA CEREC Powder, CEREC Optispray, and Occlude) and (Newtons) divided by the specimen surface
subsequent rinse of different durations (no rinse, 1 second, and 10 seconds). area.The mean and standard deviation
were determined for each group. Data were
14 analyzed with Kruskal-Wallis and Mann-
No rinse Whitney statistical tests. Nonparametric
12 1 second data analysis was used since an exploratory
10 seconds
graphical analysis found a non-normal
Shear bond strength (MPa)

distribution of the data. A Bonferroni cor-
rection was applied because multiple com-
parison tests were performed ( = 0.008).
6 Following shear bond strength testing,
each specimen was examined using a
4 stereomicroscope (magnification 10X) to
determine failure mode as either: adhesive
2 fracture at the cement/adhesive/dentin
interface, cohesive fracture in cement,
0 mixed (combined adhesive and cohesive
VITA CEREC Powder CEREC Optispray Occlude Control
fracture) in either the cement-bond
interface or the dentin-bond interface, or
cohesive fracture in dentin.
Chart 2. Percent fracture mode by powder and rinse groups.
The nonrinsed powdered dentin surface
VITA CEREC Powder no rinse
had a significant reduction in bond strength
VITA CEREC Powder 1 sec compared to the control (nonpowdered) or
VITA CEREC Powder 10 sec the rinsed powdered surfaces (P < 0.008).
CEREC Optispray no rinse
The dentin surfaces that were rinsed for
1 or 10 seconds were not significantly dif-
CEREC Optispray 1 sec
ferent from the control or from each other.
CEREC Optispray 10 sec
There was no significant difference in the
Occlude no rinse bond strength of resin cement to dentin
Occlude 1 sec based on the type of powder (P > 0.086)
Occlude 10 sec
(Chart 1). The nonrinsed groups failed
primarily with adhesive fractures while the
No powder rinsed groups failed primarily with adhesive
0 20 40 60 80 100 and mixed fractures (Chart 2).
Adhesive Cohesive cement Mixed Cohesive dentin Discussion
The manufacturers instructions for
CEREC Optispray advise the user that
as soon as the optical impression has
using a 3-way syringe tip at a standard- Irradiance of the curing light was moni- been taken, the surface should be cleaned
ized distance of 1 inch. A custom-made tored with a radiometer (LED Radiometer, with air/water spray.35 But no published
vinyl polysiloxane jig was used to main- Kerr Corporation) to verify irradiance levels articles could be found that had studied
tain the distance and angle. above 1200 mW/cm2. The bonding area the amount of rinse time required to
The tooth specimens were then placed was limited to a 2.4 mm diameter circle remove imaging powders.
in an Ultradent Jig and secured beneath determined by the Delrin insert. Following The first null hypothesis of this study
the white nonstick Delrin insert (Ultradent the application of the resin cement, all spec- was rejected; there was a significant dif-
Products, Inc.).The dual-curing resin imens were stored for 24 hours in distilled ference in bond strength of resin cement
cement was mixed and applied into the water at 37C. The specimens were then to dentin based on rinse, though not
mold according to the manufacturers loaded perpendicularly at the interface with the duration of the rinse. The results of
instructions to a height of 4 mm. The a customized probe (Ultradent Products, this study suggest that a rinse time of
cement was cured as recommended by Inc.) in a universal testing machine (Instron 1 second is sufficient to remove imaging
the manufacturer using a Bluephase 16i Corp.) and tested with a crosshead speed of powder residue. However, a rinse time
light-curing unit (Ivoclar Vivadent, Inc.). 1 mm/min until bonding failure occurred. of 0 (the nonrinsed groups) displayed

www.agd.org General Dentistry January/February 2015 75

Dental Materials Effect of imaging powders on the bond strength of resin cement

significantly lower bond strengths. The adequate for removal of the 3 tested 11. Fasbinder DJ, Dennison JB, Heys DR, Lampe K. The clin-
failure mode for the nonrinsed groups powders. The amount of residue that ical performance of CAD/CAM-generated composite
inlays. J Am Dent Assoc. 2005;136(12):1714-1723.
was almost entirely adhesive fracture, remained after rinsing with water did not
12. Fasbinder DJ. Restorative material options for CAD/
suggesting a weaker interface, while the significantly affect bond strength. CAM restorations. Compend Contin Educ Dent. 2002;
1- and 10-second rinse groups primarily 23(10):911-916, 918, 920, passim.
displayed adhesive and mixed fractures, Author information 13. Griggs JA. Recent advances in materials for all-ceramic
which was similar to the control group. Maj Jordan is a general dentist at Shaw restorations. Dent Clin North Am. 2007;51(3):713-
727, viii.
The second null hypothesis was not AFB, SC, Lt Col Bailey is the director of 14. Reich S, Hornberger H. The effect of multicolored ma-
rejected in this study. There was not a Senior Resident Education and Training, chinable ceramics on the esthetics of all-ceramic
significant difference in bond strength Lt Col Ashcraft-Olmscheid is the direc- crowns. J Prosthet Dent. 2002;88(1):44-49.
of resin cement to dentin based on the tor of Prosthodontics Education, and 15. Sulaiman F, Chai J, Jameson LM, Wozniak WT. A com-
parison of the marginal fit of the In-Ceram, IPS Em-
type of powder despite the fact that the 3 Col (ret) Vandewalle is the director of
press, and Procera crowns. Int J Prosthodont. 1997;
imaging powders differed greatly. While Dental Research, Advanced Education 10(5):478-484.
Optispray is a self-contained propel- in General Dentistry Residency, US 16. Kassem AS, Atta O, El-Mowafy O. Combined effects of
lant, CEREC Powder is applied with Air Force Postgraduate Dental School, thermocycling and load-cycling on microleakage of
a delivery unit such as the PowderPro JBSA-Lackland, Texas and Uniformed computer-aided design/computer-assisted manufacture
molar crowns. Int J Prosthodont. 2011;24(4):376-378.
after the application of a glycerin coat- Services University of the Health Sciences, 17. El-Badrawy W, Hafez RM, El Naga AI, Ahmed DR.
ing.34,35 Occlude has not been marketed Bethesda, Maryland. Nanoleakage of self-adhesive resin cements used in
as an imaging powder and contains bonding CAD/CAM ceramic material to dentin. Eur J
magnesium stearate instead of titanium Disclaimer Dent. 2011;5(3):281-290.
18. Bernhart J, Schulze D, Wrbas KT. Evaluation of the clin-
dioxide as found in traditional imaging The views expressed in this study are
ical success of CEREC 3D inlays. Int J Comput Dent.
powders.33 Occlude was utilized in this those of the authors and do not reflect 2009;12(3):265-277.
study as it has been considered an eco- the official policy of the United States Air 19. Boening KW, Wolf BH, Schmidt AE, Kastner K, Walter
nomical alternative to existing imaging Force, the Department of Defense, or the MH. Clinical fit of Procera AllCeram crowns. J Prosthet
powders. This study did not attempt to United States Government. The authors Dent. 2000;84(4):419-424.
20. Hickel R, Manhart J. Longevity of restorations in poste-
evaluate Occlude as an imaging powder do not have any financial interest in the rior teeth and reasons for failure. J Adhes Dent. 2001;
and cannot make any conclusion as to companies whose materials are discussed 3(1):45-64.
its efficacy for that purpose. Future in this article. 21. Isenberg BP, Essig ME, Leinfelder KF. Three-year clinical
research could focus on magnesium evaluation of CAD/CAM restorations. J Esthet Dent.
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surfaces and margins. 1. Birnbaum NS, Aaronson HB. Dental impressions using
CEREC ceramic inlays: a systematic review. Dent Ma-
3D digital scanners: virtual becomes reality. Compend
Self-adhesive resin cements such as ter. 1999;15(1):54-61.
Contin Educ Dent. 2008;29(8):494, 496, 498-505.
Unicem do not require an acid-etch step 2. Christensen GJ. Impressions are changing: deciding 23. Magne P, Schlichting LH, Paranhos MP. Risk of onlay
prior to bonding.36 When using etch-and- fracture during pre-cementation functional occlusal
on conventional, digital or digital plus in-office mill-
tapping. Dent Mater. 2011;27(9):942-947.
rinse type resin cements, imaging powder ing. J Am Dent Assoc. 2009;140(10):1301-1304.
24. Magne P, Paranhos MP, Schlichting LH. Influence of
may be removed more thoroughly than 3. Bernhart J, Brauning A, Altenburger MJ, Wrbas KT. Cer-
material selection on the risk of inlay fracture during
ec3D endocrownstwo-year clinical examination of
with self-adhesive cements. Remaining CAD/CAM crowns for restoring endodontically treated pre-cementation functional occlusal tapping. Dent Ma-
residue was observed to result in more molars. Int J Comput Dent. 2010;13(2):141-154. ter. 2011;27(2):109-113.
25. Ozturk AN, Inan O, Inan E, Oztrk B. Microtensile bond
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strength of cad-cam and pressed-ceramic inlays to
tested were relatively flat, but roughened ogies for comprehensive implant dentistry. J Am Dent
dentin. Eur J Dent. 2007;1(2):91-96.
with a diamond bur to simulate intraoral Assoc. 2010;141(Suppl 2):20S-24S.
26. Hill EE, Lott J. A clinically focused discussion of luting
5. Giordano R. Materials for chairside CAD/CAM-pro-
tooth preparation. Clinically, less efficient duced restorations. J Am Dent Assoc. 2006;137(Suppl): materials. Aust Dent J. 2011;56(Suppl 1):67-76.
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coating on adhesion and microleakage of computer-
when rinsing 3-dimensional preparations 6. Fasbinder DJ. Materials for chairside CAD/CAM resto-
aided design/computer-aided manufacturing fabricat-
(with vertical surfaces and more box-like rations. Compend Contin Educ Dent. 2010;31(9):702-
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704, 706, 708-709.
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10. FasbinderDJ. Clinical performance of chairside CAD/
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32. Trifkovic B, Todorovic A, Lazic V, Draganjac M, Mirkovic Align Technology, Inc., San Jose, CA There is another article on
N, Jokic B. Accuracy of optical scanning methods of 800.577.8767, www.itero.com DENTAL MATERIALS
the CEREC 3D system in the process of making ceram- Brasseler USA, Savannah, GA in the online edition.
ic inlays [in Serbian]. Vojnosanit Pregl. 2010; 67(10): 800.841.4522, www.brasselerusa.com
812-818. Impact of toothbrushing with
Buehler, Lake Bluff, IL
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Available at: http://www.pascalinternational.net/ 800.283.4537, www.buehler.com a dentifrice containing calcium
Products/48-occlude.aspx. Accessed November 6, 2014. Dentaco As, Haukeland, Norway peroxide
34. Vident. VITA CEREC Powder [product information]. 47.5525.4090, www.dentaco.no on enamel
Available at: http://www.pascalinternational.net/ Hi-Tec Dental Products, Inc., Lenoir City, TN color and
Products/48-occlude.aspx. Accessed November 6, 2014. 800.859.2006, www.hi-tecdental.com
35. Sirona Dental Inc. USA. CEREC Optispray [product in-
Instron Corp., Norwood, MA
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materials/?tab=3095. Accessed November 6, 2014 Ivoclar Vivadent, Inc., Amherst, NY
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www.agd.org General Dentistry January/February 2015 77

Implant Maintenance

Crestal approach for removing a migrated dental

implant from the maxillary sinus: a case report
Raid Sadda, DDS, MS, MFDRCSI

This article reports a rare case of a horizontally displaced dental implant Received: February 21, 2013
that migrated into the maxillary sinus 6 months after 3 implants were Accepted: June 24, 2013
inserted into the augmented maxillary posterior region. Migration of
dental implants into the maxillary sinus usually occurs during surgery and Key words: radicular cyst, maxillary sinus augmentation,
can result in serious complications. removal of migrated dental implant

hile dental implants have Under local anesthesia, 3 machined 2 clinical cases involving intraosseous
revolutionized the practice of implants were then placed at the site apical movement of an implant several
modern dentistry, they can also of the first molar and 2 premolars with years after placement.4
be problematic, especially when placed initial stability. A radiograph taken 1 week According to Pagella et al, the incidence
in the posterior maxilla. Implants in this postimplantaion confirmed the stability of metallic foreign bodies in the maxil-
area have an increased risk for failure of the implants (Fig. 3). A radiograph lary sinus has increased following the
because of low bone density and shortness taken 5 months later revealed a horizontal development of osseointegrated implants
of the alveolar ridge.1 The reasons dental migration of the implant from the site of to treat edentulous cases.5 A 2000 article
implants may migrate into the maxillary the first molar into the maxillary sinus recommended immediate removal of
sinus are the lack of initial stability during (Fig. 4). Local anesthesia was administered failed implants that have migrated into
the surgery, poor bone quality, orthe through a crestal incision, a mucoperiostal the maxillary sinus.6
most common factorlocal tissue infec- flap was raised, and part of the crestal The real reasons why dental implants
tion around the implant.1 The surgeon bone was removed (Fig. 5). At this point, migrate from their initial placement toward
must be able to manage problems that the migrated implant was seen at the floor the maxillary sinus are unknown. This
arise intraoperatively as well as those that of the sinus (Fig. 6). The implant was migration may be a technical issue related
develop postoperatively. grasped with a hemostat and removed to poor surgical preparation, drilling, or
from the sinus. The space remaining was implant placement. Lack of bone thick-
Case report irrigated; a collagen membrane was placed ness/density of an edentulous posterior
A 55-year-old man was referred to a pri- over the mucosa, and a corticocancellous maxillary segment has been proposed as an
vate dental office to have implants placed bone graft was placed and covered with explanation for inadequate implant stability
in the maxillary posterior edentulous area. a nonresorbable membrane. The wound and anchorage. Previously reported cases
Pantomograph and periapical radiographs was closed with chromic gut sutures. of dental implant migration indicated that
showed a large radiolucent lesion at the Postoperative prescription and instruc-
periapical areas of the nonrestorable maxil- tions were given. The patient tolerated
lary first and second right premolars; the the procedure well, with minimal facial
lesion extended to the maxillary sinus swelling and pain.
(Fig. 1). A computed tomography scan
confirmed the diagnosis (Fig. 2). Discussion
After local anesthesia was administered, Implants placed in the posterior maxilla
the premolars were removed and the large can fail due to the low density of the bone
lesion enucleated completely from the in that area. There are a few reports in
maxilla and maxillary sinus by separating the literature involving dental implants
the maxillary sinus mucosa from the cystic migrating into the maxillary sinus.1-6 A
lining. The lesion was sent for histopatho- 1992 article by Ueda & Kaneda reported
logic analysis and it was determined to a case of maxillary sinusitis caused by
be a radicular dental cyst. The remaining a displaced connection screw 2 months
space was filled with a corticocancellous after implant placement.1 Quiney et al
bone graft which was extended to fill reported a case of implant displacement
part of the maxillary sinus. In addition, 2 weeks postinsertion.2 More recently,
a nonresorbable membrane was placed Haben et al reported the displacement of Fig. 1. A preoperative radiograph showing a periapical
over the bone graft. No evidence of recur- a dental implant into the ethmoid sinus.3 lesion at the maxillary second premolar and a root
rence was observed 6 months postsurgery. A 2005 article by Galindo et al reported lesion at the mesial of the maxillary first premolar.

78 January/February 2015 General Dentistry www.agd.org

Fig. 2. A computed tomography scan confirming the presence of a periapical lesion.

Fig. 3. A radiograph taken 1 week Fig. 4. A radiograph taken 5 months Fig. 5. A crestal incision made to Fig. 6. The implant prior to removal by
after the insertion of 3 implants. postimplantation demonstrating the approach the implant at the floor of a hemostat.
migration of the implant into the the maxillary sinus.
maxillary sinus.

migrations may have been caused by the floor of the maxillary sinus, an alternative Surgery, New York University, New
dentists surgical technique, by an alveolar crestal approach was used.8 This approach York, and an attending oral surgeon, St.
infection or lesion that resulted in bone is minimally destructive to the maxillary Barnabas Hospital, Bronx, New York.
destruction, or by a particular bone weak- sinus, while reducing the risk of injury to
ness, such as osteoporosis or osteopenia.2,6 the maxillary artery (which is located at References
Various mechanisms have been pro- the lateral wall of the maxillary sinus). 1. Ueda M, Kaneda T. Maxillary sinusitis caused by dental
implant: report of two cases. J Oral Maxillofac Surg.
posed to explain the migration of an
implant into the maxillary sinus.7 These Conclusion 2. Quiney RE, Brimble M, Hodge M. Maxillary sinusitis
mechanisms can include changes in intra- Placing an implant in the posterior from dental osseointegrated implants. J Laryngol Otol.
sinal and nasal pressures, an autoimmune maxillawith or without sinus graft- 1990;104(4):333-334.
reaction to the implant (resulting in peri- ingcan offer a reasonably good 3. Haben CM, Balys R, Frenkiel S. Dental implant migra-
tion into the Ethmoid sinus. J Otolaryngol. 2003;32(5):
implant bone destruction and compro- prognosis; however, the procedure is not 342-344.
mised osseointegration), and resorption free of complications. An implant in a 4. Galindo P, Sanchez-Fernandez E, Avila G, Cutando A,
produced by an incorrect distribution of grafted area may increase both the risk Fernandez JE. Migration of implants into the maxillary
occlusal forces.7 of implant failure and migration to the sinus: two clinical cases. Int J Oral Maxillofac Implants.
In the present case, the implant maxillary sinus. To decrease the risk of
5. Pagella F, Emanuelli E, Castelnuovo P. Endoscopic ex-
migrated without being subjected to migration and complications, the dentist traction of a metal foreign body from the maxillary si-
occlusal forces, as the bone depth pre- should carefully study the radiographs nus. Laryngoscope. 1999:109(2 Pt 1);339-342.
vented integration of the implant prior before the second stage of implant sur- 6. Iida S, Tanaka N, Kogo M, Matsuya T. Migration of a
to second stage surgery. Bone loss in the gery in order to be aware of the quality dental implant into the maxillary sinus. A case report.
Int J Oral Maxillofac Surg. 2000;29(5):358-359.
augmented area led to implant failure. of the bone, implant stability, and the 7. Regev E, Smith RA, Perrott DH, Pogrel MA. Maxillary
The most common approach for remov- proper surgical technique indicated. sinus complications related to endosseous implants.
ing implants that have migrated into the Int J Oral Maxillofac Implants. 1995;10(4):451-461.
maxillary sinus involves a lateral-wall Author information 8. Akira Kitamura. Removal of a migrated dental implant
from a maxillary sinus by transnasal endoscopy. Br J
osteotomy; however, because the migrated Dr. Sadda is a clinical associate professor,
Oral Maxillofac Surg. 2007;45(5):410-411.
implant in the present case was close to the Department of Oral and Maxillofacial

www.agd.org General Dentistry January/February 2015 79



Exercise No. 343 Exercise No. 344 Exercise No. 345

January/February 2014, p. 42 January/February 2014, p. 61 January/February 2014, p. 73
1. B 2. D 3. A 4. D 1. B 2. C 3. B 4. A 1. C 2. D 3. B 4. D
5. C 6. C 7. A 8. D 5. C 6. A 7. C 8. B 5. B 6. C 7. C 8. B
9. C 10. D 11. C 12. A 9. B 10. A 11. B 12. B 9. C 10. C 11. B 12. D
13. B 14. D 15. A 13. B 14. A 15. D 13. C 14. B 15. A

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Cancer Screening

Ameloblastic carcinoma of the mandible

manifesting as an infected odontogenic cyst
Adepitan A. Owosho, BChD n Anitha Potluri, DMD n Richard E. Bauer III, DMD, MD n Elizabeth A. Bilodeau, DMD, MD, MSEd

Ameloblastic carcinoma (AC) is a rare malignant odontogenic tumor. distinguish them from their benign counterparts, some are more subtle
Although most ACs appear to originate de novo, some cases originate in their presentation. Therefore, it is important that dentists rule out
from a pre-existing ameloblastoma. This article presents the case malignancy in lesions that do not display obvious radiographic features.
of a 69-year-old man with an AC in the left body of the mandible. Received: April 8, 2013
Radiographically, the lesion resembled an odontogenic cyst surrounding Accepted: July 3, 2013
an impacted tooth. While ACs tend to have aggressive features that

n ameloblastic carcinoma (AC) although adjuvant radiation and/or The patient presented with periapical
is a rare malignant odontogenic chemotherapy and regional lymph node radiographs taken by the referring dentist.
tumor with a reported incidence of dissection have also been considered.6,23 A panoramic radiograph was obtained
1%-3%.1-4 In 1984, Slootweg & Muller This article presents a case involving the for further evaluation (Fig. 1). The radio-
proposed that the term ameloblastic carci- diagnosis and treatment of an AC. graphs revealed a full bony impaction of
noma should be used to designate lesions tooth No. 17, which was distoangularly
that exhibit features of both ameloblastoma Case report positioned. There was a uniform and
and carcinoma in either primary and/or A 69-year-old man was referred to the mildly enlarged radiolucent follicular space
metastatic lesions.5 Most ACs are presumed Department of Oral and Maxillofacial from the superior part of the crown to
to originate de novo, with some cases Surgery at the School of Dental the inferior and apical part of the tooth.
involving the malignant transformation of Medicine of the University of Pittsburgh, Expansion was noted toward the inferior
a pre-existing ameloblastoma.6 In 2005, the Pennsylvania for evaluation and defini- alveolar (IA) canal, pushing the IA in an
World Health Organization classified AC tive management of an impacted left inferior direction, with associated erosion
into 3 types: primary, secondary (intraosse- mandibular third molar, which had been in the superior cortex of the IA canal.
ous), and secondary (peripheral).7 A 2009 symptomatic for 2 months. The patient Mild sclerosis was noted at the posterior
study by Yoon et al reported 6 new cases stated that he had developed pain and an extent of the follicular lining and inferiorly
of AC.8 At that time, there were 104 cases infection in the lower left mandible. He within the radiolucency. A radiolucency
in the English literature; since then, several had previously sought treatment from his was also noted within the tooth coronally,
other cases have been reported.8-11 general dentist, who treated him with a consistent with internal resorption. No
The age of AC manifestation ranges course of antibiotics. lamina dura or follicle lining was noted
from 7 to 91 years with an average age of
53, although it is most frequently found
in patients after age 60, with a 2:1 male-
to-female predilection.9-11 The mandible is
involved more commonly than the max-
illa, with a posterior predilection, although
a rare case involving the anterior skull base
was reported in 2005.12
AC has aggressive clinical features, such
as pain, expansion of the jaw, and perfora-
tion of the cortex. It also may metastasize;
although the regional lymph nodes are
the most common site, distant metastases
to the lungs, brain, and liver have been
reported.8,9,13-21 In most cases, radiographic
findings reveal an ill-defined radiolucency,
often with scattered sites of focal radi-
opaque dystrophic calcification.11,14,15,19,22
Wide local resection (resulting in a
tumor-free margin of 10-15 mm) is Fig. 1. Preoperative panoramic radiograph of a 69-year-old man with an impacted left mandibular third molar
thought to be the treatment of choice; and inferior expansion of a lesion.

www.agd.org General Dentistry January/February 2015 e1

Cancer Screening Ameloblastic carcinoma of the mandible manifesting as an infected odontogenic cyst

Fig. 2. A photomicrograph of the patient, showing a Fig. 3. A photomicrograph of the patient, showing Fig. 4. A photomicrograph of the patient showed
tumor island with comedonecrosis. (H&E, magnifica- a tumor island with an increased number of mitotic increased positive staining, indicating a high
tion 200X). figures. (H&E, magnification 400X). proliferative index. (Ki-67, magnification 400X).

apically. Based on these findings, an ini-

tial diagnosis of an impacted tooth with
inflammation or a secondarily infected
cystic lesion was made. The left man-
dibular third molar was extracted and an
excisional biopsy was performed on the
associated lesion.
The histopathologic findings revealed
odontogenic tumor islands within a
fibrous stroma, exhibiting peripheral
palisading with nuclear polarization away
from the basement membrane. The central
cells were loose and discohesive, recapitu-
lating stellate reticulum. However, the
sections showed increased mitotic activity,
necrosis, and varying nuclear size, shape,
and staining (Fig. 2 and 3). No angiolym-
phatic or perineural invasion was present.
A Ki-67 staina proliferative immuno-
peroxidase markershowed an elevated
percentage of positive cells (Fig. 4). The
histologic sections, in conjunction with
immunophenotypic studies, supported the Fig. 5. A postextraction CBCT scan.
diagnosis of AC.
The patient returned for a follow-up
visit 1 week postsurgery; at that time,
a cone beam computed tomography
(CBCT) scan was taken. It revealed an distant metastases), a fluorodeoxyglucose Wide local resection of hard and soft
ill-defined radiolucency with areas of focal (FDG)-positron emission tomography tissue was planned. One month after
radiopacities and cortical disruption, con- image was performed, revealing elevated the initial biopsy, the patient underwent
sistent with postoperative surgical margins FDG uptake only in the left mandible. resection of the left mandible and
and the aggressive nature of the lesion There was no abnormal high uptake reconstruction with a secondary titanium
(Fig. 5). To investigate the presence of the anywhere else, suggesting no regional or reconstruction bar. This bar was used to
lesion in regional lymph nodes (as well as distant metastases. replate the mandible. Prior to surgery,

e2 January/February 2015 General Dentistry www.agd.org

Fig. 6. An intraoperative image of the patient 1 month postsurgery, after Fig. 7. Photograph of the 41 mm of bone and soft tissue resected surgically at the
placement of a secondary reconstruction bar. 1-month follow-up visit.

a stereolithic model was fabricated The clinical symptoms of AC are and Bilodeau are assistant professors,
and the secondary reconstruction bar more aggressive than those of its benign and Dr. Bauer is an assistant profes-
was pre-bent. Intraoperatively, 15 mm counterpart, ameloblastoma. However, sor with the Department of Oral and
margins were identified and 41 mm in the present case, the patients only Maxillofacial Surgery.
of bone and tissue were resected from symptom was pain of approximately
the left mandible (Fig. 6 and 7). The 2 months duration, persisting even after References
overlying periosteum and submucosa treatment with antibiotics. The radio- 1. Ladeinde al, Ajayi OF, Ogunlewe MO, et al. Odonto-
genic tumors: a review of 319 cases in a Nigerian
were removed. Full thickness mucosa graphic features of the present case were
teaching hospital. Oral Surg Oral Med Oral Pathol Oral
and submucosa was resected at the subtle, including mild enlargement of the Radiol Endod. 2005;99(2):191-195.
site of the extraction and biopsy. The follicular space, pushing of the IA canal 2. Taghavi N, Mehrdad L, Rajabi M, Akbarzadeh A. A
resulting orocutaneous communication inferiorly, and erosion of the superior 10-year retrospective study on malignant jaw tumors
was closed primarily. A silastic block was cortex, leading to a diagnosis of either in Iran. J Craniofac Surg. 2010;21(6):1816-1819.
3. Jing W, Xuan M, Lin Y. Odontogenic tumours: a retro-
inserted to maintain space for future an impacted tooth with inflammation spective study of 1642 cases in a Chinese population.
osseous reconstruction. or a secondarily infected cystic lesion. In Int J Oral Maxillofac Surg. 2007;36(1):20-25.
The resected segment was sent to the retrospect, these seemingly subtle features 4. Abiko Y, Nagayasu H, Takeshima M, et al. Amelo-
pathology department for definitive reflected an aggressive lesion. blastic carcinoma ex ameloblastoma: report of a
case-possible involvement of CpG island hypermeth-
histological examination. The previ-
ylation of the p16 gene in malignant transformation.
ous diagnosis of AC was confirmed; Conclusion Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
however, the anteromedial overlying This article presents a case of a mandibu- 2007;103(1):72-76.
submucosa demonstrated 2 islands of lar AC with an impacted third molar 5. Slootweg PJ, Muller H. Malignant ameloblastoma or
tumor. Due to these positive margins, a exhibiting subtle cystic radiographic fea- ameloblastic carcinoma. Oral Surg Oral Med Oral
Pathol. 1984;57(2):168-176.
wide local resection with a selective neck tures and mildly aggressive qualities. This 6. Suomalainen A, Hietanen J, Robinson S, Peltola JS. Am-
dissection and postoperative radiation case indicates that even though most ACs eloblastic carcinoma of the mandible resembling
therapy was planned. The subsequent have aggressive features delineating them odontogenic cyst in a panoramic radiograph. Oral Surg
specimen had negative margins with no from their benign counterparts, some can Oral Med Oral Pathol Oral Radiol Endod. 2006;101(5):
nodal involvement. appear subtle. Thus, care has to be taken
7. Barnes L, Eveson JW, Reichart P, Sidransky D, eds.
to rule out malignancy in lesions with World Health Organization Classification of Tumours:
Discussion subtle radiographic features. Head and Neck Tumours. Lyon, France: IARC Press;
AC is a rare malignant odontogenic tumor, 2005.
which is treated by wide surgical resection Author information 8. Yoon, HJ, Hong SP, Lee JI, Lee SS, Hong SD. Ameloblas-
tic carcinoma: an analysis of 6 cases with review of
with consideration for the possibility of Dr. Owosho is the chief resident, Oral the literature. Oral Surg Oral Med Oral Pathol Oral Ra-
adjuvant radiation and/or chemotherapy. and Maxillofacial Pathology, Department diol Endod. 2009;108(6):904-913.
Typically, cases of AC treated using con- of Diagnostic Sciences, School of Dental 9. Hall JM, Weathers DR, Unni KK. Ameloblastic carcino-
servative therapy have a high rate of recur- Medicine, University of Pittsburgh, ma: an analysis of 14 cases. Oral Surg Oral Med Oral
rence and death.9 Pennsylvania, where Drs. Potluri Pathol Oral Radiol Endod. 2007;103(6):799-807.

www.agd.org General Dentistry January/February 2015 e3

Cancer Screening Ameloblastic carcinoma of the mandible manifesting as an infected odontogenic cyst

10. Carnelio S, Solomon M, Manohar V. Ameloblastic carci- 17. Jindal C, Palaskar S, Kaur H, Shankari M. Low-grade
noma. A case report with review of literature. Indian J spindle-cell ameloblastic carcinoma: report of an un-
Dent Res. 2001;12(4):238-241. usual case with immunohistochemical findings and
11. Matsuzaki H, Katase N, Hara M, et al. Ameloblastic review of the literature. Curr Oncol. 2010;17(5):52-57.
carcinoma: a case report with radiological features of 18. Goldenberg D, Sciubba J, Koch W, Tufano RP.
computed tomography and magnetic resonance imag- Malignant odontogenic tumors: a 22-year experience.
ing and positron emission tomography. Oral Surg Oral Laryngoscope. 2004;114(10):1770-1774.
Med Oral Pathol Oral Radiol Endod. 2011;112(1):e40- 19. Bruce RA, Jackson IT. Ameloblastic carcinoma. Re-
e47. port of an aggressive case and review of the litera-
12. Ozlugedik S, Ozcan M, Basturk O, et al. Ameloblastic ture. J Craniomaxillofac Surg. 1991;19(6):267-271.
carcinoma arising from anterior skull base. Skull Base. 20. Simko EJ, Brannon RB, Eibling DE. Ameloblastic carci-
2005;15(4):269-272. noma of the mandible. Head Neck. 1998;20(7):654-
13. Akrish S, Buchner A, Shoshani Y, Vered M, Dayan D. 659.
Ameloblastic carcinoma: report of a new case, litera- 21. Infante-Cossio P, Hernandez-Guisado JM, Fernandez-
ture review, and comparison to ameloblastoma. J Oral Machin P, Garcia-Perla A, Rollon-Mayordomo A, Guti-
Maxillofac Surg. 2007;65(4):777-783. errez-Perez JL. Ameloblastic carcinoma of the maxilla:
14. Avon SL, McComb J, Clokie C. Ameloblastic carcinoma: a report of 3 cases. J Craniomaxillofac Surg. 1998;
case report and literature review. J Can Dent Assoc. 26(3):159-162.
2003;69(9):573-576. 22. Verneuil A, Sapp P, Huang C, Abemayor E. Malignant
15. Benlyazid A, Lacroix-Triki M, Aziza R, Gomez-Brouchet ameloblastoma: classification, diagnostic, and thera-
A, Guichard M, Sarini J. Ameloblastic carcinoma of the peutic challenges. Am J Otolaryngol. 2002;23(1):44-
maxilla: case report and review of the literature. Oral 48.
Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 23. Zwahlen RA, Gratz KW. Maxillary ameloblastomas:
104(6):e17-e24. a review of the literature and of a 15-year database.
16. Dhir K, Sciubba J, Tufano RP. Ameloblastic carcinoma J Craniomaxillofac Surg. 2002;30(5):273-279.
of the maxilla. Oral Oncol. 2003;39(7):736-741.

e4 January/February 2015 General Dentistry www.agd.org

Surgical Orthodontics

A large dentigerous cyst treated with decompression

and orthosurgical traction: a case report
Rodrigo Dias Nascimento, PhD n Fernando Vagner Raldi, PhD n Michelle Bianchi de Moraes, PhD n Paula Elaine Cardoso, PhD
Deborah Holleben, DDS

This article presents the case of an 8-year-old patient who presented with orthodontic treatment and surgery to allow access for orthodontic traction
a large radiolucency associated with the maxillary left canine and a super- of the permanent canine. More than 5 years post-treatment, no recur-
numerary tooth. A computed tomography scan showed the radiolucency rence was observed and the therapeutic option to position and preserve
was in close proximity to the roots of the anterior teeth, with no areas of the permanent canine was successful.
root resorption, and expansion into the left maxillary sinus. The boundar- Received: May 14, 2013
ies of the maxillary sinus floor were still preserved. After positive aspira- Accepted: July 23, 2013
tion of intralesional liquid and due to the large size of the radiolucency, a
decompression technique was selected to preserve the permanent canine. Key words: dentigerous cyst, decompression, eruption
Surgery was performed to remove the supernumerary tooth, followed by of teeth, unerupted maxillary canine

mong developmental odontogenic children may expand, causing retention of to distinguish between such a follicle and a
cysts, dentigerous cysts are the most the involved dental element and deforma- small dentigerous cyst.1 Furthermore, cystic
common; 20% of the epithelial cysts tion of the surrounding alveolar bone (with epithelium has metaplasia that is similar
in gnathic bones are dentigerous.1 The or without bone cortical expansion or to oral mucosa epithelium.3 The epithelial
dentigerous cyst originates at the separation displacement of dental roots and adjacent lining of a dentigerous cyst consists of 2-4
of the follicle that lies around the crown of anatomical structures). Due to their slow layers of nonkeratinized flattened cells, with
an impacted tooth, binding to the crowns and expansive evolution, these cysts essen- a flat interface between the epithelium and
cementoenamel junction.1 Its pathogenesis tially are asymptomatic; as a result, diagno- connective tissue.1 The capsule of fibrous
is unknown; however, it has been suggested ses are often due to radiographic findings.3 connective tissue is arranged loosely and
that it progresses through an accumulation Facial asymmetry may result from extensive contains an amorphous substance consisting
of fluid between the reduced enamel epi- injuries, although large dentigerous cysts of glycosaminoglycans, possibly accompa-
thelium and the tooth crown.1 are rare, and lesions supposedly diagnosed nied by small islands and strands of odonto-
Dentigerous cysts are primarily found in on the radiographic examination as large genic epithelial rests with an inactive aspect.1
children and adolescents (most frequently dentigerous cysts are revealed at the histo- For large cysts, marsupialization and
as a cystic lesion), although there is a high pathological examination as keratocystic decompression often are indicated as
incidence rate in the second and third odontogenic tumors or ameloblastomas.1 alternative therapies.3 These procedures
decades of life and a predilection for men Symptomatic lesions are generally the simplify the surgical procedure, assist in
and Caucasians.2 Dentigerous cysts in result of periapical inflammation of an the eruption of the involved tooth, and
overlying primary tooth, a periodontal minimize any adverse consequences.3 The
lesion that affects an adjacent tooth, or subsequent new bone formation after these
a bone break that causes disruption in procedures results in the decrease of the
communication with the oral cavity, nasal peripheral lesion size and directs the erup-
cavity, or maxillary sinuses.1 tion of the involved tooth.3 This article
It appears radiographically as a radiolu- analyzes a clinical decompression tech-
cent area, unilocular with a well-defined nique associated with surgical orthodontic
and usually sclerotic margin, associated treatment and its efficacy in treating
with the crown of an included tooth. In extensive lesions, allowing for the regenera-
order to differentiate a small dentigerous tion of bone defects and preservation of the
cyst from an enlarged dental follicle (which included dental elementresulting in its
also is located above an included tooth), it eruption in the oral cavity.
has been suggested that the typical space
around the crown of an included tooth is Case report
approximately 3-4 mm in diameter.1 An orthodontist referred an 8-year-old boy
In histopathologic analysis, a dental fol- with vestibular bulging in the region of the
licle surrounding the crown of an included maxillary left primary canine. The mucosa
Fig. 1. Clinical examination revealing a vestibular tooth appears as a thin layer of reduced had a normal appearance and there were
bulging in the region of the maxillary left canine. enamel epithelium, thus making it difficult no symptoms or crackling noises (Fig. 1).

www.agd.org General Dentistry January/February 2015 e5

Surgical Orthodontics A large dentigerous cyst treated with decompression and orthosurgical traction: a case report

Fig. 2. A panoramic radiograph of the 8-year-old patient at the initial visit showing a large Fig. 3. A computed tomography scan (coronal slice)
radiolucency associated with the maxillary left canine and a supernumerary tooth. revealing the lesion with expansive root displace-
ment of adjacent teeth.

Fig. 4. Aspiration of yellowish liquid after punch Fig. 5. Incision exposing the sealed cystic capsule. Fig. 6. The interior of the cyst after removal of the
biopsy. cystic capsule.

A panoramic radiograph revealed a radio-

lucent image at the maxillary left permanent
canine and a supernumerary tooth, both of
which were included (Fig. 2). To determine
the limits of the lesion, a computed tomog-
raphy (CT) scan was performed. The CT
scan revealed a lesion with expansive root
displacement of adjacent teeth (without
signs of resorption) while preserving the left
maxillary sinus floor (Fig. 3). Bone struc- Fig 7. The placement of furacin gauze pads and oral Fig. 8. Healed orifice before placement of a shutter.
ture did not change. The muscles in the oral mucosa suture on the borders of the orifice.
cavity had regular tomographic aspects and
the subcutaneous tissue had no appreciable
changes, suggesting an odontogenic cyst.
Based on the clinical examination and
imaging test results, an incisional biopsy The collected material was submitted (Fig. 8 and 9). At monthly follow-up
was scheduled, preceded by a punch to histopathological analysis, which con- visits, shutter reduction was performed,
biopsy. The punch biopsy collected a yel- firmed the diagnosis of odontogenic cyst. allowing for decompression as dem-
lowish liquid that contained suspended After 20 days, an acrylic shutter was onstrated by peripheral bone forma-
cholesterol crystals (Fig. 4). The decom- placed to maintain an open surgical tion. This progressive reduction was
pression was performed and the cystic cap- window, prevent the entrance of food, performed to the point that the cavity
sule fragments were collected. (Fig. 5-7). and facilitate cleaning by the patient was not deep enough to stabilize the

e6 January/February 2015 General Dentistry www.agd.org

Fig. 9. Acrylic shutter placed over the orifice to Fig. 10. Surgical removal of supernumerary tooth in Fig. 11. Surgical exposure and orthodontic traction
provide a surgical window. palate. of left maxillary canine.


Fig. 12. Histological aspects of dentigerous cyst.

Top. The fibrous cystic capsule exhibited numerous
bundles of collagen fibers associated with small
caliber vessels and small areas of bleeding (H&E,
magnification 200X). Bottom. Fibrous connective
tissue partially covered by non-keratinized stratified
squamous epithelium with 2 or 3 layers of flattened
cells and, in some cubic regions, with flat interface Fig. 13. Results 5 years and 2 months post-treatment. A. Panoramic radiograph showing the eruption of the
between epithelium and conjunctive tissue (H&E, left maxillary canine. B. Successful orthodontic traction of the maxillary left canine. C. Anterior photograph
magnification 100X). showing the erupted left maxillary canine.

shutter. At that time, the surgery was non-keratinized stratified squamous was observed, and the preservation and
scheduled for the enucleation of the epithelium, with 2-3 layers of flattened positioning of the maxillary left canine
remaining lesion. cells andin some cubic regionsa flat (with the aid of orthosurgical traction)
The patient subsequently underwent interface between the epithelium and was successful (Fig. 13).
surgical removal of the supernumerary conjunctive tissue. The fibrous cystic
tooth and orthodontic treatment in order capsule in the tissues contained numerous Discussion
to facilitate the orthodontic traction of the bundles of collagen fibers associated with Dentigerous cysts are associated with man-
maxillary left canine (Fig. 10 and 11). small caliber vessels and limited areas of dibular third molars, permanent canines,
Microscopic examination of the bleeding (Fig. 12). maxillary third molars, and second pre-
histological sections revealed fibrous Five years and two months post- molars; they also may be associated with
connective tissue covered partially by treatment, no recurrence of the lesion supernumerary teeth.1

www.agd.org General Dentistry January/February 2015 e7

Surgical Orthodontics A large dentigerous cyst treated with decompression and orthosurgical traction: a case report

Fenestration (a small opening of the Decompression and marsupialization Author information

cyst), marsupialization (a wide opening at both reduce lesion size and induce bone Drs. Nascimento, Raldi, and de Moraes
the equator of the cyst), and decompres- formation, minimizing the extent of are professors, Department of Diagnosis
sion with shutters are different methods secondary surgery by means of mitigating and Surgery, Sao Jose dos Campos Dental
that all work on the same principle.4 The pressure in the cystic cavity. It has also School, Sao Paulo State University,
difference between decompression and been observed that histological changes Brazil, where Dr. Holleben is a dentist
marsupialization has been established in have been observed after both procedures, and an intern, Oral and Maxillofacial
the literature. According to Tucker et al: as the cystic epithelium is replaced eventu- Surgery & Traumatology, and Dr.
ally by oral epithelium.4 Cardoso is a professor, Department of
Decompression and marsupialization, In the present case, decompression was Restorative Dentistry.
despite having the same function and the most appropriate treatment, due to
sharing the same basic principle of bone the large size of the cystic lesion in the oral References
regeneration, are two entirely different cavity. This technique made it possible 1. Waldron CA. Cysts and odontogenic tumors. In: Nev-
ille BW, Damm DD, Allen CM, Bouquot JE, eds. Oral
techniques. Although both of them have to preserve the permanent canine, which
and Maxillofacial Pathology. 3rd ed. St. Louis: Elsevier
the purpose of relieving the pressure in helps to establish and maintain the form Saunders; 2009:679.
the cystic cavity and allowing new bone and function of the dentition. The canines 2. Bastos EG, Cruz MC, Martins GA, Mendes MC,
formation, marsupialization is a one-stage presence in the dental arch is crucial for Marques RV. Marsupialization of mandibular dentiger-
surgery; decompression is a procedure of establishing balanced dynamic occlusion, ous cyst in a 7-year-old child in the mixed dentition:
case report [in Portuguese]. Rev Odontol UNESP. 2011;
two stages.5 esthetics, and facial harmony.9 40(5):268-271.
In the treatment of impacted teeth, 3. Berden J, Koch G, Ullbro C. Case series: treatment of
Marsupialization involves the opening it is possible to preserve them through large dentigerous cysts in children. Eur Arch Paediatr
of a window or surgical cavity on the cyst orthodontic planning; the treatment of Dent. 2010;11(3):140-145.
4. Martorelli S, Coelho E Jr, Marinho E, Albuquerque R,
wall, allowing the emptying of its contents choice is surgical exposure of the tooth
Martorelli F, Machado de Andrade F. Keratocyst odon-
while maintaining the continuity between and consequent orthodontic traction. togenic tumor of the jaw: case report and manage-
the cyst and the oral cavity. The maxillary However, after the extraction of primary ment analysis. Int J Dent Recife. 2009;8(1):50-56.
sinus or the nasal cavity may also need teeth and cyst decompression, there is the 5. Tucker WM, Pleasants JE, MacComb WS. Decompres-
emptying in cases of large cysts, impacted possibility of spontaneous eruption with- sion and secondary enucleation of a mandibular cyst:
report of case. J Oral Surg. 1972;30(9):669.
teeth associated with cysts in pediatric out orthodontic intervention. The poten- 6. Berti S de A, Pompermayer AB, Couto Souza PH, Tana-
patients, or for patients with systemic dis- tial tooth eruption also depends on the ka OM, Westphalen VP, Westphalen FH. Spontaneous
eases, such as the elderly.6 stage of its rooting. An impacted tooth eruption of a canine after marsupialization of an in-
Decompression seeks the same results without complete root formation and fected dentigerous cyst. Am J Orthod Dentofacial Or-
as marsupialization, but requires the an open apex has considerable eruption thop. 2010;137(5):690-693.
7. Giuliani M, Grossi BG, Lajolo C, Bisceglia M, Herb
placement of a device or intraoral drain potential.10 In cases with small or large KE. Conservative management of a large odontogen-
tube. The tube allows for irrigation of the cystic lesions and a permanent included ic keratocyst: report of a case and review of the liter-
cystic cavity, helping to prevent food and tooth, orthodontic evaluation and follow- ature. J Oral Maxillofac Surg. 2006;64(2):308-316.
microorganisms from accumulating in up are necessary.6 8. Maurette PE, Jorge J, Moraes M. Conservative treat-
ment protocol of odontogenic keratocyst: a preliminary
the area, which could lead to a secondary study. J Oral Maxillofac Surg. 2006;64(3):379-383.
infection. This technique provides for the Conclusion 9. Cappellette M, Cappellette M Jr, Fernandes LCM, de
permeability of the cystic cavity, since the In cases involving large dentigerous cysts Oliveira AP, de Oliveira WC. Caninos permanentes reti-
union of the cyst wall epithelium with the and the crown of a permanent tooth dos por palatino: diagnostico e terapeutica - uma
sugesto tecnica de tratamento. Revista Dental Press
mucosa derives from the exteriorization of where extraction is not indicated and the
de Ortodontia e Ortopedia Facial. 2008;13(1):60-73.
the injury. Another advantage lies in the tooth is deemed necessary for physiologi- 10. Hyomoto M, Kawakami M, Inoue M, Kirita T. Clinical
fact that after the surgical procedure, the cal occlusiona conservative treatment conditions for eruption of maxillary canines and man-
cyst capsule tends to become thicker, which such as decompression, with or without dibular premolars associated with dentigerous cysts.
would aid in either its complete removal or orthodontic traction, may be the best Am J Orthod Dentofacial Orthop. 2003;124(5):515-
enucleation in a second surgical step.7,8 treatment option.

e8 January/February 2015 General Dentistry www.agd.org

Dental Materials

Impact of toothbrushing with a dentifrice

containing calcium peroxide on enamel color
and roughness
Diala Aretha de Sousa Feitosa, DDS, MSc n Boniek Castillo Dutra Borges, PhD n Fabio Henrique de Sa Leitao Pinheiro, PhD
Rosangela Marques Duarte, PhD n Renato Evangelista de Araujo, PhD n Rodivan Braz, PhD
Maria do Carmo Moreira da Silva Santos, PhD n Marcos Antonio Japiassu Resende Montes, PhD

This in vitro study sought to evaluate both the bleaching potential and the Ra increased in all groups after brushing, only the dentifrice containing
changes to average surface roughness (Ra) of enamel after brushing with calcium peroxide resulted in an increase in reflectance.
a dentifrice. Fifty-four enamel specimens (4 x 4 x 2 mm) were divided Received: July 20, 2013
into 3 groups (n = 18) and treated with 1 of 3 dentifrices: 1 with calcium Accepted: November 12, 2013
peroxide, and 2 without. The samples were submitted to 20,000 brushing
cycles. Color and Ra were measured before and after brushing. Although Key words: dentifrice, tooth whitening, spectrophotometry, roughness

any patients consider an attrac- abrasion, and dentinal hypersensitivity.1 It dark-colored chromophore molecules in
tive smile to be synonymous is expected that adding a chemical com- dental tissues, breaking them down into
with good health.1 The increased ponent (such as a peroxide) to a whitening smaller, lightly colored, and more dif-
demand for enhanced esthetics has led dentifrice formulation would augment the fusible molecules, thus this producing a
to the development of bleaching prod- abrasive cleaning by aiding in the removal whitening effect.5 In this sense, brushing
ucts and whitening dentifrices.2 While and/or prevention of extrinsic stains.2 teeth with calcium peroxide-containing
bleaching peroxides cause decolorization Presently there is a lack of research in the whitening dentifrices might render the
(whitening) of the colored materials found literature to confirm whether these whit- enamel prone to bleaching. This may or
within the tooth, whitening dentifrices are ening dentifrices have a greater impact on may not be associated with an increase in
used to remove extrinsic stains with spe- surface roughness compared to peroxide- roughness, which varies according to the
cific abrasives and/or chemical agents, such free dentifrices. concentration of abrasives. To the best of
as hydrated silica, calcium pyrophosphate, It has been demonstrated that calcium the authors knowledge, this study is the
and hydrogen or calcium peroxides.2,3 peroxide can release oxygen ions slowly first to evaluate the bleaching potential
The high amounts of abrasives in denti- and keep oxygen concentrations high.4 and surface roughness of enamel after
frices may increase enamel roughness and Bleaching is achieved, in part, from an brushing with a dentifrice that contains
damage soft tissues and dental restorations, oxireduction reaction in which reactive calcium peroxide. Two dentifrices that did
resulting in gingival recession, cervical oxygen species attack the long-chained, not contain calcium peroxide served as
controls. The null hypotheses tested were
that there would be no differences in the
bleaching potential among the products,
Table 1. Dentifrices used in this study. and that none of the products would alter
enamel surface roughness.
Product Chemical composition Lot
Materials and methods
Colgate Total Water, sorbitol, sodium lauryl sulphate, hydrated silica, 0266BR121B
Preparation of enamel samples
Advanced Clean methyl vinyl ether and maleic anhydride copolymer,
carrageenan, flavor, sodium hydroxide, sodium fluoride, This study was approved by the University
triclosan, sodium saccharin, titanium dioxide of Pernambuco Ethics Committee under
Protocol No. 194/10. Twenty-seven
Colgate Total Water, glycerin, hydrated silica, propylene glycol, sorbitol, 0011BR123D
caries-free human third molars were
Advanced Whitening sodium lauryl, carrageenan, cellulose gum, sodium saccharin,
sodium fuoreto, triclosan, titanium dioxide, sodium hydroxide, stored for a maximum of 3 months in
CI 77891 (white) an aqueous 0.2% thymol solution. As
confirmed by stereomicroscopic evaluation
Colgate Whitening Water, glycerin, hydrated silica, sodium bicarbonate, 0051MX113E
(magnification 25X), none of the selected
Oxygen Bubbles propylene glycol, sodium triphosphate, carrageenan,
tetrasodium pyrophosphate, cellulose gum, sodium saccharin, teeth surfaces had cracks or abnormal
sodium monofluorophosphate, titanium dioxide, calcium anatomy. Using a water-cooled diamond
peroxide, sodium hydroxide saw (Isomet 1000, Buehler), a total of
54 enamel specimens (4 x 4 x 2 mm) were

www.agd.org General Dentistry January/February 2015 e9

Dental Materials Impact of toothbrushing with a dentifrice containing calcium peroxide on enamel color and roughness

Table 2. Reflectance means (SD) according to Table 3. Mean roughness values (SD) according
dentifrice and time. to dentifrice and time of measurement.

Dentifrice Before brushing After brushing Dentifrice Before brushing After brushing
Colgate Total 0.673 (0.005) Aa
0.667 (0.006) Ba
Colgate Total 0.11 (0.01) Aa
0.19 (0.04) Bb
Advanced Clean Advanced Clean
Colgate Total 0.672 (0.006) Aa 0.669 (0.005) Ba Colgate Total 0.11 (0.01) Aa 0.25 (0.09) Ba
Advanced Whitening Advanced Whitening
Colgate Whitening 0.665 (0.007) Ba 0.669 (0.004) Aa Colgate Whitening 0.10 (0.01) Aa 0.25 (0.13) Ba
Oxygen Bubbles Oxygen Bubbles
Different uppercase letters in rows and lowercase letters in columns Different uppercase letters in rows and lowercase letters in columns
indicate statistically significant differences ( P < 0.05). indicate statistically significant differences ( P < 0.05).

prepared from the labial to lingual aspects. also served as an integrating sphere that dentifrice) into the slurry bath. The total
The enamel samples were embedded maximized the collection of diffused light brushing time was 10 hours, the equiva-
in a chemically cured resin, leaving the inside the sphere. Reflectance was equal- lent of 20,000 cycles.6 Every 200 double
exposed buccal surface to be smoothed by ized arbitrarily at a wavelength of 600 nm strokes was accompanied by 20 ml of
a polishing machine (LaboPol-21, Struers, (reflectance = 1:600 nm), indicating that renewed slurry dispensed into the slurry
Inc.). Aluminum oxide disks were used in numerical values represented arbitrary bath. The toothbrushes were replaced after
sequential grit sizes of 400, 600, and 1200. units rather than absolute reflectance. 10,000 double strokes. The samples were
A final polishing was accomplished with Test samples were measured 4 times. rinsed with deionized water and cleaned
a felt cloth containing a diamond paste in Surface roughness tests were performed ultrasonically for 10 minutes before
a polishing machine (Ecomet 3, Buehler). with a roughness tester (Surftest SL-201, recording mean reflectance and Ra values,
These procedures were performed to obtain Mitutoyo America Corporation). Three as described previously.
homogeneous surfaces for treatment. measurements were taken at the center of
each specimen in different directions. The Statistical analysis
Initial color and roughness cut-off surface roughness value was 0.25 Descriptive statistics dataincluding
assessment mm and the sampling length for each means and standard deviationwere
Using a computer-assisted spectrometer measurement was 0.75 mm. The average calculated for each experimental group.
(with wavelengths ranging from 430 to surface roughness (Ra) value was obtained One-way ANOVA with repeated measure-
800 nm), color assessment was performed for each specimen. ments and Tukey multicomparison tests
based on light reflectance. A halogen were used to compare the mean reflectance
light (HL-2000-FSHA, Ocean Optics) Toothbrush test and Ra values between the groups. The
and a fiberoptic cable (QR400-7-VIS-BX, Three dentifrices were tested in this study. significance level for all statistical tests
Ocean Optics) with 6 optical fibers in a One contained calcium peroxide (Colgate was set at 5%. All data were entered and
circular arrangement were used for light Whitening Oxygen Bubbles, Colgate- analyzed by SAS software 9.1 for Windows
emission at a distance of 2 mm from the Palmolive Company), while the other 2, (SAS Institute, Inc.).
enamel slabs. Reflected light was collected Colgate Total Advanced Clean (Colgate-
by a centrally located optical fiber and Palmolive Company) and Colgate Total Results
transmitted to the spectrometer, which Advanced Whitening (Colgate-Palmolive Color
was connected to a computer. The wave- Company), were used as controls The mean reflectance values are listed in
length-dependent light reflection inten- (Table 1). After roughness and color Table 2. Statistically similar values were
sity was calculated by using spectrometer assessments, the specimens were brushed found between dentifrices either before
operating software (SpectraSuite, Ocean using a mechanical device equipped with or after brushing. However, only Colgate
Optics). Measurements were performed in 10 soft bristle toothbrush heads (Colgate- Whitening Oxygen Bubbles provided
a dark room with standardized air condi- Palmolive Company) containing dentifrice increased reflectance values after brushing.
tioning. A white standard plate (WS-1-SS, slurry. The machine was set to brush at a The control dentifrices saw a decrease in
Ocean Optics) was used to calibrate rate of 60 reciprocal strokes per minute enamel reflectance.
the measurement unit. The specimens and to generate a vertical load of 200 g
were attached to a holder so that the against the specimens. The specimens Roughness
light would always be at the same place were submerged statically during brushing All the Ra values are listed in Table 3. The
throughout repeated measurements (light by inserting 150 ml of dentifrice slurry samples presented similar Ra values before
focus diameter = 600 m); the holder (100 ml of deionized water and 50 g of brushing. All tested dentifrices produced

e10 January/February 2015 General Dentistry www.agd.org

increased Ra values, with Colgate Total scattered reflection. All dentifrices have Acknowledgments
Advanced Whitening and Colgate varying degrees of enamel roughness. All This study was supported by the Brazilian
Whitening Oxygen Bubbles yielding the 3 of the dentifrices used in the present Federal Agency for the Support and
highest Ra mean values. study contained abrasives that could have Evaluation of Graduate Education
promoted alterations in enamel. However, (CAPES) and the National Institute of
Discussion there was no decrease in reflectance after Science and Technology Photonics (INCT
Based on the findings of this study, both brushing with the dentifrice contain- Fotonica CNPq), Brazil.
null hypotheses were rejected. Although ing calcium peroxide (Colgate Oxygen
each dentifrice tested showed increased Bubbles). In this sense, it is reasonable to Disclaimer
enamel Ra values after brushing, the denti- assume that calcium peroxide might have The authors have no financial, economic,
frice containing calcium peroxide demon- provided the enamel with a clear color commercial, and/or professional interests
strated some bleaching potential. (resulting in increased light reflectance), related to topics presented in this article.
Currently, tooth color is measured regardless of surface roughness. Also, the
using a wide range of measurement fact that the dentifrice containing the References
methods, divided into subjective (visual) chemical agent calcium peroxide pro- 1. Joiner A, Pickles MJ, Lynch S, Cox TF. The measurement
of enamel wear by four toothpastes. Int Dent J. 2008;
and objective (instrumental) assess- moted the highest Ra values indicates that
ments.7 Instrumental measurement this agent worked in association with the 2. Joiner A. Whitening toothpastes: a review of the litera-
devicessuch as reflectance spectropho- abrasive found in the dentifrice. However, ture. J Dent. 2010;38(Suppl 2):e7-e24.
tometers, colorimeters, and digital image further studies should investigate if saliva 3. Joiner A. The bleaching of teeth: a review of the litera-
analysis systems (including quantitative could revert roughness alterations without ture. J Dent. 2006;34(7):412-419.
4. Huang JJ, Li YH, Sun JM, Li N. Municipal river sediment
light-induced fluorescence) are supple- compromising the bleaching potential of remediation with calcium nitrate, polyaluminium chlo-
mentary adjuncts to visual evaluation dentifrices containing calcium peroxide. ride and calcium peroxide compound. Adv Mat Res.
of tooth color. The primary difference 2012;396-398:1899-1904.
is that spectrophotometers measure the Conclusion 5. Plotino G, Buono L, Grande NM, Pameijer CH, Somma
F. Nonvital tooth bleaching: a review of the literature
reflectance of light within the entire Although all 3 dentifrices changed the
and clinical procedures. J Endod. 2008;34(4):394-407.
visible spectrum, whereas colorimeters surface roughness of the enamel samples in 6. Belli R, Rahiotis C, Schubert EW, Baratieri LN, Petschelt
only evaluate the reflected light through this in vitro study, only the dentifrice con- A, Lohbauer U. Wear and morphology of infiltrated
3 wavelengths: red, green, and blue.8 In taining calcium peroxide showed increased white spot lesions. J Dent. 2011;39(5):376-385.
addition, reflectance spectrophotometry reflectance values. 7. Brook AH, Smith RN, Lath DJ. The clinical measure-
ment of tooth colour and stain. Int Dent J. 2007;57(5):
has given reproducible results when 324-330.
measuring small changes in tooth color.9 Author information 8. Karamouzos A, Papadopoulos MA, Kolokithas G, Atha-
Since the samples treated with the denti- Dr. Feitosa is a doctoral candidate, nasiou AE. Precision of in vivo spectrophotometric co-
frice containing calcium peroxide dem- Department of Restorative Dentistry, lour evaluation of natural teeth. J Oral Rehabil. 2007;
onstrated statistically higher reflectance Pernambuco School of Dentistry,
9. Lenhard M. Assessing tooth colour change after re-
values, it is likely that this whitening University of Pernambuco, Camaragibe, peated bleaching in vitro with a 10 percent carbamide
dentifrice was the only one in the present Brazil, where Drs. Braz, Santos, peroxide gel. J Aust Dent Soc. 1996;127(11):1618-
study capable of bleaching teeth. and Montes are associate professors. 1624.
As stated previously, calcium perox- Dr. Araujo is an associate professor,
ide released oxygen ions slowly, thus Department of Biomedical Sciences, Manufacturers
maintaining high levels of oxygen inside Federal University of Pernambuco, Recife, Buehler, Lake Bluff, IL
800.283.4537, www.buehler.com
the teeth, which is capable of breaking Brazil. Dr. Borges is an associate profes-
long-chained, dark-colored chromophore sor, Department of Dentistry, Federal Colgate-Palmolive Company, New York, NY
800.226.4283, colgate.com
molecules into smaller, lightly colored, University of Rio Grande do Norte,
Mitutoyo America Corporation, Elk Grove Village, IL
and more diffusible molecules.4 This tran- Natal, Brazil. Dr. Pinheiro is an assistant 888.648.8869, www.mitutoyo.com
sition is necessary to provide the tooth professor, Division of Orthodontics, Ocean Optics, Dundein, FL
with a brightened appearance.5 University of Manitoba, Winnipeg, 727.733.2447, oceanoptics.com
External factors such as surface mor- Canada. Dr. Duarte is an associate profes- SAS Institute, Inc., Cary, NC
phology can affect the amount and type sor, Department of Restorative Dentistry, 800.727.0025, www.sas.com
of reflection. The rough surface of the Federal University of Paraba, Joao Struers, Inc., Westerville, OH
enamel after brushing results in a diffuse Pessoa, Brazil. 440.871.0071, www.struers.com

www.agd.org General Dentistry January/February 2015 e11

Obturation Techniques

Apical plug technique in a calcified

immature tooth: a case report
Kumar Raghav Gujjar, MDS n Ratika Sharma, MDS n Amith H.V., MDS n Smitha Amith, MDS n Indushekar K.R., MDS

Traumatic injury to an immature tooth may result in pulpal necrosis sec- fissure burs. The technique was proven to be successful clinically and
ondary to pulp canal obliteration, which makes the management of the radiographically at 2 years postobturation.
tooth a clinical challenge for dentists. The present case report describes Received: June 19, 2013
an innovative apical plug technique with mineral trioxide aggregate in a Accepted: September 25, 2013
calcified immature tooth using an ultrasonic tip and long, thin, tapered

pidemiological studies show that swelling, was continuous and severe with A decision was made to facilitate
11.6%-33.0% of boys and 3.6%- resultant sleep disturbance. The swell- drainage of the abscess in the maxillary
19.3% of girls suffer dental trauma ing had appeared a day after the onset of upper right central incisor through the
of varying severity before the age of 12 pain. The patients medical history was root canal, followed by apical plugging
years.1-3 Studies indicate that approxi- noncontributory; however, his dental his- with MTA. An informed consent for
mately 3.8%-24.0% of traumatized teeth tory revealed trauma in the upper front the treatment procedure was obtained
can develop varying degrees of pulp space region of the jaw 6 months prior via a from the parents with due warning of
obliteration, which develops into pulpal contact sports incident. The child had the risks involved, especially the risk
necrosis in 1%-16% of reported cases.4 reported to a general dentist with a broken of perforation while gaining access
Calcific obliteration of the pulp canal coronal tooth fragment and no evidence to the root canal.
space may happen after a severe traumatic of any displacement. Since there was no Following anesthesia, access to the
injury to immature permanent teeth.5 pulp exposure, the dentist reattached the apical third of the root canal was estab-
In such a scenario, the pulp becomes fractured coronal tooth fragment and the lished using gentle brushing strokes
necrotic, leading to the formation of a procedure was uneventful. After 6 months, with thin, long, tapered fissure burs
periapical lesion around a wide-open apex. the child reported to the dentist again with (Mani, Inc.) and a long thin ultrasonic
These conditions present the following pain and swelling, and an unsuccessful tip (Satelec-ET20 tip, Acteon North
endodontic challenges to a dentist: a par- attempt was made to drain the abscess America) in a direction parallel to the
tial or complete obliteration of the pulp through the root canal. The child was then long axis of the tooth at the cross-
canal space, causing difficulty in accom- referred to the Department of Pediatric sectional midpoint of the root canal
plishing root canal treatment; or a periapi- Dentistry. The patient was febrile, and to prevent perforation. A Glyde File
cal lesion with an open apex, potentially intraoral examination showed obliteration Prep (DENTSPLY Maillefer) was used
preventing a hermetic apical seal with of the upper labial vestibule on the right intermittently between instrumentation
conventional root canal treatment.6 side. The permanent upper right central as a chelating agent. Penetration was
Treatment options in such a situation incisor was extremely tender to touch and continued using an endodontic explorer
are either extraction or apicoectomy. There slightly labially proclined. It showed a to locate the orifice. A No. 8 file was
is little research found in the literature on yellowish discoloration in the reattached used in an attempt to negotiate the
the management of symptomatic young coronal fracture fragment. The rest of the canal. Access to the apical third of the
permanent teeth with calcific metamor- dentition was deemed healthy. root canal was successfully established.
phosis. The present case report describes a An intraoral periapical radiograph A radiograph was obtained and the esti-
novel technique of gaining access through of the permanent upper right central mated working length was established
the calcified root canal in a nonvital young incisor region revealed the reattached as 24.5 mm. The canal was sequentially
permanent upper central incisor followed coronal fracture fragment, an attempted widened by a Hedstrom file to size 30,
by apical plugging with mineral trioxide endodontic access cavity preparation, loss and the abscess was drained through the
aggregate (MTA). of lamina dura at the periapical region, root canal. The access cavity was sealed
an open apex, and calcific obliteration of with a cotton dressing. The authors
Case report the coronal pulp chamber and the cervi- found this cautious technique useful as
A 10-year-old boy reported to the Depart- cal and middle thirds of the radicular it minimized the risk of perforation. The
ment of Pediatric Dentistry, Seema Dental pulp chamber (Fig. 1). The tooth did not child was prescribed a course of amoxicil-
College, Rishikesh, India, with severe respond to sensitivity tests. Clinical and lin capsules 250 mg tid for 5 days, met-
pain and swelling in the upper front radiographic examination indicated acute ronidazole tablets 200 mg tid for 5 days,
region of the jaw which had persisted for periapical abscess in the permanent upper and ibuprofen 200 mg/paracetomol
2 days. The pain, which preceded the right central incisor. tablets 125 mg tid for 3 days.

e12 January/February 2015 General Dentistry www.agd.org

Fig. 1. Preoperative radiograph of the permanent Fig. 2. Radiograph of permanent upper Fig. 3. Radiograph of permanent
upper right central incisor. right central incisor after obturation. upper right central incisor showing
evidence of healing in the periapical
region 2 years postobturation.

The patient was assessed every 24 hours, Discussion cells under certain influences differentiate
and the canal cleansed with endodontic Fischer first indicated in 1974 that calcific into odontoblast-like cells and deposit
files so as to facilitate drainage. After metamorphosis (CM) was a response to dentin-like hard tissue.10 Reparative dentin
72 hrs, the canal of the asymptomatic trauma presenting progressive hard tissue or tertiary dentin is deposited at specific
tooth was sequentially widened with formation with maintenance of vital sites in response to injury, and the rate
a size 60 file, and filled with Metapex tissue and a pulp space observed up to the of deposition depends on the degree of
(META-BIOMED US Corporation) as an apical foramen.7 Fischer argued that such injury.10 With an increase in severity of
intracanal medicament. Two weeks later, cases require root canal treatment because injury, there is a rapid rate of dentin depo-
the tooth was irrigated with saline and the of reduced cellular content leading to sition, possibly as much as 3.5 mm/day.10
Glyde File Prep was used to remove any decreased ability for healing, thereby pre- The accelerated hard tissue formation traps
remnants of Metapex and the smear layer. disposing the pulpal tissue to infection. some pulpal cells and gives the histological
After drying the canal, white MTA powder The mechanism of hard tissue forma- appearance of osteodentin with an irregular
(DENTSPLY Tulsa Dental Specialties) was tion during CM is not yet clear, although tubular pattern. Evidence indicates that
mixed with the provided water ampule per several hypotheses have been proposed reparative dentin is produced by odonto-
the manufacturers instructions. The mix to explain this phenomenon. Torneck blast-like cells and incorporates type I and
was then placed in the canal with an amal- hypothesized that the deposition of hard III collagen in its matrix, which exhibits
gam carrier and packed to form an apical tissue was either a result of stimulation of diminished phosphophoryn content.10
plug of approximately 5 mm. A moist the preexisting odontoblasts or by loss of Neither of the above mechanisms described
cotton pellet was placed over the apical their regulatory mechanisms.8 Andreasen has been proven, therefore further investi-
plug and the access cavity was sealed. The & Andreasen described CM as a response gation is required to provide an evidence-
next day, the cotton pellet was removed to a severe injury to the neurovascular based understanding of this occurrence.
and the canal thoroughly dried with supply of the pulp, which after healing, In the treatment of calcified canals, a
absorbent points. An endodontic plugger leads to accelerated dentin deposition, total occlusion at any level of the canal
was used to check the consistency of the which in turn is closely related to the space is a common finding.11 Smith
MTA and to ensure it had completely loss and reestablishment of the pulpal performed a literature review and found
set. Subsequently, a backfill was per- neural supply.9 Ten Cate identified this that teeth with calcific metamorphosis
formed using gutta percha (DENTSPLY process as the deposition of tertiary or had a 0%-16% incidence of periapical
Maillefer) by cold compaction method. A reparative dentin in response to irrita- pathosis development.12
postobturation radiograph confirmed the tion or trauma.10 Reparative odontoblasts Teeth with CM fall into the high dif-
completion of endodontic therapy (Fig. 2). are somehow able to differentiate from ficulty category of the Endodontic Case
Figure 3 shows the success of the treat- dental pulp cells in the absence of any Difficulty Assessment proposed by the
ment at 2 years postobturation. epithelial influence.10 Subodontoblast American Association of Endodontists, and

www.agd.org General Dentistry January/February 2015 e13

Obturation Techniques Apical plug technique in a calcified immature tooth: a case report

it has been suggested that achieving a pre- An alternative for the multi-appointment The inherent disadvantage of both the
dictable outcome will be challenging for apexification procedure is a single-step traditional apexification with calcium
even experienced practitioners.13 technique by means of an apical barrier. hydroxide and the artificial apical barrier
The obliteration of the root canal Several materials, such as tricalcium with MTA is that neither technique allows
complicates endodontic treatment of a phosphate, calcium hydroxide, collagen for further root development in terms
symptomatic nonvital tooth. Traditionally, calcium phosphate, osteogenic protein-1, of thickening of the root canal walls or
the treatment in such cases involves either bone growth factor, and MTA have been continued root formation. Recently, new
extraction or apicoectomy. An early loss of proposed for use as apical barriers, and promising concepts aimed at revascularisa-
teeth, particularly in the anterior region of their biocompatibility and osteogenic tion of the necrotic pulp of such teeth
the maxilla, is associated with numerous potential have been demonstrated.19-21 In have been advocated.27-29
problems. Poor esthetics, psychological 1999, Torabinejad & Chivian introduced Revascularization has been considered
trauma, phonetic problems, and maloc- the use of MTA as an apical plug.22 The a better option for dealing with an imma-
clusion are potential consequences. The final setting time of MTA is approxi- ture tooth with a nonvital pulpeven in
possibilities of prosthetic restoration during mately 3 hours; the pH directly after cases with severe periapical infection.28,30
childhood are restricted. Apicoectomy mixing is 12.5.23 The main compounds This alternative method seems to have the
involves a surgical retrograde approach of MTA are tricalcium silicate, tricalcium potential for increasing the root length and
to access the apical portion of the tooth. aluminate, tricalcium oxide, silicate oxide, thickness of root canal walls of nonvital
Along with the obvious risks of the surgical and other mineral oxides; bismuth oxide immature teeth, assisted by blood clotting
procedure, there is a concomitant reduction is also added to increase the radiopacity and a collagen-enhanced matrix. From this
in the crown to root ratio, potentially caus- of the compound.24 perspective, it has been recently proposed
ing psychological trauma if performed at an MTA shows good sealing ability, good that apexification may not be needed in
early age, along with the inability to obtain marginal adaptation, a reasonable setting the near future.29 Nevertheless, controlled
an appropriate apical seal if performed in time, and a high degree of biocompat- clinical studies to demonstrate that the
young permanent teeth. Therefore, choos- ibility.16 The 2 important contributors revascularization method can replace
ing an orthograde technique in such cases for the favorable biologic response established treatment protocols based on
may prove to be a better option. stimulated by MTA in human periapical calcium hydroxide or MTA are warranted.
In the past, the treatment of choice in tissues are bone morphogenetic protein-2
an immature tooth with an open apex was and transforming growth factor 1.25 Summary
to achieve an apical closure by the apexifi- The stimulation of interleukin produc- Approximately 3.8%-24.0% of traumatized
cation technique using long-term calcium tion by MTA may allow for the over- teeth develop varying degrees of calcific
hydroxide dressings. Successful apexifica- growth of cementum and facilitate the metamorphosis. Although there are differ-
tion depends on the formation of a hard regeneration of the periodontal ligament ent opinions on the management of pulps
tissue barrier by cells that migrate from and formation of bone.26 In the present exhibiting canal obliteration, studies indicate
the periradicular tissues to the apex and case, advanced osseous healing of the that the incidence of pulpal necrosis in these
differentiate under the influence of specific periapical lesions was evident as early as teeth is between 1% and 16%. Endodontic
cellular signals to cells capable of secreting 6 months after placement of the MTA treatment of a symptomatic nonvital young
an organic matrix consisting of cementum apical plug. permanent tooth with a calcified canal is a
or osteodentine.14 However, the placement Contemporary data suggest that clinical challenge to dentists who work with
of calcium hydroxide has potential disad- MTA can be successfully used as an pediatric patients. The authors found that
vantages, including the variability of treat- apical barrier in teeth with necrotic the cautious technique that was used to gain
ment time (3-21 months), unpredictability pulps and open apexes. Additional access through the calcified canal was valu-
of apical closure, difficulty in patient investigations are needed to prove its able in this case, as it minimized the risk of
follow-up, and delayed treatment.15,16 The long-term efcacy.16 perforation. This technique also confirmed
duration depends on factors such as the This case confirmed that MTA acts that MTA acts as an apical barrier and can
diameters of the open apices, the degree as an apical barrier and can be consid- be considered a very effective material to
of tooth displacement by trauma, and ered a very effective material to support support regeneration of the periapical tissue
the method used for tooth repositioning. regeneration of the periapical tissue in a in a tooth with an infected root canal and
During the apexification procedure, the young permanent tooth with an infected an open apex. Sound knowledge of tooth
root canal is susceptible to reinfection root canal. Clinical and radiographic morphology, coupled with meticulous
because of the temporary coronal seal. follow-ups showed healing of the apical technique and patience, are the secrets of
The affected tooth is also susceptible to area of the affected tooth. The main success in this type of situation.
fracture.17 Rosenberg et al investigated advantage of the single-step procedure The meticulous orthograde technique
the effect of calcium hydroxide on the for the treatment of pulpless teeth with employed in the present case in gain-
microtensile fracture strength of extracted immature roots is the high predictability ing access through the calcified canal of
human permanent maxillary incisors and of apical closure and the reduction of a young permanent tooth could be of
reported severe decreases in the dentine treatment time, number of appointments, immense benefit to any dentist who works
fracture strength (23.0%-43.9%).18 and radiographs. with pediatric patients.

e14 January/February 2015 General Dentistry www.agd.org

Author information 7. Fischer C. Hard tissue formation of the pulp in relation 21. Nevins A, Finkelstein F, Laporta R, Borden BG. Induc-
Dr. Gujjar is a senior lecturer, Pediatric to treatment of traumatic injuries. Int Dent J. 1974; tion of hard tissue into pulpless open-apex teeth using
24(3):387-396. collagen-calcium phosphate gel. J Endod. 1978;4(3):
Dentistry, Faculty of Dentistry SEGi
8. Torneck C. The clinical significance and management 76-81.
University, Malaysia. Dr. Sharma is a of calcific pulp obliteration. Alpha Omegan. 1990; 22. Torabinejad M, Chivian N. Clinical applications of min-
senior lecturer, Department of Public 83(4):50-54. eral trioxide aggregate. J Endod. 1999;25(3):197-205.
Health Dentistry, M.N.R Dental 9. Andreasen J, Andreasen F. Textbook and Color Atlas 23. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR.
College, Hyderabad, India. Dr. Amith of Traumatic Injuries to Teeth. 3rd ed. Copenhagen: Physical and chemical properties of a new root-end
Munksgaard; 1994. filling material. J Endod. 1995;21(7):349-353.
H.V. is a reader/associate professor, 10. Ten Cate AR. Oral Histology: Development, Structure, 24. Camilleri J, Montesin FE, Brady K, Sweeney R, Curtis
Department of Community Dentistry, and Function. 5th ed. St Louis: Mosby; 1998. RV, Ford TR. The constitution of mineral trioxide aggre-
Peoples College of Dental Sciences, 11. Gutmann J.L, Dumsha T.C, Lovdahl P.E, Hovland E.J. gate. Dent Mater. 2005;21(4):297-303.
Bhopal, Madhya Pradesh, India, where Problem Solving in Endodontics: Prevention, Identifica- 25. Guven G, Cehreli ZC, Ural A, Serdar MA, Basak F.
Dr. S. Amith is a postgraduate trainee tion and Management. 3rd ed. St. Louis: Mosby; 1997. Effect of mineral trioxide aggregate cements on
12. Smith JW. Calcific metamorphosis: a treatment di- transforming growth factor beta1 and bone morpho-
in Oral & Maxillofacial Pathology, lemma. Oral Surg Oral Med Oral Pathol. 1982;54(4): genetic protein production by human fibroblasts in
Department of Oral & Maxillofacial 441-444. vitro. J Endod. 2007;33(4):447-450.
Pathology. Dr. Indushekar is the director 13. American Association of Endodontics. AAE Endodontic 26. Al-Rabeah E, Perinpanayagam H, MacFarland D. Hu-
of Postgraduate Studies, and depart- Case Difficulty Assessment Form and Guidelines. Avail- man alveolar bone cells interact with ProRoot and
able at: http://www.aae.org/uploadedfiles/dental_ tooth-colored MTA. J Endod. 2006;32(9):872-875.
ment head, Pedodontics & Preventive professionals/endodontic_case_assessment/2006case 27. Banchs F, Trope M. Revascularization of immature per-
Dentistry, Sudha Rustagi College of difficultyassessmentformb_edited2010.pdf. Accessed manent teeth with apical periodontitis: new treatment
Dental Sciences & Research, Faridabad, October 9, 2014. protocol? J Endod. 2004;30(4):196-200.
Haryana, India. 14. Ripamonti U, Reddi AH. Tissue engineering, morpho- 28. Hargreaves KM, Geisler T, Henry M, Wang Y. Regenera-
genesis, and regeneration of the periodontal tissues by tion potential of the young permanent tooth: what does
bone morphogenetic proteins. Crit Rev Oral Biol Med. the future hold? Pediatr Dent. 2008;30(3):253-260.
References 1997;8(2):154-163. 29. Huang GT. Apexification: the beginning of its end. Int
1. Clarkson BH, Longhurst P, Sheiham A. The prevalence 15. Metzger Z, Solomonov M, Mass E. Calcium hydroxide Endod J. 2009;42(10):855-866.
of injured anterior teeth in English school children and retention in wide root canals with flaring apices. Dent 30. Huang GT. A paradigm shift in endodontic manage-
adults. J Dent Child. 1973;4(1):21-24. Traumatol. 2001;17(2):86-92. ment of immature teeth: conservation of stem cells for
2. Jarvinen S. Fractured and avulsed permanent incisors 16. Giuliani V, Baccetti T, Pace R, Pagavino G. The use of regeneration. J Dent. 2008;36(6):379-386.
in Finnish children. A retrospective study. Acta Odontol MTA in teeth with necrotic pulps and open apices.
Scand. 1979;37(1):47-50. Dent Traumatol. 2002;18(4):217-221.
3. Baghdady VS, Ghose LJ, Enke H. Traumatized anterior 17. Andreasen JO, Farik B, Munksgaard EC. Long-term calci- Manufacturers
teeth in Iraqi and Sudanese childrena comparative um hydroxide as a root canal dressing may increase risk Acteon North America, Mount Laurel, NJ
study. J Dent Res. 1981;60(3):677-680. of root fracture. Dent Traumatol. 2002;18(3):134-137. 800.289.6367, www.acteonsupport.com
4. Amir FA, Gutmann JL, Witherspoon DE. Calcific meta- 18. Rosenberg B, Murray PE, Namerow K. The effect of
morphosis: a challenge in endodontic diagnosis and DENTSPLY Maillefer, Tulsa, OK
calcium hydroxide filling on dentine fracture strength. 800.924.7393, www.maillefer.com
treatment. Quintessence Int. 2001;32(6):447-455. Dent Traumatol. 2007;23(1):26-29.
5. Heling I, Slutzky-Goldberg I, Lustmann J, Ehrlich Y, DENTSPLY Tulsa Dental Specialties, Tulsa, OK
19. Roberts SC Jr, Brilliant JD. Tricalcium phosphate as an
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adjunct to apical closure in pulpless permanent teeth.
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1998;31(5):367-371. Child. 1967;34(1):42-47.

www.agd.org General Dentistry January/February 2015 e15

Diagnosis and Treatment Planning

Central giant cell lesion: diagnosis to rehabilitation

Ana Carolina Amorim Pellicioli, DDS n Thieni Kaefer, DDS n Marco Antonio Trevizani Martins, DDS, PhD
Vinicius Coelho Carrard, DDS, PhD n Manoela Domingues Martins, DDS, PhD

Central giant cell lesion (CGCL) is a benign bone lesion of unknown rehabilitation was performed using a removable prosthesis. The patient
etiology that primarily affects the mandible, with a predilection for female was submitted to rigorous clinical and radiographic follow-ups, with no
children and young adults. This article describes a case of a 16-year-old signs of recurrence over a 7-year period.
boy with a palatal swelling of approximately 18 months duration. Clinical, Received: October 8, 2012
radiographic, histopathological, and hematological examinations led to Accepted: March 4, 2013
a diagnosis of CGCL. Treatment involved a complete enucleation of the
lesion and the removal of several teeth. A subsequent esthetic/functional Key words: central giant cell lesion, oral rehabilitation, proliferative lesion

entral giant cell lesion (CGCL) is a Treatment options range from non- No. 12-15 (Fig. 1). A pulp vitality test was
benign bone lesion of unknown eti- surgical options to curettage and en bloc positive for all the teeth in question.
ology.1,2 It was first described by Jeffe resection.8 The latter is the treatment of Panoramic, occlusal, and periapical
in 1953.3,4 This lesion mainly affects chil- choice for more aggressive cases, due to radiographic examinations revealed a
dren and young adults (<30 years of age), the high rate of recurrence (13%-49%).9 well-defined, unilocular radiolucent
with a predilection for the female gender.1-4 Nonsurgical treatment options include cal- image at the periapex of teeth No. 12-15,
The mandible is the most common site citonin injections, intralesion injections of measuring 4 x 3 cm at its largest diameter
for CGCL, which accounts for <7% of all corticosteroids, and subcutaneous injections (Fig. 2). Computed tomography of the
benign lesions in gnathic bones.5 of -interferon.1,10,11 patients face revealed an expansive lesion
CGCL exhibits varying clinical behav- This article describes the case of a in the right maxilla causing bone destruc-
ior. Some lesions are asymptomatic and CGCL in the jaw of a 16-year-old boy and tion of the nasal fossa, maxillary sinus, and
demonstrate slow growth, whereas more discusses the histopathological, clinical, outer bone cortex (Fig. 3).
aggressive forms show rapid growth and radiological, and therapeutic features as
can cause pain, root resorption, tooth seen in the literature. Patient management
mobility, perforation of the bone cortex, after lesion removal (including prosthetic
and paresthesia.6,7 Histologically, CGCL rehabilitation) is discussed also.
consists of a proliferation of fusiform
cells in a collagenized stroma interwoven Case report
with multinucleated giant cells.3 Since A 16-year-old boy sought treatment
other conditions (such as cherubism and for swelling in the roof of his mouth.
brown tumor of hyperparathyroidism) The swelling had started approximately
can resemble CGCL histologically and 18 months earlier, and the patient reported
radiographically, CGCL is diagnosed no pain. An intraoral examination revealed
through a combination of clinical, an expansive growth in the maxilla covered
histological, radiographic, and hemato- by intact mucosa (with elastic consistency
logical examinations.3,5 upon palpation) and mobility of teeth Fig. 1. Photograph showing anterior view of a central
giant cell lesion (CGCL) with expansive growth in the
maxilla of a 16-year-old boy.

Fig. 2. Radiographs revealing a well-defined, unilocular radiolucent image in the right maxilla. Left. Panoramic view. Center. Occlusal view. Right. Periapical view.

e16 January/February 2015 General Dentistry www.agd.org

Fig. 4. Histopathology slide revealing a proliferation of
Fig. 3. Computed tomography showing an expansive lesion that is destroying adjacent bone fusiform cells in a collagenized stroma interwoven with
structures. Left. Coronal view. Right. Facial view. multinucleated giant cells (H&E, magnification 400X).

Fig. 5. Photograph of teeth No. 12-15 post- Fig. 6. Anterior radiograph of the patient after the Fig. 7. Anterior photograph showing where the teeth
extraction. extraction of teeth No. 12-15. were extracted.

The clinical and imaging examina-

tions led to the differential diagnoses
of ameloblastoma, keratocystic odonto-
genic tumor, or CGCL. Calcium and
phosphorus levels were normal, which
eliminated the diagnosis of hyperpara-
thyroidism. An incisional biopsy was
performed and the material was sent for Fig. 8. The removable partial denture (RPD) used for Fig. 9. Photograph of patients smile with the RPD.
histopathological analysis. This analysis patient esthetic/functional rehabilitation.
revealed a proliferation of fusiform
cells with a voluminous nucleus in a
collagenized stroma interwoven with
multinucleated giant cells and sites of
hemorrhage. The histopatholological
diagnosis was CGCL (Fig. 4).
Treatment consisted of the complete
enucleation of the lesion under general
anesthesia, for which it was necessary
to remove teeth No. 12-15 (Fig. 5-7).
Initially, a temporary removable partial
denture (RPD) was made of a flexible
material; later, a permanent metallic RPD
was used for esthetic/functional rehabilita-
tion (Fig. 8 and 9). The patient underwent
a rigorous clinical and radiographic follow-
up period of 7 years, during which no
signs of recurrence were noted (Fig. 10). Fig. 10. A panoramic radiograph taken 7 years post-treatment showing no signs of recurrence.

www.agd.org General Dentistry January/February 2015 e17

Diagnosis and Treatment Planning Central giant cell lesion: diagnosis to rehabilitation

Discussion activity (72% of aggressive lesions recur, Marco Martins, Carrard, and Manoela
The World Health Organization recently whereas only 3% of nonaggressive lesions Martins are assistant professors. Dr. Kaefer
defined CGCL as a localized benign lesion recur), patient age, perforation of the is a masters candidate, Department of
(manifesting at times as an aggressive pro- bone cortex, and tumor size.20-22 In the Oral Pathology, School of Dentistry,
liferative osteolytic lesion) that is formed present case, the patient showed no signs Federal University of Santa Maria, Brazil.
by fibrous conjunctive tissue containing of recurrence during a 7-year follow-up
multinucleated giant cells, hemorrhage period that involved rigorous clinical and References
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C, Filho MS. Calcitonin: a non-invasive giant cells ther-
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apy. Int J Pediatr Otorhinolaryngol. 2008;72(7):959-
CGCL is not yet well-established; how- CGCL including the intralesion injec- 963.
ever, it has been suggested that the lesion tion of corticosteroids and calcitonin 2. de Lange J, van den Akker HP, Veldhuijzen van Zanten
develops due to an exacerbated repair pro- have been studied as ways to complement GO, Engelshove HA, van den Berg H, Klip H. Calcitonin
cess following trauma or hemorrhage.13,14 or reduce the extent of surgical resection.1 therapy in central giant cell granuloma of the jaw: a
randomized double-blind placebo-controlled study. Int
CGCL is a benign lesion that is divided Calcitonin use is based on an immuno- J Oral Maxillofac Surg. 2006;35(9):791-795.
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2 subtypes: aggressive and nonaggressive.4,9 that the giant cells in this lesion are Calabrese L. Central giant cell granuloma of the jaws.
The aggressive type is more common osteoclasts.23 Harris presented 4 cases that J Craniofac Surg. 2012;21(2):383-386.
4. De Lange J, Van den Akker HP. Clinical and radiological
among young patients; it exhibits fast responded positively to calcitonin.24 Using
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growth, perforation of the bone cortex, root calcitonin as a complementary treatment Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;
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recurrence.4,9 The nonaggressive type gener- reduces the chances of sequelae.1 In the 5. Tamrikulu R, Erol B, Yilmaz U, Yaman F, Atilgan S. Cen-
ally is asymptomatic, exhibiting slow growth present case, the lesion was extensive and tral giant cell lesions (CGCL) of the jaws in children
- the review of 34 cases. Biotechnol Biotechnologic
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low incidence of recurrence.4,9 It has been prior to surgery may have reduced the size 6. Stavropoulos F, Katz J. Central giant cell granulomas: a
suggested that larger lesions with a greater of the tumor, thereby making the resec- systematic review of the radiographic characteristics
area of multinucleated giant cells are more tion less extensive. with the addition of 20 new cases. Dentomaxillofac
aggressive.15,16 The present case involved an Extensive, more aggressive, or recur- Radiol. 2002;31(4):213-217.
7. Heithersay GS, Cohn SA, Parkins DJ. Central giant cell
expansive lesion with slow growth (>1 year) ring lesions require ample surgical resec- granuloma. Aust Endod J. 2002;28(1):18-23.
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9. Speight P. Pathology and genetics of head and neck
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A conclusive diagnosis of CGCL from the standpoint of rehabilitation. World Health Organization Classification of Tumours.
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graphic, and histological examinations.3 cal resection of such lesions in the max- 10. Infante Cossio P, Martinez de Fuentes R, Carranza Car-
ranza A, Torres Lagares D, Gutierrez Perez JL. Recur-
The histopathological aspects of 2 other illa is performed to close the bone defect,
rent central giant cell granuloma in the mandible:
conditions (cherubism and brown tumor separate the nasal passage from the oral surgical treatment and dental implant restoration.
of hyperparathyroidism) are identical to cavity, and reestablish the patients abil- Med Oral Patol Oral Cir Bucal. 2007;12(3):E229-E232.
those of CGCL.17 To discard the possibil- ity to chew, speak, and swallow.26 In the 11. Sezer B, Koyuncu B, Gomel M, Gunbay T. Intralesional
ity of parathyroid abnormalities, which present case, complete enucleation of the corticosteroid injection for central giant cell granulo-
ma: a case report and review of the literature. Turk J
require different therapeutic management, lesion required removing several teeth Pediatr. 2005;47(1):75-81.
cases of suspected CGCL should be sub- and making a temporary RPD, followed 12. Tosco P, Tanteri G, Iaquinta C, et al. Surgical treatment
mitted to hematological examinations so by a definitive denture for esthetic/func- and reconstruction for central giant cell granuloma of
that calcium, alkaline phosphatase, phos- tional rehabilitation. the jaws: a review of 18 cases. J Craniomaxillofac
phorus, and parathyroid hormone levels Surg. 2009;37(7):380-387.
13. Ustundag E, Iseri M, Keskin G, Muezzinoglu B. Central
may be assessed.1,4 For cases involving the Conclusion giant cell granuloma. Int J Pediatr Otorhinolaryngol.
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whether the lesion is singular or bilateral, the diagnosis of CGCL and its treatment, 14. Kauzman A, Li SQ, Bradley G, Bells RS, Wunder JS,
as cherubism is characterized in young which involves the removal of the lesion Kandel R. Central giant cell granuloma of the jaws:
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Whitaker & Waldron reported a mean Central giant cell lesions of the jaws: a clinicopatho-
interval of 21 months between treatment Author information logic study. J Oral Maxillofac Surg. 1986;44(9):708-
and recurrence, with rare cases of recur- Dr. Pellicioli is a masters candidate,
16. Yamaguchi T, Dorfman HD. Giant cell reparative granu-
rence more than 2 years following initial Department of Oral Pathology, Dental loma: a comparative clinicopathologic study of lesions
treatment.19 The main factors associ- School, Federal University of Rio Grande in gnathic and extragnathic sites. Int J Surg Pathol.
ated with recurrence are clinical lesion do Sul, Porto Alegre, Brazil, where Drs. 2001;9(3):189-200.

e18 January/February 2015 General Dentistry www.agd.org

17. Motamedi MH, Eshghyar N, Jafari SM, et al. Peripheral
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Cherubisma case report with long term follow up.
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19. Whitaker SB, Waldron CA. Central giant cell granulo-
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U, Kleinheinz J. Central giant cell granuloma of the
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23. Flanagan AM, Tinkler SM, Horton MA, Williams DM,
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www.agd.org General Dentistry January/February 2015 e19

Diagnosis and Treatment Planning

Alveolar ridge splitting for implant placement:

a review of the procedure and report of 3 cases
Prakash S. Talreja, MDS n Chandrashekhar R. Suvarna, BDS n Preeti P. Talreja, MDS

In long-standing edentulous cases, the alveolar bone generally be placed simultaneously. This article offers a brief description of the
demonstrates vertical and horizontal atrophy. Rehabilitating procedure along with 3 case reports.
these patients with dental implants is difficult unless treatment Received: January 30, 2013
is accompanied by some kind of augmentation procedures, all of Accepted: May 7, 2013
which include specific disadvantages. One such technique, alveolar
ridge splitting, is suitable only for enhancing ridge width. It has the Key words: augmentation, ridge split,
advantage of reducing treatment time significantly, as implants can implant, piezoelectric, osteotome, chisel

vidence has shown the success is necessary for adequate insertion of alveolar ridge splitting has been success-
of implant-based replacement of implants. Augmentation procedures fully used to prepare the atrophic maxilla
missing teeth.1,2 However, reha- include block grafting, guided bone and mandible for implant insertion
bilitating patients with implants can regeneration, or distraction osteogenesis, and augmentation.1-4
be impeded by horizontal and vertical all of which have disadvantages, such Alveolar ridge splitting is suitable
atrophy of the alveolar ridge, especially as increased treatment cost and time, only for enhancing the width of the
in long-standing edentulous cases. In as well as surgical morbidity related edentulous ridge. It is accomplished
such cases, alveolar ridge augmentation to second donor site. In recent years, by making a longitudinal osteotomy

Fig. 1. (Case No. 1) Reflection of a full thickness flap Fig. 2. (Case No. 1) Using the piezoelectric saw to Fig. 3. (Case No. 1) Using a tapered osteotome for
to expose the narrow ridge. create horizontal and vertical corticotomy. ridge expansion.

Fig. 4. (Case No. 1) Implants placed in the expanded Fig. 5. (Case No. 1) Placement of splinted porcelain-fused-to-metal
ridge. (PFM) crowns.

e20 January/February 2015 General Dentistry www.agd.org

plate, extending from the edges of the ini-
tial midcrestal corticotomy. The length of
the horizontal corticotomy is dictated by
the number of implants to be placed and
the distance between the implants, while
the length of the vertical corticotomy is
usually 50% of the length of the implant
to be placed.
Next, the buccal segmented plate was
slowly dislocated in the buccal direction
by placing a small chisel in the horizontal
Fig. 6. (Case No. 2) Implant placed in the expanded Fig. 7. (Case No. 2) Placement of the PFM prosthesis. corticotomy and striking it carefully with
ridge. a mallet. A twist drill was used to mark
the implants position and depth; tapered
osteotomes were then used to expand
the buccal plate to the required depth
(Fig. 3). Care was taken to follow the
in the atrophic alveolar bone, followed plates to expand the ridge and allow path established by the twist drill in the
by lateral repositioning of the buccal implant placement.1 Subsequently, vari- bone. A gentle, slow, rotating motion was
cortex using a greenstick fracture.1 The ous approaches to this procedure have used to increase the separation of plates
space created between the buccal and been developed.5,6,11-13 by the osteotomes.
lingual/palatal cortical plate is filled The technique used in the cases pre- Two Osstem implants were placed with
with autologous, allogenic, or alloplastic sented in this article involved the use of good primary stability in the newly cre-
graft materialor without any graft a piezoelectric saw, small chisel, twist ated osteotomies. The cover screws were
material.5-8 When used in the maxilla, drill, and tapered osteotomes to expand placed next (Fig. 4) and the implants
this technique results in significantly the buccal plate as carefully as possible to were submerged for undisturbed healing
reduced treatment time compared to avoid its fracture. Threaded, self-tapping for a period of 6 months. The widened
other options, as implants are generally Osstem implants (marketed in the US as space between the cortical plates was
placed simultaneously along with the HIOSSEN Dental Implants, HIOSSEN, filled with a mix of autogenous bone
ridge split. Alveolar ridge splitting is Inc.) with resorbable blast media surface and alloplastic bone grafting material
well-suited for the maxilla, where the were placed in predetermined oste- (PerioGlas, NovaBone Products, LLC).
medullary bone is soft and the cortical otomies. Implants of any diameter and The periosteum was released on the
bone is thin, which allows for easy length can be placed using this tech- inner surface of the buccal flap, and the
expansion of the buccal cortex.9 The nique. However, if multiple implants are tissue was approximated using 3-0 black
technique can be carried out in the placed adjacent to each other, splinting braided silk suture (Mersilk, Ethicon,
mandible as well, although the risk of of the implants in the final prosthesis is Inc.). The patient was instructed not to
buccal plate fracture increases, as the recommended. wear any dentures or to place pressure on
thicker cortical plate makes the bone the healing site.
less flexible. Hence, in the mandible, a Case No. 1 Second stage surgery was performed 6
staged approach is recommended.10 A 45-year-old woman sought to replace months later. The implants were exposed,
This article presents 3 cases, each of her missing maxillary left canine and healing abutments were placed (with tissue
which involved splitting a narrow alveo- first premolar with dental implants. After approximated around them) and allowed to
lar ridge. In 2 cases, implants were placed local anaesthesia was administered, a heal for 2 weeks. Subsequently, an implant
in the maxilla simultaneously; the third crestal incision (slightly to the palatal level impression was obtained, and splinted
case involved delayed implant placement side) was made, followed by 2 diverging porcelain-fused-to-metal (PFM) crowns
in the mandible. Clinical examination vertical incisions on the line angles of the were delivered to the patient (Fig. 5).
of the cases revealed severe bone resorp- neighboring teeth. A full-thickness muco-
tion of the edentulous area. The reduced periosteal flap was reflected to expose Case No. 2
dimension of the alveolar bone was con- the underlying bone. The palatal flap A 35-year-old man sought to replace his
firmed through a cone beam computed was raised minimally to maintain blood missing maxillary left lateral incisor with
tomography scan. The procedure was supply to the bone (Fig. 1). a dental implant. A procedure similar to
explained to the patients and written Using a piezoelectric saw (Mectron that described in the first case was per-
consents were obtained. s.p.a.), rectangular corticotomies were formed and the implant was placed simul-
Originally, the ridge split technique made. The crestal horizontal corticotomy taneously with the split ridge (Fig. 6).
involved creating a sagittal osteotomy of was made 1 to 2 mm from the adjacent Second stage surgery was performed 6
the edentulous ridge using instruments teeth (Fig. 2). Next, 2 vertical corticoto- months later; at that time, a PFM pros-
(such as chisels) between the 2 cortical mies were made on the buccal cortical thesis was delivered (Fig. 7).

www.agd.org General Dentistry January/February 2015 e21

Diagnosis and Treatment Planning Alveolar ridge splitting for implant placement

Fig. 8. (Case No. 3) Photograph showing the missing Fig. 9. (Case No. 3) Implants placed in the regener- Fig. 10. (Case No. 3) Final implant-supported fixed
mandibular teeth, after an inferior horizontal ated bone between the expanded cortical plates. partial denture.
corticotomy and ridge expansion.

Case No. 3 surgery, which involved exposing the success rates of 86.2%-97.5%.14 A system-
A 36-year-old woman sought to replace implants, placing healing abutments, atic review by Aghaloo & Moy calculated
her missing mandibular left premolars and positioning an apically displaced a 97.4% survival rate for the ridge split-
and left first molar with dental implants. flap to increase the width of attached ting technique.15
Compared to the maxillary bone, the gingiva around the implant. An implant- In the 3 case reports presented here,
mandibular bone has less flexibility due supported PFM fixed partial denture there was complete patient satisfaction in
to its thicker cortical plates; thus a slightly was delivered after a healing period of 4 terms of esthetics and function. In all the
modified technique was used to split weeks (Fig. 10). cases, 6-month postprosthesis intraoral
the ridge and avoid malfracture of the periapical radiographs showed stable bone
osteotomized segment. This modification Discussion levels around the implants. Long-term
involved extending the length of the verti- The ridge split technique is one of several follow-up, which involves recalling the
cal corticotomies to match the length of options available for ridge augmenta- patients once every 6 months for clinical
the predetermined implants. In addition, tion. The technique allows simultaneous and radiographic examination, is recom-
an inferior horizontal corticotomy was implant placement in most cases, thus mended for this technique.
made by connecting the caudal ends of reducing the overall treatment time.1-4 Corticotomies during the ridge splitting
the vertical corticotomies. Moreover, as it involves expansion of the procedures have been performed using a
Using chisels and osteotomes, the buccal plate, the correction of buccal variety of instruments, including a No.
buccal segmented plate was gently dislo- concavity resulting from ridge resorption 15 blade, beaver blade, razor-sharp chisel,
cated to the buccal side (Fig. 8) and the can be achieved in some cases. Morbidity round bur, fissure bur, diamond disk,
space between the 2 plates was filled with related to second donor site may be elimi- reciprocal saw, and piezoelectric devices.
a mix of autogenous bone and PerioGlas. nated as well. In the cases presented here, a series of
Achieving primary stability was uncer- Adequate bone height is a prerequisite instruments were used to expand the bone
tain in this case; hence it was decided to for this procedure, as splitting the crest gently and to avoid the risk of buccal
place the implant after a healing period does not increase bone volume vertically.1 plate fracture. Using a piezoelectric device
of 6 months. Mersilk was used and a Although skilled surgeons can perform allows for more precise, safer corticotomies
tension-free closure of the surgical site was splitting and expansion for very thin compared to a conventional rotary bur or
achieved. To avoid pressure on the surgi- ridges, a minimum ridge width of 3 mm reciprocating saw.16,17
cal site, the patient was instructed not to with some cancellous bone is preferred.9 A As previously described, the maxilla is
wear any dentures. pyramidal ridge form with a wider base is well-suited for ridge splitting, as thinner
At the end of 6 months, the site was ideal for this technique as it prevents the cortical plates and softer medullary bone
re-entered under local anesthesia and risk of buccal plate fracture. allows for easier expansion of the maxil-
complete regeneration of new bone Predictable results have been obtained lary ridge. By contrast, the mandible has
between the separated buccal and with this technique. In a 2006 literature denser cortical plates and less cancellous
lingual plates was confirmed. Implant review, Chiapasco et al evaluated differ- bone, making it difficult to perform this
osteotomies were prepared conventionally ent augmentation procedures for reha- procedure without the risk of buccal
per the manufacturers instructions and bilitating deficient edentulous ridges and plate fracture. However, the posterior
2 Osstem implants were placed (Fig. 9). found that ridge expansion techniques mandible can be split in cases with favor-
A tension-free closure of the surgical had a reported surgical success rate of able conditions, such as a long edentulous
site was achieved and the patient was 98%-100%.14 By comparison, implants span, cancellous bone between the dense
recalled 3 months later for second stage had a survival rate of 91.0%-97.3%, with outer cortical plates, and a good bone

e22 January/February 2015 General Dentistry www.agd.org

height above the mandibular canal.9 If Conclusion 8. Scipioni A, Bruschi GB, Giargia M, Berglundh T, Lindhe
the buccal plate fractures, the mobile Ridge splitting is a predictable, effective J. Healing at implants with and without primary bone
contact. An experimental study in dogs. Clin Oral Im-
plate can be retained with bone fixation technique for the horizontal augmentation
plants Res. 1997;8(1):39-47.
screws.7 In the third case presented in of narrow edentulous ridges. Proper case 9. Misch CM. Implant site development using ridge split-
this article, a slightly different approach selection and careful clinical maneuvering ting techniques. Oral Maxillofac Surg Clin North Am.
was employed for ridge splitting in the during the procedure result in a successful 2004;16(1):65-74, vi.
mandible, with an additional, inferior surgical and prosthetic outcome. Unless a 10. Enislidis G, Wittwer G, Ewers R. Preliminary report on
a staged ridge splitting technique for implant place-
corticotomy connecting the vertical general dentist is well-trained to carry out ment in the mandible: a technical note. Int J Oral Max-
corticotomy. This step allowed for easier the ridge split procedure, referral to an oral illofac Implants. 2006;21(3):445-449.
expansion and minimized any chance of surgeon/periodontist is recommended. 11. Summers RB. The osteotome technique: part 4
bone fracture. future site development. Compend Contin Edu Dent.
The technique of ridge splitting usually Author information 12. Coatoam GW, Mariotti A. The segmental ridge-split
is performed simultaneously with implant Dr. Prakash Talreja is an assistant profes- procedure. J Periodontol. 2003;74(5):757-770.
placement, as doing so reduces the overall sor, Department of Periodontology and 13. Blus C, Szmukler-Moncler S. Split-crest and immediate
treatment time.18.19 However, simultane- Implantology, Bharati Vidyapeeth Deemed implant placement with ultra-sonic bone surgery: a
ous implant placement can result in University Dental College and Hospital, 3-year life-table analysis with 230 treated sites. Clin
Oral Impl Res. 2006:17(6):700-707.
complications, such as lack of initial Navi Mumbai, India. Dr. Suvarna is 14. Chiapasco M, Zaniboni M, Boisco M. Augmentation
implant stability, fracture of the buccal in private practice in Mumbai, India. procedures for the rehabilitation of deficient edentu-
segmented bone, and compromised Dr. Preeti Talreja is an associate profes- lous ridges with oral implants. Clin Oral Implants Res.
implant placement in the buccolingual sor, Department of Oral Medicine and 2006;17(Suppl 2):136-159.
15. Aghaloo TL, Moy PK. Which hard tissue augmentation
and apicocoronal direction.19 When the Radiology, Yerala Medical Trust Dental
techniques are the most successful in furnishing bony
primary stability of the implants is com- College and Hospital, Navi Mumbai, India. support for implant placement? Int J Oral Maxillofac
promised, an interpositional bone graft Implants. 2007;22(Suppl):49-70.
can be placed between the expanded cor- References 16. Elian N, Jalbout Z, Ehrlich B, et al. A two-stage full-arch
tices and implants can be placed after the 1. Simion M, Baldoni M, Zaffe D. Jawbone enlargement ridge expansion technique: review of the literature and
using immediate implant placement associated with a clinical guidelines. Implant Dent. 2008;17(1):16-23.
healing period of the augmented site.5,11 17. Sohn DS. Color Atlas, Clinical Applications of Piezo-
split-crest technique and guided tissue regeneration. Int
Alternatively, complications can be J Periodontics Restorative Dent. 1992;12(6):462-473. electric Bone Surgery. Seoul, South Korea: Kunja Pub-
avoided by using a staged approach.10,16,19 2. Scipioni A, Bruschi GB, Calesini G. The edentulous lishing; 2008.
In the third case report presented here, ridge expansion technique: a five-year study. Int J Peri- 18. Guirado JL, Yuguero MR, Carrion del Valle MJ, Zamora
odontics Restorative Dent. 1994;14(5):451-459. GP. A maxillary ridge-splitting technique followed by
there was concern about achieving
3. Engelke WG, Diederichs CG, Jacobs HG, Deckwer I. immediate placement of implants: a case report. Im-
adequate primary stability; hence the Alveolar reconstruction with splitting osteotomy and plant Dent. 2005;14(1):14-20.
implants were placed after healing of the microfixation of implants. Int J Oral Maxillofac Implants. 19. Sohn DS, Lee HJ, Heo JU, Moon JW, Park IS, Romanos
augmented site was completed. 1997;12(3):310-318. GE. Immediate and delayed lateral ridge expansion
For the cases presented in this article, 4. Chiapasco M, Ferrini F, Casentini P, Accardi S, Zaniboni technique in the atrophic posterior mandibular ridge.
M. Dental implants placed in expanded narrow eden- J Oral Maxillofac Surg. 2010;68(9):2283-2290.
the intercortical area was filled with a
tulous ridges with the Extension Crest device: a
mixture of autogenous bone and allo- 1-3-year multicenter follow-up study. Clin Oral Im-
plastic bone grafting material. Although plants Res. 2006(3);17:265272. Manufacturers
some dentists may prefer to place particu- 5. Lustmann J, Lewinstein I. Interpositional bone grafting Ethicon, Inc., Somerville, NJ
technique to widen narrow maxillary ridge. Int J Oral 877.384.4266, www.ethicon.com
late bone grafting materials around the
Maxillofac Implants. 1995;10(5):568-577. HIOSSEN, Inc., Fairless Hills, PA
implants and in the intercortical space, 6. Duncan JM, Westwood RM. Ridge widening for the 888.678.0001, www.hiossen.com
it has been reported that a bone graft thin maxilla: a clinical report. Int J Oral Maxillofac Im- Mectron s.p.a., Carasco, Italy
usually is unnecessary.2,7,8,12,16 A barrier plants. 1997;12(2):224-227. 39.0185.351374, dental.mectron.com
membrane was not used, as periosteum is 7. Basa S, Varol A, Turker N. Alternative bone expansion
technique for immediate placement of implants in the NovaBone Products, LLC, Jacksonville, FL
believed to be the best possible biologic 386.462.7660, www.novabone.com
edentulous posterior mandibular ridge: a clinical report.
membrane, containing a rich supply of Int J Oral Maxillofac Implants. 2004;19(4):554-558.
osteogenic cells.18

www.agd.org General Dentistry January/February 2015 e23


Management of severe mandibular deviation

following partial mandibular resection: a case report
Husain Harianawala, BDS, MDS n Mohit Kheur, BDS, MDS n Supriya Kheur, BDS, MDS n Jay Matani, BDS, MDS

Extensive mandibular resection commonly leads to a deviation of 4 months, the patients chewing ability, tongue movement, and facial
the mandible, facial disfigurement, and difficulty with speech and esthetics were improved.
mastication. The rehabilitation of these patients is a prosthodontic Received: August 22, 2013
challenge. This article presents the case of a 60-year-old man Revised: December 20, 2013
who sought prosthetic rehabilitation after a right segmental Accepted: January 30, 2014
The prosthetic rehabilitation was planned in 2 phases. A palatal Key words: hemimandibulectomy,
ramp was constructed, followed by a mandibular guiding flange. After guiding flange prosthesis, palatal ramp, rehabilitation

urgical removal of a malignant neo- can accompany a mandibular resection.6 with a segmental hemimandibulectomy
plasm is the most common cause This article describes the case of a patient was performed. Primary reconstruction
of partial mandibular loss.1 Patients who underwent a hemimandibulectomy with a rigid fixation plate and a pec-
treated for tumors of the head and neck and highlights the multidisciplinary toralis major myocutaneous (PMMC)
can suffer from morbidity and disability, approach and prosthetic management. flap was performed successfully (Fig. 1).
induced mainly by surgical resection, Periodontally compromised maxillary
radiation, and chemotherapy.1 The degree Case report teeth that would be in the line of the
of disability depends on tumor location A 60-year-old man reported to the M.A. oncology radiation treatment were
and size, the duration and quantity of Rangoonwala College of Dental Sciences extracted at the time of surgery. The sur-
radiation therapy, type of reconstruction, & Research Centre hospital in Pune, gical resection was followed by a 5-week
and the patients age and medical status. India with the chief complaint of loose radiation regimen consisting of 6000 rads
Tumor resection should be as conservative teeth in the right posterior mandibular and 33 cycles.
as possible, with the goal of preserving the region. Careful examination and investi- Prosthetic rehabilitation began 1 month
condyle and teeth in the vicinity, primary gation led to the diagnosis of a squamous postsurgery. The patient had a dental
reconstruction, implant placement, and, in cell carcinoma lesion, extending from the midline deviation of 2.1 cm to the right
some cases, intermaxillary fixation.2 Recent mandibular first molar to the anterior side, and was unable to occlude in maxi-
case reports have reported using dental border of the ramus. Following discus- mum intercuspation despite manual guid-
implants in the rehabilitation of completely sions with the hospitals Head & Neck ance (Fig. 2). Diagnostic impressions were
or partially edentulous patients who have Cancer Team, a radical neck dissection made with a modified stock impression
undergone mandibular resection.3,4
Physiotherapy should be started immedi-
ately after surgery to prevent scar formation
and trismus. Other factors that may have
an impact on the prognosis are the struc-
ture and volume of resected tissue, whether
the mandibular resection is combined with
a partial or complete glossectomy, and/
or whether a partial pharyngectomy is
required.5 Clinicians need to be aware that
these patients may also be impacted by
psychological and social difficulties post-
surgery.6 Surgeons must work in conjunc-
tion with prosthodontists to formulate a
reconstruction plan that will best allow the
patient to lead a healthy, dignified life.
An interdisciplinary approach is required
to manage facial disfigurement, distorted
speech, salivation, deglutition, occlusal dis-
harmony, and the psychosocial issues that Fig. 1. Radiographic presentation following surgical reconstruction.

e24 January/February 2015 General Dentistry www.agd.org

21 mm

Fig. 2. Anterior photograph showing mandibular Fig. 3. Palatal ramp prosthesis on the model. Fig. 4. Palatal ramp in situ.

Fig. 5. Anterior photograph showing gradual correction of deviation. Fig. 6. Cast of partial denture design.

tray with irreversible hydrocolloid A heat-cured acrylic record base (DPI side of the mouth (Fig. 5). Occlusal equili-
(Dentalign, Prime Dental Products Pvt. RR Heat Cure, Dental Products of India) bration was performed and the ramp was
Ltd.) and poured in Type III dental stone was fabricated with a wrought wire adjusted for a final time. The patient was
(KAL Rock, Kalabhai Karson Pvt. Ltd.). circumferential clasp on the anterior abut- asked to wear the prosthesis until he felt
The patient had carious root stumps, but ment tooth and an Adams clasp over the no strain in the temporomandibular joint
declined to have them extracted following first molar. The palatal ramp was fabri- and surrounding musculature.
his major surgery. Periodontal therapy cated by adding an autopolymerizing resin
(including oral prophylaxis and root plan- (DPI RR Cold Cure, Dental Products of Phase 2
ing) was followed by restoring the carious India) to the palatal aspect of the record The second phase of rehabilitation began
lesions on the remaining teeth. Given the base on the non-resected side and manu- after the patient had become comfortable
extensive midline deviation, the treatment ally guiding the mandible closer to the with and accustomed to the palatal ramp.
plan was divided into 2 phases: correction maximum intercuspal position within To maintain the mandible in the correct
of the mandibular deviation followed by physiologic limits. To ensure smooth glid- position against the maxilla, a mandibu-
definitive prosthetic treatment for long- ing of the mandible, minor adjustments lar cast partial denture was fabricated
term comfort and function. were made, followed by finishing and with a buccal guiding flange on the non-
polishing procedures (Fig. 3). resected side.
Phase 1 The patient was instructed to use the The cast partial denture was designed
A long lever arm and a compromised palatal ramp for at least 2 hours a day for so as to employ alternating buccal and
tissue bed on the resected side of the 5 days, gradually increasing the duration lingual retentive clasp arms on successive
patients mouth would create exces- after the fifth day (Fig. 4). The patient posterior teeth on the non-resected side
sive prosthetic movement. An angular was recalled for the next reline only after of the mouth (Fig. 6). Reciprocating arms
pathway of closure would induce lateral he was completely comfortable with the were planned to have a bracing effect on
forces which could dislodge the den- palatal ramp prosthesis. The deviation was these teeth. To achieve maximum sup-
ture.7 Because of these factors, a palatal corrected with 7 relines over a period of port, rest seats were planned for all pos-
ramp was selected as the first step to 16 weeks until the maximum intercuspal terior teeth, in addition to an interrupted
correct the deviation.8 position was achieved on the non-resected linguoplate major connector to brace all

www.agd.org General Dentistry January/February 2015 e25

Prosthodontics/Removable Management of severe mandibular deviation following partial mandibular resection

Fig. 7. Trial framework of partial denture to determine jaw relationship. Fig. 8. Try-in of partial denture.

of the mandibular anterior teeth and a

proximal plate minor connector adjacent
to every edentulous span. The lattice-type
minor connector for the outrigger was
kept short to reduce the leverage effect
in the partial denture while providing
enough lip support for improved esthetics.
The minor connector extension (for sup-
porting the guiding flange) was extended
from the buccal extensions of the embra-
sure clasps and the edentulous span. The Fig. 9. Final partial denture in situ.
angulation of the minor connector on the
buccal flange was adjusted on the cast.
Both arches were prepared for the cast
partial denture. To increase the retention,
stability, and support of the mandibular onto a semi-adjustable articulator (Hanau The patient was instructed to wear
denture, the maximal extension of the Wide-Vue, Whip Mix Corporation) the mandibular denture for 1 hour/day
lingual flangewithin physiologic (Fig. 7). Care was taken to reduce the for the first week, then increase its use
limitswas ensured on the non-resected frontal plane rotation of the residual gradually. He reported difficulty masti-
side. A polyether adhesive (Polyether mandible, which is known to occur due cating during the initial period; however,
Tray Adhesive Refill, 3M ESPE) was to muscle imbalance that can occur after mastication improved over time, and the
applied over the custom autopolymerized mandibular resection. As the patients lips patient was satisfied with the esthetic
resin tray. Next, a polyether impression and cheeks were pulled medially due to result of the treatment.
(Impregum, 3M ESPE) was made and scarring, the denture teeth were placed The patient made regular recall visits
poured in type IV gypsum (Ultra Rock, buccal to the crest of the ridge on the during which the health of the abutment
Kalabhai Karson Pvt. Ltd.). non-resected side and lingually at a higher teeth and the partial denture were re-eval-
A framework cobalt-chromium alloy level on the resected side (Fig. 8).9 With a uated. The tissue surface of the outrigger
(IPS d.Sign, Ivoclar Vivadent, Inc.) was lateral resection, bilateral occlusal contacts was relined 6 months post-treatment
fabricated. Autopolymerizing resin was serve as a stabilizing factor and mastication when increased fibrosis was seen in the
added over the minor connector overly- is confined to the non-resected site. PMMC flap.
ing the outrigger to act as a custom tray. During the try-in stage, the buccal exten-
Next, a functional impression was made sion of the cast partial frame was relined Discussion
using a low-fusing compound, followed with autopolymerizing resin to verify the Rehabilitation of patients who have
by a secondary impression using a light- jaw relation. Heat-cured fiber-reinforced undergone mandibular resection is a
bodied condensation silicone (Speedex, resin (Triplex Hot, Ivoclar Vivadent, Inc.) greater clinical challenge compared to
Coltene/Whaledent, Inc.). An altered was used as the final denture base material. patients with maxillary defects. In the
cast was poured using the Type III dental A laboratory remount was followed by present case, the mandibular devia-
stone. Record bases and occlusal rims were finishing and polishing of the cast partial tion was very large due to the extended
fabricated over the minor connectors. The denture; at which point, the prosthesis was radiotherapy postsurgery. Correcting
jaw relation was recorded and transferred delivered to the patient (Fig. 9). such a mandibular deviation against the

e26 January/February 2015 General Dentistry www.agd.org

forces of the musculature and sclerosing strategically in patients with a recon- 6. Rehmani AA. The complete rehabilitation of patient
tissue requires a significant lateral force. structed mandible, restoring occlusal and with lateral mandibular defect. J Ind Prosthodont Soc.
The palatal ramp prosthesis over the masticatory function while also achieving
7. Beumer J III, Curtis TA, Marunick MT. Maxillofacial Re-
maxillary arch was chosen to correct the an acceptable esthetic result. habilitation: Prosthodontic and Surgical Consideration.
deviation as it provided a larger base for St. Louis: Ishiyaku Euroamerica; 1996.
stability and support of the prosthesis. Author information 8. Adisman K. Prosthetic reconstruction of a resected
The acrylic plate also made it easy and Drs. Harianawala and Matani are research- mandible. J Prosthet Dent. 1962;12:384-392.
9. Kokubo Y, Fukushima S, Sato J, Seto K. Arrangement of
convenient to reline the palatal ramp ers and practioners, Department of artificial teeth in the neutral zone after surgical recon-
regularly until the maximum intercuspal Prosthodontics, M.A. Rangoonwala College struction of the mandible: a clinical report. J Prosthet
position was achieved. of Dental Sciences & Research Centre, Dent. 2002;88(2):125-127.
After the deviation was corrected and Pune, India, where Dr. M. Kheur is a pro- 10. Shaw RJ, Sutton AF, Cawood JI, et al. Oral rehabilita-
tion after treatment for head and neck malignancy.
stabilized, a guiding flange prosthesis was fessor. Dr. S. Kheur is a professor, Dr. D. Y.
Head Neck. 2005;27(6):459-470.
placed over the mandibular arch as the Patil Dental College, Pimpri, India. 11. Kanan RY, Mathur BS, Tzafetta K. Single flap recon-
final restoration. This design was selected struction for complex oro-facial defects using chimeric
because it had a reduced bulk and offered References free fibular flap variants. J Plast Reconstr Aesthet Surg.
negligible interference to tongue move- 1. Beumer J III, Marunick MT, Esposito SJ. Maxillofacial 2013;66(3):358-363.
ments compared to other types of pros- Rehabilitation: Surgical and Prosthodontic Manage-
ment of Cancer-Related Acquired, and Congenital De-
theses, thus improving speech and overall fects of the Head and Neck. 3rd ed. Hanover Park, IL: Manufacturers
comfort. The success of this treatment Quintessence Publishing Co.; 2011. Coltene/Whaledent, Inc., Cuyahoga Falls, OH
330.916.8800, www.coltene.com
has led the authors to treat other cases 2. Schneider RL, Taylor TD. Mandibular resection guid-
using a similar protocol. ance prostheses: a literature review. J Prosthet Dent. Dental Products of India, Mumbai, India
1986;55(1):84-86. 99.22.22079351, www.dpi.co.in
3. Sistos RJ, Jimenez CR, Benavides RA. Prosthetic and Ivoclar Vivadent, Inc., Amherst, NY
Conclusion surgical treatment of patient previously subjected to 800.533.6825, www.ivoclarvivadent.us
Reconstructing a mandibular defect by hemi-mandibulectomy. Rev Odont Mex. 2013;17(1):
Kalabhai Karson Pvt. Ltd., Mumbai, India
means of microvascular free flaps allows 42-46.
91.22.2578.1823, www.kalabhai.com
4. Sravanthi Y, Rathod A, Deepa KL, Priyadarshini I. Reha-
the maxillofacial prosthodontist to Prime Dental Products Pvt. Ltd., Maharashtra, India
bilitation of mandibulectomy patient with an overden-
achieve a more effective rehabilitation.10,11 ture: a case report. Ind J Pub Health Res Dev. 2013; 91.72601.47129, www.prime-dental.com
It is critical to both manage the mandib- 4(2):297-300. Whip Mix Corporation, Louisville, KY
ular deviation and provide psychological 5. Robinson JE, Rubright WC. Use of a guide plane for 800.626.5651, whipmix.com
counseling to the patient.6 Proper mul- maintaining the residual fragment in partial or hemi- 3M ESPE, St. Paul, MN
mandibulectomy. J Prosthet Dent. 1964;14(5): 992- 888.364.3577, solutions.3m.com
tidisciplinary treatment planning allows 999.
dentists to place osseointegrated implants

www.agd.org General Dentistry January/February 2015 e27

Diagnosis of Oral Pathology

Rare oral cartilaginous choristoma: a case report

and review of the literature
Marina Lara de Carli, DDS, PhD n Felipe Fornias Sperandio, DDS, PhD n Fernanda Rafaelly de Oliveira Pedreira, DDS n Alessandro
Antonio Costa Pereira, DDS, PhD n Joao Adolfo Costa Hanemann, DDS, PhD

Cartilaginous choristomas are extraosseous benign tumors. They occur in a pale blue cytoplasm surrounded by a light basophilic stroma and no
abnormal sites that usually do not contain chondrocytes. The oral variant evidence of malignity. Following surgical excision, the lesion did not recur,
of this entity is considered to be very rare, with only 38 cases currently which is similar to other reported cases of oral cartilaginous choristomas.
published in the literature. This article presents a case of an oral cartilagi- Received: September 30, 2013
nous choristoma lesion. In addition to presenting clinical and histological Revised: January 14, 2014
diagnoses, this article compares the present case to recently reported Accepted: March 6, 2014
cases. Special attention was given to analyzing cells of the oral cartilagi-
nous choristoma, which appear as well-differentiated chondrocytes with Key words: choristoma, hyaline cartilage, biopsy, tongue

ral cartilaginous choristoma is a very well-circumscribed, measuring 10 mm in a mature hyaline matrix (Fig. 3). Based on
rare extraosseous chondroma that diameter (Fig. 1). No other lesions were these findings, the lesion was diagnosed as
is found usually on the tongue.1-3 observed in the oral cavity. a cartilaginous choristoma of the tongue.
Although its origins are a topic of debate An excisional biopsy of the lesion was The postoperative period was uneventful,
(and may include metaplastic and also performed under local anesthesia and and there were no signs or symptoms of re-
developmental derivations), a cartilaginous the obtained specimen was fixed in 10% occurrence at a 4-month follow-up (Fig. 4).
choristoma shows benign behavior and buffered formalin and embedded in paraf-
generally does not recur after a simple fin wax. Next, 5 m-thick sections were Discussion
excisional procedure.2,4-7 This slow-grow- obtained and stained (H&E). The histo- The histological appearance of a cartilagi-
ing and asymptomatic mass may resemble pathological analysis showed that the lesion nous choristoma resembles that of benign
other oral benign soft tissue tumors; as a was located in the oral submucosa and chondromas; however, choristomas occur in
result, a histological evaluation must elimi- encapsulated completely by dense fibrous sites that usually do not contain chondro-
nate the possibility of clinically similar connective tissue (Fig. 2). The lesion cytes.3,6,8 As a result, cartilaginous choris-
lesions based on the characteristic appear- consisted of a benign proliferation of well- tomas are rare soft tissue lesions that occur
ance of the chondromas cells.6,8 developed chondrocytesexhibiting small mostly on the hands and feet.9 Conversely,
and highly basophilic nucleiinserted in the very rare oral cartilaginous choristoma is
Case report
This case study was conducted in compli-
ance with the Helsinki Declaration on
medical research protocols and ethics.
Permission was granted by the Alfenas
Federal University Institutional Review
Board. The patient signed an informed
consent agreement.
A 59-year-old man had an asymptom-
atic nodular lesion (2 years duration)
located in the dorsum of the tongue. The
patient reported that the lesions size had
not changed since it was first noticed.
The patient`s systemic condition was
normal and he reported that no previous
trauma had occurred in the area. The
extraoral examination was uneventful,
while the intraoral assessment revealed Fig. 1. Photograph of a sessile yellowish nodule with Fig. 2. Photomicrograph of the surgical specimen
a single, flaccid, round, sessile nodule erythematous borders on the dorsum surface of the showing a mature hyaline cartilage tissue separated
in the posterior third of the tongue patients tongue. from the adjacent skeletal muscle and overlying
dorsum. The lesion had a yellowish color squamous epithelium by a thin capsule of fibrous
with erythematous borders and was connective tissue (H&E, magnification 50X).

e28 January/February 2015 General Dentistry www.agd.org

In the present case, an excisional biopsy
was conducted. A follow-up visit 4 months
post-treatment showed no signs or symp-
toms of recurrence. Histologically, the
present case had no other mesenchymal
tissue except for the mature cartilage.
Previous cases in the literature (including
extraoral choristomas) reveal that these
tumors often exhibit a variety of mesen-
chymal tissues along with the chondrocyte
cells, such as adipose and bony tissues.1,8,15
In the present case, the tumor consisted
solely of chondrocytes.
Fig. 3. Photomicrograph showing small chondrocytes Fig. 4. Photograph of the patients tongue 4 months According to the literature, immuno-
with a clear cytoplasm and round nuclei (H&E, post-treatment with no signs of recurrence. histochemical studies may serve as an
magnification 400X). additional resource to characterize the
chondrocytes found in the choristoma
while also helping to distinguish between
the rare cartilaginous choristoma and other
Table. Comparison of 3 recent case reports of oral cartilaginous choristoma soft oral benign lesions. Calcium-binding
and the present study.7,13,14 proteins (such as S100) are expressed by
both choristomas and oral schwannomas.
Cytokeratins and the epithelial membrane
Patient Duration Size Follow-up
Source (years/gender) (years) Location (mm) (months/recurrence) antigen usually are present in pleomorphic
adenomas; these markers are not found in
Shibasaki et al (2013) 25/female 1.5 Lower lip 20 36/no recurrence
cartilaginous choristomas.5,6,13,16 In addi-
Pereira et al (2012) 64/female >5 Dorsum, midline 5 9/no recurrence tion, calponin and muscle-specific actins
left, posterior third are not expressed by choristomas; this may
Saha et al (2011) 11/female 11 NA NA NA help to distinguish them from inflamma-
Present case (2015) 59/male 2 Dorsum, midline 10 4/no recurrence tory myofibroblastic tumors.17
right, posterior third The present case was very easily diagnosed
as an encapsulated mass of mature chondro-
Abbreviation: NA, not available.
cytes inserted in a hyaline matrix residing
in the oral submucosa. The cellular and
nuclear morphology of the chondrocytes
usually found on the tongue (mainly in the schwannoma or a neurofibromabenign was examined to eliminate the possibility
lateral borders).1,8 tumors that originate from the nerve sheath. of the rare chondrosarcoma of the tongue,
According to the literature, a number A neurofibroma presents with a hamarto- a condition that may also be included in a
of conditions may indicate a clinical matous hyperplasic appearance.11,12 These differential diagnosis due to its similar loca-
differential diagnosis for cartilaginous tumors should be treated with excision and tion, size, and nodular-shaped growth.6,18-20
choristoma.6,8 Sialoliths and pleomorphic usually have low rates of reccurrence.10-12 Typically, no mitotic figures can be
adenomas have been found; however they Previously, only 37 cases of oral carti- distinguished in the analyzed field of the
are rare in this region. Neurofibromas, laginous choristomas had been published choristoma and the cells should be repre-
schwannomas, and granular cell tumors in the literature.7,8,13,14 In their 2012 litera- sented (as with an intraosseous maxillary
are more common and were considered as ture review, Norris & Mehra reviewed 34 chondroma) by well-differentiated chon-
differential diagnoses in the present case. cases and designated the most significant drocytes surrounded by light basophilic
The oral cartilaginous choristoma is clinical aspects of this lesion.8 Based on stroma.15 Individually, these chondrocytes
generally not considered as a clinical the literature, an oral cartilaginous choris- should have a pale blue cytoplasm with
diagnosis due to its rarity. A granular cell toma occurs most frequently in the tongue no evidence of malignancy. Oddly shaped
tumor is a relatively rare lesion in the and usually does not show inclinations chondrocytes (either binucleated or with
dorsal region of the tongue. It occurs in all based on age or gender.4 In the present pleomorphic nuclei) usually suggest a
age groups, but most frequently in patients case, the choristoma was also found on malignant lesion, such as a chondrosar-
40-60 years of age. This lesion is thought the patients tongue and had no significant coma.21,22 In addition, chondrosarcoma cells
to arise from Schwann cells and charac- clinical differences compared to previously show varying mitotic activity and frequently
teristically has a yellowish color.10 A single reported cases. A literature review of 3 are arranged in lobules separated by thin
asymptomatic, slow-growing nodule on the recent cases confirmed the lesions predi- fibrous septa; in addition, occasional calcifi-
tongue (10-20 mm) also may represent a lection for the tongue (Table).7,13,14 cation may occur within the lesion.21,23

www.agd.org General Dentistry January/February 2015 e29

Diagnosis of Oral Pathology Rare oral cartilaginous choristoma: a case report and review of the literature

Conclusion of such lesions. Arch Pathol Lab Med. 1990;114(5): 15. Scivetti M, Maiorano E, Pilolli GP, et al. Chondroma
When diagnosing painless, slow-growing, 541-542. of the tongue. Clin Exp Dermatol. 2008;33(4):460-
5. Toida M, Sugiyama T, Kato Y. Cartilaginous choristoma 462.
nodular lesions located on the tongue,
of the tongue. J Oral Maxillofac Surg. 2003;61(3):393- 16. Santos PP, Freitas VS, Pinto LP, Freitas Rde A, de Souza
dentists should take care to distinguish 396. LB. Clinicopathologic analysis of 7 cases of oral
(both clinically and histologically) between 6. Rossi-Schneider TR, Salum FG, Cherubini K, Yurgel LS, schwannoma and review of the literature. Ann Diagn
oral choristomas and malignant neoplasms. Figueredo MA. Cartilaginous choristoma of the Pathol. 2010;14(4):235-239.
tongue. Gerodontology. 2009;26(1):78-80. 17. Salgueiredo-Giudice F, Fornias-Sperandio F, Martins-
7. Shibasaki M, Iwai T, Chikumaru H, Inayama Y, Tohnai I. Pereira E, da Costa dal Vechio AM, de Sousa SC, dos
Author information Cartilaginous choristoma of the lower lip. J Craniofac Santos-Pinto-Junior D. The immunohistochemical pro-
Dr. de Carli is a postdoctoral candidate, Surg. 2013;24(2):e192-e194. file of oral inflammatory myofibroblastic tumors. Oral
Department of Clinic and Surgery, School 8. Norris O, Mehra P. Chondroma (cartilaginous choristo- Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;
of Dentistry, Alfenas Federal University, ma) of the tongue: report of a case. J Oral Maxillofac 111(6):749-756.
Minas Gerais, Brazil, where Dr. Pedreira Surg. 2012;70(3):643-646. 18. Forman G. Chondrosarcoma of the tongue. Br J Oral
9. Chung EB, Enzinger FM. Chondroma of soft parts. Surg. 1967;4(3):218-221.
is a masters candidate, Dr. Hanemann Cancer. 1978;41(4):1414-1424. 19. Al-Rawi M, Harper T, Bafakih F. Chondrosarcoma of
is a professor, and Drs. Sperandio 10. Speight P. Pathology and genetics of head and neck the tongue: a case report and a review of the litera-
and Pereira are professors, Institute of tumours. In: Barnes L EJ, Reichart P, Sidransky D, eds. ture. Laryngoscope. 2013;123(2):418-421.
Biomedical Sciences. World Health Organization Classification of Tumours. 20. Angiero F. Extraskeletal myxoid chondrosarcoma of the
Lyon, France: IARC Press; 2005:185-186. left buccal mucosa. Anticancer Res. 2012;32(8):3345-
11. Cohen M, Wang MB. Schwannoma of the tongue: two 3350.
References case reports and review of the literature. Eur Arch Oto- 21. Gallego L, Junquera L, Fresno MF, de Vicente JC.
1. Sera H, Shimoda T, Ozeki S, Honda T. A case of chon- rhinolaryngol. 2009;266(11):1823-1829. Chondrosarcoma of the temporomandibular joint. A
droma of the tongue. Int J Oral Maxillofac Surg. 2005; 12. Marocchio LS, Oliveira DT, Pereira MC, Soares CT, case report and review of the literature. Med Oral
34(1):99-100. Fleury RN. Sporadic and multiple neurofibromas in Patol Oral Cir Bucal. 2009;14(1):E39-E43.
2. Matsushita K, Tahara M, Sato H, Nakamura E, Fujiwara the head and neck region: a retrospective study of 22. Takahama A Jr., Alves Fde A, Prado FO, Lopes MA,
T. Cartilaginous choristoma deep in the upper midline 33 years. Clin Oral Investig. 2007;11(2):165-169. Kowalski LP. Chondrosarcoma of the maxilla: report of
oral vestibule. Br J Oral Maxillofac Surg. 2004;42(5): 13. Pereira GW, Pereira VD, Pereira Junior JA, da Silva RM. two cases with different behaviours. J Craniomaxillo-
436-438. Cartilaginous choristoma of the tongue with an immu- fac Surg. 2012;40(3):e71-e74.
3. Chou LS, Hansen LS, Daniels TE. Choristomas of the nohistochemical study. BMJ Case Rep. 2012. 23. Goutzanis L, Kalfarentzos EF, Petsinis V, Papadogeor-
oral cavity: a review. Oral Surg Oral Med Oral Pathol. 14. Saha R, Tandon S, Kumar P. Chondroid choristoma: re- gakis N. Chondrosarcoma of the mandibular condyle
1991;72(5):584-593. port of a rare case. J Clin Pediatr Dent. 2011;35(4): in a patient with Werner syndrome: a case report.
4. Munro JM, Singh MP. Chondroma of the tongue. Re- 405-407. J Craniomaxillofac Surg. 2013;41(7):e170-e174.
port of a case and a consideration of the histogenesis

e30 January/February 2015 General Dentistry www.agd.org

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Diagnosis and Treatment Planning

Atypical presentation of salivary mucocele:

diagnosis and management
Kumar Nilesh, MDS n Jagadish Chandra, MDS

A mucocele is a common pathological lesion involving the minor size and position of the lesion, and aspiration was used to help in the
salivary glands. It usually presents as an asymptomatic small superficial eventual diagnosis. An intraoral approach was used in the complete
swelling over the lower labial mucosa. However, uncommon variants removal of the lesion.
of oral mucoceles sometimes occur. Such lesions may be difficult to Received: September 24, 2013
diagnose due to their unusual size and atypical clinical presentation. Accepted: January 13, 2014
This article describes the case of a deeply embedded large mucocele
over the buccal mucosa. Ultrasonography was used to visualize the Key words: mucocele, buccal mucosa, surgical excision

ral mucoceles are common patient first noticed the swelling approxi- The overall clinical presentation was sug-
lesions of the minor (accessory) mately 1 year earlier. Since then, the gestive of a benign submucosal lesion and
salivary glands.1 Clinically, an swelling had grown gradually to its size the differential diagnosis was a lipoma,
oral mucocele presents as a soft, bluish at presentation. A clinical examination fibroma, dermoid cyst, or mucocele.
to transparent cystic swelling below the of the patients face showed a nontender Ultrasonography was advised to study
mucosa. Mucoceles can appear at any site oval swelling of approximately 1.5 cm the nature, size, and extent of the lesion.
where minor salivary glands are present. behind the corner of the mouth (Fig. 1). The ultrasonogram showed a hypoeco-
However, they are most commonly seen The skin overlying the lesion was normal genic oval mass of 42 x 33 x 24 mm
on lower lips, and are rarely >1.5 cm in and pinchable. Intraoral examination within the buccal subcutaneous tissue
diameter.2 Because of the typical oral revealed a dome-shaped swelling of (Fig. 3). Based on this radiological assess-
mucocele presentation, a large mucocele approximately 4 cm in diameter occupy- ment, a diagnosis of a fluid-filled cystic
at an unusual site may cause a diagnostic ing almost the entire left buccal mucosa lesion was established. Aspiration of the
dilemma. The article presents a case of a (Fig. 2). The swelling was nontender, cystic fluid was carried out under local
large buccal mucocele, and its presenta- soft, and fluctuant on palpation, with anesthesia, using an 18 gauge needle.
tion, diagnosis, and surgical removal. normal overlying mucosa. The patients Four ml of a white, viscous fluid was
oral hygiene was poor, and he was miss- aspirated and sent for cytochemical evalu-
Case report ing his mandibular left first molar. The ation. The fluid consisted of mucus and
A 30-year-old man presented with the cervical lymph nodes were not palpable. numerous inflammatory cells. Chemical
chief complaint of a painless intraoral No significant medical history or history analysis of the aspirated fluid showed
swelling over the left buccal mucosa. The of trauma were reported by the patient. increased amylase and protein counts.

Fig. 1. Facial photograph showing extraoral swelling. Fig. 2. Anterior photograph showing large intraoral swelling
occupying almost the entire left buccal mucosa.

e32 January/February 2015 General Dentistry www.agd.org


Fig. 3. Ultrasonogram showing a hypoecogenic oval Fig. 4. Surgical removal of lesion. Left. Line diagram showing the incision design: linear incision placed over
mass within the buccal subcutaneous tissue. the buccal mucosa along the occlusal plane (1); Stensen duct on the buccal mucosa needs to be identified
and preserved (2). Right. Lesion exposed completely by submucosal blunt dissection.

1 2

Fig. 5. Histopathology. Left. Section showing mucin pooling along with mucinophages (1) surrounded by a fibrous connective tissue capsule (2) (H&E, magnification
10X). Center. Section showing lining of the lesion (1) with associated minor salivary glands (2) (H&E, magnification 10X). Right. Section at higher magnification
showing large vacuolated cells with empty cytoplasm (white arrow) and mucinophages (gray arrow) (H&E, magnification 40X).

Based on the clinical, radiological, and the patient showed complete healing of the not allow an adequate salivary flow, with
cytochemical evaluations, a final diagno- surgical site with no recurrence. subsequent ductal distention presenting as
sis of buccal mucocele was established. a mucosal swelling.4
Surgical excision of the lesion by intraoral Discussion
approach was executed under local anesthe- Etiopathogenesis and types Clinical presentation
sia. After attaining adequate anesthesia, a Mucoceles are cavities filled with mucus Clinically, mucoceles present as asymptom-
linear incision of approximately 3 cm was and lined by epithelium or covered by atic swellings over the oral mucosa. They are
made over the buccal mucosa, keeping it granulated tissue.1,3 Based on its etio- usually small in size, with a mean diameter
parallel to the occlusal plane. Care was taken pathogenesis, mucoceles can be classified of <1 cm.1 They affect both genders in all
to indentify and preserve the opening of the as extravasation or retention types. An age groups, with the peak age of incidence
Stensen duct over the buccal mucosa (usu- extravasation mucocele is caused by between 10 and 29 years.1,2 The lower lip is
ally present on the buccal mucosa opposite trauma to the excretory duct of a minor the most common site, although they can
the crown of the maxillary first molar). salivary gland. Trauma causes rupture of be found in any region where there are sali-
Submucosal blunt dissection was elected to the duct, resulting in extravasation and vary glands. However, they are more rare in
free the lesion from the surrounding tissue accumulation of saliva in the surrounding the palate, retromolar space, and the buccal
(Fig. 4). The excised lesion was sent for his- connective tissue. An extravasation cyst mucosa.5 In a review of 1824 cases of oral
topathological evaluation. The microscopic consists of a central pool of extravasated mucoceles, Chi et al reported the incidence
examination revealed a fibrous capsule with mucus surrounded by granulation tissue to be highest on the lip (82%), followed by
central pooling of mucin along with muci- (such as a pseudocyst). Unlike extravasa- floor of the mouth (6%), ventral tongue
nophages. Associated minor salivary glands tion cysts, retention cysts result from (5%), buccal mucosa (5%), palate (1%),
were also noted (Fig. 5). The histopatho- ductal obstruction due to sialolithiasis, and reteromolar region (<1%).6 The present
logical analysis confirmed the diagnosis of periductal scars, or invasive tumors. The case was uncommon in view of its large size
a salivary mucocele. At a 2-year follow-up, narrowing of the ductal opening does and location on the buccal mucosa.

www.agd.org General Dentistry January/February 2015 e33

Diagnosis and Treatment Planning Atypical presentation of salivary mucocele: diagnosis and management

Investigation and diagnosis as erbium or carbon dioxide), intral- 3. Guimaraes MS, Hebling J, Filho VA, Santos LL, Vita TM,
A mucocele with its usual presentation esional corticosteroids, topical -linolenic Costa CA. Extravasation mucocele involving the ven-
tral surface of the tongue (glands of Blandin-Nuhn).
can be easily diagnosed based on its acid, and intralesional sclerosing agent.9-13
Int J Paediatr Dent. 2006;16(6):435-439.
clinical appearance. However, an unusual Surgical excision was chosen for the 4. Cecconi D, Achilli A, Tarozzi M, et al. Mucoceles of the
presentationin relation to its size and present case to allow for the complete oral cavity: a large case series (1994-2008) and a liter-
locationmay require further evalua- removal of the lesion and subsequent ature review. Med Oral Patol Oral Cir Bucal.
tion. Ultrasonography or other advanced histopathological evaluation to confirm 2010;15(4):e551-e556.
5. Cataldo E, Mosadomi A. Mucoceles of the oral mu-
diagnostic methods (such as magnetic the diagnosis. cous membrane. Arch Otolaryngol. 1970;91(4):360-
resonance imaging) are extremely helpful 365.
in visualizing the form, diameter, and Conclusion 6. Chi AC, Lambert PR, Richardson MS, Neville BW.
position of the lesion relative to adjacent The presentation of a typical oral muco- Oral mucoceles: a clinicopathologic review of 1,824
cases, including unusual variants. J Oral Maxillofac
organs.7 Ultrasonography in the present cele results in a simple diagnosis. When
Surg. 2011;69(4):1086-1093.
case showed a hypoecogenic oval mass an atypical presentation occurs, however, 7. Shah GV. MR imaging of salivary glands. Magn Reson
within the subcutaneous tissue underlying it is important to evaluate and investigate Imaging Clin N Am. 2002;10(4):631-662.
the buccal mucosa. the lesion in a stepwise manner to reach 8. Layfield LJ, Gopez EV. Cystic lesions of the salivary
Fine needle aspiration is a useful diag- a definitive diagnosis. Oral mucocele glands: cytologic features in fine-needle aspiration bi-
opsies. Diagn Cytopathol. 2002;27(4):197-204.
nostic technique for evaluating patients should be included as a differential diag- 9. Bodner L, Tal H. Salivary gland cysts of the oral cavity:
with salivary gland nodules and enlarge- nosis for any submucosal swelling over the clinical observation and surgical management. Com-
ment. Differentiating between mucoceles buccal mucosa. Recognizing these vari- pendium. 1991;12(34):150, 152, 154-156.
and vascular lesions preoperatively is ants is important to avoid misdiagnosis. 10. Yague-Garcia J, Espana-Tost AJ, Berini-Aytes L, Gay-
Escoda C. Treatment of oral mucocele-scalpel versus
very importantif a large angioma is
CO2 laser. Med Oral Patol Oral Cir Bucal. 2009;14(9):
mistaken for a mucocele, the excision of Author information e469-e474.
the vascular lesion can result in major Dr. Nilesh is a reader, School of Dental 11. Iyer VH, Moorthy V, Ramalingam P. Use of lasers in the
bleeding.8 Sciences, Krishna Institute of Medical management of mucoceles: two case reports. Int J La-
Sciences, Karad, India. Dr. Chandra is ser Dent. Available at: http://www.jaypeejournals.com/
Management a professor, Yenepoya Dental College & =TOP&IN=_eJournals/images/JPLOGO.gif&IID=3
Surgery remains the mainstay for treat- Hospital, Mangalore, India. 26&isPDF=YES. Accessed October 27, 2014.
ment of oral mucoceles. Three possible 12. Seo J, Bruno I, Artico G, dal Vechio A, Migliari DA.
surgical approaches are the complete References Oral mucocele of unusual size on the buccal mucosa:
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literature include cryotherapy, laser (such

e34 January/February 2015 General Dentistry www.agd.org