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A NNALI DI STOMATOLOGIA www.annalidistomatologia.eu VOLUME 15 NUMERO 1 - 2024 A Journal of Odontostomatologic Sciences PublyMed srls  A Annali............. EDITOR IN CHIEF Gambarini Gianluca NNALI DI STOMATOLOGIA Generali Luigi University Modena Italy Quinzi Vincenzo University l’Aquila Italy University Sapienza Roma Italy Giancotti Aldo Scopelliti Domenico University Tor Vergata Roma Italy Dir. Uoc Maxillosurgery Surgery Asl Roma 1 Signorini Luca University UniCamillus Roma Italy Semper Marc Grande Nicola Maria University Cattolica Sacro Cuore Roma Italy Bremen Germany ASSOCIATE EDITORS Isufi Almira Severino Marco Abiad Roula University Perugia Italy University Beirut Arabia University Boston Usa Terauchi Yoshi Atav Ayfer Jantarat Jeeraphat University Tokio Japan University Istambul Turkey University Bangkok Thailand Testarelli Luca Basilicata Michele Jaramillo David University Sapienza Roma Italy University Tor Vergata Roma Italy University Texas Usa Valentini Valentino Benedicenti Stefano Kaitsas Vassilios University Sapienza Roma Italy University Genova Italy Roma Italy Wei Xi Bouquot Jerry Krishna Gopi Guanghua University China West Virginia University University Calcut India Laganà Giuseppina ASSISTANT EDITORS Chaniotis Antonis University Athens Greece University Tor Vergata Roma Italy Brauner Edoardo University Sapienza Roma Italy Consolo Ugo Manzo Paolo University Modena Italy Member Ebo-Ibo Italy D’Angelo Maurilio University Sapienza Roma Italy Cotti Elisabetta Marsili Domenico University Cagliari Italy Roma Italy Di Nardo Dario University Sapienza Roma Italy D’Addona Antonio Nagni Matteo University Cattolica Sacro Cuore Roma Italy University San Raffaele Milano Italy Miccoli Gabriele University Sapienza Roma Italy De Angelis Francesca Nassen Allen Ali University Sapienza Roma Italy University Harward Usa Piccoli Luca University Sapienza Roma Italy De Biase Alberto Olivi Giovanni University Sapienza Roma Italy Roma Italy Reda Rodolfo University Sapienza Roma Italy De Nuccio Claudio Pedullà Eugenio University Catania Italy Seracchiani Marco University Cattolica Sacro Cuore Roma Italy University Sapienza Roma Italy Dettori Claudia Perez Ruth Alfayate University Europea Madrid Zanza Alessio University Cagliari Italy University Sapienza Roma Italy Docimo Raffaella Piasecki Lucila University Tor Vergata Roma Italy University Buffalo Usa CONTACTS Dorn Samuel Pistilli Roberto Editor in Chief West Virginia University Hospital San Camillo Roma Italy Gianluca Gambarini [email protected] Fidler Ales Poli Figuereido Jose’ Antonio Managing Editor University Ljubljana Slovenia University Rio Grande Do Sol Brasil Alessandro Zurli Varesi [email protected] Foschi Federico Politano Gianfranco King’s College London Inghilterra University Leuven Managing Office - Sponsor e Marketing Donatella Alonzi Franco Vittorio Pongione Giancarlo [email protected] Roma Italy Roma Italy Publishing Operations Manager Galli Massimo Pozzi Alessandro Raffaele Salvati University Sapienza Roma Italy University Tor Vergata Roma Italy [email protected] IIANNALI DI STOMATOLOGIA Annali di Stomatologia 2018; IX (4): 141 Trimestrale edito da PublyMed srls, Via Treviso, 17/A - 00161 Roma - P.I. 16532301005 +39 06 44.24.99.41 - [email protected] - www.annalidistomatologia.eu Reg. Trib. Roma n. 421 18/12/2009 Editorial Dear Colleagues, Esteemed Readers and Friends It is an honor and privilege to introduce myself as the new Editor-in-Chief of “An- nali di Stomatologia”, one of the oldest and most important Italian scientific dental journal, which is now aiming at regaining a relevant role in the international dental community as well. With a background deeply rooted in dental research and a passion for advancing the field, I am committed to fostering a platform that cham- pions innovation, excellence, and the exchange of cutting-edge ideas. This journal seeks to be a beacon for dental professionals, researchers, and scholars, providing a space where original, innovative studies, comprehensive reviews, and insight- ful commentaries converge to shape the future of dental science. In office since January 1st,2024, I am eager to embark on this journey of exploration, collabora- tion, and knowledge dissemination within the dynamic realm of dental sciences. I am also glad to introduce our new Editorial Board, which comprehends both well-known Italian and international experts and young researchers, all of them dedicated to ensuring the highest stan- dards of peer-reviewed content, encompassing a wide spectrum of dental specialties. From clinical breakthroughs to fundamental research, we aim to showcase the diverse facets of modern dentistry. Our commitment to rigorous evalu- ation and constructive feedback will uphold the integrity of the scientific process and contribute to the advancement of dental knowledge. We all understand the pivotal role dental research plays in improving patient care, addressing emerg- ing challenges, and driving innovation in oral health. As we embark on this exciting venture, we invite researchers, clinicians, academicians, and all stakeholders in dental sciences to contribute to the journal by sharing their expertise and insights. I am enthusiastic about the potential growth of “Annali di Stomatologia” in the next years, and I look forward to your valuable contributions, engagement, and support. With warmest regards Gianluca Gambarini Editor in Chief Annali di Stomatologia 10.59987/ads/2024.1.1-1 1 

https://www.annalidistomatologia.eu/ads/article/view/281

A Comprehensive Multimethod Analysis of Mechanical Properties of two different heat treatments for endodontic Nickel-titanium instruments Nicola Maria Grande1 Authors Krithika Datta2 Nicola Maria Grande -Università Cattolica Lucila Piasecki3 del Sacro Cuore, Roma. Maurilio D’Angelo4 Krithika Datta - Saveetha Dental Institute, Edit Xhaijanka5 Chennai, India. Luca Testarelli4 Lucila Piasecki - New York University at Dario di Nardo4 Buffalo, USA. 1 Università Cattolica del Sacro Cuore, Roma Maurilio D’Angelo - Sapienza, Università di Roma. 2 Saveetha Dental Institute, Chennai, India 3 New York University at Buffalo, USA Edit Xhaijanka - Università di Tirana, 4 Sapienza, Università di Roma Albania. 5 Università di Tirana, Albania Luca Testarelli - Sapienza, Università di Roma. Corresponding author: Maurilio D’Angelo Dario di Nardo - Sapienza, Università di Roma. [email protected] Abstract The purpose of the present study was to evaluate the influence of the two different heat treatments of the mechanical properties of two commercial products: X7 Fire- License wire and X7 Utopia Nickel-titanium rotary instruments (EdgeEndo, Albuquerque, New This work is licensed under a Creative Mexico). The present article was written following the guidelines of PRILE (Prefered Commons Attribution-NonCommercial- Reporting Items for Laboratory studies in Endodontology). Since both instruments NoDerivatives 4.0 International License. are available with same design, size and taper the influence of the two different heat Authors contributing to Annali di treatments on various mechanical properties could be properly evaluated. 50 instru- Stomatologia agree to publish ments for each group, as determined by power analysis, were selected and tested their articles under the Creative using methods and devices validated in previous studies. Data were collected and Commons Attribution-NonCommercial- statistically analyzed using a 1-way ANOVA test followed by the post hoc Tukey test NoDerivatives 4.0 International License, with significance set to a 95% confidence level. Results showed that X7 Utopia were which allows third parties to copy and redistribute the material providing found to be more rigid, with a statistically significant difference when compared to appropriate credit and a link to the X7 Firewire. Similarly, X7 Utopia were found to be significantly more resistant to tor- license but does not allow to use the sion, while no statistically significant difference was found between the two tested material for commercial purposes and to instruments when subjected to a cyclic fatigue test. Cutting efficiency was signifi- use the material if it has been remixed, cantly higher for X7 Utopia instruments, and also instrumentation time was signifi- transformed or built upon. cantly shorter when compared with X7 Firewire. X7 Firewire instruments showed a How to Cite higher tendency to flues deformations during usage. We can conclude that thermal NM Grande, K Datta, L Piasecki, treatments of nickel-titanium instruments can significantly impact all their mechan- M D’Angelo, E Xhaijanka, L Testarelli, ical properties in vitro and overall performance in root canal procedures. Therefore, D di Nardo. understanding the differences in thermal treatments is crucial for manufacturers to A Comprehensive Multimethod Analysis improve instruments and for dental professionals to tailor these instruments to spe- of Mechanical Properties of two different cific clinical requirements. heat treatments for endodontic Nickel-titanium instruments Annali Di Stomatologia, 15(1), 3-8. Key words: endodontic instruments, nickel-titanium, heat treatment https://doi.org/10.59987/ads/2024.1.3-8 Introduction Nickel-titanium (NiTi) instruments are widely used in endodontics due to their flexibil- ity, shape memory, and resistance to cyclic fatigue. In the last decades NITi rotary in- strumentation technique have been considered as golden standard to achieve proper canal shaping with a more efficient, rapid and simple clinical approach, even if intra- canal separation or rotary instruments is still a major concern for the majority of cli- nicians (1). In the last decades improvements in design, motions and manufacturing have been proposed to provide clinicians with safer and more efficient NiTi rotary in- struments. In recent years, however, the majority of manufacturers have focused their interest in improving heat treatment (HT) procedures before, during or after the grinding process (1,2) . Several studies have shown the benefits of such treatments; however, 10.59987/ads/2024.1.3-8 3  A Comprehensive Multimethod Analysis of Mechanical Properties of two different heat treatments for endodontic Nickel-titanium instruments they are proprietary and not disclosed by manufactur- querque, New Mexico, USA) and have a constant taper, ers (3-5).It has been shown that many mechanical prop- a parabolic cross-section, a non cutting tip and a 1mm erties can be influenced by the heat treatments, even maximum flute diameter. Even if design and dimensions if overall performance is still a combination of instru- are same the X7 NiTi rotary instruments are currently ments’ design, dimensions, motions and alloy (6-8) commercialized with two different names, due to two Currently the heat treatment of endodontic NiTi instru- different types of heat treatment. “Fire-Wire” X7 instru- ments has become a crucial aspect of their manufac- ments are made of an Annealed Heat Treated (AHT) turing process, playing a pivotal role in enhancing their nickel-titanium alloy brand named Fire-Wire (more duc- mechanical properties and overall performance in root tile). According to the manufacturer (11) such alloy im- canal procedures. Heat treatment involves subjecting proves flexibility, resistance to cyclic fatigue and reduces the NiTi alloy to specific temperature and time condi- bounce-back effect inside curvatures, and instruments tions to modify its microstructure. The primary goals of closely follow the anatomy of the canal without straight- heat treatment for endodontic NiTi instruments are to ening out, reducing the risk of ledging, transportation, enhance their flexibility, resistance to fracture, and to es- and perforation. It also allows the NiTi rotary instru- t0ablish a balanced combination of hardness and tough- ments to be easily straightened with clinicians fingers ness (5-8). (prebendable). The EdgeX7 “Utopia” is a more recently The process typically involves a sequence of steps, commercialized, NITi rotary instrument that, according including solution treatment, quenching, and aging. to manufacturer,provides all of the benefits of the origi- During solution treatment, the NiTi alloy is heated to a nal Firewire X7 blade design while taking performance temperature where it transitions from a martensitic to to a different level with more cutting efficiency, due to a an austenitic phase. This phase transition is critical for different proprietary heat -treatment (11). imparting the desired shape memory and superelas- Since both instruments are available with same design, ticity to the instruments. Quenching follows, where sizes and tapers, and are meant to be used with the the heated alloy is rapidly cooled to lock in the austen- same protocol and same motion’s parameters (rotational itic phase and achieve the desired mechanical prop- speed and torque), the purpose of the present study was erties. Subsequently, aging is performed to optimize to evaluate the influence of the two different heat treat- the balance between hardness and toughness, ensur- ments of the mechanical properties of the two commer- ing the instrument’s durability during clinical use (1,7). cial products (X7 Firewire and X7 Utopia instruments). The controlled application of heat treatment mainly ad- The null hypothesis was that no changes in the in vitro dresses some of the challenges associated with NiTi mechanical properties were provided by the different instruments, such as their susceptibility to cyclic fatigue heat treatments. and potential for breakage. The process enhances the instruments’ fatigue resistance by refining the grain struc- Materials and Methods ture and controlling phase transformations, leading to a The present article was written following the guidelines more robust and reliable endodontic tool (9). Manufactur- of PRILE ( Prefered Reporting Items for Laboratory stud- ers continually refine heat treatment processes to tailor ies in Endodontology (Nagendrabu 2021) , as shown in NiTi instruments for specific clinical applications (10). the flow chart of the study (Fig.1). X7 instruments are manufactured by Edge Endo (Albu- Figure 1. 4 10.59987/ads/2024.1.3-8 N.M. Grande et al. Sample selection length of the fragments (FL) was measured with a digital caliber and statistically analyzed to evaluate the correct A total of 50 new X7 NiTi instruments and 50 new XT positioning of the instruments inside the artificial canal Utopia NiTi instruments size 25 and .04 taper (Edg- and to verify the comparability of the results of the cyclic eEndo, Albuquerque, New Mexico, USA) were selected fatigue test. All data were statistically analyzed using a for the study and divided in 5 groups of ten each (Fig 1-way ANOVA test followed by the post hoc Tukey test 2a). Each group was then subjected to one of the follow- with significance set to a 95% confidence level. Mean ing mechanical tests: stiffness, cyclic fatigue, torsional values, the standard deviations and statistical signifi- resistance, cutting efficiency, durability. According to cance of the cyclic fatigue tests are displayed in table 1. manufacturer all the instruments have same design and dimensions, while they differ only due to different heat Torsional test treatments, even if such manufacturing processes are proprietary and not disclosed (11). Ten instruments for each product underwent the torsion- Before starting the laboratory assessment all the 100 al resistance test using a methodology which has been instruments were examined under dental stereomicro- validated by studies published in peer-review indexed scope (Kaps,Asslar,Germany) at x10 magnification to journals (16) and follows iSO Guidelines 3630-1. Tests identify major irregularities or defects in the blade de- were performed with a custom-made torsiometer-like sign, which could affect properties of the NiTi instru- device at 300 rpm, because it has been demonstrated ments and make them not valid for the investigation. No that rotational speed does not affect the results. The instrument was discarded and all 100 samples were ac- device allowed to avoid the bending of the coronal part cepted for the study. of the instrument and to have a straight angle of inser- Sample size for each mechanical test was determined tion, since it has been demonstrated that such coronal by power analysis and calculated based on preliminar intereferences and stresses can deeply influence the data obtained after 6 initial measurements with a power torsional resistance. The test was performed blocking of 80% and a 0,05 alpha type of error. For the five previ- the tip of the instrument with a vise at 3 mm from the tip ously mentioned tests sample size calculations were 3. (fig 2d) and rotating it at 300 rpm in the clockwise direc- 4, 3, 4 and 6 respectively and, consequently, a total num- tion with a dedicated electronic motor (Kavo, Biberach, ber of 10 instruments per group was considered more Germany) allowing a real-time (0.1 seconds) recording than enough for each dependent variable. of the torque with a sensitivity of 0.05 Ncm. The torque at fracture results were collected on a spreadsheet. The Stiffness Test length of the fragments (FL) was measured with a digital caliber and statistically analyzed to evaluate the correct Ten instruments for each product underwent the stiff- positioning of the instruments’ tip inside the torsiometer ness test (resistance to bending stress). The stiffness and to verify the comparability of the results of the tor- tests were performed using a device, which has been sional test. used in previously published peer-review studies (12) All data were statistically analyzed using a 1-way ANO- and follows ISO 3630-1 international standard guidelines VA test followed by the post hoc Tukey test with signifi- for mechanical tests of endodontic instruments (fig 2b). cance set to a 95% confidence level. Mean values, the The device consists of a load cell, an electronic display, standard deviations and statistical significance of the and a mobile holder to allow repeatable positioning of torsional tests are displayed in table 1 the instruments on the load cell. The stiffness tests were performed by bending each file at a 45° angle at 3 mm Cutting efficiency test from its tip and recording the applied force (g). The mea- surements indicated by the electronic display connected Ten instruments for each product underwent the cut- to the load cell were recorded. The higher the values, the ting efficiency test using a methodology (Fig 2e) which stiffer (less flexibile) the instrument was. Mean values,the has been validated by studies published (17,18) in standard deviations and statistical significance of the cy- peer-review indexed journals. The device consisted clic fatigue tests are displayed in table 1. of a main frame to which a mobile plastic support for the handpiece was connected and a stainless-steel Cyclic fatigue test block containing the Plexiglas plates (Inplex, Rome, Italy), against which the cutting efficiency of the instru- Ten instruments for each product were subjected to the ments was tested. A notch 1 mm in depth and width test . All instruments were rotated in a stainless-steel ar- had been created on the lateral wall of the Plexiglas tificial canal of 16 mm characterized by a 90° angle of plate that measured 1 mm in thickness, to prevent the curvature and a 2-mm radius of curvature (fig 2c) using instruments from slipping out the smooth surface of glycerin as a lubricant to avoid any friction between the the plastic. The dental handpiece was mounted upon a files and the artificial canal. The methodology has been mobile device connected to a fixed weight (150 g), that validated by many studies published in peer-review in- for gravity drove the horizontal instrument against the dexed journals (13-15). Speed ( 300 rpm clockwise) and Plexiglas block in a precise and reproducible way. The torque (2N) were selected according to the manufactur- plastic support for the handpiece allowed for precise ers’ recommendation and each test was performed by and simple three-dimensional alignment and position- the same expert operator. Each instrument was carefully ing of the instrument, as soon as it came perpendicu- inserted at the same length (16mm) and rotated inside larly into contact with the notch created on the wall of the canal until a visible and/or audible sign of fracture the Plexiglas specimen without bending. Once every- was detected. The time to fracture (TtF) was measured thing was fixed, the motor of the testing device was using a digital chronometer with a sensitivity of 0.01 sec- switched on and the instrument removed material and onds. The test was performed at room temperature. The penetrated actively The cutting efficiency was tested 6 10.59987/ads/2024.1.3-8 5  A Comprehensive Multimethod Analysis of Mechanical Properties of two different heat treatments for endodontic Nickel-titanium instruments Figure 2. mm from the tip of each instrument (max diameter = speed and 2,5 N torque). Overall, each instrument was 0,49 mm) and instruments were rotated at 350 rpm and supposed to prepare 20 canals (19) to working length 2,5 N torque setting for 30 seconds. Each instrument without any breakage or deformation of flutes (fig 2g). was tested in linear cutting unidirectional lateral mo- An initial manual glide-path using a manual k-file n.15 tion and the maximum penetration depth of the instru- was performed to ensure patency and a slight preliminar ments was the criterion for cutting Each plastic block enlargement to facilitate the .04 25 instruments progres- was used to test one instrument from each of the two sion to the working length. All canals were prepared by groups tested. The precise length of the plastic block the same expert clinicians using Mimeraci technique cut in 1 min was measured in mm for all groups tested in steps: manual insertion, activation and progression using a computerized program (Adobe Photoshop CS4) in small steps (1-2 mm) , removal of the file from ca- with a precision of 0.1 mm. The 1 mm notch was sub- nal, cleaning of flutes and irrigation with distilled water. tracted to the length obtained. Maximum penetration Each step of the technique was repeated till working depth was calculated, mean and standard deviations of length was reached.The total instrumentation time, the each group were calculated and data were statistically incidence of instruments ‘ separation or deformation of analyzed with a one-way ANOVA test with significance flutes ( under microscope inspection at x10 magnifica- set at 95 % confidence interval. tion) were recorded. For the instrumentation time mean and standard deviations of each group were calculated Durability test and data were statistically analyzed with a one-way Each instrument was used to prepare five artificial 3d ANOVA test with significance set at 95 % confidence plastic (Fig 2f) molar tooth (Orodeka,Firenze, Italia) with interval. Data concerning separated or deformed instru- the same motor and the same parameters (350 rpm ments were only recorded. Table 1. Mean (standard deviation) results of different tests for the two instruments Test Parameters x7 firewire x7 utopia P-values Stiffness maximum load 131,3 +/- 9,2 84, 2 +/- 6,5 <.001 Cyclic fatigue time to fracture (s) 19,6 +/- 2,9 20,3 +/- 3,9 .412 Torsional resistance Maximum torque (N. cm) 1, 34 +/- 0,28 1.01 +/- 0,19 <.001 Cutting ability Penetration (cm) 13,4 +/- 2,6 9,8 +/- 3,9 <.001 Instrumentation time Seconds (s) 12,9 +/- 7,7 16,1 +/- 9,2 <.001 Intracanal breakage number of instruments 0 0 NA Flute Deformation number of instruments 4 0 NA 6 10.59987/ads/2024.1.3-8 N.M. Grande et al. Results Differences in thermal treatments of NiTi endodontic in- struments stem from variations in methods and objec- Results are summarized in table 1. For the stiffness test tives (10). A relevant topic is in the pursuit of a balance X7 Utopia were found to be more rigid, with a statistically between flexibility and resistance to cyclic fatigue. Heat significant difference when compared to X7 Firewire. treatment seeks to achieve this equilibrium through care- X7 Utopia were also found to be more resistant to tor- ful control of temperature and time during the thermal sion, showing significantly higher values for maximum processes. The challenge is to prevent excessive hard- torque at failure when compared to X7 Firewire, while ness that could compromise flexibility while ensuring no statistically significant difference was found between sufficient toughness to resist cyclic loading, by creating the two tested instruments when subjected to a cyclic gradient structures within the material to optimize both fatigue test. For both torsional and cyclic fatigue tests no flexibility and fatigue resistance. significant differences were noted in the two groups con- In the present study all the tested instruments had a simi- cerning fragment lengths, demonstrating a correct test- lar resistance to a cyclic fatigue test which was performed ing procedure. Under the conditions of the present test, in a very challenging complex ,abrupt apical curvature. cutting efficiency was significantly higher for X7 Utopia Differences in the thermal treatment protocols contrib- instruments, and also instrumentation time was signifi- ute to the development of NiTi instruments with specific cantly shorter when compared with X7 Firewire. During characteristics for various clinical applications (1,7). For durability tests all instruments were able to reach work- instance, instruments designed for shaping procedures ing length without any intracanal breakage. On the con- may undergo thermal treatments that prioritize flexibility trary four X7 Firewire instruments which exhibited visible to navigate curved root canals efficiently. In contrast, in- signs of flute deformation were discarded and were not struments intended for more simple and rapid techniques able to prepare all the 20 canals, while no X7 Utopia in- may prioritize durability and cutting efficiency. Results strument showed any sign of plastic deformation. from the present study confirmed the significant impact of the different heat treatments. They showed that the Discussion X7 Utopia were less flexible, but more resistant to tor- sion and efficient in cutting when compared to Firewire The results of the present study showed that thermal X7. This property may be also more helpful in retreat- treatment of nickel-titanium endodontic instruments in- ment cases, making removal of gutta-percha easier and volveing intricate processes can significantly impact all faster. Moreover less plastic deformation of flutes were their in vitro mechanical properties (flexibility, strength observed after clinical use, leading to more durability. and cutting ability) and overall performance in root canal The question whether such plastic deformations are a procedures (10, 20). Even if many factors contribute to the weak point or not is still open. Obviously permanently success of endodontic therapy, root canal instrumenta- deformed rotary instruments should be discarded (which tion has a relevant role, because it create a proper shape negatively affects durability), but such feature is also to perform both final irrigation and obturation procedures considered beneficial, since it is a clinical warning that correctly (21-25). Understanding the in vitro differences could prevent sudden, unexpected intracanal failure. It in thermal treatments is crucial for manufacturers to is considered a warning because such plastic deforma- provide instruments with different properties and dental tions usually occurs immediately prior to breakage. professionals to tailor these instruments to specific clini- In summary we may conclude that heat treatment meth- cal requirements (1,5). In the present study two different ods provide a well-established positive approach, and heat treatments from the same manufacturer and applied new technologies offer more sophisticated and targeted to the same instrument design were tested and results modifications, like the differences shown between the two showed significant differences between the two groups. tested X7 instruments. Such avenues contribute to the As dimensions and designs were same these difference ongoing evolution of NiTi rotary instruments, continually are only related to the difference in the heat treatments. improving their performance and expanding their appli- Heat treatment typically involves processes like aus- cability in endodontic practice, ultimately benefiting den- tenitization, quenching, and aging (9). Austenitization tal practitioners and patients alike by providing tailored involves heating the NiTi alloy to a specific temperature instruments for the case and overall by enhancing the to transform it from a martensitic to an austenitic phase. efficiency and safety of endodontic shaping procedures. Subsequent quenching rapidly cools the alloy, fixing the desired phase and enhancing properties like shape References memory. Aging, the final step, optimizes the balance 1. Zupanc J, Vahdat-Pajouh N, Schäfer E. New thermome- between hardness and toughness. Variations in time, chanically treated NiTi alloys - a review. Int Endod J. 2018 temperatures, heating and cooling processes may differ- Oct;51(10):1088-1103. doi: 10.1111/iej.12924. Epub 2018 entiate the heat treatments and ideally these advanced Apr 19. PMID: 29574784. 2. Kim E, Ha JH, Dorn SO, Shen Y, Kim HC, Kwak SW. techniques should allow for precise control over specific Effect of Heat Treatment on Mechanical Properties of attributes, offering a more tailored approach to perfor- Nickel-Titanium Instruments. J Endod. 2023 Nov 2:S0099- mance (5). Unfortunately heat treatments are proprietary 2399(23)00713-6. doi: 10.1016/j.joen.2023.10.018. Epub and not disclosed by manufacturers in details. Manufac- ahead of print. PMID: 37924940 turers only state the improvements in clinical or in vitro 3. Plotino G, Grande NM, Testarelli L, Gambarini G, Cast- performance of the commercial instruments by mention- agnola R, Rossetti A, Özyürek T, Cordaro M, Fortunato L. Cyclic Fatigue of Reciproc and Reciproc Blue Nickel- ing the different applied HTs. They usually focus only on titanium Reciprocating Files at Different Environmental a few main properties, avoiding to mention all the differ- Temperatures. J Endod. 2018 Oct;44(10):1549-1552. doi: ences (advantages and disadvantages) in performance 10.1016/j.joen.2018.06.006. Epub 2018 Aug 23. PMID: 30 related to these changes (10). As a consequence, clini- 4. Gambarini G, Galli M, Di Nardo D, Seracchiani M, Don- cians are not aware of all proerties which could affect francesco O, Testarelli L. Differences in cyclic fatigue lifes- clinical performance in a positive or negative way (2). pan between two different heat treated NiTi endodontic 10.59987/ads/2024.1.3-8 7  A Comprehensive Multimethod Analysis of Mechanical Properties of two different heat treatments for endodontic Nickel-titanium instruments rotary instruments: WaveOne Gold vs EdgeOne Fire. J 15. Gambarini G, Miccoli G, Seracchiani M, Khrenova T, Don- Clin Exp Dent. 2019 Jul 1;11(7):e609-e613. doi: 10.4317/ francesco O, D&#39;Angelo M, Galli M, Di Nardo D, Testarelli jced.55839. PMID: 31516658; PMCID: PMC6731004. L. Role of the Flat-Designed Surface in Improving the Cyclic 5. Kasuga Y, Kimura S, Maki K, Unno H, Omori S, Hirano K, Fatigue Resistance of Endodontic NiTi Rotary Instruments. Ebihara A, Okiji T. Phase transformation and mechanical Materials (Basel). 2019 Aug 8;12(16):2523. doi: 10.3390/ properties of heat-treated nickel-titanium rotary endodon- ma12162523. PMID: 31398814; PMCID: PMC6720207. tic instruments at room and body temperatures. BMC Oral 16. Zanza A, Seracchiani M, Di Nardo D, Reda R, Gambarini Health. 2023 Oct 30;23(1):825. doi: 10.1186/s12903-023- G, Testarelli L. A Paradigm Shift for Torsional Stiffness of 03550-6. PMID: 37904159; PMCID: PMC10614384. Nickel-Titanium Rotary Instruments: A Finite Element Anal- 6. Martins JNR, Martins RF, Braz Fernandes FM, Silva ysis. J Endod. 2021 Jul;47(7):1149-1156. doi: 10.1016/j. EJNL. What Meaningful Information Are the Instruments joen.2021.04.017. Epub 2021 Apr 27. PMID: 33915175. Mechanical Testing Giving Us? A Comprehensive Re- 17. Giansiracusa Rubini A, Plotino G, Al-Sudani D, Grande NM, view. J Endod. 2022 Aug;48(8):985-1004. doi: 10.1016/j. Sonnino G, Putorti E, Cotti E, Testarelli L, Gambarini G. A joen.2022.05.007. Epub 2022 Jun 3. PMID: 35667567. new device to test cutting efficiency of mechanical end- 7. Martins JNR, Silva EJNL, Marques D, Pereira MR, Vieira odontic instruments. Med Sci Monit. 2014 Mar 6;20:374- VTL, Arantes-Oliveira S, Martins RF, Braz Fernandes F, 8. doi: 10.12659/MSM.890119. PMID: 24603777; PMCID: Versiani M. Design, Metallurgical Features, and Mechani- PMC3948890. cal Behaviour of NiTi Endodontic Instruments from Five 18. Plotino G, Giansiracusa Rubini A, Grande NM, Testarelli L, Different Heat-Treated Rotary Systems. 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Clin Ter. 2017 Jan-Feb;168(1):e23-e27. doi: 10.7417/ 2014 Dec;40(12):2086. PMID: 21846552. CT.2017.1977. PMID: 28240758. 13. Gambarini G, Miccoli G, Seracchiani M, Morese A, Piasecki 24. Rubini AG, Sannino G, Pongione G, Testarelli L, Al Su- L, Gaimari G, Di Nardo D, Testarelli L. Fatigue Resistance dani D, Jantarat J, De Luca M, Gambarini G. Influence of New and Used Nickel-Titanium Rotary Instruments: a of file motion on cyclic fatigue of new nickel titanium in- Comparative Study. Clin Ter. 2018 May-Jun;169(3):e96- struments. Ann Stomatol (Roma). 2013 Mar 20;4(1):149- e101. doi: 10.7417/T.2018.2061. PMID: 29938739. 51. doi: 10.11138/ads.0149. PMID: 23741535; PMCID: 14. Plotino G, Grande NM, Mazza C, Petrovic R, Testarelli PMC3671806. L, Gambarini G. Influence of size and taper of artificial 25. Gambarini G, Plotino G, Piasecki L, Al-Sudani D, Testarelli canals on the trajectory of NiTi rotary instruments in cy- L, Sannino G. Deformations and cyclic fatigue resistance clic fatigue studies. Oral Surg Oral Med Oral Pathol Oral of nickel-titanium instruments inside a sequence. Ann Sto- Radiol Endod. 2010 Jan;109(1):e60-6. doi: 10.1016/j.tri- matol (Roma). 2015 May 18;6(1):6-9. PMID: 26161246; pleo.2009.08.009. Epub 2009 Nov 17. PMID: PMCID: PMC4475905. Contributions Conceptualization Methodology Validation Data Writing– Writing– Supervision Curation Original draft review Author 1 Author 2 Author 3 Author 4 Author 5 Author 6 Author 7 Funding: This research was partially funded from Sapienza University of Rome “ Progetto Medio di Ateneo 2020 su test per strumenti endodontici” Conflicts of Interest: The authors declare no conflict of interest. 8 10.59987/ads/2024.1.3-8 

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In Vivo Biocompatibility Authors Machiavelli Clavesia - School of Medicine and Biodegradation Test of Two and Health Sciences, Atma Jaya Catholic University of Indonesia, Pluit Raya No. 2, North Jakarta, 14440 Barrier Membranes for Guided Stephani Dwiyanti - Department of Dental Medicine, School of Medicine and Tissue Regeneration Health Sciences, Atma Jaya Catholic University of Indonesia, Pluit Raya No. 2, North Jakarta, 14440 Veronika Maria Sidharta - Department of Machiavelli Clavesia1 Histology, School of Medicine and Health Stephani Dwiyanti2 Sciences, Veronika Maria Sidharta3 Atma Jaya Catholic University Dyonesia Ary Harjanti4 of Indonesia, Pluit Raya No. 2, Mora Octavia2 North Jakarta, 14440 Eko Adi Prasetyanto5 Dyonesia Ary Harjanti - Department Tena Djuartina6 of Anatomical Pathology, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, 1 School of Medicine and Health Sciences, Atma Jaya Catholic Pluit Raya No. 2, North Jakarta, 14440 University of Indonesia, Pluit Raya No. 2, North Jakarta, 14440 Mora Octavia - Department of Dental 2 Department of Dental Medicine, School of Medicine and Health Sciences, Medicine, School of Medicine and Health Atma Jaya Catholic University of Indonesia, Pluit Raya No. 2, North Jakarta, 14440 Sciences, 3 Department of Histology, School of Medicine and Health Sciences, Atma Jaya Catholic University of Atma Jaya Catholic University of Indonesia, Pluit Raya No. 2, North Jakarta, 14440 Indonesia, Pluit Raya No. 2, North 4 Department of Anatomical Pathology, School of Medicine and Health Sciences, Jakarta, 14440 Atma Jaya Catholic University of Indonesia, Pluit Raya No. 2, North Jakarta, 14440 Eko Adi Prasetyanto - Department of 5 Department of Pharmacy, School of Medicine and Health Sciences, Pharmacy, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Pluit Raya No. 2, North Jakarta, 14440 Atma Jaya Catholic University of 6 Department of Biomedical and Anatomy, School of Medicine and Health Sciences, Indonesia, Pluit Raya No. 2, North Atma Jaya Catholic University of Indonesia, Pluit Raya No. 2, North Jakarta, 14440 Jakarta, 14440 Tena Djuartina - Department of Corresponding author: Yohanes Eko Adi Prasetyanto Biomedical and Anatomy, School of E-mail: [email protected] Medicine and Health Sciences, Atma Jaya Catholic University Abstract of Indonesia, Pluit Raya No. 2, North Jakarta, 14440 This study evaluates biocompatibility and biodegradation properties of PCL/Chi- tosan/BG-NP/Tetracycline and compares them with commercially available Sure- Derm membrane in Sprague Dawley Rats.Two different membranes (PCL/Chitosan/ BG-NP/Tetracycline membrane and SureDerm membrane) were randomly inserted into subcutaneous pouches in the backs of 54 Sprague Dawley rats. The animals License were sacrificed at day 7, 21, and 63. Biocompatibility properties (number and distri- This work is licensed under a Creative bution of inflammatory cells, necrosis, neovascularisation, fibrosis, fatty infiltrate, Commons Attribution-NonCommercial- tissue integration, tissue ingrowth) was assessed according to DIN EN ISO 10993- NoDerivatives 4.0 International License. 6. Biodegradation property was assessed macroscopically to check for membrane degradation rate. In terms of biocompatibility properties, the test membrane had Authors contributing to Annali di Stomatologia agree to publish overall irritancy score of 0 at day 7 and 21, and 0.66 at day 63, and it is considered their articles under the Creative non-irritant. Biodegradation of test membrane is faster compared to SureDerm at Commons Attribution-NonCommercial- day 7 and 21. However, there is no significant difference between the two mem- NoDerivatives 4.0 International License, branes at day 63. The GTR membrane PCL/Chitosan/BG-NP/Tetracycline is a good which allows third parties to copy and membrane with comparable biocompatibility and biodegradation properties to the redistribute the material providing SureDerm membrane. appropriate credit and a link to the license but does not allow to use the material for commercial purposes and to Key words: Biocompatibility, Biodegradation, In Vivo, Polycaprolactone, Guided Tis- use the material if it has been remixed, sue Regeneration transformed or built upon. Introduction How to Cite C Machiavelli, S Dwiyanti,VM Sidharta, D Periodontitis is the main cause of tooth loss in adults. Research conducted in Jember Re- Ary Harjanti, M Octavia, gency for the period January-December 2014, several reasons for tooth extraction were E Adi Prasetyanto, T Djuartina. found, such as periodontitis (583 cases), caries (302 cases), impaction (58 cases), and In Vivo Biocompatibility and Biodegradation Test of Two Barrier persistence (1 case) [1]. Periodontitis was responsible for the largest number of extracted Membranes for Guided Tissue tooth in all sociodemographic groups [1]. Regeneration Periodontitis affects many people throughout the world. According to the Ministry of Annali Di Stomatologia, 15(1), 9-16. Health of the Republic of Indonesia (Depkes RI), periodontitis ranks second in Indone- https://doi.org/10.59987/ads/2024.1.9-16 sia [2]. 10.59987/ads/2024.1.9-16 9  In Vivo Biocompatibility and Biodegradation Test of Two Barrier Membranes for Guided Tissue Regeneration Periodontitis is a serious infectious disease and if not Materials and Methods treated properly it can result in tooth loss [3]. The buildup of plaque bacteria on the surface of the teeth is the main Research Design cause of periodontitis [3]. Plaque buildup initially causes This is an in vivo experimental research using Sprague gingivitis, which further develop into periodontitis result- Dawley rats. ing in tissue damage periodontal support in the form of Ethical clearance for this research was granted prior to damage to the fibers, periodontal ligament and alveolar the commencement of the study by the Research Ethics bone. It can eventually cause mobility and tooth loss [3]. Committee of the School of Medicine and Health Sci- One of the surgical treatment of periodontitis is carried ences Atma Jaya Catholic University of Indonesia. All out using the Guided Tissue Regeneration (GTR) [4]. rats were kept under standard conditions in a purpose- This GTR method uses a barrier membrane which pre- designed room for experimental animals. They were vent epithelial tissue invasion and ensure the growth of treated according to the Animals in Research: Reporting periodontal ligament cells in the defect area [4]. GTR In Vivo Experiments guidelines for animal care, with free membrane should have a good biocompatibility, mechan- access to water and a standard diet. ical strength, biodegradability and antibacterial proper- ties. Barrier membranes are also useful for wound heal- Study Materials ing, isolation of gingival defects and clots stabilisation [5]. Numerous investigations have focused on the develop- In this research, there were 2 types of membranes used: ment of resorbable materials for GTR membranes, ex- test membranes with the composition PCL/Chitosan/BG- emplified in the research conducted by Dikici et al [6]. NP/Tetracycline and commercially available SureDerm This research used polycaprolactone (PCL) which show as control membrane (Table 1). a good results because it has better biological properties For negative control, the sham group was used. There than other polymers [6]. The PCL membrane also has were 9 groups in this study, namely; good mechanical, biocompatibility properties, and slow 1. Positive Control 1: Rat inserted with SureDerm degradation rate [6]. This supports the use PCL as one membrane, terminated at day 7. of the composition for GTR membranes. However, our 2. Positive Control 2: Rat inserted with SureDerm research combines two polymers so that the hydropho- membrane, terminated at day 21. bic nature of PCL can be overcome [6]. 3. Positive Control 3: Rat inserted with SureDerm Chitosan is chosen as another polymer because it has membrane, terminated at day 63. good hydrophilic properties [7]. Chitosan also has an- 4. Experimental Group 1: Rat inserted with PCL/Chi- tibacterial, anti-fungal, and wound healing properties tosan/BG-NP/Tetracycline membrane, terminated [8]. Another component, Bioactive Glass Nanoparticles at day 7. (BG-NP), is added to increase membrane stiffness. BG- 5. Experimental Group 2: Rat inserted with PCL/Chi- NP also shows adequate extensibility in wet conditions tosan/BG-NP/Tetracycline membrane, terminated and is osteoconductive [9]. at day 21. An alternative way to increase the antibacterial effect of a 6. Experimental Group 3: Rat inserted with PCL/Chi- membrane is with the help of antibiotics [10]. Several re- tosan/BG-NP/Tetracycline membrane, terminated searchers have succeeded in combining tetracycline into at day 63. a polymer solution to develop a membrane barrier [11]. 7. Negative Control 1: Sham group, no membrane in- serted, but still undergo incision and suture, termi- Tetracycline is an effective bacteriostatic agent against nated at day 7. many Gram-negative species including periodontopatho- 8. Negative Control 2: Sham group, no membrane in- gens such as Aggregatibacter actinomycetemcomitans serted, but still undergo incision and suture, termi- [12]. Tetracycline acts as a collagenase inhibitor, has nated at day 21. anti-inflammatory action, bone resorption inhibitor, and 9. Negative Control 3: Sham group, no membrane in- increases the attachment of fibroblasts to the root surface serted, but still undergo incision and suture, termi- which increases periodontal tissue regeneration [12]. nated at day 63. Based on the description above, we fabricate barrier membranes containing PCL/Chitosan/BG-NP/Tetracy- Animals cline using electrospinning method. The objective of this research is to evaluate biocompatibility and biodegrada- Fifty-four Sprague Dawley rats (mass, ± 100-300 g) were tion properties of PCL/Chitosan/BG-NP/Tetracycline and used in this study. Each group contained six rats allo- to compare them with commercially available SureDerm cated to each of 3 observation time points (7, 21, and membrane in Sprague Dawley Rats. 63 days). Table 1. Test and Control Article Descriptions Function Name Description Implant Sizes (mm x mm) PCL/Chitosan/BG-NP/ PCL/Chitosan/BG-NP/ Test Membrane 10.0 x 10.0 Tetracycline Membrane Tetracycline Membrane Homologous acellular dermis Positive Control SureDerm Membrane 10.0 x 10.0 and penicillin Negative Control Sham Operation Without biomaterial insertion 10.0 x 10.0 10 10.59987/ads/2024.1.9-16 M. Clavesia et al. Biocompatibility properties were tested according to the Explantation and Biodegradation Test DIN EN International Organization for Standardization (ISO) 10993-6 standard for investigating the effects of After trial periods of 7, 21, and 63 days, each group re- subcutaneous implantation on local tissues. Assess- ceived an overdose of Ketamine/Xylazine for euthana- ment of biodegradation was done with the help of 10x10 sia. By adding a safety margin of approximately 5 mm mm mica plastic, which was further divided into 9 small on each side of the implanted membrane, a 20x20 mm boxes. If the membrane covered <1/2 of the small box, sample was removed from the back of the rat using a a degradation value of 11.11% is given. If the membrane scalpel, blade, and blunt scissors. Mica plastic was put covered >1/2 of the small box, a degradation value of on top of the biopsied sample to measure the degrada- 0% was given. tion value of the membrane (Figure 2). Subcutaneous Implantation Fixation and Histopathological Staining The rat was anesthetized intramuscularly using a sy- The sample was placed in a 10% Neutral Buffered For- ringe containing a combination of ketamine [90 mg/kg] malin solution for 24 hours for fixation and were then and xylazine [10 mg/kg]. The rat were then shaved and sent for histological processing [13,15]. After fixation, disinfected in the upper back area, and a transverse each sample was dehydrated in a series of alcohol so- incision was made on the rat’s backs with a scalpel. A lutions of increasing concentration and subsequently 10x10 mm of GTR membrane was inserted into the back embedded in paraffin [15]. The samples were cut into 4 subcutaneously [13] (Figure 1). The incision was closed parts using a scalpel, after which they were further cut with standard suture material (Prolene 6.0) [13]. Beta- into 4 µm thick sections and stained with Hematoxylin dine and gauze was applied on the wound. The rat was and Eosin and Masson Trichrome for descriptive and housed in separate cage until it was in stable condition, semiquantitative histological evaluation [15]. after which the rats were moved back into their respec- tive cages [13]. Semiquantitative Histological Analysis Ac- cording to DIN EN ISO 10993-6 Semiquantitative histological analysis was performed on each subcutaneous slide scanned according to the area of interest, without overlap, and captured at 400× magni- fication producing a score value indicating greater domi- nance among them. The response of tissue-membrane biological parameters is evaluated and assessed, as fol- lows: (Table 2) [14]. 1. The number and distribution of inflammatory cells semiquantitatively by looking at changes in neu- trophils, lymphocytes, plasma cells, macrophages, and giant cells as a function of distance from the material/tissue [14]. 2. Presence and extent of necrosis [14]. Figure 1. Membrane Implantation into the Subcutaneous 3. Inflammatory response parameters (neovascu- Back of Rats larization, capillaries with supporting fibroblas- tic structures, degree of fibrous capsule fibrosis stained with Masson Trichrome staining, and fat infiltration) [14]. Measurements were scored according to ISO 10993-6 guidelines: 0, none; 1, slight; 2, moderate; 3, marked; 4, complete/severe [15].Neovascularization was scored according to capillaries present: 0, none; 1, minimal cap- illary proliferation; 2, groups of 4–7 capillaries ; 3, broad band of capillaries; 4, an extensive band of capillaries [15]. Inflammation is descriptively assessed based on the number of macrophages, polymorphonuclear cells, lymphocytes, plasma cells, and giant cells present [15]. Graded using the following scoring system: 1, Rare, 1-5/ phf; 2, 6-10/phf; 3. heavy infiltrate; 4, packed [15]. Ne- crosis was evaluated, with the following grading system: 1, minimal; 2, mild; 3. moderate; 4, marked [15]. Fibro- sis was evaluated, with the following grading system 1, narrow band; 2, moderately thick band; 3, thick band; 4, extensive band [15]. Finally, fatty infiltrate is assessed us- ing the following scoring system 1, minimum amount of fat; 2, several layers of fat; 3, elongated and widespread accumulation of fat cells; 4, extensive fat completely [15]. Irritation score is obtained by adding up scores of PMN Figure 2. Macroscopic Aspects of Tissue Re- cells, lymphocytes, plasma cells, macrophages, giant sponse to Different Membranes After Implantation cells, necrosis which will then multiplied by two, then 10.59987/ads/2024.1.9-16 11  In Vivo Biocompatibility and Biodegradation Test of Two Barrier Membranes for Guided Tissue Regeneration adding up with scores of neovascularization, fibrosis, Results and fatty infiltrate. The overall irritancy score of the test article at each Biocompatibility Test study time point was calculated as follows: Overall irri- Data of the biocompatibility test in the form of mean tancy score = test membrane irritancy score (PCL/Chito- histological evaluation for irritation/reactivity-cell type/ san/BG-NP/Tetracycline membrane) – average irritancy respone according to ISO 10993-6 for day 7,21, and score of control membrane (Surederm membrane) If the 63 is presented in Table 4,5, and 6. [15]. Lymphocyte result was a negative number, the irritancy score was cells, plasma cells, and macrophage cells were found considered to be 0.0. The irritancy grade was then deter- on the SureDerm membrane and PCL/Chitosan/BG- mined according to Table 3. NP/Tetracycline membrane on day 7 and day 21 (Table Table 2. Histological Evaluation System for Irritation/Reactivity – Cell Type/Response [13] Score (phf = Per High Powered (x400) Field) Respone 0 1 2 3 4 PMN cells 0 Rare, 1-5/phf 6-10/phf Heavy infiltrate Packed Lymphocytes 0 Rare, 1-5/phf 6-10/phf Heavy infiltrate Packed Plasma cells 0 Rare, 1-5/phf 6-10/phf Heavy infiltrate Packed Macrophages 0 Rare, 1-5/phf 6-10/phf Heavy infiltrate Packed Giant cells 0 Rare, 1-2/phf 3-5/phf Heavy infiltrate Packed Necrosis 0 Minimal Mild Moderate Packed Neovascularization 0 Minimal capillary Groups of 4-7 Broad band Extensive band proliferation capillaries with of capillaries of capillaries focal, 1-3 buds supporting with supporting with supporting fibroblastic structures fibroblastic Fibrocytes/ 0 Narrow band Moderately Thick band Extensive band fibroconnective tissue, thick band fibrosis Fatty infiltrate 0 Minimal amount Several layers of Elongated and Extensive fat of fat associated fat and fibrosis broad accumulation surrounding the with fibrosis of fat cells about the implant implant site Table 3. Irritancy/Reactivity Grade. Adapted from DIN EN ISO 10993-6 [13] Overall Irritancy Score Irritancy/Reactivity Status 0.0 to 2.9 Minimal or no reaction (non irritant) 3.0 to 8.9 Slight reaction (slight irritant) 9.0 to 15.0 Moderate reaction (moderate irritant) >15.1 Severe reaction (severe irritant) - Irritation Score: (PMN Cells + Lymphocytes + Plasma Cells + Macrophages + Giant Cells + Necrosis) x 2 + (Neovascularization + Fibrosis + Fatty Infiltrate) - Overall Irritation Score: PCL/Chitosan/BG-NP/Tetracycline Membrane Irritation Score – SureDerm Membrane Irritation Score Table 4. Mean Histological Evaluation for Irritation / Reactivity – Cell Type / Response According to ISO 10993-6 Guide- lines for Day 7 Neovas- Tissue Tissue PMN Lympho- Plasma Macro- Giant Ne- Fatty cularisa- Fibrosis Integra- In- Cell cytes Cell phages Cells crosis Infiltrate tion tion growth SureDerm 0.5 ± 0.67 ± 0.5 ± 0 0 0 0 0 0 0 0 Membrane 0.84 1.21 0.84 Negative 0.33 ± 0 0 0 0 0 0 0 0 0 0 Control 0.52 PCL/ Chitosan/ 0.33 ± 0.33 ± 1.17± BG-NP/ 0 0 0 0 0 0 0 0 0.52 0.52 1.33 Tetracycline membrane 12 10.59987/ads/2024.1.9-16 M. Clavesia et al. 4 & 5). On the other hand, there were no cells found irritant status of non irritant on day 7, day 21, and day on day 7, day 21, and day 63 for the negative control 63 (Table 7). Exemplary histological images stained with (Table 4, 5, 6). Hematoxylin and Eosin as well as Masson Trichrome of The PCL/Chitosan/BG-NP/Tetracycline membrane has a the three groups at day 7, 21, and 63 can be seen in comparable irritation score as SureDerm membrane and Figure 3 and 4. Table 5. Mean Histological Evaluation for Irritation / Reactivity – Cell Type / Response According to ISO 10993-6 Guide- lines for Day 21 Neovas- Tissue Tissue PMN Lympho- Plasma Macro- Giant Ne- Fatty cularisa- Fibrosis Integra- In- Cell cytes Cell phages Cells crosis Infiltrate tion tion growth SureDerm 0.5 ± 0.33 ± 0 1± 1.27 0 0 0 3± 1.10 0 0 0 Membrane 0.84 0.82 Negative 2.67 ± 0 0 0 0 0 0 0 0 0 0 Control 1.51 PCL/ Chitosan/ 0.5 ± 0.5 ± 2.33 ± BG-NP/ 0 0 0 0 0 0 0 0 0.55 0.55 1.37 Tetracycline membrane Table 6. Mean Histological Evaluation for Irritation / Reactivity – Cell Type / Response According to ISO 10993-6 Guide- lines for Day 63 Neovas- Tissue Tissue PMN Lympho- Plasma Macro- Giant Ne- Fatty cularisa- Fibrosis Integra- In- Cell cytes Cell phages Cells crosis Infiltrate tion tion growth SureDerm 1.67 ± 0 0 0 0 0 0 0 0 0 0 Membrane 1.86 Negative 1.67 ± 0 0 0 0 0 0 0 0 0 0 Control 0.82 PCL/ Chitosan/ 2.33 ± BG-NP/ 0 0 0 0 0 0 0 0 0 0 1.03 Tetracycline membrane Figure 3. Exemplary Histological Images Stained with He- Figure 4. Exemplary Histological Images Stained with matoxylin and Eosin of the Three Groups at Day 7, 21, Masson Trichrome for Fibrosis Evaluation of the Three and 63. Groups at Day 7, 21, and 63 A. Negative Control, Day 7; B. Negative Control, Day 21; C. Nega- A. Scoring 0, Negative Control, Day 7; B. Scoring 0, Negative Con- tive Control, Day 63; D. SureDerm Membrane, Day 7; E. SureDerm trol, Day 21; C. Scoring 1, Negative Control, Day 63; D. Scoring 2, Membrane, Day 21; F. SureDerm Membrane, Day 63; G. PCL/Chi- SureDerm Membrane, Day 7; E. Scoring 3, SureDerm Membrane, tosan/BG-NP/Tetracycline Membrane, Day 7, H. PCL/Chitosan/BG- Day 21; F. Scoring 4, SureDerm Membrane, Day 63; G. Scoring 3, NP/Tetracycline Membrane, Day 21; I. PCL/Chitosan/BG-NP/Tetra- PCL/Chitosan/BG-NP/Tetracycline Membrane, Day 7, H. Scoring 2, cycline Membrane, Day 63 PCL/Chitosan/BG-NP/Tetracycline Membrane, Day 21; I. Scoring 3, PCL/Chitosan/BG-NP/Tetracycline Membrane, Day 63 10.59987/ads/2024.1.9-16 13  In Vivo Biocompatibility and Biodegradation Test of Two Barrier Membranes for Guided Tissue Regeneration Biodegradation Test Discussion Based on the results of biodegradation tests, it can be Biocompatibility Test seen that the commercial SureDerm membrane was The GTR membrane has several criteria or requirements only slightly degraded on day 7 (27.5 ± 6.12%) and day to be called an ideal membrane. The first requirement is 21 (28.33 ± 14.02%), while the PCL/Chitosan/BG-NP/ to have biocompatibility properties [16]. Biocompatibility Tetracycline membrane has greater degradation on day is the ability of the material to adapt to the environment 7 (50 ± 6.32%) and day 21 (50 ± 6.32%) (Table 7). where the membrane must not harm the body and have The percentage degradation test of SureDerm mem- non-toxic properties [16]. The membrane must not trig- brane and PCL/Chitosan/BG-NP/Tetracycline mem- ger the host’s immune system, sensitization, or chronic brane was compared using independent t-test for each inflammatory reactions [17]. Based on the results of the timeline. It was found that percentage degradation of the biocompatibility test, it can be seen that the GTR mem- two membranes were statistically significant for day 7 brane with the composition (g) PCL/Chitosan/BG-NP/ and day 21 in which PCL/Chitosan/BG-NP/Tetracycline Tetracycline = 11/0.5/0.5/0.04 has comparable irritancy membrane was degraded more quickly, but not signifi- score as the SureDerm commercial membrane and the cant for day 63. irritancy score overall non-irritant or non-irritating. Rate of degradation of the two membranes was faster This testing is in line with the research of Osathanon et al in the first 21 days, after which the degradation became [18]. Osathanon et al’s research discusses the biological more slowly (Figure 5). basis of GTR membranes in periodontal tissue healing Table 7. Mean Irritation Score After Membrane Implantation Day 7, Day 21, Day 63 Overall Study Group Irritation Score Irritation Status Irritation Score SureDerm Membrane 2.84 ± 0.87 Negative Control 0.33 ± 0.39 Day 7 0 Non Irritant PCL/Chitosan/BG-NP/Tetracycline 2.49 ± 0.60 membrane SureDerm Membrane 6.66 ± 0.87 Negative Control 2.67 ± 0.39 Day 21 0 Non Irritant PCL/Chitosan/BG-NP/Tetracycline 4.33 ± 0.60 membrane SureDerm Membrane 1.67 ± 0.87 Negative Control 1.67 ± 0.39 Day 63 0.66 Non Irritant PCL/Chitosan/BG-NP/Tetracycline 2.33 ± 0.60 membrane Irritation Score: (PMN Cells + Lymphocytes + Plasma Cells + Macrophages + Giant Cells + Necrosis) x 2 + (Neovascularization + Fibrosis + Fatty Infiltrate) - Overall Irritation Score: PCL/Chitosan/BG-NP/Tetracycline Membrane Irritation Score – SureDerm Membrane Irritation Score Figure 5. Biodegradation Test Chart 14 10.59987/ads/2024.1.9-16 M. Clavesia et al. Table 8. Mean Biodegradation Test Data Post Membrane Implantation Day 7, Day 21, Day 63 Biodegradation Percentage (%) Sample Day 0 Day 7 Day 21 Day 63 SureDerm Membrane 0 27.5 ± 6.12 28.33 ± 14.02 91.25 ± 7.50 PCL/Chitosan/BG-NP/Tetracycline 0 50 ± 6.32 50 ± 6.32 95 ± 5.48 membrane P-value - <0.01** <0.05* >0.05 ns Note: ns: Non-Significant (p-value >0.05); * : Significant (p-value <0.05); ** : Very Significant (p-value <0.01) and regeneration [18]. Bioactive GTR membranes have ideal criteria of a GTR membrane, but further observa- been investigated and developed with the aim of creat- tions need to be made to determine the time needed for ing membranes that not only act as a physical barrier all samples to be completely degraded. but also induce biologics to enhance periodontal tissue Compared to SureDerm membrane, the test membrane regeneration [18]. PCL has been introduced as a candi- is thinner. The SureDerm commercial membrane has a date material for bioactive GTR membranes due to its thickness of 0.26 mm [23]. The test membrane has a biocompatibility and simple fabrication procedures [18]. thickness of 0.13 ± 0.03 mm [23]. A thicker membrane Modification with other agents or biomolecules can be will have stronger mechanical strength than a thin one. easily made [18]. PCL can be useful for promoting peri- Therefore SureDerm membrane degrade less rapidly odontal tissue formation [18]. due to its thicker thickness compared to the PCL/Chito- Sarasam et al used a PCL/chitosan membrane which san/BG-NP/Tetracycline coated GTR membrane. improves mechanical properties and cell viability com- pared to pure chitosan [19]. Chitosan is a polysaccharide Research Limitations that is much sought after in biomedical applications and has been mixed with various macromolecules to reduce The research has limitations. This research model, us- undesirable properties [19]. Dissolved chitosan and PCL ing a subcutaneous pouch of rats does not fully reflect homogeneously in various mass ratios in a mixture of the conditions of the oral cavity and the oral microbi- 77% acetic acid in water and processed into uniform ome, so there could be variation in biocompatibility and membranes [19]. Dynamic mechanical and thermal anal- biodegradation properties. ysis shows that the crystallinity of PCL is suppressed The subcutaneous model is also less representative of and its storage modulus is increased by the addition of the actual condition of GTR, in which the membrane chitosan [19]. should be placed on a bone defect that has been filled Another component of the membrane, bioactive glass is with bone graft, it is recommended that futher research a promising material for tissue regeneration due to its can be carried out on more representative model, such controlled degradability and ability to stimulate the for- as in bone defect on larger animals such as monkeys. mation of new tissue [20]. Bioactive glass has demon- strated excellent bioactivity and biocompatibility when Conclusion implanted in bone defects [9]. Bioactive glass degrada- The GTR membrane PCL/Chitosan/BG-NP/Tetracycline tion promotes osteogenesis by stimulating ions. stimu- composition (g) 11/0.5/0.5/0.04 is ideal as a GTR mem- lates osteoconductivity [20]. PCL (polycaprolactone) brane because it has a good biocompatibility properties. which is hydrophobic in nature was mixed with chitosan The PCL/Chitosan/BG-NP/Tetracycline membrane has a which has hydrophilic properties [20]. PCL, known for its comparable irritation score as SureDerm membrane and robust mechanical strength, can contribute to enhanc- irritant status of non irritant. The PCL/Chitosan/BG-NP/ ing the mechanical properties of chitosan, which tends Tetracycline membrane also has good biodegradation to be inherently brittle [20]. A mixture of the two materi- properties which allows sufficient time for periodontal tis- als shows good biocompatibility with each other because sue formation. However, the degradation rate is faster PCL’s low melting point makes it easier to mix the two compared to SureDerm membrane. polymers [19]. References Biodegradation Test 1. Fithri Z, Rochim A, Cholid Z. Distribusi pencabutan gigi Based on the biodegradation test results listed in Table berdasarkan karakteristik sosiodemografi pada pasien 7, it can be seen that all samples were not completely RSGM universitas jember periode januari-desember 2014 (Distribution of tooth extraction based on sociodemograph- degraded on days 7 and 21 therefore they act as good ic characteristic of dental hospital of university of jember barrier and allow sufficient rate of periodontal tissue Pat. Pustaka Kesehatan. 2017 Aug 11;5(1):177–84. formation of 4-6 weeks [22]. The addition of BG-NP in- 2. Badan Penelitian dan Pengembangan Kesehatan -. Lapo- crease the stiffness of the membrane so that it does ran Nasional Riskesdas 2018 [Internet]. Jakarta: Lembaga not decompose or degrade easily. BG-NPs caused a Penerbit Badan Penelitian dan Pengembangan Kesehat- significant increase in membrane thickness and surface an; 2020. Available from: https://repository.badankebi- jakan.kemkes.go.id/id/eprint/3514/ area [21]. Samples on day 63 was completely degraded 3. American Academy of Periodontology. The American and invisible to the naked eye. This shows that the test Academy of Periodontology statement regarding gingival membrane has a degradation capability that meets the curettage. J Periodontol. 2002 Oct;73(10):1229–30. 10.59987/ads/2024.1.9-16 15  In Vivo Biocompatibility and Biodegradation Test of Two Barrier Membranes for Guided Tissue Regeneration 4. Ziccardi VB, Buchbinder D. Guided tissue regeneration in 14. Neto AM, Sartoretto SC, Duarte IM, Resende RF, Alves dentistry. N Y State Dent J. 1996 Dec;62(10):48–51. AT, Mourao CF, et al. In vivo comparative evaluation of 5. Bottino MC, Thomas V, Schmidt G, Vohra YK, Chu biocompatibility and biodegradation of bovine and porcine TMG, Kowolik MJ, et al. Recent advances in the devel- collagen membranes. Membranes. 2020 Dec;10(12):423. opment of GTR/GBR membranes for periodontal regen- 15. Naenni N, Lim HC, Strauss FJ, Jung RE, Hammerle CH, eration—A materials perspective. Dental Materials. 2012 Thoma DS. Local tissue effects of various barrier mem- Jul;28(7):703 21. branes in a rat subcutaneous model. Journal of Periodon- 6. Aldemir Dikici B, Dikici S, Reilly GC, MacNeil S, Claeys- tal; Implant Science. 2020 Oct;50(5):327. sens F. A novel bilayer polycaprolactone membrane for 16. Matyjaszewski K, Möller M, editors. Polymer science: a guided bone regeneration: combining electrospinning and comprehensive reference. Amsterdam: Elsevier; 2012. emulsion templating. Materials. 2019 Aug 20;12(16):2643. 17. Sam G, BRM P. Evolution of barrier membranes in peri- 7. Zhang L, Dong Y, Zhang N, Shi J, Zhang X, Qi C, et al. Po- odontal regeneration-”Are the third generation membranes tentials of sandwich-like chitosan/polycaprolactone/gelatin really here?”. Journal of Clinical and Diagnostic Research. scaffolds for guided tissue regeneration membrane. Mate- 2014 Dec 5;8:12. rials Science and Engineering: C. 2020 Apr;109:110618. 18. Osathanon T, Chanjavanakul P, Kongdecha P, Clayhan 8. Xu C, Lei C, Meng L, Wang C, Song Y. Chitosan as a bar- P, Huynh NC-N. Polycaprolactone-based biomaterials for rier membrane material in periodontal tissue regeneration. guided tissue regeneration membrane. Periodontitis - A Journal of Biomedical Materials Research Part B: Applied Useful Reference. 2017 Biomaterials. 2012 Jul;100(5):1435–43. 19. Sarasam AR, Krishnaswamy RK, Madihally SV. Blending 9. Mota J, Yu N, Caridade SG, Luz GM, Gomes ME, Reis chitosan with polycaprolactone: Effects on physicochemi- RL, et al. Chitosan/bioactive glass nanoparticle composite cal and antibacterial properties. Biomacromolecules. 2006 membranes for periodontal regeneration. Acta Biomateria- Apr;7(4):1131–8. lia. 2012 Nov;8(11):4173–80. 20. Pajares-Chamorro N, Chatzistavrou X. Bioactive glass 10. Yilmaz Atay H. Antibacterial activity of chitosan-based nanoparticles for tissue regeneration. ACS Omega. 2020 systems. In: Jana S, Jana S, editors. Functional Chitosan. Jun 9;5(22):12716–26. Singapore: Springer Singapore; 2019;457–89. 21. Lin S, Ionescu C, Pike KJ, Smith ME, Jones JR. Nano- 11. Mad Jin R, Sultana N, Baba S, Hamdan S, Ismail AF. Po- structure evolution and calcium distribution in sol–gel de- rous PCL/chitosan and nHA/PCL/chitosan scaffolds for tis- rived bioactive glass. J Mater Chem. 2009;19(9):1276. sue engineering applications: fabrication and evaluation. 22. Fraser D, Caton J, Benoit DSW. Periodontal wound heal- Journal of Nanomaterials. 2015;2015:1–8. ing and regeneration: insights for engineering new thera- 12. Seymour RA, Heasman PA. Tetracyclines in the manage- peutic approaches. Frontiers in Dental Medicine. 2022 Mar ment of periodontal diseases. Journal of Clinical Periodon- 2;3:815810. tology. 1995;22(1):22–35. 23. Kandelousi PS, Rabiee SM, Jahanshahi M, Nasiri F. The 13. Lindner C, Alkildani S, Stojanovic S, Najman S, Jung O, effect of bioactive glass nanoparticles on polycaprolac- Barbeck M. In vivo biocompatibility analysis of a novel bar- tone/chitosan scaffold: Melting enthalpy and cell viabil- rier membrane based on bovine dermis-derived collagen ity. Journal of Bioactive and Compatible Polymers. 2019 for guided bone regeneration (GBR). Membranes. 2022 Jan;34(1):97–111. Mar;12(4):378. 16 10.59987/ads/2024.1.9-16 

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Double Full-Arch Implant-Supported Fixed Complete Dental Prostheses (IFCDPs): advanced monolithic zirconia solutions Andrea Berzaghi1 DDS, MSc, PhD Authors Sergio Bortolini1 DDS, Associate Professor Andrea Berzaghi, DDS, MSc, PhD - Department of Surgery, Medicine, Dentistry and Morphological Sciences Department of Surgery, Medicine, Dentistry and Morphological 1 with Interest in Transplant, Oncology and Sciences with Interest in Transplant, Oncology and Regenerative Medicine, Regenerative Medicine, University of University of Modena and Reggio Emilia (UNIMORE), Modena and Reggio Emilia (UNIMORE), Via del Pozzo 71, 41125 Modena, Italy. Via del Pozzo 71, 41125 Modena, Italy. Sergio Bortolini, DDS, Associate Corresponding author: Andrea Berzaghi Professor - Department of Surgery, [email protected] Medicine, Dentistry and Morphological Sciences with Interest in Transplant, Oncology and Regenerative Medicine, Abstract University of Modena and Reggio Emilia Among the latest generation of prosthetic materials, zirconia represents one of the (UNIMORE), Via del Pozzo 71, 41125 Modena, Italy. most versatile ceramic materials offering options for rehabilitation of both anterior and posterior sectors. In the last two decades, zirconia frameworks have become increasingly popular in the implant prosthesis and the introduction of CAD/CAM technology has made it possible to approach full-arch restorations in a different way and with promising success rates. In this case report we present Double Full- Arch Implant-Supported Fixed Complete Dental Prostheses (IFCDPs) using digital License technology to fabricate advanced monolithic zirconia solutions. We report a brief This work is licensed under a Creative examination of the advantages of the two solutions in comparison. Commons Attribution-NonCommercial- NoDerivatives 4.0 International License. Key words: Zirconia, monolithic zirconia, metal bar, Implant-supported fixed com- Authors contributing to Annali di plete dental prostheses. Stomatologia agree to publish their articles under the Creative Commons Attribution-NonCommercial- Introduction NoDerivatives 4.0 International License, which allows third parties to copy and The recent evolution of ceramic materials in prosthetic dentistry is aimed at increas- redistribute the material providing ing the mechanical and aesthetic properties and simplifying the manufacturing and appropriate credit and a link to the decision-making processes for clinicians and technicians. Until a few years ago it was license but does not allow to use the universally recognized in the literature that the most mechanically resistant ceramics of- material for commercial purposes and to use the material if it has been remixed, fered less advanced aesthetic characteristics, most of the time resulting more opaque, transformed or built upon. therefore less translucent and attractive1. In the panorama of the latest generation of prosthetic materials, zirconia represents one of the most versatile ceramic materials of- How to Cite fering options for rehabilitation of both anterior and posterior sectors. The 3mol% Y-TZP A. Berzaghi, S Bortolini. and the recent 4/5mol% Y-TZP are heterogeneous materials in composition, structure, Double Full-Arch Implant-Supported mechanical and optical properties and offer dentists and laboratories solutions that Fixed Complete Dental Prostheses (IFCDPs): advanced monolithic zirconia can be layered or monolithic with a different compromise between strength and aes- solutions thetics1-6. In particular, the introduction of monolithic zirconia for its characteristics of Annali Di Stomatologia, 15(1), 17-20. reliability and practicality has led to a downsizing in prosthetic design with indisputable https://doi.org/10.59987/ads/2024.1.17-20 advantages for clinicians and technicians7-9. In the last two decades, zirconia frame- works have become increasingly popular in the implant prosthesis and the introduction of CAD/CAM technology has made it possible to approach full-arch restorations in a different way and with promising success rates10-13. The aim of this clinical report is to describe the prosthodontic management of a female patient with Double Full-Arch Implant-Supported Fixed Complete Dental Prostheses (IFCDPs) using digital technology to fabricate advanced monolithic zirconia solutions: monolithic screw-retained zirconia design in the upper jaw compared to the innovative design which features monolithic zirconia supported by a metal bar made of cobalt chromium (Co-Cr) in inferior arch. We report a brief examination of the advantages of the two solutions in comparison. 10.59987/ads/2024.1.17-20 17  Double Full-Arch Implant-Supported Fixed Complete Dental Prostheses (IFCDPs): advanced monolithic zirconia solutions Figure 4. Zirconia superstructure coupled to the metal bar. Zirconia Ceramotion Z Hybrid 1300/1020 Mpa (Dentaurum s.p.a) was chosen for the superstructure. man), both arches were loaded immediately using stan- dardized prosthodontic techniques to produce an interim resin prosthesis. The definitive prosthodontic treatment was initiated after 10 weeks of loading the maxillary and mandibular implants. Appropriate abutments were placed on the implants to obtain parallelism and path of draw. Final impression of the implants were made us- ing polyether impression material after rigidly splinting all impression copings. Using standard prosthodontic pro- tocols, maxillomandibular relationships and trial denture procedures were accomplished to fabricate prototype prosthesis (interim acrylic resin prosthesis) using CAD/ CAM technology. In maxilla a screw-retained interim acrylic resin prosthesis while in the mandible an interim acrylic resin prosthesis supported by a Co-Cr metal bar were made. Minor adjustments were made to prosthetic contours, occlusion and esthetics. The bar was milled from a solid block of Co-Cr. The bar was planned on incorporating a zirconia overlay prosthesis (Fig. 4) only up to the last tooth on either side. After confirmation of the aesthetic and functional result, patient’s written ap- proval was obtained in order to use this for copy milling the definitive zirconia prosthesis (Zirconia Ceramotion Figure 1-3. Panoramic radiograph and photos of the initial Z Hybrid 1300/1020 Mpa, Dentaurum s.p.a). The over- case. Patient comes to our observation with incongruous lay mandibular prosthesis and the maxillary monolithic complete dentures. screw-retained zirconia was milled from a solid blank of pre-sintered zirconia, which was then infiltrated with Case Report stains and veneered with feldspathic porcelain at aes- thetic and gingival region (Figg. 5-7). Passive fit of both An 80-year-old female patient, an edentulous patient prostheses was confirmed. A post-treatment panoramic with Complete Dental Prostheses, comes to our obser- radiograph was taken to confirm seating of the prosthe- vation requesting a fixed Double Full-Arch prosthodontic ses (Fig.8). solution. Patient’s existing complete dentures made by monolithic zirconia: zirconia on a metal bar in lower arch, his general dentist was deemed unsatisfactory to the screw-retained zirconia in upper arch. Gingival and den- patient and the clinician (Figg.1-3). Patient’s medical tal aesthetic ceramization with Ceramotion One Touch history revealed that she had a history of multiple im- ceramic pastes (Dentaurum s.p.a). Dental technician plant failures. Patient also had a history of smoking for Mdt Germano Rossi. several decades and was aware of his bruxism. Based on patient’s history, clinical and radiographic findings, Discussion the patient was diagnosed with a Class C Classifica- tion System ABC14. 8 implants were planned for being The advantages of the monolithic screw-retained restored with a maxillary screw-retained monolithic zir- prosthesis are many. The screw-retained prosthesis conia IFCDP. 6 mandibular implants were planned on traditionally represents the first choice in full-arch im- being restored with Metal-Zirconia Implant Fixed Hybrid plant-prosthetic rehabilitation for fewer biological com- Full-Arch Prosthesis: restoration that provides monolith- plications and easier management of complications15,16. ic zirconia supported by cobalt chromium bar. After the Zirconia guarantees advanced mechanical properties surgical implant placement (implants Even Mech & Hu- with a low complication rate; excellent biocompatibility; 18 10.59987/ads/2024.1.17-20 A. Berzaghi et al. favorable wear characteristics; reduced accumulation of plaque and biofilm; satisfactory gingival and dental aesthetics associated with minimal ceramization of non-functional areas; reduced pigmentation compared to acrylic resin. The CAD-CAM design and production of zirconia has led to further advantages: better preci- sion of the prosthesis thanks to modern manufacturing systems; availability of a permanent digital file with the possibility of duplicating the prosthetic restoration; pos- sibility of making temporary posts in PMMA. However, the monolithic zirconia screw-retained design remains a complex prosthetic solution, in which clinical suc- cess is linked to the knowledge of the materials and the high precision required by 3Y-TZP17,18,19. The need to guarantee the framework suitable dimensions in ar- eas at risk of fracture, the impossibility of recovery of the structure in the event of failure, the low tolerance to imprecision imprecisions and the opacity of the high- strength material represent the current limits of this prosthesis17,20. Metal-Zirconia Implant Fixed Hybrid Full-Arch Prosthesis currently represents the most ad- vanced implant-prosthetic design in the field of implant- supported restorations and represents the evolution of screw-retained monolithic solutions, potentially able to solve some critical issues21,22. The metal bar gives stiff- ness, excellent tensile strength, high fracture strength, passive fit and allows you to manage long spans be- tween adjacent implants and extend cantilevers. It also allows versatile use on different implant platforms, com- pensates for problems of unfavorable angles and of- fers the possibility, if necessary, to be segmented. The metal frameworks obtained by laser sintering/melting procedures have improved the “fit”, the “bonding” and the corrosion resistance compared to the bars obtained by casting23. The monolithic zirconia in this prosthetic design represents the first choice solution for reasons related to the intrinsic characteristics of the material and to the prosthetic technologies. From an aesthetic point of view, the metal framework gives the possibility to take full advantage of the new generations of trans- Figure 5-7 Case concluded. Double Full-Arch Implant-Sup- lucent zirconia without risk of structural failure. Starting ported Fixed Complete Dental Prostheses in monolithic zir- from the CAD design information on the bar, we can conia: zirconia on a metal bar in lower arch, screw-retained create PMMA provisionals that act as prototype pros- zirconia in upper arch. Gingival and dental aesthetic cerami- theses useful in the preliminary evaluation and approv- zation with Ceramotion One Touch ceramic pastes (Dentau- rum s.p.a). Dental technician Mdt Germano Rossi. al phase17,20. Figure 8 End of case panoramic radiograph. 10.59987/ads/2024.1.17-20 19  Double Full-Arch Implant-Supported Fixed Complete Dental Prostheses (IFCDPs): advanced monolithic zirconia solutions Conclusion 9. Candido LM, Miotto LN, Fais L, Cesar PF, Pinelli L. Me- chanical and Surface Properties of Monolithic Zirconia. The innovative design of the implant-supported re- Oper Dent. 2018 May/Jun;43(3):E119-E128. habilitation of the lower arch that uses a monolithic 10. Al‐Amleh B, Lyons K, & Swain M. Clinical trials in zirco- structure in zirconia on a metal bar was born to ex- nia: A systematic review. Journal of Oral Rehabilitation 2010;37:641-652. ploit the aesthetic potential of the latest generation zir- 11. Raigrodski A J, Hillstead MB, Meng, GK, Chung K H. conia even in the presence of extensive cantilevers. Survival and complications of zirconia‐based fixed den- The diffusion of CAD/CAM technology together with tal prostheses: A systematic review. Journal of Prosthetic the promising characteristics of aesthetics, reliability Dentistry 2012;107:170-177. and versatility of this advanced solution make mono- 12. Mendez Caramês JM, Sola Pereira da Mata AD, da Silva lithic zirconia on bar a successful and widespread re- Marques D N, de Oliveira Francisco H C. Ceramic‐Ve- neered Zirconia frameworks in full‐arch implant rehabili- habilitation in the coming years. The use of the latest tations: A 6‐month to 5‐year retrospective cohort study. generation multilayered zirconia for the construction of International Journal of Oral and Maxillofacial Implants monolithic structures allows to overcome the limits of 2016;31:1407-1414. the traditional 3Y-TZP. The incorporation of 4Y-TZP in 13. Abdulmajeed AA, Lim KG, Närhi TO, Cooper LF. Complete‐ multi-translucent implant-prosthetic structures allows arch implant‐supported monolithic zirconia fixed dental to provide degrees of aesthetics and reliability unthink- prostheses: A systematic review. Journal of Prosthetic Den- tistry 2016;115(6):672-677. able until two years ago for monolithic screw-retained 14. Bortolini S, Berzaghi A et al. Classification system for par- structures. The new generations of 4Y-TZP and multi- tial edentulism: ABC classification. Annali di Stomatologia translucent monolithic zirconia materials, incorporating 2022; XIII (1-4): 21-26 3Y, 4Y and 5Y-TZP with varying translucency levels, 15. Sailer I, Muhlemann S, Zwahlen M, Hammerle CHF, appear to be promising in these designs as well. In Schneider D. Cemented and screw-retained implant re- particular, some types of 4Y-TZP with high mechanical con- structions: a systematic review of the survival and complication rates. Clinical Oral Implants Research 2012; performance24,25 can represent promising materials in 23:163–201. this sense. 16. Sherif S, Susarla HK, Kapos T, Munoz D, Chang BM, Wright RF. A systematic review of screw-versus cement- Acknowledgments retained implant-supported fixed restorations. Journal of Prosthodontics 2014;23(1):1-9. The authors would like to thank Dentaurum Italia S.p.a. 17. Rojas Vizcaya F. Retrospective 2- to 7-Year Follow-Up for supporting this article. Study of 20 Double Full-Arch Implant-Supported Mono- We thank for the technical realization Mdt Germano Ros- lithic Zirconia Fixed Prostheses: Measurements and Rec- si, Alba Adriatica (Te). ommendations for Optimal Design. J Prosthodont. 2018 Jul;27(6):501-508. 18. Worni A, Kolgeci L, Rentsch-Kollar A, Katsoulis J, Meric- References ske- Stern R. Zirconia-Based Screw-Retained Prostheses 1. Kontonasaki E, Giasimakopoulos P, Rigos AE. Strength Supported by Implants: A Retrospective Study on Techni- and aging resistance of monolithic zirconia: an update to cal Complications and Failures. Clin Implant Dent Relat current knowledge. Jpn Dent Sci Rev. 2020 Dec;56(1):1- Res 2015;17:1073-1081. 23. 19. Amin S, Weber HP, Kudara Y, Papaspyridakos P. Full- 2. Zhang Y, Kelly JR. Dental Ceramics for Restoration and Mouth Implant Rehabilitation With Monolithic Zirconia: Metal Veneering. Dent Clin North Am. 2017 Oct;61(4):797- Benefits and Limitations. Compend Contin Educ Dent 819. 2017 Jan;38(1):e1-e4. 3. Zhang Y, Lawn BR. Novel zirconia materials in dentistry. J 20. Carames J, Tovar Suinaga L, Yu YC, Pérez A, Kang M. Dent Res 2018;97:140–7. Clinical Advantages and Limitations of Monolithic Zirconia 4. Güth JF, Stawarczyk B, Edelhoff D, Liebermann A. Zirco- Restorations Full Arch Implant Supported Reconstruction: nia and its novel compositions: What do clinicians need to Case Series. Int J Dent 2015;2015:392-496. know? Quintessence Int. 2019;50 (7):512-520. 21. Stumpel LJ, Haechler W: The Metal-Zirconia Implant Fixed 5. Camposilvan E, Leone R, Gremillard L, Sorrentino R, Hybrid Full-Arch Prosthesis: An Alternative Technique for Zarone F, Ferrari M, Chevalier J. Aging resistance, me- Fabrication. Compend Contin Educ Dent 2018;39:176- chanical properties and translucency of different yttria- 181. stabilized zirconia ceramics for monolithic dental crown 22. Bidra AS. Complete Arch Monolithic Zirconia Prosthesis applications. Dent Mater. 2018;34:879–90. Supported By Cobalt Chromium Metal Bar: A Clinical Re- 6. Zhang F, Reveron H, Spies BC, Van Meerbeek B, Cheva- port. J Prosthodont. 2020 Apr 1. lier J. Trade-off between fracture resistance and translu- 23. Abduo J. Fit of CAD/CAM implant frameworks: a compre- cency of zirconia and lithium-disilicate glass ceramics for hensive review. J Oral Implantol. 2014 Dec;40(6):758-66. monolithic restorations. Acta Biomater 2019;91:24–34. 24. Spies BC, Zhang F, Wesemann C, Li M, Rosentritt M. Reli- 7. Stawarczyk B, Keul C, Eichberger M, Figge D, Edel- ability and aging behavior of three different zirconia grades hoff D, Lümkemann N. Three generations of zirconia: used for monolithic four-unit fixed dental prostheses. Dent From veneered to monolithic. Part I. Quintessence Int. Mater. 2020 Sep 15:S0109-5641(20)30213-X. 2017;48(5):369-380. 25. Chiari A, Mantovani S, Berzaghi A, Bellucci D, Bortolini S, 8. Stawarczyk B, Keul C, Eichberger M, Figge D, Edel- Cannillo V. (2023). Load bearing capability of three-units hoff D, Lümkemann N. Three generations of zirconia: 4Y-TZP monolithic fixed dental prostheses: An innova- From veneered to monolithic. Part II. Quintessence Int. tive model for reliable testing. Materials & Design March 2017;48(6):441-450 2023;227:111751. 20 10.59987/ads/2024.1.17-20 

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Early Childhood Caries Assessment and Related Risk Factors among a Group of Lebanese Preschool Children: A Cross-Sectional Study Ahmad Tarabaih Authors Ahmad Tarabaih - Assistant Professor of Pedodontics, Faculty of Dentistry, Assistant Professor of Pedodontics, Faculty of Dentistry, Beirut Arab University, Beirut, Beirut Arab University, Beirut, LebanonMaster in Pediatric Dentistry, Faculty of Dentistry, Beirut Arab University, Beirut, LebanonMaster in Pediatric Dentistry, Lebanon. Faculty of Dentistry, Beirut Arab University, Beirut, Lebanon. Corresponding author: Ahmad Tarabaih ABSTRACT Objective License The study aimed to assess the prevalence of Early Child Caries and its associated This work is licensed under a Creative risk factors among a group of Lebanese preschool children. Commons Attribution-NonCommercial- NoDerivatives 4.0 International License. Materials and Methods Authors contributing to Annali di An observational, cross-sectional study design that included 388 children recruited Stomatologia agree to publish from different schools in Beirut, Lebanon. The parents were interviewed to answer their articles under the Creative Commons Attribution-NonCommercial- a questionnaire developed by the World Health Organization (WHO, 1997) and Car- NoDerivatives 4.0 International License, ies Assessment Risk tool developed by the American Academy of Pediatric Dentist- which allows third parties to copy and ry (AAPD, 2019). Then, caries prevalence was assessed by examining the children redistribute the material providing using the WHO decayed, missed or filled primary teeth (dmft) index and the rating appropriate credit and a link to the scores of dental caries were classified as very low <1.2, low 1.2 – 2.6, moderate 2.7 license but does not allow to use the – 4.4 and high 4.4 (WHO, 1997). material for commercial purposes and to use the material if it has been remixed, transformed or built upon. Results How to Cite The mean age of the children was 4.03 ± 0.82 years. The prevalence of ECC was A Tarabaih. 71.1% and the mean dmft index was noted to be 3.11 ± 3.67. Based on the risk as- Early Childhood Caries Assessment and sessment results, 68% of the preschool children had high caries risk whereas 32% Related Risk Factors among a Group of had low caries risk. A statistically significant differences in mean dmft scores were Lebanese Preschool Children: A Cross- noted in which 3-years-old children exhibited a lower mean dmft value compared Sectional Study to 4 and 5 years olds (p<0.001). In addition, a significant difference was also found Annali Di Stomatologia, 15(1), 21-26. https://doi.org/10.59987/ads/2024.1.21-26 in dmft scores between middle socioeconomic status (SES) schools and low SES schools (p=0.016). Conclusion Oral health promotion programs are to be implemented on regular basis to enhance the oral health status and general well-being of young children. Key words: Early Childhood Caries, Children, Risk Assessment, Socio-demo- graphic Factors INTRODUCTION ECC is defined as the presence of one or more decayed, missed or filled primary tooth in children under six years old [1]. ECC starts as white spot lesions along the gingival margin of maxillary deciduous incisors, leading to a complete crown destruction in the progression of caries [2]. The main risk factors in the development of ECC can be cat- egorized as microbiological, dietary, and environmental risk factors [3]. ECC affects both the child’s oral and general health. Although it is largely a preventable condition, it is considered as a major oral health problem, mainly in socially disadvantaged populations and remains one of the most common childhood diseases worldwide [4]. 10.59987/ads/2024.1.21-26 21  Early Childhood Caries Assessment and Related Risk Factors among a Group of Lebanese Preschool Children: A Cross-Sectional Study The ECC prevalence has been reported between 1% developed the Caries Risk Assessment (CRA) tool to and 12% in developed countries but is as high as 70% help in assessing the caries development risk levels and in developing countries. The underlying risk factors for identifying individual’s specific behaviors or risk factors ECC in different populations have been studied through- [6]. The CRA tool includes risk factors (social, behavior- out different developed countries [5]; however, minimal al, medical, clinical factors), protective factors and dis- epidemiological studies described the status of ECC in ease indicators. The WHO questionnaire demonstrates Lebanon. It is of prime importance to build strong base- the assessment of associated risk factors through gath- line data that can help in identifying ECC and, further- ering data that focuses on socioenvironmental determi- more, aid in planning appropriate treatment plans and nants and modifiable risk factors of oral health in children implementing essential preventive measures. [9]. The questionnaire includes questions concerning the The risk assessment techniques utilized in medical prac- child’s gender and age, place of residence, oral health tices can provide enough data to precisely measure a status and oral hygiene habits. It also includes dietary person’s susceptibility to disease and allow for preven- habits, personal or social issues experienced due to tive interventions. Caries risk assessment (CRA), how- oral cavity problems and parents’ educational level. ever, (1) enhances the treatment process of the disease The Kolmogorov-Smirnov normality test was conducted rather than treating its outcome, (2) aids in individual- and showed that our data were not normally distributed. izing preventive discussions as it allows an understand- Qualitative data were presented as frequencies and per- ing of the disease factors for a specific patient, (3) in- centages whereas quantitative data were presented as dividualizes, chooses, and decides on the frequency of median, range, mean, and standard deviation values. a patient’s preventive and restorative treatment and (4) The Mann-Whitney U test and Kruskal-Wallis test were predicts the progression or stability of caries [6]. used for comparisons between two groups and more Therefore, the purpose of the present study is to as- than two groups respectively. Furthermore, Dunn’s test sess the ECC prevalence and its associated risk factors was used for pair-wise comparisons when the Kruskal- among a group of Lebanese preschool children from Wallis test was significant. The significance level was set different SES schools, assuming that ECC don’t differ at p ≤ 0.05 and statistical analysis was performed with among different study variables. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp [10]. MATERIALS AND METHODS Study Settings RESULTS This is an observational, cross-sectional study to de- Demographic Data termine the status of ECC among a group of Lebanese preschoolers. The study was conducted between De- The study sample included 388 children where 193 chil- cember 2021 and March 2022 in which four schools in dren were boys (49.7%) and 195 children were girls Beirut, Lebanon, were enrolled from two socioeconomic (50.3%). The mean age of the children was 4.03 ± 0.82 classes (middle and low). All children between the ages years. As for the geographic location, 62.6% and 37.4% of 3 and 5 years were randomly selected. The study was of participants lived in urban and peri-urban areas respec- approved by the scientific and ethical review committee tively. The demographic variables are presented in table 1. and institutional review board at Beirut Arab University (BAU IRB code: 2022-H-0098-D-M-0480). Clinical Examination Among clinical examination, 9% of participants had Population Settings non-cavitated (incipient/white spot) lesions or enamel The sample size was calculated using the free calcu- defects, 71.7% of participants had previous history of lator on Raosoft.com. The total sample size required caries (visible cavities/ fillings/ missing teeth) with mean was 388 participants considering a 5% margin of error, dmft index of 3.12 ± 3.67 (Table 2). 95% confidence level and estimated population size of 445,000. Dental Caries Index All children who were medically compromised, defi- The present study showed a statistically significant nitely negatively cooperated - based on Frankl clas- difference in mean dmft values between age groups sification- during the dental examination [7], or whose where 3-year-old children exhibited the lowest value parents refused to participate in study were excluded. compared to older groups (p<0.001). Also the mean value of dmft scores were significantly lower among Data Collection middle SES schools in compared to low class group (p=0.016). (Tables 3 and 4) Clinical examination was done by one trained and cali- brated examiner (κ=87%). The examiner interviewed Dental Care the preschool children’s parents at school premises to ensure that the questionnaires were understood and Dental care had also revealed that 36.4% of the par- completed. The child’s dental status was then evaluated ticipants had dental visits in the past 12 months, 63.1% using the dmft index described by the WHO. The dental didn’t had have visits or received dental care in the past status was evaluated using dmft index according to the 12 months. The common reason for last dental visit was World Health Organization oral health surveys and the pain or troubles with teeth, gum or mouth in which 45.4% rating scores of dental caries were classified as very low was shown in responses. As regards to the frequency <1.2, low 1.2 – 2.6, moderate 2.7 – 4.4 and high 4.4 [8]. of dental cleaning, it was common to clean once/day The American Academy of Pediatric Dentistry (AAPD) (43.3%) followed by twice or more times/day (21.9%). 22 10.59987/ads/2024.1.21-26 A. Tarabaih Table 1. Frequencies (n) and percentages (%) for demographic data of the study participants Demographic Data n % Gender Boy 193 49.7 Girl 195 50.3 Age 3y 125 32.2 4y 126 32.5 5y 137 35.3 Location Urban 243 62.6 Peri-urban 145 37.4 School Middle Socioeconomic Status 175 45.1 Low Socioeconomic Status 213 54.9 Table 2. Descriptive statistics for clinical examination Clinical Examination n % 1. Child has non-cavitated (incipient/white spot) caries or enamel 35 9 defects 2. Child has visible cavities or fillings or missing teeth due to caries 276 71.7 3. Child has visible plaque on teeth 40 10.3 4. Decayed teeth (d): [Mean (SD), Median (Range)] 2.86 (3.44), 2 (0-18) 5. Missing teeth (m): [Mean (SD), Median (Range)] 0.06 (0.29), 0 (0-3) 6. Filled teeth (f): [Mean (SD), Median (Range)] 0.19 (0.67), 0 (0-6) 7. dmft index: [Mean (SD), Median (Range)] 3.11 (3.67), 2 (0-18) Table 3. Frequencies (n) and percentages (%) for dmft dmft = 0 dmft >0 Mean ± SD p-value n% n% Gender Boy 48 12.4 145 37.4 3.06 ± 3.18 p = 0.765 Girl 62 15.9 133 34.3 3.16 ± 3.53 Age 3y 51 13.1 74 19.1 0.85 ± 0.86 4y 31 8.0 95 24.5 3.66 ± 3.07 p<0.001* 5y 28 7.2 109 28.1 4.68 ± 3.91 School Middle SES 57 14.7 118 30.4 45.1 p = 0.016* Low SES 53 13.6 160 41.3 54.9 10.59987/ads/2024.1.21-26 23  Early Childhood Caries Assessment and Related Risk Factors among a Group of Lebanese Preschool Children: A Cross-Sectional Study Table 4. Multiple Comparison between Age and dmft Multiple Comparisons Dependent Variable: dmft Mean 95% Confidence Interval (I) Age (J) Age Std. Error Sig. Difference (I-J) Lower Bound Upper Bound 4 years -2.81073* .28395 .000 -3.4964 -2.1251 3 years 5 years -3.83083* .34320 .000 -4.6592 -3.0025 3 years 2.81073* .28395 .000 2.1251 3.4964 Dunnett T3 4 years 5 years -1.02010 .43189 .056 -2.0579 .0177 3 years 3.83083* .34320 .000 3.0025 4.6592 5 years 1.02010 .43189 .056 -.0177 2.0579 *The mean difference is significant at the 0.05 level. Tooth brush and toothpaste were the only cleaning Children with low SES had significantly higher dmft scores method reported by all participants. Moreover, 35.7% of compared to children from middle SES (p<0.001). SES participants reported using fluoridated tooth paste while influences dental caries and is determined by the educa- 42.1% didn’t know if the used toothpaste was fluoridated tional level, health beliefs and accessibility to health care or not. information [13]. In addition, the low frequency of tooth brushing can be contributed to the low SES in the current Dietary Habits study. In contrary, a higher frequency of tooth brushing was seen in Freire and colleagues’ study due to parental The majority of participants consumed cariogenic food, supervision and guidance during teeth brushing [14]. in which 88.9% of the participants had biscuits, cakes, The majority of the participants (45.3%) visited a den- cream cakes, sweet pies, buns and 62.3% of the par- tist due to pain but only 19% continued the treatment. ticipants had sweets/candy several times. The major- This is reflected by the participants’ inability to afford ity of participants had high consumptions of fresh fruits non-urgent treatments or receive dental care in the past (89.7%) several times, while those who consumed tea 12 months (63.1%) due to the severe economic crisis with sugar were low (24.8%). Moreover, almost half of that Lebanon was going through and therefore, not all the participants (49.8%) were given milk daily. participants were capable of continuing their dental treat- ments or receive dental care as costs of treatments were Risk Factors, Protective Factors and Risk expensive. This result corroborates with results of other Assessment studies [15,16,17]. In contrary, free regular check-ups Children who had snacks between meals showed the are offered in countries with free public dental health highest percentage of participants (68.3%) in risk factors care services, allowing 90% of children to attend regular and 42.5% of the mother/primary caregiver had active checkup appointments as in Norway [18]. decay in the past 12 months. Regarding the protective The importance of fluoride lies in the exertion of its anti- factors, 21.9% of the participants brushed daily and cariogenic action through inhibiting tooth demineraliza- 6.7% of the participants received fluoride varnish in the tion, promoting tooth remineralization and inhibiting past 6 months. As for the risk assessment, 32% of the plaque bacteria [19]. Participants reported that they nei- participants had a low caries risk compared to 68% of ther used nor knew if they used fluoridated toothpaste the participants who had a high caries risk. which is a reflection of parental limited knowledge about fluoride which interprets the high caries level in the cur- DISCUSSION rent study. However, children having lower prevalence of dental caries was a reflection of parents having a better ECC is recognized as a major public health problem due awareness regarding fluoride. to its high prevalence and negative health impacts if left The revealed results of the dietary habits explain the untreated [11]. The present study assessed the preva- high caries prevalence and the high risk of forming ini- lence of ECC and its associated risk factors among a tial lesions. Children usually do not have control over group of Lebanese preschool children who aged be- their food choices as their eating habits were shaped tween 3 and 5 years. by their parents [20], and parents pamper their children The mean dmft value of children aged between 4 and 5 with inexpensive, high-sugar-content snacks that con- years were significantly higher than 3 years old children tribute to tooth decay [21]. One assumption regarding (p<0.001), indicating that the level of caries increases these findings could be attributed to cultural factors, as with age. Also, the current study’s prevalence of ECC Middle Eastern countries including Lebanon, habitually was still high (71.7%) and yet is similar to that reported include high sugar snacks in children’s diet intake [22]. in 2023 by Tabbara (70.4%) [12]. This is reflected by the The frequent consumption of sugary snacks and bever- fact that as children increase in age, they become more ages causes a frequent drop in the saliva’s pH and its susceptible to certain dietary and behavioral attitudes, acidic media to attack the tooth surface, breaking down which increase their teeth’s susceptibility to decay. the enamel and developing dental caries. Furthermore, 24 10.59987/ads/2024.1.21-26 A. Tarabaih snacks such as sweets and candies can adhere to the 2017;5:157. Published 2017 Jul 18. doi:10.3389/ teeth surface for a period of time, causing an interac- fped.2017.00157 tion between the bacteria and these sugars, leading to 4. Goswami P. Early childhood caries- a review of its caries development. In addition, children were exposed aetiology, classification, consequences, preven- to high-risk factors associated with dental caries, noting tion and management. J. Evolution Med. Dent. that their mothers had active dental caries and those Sci. 2020;9(10):798-803, DOI: 10.14260/jemds/ children had frequent sugar exposure per day. Moth- 2020/173 ers are the primary source of Streptococcus mutans, 5. Rai NK and Tiwari T. Parental Factors Influencing the and during the first two years of a child’s life, the degree Development of Early Childhood Caries in Devel- of vertical transfer of bacteria increases in response to oping Nations: A Systematic Review. Front. Public the mother’s poor oral hygiene, exposure to sugar, and Health 2018; 6:64. doi: 10.3389/fpubh.2018.00064 snacking frequency [3]. 6. Caries-risk Assessment and Management for In- A significant deficiency concerning the protective factors fants, Children, and Adolescents. Pediatr Dent. in relation to dental caries was present in brushing daily 2017;39(6):197-204. using fluoridated toothpaste, which was a reflection of 7. Frankl, S. N. “Should the parent remain with the parents’ lack of supervision and parental awareness. child in the dental operatory?.” J. Dent. Child. 29 Another protective factor deficiency was observed in (1962): 150-163. receiving fluoride from a health professional, which re- 8. World Health Organization. (‎1997)‎. Oral health sur- sulted from Lebanon’s economic crisis that left parents veys: basic methods, 4th ed. World Health Organi- unable to afford the costs of topical fluoride treatments. zation. https://iris.who.int/handle/10665/41905 The high caries risk percentage can be explained by the 9. World Health Organization. (2013). Oral health sur- presence of visible cavities or fillings or missing teeth veys: basic methods, 5th ed. World Health Organi- due to caries, visible plaque and non-cavitated (incipi- zation. ent/white spot caries) or enamel defects. In contrary, a 10. IBM Corp. Released 2015. IBM SPSS Statistics for study reported that the majority of their participants were Windows, Version 23.0. Armonk, NY: IBM Corp. of moderate risk (71.3%) with less missing teeth due to caries and less visible plaque [23]. 11. Naidu R, Nunn J, Donnelly-Swift E. Oral health- In conclusion, ECC among children is certainly a global related quality of life and early childhood caries problem, with consequences extending beyond its clini- among preschool children in Trinidad. BMC Oral cal signs and symptoms. Our results revealed a defi- Health. 2016;16(1):128. Published 2016 Dec 7. ciency in oral health care knowledge, and therefore, oral doi:10.1186/s12903-016-0324-7 hygiene education through awareness campaigns and 12. Hisham Hassan Tabbara. The Impact of Selected educational programs is mandatory, along with nutrition Social Determinants on the Prevalence and Sevirity promotion campaigns that aim in providing consultation of Early Childhood Caries among a Group of Leba- on dietary habits. nese Preschool Children. Sch J Dent Sci, 2023 Apr 10(4): 60-68. 13. T S, Kumar B S, Datta M, V T H, Nisha V A. Prevalence, LIMITATIONS severity and associated factors of dental caries in 3-6 This cross sectional study was conducted between De- year old children. J Clin Diagn Res. 2013;7(8):1789- cember 2021 and March 2022 where the pandemic dis- 1792. doi:10.7860/JCDR/2013/6201.3277. ease - Covid-19; was still restricting the country. There- 14. Freire M, Graça SR, Dias S, Mendes S. Oral health- fore, difficulties were faced in getting access to variety related quality of life in portuguese pre-school chil- of schools from different socioeconomic statuses and in dren: a cross-sectional study. Eur Arch Paediatr different locations in Beirut. Moreover, due to the fear of Dent. 2022;23(6):945-952. doi:10.1007/s40368- spreading Covid-19, many schools rejected the request 022-00741-7 of being part of the study. 15. Bulut G, Bulut H. Zero to five years: First dental visit. Eur J Paediatr Dent. 2020;21(4):326-330. Informed Consent Statement: Informed consent was doi:10.23804/ejpd.2020.21.04.13 obtained from all subjects involved in the study. Written 16. Alshahrani NF, Alshahrani ANA, Alahmari MA, informed consent has been obtained from the patients to Almanie AM, Alosbi AM, Togoo RA. First dental publish this paper. visit: Age, reason, and experiences of Saudi chil- dren. Eur J Dent. 2018;12(4):579-584. doi:10.4103/ Conflicts of Interest: The authors declare no conflict ejd.ejd_426_17 of interest. 17. Murshid EZ. Children’s ages and reasons for re- ceiving their first dental visit in a Saudi communi- ty. Saudi Dent J. 2016;28(3):142-147. doi:10.1016/j. References sdentj.2015.12.003 1. Policy on Early Childhood Caries (ECC): Classifi- 18. Åstrøm AN, Agdal ML, Sulo G. Exploring avoid- cations, Consequences, and Preventive Strate- ance of dental care due to dental fear and eco- gies. Pediatr Dent. 2018;40(6):60-62. nomic burden -A cross-sectional study in a national 2. Kawashita Y, Kitamura M, Saito T. Early childhood sample of younger adults in Norway. Int J Dent Hyg. caries. Int J Dent. 2011;2011:725320. doi:10.1155/ 2024;22(1):148-157. doi:10.1111/idh.12657 2011/725320 19. Nassar Y, Brizuela M. The Role of Fluoride on Car- 3. Anil S, Anand PS. Early Childhood Caries: Preva- ies Prevention. In: StatPearls. Treasure Island (FL): lence, Risk Factors, and Prevention. Front Pediatr. StatPearls Publishing; March 19, 2023. 10.59987/ads/2024.1.21-26 25  Early Childhood Caries Assessment and Related Risk Factors among a Group of Lebanese Preschool Children: A Cross-Sectional Study 20. Samaddar A, Shrikrishna SB, Moza A, Shenoy R. 22. Elamin A, Garemo M, Gardner A. Dental caries Association of parental food choice motives, at- and their association with socioeconomic charac- titudes, and sugar exposure in the diet with early teristics, oral hygiene practices and eating habits childhood caries: Case-control study. J Indian Soc among preschool children in Abu Dhabi, United Pedod Prev Dent. 2021;39(2):171-177. doi:10.4103/ Arab Emirates - the NOPLAS project. BMC Oral jisppd.jisppd_104_21 Health. 2018;18(1):104. Published 2018 Jun 8. 21. Athavale P, Khadka N, Roy S, et al. Early Child- doi:10.1186/s12903-018-0557-8 hood Junk Food Consumption, Severe Dental Car- 23. Muhson, Z. N., Thabit, S., Al-ward, F. S., & Al Shatari, ies, and Undernutrition: A Mixed-Methods Study S. A. (2020). Caries risk assessment of a sample from Mumbai, India. Int J Environ Res Public of children attending preventive specialized dental Health. 2020;17(22):8629. Published 2020 Nov 20. center in Al Resafa, Baghdad. Journal of Baghdad doi:10.3390/ijerph17228629 College of Dentistry, 32(4), 17-24. https://api.se- manticscholar.org/CorpusID:230588632 26 10.59987/ads/2024.1.21-26 

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Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva- Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies Authors Alireza Sarraf Shirazi1 Alireza Sarraf Shirazi - Professor, Sara Majidinia2 Department of Pediatric Tahereh Parhizkar3 Dentistry, Mashhad University of Medical Sciences, Masshad, Iran ORCID: 1 Professor, Department of Pediatric Dentistry, Mashhad University of Medical Sciences, 0000-0001-6539-5478 Masshad, Iran ORCID: 0000-0001-6539-5478 Sara Majidinia - Assistant Professor, 2 Assistant Professor, Dental Research Center, Department of Operative Dentistry, Mash- Dental Research Center, Department had Dental School, Mashhad University of Medical Sciences, Mashhad, IranORCID: of Operative Dentistry, Mashhad Dental 0000-0002-7601-114X School, Mashhad University of Medical 3 Postgraduate student, Department of Operative Dentistry, Mashhad Dental School, Sciences, Mashhad, IranORCID: Mashhad University of Medical Sciences, Mashhad, Iran 0000-0002-7601-114X Tahereh Parhizkar - Postgraduate student, Department of Operative Corresponding author: Tahereh Parhizkar Dentistry, Mashhad Dental School, E-mail: [email protected] Mashhad University of Medical Sciences, Mashhad, Iran ABSTRACT Background Saliva contamination during the try-in procedure is one of the leading causes of License decreased bond strength of resin to zirconia. In this meta-analysis, we evaluated This work is licensed under a Creative the effects of different cleaning methods on the bond strength of the zirconia res- Commons Attribution-NonCommercial- toration. NoDerivatives 4.0 International License. Authors contributing to Annali di Methods Stomatologia agree to publish A systematic search was performed through MEDLINE via PubMed, EMBASE, Sco- their articles under the Creative pus, ISI web of knowledge, and Cochrane databases. In vitro articles in which the Commons Attribution-NonCommercial- NoDerivatives 4.0 International License, cleaning methods were compared with contaminated and non-contaminated sur- which allows third parties to copy and faces were selected for this study. The duration of storage was separated into two redistribute the material providing subgroups of <1 and >1 week. appropriate credit and a link to the license but does not allow to use the material for commercial purposes and to Results use the material if it has been remixed, Out of 909 results of database searches, 15 studies were included in the system- transformed or built upon. atic review. In the storage period of <1 week, there were significant differences How to Cite between the saliva-contaminated, decontamination with air abrasion (SDM: 2.478, A Sarraf Shirazi, S Majidinia, T Parhizkar. P<0.01), and Ivoclean (SDM: 3.055, P<0.01) groups. Also, in the storage period of Effect of Different Cleaning Methods >1 week, significant differences were observed between air abrasion (SDM: 2.714, on Bond Strength of Resin to Saliva- P<0.01), Ivoclean (SDM: 2.575, P<0.01), and argon plasma (SDM: 1.998, P<0.01) Contaminated Zirconia: A Systematic groups. There was a significant difference between non-contaminated and isopro- Review and Meta-analysis of in Vitro Studies panol (<1 week storage period: SDM: -3.252, P=0.05; >1 week storage period; SDM: Annali Di Stomatologia, 15(1), 27-38. -1.302, P<0.01) and phosphoric acid (<1 week storage period: SDM: -1.584, P<0.01; https://doi.org/10.59987/ads/2024.1.27-38 storage period >1 week; SDM: -2.021, P<0.01) decontaminated groups. Conclusion Sandblasting with airborne-particle abrasion (Al2O3), Ivoclean, and argon plasma has been effective in recovering the bond strength of resin to saliva-contaminated zirconia, while bond strength of decontaminated surface with alcohol and phosphoric acid is sig- nificantly weaker than in non-contaminated situations. Key words: Bond strength, cleaning, saliva contamination, zirconia. 10.59987/ads/2024.1.27-38 27  Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies Introduction ramic, which was superior to isopropanol and phosphoric acid in a previous study by Yang et al (9). Recently, the use of the high-strength ceramic mate- This meta-analysis evaluated the effects of different rial yttrium-oxide-partially-stabilized zirconia (YPSZ) cleaning methods on the shear bond strength of zirco- ceramic, as a restorative dental material, has gained nia restorations contaminated with saliva. tremendous interest in dentistry. Considering the ad- vantages of zirconia, such as esthetic, biocompatibil- METHODS ity, mechanical characteristics, and excellent optical behavior, it is used in implants, implant abutments all- This study was conducted based on the Preferred Re- ceramic crowns and bridges, all-ceramic post and core porting Items for Systematic Reviews and Meta-Analy- systems, and for single and/or multi-unit fixed dental ses (PRISMA) statement (10). The PICOS was identified prostheses (1). In addition, the application of the ce- as Table 1. mentation process between the tooth and restoration plays an important role in the clinical success of zirco- Search strategy nia restorations. Although recently there have been advances in ad- We electronically searched MEDLINE via PubMed, EM- hesive promotors, the use of resin-bonded minimal BASE, Scopus, ISI Web of Science, and Cochrane da- invasive restorations in reconstructive dentistry has tabases using the search strategy of (Zirconia OR zirco- increased significantly. Adhesive resin cements have nium OR Ceramic OR Ceramics OR 3Y-TZP OR CAD/ become popular because they increase retention and CAM OR CAD-CAM) AND (Contamination OR Clean- marginal adaptability (2). However, the bonding sur- ing OR Decontamination OR Cleansing) AND ((Bond face is prone to contamination and moisture, leading strength) OR Bonding OR Adhesion OR Adhesive OR to decreased bond strength; it is difficult to avoid the Adhesives OR μTBS) on 7 February 2021 without time contamination of the bonding interface (3). and language limitation. Before adjusting the restoration, there is a need for a try-in procedure to achieve optimal fixation. During this Eligibility criteria procedure, the bonding surface might become contam- The inclusion criteria for this study were: inated by silicone indicators, blood, or saliva. Among 1. A comparison of bond strengths between a cleaning them, saliva contamination is one of the main causes method and a control group of decreased bond strength (4). Zirconium shows a 2. Zirconia-adjusted ceramics strong affinity for the phosphate groups found in saliva, 3. Zirconia ceramics which were contaminated with which react with the zirconia surface (5). Hence, sever- saliva al cleaning methods have been studied to clean these 4. The studies used appropriate statistical tests to an- contaminations and prepare an appropriate bonding alyze the bond strength data and the sample size. surface for clinically successful restoration. Cleaning P-values, means, and standard deviations were re- with water, alcohol (70% to 96% isopropanol), phos- ported in the results. phoric acid, a newly introduced product Ivoclean, plas- ma, and additional airborne particle abrasion (Al2O3) Study selection and data extraction are some of the well-known methods used to remove zirconia surface contamination (6). The results of the searches were imported into the End- Both acid etching and alkaline-based agents can be used Note application, and after removing duplicated studies, as chemical cleaning methods. Previous studies have re- two authors (SM and TP) independently screened the ported that sandblasting with Al2O3 and chemical clean- articles based on titles and abstracts. Studies that did ing methods like Ivoclean are effective methods in recov- not meet the inclusion criteria in titles or abstracts were ering the bond strength (7). Studies have claimed that excluded from the study. In case of any disagreement, it acid-based methods can recover the bond strength, but was resolved after discussion or by an expert research- phosphoric acid leaves a phosphorous residue that can er’s (AS) comment. Afterward, possible related studies weaken the resin-cement bond (8). Also, airborne par- were investigated in the full-text stage. For complete ticle abrasion is recommended as an effective method coverage of published studies, the reference list of each in recovering the strength of resin bonds to zirconia ce- article was also checked. Finally, the data regarding the Table 1. Search strategy using PICOs analysis Definition Participants Zirconia restorations Innervation Different cleaning methods Comparison Contaminated/non contaminated zirconia Outcomes Bond strength Study design Invitro studies 28 10.59987/ads/2024.1.27-38 A.Sarraf Shirazi et al. type of intervention, duration of the storage period, the Risk of bias assessments comparison, and the bond strengths from each study were extracted using a data extraction table. The risk of bias was assessed in terms of randomization, The authors of articles with insufficient data were con- use of the material according to instructions, sample size tacted via e-mail to receive the missing data and infor- calculation, identical interventions other than the inter- mation. If no response was received within two weeks vention of interest, same operator outcome measure- of the initial e-mail contact, a second e-mail was sent. ments, and blinding of outcome assessors. Papers that One month after the first contact, the article was ex- reported one or two items were classified as high risk of cluded if no reply or an incomplete reply was received bias, with three or four as medium risk and five to six as from the authors. low risk. All the eligible articles were compared with contami- nated and non-contaminated surfaces according to the Statistics cleaning methods (including air abrasion, isopropanol, The statistical analyses were conducted using the com- Ivoclean, phosphoric acid, argon plasma, and sodium prehensive meta-analysis 2 (CMA2) software with 95 hypochlorite). The duration of storage was categorized confidence intervals and an 0.05 level of significance into two subgroups of <1 and >1 week. A summary of for P-value. The outcomes were reported as standard- the included studies is presented in Table 2 ized differences in means (SDM) between the interven- Table 2. The summary of eligible studies in this meta analysis Type of bond Duration First author, year Country Cleaning method Cement type strength of storage Air abrasion Farahnaz < 1 week Iran Isopropanol 3M ESPE Shear Nejatidanesh 2018 >1 week Ivoclean Air abrasion < 1 week Da-Hye Kim, 2015 Korea Panavia F2 Shear Ivoclean >1 week Isopropanol < 1 week Christoph Piest, 2018 Germany Panavia 21 Tensile Argon plasma >1 week Philip Guers, 2019 Germany Isopropanol Panavia 21 Tensile < 1 week Isopropanol Mayara Noronha, < 1 week Brazil Ivoclean Variolink LC Shear 2020 >1 week Argon plasma Francisco Martinez, Ivoclean Spain Panavia SA Shear >1 week 2021 Argon plasma Asuka Kawaguchi, Air abrasion < 1 week Japan Panavia V5 μ Tensile 2017 Phosphoric acid >1 week Air abrasion < 1 week Ryo Ishi, 2014 Japan Ivoclean Not mentioned Shear >1 week Phosphoric acid Isopropanol < 1 week Sa Feitosa 2014 USA Ivoclean Multilink Shear >1 week Phosphoric acid PanaviaSA/ Rely Akifumi Takahashi, Japan Ivoclean X unicem2/Speed Tensile <1 week 2018 Cem Rely X unicem2/ Stephanie Krifka, Germany Sodium hypochlorite Multilink/ Rely X Shear <1 week 2017 ultimate Ivoclean Akin Aldag, 2014 Turkey Variolink II μ Shear <1 week Sodium hypochlorite Air abrasion Pattarika Angkasith, USA Ivoclean Not mentioned Shear >1 week 2016 Phosphoric acid < 1 week Zhang S, 2010 Slovenia Phosphoric acid Panavia 21 Tensile >1 week Elisabetta Mangione, Air abrasion Panavia 21/ < 1 week Switzerland μ Shear 2019 Phosphoric acid Variolink II >1 week 10.59987/ads/2024.1.27-38 29  Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies tion and control groups. The results were presented in analysis, there was no significant difference between the forest plots, too. The control group could only be con- non-contaminated and air abrasion cleaning groups in the taminated with saliva or non-contaminated, considered storage period of >1 week (6 studies; 10 comparisons; negative and positive control groups, respectively. The SDM: -0.441, P=0.27); however, there was a significant duration of storage was categorized into two groups difference between the non-contaminated and air abra- of <1 and >1 week. Due to diversities in the cement sion cleaning groups in the storage period of <1 week (3 types applied, duration of storage, different operators studies; 4 comparisons; SDM: -0.795, P<0.01). In addi- and conditions a random-effect model was used for the tion, there was a significant difference between the air meta-analysis. abrasion and surface-contaminated groups in both stor- age periods of <1 week (3 studies; 4 comparisons; SDM: 2.478, P<0.01) and >1 week (6 studies; 10 comparisons; RESULTS SDM: 2.714, P<0.01) (Supplementary Figures 1-4). After two steps of assessing the eligibility of the studies, of 909 results of database searches, 15 studies were Isopropanol included in this systematic review (6, 12-25) (Figure 1). Table 3 summarizes the results of meta-analyses. Five included studies assessed the cleaning effects of isopropanol. In terms of isopropanol, although there Air abrasion was a significant difference between the saliva-con- taminated group and the group decontaminated with Six included studies assessed the cleaning effects of isopropanol with storage periods of >1 week (3 stud- the air abrasion method. According to the present meta- ies; 4 comparisons; SDM: 0.048, P=0.87), there was Records idenfied through Addional records idenfied database searching through other sources Idenficaon (n = 1273) (n = 0) ' Records aer duplicates were removed (n = 909) Screening Records screened Records excluded (n = 909) (n = 861) Full-text arcles excluded, with reasons Full-text arcles assessed (n = 33) for eligibility (n = 48) - not met eligibility criteria (n=28) - conference abstracts (n=3) Eligibility - duplicaon (n=2) Studies included in qualitave synthesis (n = 15) Studies included in quantave Included synthesis (meta-analysis) (n = 15) Figure 1. PRISMA Flow Diagram. 30 10.59987/ads/2024.1.27-38 A.Sarraf Shirazi et al. Table 3. Summary of the results of meta-analyses Intervention 95% confidence interval Standard (Forest plot in Comparison Storage difference P-value supplementary Upper in means Lower limit material) limit Air abrasion (SF1) Non-contaminated <1 week -0.795 -1.360 -0.230 <0.01* Air abrasion (SF2) Non-contaminated >1 week -0.441 -1.235 0.353 0.27 Air abrasion (SF3) Contaminated <1 week 2.478 0.646 4.310 <0.01* Air abrasion (SF4) Contaminated >1 week 2.714 1.782 3.647 <0.01* Isopropanol (SF1) Non-contaminated <1 week -3.252 -6.498 -0.005 0.05* Isopropanol (SF2) Non-contaminated >1 week -1.302 -2.146 -0.458 <0.01* Isopropanol (SF4) Contaminated >1 week 0.048 -0.556 0.653 0.87 Ivoclean (SF1) Non-contaminated <1 week -0.144 -0.494 0.205 0.41 Ivoclean (SF2) Non-contaminated >1 week -0.317 -0.646 0.013 0.06 Ivoclean (SF3) Contaminated <1 week 3.055 1.318 4.791 <0.01* Ivoclean (SF4) Contaminated >1 week 2.575 1.455 3.695 <0.01* Phosphoric acid Non-contaminated <1 week -1.584 -2.129 -1.039 <0.01* (SF1) Phosphoric acid Non-contaminated >1 week -2.021 -2.677 -1.365 <0.01* (SF2) Phosphoric acid Contaminated <1 week 0.980 -0.530 2.490 0.20 (SF3) Phosphoric acid Contaminated >1 week 0.789 -0.298 1.876 0.15 (SF4) Argon plasma (SF2) Non-contaminated >1 week -1.143 -3.352 1.067 0.31 Argon plasma (SF4) Contaminated >1 week 1.998 1.278 2.717 0.00* Sodium Contaminated <1 week 0.217 -0.214 0.647 0.32 hypochlorite (SF3) SF: Supplementary figure a significant difference between the non-contaminated Phosphoric acid group and the group with isopropanol cleaning method in both storage periods of <1 week (3 studies; 3 com- Six included studies assessed the cleaning effects of parisons; SDM: -3.252, P=0.05) and >1 week (4 stud- phosphoric acid. In assessing the effects of phosphoric ies; 5 comparisons; SDM: -1.302, P<0.01) (Supplemen- acid as a cleaning method, there was no significant dif- tary Figures 1,2 and 4). ference between decontaminated and contaminated groups in <1-week storage (5 studies; 6 comparisons; SDM: 0.980, P=0.20) and >1-week storage (6 studies; Ivoclean 10 comparisons; SDM: 0.789, P=0.15). However, a sig- Nine included studies assessed the cleaning effects of nificant difference was observed between the surfaces Ivoclean. There was a significant difference between cleaned with phosphoric acid and non-contaminated sur- the Ivoclean-decontaminated group and the contami- faces in storage periods of <1 week (5 studies; 6 com- nated groups in both storage periods of <1 week (4 parisons; SDM: -1.584, P<0.01) and >1 week (6 studies; studies; 6 comparisons; SDM: 3.055, P<0.01) and >1 10 comparisons; SDM: -2.021, P<0.01) (Supplementary week (7 studies; 9 comparisons; SDM: 2.575, P<0.01). Figures 1-4). However, there was no significant difference between non-contaminated groups and the Ivoclean group in the storage durations of <1 week (4 studies; 6 compari- Argon plasma sons; SDM: -0.144, P=0.41) and >1 week (7 studies; Three included studies assessed the cleaning effects 9 comparisons; SDM: -0.317, P=0.06) (Supplementary of argon plasma. Although there was a significant dif- Figures 1-4). ference between decontaminated and contaminated 10.59987/ads/2024.1.27-38 31  Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies Supplementary figure 1. The meta-analysis of the comparison of bond strength between cleaned surface with different cleaning methods and non-contaminated surface. Duration of storage was <1 week in these studies. 32 10.59987/ads/2024.1.27-38 A.Sarraf Shirazi et al. Supplementary figure 2. The meta-analysis of the comparison of bond strength between cleaned surface with different cleaning methods and non-contaminated surface. Duration of storage was >1 week in these studies. 10.59987/ads/2024.1.27-38 33  Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies Supplementary figure 3. The meta-analysis of the comparison of bond strength between cleaned surface with different cleaning methods and contaminated surface. Duration of storage was <1 week in these studies. 34 10.59987/ads/2024.1.27-38 A.Sarraf Shirazi et al. Supplementary figure 4. The meta-analysis of the comparison of bond strength between cleaned surface with different cleaning methods and contaminated surface. Duration of storage was >1 week in these studies. 10.59987/ads/2024.1.27-38 35  Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies Supplementary Table 1. Details of Risk of Bias assessments. Use of Same op- material Sample Identical Blinding of Random- erator out- Overall risk Study according size interven- outcome ization come mea- of bias to instruc- calculation tions* assessors surements tions Nejatidanesh UC Yes Yes Yes UC UC Medium 2018 Kim 2015 UC Yes No Yes UC UC High Piest 2018 UC Yes No Yes UC UC High Güers 2019 UC Yes No Yes UC UC High Noronha UC Yes No Yes UC UC High 2020 Martínez Yes Yes Yes Yes UC UC Medium 2021 Kawaguchi UC Yes No Yes UC UC High 2017 ISHII 2015 UC Yes No Yes UC UC High Feitosa 2015 UC Yes No Yes Yes UC Medium Takahashi UC Yes No Yes UC UC High 2017 Krifka 2017 No Yes No Yes UC UC High Aladağ 2015 No Yes No Yes UC UC High Angkasith UC Yes No Yes UC UC High 2015 Zhang 2010 No Yes No Yes UC UC High Mangione UC Yes Yes Yes UC UC Medium 2019 groups with a storage period of >1 week (3 studies; 3 overall risk of bias in four studies was medium and high comparisons; SDM: 1.998, P<0.01), there were no sig- in eleven studies. nificant differences between the argon plasma group and non-contaminated group with storage of >1 week (3 Discussion studies; 3 comparisons; SDM: -1.143, P: 0.31) (Supple- This study was performed to evaluate the effects of dif- mentary Figures 2 and 4). ferent decontamination methods on the bond strength of resin to zirconia ceramic after contamination with Sodium hypochlorite saliva. The meta-analysis results showed that air abra- Two included studies assessed the cleaning effects of sion, Ivoclean, and argon plasma were effective clean- sodium hypochlorite. Finally, a meta-analysis of the ef- ing methods compared with other methods, including fects of sodium hypochlorite did not show a significant isopropanol, phosphoric acid, and sodium hypochlorite. difference between the decontaminated and contaminat- In addition, Ivoclean could completely recover the bond ed groups with a storage period of <1 week (2 studies; strength to the same level as the non-contaminated sur- 4 comparisons; SDM: 0.217, P=0.32) (Supplementary face in both <1 and >1 week storage periods. In the <1 Figure 3). week storage period, there was a significant difference between air abrasion decontaminated and non-contam- inated groups. Risk of bias Over the past years, YTZP, as a core material for manu- Supplementary Table 1 presents the results of risk of facturing dental restorations, has gained widespread bias assessments. The randomization procedure was popularity in dentistry. It is being used in various types unclear in most of the studies. Appropriate sample size of restorations, including full-coverage crowns, fixed par- calculation was carried out only in three studies. The tial prostheses, veneers, endodontic posts, and implant same operator for outcome measurements was men- abutments, mainly due to high biocompatibility, excellent tioned only in one study, and blinding of outcome asses- mechanical properties, aesthetics, and suitable optical sors was reported in none of the included studies. The behavior (15). Selecting an appropriate cementation pro- 36 10.59987/ads/2024.1.27-38 A.Sarraf Shirazi et al. cess between the tooth and zirconia restoration plays a and Ivoclean cleaning methods, used to eliminate saliva, crucial role in the clinical success of the restoration. It is could not achieve a durable resin bonding to zirconia af- important to have an optimal bond strength at two dif- ter application (29). Our meta-analysis showed that air ferent interfaces (dentin-resin cement and ceramic-resin abrasion, Ivoclean, and argon plasma effectively cleaned cement interfaces) in bonding the ceramic to the tooth saliva-contaminated zirconia ceramic interfaces, with the substrate. Although zirconia restorations can be luted least effects on the bond strength. with both traditional and resin adhesive cements, using The present study had some limitations, including the resin can be beneficial in many cases due to its better limited number of clinical trials for our purpose. Also, the retention and marginal seal (26). bond strength of resin cement to zirconia has been mea- The restorative surface is at risk of becoming contami- sured with different methods in the included articles, and nated during a try-in session. The ceramics might be- the meta-analyses of the data were carried out by ignor- come contaminated by saliva, blood, or silicone disclos- ing the differences in applied methods, types of cement, ing agents in the try-in procedure, negatively affecting and duration of storage. Therefore, the mentioned limita- the composite-ceramic bond strength clinically (14). Un- tions should be addressed in future studies. fortunately, it is impossible to avoid ceramic surface con- tamination; therefore, there are several cleaning meth- ods to remove the contamination, obtain a clean bonding Conclusion surface, and provide a strong bond. Rinsing with water, In different decontamination methods, sandblasting with immersing in isopropanol, cleaning with ethanol, phos- airborne-particle abrasion (Al2O3), an alkaline-based sur- phoric acid, sodium hypochlorite, and airborne-particle face cleansing agent called Ivoclean, and argon plasma abrasion with Al2O3 are some techniques that decontami- are effective in recovering the bond strength of resin nate the zirconia surface (17). The present meta-analy- to saliva-contaminated zirconia. Ivoclean can recover sis showed that air abrasion, Ivoclean, and argon plasma the bond strength to the same level as a non-contam- are effective cleaning methods for the decontamination inated surface. Alcohol (70% to 96% isopropanol) and of saliva-contaminated surfaces. phosphoric acid cannot significantly improve the bond Air abrasion is not a new technique, but it has recently strength of saliva-contaminated surfaces, which was regained attention in dentistry. This method removes the significantly weaker than the non-contaminated surface. contaminated layers from the surface, allowing the resin Future well-designed studies, especially clinical investi- cement to create a stronger micromechanical interlock- gations, can make the available evidence in this regard ing (27). Based on our assessment, air abrasion can sig- more conclusive. nificantly improve the strength of contaminated surfaces. Ivoclean is an alkaline surface cleansing agent whose Acknowledgement main composition is sodium hydroxide (NaOH) solution, which can enhance the phosphate adsorption proper- This study was supported by a grant from Mashhad Uni- ties. By absorbing the phosphate contaminants found in versiy Research Council, which is gratefully acknowl- the saliva, Ivoclean can recover the strength of bonds edged. in 20 seconds based on the manufacturer’s claims (27). Based on our meta-analysis, Ivoclean decontamination References significantly enhances the bond strengths of saliva-con- 1. Denry I, Kelly JR. State of the art of zirconia for dental ap- taminated surfaces to the same level as non-contaminat- plications. Dental materials. 2008;24(3):299-307. ed surfaces in all the investigated conditions. 2. Thompson JY, Stoner BR, Piascik JR, Smith R. Adhesion/ Although the present study found the same level of bond cementation to zirconia and other non-silicate ceramics: strength between non-contaminated and decontaminat- Where are we now? Dental Materials. 2011;27(1):71-82. ed groups with argon plasma, the small number of in- 3. Brauchli L, Eichenberger M, Steineck M, Wichelhaus A. Influence of decontamination procedures on shear cluded studies makes the conclusion unreliable. A direct forces after contamination with blood or saliva. American comparison of argon plasma with Ivoclean showed that Journal of Orthodontics and Dentofacial Orthopedics. the cleaning paste was more effective in removing saliva 2010;138(4):435-41. contamination (17). 4. Phark J-H, Duarte Jr S, Kahn H, Blatz MB, Sadan A. Influ- Quaas et al used four different cleaning methods, in- ence of contamination and cleaning on bond strength to cluding air abrasion with 50-μm Al2O3, phosphoric acid modified zirconia. dental materials. 2009;25(12):1541-50. 5. Patel D. Influence of saliva contamination on resin bond for 60 s once or 30 s twice, and isopropanol on a con- durability to zirconia-Effect of cleaning methods 2015. taminated resin surface to compare the effects. They 6. Zhang S, Kocjan A, Lehmann F, Kosmač T, Kern M. In- concluded that air abrasion of the contaminated surface fluence of contamination on resin bond strength to nano‐ provided higher bonding stress than other methods after structured alumina‐coated zirconia ceramic. European 3 and 150 days compared to alcohol cleaning, which did journal of oral sciences. 2010;118(4):396-403. not result in durable bond strength after the same time 7. Charasseangpaisarn T, Wiwatwarrapan C, Siriwat N, Khochachan P, Mangkorn P, Yenthuam P, et al. Different (28). Kim et al used seven different conditions, includ- cleansing methods effect to bond strength of contaminated ing non-contaminated, water-spray rinsing, additional air zirconia. JDAT. 2018;68(DFCT Supplement):28-35. abrasion, Ivoclean, sodium dodecyl sulfate, hydrogen 8. Phark J-H, Duarte S, Kahn H, Blatz MB, Sadan A. Influ- peroxide, and sodium hypochlorite, to clean the saliva- ence of contamination and cleaning on bond strength to contaminated zirconia. Air abrasion and solutions like modified zirconia. Dental Materials. 2009;25(12):1541-50. Ivoclean or sodium hypochlorite seemed to be effective 9. Yang B, Lange-Jansen HC, Scharnberg M, Wolfart S, Ludwig K, Adelung R, et al. Influence of saliva contami- in removing the contamination and, at the same time, nation on zirconia ceramic bonding. Dental Materials. in enhancing the resin bond strength. In contrast, water 2008;24(4):508-13. spray decreased the bond strength (13). Also, a study 10. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. in Japan showed that water rinsing, phosphoric acid, Preferred reporting items for systematic reviews and 10.59987/ads/2024.1.27-38 37  Effect of Different Cleaning Methods on Bond Strength of Resin to Saliva-Contaminated Zirconia: A Systematic Review and Meta-analysis of in Vitro Studies meta-analyses: the PRISMA statement. PLoS medicine. taminated zirconia on surface free energy and resin ce- 2009;6(7):e1000097. ment bonding. Dental materials journal. 2015:2014-066. 11. Irmak Ö, Yaman BC, Orhan EO, Kılıçarslan MA, Mante FK, 20. Feitosa S, Patel D, Borges A, Alshehri E, Bottino M, Özcan Ozer F. Influence of cleaning methods on bond strength to M, et al. Effect of cleansing methods on saliva-contaminated saliva contaminated zirconia. Journal of Esthetic and Re- zirconia—an evaluation of resin bond durability. Operative storative Dentistry. 2018;30(6):551-6. dentistry. 2015;40(2):163-71. 12. Nejatidanesh F, Savabi O, Savabi G, Razavi M. Effect of 21. Takahashi A, Takagaki T, Wada T, Uo M, Nikaido T, Tagami cleaning methods on retentive values of saliva‐contami- J. The effect of different cleaning agents on saliva contami- nated implant‐supported zirconia copings. Clinical oral im- nation for bonding performance of zirconia ceramics. Den- plants research. 2018;29(5):530-6. tal materials journal. 2018:2017-376. 13. Kim D-H, Son J-S, Jeong S-H, Kim Y-K, Kim K-H, Kwon 22. Krifka S, Preis V, Rosentritt M. Effect of decontamination T-Y. Efficacy of various cleaning solutions on saliva-con- and cleaning on the shear bond strength of high translu- taminated zirconia for improved resin bonding. The journal cency zirconia. Dentistry journal. 2017;5(4):32. of advanced prosthodontics. 2015;7(2):85-92. 23. Aladağ A, Elter B, Çömlekoğlu E, Kanat B, Sonugelen M, 14. Piest C, Wille S, Strunskus T, Polonskyi O, Kern M. Ef- Kesercioğlu A, et al. Effect of different cleaning regimens ficacy of plasma treatment for decontaminating zirconia. J on the adhesion of resin to saliva‐contaminated ceramics. Adhes Dent. 2018;20(4):289-97. Journal of Prosthodontics. 2015;24(2):136-45. 15. Güers P, Wille S, Strunskus T, Polonskyi O, Kern M. Dura- 24. Angkasith P, Burgess JO, Bottino MC, Lawson NC. Clean- bility of resin bonding to zirconia ceramic after contamina- ing methods for zirconia following salivary contamination. tion and the use of various cleaning methods. Dental Mate- Journal of Prosthodontics. 2016;25(5):375-9. rials. 2019;35(10):1388-96. 25. Mangione E, Özcan M. Adhesion of resin cements to con- 16. Noronha MdS, Fronza BM, André CB, de Castro EF, taminated zirconia resin cements on zirconia: effect saliva- Soto‐Montero J, Price RB, et al. Effect of zirconia de- contamination and surface conditioning. Journal of Adhe- contamination protocols on bond strength and surface sion Science and Technology. 2019;33(14):1572-83. wettability. Journal of Esthetic and Restorative Dentistry. 26. Sankar S, Kondas VV, Dhanasekaran SV, Elavarasu PK. 2020;32(5):521-9. Comparative evaluation of shear bond strength of zirconia 17. Martínez-Rus F, Rodríguez C, Salido MP, Pradíes G. In- restorations cleansed various cleansing protocols bonded fluence of different cleaning procedures on the shear with two different resin cements: An In vitro study. Indian bond strength of 10-methacryloyloxydecyl dihydrogen Journal of Dental Research. 2017;28(3):325. phosphate-containing self-adhesive resin cement to saliva 27. Radain SA. The effect of saliva contamination and different contaminated zirconia. 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Analyzing the Dental Market Through Porter’s Five Forces Framework Alessandro Quaranta1 Authors Wang Lai Hui2 Alessandro Quaranta - Clinical Professor, School of Dentistry. The University 1 Clinical Professor, School of Dentistry. of Sydney. Scientific and Education The University of Sydney. Scientific and Education Manager, Manager, Smile Specialists Suite, Smile Specialists Suite, Newcastle-Neutral Bay, NSW. Newcastle-Neutral Bay, NSW. Australia; [email protected] Australia; [email protected] 2 Director, Smile Specialists Suite, Newcastle-Neutral Bay, Wang Lai Hui - Director, Smile Specialists NSW. Australia; [email protected] Suite, Newcastle-Neutral Bay, NSW. Australia; [email protected] Corresponding author:Alessandro Quaranta E-mail: [email protected] Abstract License This commentary explores the dental healthcare market through the lens of Porter’s This work is licensed under a Creative Five Forces, a model for analyzing the competitive environment of a market. By ap- Commons Attribution-NonCommercial- plying this framework, it is possible to elucidate the market dynamics affecting den- NoDerivatives 4.0 International License. tists, dental specialists, and patients, providing insights into the consequences and challenges faced by each group within this unique and complex market. Authors contributing to Annali di Stomatologia agree to publish their articles under the Creative Key words: Dental, healthcare, market Commons Attribution-NonCommercial- NoDerivatives 4.0 International License, Introduction which allows third parties to copy and redistribute the material providing The dental healthcare market represents a unique sector within the broader healthcare appropriate credit and a link to the industry, characterized by its imperfect, yet highly competitive nature. This commentary license but does not allow to use the seeks to dissect these dynamics using Porter’s Five Forces – a business tool traditionally material for commercial purposes and to used to assess the competitiveness of a market. These forces include the threat of new use the material if it has been remixed, entrants, the bargaining power of suppliers, the bargaining power of buyers, the threat of transformed or built upon. substitute products or services, and competitive rivalry. How to Cite A. Quaranta, W Lai Hui. The dental market as a model of an imperfect highly competitive market Analyzing the Dental Market Through Porter’s Five Forces Framework The dental market is characterized as an imperfect yet highly competitive market for Annali Di Stomatologia, 15(1), 39-41. several reasons: https://doi.org/10.59987/ads/2024.1.39-41 • Imperfections Stemming from Entry Barriers: High costs for equipment and train- ing, stringent regulations, and limited insurance network access create substantial barriers for new dental providers. These barriers result in fewer providers in certain areas, contributing to imperfect competition due to restricted market access. • High Competition Driven by Price Sensitivity: Dental services, often seen as discretionary, evoke high price sensitivity among patients. This sensitivity leads pa- tients to actively compare prices and care quality, intensifying competition among providers. • Uneven Pricing Dynamics: The partial or non-coverage of dental services by in- surance plans leads to price discrimination and variable pricing among providers. This variability in pricing further contributes to an uneven playing field in the market. • Information Asymmetry: A notable power imbalance exists due to information asymmetry between patients and dental providers. Patients often lack the expertise to make fully informed decisions, relying heavily on provider trustworthiness. This re- liance complicates their ability to effectively compare different providers, as noted in • Concentration of Providers: The prohibitive costs associated with setting up a dental practice in many countries, as highlighted by Dunn [1] lead to a concentration of providers in certain regions, thus limiting competition. • Price Discrimination and Decision Factors: Studies like those by Gray [2] reveal that cost was overwhelmingly chosen as the key factor likely to prevent a patient from seeking dental treatment. In several countries, It is also common for uninsured patients to shop around for dental care, with price being a significant decision-making 10.59987/ads/2024.1.39-41 39  Analyzing the Dental Market Through Porter’s Five Forces Framework factor. Providers often engage in price discrimination In markets where reduced competition from new entrants based on insurance coverage and patient’s willing- is experienced existing dental practices can benefit from ness to pay. a relatively stable market position. In essence, the imperfect nature of the dental market The limited entry of new providers may result in fewer stems from entry barriers and variable pricing, while its choices and potentially higher prices for buyers (patients). competitiveness is driven by patient price sensitivity and However, in the context of the EU and other countries the need for providers to compete through price, quality, (Latin America), the mutual recognition of professional and service offerings. qualifications facilitates the cross-border mobility of den- tal professionals, which introduces a nuanced dimension Porter’s five forces of competition to the threat of new entrants. While traditional barriers such as the cost of education and practice setup remain, The Five Forces of Porter is a widely recognized frame- the ease of movement across borders provided by mu- work for analyzing the competitive environment of a tual recognition agreements can stimulate competition market. Developed by Michael E. Porter of Harvard by reducing regulatory constraints. This can lead to Business School [3], this model provides a comprehen- increased market fluidity, offering patients more choic- sive view of the competitive forces that shape industry es and potentially more competitive pricing structures. attractiveness and profitability. It examines the interplay However, it also poses a challenge for existing practices of five key forces: the threat of new entrants, the bar- that may face new competitors, capable of offering di- gaining power of suppliers, the bargaining power of buy- verse and possibly more affordable dental services. The ers, the threat of substitute services, and the intensity or overall effect is a gradual shift towards a more dynam- products of competitive rivalry. By evaluating these forc- ic and less predictable market landscape, where dental es, businesses can develop strategies to improve their providers must adapt to the increased potential for new market position and competitive advantage. entrants within their local markets. • Threat of New Entrants: This force examines how easy or difficult it is for new competitors (dental pro- Bargaining Power of Suppliers viders) to enter in a market, thus affecting compe- tition. Suppliers of dental equipment and materials hold signif- • Bargaining Power of Suppliers: This force looks icant power due to the specialized nature of their prod- at the power of suppliers to drive up the prices of ucts. The cost, the quality, and the timing of delivery of business (dental providers) inputs. In the dental in- these supplies directly influence the operational efficien- dustry, suppliers of dental materials and equipment cy and service quality of dental practices. can have a significant influence, especially if there The businesses (dental providers) will depend on sup- are few alternatives. pliers for quality materials, which can have an impact on • Bargaining Power of Buyers: This refers to the profit margins and service pricing. power of the customers (dental patients) to negoti- In the case of Dental Specialists, these practices may ate lower prices or better services. In dentistry, pa- require more advanced equipment and may face higher tients often have a high degree of price sensitivity, operational costs, influencing service pricing. Efficient especially for elective procedures not covered by supply chain management and negotiations are there- insurance, giving them a certain level of bargaining fore vital for maintaining a competitive edge in the den- power. tal market. • Threat of Substitute Products or Services: This force is about the danger of customers (dental) pa- Bargaining Power of Buyers (Patients) tients choosing alternatives to traditional services. The leverage of patients and dental insurance in the • Competitive Rivalry: This is the degree of com- dental market is magnified by their price elasticity and petition among existing players (incumbent dental the discretionary nature of dental expenditures, The dis- providers) in the industry. In the dental market, the cretionary nature of many dental services, coupled with rivalry can be high due to a mix of local and larger varied insurance coverage, enhances the bargaining group practices, the range of services offered, and power of patients and insurance [4,5] the quality of care. This force is often the most pow- . Dentists will need to balance service quality with com- erful of the five, as it encompasses the direct com- petitive pricing to attract and retain patients. petition the businesses (dental practices) face in the As for the buyers (dental patients), they will enjoy greater daily operations. leverage in price negotiations, especially for uninsured patients who shop around for services., THE DENTAL MARKET AND THE FIVE FORCES OF COMPETITION Threat of Substitute Products or Services Threat of New Entrants: The dental market faces threats from alternative treat- In most of the developed high-income countries, the ments and advancements in dental technology. dental market exhibits significant barriers to entry, pri- The proliferation of substitute products, such as di- marily due to the high costs of dental education, practice rect-to-consumer dental aligners and home whitening set-up and equipment, and compliance with stringent kits, represents a burgeoning challenge for traditional regulations. The research by Dunne [1] highlights these dental practices. Dental professionals must respond by barriers, emphasizing the financial and regulatory hur- emphasizing the benefits of professional care and the dles new dental providers must overcome. This high en- potential risks associated with unguided treatments. try threshold limits the influx of new competitors, thereby While the quality and safety of such substitutes can be shaping the market’s competitive landscape. variable, their accessibility and lower cost can attract a 40 10.59987/ads/2024.1.39-41 A. Quaranta et al. segment of cost-conscious patients. It is therefore es- ing patients both challenges and opportunities in their sential for both dentists and specialists to stay updated healthcare choices. Future research should focus on with technological advancements and alternative treat- evolving market trends, especially the impact of tech- ment methods to remain competitive. nological advancements and policy changes on these dynamics. Existing Rivals References Intense competition exists among dental providers, driv- en by patient price sensitivity and variable pricing strat- 1. Dunne T, Klimek SD, Roberts MJ, Xu DY. Entry, exit, and egies. This is exacerbated by information asymmetry, the determinants of market structure. The RAND Journal of Economics. 2013;44(3), 462–487. doi:10.1111/1756- as noted by Baldwin [4] and Sever [6] which can lead 2171.12027. to quality of service and trust-based competition rather 2. Gray L, McNeill L, Yi W, Zvonereva A, Brunton P, Mei L. than just price or quality. The “business” of dentistry: Consumers’ (patients’) criteria High competition necessitates differentiation through qual- in the selection and evaluation of dental services. PLoS ity of service, pricing strategies, and building patient trust. ONE. 2021;16(8): e0253517. https://doi.org/10.1371/jour- The high competition is also a drive for an increased nal.pone.0253517. 3. Porter ME. How Competitive Forces Shape Strategy. Har- need to specialize and offer superior expertise to buyers. vard Business Review. 1979. Patients can benefit from competitive pricing and a range 4. Baldwin A, Sohal A. Service quality factors and outcomes of service quality options but may face challenges in as- in dental care. Managing Service Quality: An International sessing service quality due to information asymmetry. Journal. 2003;13(3):207-216. 5. Nasseh K, Bowblis JR, Vujicic M, Huang SS. Consolidation in the dental industry: a closer look at dental payers and Conclusion providers. Int J Health Econ Manag. 2020 Jun;20(2):145- An analysis of the dental healthcare market, through the 162. focus lens of Porter’s Five Forces, reveals a complex 6. Sever I, Verbič M, Sever EK. Valuing the delivery of den- tal care: Heterogeneity in patients’ preferences and will- interplay of factors affecting dentists, specialists, and ingness-to-pay for dental care attributes. J Dent. 2018 patients. The market’s imperfect yet competitive nature Feb;69:93-101. doi: 10.1016/j.jdent.2017.12.005. Epub demands strategic responses from providers while offer- 2017 Dec 11. 10.59987/ads/2024.1.39-41 41 

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Use of the electrical device on dental implant’s bacterial biofilm: a preliminary in vitro study Giovanni Falisi1 Authors Gianluca Botticelli1 Giovanni Falisi - Department of Life, Eduardo Basanes Rivera2 Health and Environmental Sciences, Antonio Scarano3 University of L’Aquila, L’ Aquila, Italy Roberto Gatto1 Gianluca Botticelli - Department of Life, Sofia Rastelli1 Health and Environmental Sciences, Carlo Di Paolo4 University of L’Aquila, L’ Aquila, Italy Paola Di Giacomo4 Eduardo Basanes Rivera - Department of Dentistry, University ANAHUAC of North 1 Department of Life, Health and Environmental Sciences, University of L’Aquila, L’ Aquila, Mexico Italy Antonio Scarano - Department of 2 Department of Dentistry, University ANAHUAC of North Mexico Innovative Technology in Medicine and 3 Department of Innovative Technology in Medicine and Dentistry, University of Chieti- Dentistry, University of Chieti-Pescara, Chieti, Italy Pescara, Chieti, Italy 4 Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, Italy. Roberto Gatto - Department of Life, Health and Environmental Sciences, University of L’Aquila, L’ Aquila, Italy Corresponding author: Gianluca Botticelli Sofia Rastelli - Department of Life, Health and Environmental Sciences, University of L’Aquila, L’ Aquila, Italy Abstract Carlo Di Paolo - Department of Oral Background. Mucositis and peri-implantitis are pathologies that may be encoun- and Maxillo-Facial Sciences, Sapienza tered during dental implant rehabilitation. Therapeutic strategies for their resolution University of Rome, Italy. range from non-surgical to surgical treatments and aimed at eliminating the biofilm Paola Di Giacomo - Department of Oral from the implant’s surface, through mechanical, chemical or photodynamic agents. and Maxillo-Facial Sciences, Sapienza Aim. The aim was to evaluate the effect of the electric field generated by the Xim- University of Rome, Italy. plant machine on the bacterial load and on the biofilm grown on dental implants. Materials and Methods. Ten dental implants were brought into contact with a do- nor’s saliva, then five implants were treated with the electric field and four were not treated. Bacterial biofilm was then measured by resazurin assay, both on treated and un- License treated implants. This work is licensed under a Creative Results. The study showed the preliminary success of the electrofield in reduc- Commons Attribution-NonCommercial- ing the microbial population and destroying the clinical biofilm, compared with a NoDerivatives 4.0 International License. sterile implant as control. Authors contributing to Annali di Stomatologia agree to publish Key words: mucositis, periimplantitis, biofilm removal. their articles under the Creative Commons Attribution-NonCommercial- NoDerivatives 4.0 International License, Introduction which allows third parties to copy and The treatment of choice for the resolution of both partial and total edentulism of patients redistribute the material providing appropriate credit and a link to the consists in the use of dental implants (1-5). In recent decades, their use has exponen- license but does not allow to use the tially evolved. Mucositis and peri-implantitis are pathologies that may be encountered material for commercial purposes and to during dental implant rehabilitation. (6-10). use the material if it has been remixed, The first one is characterized by all the signs of inflammation without radiographic signs transformed or built upon. of bone loss, while the second one is also characterized by purulent exudate and radio- graphic signs of peri-implant bone loss. How to Cite G Falisi, G Botticelli, E Basanes Rivera, When we talk about peri-implant bone loss we must differentiate it from biological fac- A Scarano, R Gatto, S Rastelli, tors, such as physiological remodeling or mechanical stress. The inflammatory-bacterial C Di Paolo, P Di Giacomo. etiology determines resorption between the interface of the bone and implant and its Use of the electrical device on dental consequent loss (11-16). implant’s bacterial biofilm: a preliminary In the literature, therapeutic strategies for the resolution of these two pathological condi- in vitro study. tions range from non-surgical to surgical treatment and aimed at eliminating the superfi- Annali Di Stomatologia, 15(1), 43-47. https://doi.org/10.59987/ads/2024.1.43-47 cial biofilm, through mechanical and/or chemical agents (7). As demonstrated in many scientific papers, these techniques present critical issues linked to the partial elimination of bacteria and surface contaminants. In recent years the metallurgical industry has conducted studies on the electrochemical 10.59987/ads/2024.1.43-47 43  Use of the electrical device on dental implant’s bacterial biofilm: a preliminary in vitro study cleaning of metal surfaces to eliminate and decontami- sinki. The informed consent was obtained from all indi- nate biofilm and prevent its formation. vidual participants included in the study. The electric current would act on the electrochemical The salivary collection was performed in the morning and bonds of the polysaccharide particles of the biofilm the subject was asked not to practice the oral hygiene layer, determining a reduction in hydrogen bonding, routine before the collection 5 ml of saliva was collected. also breaking the bonds that determine adhesion to Contamination of the implants was performed using a surfaces. (17) bacterial culture in the logarithmic phase of growth, pre- This new technique would allow the elimination and pared by growing ten colonies of saliva in 5 ml of Brain decontamination of the metal implant surfaces while Hearth Infusion (BHI) broth (Oxoid ThermoFisher Sci- keeping them intact, which does not happen with me- entific, US) supplemented with 5% defibrinated sheep chanical procedures that alter their shape (10). blood in an anaerobic environment for 96 hours at 37°C. The aim of the work was to evaluate the effect of the The bacterial suspension was adjusted to the OD of 0.5 electric field on the reduction and decontamination of McFarland scale and subsequently diluted 1:1000. The bacterial plaque on the implant surface. formation of bacterial biofilm on the implants occurred by incubating the devices in a sterile vial (Eppendorf MATERIALS AND METHODS Safe-Lock Tubes, Eppendorf Italy) with 900 μL of bacte- rial suspension prepared as described above. The sam- Bacterial contamination of dental implants ples were incubated in an upright position for 48 hours Ten dental implants in grade 4 titanium (sandblasted and at 37°C. After incubation, the implants were washed etched with double acid attack) with a length of 13 and three times in a sterile 0.9% NaCl solution to remove the a diameter of 4,2 (SEVENTIN-ONE by company Maco planktonic form of non-adherent bacteria. dental care Salerno Buccino) were used. A healthy volunteer who presented with active peri-im- Electrical treatment of implants plant pathology, with signs of inflammation, suppuration After bacterial contamination, five implants were trans- and with radiographic signs of peri-implant bone loss ferred to the treatment chamber with the addition of 100 was recruited to donate his saliva. μl of 0.9% NaCl solution and treated using the “Peri- The present study has been conducted in accordance implantitis Protocol” of the X-IMPLANT instrument. (Fig- the principles and guidelines of the Declaration of Hel- ure 1, 2) This protocol consisted of four cycles of electrical cur- rent (alternating electrical current at 625 kHz, 260 Vpp, 15 W and 180 mA) performed on the implant according to the programmed times of the machine, the electrode was positioned in 4 tangential positions peripherally at 90 ° from the previous position. Once the treatment phase with the Ximplant instrument was completed, the implants were further washed with 0.9% NaCl solution. Four implants were not treated. One implant was sterile and incubated with 900 μl of BHI was used as a nega- tive control. Both treated and untreated implants were added to a re- agent, resazurin (Labbox italia srl) and incubated for vi- sual evaluation at 2 hours, one day, two days and the final third day of the experimental procedures. (19) Table 1. Statistical analysis Descriptive statistics was performed. Chi-squared test was used to assess significant differences between the Figure 1. Treatment chamber two groups (treated vs not treated) in each reference time with p<0.05. (Figure 1 and Table 2) Results All treated implants did not show any color change, as the control sterile implant. All not-treated implants showed a color change already after two hours. Discussion It is now proven that the presence of bacteria leads to the formation of biofilm on all surfaces, both biological and non-biological, as demonstrated by scientific studies on biofilm, the first to be formed is made up of beneficial bacteria called commensals. (12-15) However, the reduced host response and environmental Figure 2. Device modifications caused by clinical alterations can lead to a 44 10.59987/ads/2024.1.43-47 G. Falisi et al. Table 1. Row data. Negative = no color change; Positive= color change Implants # After 2 hrs After 1 day After 2 days After 3 days C1 Negative Negative Negative Negative 2 Negative Negative Negative Negative 3 Negative Negative Negative Negative 4 Negative Negative Negative Negative 5 Negative Negative Negative Negative 6 Negative Negative Negative Negative 7 Positive Positive Positive Positive 8 Positive Positive Positive Positive 9 Positive Positive Positive Positive 10 Positive Positive Positive Positive Table 2. Chi-square analysis. dF= degree of freedom. Time χ2 value dF P value T1 =after 2 hrs 9000 1 0.003 T2 = after 1 day 9000 1 0.003 T3= after 2 days 9000 1 0.003 T4= after 3 days 9000 1 0.003 shift in the commensal microbial flora towards the devel- such as 12% chlorhexidine after appropriate mechanical opment of pathogenic species, an event called dysbiosis. debridement was used, it did not improve the scores of Dysbiosis causes an increase in the production of in- gingival bleeding after probing (BOP) compared to control flammatory mediators, which induce the production of groups where mechanical debridement alone was used. toxic products in the host cell which in turn lead to the Even the potential beneficial effects (reduction of BOP destruction of the tissues around the implant. and deep bleeding) hypothesized using systemic anti- In the literature, various surgical and non-surgical strate- biotics (azithromycin) failed three/six months after treat- gies have been introduced for the elimination of patho- ment, just as the use of probiotics had no benefit com- logical biofilm from surfaces. (20-24) pared to mechanical therapy. (28, 29) Both are based on periodontal treatments and prevention On the other hand, the use as an alternative to mechani- because it is considered essential to give appropriate hy- cal therapy such as, for example, the use of ultrasound giene instructions to the patient to reduce the bacterial instruments, glycine sandblasting sprays or YAG lasers load keeping the peri-implant tissues healthy (25-27). has a good result in clinical terms with reduction of BOP, In some scientific works where the use of oral antiseptics compared to mechanical debridement alone. Contingency tables. PP= peri-implantitis protocol yes/no. 10.59987/ads/2024.1.43-47 45  Use of the electrical device on dental implant’s bacterial biofilm: a preliminary in vitro study The use of both photonic and laser techniques, however, 7. Gosau, M.; Hahnel, S.; Schwarz, F.; Gerlach, T.; Reichert, mostly control the progression of the peri-implant pathol- T. E.; Bürgers, R. Effect of six different peri-implantitis dis- ogy rather than resolve it (30,31). infection methods on in vivo human oral biofilm. Clin. Oral Implants Res. 2010, 21, 866− 872. The poor results of bacterial decontamination regarding 8. Abrahamsson, I. Effect of cleansing of biofilm formed on these techniques could be attributed to the difference in titanium discs. Clin. Oral Implants Res. 2015, 26, 931−936. the titanium surface compared to that of the dental root. 9. Renvert, S.; Roos-Jansak̊er, A.M.; Claffey,N.: Non-surgical This implies that the re-osseointegration phase is defi- treatment of peri-implant mucositis and peri-implantitis: A cient with the interposition of fibrous tissue between the literature review. J. Clin. Periodontol. 2008, 35, 305−315. bone and the implant as demonstrated by histological 10. Rabinovitch, C.; Stewart, P. S. Removal and inactivation of Staphylococcus epidermidis biofilms by electrolysis. Appl. studies. (32, 33). Environ. Microbiol. 2006, 72, 6364−6366.) However, in recent years, electrochemical treatments 11. Carinci F, Lauritano D, Bignozzi CA, Pazzi D, Candotto V, for the decontamination of biofilm have appeared. They Santos de Oliveira P, Scarano A. A New Strategy Against cause a polarization of metal surfaces, preventing mi- Peri-Implantitis: Antibacterial Internal Coating. Int J Mol Sci croorganisms from attaching and breaking the anchoring 2019; 20: 3897. bonds to the structures. Furthermore, the electrochemi- 12. Caton JG, Armitage G, Berglundh T, Chapple ILC, Jepsen S, Kornman KS, Mealey LB, Papapa- nou NP, Sanz M, cal activity determines a change in PH with the forma- Tonetti SM. A new classification scheme for periodontal tion of oxidizing ions which reduce the number or kill the and peri-implant diseases and conditions - Introduction bacteria present. (34) and key changes from the 1999 classification. J Clin Peri- Lately, some scientific works have dealt with implant de- odontol 2018; 20: S1-S8. contamination from biofilm using low intensity direct cur- 13. Ting M, Craig J, Balkin BE, Suzuki JB. Peri-implantitis: A rents. They have given good results as no live bacteria Comprehensive Overview of Systematic Reviews. J Oral Implantol 2018; 44: 225-247. were present at the anode level, while at the cathode the 14. Torrungruang K, Jitpakdeebordin S, Charatku- langkun O, colonies were three times reduced. (35) Gleebbua Y. Porphyromonas gingivalis, Aggregatibacter Since Our study aimed to evaluate the alternating cur- actinomycetemcomitans, and Treponema denticola / Pre- rent on a contaminated implant surface, the results allow votella intermedia Co-Infection Are Associated with Severe us to evaluate the good response of bacterial decontami- Periodontitis in a Thai Population. PLoS One 2015; 10: nation. e0136646. The data from this work should be verified with other in 15. Al-Ahmad A, Muzafferiy F, Anderson AC, Wölber JP, Ratka-Krüger P, Fretwurst T, Nelson K, Vach K, Hellwig vitro and in vivo works due to the characteristic of the E. Affiliations expand. Shift of microbial composition of oral bacterial flora which varies from above to below the peri-implantitis-associated oral biofilm as revealed by 16S gums, with a larger sample size. rRNA gene cloning. J Med Microbiol 2018; 67: 332-340. 16. Falisi G, Foffo G, Severino M, Paolo C, Bianchi S, Bernardi S, Pietropaoli D, Rastelli S, Gatto R, Botticelli G. SEM- Conclusions EDX Analysis of Metal Particles Deposition from Surgical Burs after Implant Guid- ed Surgery Procedures. Coatings Considering the limits of this scientific work, the results 2022; 12: 240. push us to continue and follow the path of using electric 17. Bernardi S, Qorri E, Botticelli G, Scarano A, Marzo G, Gatto current in peri-implant treatment therapy. R, Greco Lucchina A, Mortellaro C, Lupi E, Rastelli C, Fal- Expanding new treatment strategies. isi G. Use of electrical field for biofilm implant removal. Eur Rev Med Pharmacol Sci. 2023 Apr;27(3 Suppl):114-121. doi: 10.26355/eurrev_202304_31328. PMID: 37129321. References 18. Matys J, Botzenhart U, Gedrange T, Dominiak M. Thermo- dynamic effects after Diode and Er:YAG laser irradiation of 1. Falisi G, Di Paolo C, Rastelli C, Franceschini C, Rastelli grade IV and V titanium implants placed in bone an ex vivo S, Gatto R, Botticelli G. Ultrashort Implants, Alternative study. Preliminary report. Biomed Tech 2016; 61: 499-507. Prosthetic Rehabilitation in Mandibular Atrophies in Fragile 19. A Mehring, N Erdmann, J Walther, J Stiefelmaier, D Stri- Subjects: A Retrospective Study. Healthcare 2021; 9: 175. eth, R Ulber . A simple and low-cost resazurin assay for 2. Falisi G, Bernardi S, Rastelli C, Pietropaoli D, DE Ange- vitality assessment across species J Biotechnol. 2021 Jun lis F, Frascaria M, Di Paolo C. “All on short” prosthetic- 10:333:63-66. doi: 10.1016/j.jbiotec.2021.04.010. Epub implant supported rehabilitations. ORAL Implantol 2017; 2021 Apr 30. 10:477-487. 20. Mellado-Valero A, Buitrago-Vera P, Solá-Ruiz MF, Ferrer- 3. Scarano A, Bernardi S, Rastelli C, Mortellaro C, Vittorini García JC. Decontamination of dental implant surface in P, Falisi G. Soft tissue augmentation by means of silicon peri-implantitis treatment: a literature review. Med Oral Pa- expanders prior to bone volume increase: a case series. J tol Oral Cirugia Bucal 2013; 18: e869-876. Biol Regul Homeost Agents 2019; 33: 77-84. 21. Patianna G, Valente NA, D’Addona A, Andreana S. In vi- 4. Inchingolo F, Tatullo M, Marrelli M, Inchingolo AM, Inchin- tro evaluation of controlled-release 14% doxycycline gel golo AD, Dipalma G, Flace P, Girolamo F, Tarullo A, Laino for decontamination of machined and sandblasted acid- L, Sabatini R, Abbinante A, Cagiano R.: Regenerative etched implants. J Periodontol 2018; 89: 325-330. surgery performed with platelet-rich plasma used in sinus 22. Di Domenico EG, Oliva A, Guembe M. The Current Knowl- lift elevation before dental implant surgery: an useful aid edge on the Pathogenesis of Tissue and Medical Device- in healing and regeneration of bone tissue. Eur Rev Med Related Biofilm Infections. Microorganisms 2022; 10: 1259. 23. Scarano A, Piattelli A, Polimeni A, Di Iorio D, Carinci F. Pharmacol Sci 2012; 16: 1222-1226. Bacterial adhesion on commercially pure titanium and 5. Manicone PF, Passarelli PC, Bigagnoli S, Pas- torino R, anatase-coated titanium healing screws: an in vivo human Manni A, Pasquantonio G, D’Addona A. Clinical and radio- study. J Periodontol 2010; 81: 1466-1471. graphic assessment of implant-supported rehabilitation of 24. Botticelli G, Calabria E, Severino M, Foffo G, Petrelli P, partial and complete edentulism: a 2 to 8 years clinical fol- Galli M, Calabria E, Giudice A, Gatto R, Falisi G. Ultrashort low-up. Eur Rev Med Pharmacol Sci 2018; 22: 4045- 4052. implant in the upper jaw, an alternative therapeutic proce- 6. Schwarz F, Derks J, Monje A, Wang HL. Peri-implantitis. J dure after the failure of the sinus lift: a case report. Annali Clin Periodontol 2018; 45: S246-266. di Stomatologia 2020; XI: 28-32. 46 10.59987/ads/2024.1.43-47 G. Falisi et al. 25. Vanden Bogaerde L. A proposal for the classification of 31. Roccuzzo A, Stähli A, Monje A, Sculean A, Salvi GE. Peri- bony defects adjacent to dental implants. Int J Periodontics Implantitis: A Clinical Update on Prevalence and Surgical Restorative Dent 2004; 24: 264- 271. Treatment Outcomes. J Clin Med 2021; 10: 1107. 26. Mummolo S, Botticelli G, Quinzi V, Giuca G, Mancini L, 32. Bianchi S, Bernardi S, Mattei A, Cristiano L, Mancini L, Marzo G. Implant-safe test in patients with peri-implantitis. Torge D, Varvara G, Macchiarelli G, Marchetti E. Morpho- J Biol Regul Homeost Agents 2020; 34: 147-153. logical and Biological Evaluations of Human Periodontal 27. Alani A, Bishop K. Peri-implantitis. Part 2: Prevention and Ligament Fibro- blasts in Contact with Different Bovine maintenance of peri-implant health. Br Dent J 2014; 217: Bone Grafts Treated with Low-Temperature Deproteinisa- 289-297. tion Protocol. Int J Mol Sci 2022; 23: 5273. 28. Hathroubi S, Mekni MA, Domenico P, Nguyen D, Jacques 33. Bosshardt DD, Brodbeck UR, Rathe F, Stumpf T, Imber M. Biofilms: Microbial Shelters Against Antibiotics. Microb JC, Weigl P, Schlee M. Evidence of re-osseointegration Drug Resist Larchmt N 2017; 23: 147-156. after electrolytic cleaning and regenerative therapy of peri- 29. Marín-Jaramillo RA, Villegas-Giraldo A, Duque- Duque A, implantitis in humans: a case report with four implants. Clin Giraldo-Aristizabal A, Muñoz-Giraldo V. Guía de práctica Oral Investig 2022; 26: 3735-3746. clínica para la prevención y el tratamiento de enferme- 34. Ratka C, Weigl P, Henrich D, Koch F, Schlee M, Zipprich dades periimplantares. Rev Fac Odontol Univ Antioquia H. The Effect of In Vitro Electrolytic Cleaning on Biofilm- 2019; 31: 6-25. Contaminated Implant Surfaces. J Clin Med 2019; 8: 1397. 30. Scarano A, Lorusso F, Inchingolo F, Postiglione F, Petrini 35. Sahrmann P, Zehnder M, Mohn D, Meier A, Imfeld T, M. The Effects of Erbium-Doped Yttrium Aluminum Gar- Thurnheer T. Effect of low direct current on anaerobic mul- net Laser (Er: YAG) Irradiation on Sandblasted and Acid- tispecies biofilm adhering to a titanium implant surface. Etched (SLA) Titanium, an In Vitro Study. 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In vitro evaluation of a new endodontic device for assessment of canal cleanliness Randolph Cross1 Authors Gianluca Gambarini2 Randolph Cross - Private practice, Watsonville, Ca, USA 1 Private practice, Watsonville, Ca, USA Gianluca Gambarini - Sapienza 2 Sapienza University of Roma, Italy University of Roma, Italy Corresponding author: Gianluca Gambarini [email protected] Abstract A new testing device (Endocator, Endocator Inc, Aptos, CA, USA) has been re- License cently developed to assess presence of remaining organic debris inside canals , This work is licensed under a Creative In the present study the reliability of the device was assessed in vitro by checking Commons Attribution-NonCommercial- the risk of possible cross-contamination during the sampling procedure. Five new NoDerivatives 4.0 International License. syringes were used for sampling procedure in five artificial canals which had been previously filled with organic and inorganic debris (contaminated canals). The re- Authors contributing to Annali di corded Endocator measurement were noted as Group 0. Other five new syringes Stomatologia agree to publish their articles under the Creative were used for sampling procedures in artificial canals in which no instrumenta- Commons Attribution-NonCommercial- tion, debridement or filling with debris had been performed (untouched canals). NoDerivatives 4.0 International License, The recorded Endocator measurement were noted as Group A (sterile syringes). which allows third parties to copy and In Group B (non-sterile syringes) the sampling procedure in the untouched ca- redistribute the material providing nals was repeated by using the same 5 syringes previously used for sampling in appropriate credit and a link to the the contaminated canals. In all cases procedure precisely followed the instruction license but does not allow to use the material for commercial purposes and to of use (IFU) provided by the manufacturer. . Descriptive analysis was performed use the material if it has been remixed, to determine mean and standard deviation (SD) of the findings for the 3 groups. transformed or built upon. Paired T-test with Bonferroni correction was executed to find out significant differ- ences (p<0.05) between the 3 groups. Results showed that ,even if the canals were How to Cite same and all well cleaned, Group B provided significantly higher mean values than R Cross, G Gambarini. Group A (p<0.05). In Group O canals (non-cleaned, contaminated canals) mean val- In vitro evaluation of a new endodontic device for assessment of canal ues were significantly higher than the other two groups (p<0.05) . Results showed cleanliness. a potential risk that even a minimal cross-contamination can significantly affect Annali Di Stomatologia, 15(1), 49-54. Endocator measurements due to the high sensitivity of the system. Therefore, au- https://doi.org/10.59987/ads/2024.1.49-54 thors suggested to use a new sterile syringe for each sampling procedure and proposed manufacturer should write this recommendation in the IFU (Instruction of Use) of the product. Key words: canal cleanliness, testing device, endodontic Copyright: authors retain copyright of the article Introduction In the last decades there has been a lot of progress in materials and techniques for the endodontic treatment, aiming at improving performance and clinical outcomes (1-4). The major innovation in the shaping and cleaning procedures, has been the widespread and consolidated clinical use of nickel-titanium (Niti) rotary instrumentation as the golden standard for canal preparation, and, more recently, the introduction of innovative propri- etary heat treatments in the manufacturing process. Such innovations result in more flex- ible and resistant NiTi instruments (5-6), which allow to simplify canal shaping by making it easier and faster to perform. Moreover, they minimize iatrogenic errors and overall improve safety and efficiency of the shaping procedure also in complex canals (7-8). Besides these improvements, innovations have been proposed also in the root canal cleaning procedures, mainly related to the development of new irrigating solutions and devices to activate irrigants inside canals (9-12). However, such improvements so far had a smaller impact on the quality of the procedure and on the treatment outcome. In recently published reviews there is no evidence about superiority of these new cleaning 10.59987/ads/2024.1.49-54 49  In vitro evaluation of a new endodontic device for assessment of canal cleanliness procedures and devices when compared to traditional vide a strong clinical recommendation through objective syringe irrigation with sodium hypochlorite and ethyl- measurements, checking when root canal cleaning is enediaminetetraacetic acid (EDTA) (13). Proper canal satisfactory completed. It consists of a dedicated swab cleaning and disinfection is influenced by many factors (Endotester) and a luminometer (Endocator) as shown including canal complexities, presence of biofilm, differ- by figs 1-2. Endotester is containing the swab and the re- ences between composition of pulp remnants, iatrogenic agent for testing the amount of debris inside a root canal errors which may lead to incomplete or unsatisfactory (fig.2) , by using a methodology which utilizes an enzyme debridement and disinfection of the endodontic space cycling method, based on a combination of luminescent (14-18). Even if some antibacterial effect can be pro- reactions from firefly luciferase, pyruvate, orthophos- vided by proper canal obturation by entombing bacte- phate dikinase (PPDK) and pyruvate kinase (PK). The ria (19-20), poor cleaning is likely the main factor which luminescence is measured by Endocator and provides negatively affects both the short and long-term outcome a quantitative analysis, or the above-mentioned reac- of the treatment. tions induced by organic and inorganic debris. This new In clinical practice endodontists have to face a big chal- device has been evaluated by the authors in previous lenge. While it is relatively easy to decide when to end in vitro research (25) with promising results, even if the shaping procedures (usually when working length is procedure must be properly performed to avoid errors reached by a Niti rotary instrument with adequate tip size which could affect performance, including false positive and taper), clinicians have little or no clue when to end or negative results. Therefore, in the present study the the final cleaning procedure. Besides visualization under reliability of the device was assessed in vitro by check- magnification, which may reveal only huge amount of ing the risk of possible cross-contamination during the left debris, and visualization of debris, blood or exudates sampling procedure. on paper points used to dry the canal, clinicians have no devices to verify quality of cleaning (21). in the last Methodology decade new devices and techniques like fluorescence- Ten transparent resin training blocks (fig.3) for root canal based imaging or spectroscopy have been developed obturation (SystemB blocks, Kerr, Glendora, CA, USA) to provide clinical hints and help in detecting residual were selected and randomly divided into two groups of bacteria and/or debris after cleaning and shaping proce- 5 each. The use of transparent blocks allowed to visu- dure are completed (22-24), but none of them so far has ally check the procedure, including proper insertion of been successfully commercialized or gained popularity the sampling needle and visual (macroscopic) check of amongst practitioners. To become effective and widely presence of debris which could interfere with results. used in clinical practice such devices should be simple, Each block consisted in one artificial curved canal with rapid to use, reliable and cost effective. A new testing dimensions already designed (taper .06 and apical size device (Endocator, Endocator Inc, Aptos, CA, USA) has 25) for root canal filling (Fig 3), thus reducing any bias been recently developed to fulfill these requirements related to production of additional debris or any artificial (fig.1) and assess presence of remaining organic debris contamination generated by NiTi rotary instrumentation. inside canals (25). Ideally, the new device should pro- Sample size was selected by using Power Analysis and Figure 1. Figure 2. 50 10.59987/ads/2024.1.49-54 R. Cross et al. calculated from results obtained after 4 preliminary mea- part to collect the liquid inside the tube and then inserted surements, by choosing a power of 80% and a 0.05 alpha to the full length to mix the sample solution with the re- type error (G*Power, Heinrich-Heine-Universität Düssel- leasing surfactant reagent. A correct mixing of the two dorf, Düsseldorf, Germany). Since sample calculation components was then provided by shaking the Endotest- showed that 3 specimens could be sufficient to provide er casing for at least 10 seconds and checked by visual- significant data (effect size = 1.48), a total number of 5 izing the dissolution of the luminescent reagent within artificial transparent block was chosen for each group. the sample solution. As the last step, the Endotester was Five new syringes were used for sampling procedure inserted into the Endocator to measure the generated in five transparent training blocks which had been pre- luminescence, and results where quickly displayed af- viously filled with organic and inorganic debris (artifi- ter 10 seconds. Overall, each sampling and measuring cially contaminated canals). The recorded Endocator procedure was completed in less than 1 minute and was measurement were noted as Group 0. Other five new performed by one trained operator to eliminate intra- syringes were used for sampling procedures in artificial examiner variables. Three consecutive samples were canals in which no instrumentation, debridement or filling taken for each block to assess consistency of results with debris had been performed (untouched canals). The The device allows to display results using to 2 different recorded Endocator measurement were noted as Group measuring scales, in which the higher the score the high- A (sterile syringes). In Group B (non-sterile syringes) er is the amount of organic material collected. RLU is a the sampling procedure in the untouched canals was continuous scale, with values ranging from 0 to more repeated by using the same 5 syringes previously used than 600000, while ES shows values from 0 to 100. In the in the contaminated canals. In all cases the sampling IFU, the following clinical correlation was provided only procedure precisely followed the instruction of use (IFU) for ESE values : 0-30 is clean, 31-60 is contaminated, provided by the manufacturer. A sterile irrigation syringe and 61-100 is dirty. On the contrary,no information about with sterile 27-gauge needle containing 1 ml of distilled the correlation between the two scales was provided by water was inserted into the artificial canal, injecting the the manufacturer. The Endoscore (ES) is suggested only solution and then agitating it with a slight up and down to briefly simplify clinical evaluation of canal cleanliness motion of the needle. Then, after inserting the needle 3-4 by proposing a division in the three above mentioned mm from the apex, the irrigating solution was collected categories , which are not being precisely or directly cor- and transferred to the Endotester. related to RLU results. RLU results are more precise and After removing the swab stick from the main body of En- accurate, and consequently in the present study statisti- dotester and the collected sample liquid (one/two drops) cal analysis was performed only using them. Descriptive was released by the needle inside the upper part of the analysis was performed to determine mean and standard tube main body (fig 4). Injection was easy to perform but deviation (SD) of the findings for the 3 groups. Paired T- attention was paid since a too small amount or a too big test with Bonferroni correction was executed to find out amount of liquid may interfere with results, by diluting or significant differences (p<0.05) between the 3 groups . concentrating the amount of debris. Then swab stick was Statistical analysis was undertaken using SPSS (SPSS, inserted inside the casing, initially moved in the upper v25.0 for Windows, SPSS Inc Chicago, IL, USA Figure 3. Figure 4. 10.59987/ads/2024.1.49-54 51  In vitro evaluation of a new endodontic device for assessment of canal cleanliness Table 1. Descriptive analysis. ES (Endoscore). RLU (Relative Luminescence Unit). Group 0 (dirty blocks, clean syringe), Measurement unit Group 0 Sample 1st 2nd 3rd 1 100/192932 100/113568 100/88764 2 100/198885 100/102934 100/95411 Resin block 3 100/679199 100/213908 100/110980 4 100/488916 100/113515 100/70267 5 100/310117 100/98766 100/90457 Sample Mean 100/374009.8 100/128538.2 100/91175.8 Sample SD 0/208497.0 0/48165.8 0/14608.7 Overall group Mean 100/197907.9 Overall group SD 0/173224.9 Results ine diphosphate (ADP) and adenosine monophosphate (AMP) present inside canals. In the past ATP monitoring All Measurements, mean and standard deviation (SD) technology has been used in determining cleanliness lev- values for groups 0 (dirty blocks, clean syringe), A els, allowing rapid and accurate measurements of organic (clean blocks, clean syringe) and B (clean blocks, dirty residues by detecting ATP using luciferase, even if with syringe), consecutive samples (1st, 2nd, 3rd) and resin some risks of bias (25). Therefore, Endocator technology blocks (1, 2, 3, 4, 5) are reported in Table 1. A signifi- uses an improved new ATP + ADP + AMP monitoring sys- cant difference was noted between Group A (sterile tem which can analyze a greater range of organic resi- syringes) and Group B (non-sterile syringes) . Even if dues with increased sensitivity and precision. However, the canals were same and well cleaned, Group B pro- such higher sensitivity may more easily produce varia- vided significantly higher mean values than Group A tions and errors in the measurements due to inadvertent (p<0.05). Group O canals (non-cleaned, contaminated contamination or errors in the sampling technique, which canals) mean values were significantly higher than the is the most critical step in the procedure. other two groups (p<0.05). Group 0 showed highest The monitoring technology is a simple, easy to perform values 100/197907.9±0/173224.9, followed by Group B step which allows objective measuremenst and is mini- 84.3/32352.4±21.4/39095.1 showing that not only dirty mally influenced by operators’ skills. On the contrary blocks, but also contaminated syringes used on clean the sampling procedure is more subjective and can be blocks could lead to ES/RLU values corresponding to influenced by many factors, including the risk of cross- dirty canal. On the other hand, Group A expressed the contamination. For example the dentists could use a lowest values 24.9/201.1±8.5/123.5, showing that col- syringe to collect the liquid for evaluation of the initial lecting a sample from a clean resin block with a clean sy- presence of debris (first measurement after starting of ringe could lead to values corresponding to clean chan- the procedure) and then use the same syringe to col- nel even if a small amount of organic residue was always lect the liquid for final evaluation of the cleaning results detected. Considering the 3 consecutive samples, each (second measurement). A similar situation could also group expressed a decreasing trend, which is related to happen when dentists check only final canal debride- the fact that each sampling procedure adds some new ment, but results provided by Endocator are not good, irrigant and provides some agitation of the solution. thus suggesting further cleaning procedures. After per- forming such improved cleaning, dentists may check Discussion again canal cleanliness (second measurement) by us- The new testing device is based on a method producing ing the same syringe used for the first measurement. a given amount of luminescence, which is directly related All these clinical situation may lead to some contamina- to the amounts of adenosine triphosphate (ATP), adenos- tion and reduce reliability of the system. It is intuitive that initially the syringe should be a sterile one, while 52 10.59987/ads/2024.1.49-54  R. Cross et al. A (clean blocks, clean syringe) and B (clean blocks, dirty syringe). SD (Standard Deviation). ES/RLU A B 1st 2nd 3rd 1st 2nd 3rd 38/456 41/457 26/176 100/82652 97/16461 78/4707 37/333 25/175 18/108 100/113421 100/24409 70/2798 30/270 24/168 16/96 96/15131 64/1916 25/157 24/168 20/140 14/84 100/98756 100/32277 73/3080 26/182 19/114 15/90 100/72432 94/14733 68/2356 31/281.8 25.8/210.8 17.8/110.8 99.2/76478.4 91/17959.2 62.8/2619.6 6.3/118.3 8.8/139.7 4.8/37.5 1.8/37679.7 15.3/11364.8 21.5/1638.2 24.9/201.1 84.3/32352.4 8.5/123.5 21.4/39095.1 same concept may not be so intuitive when applied to a where 0 corresponds to a properly cleaned canal without second measurement in the same clinical case. More- any organic material and 100 to a non-cleaned canal. over, no recommendation is provided by manufacturer The ES scale is meant to be used in clinical practice with about syringes. Hence, the purpose of this study was a simplified range of values as described in IFU: 0-30 to assess the risk of cross-contamination with syringe, clean, 31-60 contaminated, and 61-100 dirty. In the pres- and to assess whether this risk could significantly affect ent study, even if number of specimens was low, varia- measurements and promote the use of a new syringe tions in the measurements in a few cases due to inad- for each sampling procedure, even if in the same tooth vertent contamination were able to wrongly differentiate in the same clinical procedure a cleaned canal into a contaminated canal, according to Results of the present study showed that the risk of the proposed ES scale. RLU is a continuous scale, with cross contamination is significant. Clean, non-instru- wider values ranging from 0 to more than 600.000, which mented canals were properly assessed by the method- is probably more precise and useful for vitro or clinical ology showing only a minimal quantity of residual debris studies. However, manufacturer provided no information (probably derived from manufacturing) in a very precise about the correlation between RLU values and canal and reliable way when a new sterile syringe was used. cleanliness in vivo. On the contrary second measurements of the same Hence, we may conclude that there is a significant risk sample using a syringe who had been previously slightly that even a minimal cross-contamination can signifi- contamined ( being used for sampling in a canal full of cantly affect Endocator measurements due to the high debris) provided significantly different results and canals sensitivity of the system. Therefore, authors recommend were evaluated as partially or poorly cleaned. This is ob- clinicians to use a new sterile syringe for each sampling viously related to the high sensitivity of the Endocator, procedure and suggest manufacturer to write this recom- and to the presence of residual debris in the needle or in mendation in the IFU (Instruction of Use) of the product. the syringe previously used. In fact in a previous study performed by authors to determine precision and reliabil- References. ity of measurements using Endocator, successive mea- 1. Piasecki L, Carneiro E, Xavier da Silva Neto U, Ditzel surements on the same sampling provided better results Westphalen VP , Brandão CG, Gianluca Gambarini G, than the first ones (25), because the sampling method Azim AA. 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A NNALI DI STOMATOLOGIA www.annalidistomatologia.eu VOLUME 14 NUMERO 4 - 2023 A Journal of Odontostomatologic Sciences PublyMed srls  A NNALI Annali............. DI STOMATOLOGIA EDITOR IN CHIEF D’Antò Vincenzo Ciulli Emanuele, Italy University of Naples, Italy [email protected] Gatto Roberto [email protected] University of L’Aquila, Italy Di Carlo Gabriele [email protected] Basilicata Michele University of Rome “La Sapienza”, Italy University of Tor Vergata Italy [email protected] CONSULTANT EDITORS [email protected] Falisi Giovanni University of L’Aquila, Italy Allaf Ferdi De Angelis Francesca [email protected] Turkish Aligner Society,Turchia University of Rome “La Sapienza”, Italy [email protected] [email protected] Marsili Domenico, Italy [email protected] Caruso Silvia De Nuccio Claudio University of L’Aquila, Italy University Cattolica del Sacro Cuore, Italy Nagni Matteo, Italy [email protected] [email protected] [email protected] Docimo Raffaella Yisrael Kornblit Jamal Sied University of Tor Vergata , Italy Roly Doctor, Italy [email protected] [email protected] [email protected] J.L. 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Trib. Roma n. 421 18/12/2009 Editorial Oral surgery and Implantology in the digital era We live in the digital era. The digital devices have become part of our lives and we are using them every day. They involve dentistry too. A frequent mistake is to consider oral surgery and implantology as independent procedures not integrated with the comprehensive treatment plan and above all the prosthetic planning. Our patients ask us for teeth, not implants and that’s why we have to plan prosthet- ics first. The digital approach helps a lot in this field. When we start a surgical plane on e new patient data we need DICOM files from a CBCT and STL files from an intraoral scanner. We can acquire other digital data about occlusion to design the shape and position of new teeth. At this point, we have a digital project that the patient can approve. We can use programs that are also shared to match DICOM and STL files to create a digital patient. Only after that, we can design the artificial roots (dental implant) and if we need, a new bone volume to regenerate. To create this volume we can use free programs available on the net and export files to create devices like grids useful for the regeneration. Obviously, the implant insertion is made by 3D printed surgical stents or navigation to precisely replicate the planning. The whole process is exactly contrary to what we did in the past: the bone volume to regenerate is dictated by the implant position that is designed as a consequence of the prosthetic planning. Further developments will be due to the implementation of Artificial Intelligence (A. I.). Already programs exploit the AI for segmentation and basic diagnostic processes (like detectection of the inferior alveo- lar nerve). Shortly, the A.I. will substitute human judgment for more complex processes in medicine reducing mistakes. Also, medical journals are preparing to receive this revolution. The New English Journal of Medicine, the most important medical review in the world, will present in 2024 NEMJ AI for international researchers. Some are scared of this revolution, but I think that, under human control, this will be a great opportunity to improve the treatment of our patients Luca Signorini 10.59987/ads/2023.4.1-1 1 

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Article Double-blind comparison between optical and conventional impressions for the production of mandibular advancement devices Edoardo Bianchi 1 used to manufacture them. The aim of this study was Andrea Toffoli 2 to compare the clinical adequacy of MADs produced Marzia Segù3 * starting from conventional analog versus digital Alberto Azzi4 impressions; (2) Methods: Four patients were re- Guido Maria Macaluso5 cruited. For each of them, two MADs were produced: Simone Lumetti6 one starting from an intraoral scan and the other Edoardo Manfredi7 from the digitalization of a plaster model based on analog impressions. Clinical parameters of the two devices were evaluated and compared; (3) Results: 1 DDS, PhD Candidate; Dental School, University of No statistically significant differences in the clinical Parma; Department of Medicine and Surgery, Via parameters evaluated were found between the two Gramsci 14, 43126, Parma, PR, Italy. Electronic ad- groups of devices; (4) Conclusion: Optical and con- dress: [email protected]. ventional impressions show similar accuracy in the 2 DDS, PhD; Dental School, University of Parma; De- production of MADs. partment of Medicine and Surgery, Via Gramsci 14, 43126, Parma, PR, Italy. Electronic address: andrea. Keywords: digital dentistry; sleep medicine; man- [email protected]. dibular advancement device 3 DDS, PhD, MSc; Dental School, University of Parma; Department of Medicine and Surgery, Via Gramsci 14, Introduction 43126, Parma, PR, Italy. Electronic address: marzia. [email protected] Obstructive sleep apnea syndrome (OSAS) is a sleep 4 DDS; Dental School, University of Parma; Department disorder characterized by partial or complete obstruction of Medicine and Surgery, Via Gramsci 14, 43126, of the upper airway during sleep, leading to disrupted Parma, PR, Italy. Electronic address: alberto.azzi9@ breathing patterns [1,2]. It is relatively common, affect- gmail.com ing approximately 2-4% of adults in the general popu- 5 MD, MSc; Dental School, University of Parma; Depart- lation. While OSAS can occur at any age, it is more ment of Medicine and Surgery, Via Gramsci 14, 43126, prevalent in middle-aged males [3]. Several risk factors Parma, PR, Italy. Institute of Materials for Electronics contribute to the development of this condition, includ- and Magnetism, National Research Council, Parco ing obesity (BMI > 30), upper airway obstructions such Area delle Scienze 37/A, 43124, Parma, PR, Italy. as nasal turbinate hypertrophy, septum deviations or na- Electronic address: [email protected]. sal polyps, tobacco and alcohol consumption, and the 6 DDS, PhD, MSc; Dental School, University of Parma; presence of craniofacial anomalies like maxillary hypo- Department of Medicine and Surgery, Via Gramsci 14, plasia or micrognathia. The consequences of OSAS are 43126, Parma, PR, Italy. Electronic address: simone. significant, impacting various aspects of an individual’s [email protected]. life. Daytime sleepi-ness, impaired vigilance, and cog- 7 DDS, PhD, MSc; Dental School, University of Parma; nitive dysfunction are common symptoms that affect Department of Medicine and Surgery, Via Gramsci 14, a person’s ability to perform daily activities effectively. 43126, Parma, PR, Italy. Electronic address: edoardo. These symptoms also contribute to an increased risk [email protected]. of motor vehicle accidents, occupational injuries, and a lower overall quality of life [4]. The diagnosis should be Corresponding author: [email protected]; Tel: +39 based on the patient’s medical history and on a clinical 0521 033670 and instrumental examination. Questionnaires like the Epworth Sleepiness Scale, Berlin questionnaire, and Abstract STOP-Bang questionnaire are used to guide the clinical assessment. The most accurate diagnostic examination (1) Background: Obstructive sleep apnea syndrome for OSAS is polysomnography, which is performed in a (OSAS) is a sleep disorder with a high social and sleep laboratory. Polysomnography involves continuous health impact. Mandibular advancement devices noc-turnal recordings, including measurements of vari- (MADs) are considered a viable treatment option ous parameters such as electroen-cephalogram, elec- and a possible first-line treatment in this setting. No trooculogram, electromyography, nasal and oral airflow, study in the literature has investigated clinical as- respiratory effort, oxygen saturation, body position, and pects of these devices in relation to the procedures electrocardiogram. Moreover, considerable evidence 10.59987/ads/2023.4.15-21 15  Double-blind comparison between optical and conventional impressions for the production of mandibular advancement devices suggests that OSAS is independently associated with Materials and Methods cardiovascular disease, cerebrovascular disease, and In this research study, the focus was on evaluating the type 2 diabetes [5,6]. Thus, early diagnosis and effective clinical parameters of mandibular advancement devices management of OSAS are crucial for reducing the risk (MADs) produced using two different impression tech- of these comorbidities. Continuous positive airway pres- niques: intraoral scans and digitalization of traditional sure (CPAP) is the treatment of choice for mild, mod- plaster models. The aim was to identify which of these two erate, and severe OSAS, and should be offered as an methods might offer the best accuracy for MAD fabrication. option to all patients. Alternative therapies may also be During the experimental phase, both the intraoral scan proposed depending on the severity of the OSAS and and traditional plaster model techniques were utilized the patient’s anatomy, risk factors, and preferences [7]. to produce the MADs for each volunteer. These de- In recent years, oral appliances (OAs) have emerged as vices were then thoroughly evaluated based on sev- a popular alternative treatment for OSAS and snoring eral critical clinical parameters. The ease of insertion [8]. OAs, specifically mandibular advancement devices and removal of the MADs was assessed to determine (MADs), are recommended for patients with mild to how user-friendly and manageable they were for the moderate OSAS who prefer them over CPAP or who do volunteers. Adequacy of shape and margins examined not respond well to CPAP [7]. MADs cover the upper and the precision and accuracy of the devices in fitting the lower teeth, holding the mandible in an advanced posi- individual’s dental anatomy. Retention, another cru- tion, typically forward by 5 to 11 mm (50-75% of maxi- cial parameter, gauged how well the MADs stayed in mal protrusion) [4], to improve the patency of the upper place during use, ensuring optimal effectiveness dur- airway during sleep by enlarging it and/or by decreas- ing sleep. Comfort, a significant aspect, was evalu- ing its collapsibility. Anterior movement of the tongue or ated to ascertain the overall satisfaction and tolerance mandible can increase the cross-sectional airway size of the participants with each MAD, aiming to iden- and may also improve upper airway muscle tone [9]. tify the technique that provided a more comfortable fit. Traditionally, the production of oral devices involved To achieve this, four healthy volunteers were recruited conventional impression taking and manual construc- as participants from among the patients attending a pri- tion of the appliance. However, with advancements in vate dental office (Table 1). computer tech-nology and dental processing, a fully digital workflow based on CAD/CAM (Comput-er-Aided Design/Computer-Aided Manufacturing) technology has Table 1. Patients recruited for the study become feasible [10]. Intraoral scanners (IOS) have be- come widely available and offer an efficient and accu- Sex Age rate alternative to conventional impressions. Numerous Patient 1 Male 40 studies have reported that current intraoral scanners Patient 2 Male 40 demonstrate clinically valuable accuracy, at least com- parable to con-ventional impression-based approaches. Patient 3 Male 36 Whereas in vivo studies report that full-arch impres- Patient 4 Male 30 sions are associated with distortion phenomena, for single-tooth restorations or fixed partial prostheses of up to 4-5 elements, the scientific literature deems the accu- The patients selected were all healthy adult men with racy of optical impressions to be satisfactory and similar good oral health. Patients with contraindications to oral to conventional impressions. However, for more exten- devices, such as periodontal disease, dental mobility, sive restorations such as partial fixed prostheses with poor tooth retention, inadequate temporomandibular more than 5 elements or full-arch prostheses on teeth joint range of motion, or extensive tooth loss, were ex- or implants, intraoral scanning might not offer the same cluded from the study. All volunteers had lost no more level of precision as conventional impressions [11,12]. than one tooth, excluding third molars, during their life- Regarding orthodontic purposes, digital models ap- time, making them ideal candidates for the research. pear to be as reliable as traditional plaster models, In this study, two impressions of both dental arches were and full-arch impressions obtained using IOS can re- taken from each patient to compare the effectiveness of place traditional ones [13-15]. Although the precision conventional and digital impression techniques. of these complete-arch scans is currently considered The first set of impressions was obtained using a con- in-ferior to that obtained using conventional impres- ventional technique. Monophasic impressions were tak- sions, reports also show that IOS is sufficiently ac- en using a polyvinyl siloxane material and standard im- curate for the fabrication of occlusal devices, such pression trays were utilized to capture the dental arches’ as Michigan splints, in a fully digital workflow [16,17]. detailed morphology. The conventional method involves Currently, no study in the literature evaluates the use carefully inserting the tray into the patient’s mouth and of optical impressions in the production of MADs used allowing the impression material to set and capture the in OSAS treatment, and overall, no study has investi- teeth and surrounding structures accurately. gated aspects such as the accuracy, fit and comfort of The second set of impressions was obtained using a MADs in relation to device manufacturing procedures. state-of-the-art digital impression system. The CEREC The aim of this study is to assess the clinical accuracy Omnicam® intraoral scanner with CEREC Ortho SW of MADs produced using CAD/CAM technology with two 1.2® software (Dentsply Sirona; North Carolina, USA) different impression techniques: conventional impres- was employed for this purpose. The intraoral scanner is sion taking and intraoral scanning. By comparing the a handheld device equipped with advanced optical tech- two approaches, researchers hope to shed light on the nology that allows for the non-invasive capture of the potential benefits and limitations of using digital impres- dental arches in a three-dimensional digital format, pro- sions in the production of MADs for patients with OSAS. viding real-time visualization and accurate digital models 16 10.59987/ads/2023.4.15-21 E. Bianchi et al. of the patient’s teeth and surrounding oral structures. software (Dentsply Sirona; North Carolina, USA) was During the acquisition of both conventional and digital used for the acquisition of full-arch digital impressions. A impressions, the intermaxillary relationship was record- full-arch guided scanning procedure was used, requiring ed in maximum intercuspation. Furthermore, to ensure the operator to wield the intraoral scanner throughout the optimal fit and function of the MADs, the patient’s maxi- process. The scanner is powder-free and relies on the mal mandibular protrusion was carefully recorded. This principle of optical triangulation with video sequencing measurement considered the distance from the upper using white LED for image acquisition. All digital scan- right central incisor to the lower right central incisor dur- ning procedures were performed by the same expert op- ing mandibular protrusion movement, according to the erator. Using Cerec Omnicam® with the Cerec Ortho® oral devices manufacturer’s indications. software, a 3D digital model is generated and available Once the conventional and digital impressions of the pa- directly after imaging, and the integrated model analy- tients’ dental arches were obtained, two Narval CCTM sis tools allow quick access to the clinical information. dental devices (Resmed Inc., California, USA) were The scan data were later exported as STL digital files produced for each patient using computer-aided design/ and sent to the laboratory in this format, attached to computer-aided manufacturing (CAD/CAM) techniques. the order form, through the Narval Easy online portal. The Narval CCTM devices are bi-block MADs made In order to compare the MADs produced starting from from semi-rigid, biocompatible polymer plastic materials. the two different impression techniques, a list of clinical For the devices produced from the traditional impressions, parameters was drawn up to be used to test the quality a skilled dental technician transformed the impressions of the devices. into plaster models. These plaster models were then The literature was searched to identify objective clini- scanned to create accurate digital models. These digital cal parameters able to define the clinical fit of oral ap- models served as the basis for designing the mandibu- pliances, but poor results were found. In fact, most of lar advancement devices through CAD/CAM processes. the published studies concern fixed prostheses or use in To ensure unbiased evaluation, a double-blind proce- vitro measurements to evaluate device accuracy. Only a dure was employed for the testing phase. An expert few studies suggested clinical parameters that may be dental clinician with specialized training in dental sleep used to evaluate the accuracy of oral devices, such as medicine, who was unaware of the type of MAD being orthodontic appliances or occlusal devices [17-21]. No used, delivered and evaluated the two devices for each study that included evaluation of the clinical accuracy of patient. Additionally, the patients themselves were un- MADs was found. Supplementing the articles found in aware of the type of device they were testing. To main- the literature, a list of parameters was established, with tain anonymity during the evaluation process, a second univocal definitions. Numerical scores were provided operator assigned a unique code to each test device. for each parameter based on objective criteria. Table 2 This coding system ensured that the evaluator and pa- shows the list of parameters and scores. tients could not determine which MAD was conventional Statistical analysis was carried out by means of paired and which was digital. After receiving the MADs, the vol- t-test to compare the scores obtained using the different unteers were instructed to wear them for several nights devices for the five parameters considered (insertion, re- during sleep. They were then asked to provide feedback moval, adequacy of margins and shape, retention, and on their experience, particularly regarding the level of comfort). The aim of the statistical analysis was to re- comfort achieved and any unexpected events they en- port differences between the scores obtained by the two countered while using the devices. groups of devices for each parameter analyzed. A com- The devices consisted of two parts, i.e., an upper and prehensive assessment of each device was also carried a lower splint, interconnected by exchangeable rods of out, considering the total score obtained by summing the different lengths. Although five design variations were parameter scores. The comprehensive score was com- available covering a range of patient needs and ana- pared between the devices using the same statistical tomical constraints, only one was selected for this study analysis method. (“facial band” for both the upper and the lower jaw), to ensure that the devices were comparable. However, Results in accordance with the manufacturer’s indications and Tables 3 and 4 show the single parameter scores ob- based on the clinical evaluations, one patient was given tained by each device, as well as the total score for each different designs due to his particular dental morphology device. (“incisors full coverage” for both the upper and the lower jaw for the digital device; “incisors full coverage” for the None of the devices were found during the clinical evalu- lower jaw and “facial band” for the upper jaw for the ana- ation to cause side effects (such as gum soreness or logic device). crushing), and none of the patients reported side effects The amount of mandibular advancement was set at 60% or discomfort after wearing them for a few nights. of maximum protrusion for all the patients. The devices Paired t-tests were carried out to test for statistically sig- were fabricated using CAD/CAM technology starting nificant differences between the two groups of devices from the scanned plaster casts and optical impressions for both total scores and single parameters (Figure 1). of the dental arches. Computer-aided design (CAD) The tests were performed using a 95% confidence level enables high degree of customization to suit the com- (definition of statistical significance: p< 0.05). plex dental anatomy of each patient. A virtual articulator was used in this stage. Computer-aided manufacturing (CAM) using selective laser sintering of a biocompatible Discussion polymer material (polyamide) guarantees consistent, in- The aim of this study was to evaluate the clinical accu- dustrial-strength manufacturing. In this study, the Cerec racy of MADs produced both from digital and traditional Omnicam® intraoral scanner with Cerec Ortho SW 1.2® impressions. The effectiveness of the devices for the 10.59987/ads/2023.4.15-21 17  Double-blind comparison between optical and conventional impressions for the production of mandibular advancement devices Table 2. Parameters and scores CLINICAL PAREMETER SCORE 0 (low) 1 (acceptable) 2 (optimum) Insertion It is not possible to obtain The device can be placed The device can be easily complete insertion and the with difficulty, or it is placed, with no need for proper positioning of the necessary to apply high adjustments (snap fit) device or too little pressure, or it is necessary to make adjustments on the device. Removal Difficulties occur in re- The device can be easily The device can be easily moving the device / the removed from oral cavity but removed by the patient patient cannot remove the only after adjustments with no need for ad- device independently just-ments Adequacy of margins Inaccuracies or areas of Mild inaccuracies are found, Perfect congruence and shape excessive pressure on or the device can be worn between shape/margins tissues are found, or the without discom-fort after of the device and patient’s patient reports adjustments tissues discomfort wearing the de- vice as a consequence of excessive pressure on the teeth or gums Retention Retention of the device is The device dislocates either The retention of the device lacking in both the upper the upper or the lower jaw is sufficient to allow usual and lower jaws during mouth during mouth opening and oral functions (such as opening and closing closing swallowing, mouth ope- ning and closing) Comfort The patient struggles with The patient feels slight The patient feels the device and cannot get discomfort when wearing the comfortable wearing the used to it device but bears it device Table 3. Scores obtained from clinical examination of the devices Patient 1 Patient 2 Patient 3 Patient 4 Parameter Analog Digital Analog Digital Analog Digital Analog Digital Insertion 2 2 2 1 1 2 1 2 Removal 2 2 2 1 1 2 1 2 Adequacy of margins and 2 2 1 1 2 1 2 2 shape Retention 1 2 2 2 1 2 1 2 Comfort 2 2 1 0 2 1 2 2 treatment of OSAS was not evaluated, although consid- vices could lead to wastage of time and resources for erable evidence exists supporting the effectiveness of both dental clinics and laboratories. Moreover, ill-fitting MADs in this setting. devices may negatively impact patient comfort and com- In the existing literature, no studies have specifically in- pliance, ultimately affecting the overall effectiveness of vestigated aspects such as accuracy, fit, and comfort of the treatment. mandibular advancement devices in relation to device Traditionally, the MAD production process involves tak- manufacturing procedures. These aspects hold signifi- ing impressions using alginate or elastomeric materials. cant importance in clinical practice, as poorly fitting de- However, advancements in technology now enable spe- 18 10.59987/ads/2023.4.15-21 E. Bianchi et al. Table 4. Total of the scores and arithmetical means obtained by the two different groups of devices Total Arithmetic mean Parameter Analog Digital Analog Digital Insertion 6 7 1.5 1.75 Removal 6 7 1.5 1.75 Adequacy of margins and shape 7 6 1.75 1.5 Retention 5 8 1.25 2 Comfort 7 5 1.75 1.25 TOTAL SCORE 24 28 (objective parameters) TOTAL SCORE 31 33 (including patient’s comfort) cialized laboratories to work directly from digital scans of quate accuracy for producing mandibular advancement dental arches. In modern clinical practice, full-arch scans devices (MADs). This finding suggests that intraoral are not only used for MAD fabrication but also for orth- scanners may be a viable and reliable option for clinical odontic purposes, such as diagnosis and production of practice, potentially enhancing the available evidence orthodontic appliances. While some studies have exam- in the field of dental sleep medicine. However, it should ined the accuracy of intraoral scans, they have primarily be noted that the cost of producing two devices per pa- been laboratory-based and focused on in vitro measure- tient, as required for the study’s design, makes this ap- ments. Only a few studies have conducted clinical as- proach more suitable for scientific research purposes sessments on the accuracy of oral appliances produced rather than routine clinical practice. Nevertheless, some from full-arch scans, specifically orthodontic appliances valuable conclusions can still be drawn from the present or occlusal devices, and no such study has evaluated study. First, all the tested devices exhibited at least an MADs. Therefore, the current study’s contribution lies in acceptable level of accuracy, with none of the devices its development of a comprehensive set of clinical pa- considered inadequate in any parameter. While one de- rameters used to assess the fit of intraoral appliances vice based on an optical impression received a negative and facilitate comparisons between different devices. patient comfort evaluation, this aspect is subjective, and The parameters established were supplemented with a the other parameters were deemed more meaningful. scoring system and provided with detailed definitions, in Overall, both impression techniques produced satisfac- order to make them objective and unambiguous. Further- tory results, suggesting that they can be considered suit- more, the devices were clinically tested using a double- able for clinical practice. blind procedure, to avoid conditioning of any kind. One of Upon comparing the two groups of devices, no statisti- the essential achievements of this study was the produc- cally significant differences were found in the compre- tion of two different MADs for each patient—one based hensive evaluation (total score) or individual parameters. on an optical scan and the other from a traditional im- This indicates that the accuracy of the MADs fabricated pression. This comparative approach allowed for a com- from optical impressions was similar to those made from prehensive evaluation, considering potential anatomical conventional impressions. variations between patients. It is crucial to assess how Furthermore, it is worth noting that all the devices pro- these differences might affect the clinical fit and reten- duced from optical impressions received the maximum tion of the MADs. By making these direct comparisons, score for retention. This finding is particularly notewor- the study aimed to provide more robust evidence for the thy because retention is a critical aspect of MADs. Poor clinical use of intraoral scanners in MAD fabrication. retention can lead to discomfort for patients and com- The primary limitation of the present study is the rela- promise the overall effectiveness of the treatment. The tively small number of patients included in the research, ability of the devices from optical impressions to achieve which affects the statistical power and generalizability maximum scores for retention suggests their general of the results. However, the study has laid the ground- high-quality construction and potential clinical utility. A work for future investigations, and the aspects examined deficiency in parameters such as comfort or adequacy herein could serve as a basis for more extensive and of margins can often be rectified through chairside ad- robust statistical analyses in subsequent studies with justments, whereas poor retention is a trickier problem larger patient cohorts. to solve, suggesting poor general quality of the device. Despite the limitations, the current study demonstrates Insufficient retention can, in some cases, even make it that the use of an intraoral scanner can provide ade- necessary to remake the device. 10.59987/ads/2023.4.15-21 19  Double-blind comparison between optical and conventional impressions for the production of mandibular advancement devices Figure 1. Conclusions to acknowledge the need for further research involving The findings of the current study indicate that mandibu- larger patient cohorts. Expanding the sample size and lar advancement devices (MADs) produced using CAD/ including a more diverse patient population would help CAM techniques, whether starting from optical digital establish more statistically significant conclusions. Con- impressions or conventional polyvinyl-siloxane impres- ducting multicenter studies with standardized protocols sions, demonstrate comparable clinical fit and accuracy. could also enhance the reliability and generalizability of These results suggest that a fully digital workflow can be the findings. effectively utilized for MAD fabrication in clinical practice, Incorporating additional outcome measures could pro- offering the possibility of obtaining high-quality devices vide a comprehensive assessment of the MADs’ per- with excellent clinical fit, similar to those produced from formance and patient satisfaction. Long-term follow-ups conventional impressions. to evaluate treatment efficacy, adherence, and potential The adoption of CAD/CAM technology in MAD fabrica- side effects would offer valuable insights into the devic- tion has shown promising outcomes, providing a more es’ overall clinical effectiveness. streamlined and efficient approach to device production. Furthermore, exploring the cost-effectiveness of the digi- The digital workflow allows for precise customization and tal workflow compared to traditional methods would be better adaptation to the individual patient’s dental anat- beneficial for healthcare providers and patients alike. omy, potentially leading to improved patient comfort and Understanding the economic implications could poten- treatment efficacy. Additionally, the digital process re- tially lead to more widespread adoption of CAD/CAM duces the reliance on physical materials and manual la- techniques in dental sleep medicine. bor, contributing to cost savings and shorter turnaround Funding: This research received no external funding times for device delivery. Institutional Review Board Statement: The study was While the study’s results are encouraging, it is essential approved by the Unit Internal Review Board (17-1023). 20 10.59987/ads/2023.4.15-21 E. Bianchi et al. Informed Consent Statement: Informed consent was 11. Abduo J, Elseyoufi M. “Accuracy of intraoral scanners: a obtained from all subjects involved in the study. Written systematic review of influencing factors”. Eur J Prsthodont informed consent has been obtained from the patients to Restor Dent. 2018 Aug 30;26(3):101-121. 12. 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https://www.annalidistomatologia.eu/ads/article/view/267

Original research article Physicochemical properties of two commercially available bioceramic sealers: An in vitro study Tugba Turk1 groups. Based on the findings of this study, we may Luca Piccoli2 conclude that there is a great similarity in chemical Francesca Romana Federici3 composition and manufacturing or, more likely, the Ayfer Atav Ates4 two products, which are made by the same manufac- Maurilio D’ Angelo5 turers, are identical. Alberto de Biase6 Keywords: Root canal, sealer, obturation, bioceramic 1 University of Smirne, Turkey. Copyright. Authors retain copyright of the article [email protected] 2 University of Rome La Sapienza, Italy [email protected] Introduction 3 University of Rome La Sapienza, Italy [email protected] Successful endodontic therapy is accomplished by prop- 4 Istinye University , Istanbul, Turkey. er shaping and cleaning procedures followed by three- [email protected] dimensional, hermetic sealing of the root canals with 5 University of Rome La Sapienza, Italy appropriate root canal filling materials (1). Endodontic [email protected] filling materials are placed permanently in the root ca- 6 University of Rome La Sapienza, Italy. nal to ensure long-term endodontic success, aiming [email protected] at avoiding leakage of bacterial invasion by blocking the pathways of communication between the root canal system and its surrounding tissues (2). For many de- Corresponding author: cades gutta-percha has been the golden standard and Maurilio D’Angelo the ideal core material of the filled root canals, being [email protected] inert, biocompatible, non-resorbable and thermoplastic (1). However, due to the inability of gutta-percha to ad- here to dentine, a root canal sealer was also needed Abstract to improve sealing, even if sealer was considered the weak part of the obturation, being more toxic and re- A great number of bioceramic sealers commercially sorbable. Ideally, a sealer should also exhibit alkalinity available nowadays show a great diversity in their and bioactive properties to improve tissue healing and biological, chemical, and physical properties. Such remineralization. For many years several root canal differences can also significantly affect clinical sealers have been commercialized with a great diversi- performance, and consequently, new commercially ty in their biological, chemical, and physical properties, available products must be carefully investigated to but none of them possessed all the ideal properties de- assess quality and check differences with existing scribed by Grossman (3). products. The current in vitro study investigated five In recent times endodontics has made huge progress, physicochemical properties (setting time, solubil- especially with advancements in nickel-titanium file de- ity, pH analysis, radiopacity, and film thickness) of sign and metallurgy (4-6). New operative techniques two commercially available bioceramic sealers. The have been developed, focusing on making chemo- null hypothesis was that the composition of the two mechanical preparation more rapid and efficient, and products was the same, the manufacturing site was ideally increasing quality by providing more predict- the same and consequently, they should exhibit the able cleaning and shaping results (7-10). As a conse- same properties when subjected to in vitro tests. quence, there has been a similar interest in improving Tests were conducted based on the International the simplicity and quality of root canal obturation, with Standard Organization (ISO) 6876/2012 recommen- a continuous request for alternative sealers that are dations. For each test 10 samples for each product more biocompatible, more bioactive, and more capa- were evaluated. All data were recorded and ana- ble of bonding to the root canal wall when compared lyzed statistically by ANOVA and Tukey’s test at the to traditional resin-based or eugenol-based sealers 5% significance level. For all tests, no statistically (11-16). Therefore, the criteria for the ideal material for significant differences were found between the two use in endodontic obturations must be comprehensive 10.59987/ads/2023.4.43-48 43  Physicochemical properties of two commercially available bioceramic sealers: An in vitro study and include the following characteristics: non-toxic, in- this process was repeated until the needle no longer in- soluble in tissue fluids, dimensionally stable, antibacte- dented the sealer surface. The final setting time (min) rial, hard tissue conductive, biocompatible, radiopaque was recorded and all data were analyzed statistically by and easy to handle (3).  New bioceramic sealers were ANOVA and Tukey’s test at the 5% significance level. developed to fulfill these requests, and in the last de- cade, these products have become more widely inves- Solubility test tigated and clinically used worldwide, even if they are generally more expensive than traditional sealers (15). The test was carried out in accordance with the ISO However, the various bioceramic sealers commercially 6876/2012 recommendations using 10 samples for each group. Similarly, to the setting time tests gypsum molds available nowadays show a great diversity in their bio- with an internal diameter of 10 mm and height of 2 mm logical, chemical, and physical properties: most of them were fabricated, then filled with the endodontic sealers are mainly related to their chemical composition, but and stored in an incubator (ICT-120 Permax, Treviglio also to the manufacturing process. Such differences can Italy) with 95% humidity at 37 °C for 24 hours for set- also significantly affect clinical performance, and con- ting. The disc-shaped specimens were then removed sequently, new commercially available products must from the mould, and weighed (initial mass = W1) by be carefully investigated to assess quality and check using an analytical balance (Mettler-Toledo, model differences with existing products (11-13). It has been AE1633, Novate Milanese, Italy)) with an accuracy of shown that the safety data sheets and manufacturer 0.001 g. Then, each specimen was hung using a ny- details of currently available bioceramic sealers were lon thread in a closed plastic fbootle containing 10 mL imprecise. Moreover, little detail on composition was of saline solution and stored again in the incubator for provided by manufacturers (11). two weeks with the same humidity and temperature de- The current in vitro study investigated five physicochem- scribed above. The specimens were then removed from ical properties (setting time, solubility, pH analysis, ra- the incubator, dried with absorbent paper, and placed in diopacity and film thickness) of two commercially avail- a dehumidifying chamber for 24 hours. After completing able bioceramic sealers: a new one and the one which this procedure the specimens were weighed again (final has been most extensively evaluated in the last decade. mass = W2) and the material loss was calculated as a The null hypothesis was that they should exhibit the percentage of the difference in weight by the following same properties when subjected to in vitro tests, be- formula: (w1-w2) /w1 x100. All data were analyzed cause manufacturing site and process are the same. statistically by ANOVA and Tukey’s test at the 5% sig- nificance level. Materials and methods For each group and for each test 2 samples were taken PH analysis from a different package. Overall 5 packages of Endo- The test was carried out using 10 specimens for each sequence BC sealer (BUSA/Brasseler USA. Savannah, group. Each sample of root canal sealer was inserted GA) and 5 packages of Edge Bioceramic (EdgeEndo, into polytetrafluoroethylene tubes to obtain discs with Albuquerque, New Mexico, USA) were used. Sample a 5 mm diameter and 2 mm thickness. After the sealer size was determined by Power Analysis and for each setting in an incubator (ICT-120 Permax, Treviglio Italy test it was calculated based on a power of 80% and a ) with 95% humidity at 37 °C. for 24 hours, each speci- 0.05 alpha type error (G*Power, Heinrich-Heine-Univer- men was immersed into a closed flask containing 10 mL sität Düsseldorf, Düsseldorf, Germany). For each group, of distilled water at an initial pH of 7 and a temperature the indicated sample size was 10. All samples were of 25 °C. Then the specimens were stored again in an analyzed before the expiration dates established by the incubator at 37 °C and 95% relative humidity for 7 (?). manufacturers. The calibration of the pH meter (Jen-way 3510 bench pH meter, UK) was performed with a standard solution at Setting time. pH 4.0 and 7.0 at a constant temperature of 25 °C. The pH of the solution was measured after 24 hours. All data Setting time was evaluated based on the International were recorded and analyzed statistically by ANOVA and Standard Organization (ISO) 6876/2012 recommenda- Tukey’s test at the 5% significance level. tions, with a slight change. Gypsum molds to measure the setting time of the bioceramic sealers instead of the Radiopacity recommended stainless steel ones were selected. This choice was performed to avoid any risk of incomplete The test was performed following the recommendation setting related to the mold because gypsum contains described in ISO 6876/2012. For each group, each of water and bioceramic sealers require moisture for set- the five packages was used to make two disc-shaped ting, whilst stainless steel does not contain water. For specimens (10 x 1 mm). Overall, ten specimens for each each group, each of the five packages was used to fill group were tested. After setting the materials in an in- two molds. Overall, ten specimens for each group were cubator (ICT-120 Permax, Treviglio Italy) with 95% hu- tested and stored in an incubator (ICT-120 Permax, midity at 37 °C. for 24 hours, radiographs were taken Treviglio Italy) with 95% humidity at 37 °C. The setting using periapical digital film (Digora, Dexis) including a time was measured using a Gilmore needle, with a total graduated aluminum step wedge varying from 2 to 16 weight of 100 g and a flat end of diameter 2.0 mm, start- mm in thickness for comparison. The dental X-ray unit ing 1 h before the setting time specified by the manu- (Kodak) was set at 70 kVp, 10 mA, and a distance of 50 facturer, and was repeated every 5 minutes. The needle cm. The radiopacity of sealers was compared to that of was carefully placed vertically against the sealer and if the aluminum step wedge using VIXWIN-2000 software. an indentation was visible it was raised to clean, and All data (mmAl) were recorded and analyzed statistically 44 10.59987/ads/2023.4.43-48 Tugba Turk et al. by ANOVA and Tukey’s test at the 5% significance level. affect the clinical performance of these materials and Film thickness highlighted the importance of using reputable materials Tests were performed according to the ISO 6876/2012 that have been adequately researched both in vitro and recommendations. Initially, the total thickness of two piec- in clinical practice (11). es of flat glass plates (5 mm in thickness, 200 × 10 mm Results from the present study showed that in all the in surface area) placed over one another was measured vitro physical and chemical tests performed there was (TH1) using an electronic digital caliper (ELE Digital Cali- no statistically significant difference between the two per, Atessa, Italy). Each glass was also weighted with groups. This could be explained by a great similarity in an analytical balance (Adam Equipment 4-digit precision manufacturing or, more likely, the two products, which are weighing balance, UK) with an accuracy of 0.001 g. For made by the same manufacturers, are identical. EndoSe- each group, 10 samples of sealer were collected from quence BC sealer could also be considered as a control the syringe transferred immediately onto the lower glass because of its reputation as a gold standard for studies plate and covered by the upper glass plate. The weight on bioceramic sealers. It is one of the very first commer- glasses with sealer were measured again to ensure a cial products and has been subjected in recent years to similar amount of sealer (0,05 ml) in all specimens, and many in vitro and vivo researches, which provided excel- specimens were put into an incubator with a 150 N load lent results, and currently it is the bioceramic sealer most weight vertically applied for 3 minutes on the upper glass widely investigated in dental literature and most validated plate. After 10 minutes the total thickness (TH2)of the for clinical use (16-24). On the contrary no studies are plates, including the sealer, was measured again using available concerning Edge Bioceramic sealer. the same digital caliper, and the amount of the film thick- Setting time was similar between the two products, ness (μm )was obtained by subtracting the initial mea- which are both available in premixed syringes inside surement of the two glasses from final total thickness of which inorganic components of the sealers (calcium the glass plates ( TH2-TH1) All data were recorded and phosphate, silicates) are premixed with water-free thick- analyzed statistically by ANOVA and Tukey’s test at the ening vehicles. This formulation enables the sealer to be 5% significance level. delivered in the form of a premixed paste, and water/ moisture is required for the setting reaction. This is a very user-friendly way of applying the sealer into canals Results and also avoids poor performance related to incorrect Results are shown in Table 1. Mean values, standard mixing of the sealers. In a clinical environment, the set- deviation, and significance are shown for each of the fol- ting reaction can be also catalyzed by the presence of lowing five in vitro tests: setting time, solubility, pH analy- moisture in dentinal tubules and be completed in a few sis, radiopacity, and film thickness. Mean values for the hours, even if it could be longer in particularly dried ca- setting time (min) were 90,25 and 86,77, respectively for nals. Therefore, the amount of moisture present in the BC Endosequence and Edge Bioceramic. Mean values dentinal tubules of the canal walls and, consequently, for the solubility test (%) were 3,4 and 3,6, respectively the setting time could also be affected by differences in for BC Endosequence and Edge Bioceramic. Mean val- the absorption with paper points. On the contrary, too ues for PH were 10,8 and 10,9 respectively for BC En- much water left inside canals could decrease the micro- dosequence and Edge Bioceramic. Mean values for the hardness of the material. radiopacity (mmAl) were 3,25 and 3,6, respectively for In the present study, the solubility of both products was BC Endosequence and Edge Bioceramic. Mean values slightly higher than the minimum ISO standard value, for the film thickness (μm) were 48 and 45, respective- with no statistically significant differences between the ly for BC Endosequence and Edge Bioceramic For all two groups. Such high values could be attributed to seal- tests, no statistically significant differences were found ers’ hydrophilic nanosized particles, which have a posi- between the two groups. tive effect on film thickness and flowability but could also increase their surface area and allow more liquid mol- ecules to come into contact with the sealer and conse- Discussion quently increase its solubility. These results are in accor- Bioceramic sealers have shown more favorable proper- dance with previous studies on bioceramic sealers, but ties when compared to traditional sealers, documented they also conflict with other studies that demonstrated by many in vitro and in vivo studies (17-24). These stud- that the solubility of Endosequence BC sealer was con- ies have also shown significant differences amongst sistent with ISO standards (23). Such different findings currently available bioceramic sealers (17-24 ). In a re- could be related to variations in the test methods (24); cent review, authors showed that in the last years, en- more precisely variations in the procedure used to dry dodontists faced a rapid increase in materials identified samples may result in significant differences. Another as bioceramics on the market, but these materials have important factor is the time between mixing the sealer different chemistries, and some of the constituents are and immersion in the storage solution. In some stud- not declared (11). The authors conclude that this may ies, mixed sealers were immersed after 150% or 300% Table1 SettingT time (min) Solubility test (%) PH analysis Radiopacity (mmAl) Film thickness (μm) BC Endosequence 90,25 +/- 12,5 3,4 +/-0,4 10,8 +/- 0,25 3,25. +/- 0,25 48 +/- 0,1 Edge Bioceramic 86,75 +/- 11,5 3,6 +/-0,5 10,9 +/- 0,25 3,6 +/- 0,5 45 +/- 0,2 NS NS NS NS NS 10.59987/ads/2023.4.43-48 45  Physicochemical properties of two commercially available bioceramic sealers: An in vitro study of their setting time compared with 300% whilst others used a set duration of 24 h after mixing. It is noticeable 1. Pirani C, Camilleri J. Effectiveness of root canal filling ma- that the reported solubility values were inversely relat- terials and techniques for treatment of apical periodonti- tis: A systematic review. Int Endod J. 2023 Oct;56 Suppl ed to the duration between mixing and immersion (24) 3:436-454. doi: 10.1111/iej.13787. Epub 2022 Jul 5. PMID: Both sealers showed a strong alkaline pH after 24 35735776. hours, with no significant differences between the two 2. Gambarini, G.; Testarelli, L.; Pongione, G.; Gerosa, R.; groups. This is a positive finding because it can deter- Gagliani, M. Radiographic and Rheological Properties of mine a prolonged setting time, thus allowing adequate a New Endodontic Sealer. Aust. Endod. J. 2006, 32 (1), time for obturation and a long-lasting antibacterial ef- 31–34. https://doi.org/10.1111/j.1747-4477.2006.00005.x 3. Ortega MA, Rios L, Fraile-Martinez O, Liviu Boaru D, De fect that eliminates the residual bacteria that survived Leon-Oliva D, Barrena-Blázquez S, Pereda-Cerquella C, after chemo-mechanical canal preparation. An alkaline Garrido-Gil MJ, Manteca L, Bujan J, García-Honduvilla N, pH may also contribute to enhanced osteogenic poten- García-Montero C, Rios-Parra A. Bioceramic versus tradi- tial by activating alkaline phosphatase, neutralizing lac- tional biomaterials for endodontic sealers according to the tic acid from osteoclast, and allowing tissue repair with ideal properties. Histol Histopathol. 2023 Sep 8:18664. the formation of hydroxyapatite. An alkaline PH is also Doi 10.14670/HH-18-664. Epub ahead of print. PMID: 37747049. related to improved biocompatibility. PH data from the 4. Gambarini G, Miccoli G, Seracchiani M, Khrenova T, Don- present study are similar to values obtained in other francesco O ;Angelo M, Galli M, Di Nardo D, Testarelli L. studies which analyzed EndoSequence BC sealer (25). Role of the Flat-Designed Surface in Improving the Cyclic Radiopacity of root canal obturation materials is a fun- Fatigue Resistance of Endodontic NiTi Rotary Instruments. damental physical property that allows radiographic Materials (Basel). 2019 Aug 8;12(16):2523. doi: 10.3390/ evaluation of the root canal filling. In clinical practice, ma12162523. PMID: 31398814; PMCID: PMC6720207. 5. Plotino G, Grande NM, Testarelli L, Gambarini G, Cast- the quality of the filling is checked by radiographs im- agnola R, Rossetti A, Özyürek. Gambarini G, Miccoli G, mediately after obturation. Single-cone hydraulic con- Seracchiani M, Khrenova T, Donfrancesco O; Angelo M, densation with bioceramics allows to verify if overfilling Galli M, Di Nardo D, Testarelli L. Role of the Flat-Designed or underfilling is present, and if needed clinicians can Surface in Improving the Cyclic Fatigue Resistance of End- modify the obturation by adding more sealer of placing odontic NiTi Rotary Instruments. Materials (Basel). 2019 the gutta-percha cone more apically or coronally, due Aug 8;12(16):2523. doi: 10.3390/ma12162523. PMID: 31398814; PMCID: PMC6720207. to an adequate setting time of the sealer. An ideal 6 Zanza, A.; D’Angelo, M.; Reda, R.; Gambarini, G.; Testarelli, material should be clearly visible inside and outside the L.; Nardo, D. D. An Update on Nickel-Titanium Rotary In- canal,also to detect overextension ( a moderate one is struments in Endodontics: Mechanical Characteristics, usually tolerated by tissue due to the biocompatibility Testing and Future Perspective—An Overview. Bioengi- of the bioceramic sealer ) and its possible resorption neering 2021, 8 (12), 218. https://doi.org/10.3390/bioengi- over time. In the present study, the radiopacity test was neering8120218. 7. Ali, A.; Bhosale, A.; Pawar, S.; Kakti, A.; Bichpuriya, A.; performed following ISO 6876/2001 recommendations, Agwan, M. A.; Agwan, A. S. Current Trends in Root Canal using aluminum as the control material. Both products Irrigation. Cureus 2022, 14 (5), e24833. https://doi.org/ showed higher values compared to the ISO minimal re- 10.7759/cureus.24833 quirements (radiopacity equivalent to 3 mm thick), but 8. Li, Q.; Zhang, Q.; Zou, X.; Yue, L. Evaluation of Four Final there were no statistically significant differences be- Irrigation Protocols for Cleaning Root Canal Walls. Int. J. tween the two groups. For both products film thickness Oral Sci. 2020, 12 (1), 29. https://doi.org/10.1038/s41368- 020-00091-4. was in accordance with ISO minimal requirements and 9. Plotino, G.; Grande, N. M.; Mercade, M.; Cortese, T.; Staf- in accordance with other published studies for EndoSe- foli, S.; Gambarini, G.; Testarelli, L. Efficacy of Sonic and quence BC sealer (25) Ultrasonic Irrigation Devices in the Removal of Debris from Canal Irregularities in Artificial Root Canals. J. Appl. Oral Sci. 2019, 27, e20180045. https://doi.org/10.1590/1678- Conclusions 7757-2018-0045 The present in vitro study investigated five physicochem- 10. Plotino, G.; Grande, N. M.; Tocci, L.; Testarelli, L.; Gam- ical properties (setting time, solubility, pH analysis, radi- barini, G. Influence of Different Apical Preparations on Root Canal Cleanliness in Human Molars: A SEM Study. J. Oral opacity, and film thickness) of two commercially avail- Maxillofac. Res. 2014, 5 (2), e4. https://doi.org/10.5037/ able bioceramic sealers: BC EndoSequence and Edge jomr.2014.5204 Bioceramic. Based on the findings of this study, which 11. Cardinali F, Camilleri J. A critical review of the material prop- showed no statistically significant differences in all tests erties guiding the clinician’s choice of root canal sealers. between the two products we may conclude that there Clin Oral Investig. 2023 Aug;27(8):4147-4155. doi: 10.1007/ is a great similarity in manufacturing or, more likely, the s00784-023-05140-w. Epub 2023 Jul 17. PMID: 37460901; PMCID: PMC10415471. two products, which are made by the same manufactur- 12. Dong X, Xu X. Bioceramics in Endodontics: Updates and ers, are identical. Future Perspectives. Bioengineering (Basel). 2023 Mar 13;10(3):354. doi: 10.3390/bioengineering10030354. PMID: Declaration of competing interest 36978746; PMCID: PMC10045528. The authors have no conflict of interest relevant to this 13. Hamdy, T.M., Galal, M.M., Ismail, A.G. et al. Physicochemi- article. cal properties of AH plus bioceramic sealer, Bio-C Sealer, and ADseal root canal sealer. Head Face Med 20, 2 (2024). https://doi.org/10.1186/s13005-023-00403-z Acknowledgments 14. Kwak SW, Koo J, Song M, Jang IH, Gambarini G, Kim HC. There was no funding related to this study. Physicochemical Properties and Biocompatibility of Various References Bioceramic Root Canal Sealers: In Vitro Study. J Endod. 2023 Jul;49(7):871-879. doi: 10.1016/j.joen.2023.05.013. Epub 2023 May 22. PMID: 37225037. 46 10.59987/ads/2023.4.43-48 Tugba Turk et al. 15. Jitaru S, Hodisan I, Timis L, Lucian A, Bud M. The use of 20. Rodríguez-Lozano FJ, López-García S, García-Bernal D, bioceramics in endodontics - literature review. Clujul Med. Tomás-Catalá CJ, Santos JM, Llena C, Lozano A, Murcia 2016;89(4):470-473. doi: 10.15386/cjmed-612. Epub 2016 L, Forner L. Chemical composition and bioactivity potential Oct 20. PMID: 27857514; PMCID: PMC5111485. of the new Endosequence BC Sealer formulation HiFlow. 16. Mann A, Zeng Y, Kirkpatrick T, van der Hoeven R, Silva Int Endod J. 2020 Sep;53(9):1216-1228. doi: 10.1111/ R, Letra A, Chaves de Souza L. Evaluation of the Physi- iej.13327. Epub 2020 Jun 18. PMID: 32412113. cochemical and Biological Properties of EndoSequence 21. Badawy RE, Mohamed DA. Evaluation of new bioceramic BC Sealer HiFlow. J Endod. 2022 Jan;48(1):123-131. doi: endodontic sealers: An in vitro study. Dent Med Probl. 2022 10.1016/j.joen.2021.10.001. Epub 2021 Oct 20. PMID: Jan-Mar;59(1):85-92. doi: 10.17219/dmp/133954. PMID: 34678358. 35254010. 17. Abdulsamad Alskaf MK, Achour H, Alzoubi H. The Effect of 22. Chybowski EA, Glickman GN, Patel Y, Fleury A, Solomon E, Bioceramic HiFlow and EndoSequence Bioceramic Seal- He J. Clinical Outcome of Non-Surgical Root Canal Treat- ers on Increasing the Fracture Resistance of Endodonti- ment Using a Single-cone Technique with Endosequence cally Treated Teeth: An In Vitro Study. Cureus. 2022 Dec Bioceramic Sealer: A Retrospective Analysis. J Endod. 2018 28;14(12):e33051. doi: 10.7759/cureus.33051. PMID: Jun;44(6):941-945. doi: 10.1016/j.joen.2018.02.019. Epub 36721549; PMCID: PMC9883056. 2018 Mar 29. Erratum in: J Endod. 2018 Jul;44(7):1199. 18. Yang R, Tian J, Huang X, Lei S, Cai Y, Xu Z, Wei X. A com- PMID: 29606401. parative study of dentinal tubule penetration and the re- 23. Zhou HM, Shen Y, Zheng W, Li L, Zheng YF, Haapasalo M. treatability of EndoSequence BC Sealer HiFlow, iRoot SP, Physical properties of 5 root canal sealers. J Endod. 2013 and AH Plus with different obturation techniques. Clin Oral Oct;39(10):1281-6. doi: 10.1016/j.joen.2013.06.012. Epub Investig. 2021 Jun;25(6):4163-4173. doi: 10.1007/s00784- 2013 Aug 27. PMID: 24041392. 020-03747-x. Epub 2021 Feb 26. PMID: 33638051; PMCID: 24. Camilleri, J., Atmeh, A., Li, X. &amp; Meschi, N. (Present PMC8137581. status and future directions: Hydraulic materials for end- 19. Mann A, Zeng Y, Kirkpatrick T, van der Hoeven R, Silva odontic use. Int Endod J 2022, 55(Suppl. 3): 710–777. R, Letra A, Chaves de Souza L. Evaluation of the Physi- https://doi.org/10.1111/iej.13709 cochemical and Biological Properties of EndoSequence 25. Candeiro GT, Correia FC, Duarte MA, Ribeiro-Siqueira DC, BC Sealer HiFlow. J Endod. 2022 Jan;48(1):123-131. doi: Gavini G. Evaluation of radiopacity, pH, release of calcium 10.1016/j.joen.2021.10.001. Epub 2021 Oct 20. PMID: ions, and flow of a bioceramic root canal sealer. J Endod. 34678358. 2012 Jun;38(6):842-5. doi: 10.1016/j.joen.2012.02.029. 10.59987/ads/2023.4.43-48 47 

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Case report Agenesis of an upper lateral incisor: case report and literature review Irene Cusenza* plan towards an initial orthodontic treatment that dis- Vittorio Pensa* talised the ectopic canine; it was subsequently treated Marta Todaro* endodontically and prosthetically. Once the treatment Luciano Pacifici*** was completed, after informed consent and drug treat- Umberto Manica* ment, implant placement was performed in site 2.2 and Roberto Sgreccia* subsequent prosthesis of the same. Matteo Nagni** Results *Dental School, Università Vita-Salute San Raffaele, Mi- Follow-up at 12 months after functional loading showed lano, Italia e Dipartimento di Odontoiatria, IRCCS Ospe- excellent healing of the patient’s hard and soft tissues dale San Raffaele, Milano, Italia on both intraoral objective examination and radiographic **MSc, Dental School, Vita-Salute San Raffaele Univer- examination. sity, Milan, Italy and Department of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy ***Department of Oral and Maxillofacial Sciences Sa- Conclusions pienza University of Rome, Rome, Italy Agenesis of a tooth element can be treated optimally, with a good prognosis over time, if the clinical approach is multidisciplinary and accompanied by a correct clinical Corresponding author: Pensa Vittorio evaluation of the patient. E-mail: [email protected] Introduction Abstract Dental agenesis is defined as the failure to form a tooth Agenesis is a condition, generally congenital, involv- follicle, which therefore does not lead to the development ing the absence of one or more elements in the arch. It of the element itself [1,2]. The percentage of the popula- can involve both deciduous and permanent dentition, tion affected by agenesis is between 6-10% and there compromising the aesthetics, but also the function, are cases in which this failure to develop affects more of the patient’s dentition. The appropriate clinical ap- than one tooth: in this case, we will speak of multiple proach does not involve the application of a single agenesis [3,4]. The factors that can lead to problems of branch of dentistry, but rather a multidisciplinary ap- this type are divided into internal and external. The fac- proach is essential. tors defined as internal can be associated with genetic disorders, hereditary and/or hormonal imbalances; those Key words: Agenesis, Lateral incisor, Single implants, defined as external can for example be due to trauma, Orthodontic treatment. malnutrition, systemic and/or local infections [5,6]. Agen- esis can affect both milk and definitive teeth and tends to occur in a greater percentage in the lower jaw, bilaterally Purpose affecting the lateral incisors [5]. In the second case, it The present study focuses on agenesis of the upper lat- is important to assess the timing of tooth replacement. eral incisors, in particular of the 2.2 element, by means This is because we must neither be too hasty in giving of a literature review and the description of a case report a diagnosis of agenesis, nor too cautious and risk mak- that aims to propose a possible clinical approach for the ing the problem worse by not intervening. An agenesis, treatment of agenesis of a 2.2. The treatment chosen especially if multiple, can in fact bring various problems was an implant-prosthetic rehabilitation, preceded by to the patient such as problems with occlusion, social orthodontic treatment for the distalisation of the ectopic problems due to incorrect phonetics or aesthetics and 2.3 element. We therefore present the clinical results ob- problems during chewing [7,8,9]. A dentist therefore has tained following the choice of this treatment plan. mainly three paths to follow to remedy this problem. That of the orthodontic approach, aimed at closing the Materials and Methods spaces between the teeth left by the agenesis by means of orthodontic appliances; that of implantology, should Following the objective examination, it was possible to the patient be at a useful age for implantation; and the diagnose agenesis of element 2.2, the seat of which was road of prosthetics, going to replace the missing element occupied by element 2.3. This directed the treatment with mobile solutions suitable even for young patients 10.59987/ads/2023.4.3-7 3  Agenesis of an upper lateral incisor: case report and literature review [9,10,11,12]. The literature also suggests that dental im- 2.3 element. All surgical procedures were carried out in plants are currently a successful therapeutic alternative compliance with the rules laid down in the wake of the that can also be used in patients with systemic diseases Covid-19 pandemic situation, so as to promote patient [13, 14]. and staff safety [18]. Although in some situations the placement of axial im- plants in basal bone may be hindered by insufficient re- CASE REPORT sidual bone height, the placement of fixtures in native bone, when possible, should be preferred [15]. A 29-year-old female patient, a smoker, came to the De- The choice of fixture type and prosthetic mode can in- partment of Dentistry of the IRCCS San Raffaele Hospi- fluence implant success in the short and long term; it tal in Milan with the aim of improving the aesthetics of the follows that pre-surgical planning is a key point of reha- anterior sector of her smile. A clinical and radiographic bilitation [16, 17]. examination was then performed (Figure 1,2) from which The present study focuses on agenesis of the upper lat- multiple agenesis was revealed. Specifically, this clinical eral incisors, in particular of the 2.2 element, by means case deals with the rehabilitation of the agenesis of ele- of a literature review and the description of a case report ment 2.2. that aims to propose a possible clinical approach for the The case evaluation also revealed that tooth 23 was in treatment of agenesis of a 2.2. The treatment chosen a mesial position compared to its usual position, which was an implant-prosthetic rehabilitation, preceded by caused a reduction of the arch space between elements orthodontic treatment for the distalisation of the ectopic 2.1 and 2.3. Figure 1. Pre-operative orthopantomography. Figure 2. Intra-oral photo. 4 10.59987/ads/2023.4.3-7 I. Cusenza et al. It was proposed to the patient to perform an orthodontic Biosafin, Ancona, Italy) with open technique (figure 4-5). correction, distalising tooth 23 and thus creating space The previously raised flap was then repositioned and for the subsequent implant-prosthetic rehabilitation adjusted with 4-0 non-resorbable suture (Vicryl; Ethicon, of the edentulous site. The first phase of treatment in- Johnson & Johnson, New Brunswick, NJ, USA). volved orthodontic therapy in order to distalise element After surgery, the patient was prescribed post-surgical 2.3 which, due to agenesis, had occupied the site of ele- drug therapy including: Medrol 0.16 mg (1\2 two days ment 2.2. Once the orthodontic treatment was complet- after surgery and 1\4 three days after surgery) and Tora ed, it was possible to obtain the necessary space for an Dol drops 20 ml (25 drops as needed). Finally, the pa- implant-prosthetic rehabilitation of element 2.2. The sec- tient was advised to avoid any brushing trauma at the ond phase of treatment included endodontic treatment surgical site as well as smoking. After one week, the pa- of element 2.3, which was subsequently prosthetised by tient underwent a follow-up examination and at the same performing a prosthetic preparation with modified cham- time the sutures were removed. fer (Figure 3). Approximately six months after surgery, in order to After this procedure was completed, it was decided achieve complete healing of the tissues and proper to schedule surgery for the insertion of the endosse- osseointegration of the implant, a definitive prosthetic ous implant. Before starting surgery, the following drug crown could be inserted. therapy was prescribed: Levoxacin 500 mg (1 per day for 10 days to be started the day before surgery) and Medrol 0.16 mg (1 tablet the morning of surgery). The FOLLOW-UP surgical phase was performed under local anaesthesia The patient was placed in a follow-up program to moni- (Optocaine 20 mg/ml with adrenaline 1:80,000; Molteni tor hard and soft tissue healing following implant place- Dental, Florence, Italy). ment. The patient was monitored one week after implant It then proceeded with implant insertion, in site 2.2, TTSI placement, then after 6 and 12 months. Meanwhile, the Winsix 2.9 mm diameter x 11 mm length (TTx, Winsix, patient was instructed in home oral hygiene manoeuvres in order to maintain proper implant health. The home oral hygiene sessions were flanked by quarterly, and then six-monthly, professional oral hygiene sessions. Home and professional hygiene maintenance is one of the main prerequisites for implant success [19, 20] RESULTS The patient was then reassessed at a follow-up of ap- proximately 12 months after functional prosthetic loading (Figure 6). The radiographic evaluation was performed by taking an endoral radiograph from which a correct im- plant osseointegration was revealed (Figure 7). On the other hand, the healing of the peri-implant soft tissues was assessed by means of an intraoral clinical examina- Figure 3. Prosthetic preparation of the modified chamfer tion, from which it was inferred that they had excellent osseointegration. Figure 4 e 5. Implant placement. 10.59987/ads/2023.4.3-7 5  Agenesis of an upper lateral incisor: case report and literature review coordination between the orthodontist and oral surgeon, in collaboration with the restorative dentist and periodon- tist [22]. Among the various treatment options, implants seem to be the best therapeutic solution as they are more pre- dictable than traditional prosthetic solutions such as bridges over natural teeth or adhesive bridges such as Maryland [2,9,11]. Although the clinical case presented itself with a need for prosthetic rehabilitation related to tooth 23, with a view to a correct diagnosis, preservation of tooth substance and an aesthetically performing rehabilitation, in this rare case we proceeded with the rehabilitation of tooth 22 with an implant-prosthetic solution. A correct diagnosis and an appropriate treatment strat- egy for these rare conditions are mandatory to prevent future complications. Furthermore, this rare case could contribute to future studies on the incidence of agenesis Figure 6. Prosthetic finalisation. of lateral incisors in cases already treated prosthetically. In conclusion, implants appear to be an excellent thera- peutic option for the rehabilitation of agenesis in aesthet- ic areas provided the clinical conditions are favourable. Indeed, it is necessary that the bone thickness and qual- ity, as well as the tissue phenotype, are adequate. CONCLUSION The Authors of this paper agree that implant-prosthetic rehabilitation of one or more agenesis in aesthetic ar- eas can be an excellent treatment option provided the patient’s clinical condition is favourable. This predictable and safe procedure will allow the restoration of adequate masticatory function. References 1. Citak M, Cakici EB, Benkli YA, Cakici F, Bektas B, Buyuk SK. Dental anomalies in an orthodontic patient popula- tion with maxillary lateral incisor agenesis. Dental Press J Orthod. 2016 Nov-Dec;21(6):98-102. doi: 10.1590/2177- Figure 7. Rx - endoral performed at 12 months follow-up 6709.21.6.098-102.oar. 2. Neagu, David; Casal-Beloy, Isabel; Luaces Rey, Ramón; López-Cedrún, José Luis. Agenesia dental ISSN: 1695- 4033 , 1695-9531; DOI: 10.1016/j.anpedi.2019.03.002 3. Bassiouny DS, Afify AR, Baeshen HA, Birkhed D, Zawawi KH. Prevalence of maxillary lateral incisor agenesis and DISCUSSION associated skeletal characteristics in an orthodontic patient population. Acta Odontol Scand. 2016 Aug;74(6):456-9. doi :10.1080/00016357.2016.1193625. Epub 2016 Jun 16. Dental agenesis is a number anomaly due to the failure 4. De Santis D, Pancera P, Sinigaglia S, Faccioni P, Albanese of one or more dental elements to form a dental folli- M, Bertossi D, Luciano U, Zotti F, Matarese M, Lucchese cle [6]. Despite the extreme prevalence of this malfor- A, Croce S, Donadello D, Ricciardi G, Kumar N, Nocini R, mation, the aetiology remains undetermined, although Nocini P F. Tooth agenesis: part 1. Incidence and diagno- both environmental and genetic factors are believed to sis in orthodontics. J Biol Regul Homeost Agents. 2019 be at the root [4,5,21]. Possible environmental causes Jan-Feb;33(Suppl 1):19-22. 5. Brook AH. A unifying aetiological explanation for anom- include trauma, radiotherapy and chemotherapy, as well alies of human tooth number and size. Arch Oral Biol. as osteomyelitis, hormonal and metabolic influences. 1984;29(5):373-8. doi: 10.1016/0003-9969(84)90163-8. The diagnostic phase in the first place, and then correct 6. Choi, Soo Ji; Lee, Je Woo; Song, Ji Hyun. Dental anomaly treatment planning in agreement with the patient, are ex- patterns associated with tooth agenesis ISSN: 0001-6357, tremely important, as the therapeutic solutions chosen 1502-3850; DOI: 10.1080/00016357.2016.1273385; and subsequently implemented may focus on several 7. Fujiwara T, Nakano K, Sobue S, Ooshima T. Simultaneous occurrence of unusual odontodysplasia and oligodontia possible options. in the permanent dentition: report of a case. Int J Pae- In accordance with the literature, it can be stated that diatr Dent. 2000 Dec;10(4):341-7. doi: 10.1046/j.1365- successful and satisfactory dental treatment is always 263x.2000.00217.x. the goal of the patient and the dentist, which means that 8. Kavadia S, Papadiochou S, Papadiochos I, Zafiriadis L. the patient’s needs are resolved in a functional and aes- Agenesis of maxillary lateral incisors: a global overview thetic manner. Optimal results require multidisciplinary of the clinical problem. Orthodontics (Chic.). 2011 Win- ter;12(4):296-317. 6 10.59987/ads/2023.4.3-7 I. Cusenza et al. 9. Richardson G, Russell KA. Congenitally missing maxillary restorations. Journal of Osseointegration, 10(4), 130-135. lateral incisors and orthodontic treatment considerations doi:10.23805/JO.2018.10.04.04. for the single-tooth implant. J Can Dent Assoc. 2001 17. Gherlone, E. F., Capparé, P., Pasciuta, R., Grusovin, M. Jan;67(1):25-8. G., Mancini, N., & Burioni, R. (2016). Evaluation of re- 10. De Santis D, Pancera P, Sinigaglia S, Faccioni P, Bertossi sistance against bacterial microleakage of a new conical D, Luciano U, Zotti F, Kumar N, Donadello D, Manuelli M, implant-abutment connection versus conventional connec- Lucchese A, Tacchino U, Ricciardi G, Nocini R, Albanese tions: An in vitro study. New Microbiologica, 39(1), 59-66. M. Tooth agenesis: part 2. Orthodontic treatment and pros- 18. Capparè, P., D’ambrosio, R., De Cunto, R., Darvizeh, A., thetic possibilities. J Biol Regul Homeost Agents. 2019 Jan- Nagni, M., & Gherlone, E. (2022). The usage of an air Feb;33(1 Suppl. 1):23-28. purifier device with HEPA 14 filter during dental proce- 11. Kinzer GA, Kokich VO Jr. Managing congenitally missing dures in COVID-19 pandemic: A randomized clinical tri- lateral incisors. Part III: single-tooth implants. J Esthet al. International Journal of Environmental Research and Restor Dent. 2005;17(4):202-10. doi: 10.1111/j.1708- Public Health, 19(9) doi:10.3390/ijerph19095139. 8240.2005.tb00116.x. 19. Tecco, S., Grusovin, M. G., Sciara, S., Bova, F., Pantaleo, 12. Sabri R. Management of missing maxillary lateral incisors. G., & Capparé, P. (2018). The association between three J Am Dent Assoc. 1999 Jan;130(1):80-4. doi: 10.14219/ attitude-related indexes of oral hygiene and secondary im- jada.archive.1999.0032. plant failures: A retrospective longitudinal study. Internatio- 13. D’Orto, B.; Polizzi, E.; Nagni, M.; Tetè, G.; Capparè, P. Full nal Journal of Dental Hygiene, 16(3), 372-379. doi:10.1111/ Arch Implant-Prosthetic Rehabilitation in Patients with Type idh.12300. I Diabetes Mellitus: Retrospective Clinical Study with 10 20. Cattoni, F., Tetè, G., D’orto, B., Bergamaschi, A., Polizzi, Year Follow-Up. Int. J. Environ. Res. Public Health2022, 19, E., & Gastaldi, G. (2021). Comparison of hygiene levels in 11735. https://doi.org/10.3390/ijerph191811735. metal-ceramic and stratified zirconia in prosthetic rehabili- 14. Tetè, G., Polizzi, E., D’orto, B., Carinci, G., & Capparè, P. tation on teeth and implants: A retrospective clinical study (2021). How to consider implant-prosthetic rehabilitation in of a three-year follow-up. Journal of Biological Regulators elderly patients: A narrative review. Journal of Biological and Homeostatic Agents, 35(4), 41-49. doi:10.23812/21- Regulators and Homeostatic Agents, 35(4), 119-126. 4supp1-4. doi:10.23812/21-4supp1-11. 21. Arte S, Nieminen P, Pirinen S, Thesleff I, Peltonen L. Gene 15. Gherlone, E. F., D’Orto, B., Nagni, M., Capparè, P., & Raffa- defect in hypodontia: exclusion of EGF, EGFR, and FGF-3 ele, V. (2022). Tilted implants and sinus floor elevation tech- as candidate genes. J Dent Res. 1996 Jun;75(6):1346-52. niques compared in posterior edentulous maxilla: A retro- doi: 10.1177/00220345960750060401. spective clinical study over four years of follow-up. Applied 22. Krassnig M, Fickl S. Congenitally missing lateral incisors--a Sciences (Switzerland), 12(13) doi:10.3390/app12136729. comparison between restorative, implant, and orthodontic 16. Ferrari Cagidiaco, E., Carboncini, F., Parrini, S., Doldo, approaches. Dent Clin North Am. 2011 Apr;55(2):283-99, T., Nagni, M., Nuti, N., & Ferrari, M. (2018). Function- viii. doi: 10.1016/j.cden.2011.01.004. Epub 2011 Mar 9. al implant prosthodontic score of a one-year prospective study on three different connections for single-implant 10.59987/ads/2023.4.3-7 7 

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Case report A comparative analysis of mechanical properties of different reciprocating Niti endodontic instruments Maya Feghali* and WaveOne Gold) which were all significantly Alaa Al Daeen Al Atta** more resistant than Reciproc. Flexibility of Direct R Massimo Galli*** Gold and Reciproc was significantly lower than the other tested instruments. *Private practictioner, Paris, France Since the tip and taper dimensions are almost the **Private practictioner, Unit Arab Emirates same for every instrument tested, and since the ***University of Rome, La Sapienza Direct R gold has the same cross-sectional design as Reciproc and Reciproc Blue, the explanation of Corresponding author: Massimo Galli massimo. these results must be due to the proprietary ther- [email protected] mal treatments of the instruments. Direct R-Gold heat treatment allowed a significant increase in Key words: Endodontic instrument, Nickel-titanium, both torsional and fatigue resistance, which is a reciprocation clinically relevant advantage in a single-file tech- nique where only one instrument is used and, as a consequence, it is subjected to all instrumentation Abstract stresses. Despite it is not questionable that static tests give Introduction readers only a partial view of the performance of an endodontic instrument they are currently accepted The goal of any endodontic therapy is to obtain a che- as valid ones to evaluate and compare mechanical mo-mechanical disinfection and debridement of the root properties of endodontic instruments. canal, by proper shaping and cleaning procedures, and Therefore, aim of the present study was to evaluate to obtain a stable apical and coronal sealing, to avoid a new single-file reciprocating instrument (Direct R- the re-infection of the root canal system (1-2). These Gold 25, Direct Endo, Paris, France) and compare objectives were indicated many decades ago and are by using the three above-mentioned tests them still valid; on the contrary the way they are reached with the same features of other reciprocating in- drastically changed with the introduction of Nickel-Tita- struments which have been commercialized since nium (NiTi) rotary instruments, which completely revo- many years and consequently have been widely lutionized the root canal treatment (RCT). NiTi rotary investigated: Wave One Gold Primary (Dentsply- files increased the predictability, speediness, and effec- Maillefer, Baillagues, Switzerland), Reciproc and tiveness of the RCT, due to the improved properties of the Reciproc Blue (VDW, Munchen, Germany). the alloy (3). Moreover, in the last decade new thermal For each of the four tested instruments (in size 25) treatments have been developed to improve flexibility 60 instruments were selected and randomly divided and fatigue resistance of the instruments, resulting in a into three groups (n=20). Each group was subjected differentiation between heat-treated (HT) and non heat- to a different in vitro mechanical test. Prior to test, treated (NHT) instruments, with the first type of instru- each instrument was carefully examinated under ments being pre-bendable and showing less bounce magnification. Instruments with visible defects and back (4). All these improvements currently allow a more flute deformation were discarded. Stiffness, cyclic efficient and safe instrumentation of curved canals. fatigue, torsional resistance tests were performed Another important improvement in the shaping proce- using methodologies validated in previous studies. dure has been the introduction of the reciprocating mo- For each test data were recorded, then the mean tion (RM). The idea was to simplify shaping by using a values and the standard deviations were statisti- single-file technique, while keeping safety, thanks to a cally analyzed using a 1-way ANOVA test followed motion which is less stressful than continuous rotation, by the post hoc Tukey test with significance set to a because the instruments is not continuously engaged, 95% confidence level. but works by alternating engagement and disengage- Results showed that Direct R Gold was significantly ment of the blades (5). more resistant in terms of torsional resistance when RM has been defined as a repeated backward and for- compared with all the other instruments. In terms ward (CW/CCW) movement; this kind of cinematic can of cyclic fatigue resistance no statistically relevant be applied to every endodontic file. There are many differences were found amongst the three thermally kinds of RM: treated instruments (Direct R Gold, Reciproc Blue - complete reciprocation (oscillation), 10.59987/ads/2023.4.9-13 9  A comparative analysis of mechanical properties of different reciprocating Niti endodontic instruments - partial reciprocation (rotational effect), three groups (n=20). Each group was subjected to a dif- - hybrid reciprocation (combined movements). ferent in vitro mechanical test, according to the current According to the review of the literature of Grande &Plo- dental literature. Prior to test, each instrument was care- tino (6-7) it can be stated the reciprocating motion en- fully examinated under magnification. Instruments with hance the metallurgical in vitro performances of the NiTi visible defects and flute deformation were discarded. files without significantly affecting in any way the cutting efficiency of the same files. These undoubtfully advantages has brought the manu- Bending Resistance (Stiffeness) Test facturer to produce new endodontic motors and a lot of Twenty instruments for each brand underwent the bend- different instruments thought to be used in counterclock- ing resistance test (Fig. 1a). The stiffness tests were per- wise reciprocating motion. Whenever a new NiTi instru- formed using a device already validated in a previously ment is released on the market, it is important to evalu- published study (10). The device consists of a load cell, ate the file characteristics and compare to similar files an electronic display, and a mobile holder to allow re- already present on the market. Indeed, it is well known peatable positioning of the instruments on the load cell. the influence of each characteristic on a particular per- The stiffness tests were performed by bending each file formance of the NiTi rotary file (6-7). To be more precise, at a 45° angle at 3 mm from its tip and recording the ap- the cyclic fatigue is influenced by two main characteris- plied force (g). The higher the value, stiffer (less flexible) tics: the metal mass at the point of maximum stress and the instrument. The measurements indicated by the elec- the percentage of martensite. Lower the mass, higher tronic display connected to the load cell were recorded, the cyclic fatigue resistance and higher the martens- and then the mean values and the standard deviations ite percentage, higher the cyclic fatigue resistance as of the bending force were statistically analyzed using a well. Similarly, the bending properties on the file are 1-way ANOVA test followed by the post hoc Tukey test influenced in the same way as the cyclic fatigue resis- with significance set to a 95% confidence level. tance. The torsional resistance is instead influenced mainly by the cross-sectional design and specifically by the distribution of the mass around the rotation cen- Cyclic Fatigue Test ter of the file. The greater the mass gathered far from the rotation center, the greater is the torque to fracture. Twenty instruments for each brand were rotated accord- On the other hand, several studies demonstrate that ing to the manufacturers’ recommendation in a stainless- the martensite percentage, does not or negatively af- steel artificial canal of 16 mm characterized by a 90° fect the torsional resistance (8). Finally, the cutting ef- angle of curvature and a 2-mm radius of curvature using ficiency has been demonstrated depending mainly on glycerin as a lubricant to avoid any friction between the the cross-sectional, tip and flute design. The s shaped files and the artificial canal (Fig. 1b). Resulting speed cross section is the most cutting efficient, as demon- was always same (300 rpm). Each test was performed strated by Plotino et al (7). by the same expert operator to avoid error due to differ- Therefore, the influence of each single characteristic ent operators’ skill. Each instrument reciprocated inside of a file is well-known from the literature, despite that the canal until a visible and/or audible sign of fracture the performance of a file is influenced by the interaction was detected (11-12). The time to fracture (TtF) was between all these different factors and this result is still measured using a digital chronometer with a sensitivity impossible to predict. of 0.01 seconds. The higher the value the more resistant Despite it is not questionable that static tests give readers the instrument. only a partial view of the performance of a new instru- The length of the fragments (FL) was measured with a ment (8), it is likewise not questionable that the scientific digital caliber and statistically analyzed to evaluate the method is based on repeatable and comparable studies, correct positioning of the instruments inside the artificial and nowadays these kinds of parameters can only by ob- canal (13) and to verify the comparability of the results of tained using the static test used. Therefore, it is possible the cyclic fatigue test. only using the cyclic fatigue, bending and torsional resis- The mean values and the standard deviations of both tance tests. This comparison could help the general den- TtF and FL were statistically analyzed using a 1-way tist as well as the endodontists, who undoubtfully already ANOVA test followed by the post hoc Tukey test with sig- knows the other instruments tested, to preliminary evalu- nificance set to a 95% confidence level. ate the potential performances of the newly released one. Therefore, aim of the present study was to evaluate Torsional Resistance Test the stiffness, the cyclic fatigue and torsional resistance of a new (9) single-file reciprocating instrument (Di- Twenty instruments for each brand underwent the tor- rect R-Gold, Direct Endo, Paris, France) and compare sional resistance test ((Fig. 1c). The torsional resistance them with the same features of other reciprocating in- test was performed with a custom-made torsiometer-like struments which have been commercialized since many device previously validated in a published study at 300 years and consequently have been widely investigated : rpm in counterclockwise reciprocating motion because it Wave One Gold Primary (Dentsply-Maillefer, Baillagues, has been demonstrated that rotational speed does not Switzerland), Reciproc and the Reciproc Blue (VDW, affect the results (8,14). The device was used to avoid Munchen, Germany). the bending of the coronal part of the instrument and to have a straight angle of insertion because it has been demonstrated in recently published studies that it can Materials and Methods deeply influence the result of the torsional test. Precisely, For each of the four tested instruments (in size 25 ) sixty the test was performed blocking the tip of the instrument instruments were selected and randomly divided into with a vise at 3 mm from the tip and rotating it at 300 10 10.59987/ads/2023.4.9-13 M. Feghali et al. Figure 1. The three tests : A. Stiffness. B Fatigue resistance C Torsional resistance rpm in the counterclockwise direction with a dedicated cantly more resistant than Reciproc. Flexibility of Direct electronic motor (Kavo, Biberach, Germany) allowing R Gold and Reciproc was significantly lower than the a real-time (0.1 seconds) recording of the torque with other tested instruments. a sensitivity of 0.05 Ncm. The torque at fracture results were collected on a spreadsheet. The higher the value Discussion the more resistant the instrument. The length of the fragments (FL) was measured with a In the current study, a three methods approach was digital caliber and statistically analyzed to evaluate the performed to compare Direct R-Gold, a new HT recip- correct positioning of the instruments’ tip inside the tor- rocating NiTi file recently introduced on the market and designed to be used in a single-file technique with the siometer and to verify the comparability of the results of most commonly used and tested single-file reciprocat- the torsional test. The mean values and the standard ing instruments commercially available. The instruments deviations of both FL and the torque at fracture were tested in this study share some characteristics such as statistically analyzed using 1-way ANOVA followed by the taper and the tip dimensions, 0.25mm for all of them the post hoc Tukey test with significance set to a 95% and the shaping technique. Indeed, each of the tested confidence level. file is thought to be used in a CCW reciprocating single- file technique. Moreover, the Direct R Gold presents Results a s-shaped cross-sectional design, which is the same Results are shown in Table 1. Direct R showed the best design as the Reciproc and Reciproc Blue instruments mechanical performance in terms of torsional resistance (5). According to the manufacturer (9), the Direct R Gold with statistically significant difference with all the other instruments undergo a proprietary treatment, but at the instruments. In terms of cyclic fatigue resistance no sta- moment no published study on this kind of treatment is tistically relevant differences were found amongst the present in literature, while many studies are available for three thermally treated instruments (Direct R Gold, Re- the other two HT instruments . It must be underlined that ciproc Blue and WaveOne Gold) which were all signifi- HT are not disclosed by manufacturers and it has been Table 1. Mean values and SD of Stiffness, Cyclic Fatigue and Torsional Resistance tests of the four instruments tested (significant difference *) Direct R Gold Reciproc Reciproc Blue Wave One Gold Mean SD Mean SD Mean SD Mean SD Stiffness (g) 146.3 11.0 157.2 8.3 82.2* 3.2 88.5* 12.01 Cyclic fatigue (s) 12.8 0.5 9.27* 1.18 13.31 1.26 11.98 1.20 Torsional resistance (Ncm) 1.54* 0.12 0.66 0.08 0.52 0.07 0.46 0.09 10.59987/ads/2023.4.9-13 11  A comparative analysis of mechanical properties of different reciprocating Niti endodontic instruments demonstrated that they are different from each manu- the absence of dynamic investigations, such as cutting facturer, and consequently these differences may result efficiency (16), shaping ability, centering ability. in different mechanical in vitro properties and clinical Hence we may conclude that, despite the clinical rele- performance (8). vance of in vitro studies can be doubtful, the importance Therefore, despite similarities in design and method of of understanding the in vitro performances of new in- use, comparative tests are needed when new instru- struments introduced on the market is undoubtedly (8). ments with new HTs are commercialized to compare The evaluation of different in vitro characteristics, such their performances with the mostly known competitor as flexibility, cyclic fatigue and torsional resistance and instruments (15). comparison with widespread file could give provide im- Reciproc and Reciproc Blue are instruments from VDW portant preliminar data on the quality positioning of new designed for be used in CCW reciprocating single-file products and possible advantages in clinical practice technique (4,5). The two instruments shares every design characteristic (tip 0.25 and taper 0.08 variable and present an S-shaped cross-sectional design) but References differ from for the heat treatment of the alloy; Recip- 1. Valenti-Obino F, Di Nardo D, Quero L, Miccoli G, Gam- roc presents M-Wire heat treatment, containing the barini G, Testarelli L, Galli M. Symmetry of root and root austenite phase with small amounts of martensite and canal morphology of mandibular incisors: A cone-beam R-phase at body temperature, and the Reciproc Blue computed tomography study in vivo. J Clin Exp Dent. 2019 Jun 1;11(6):e527-e533. doi: 10.4317/jced.55629. PMID: alloy is the Blue Wire, which is characterized by lower 31346372; PMCID: PMC6645266. transformation temperatures but a greater amount of 2. Gambarini G, Testarelli L, Pongione G, Gerosa R, Gagliani stable martensite than M-Wire, leading to softer and M. Radiographic and rheological properties of a new en- more ductile NiTi files. As previously mentioned, the dif- dodontic sealer. Aust Endod J. 2006 Apr;32(1):31-4. doi: ferent thermal treatment of the alloys can explain the 10.1111/j.1747-4477.2006.00005.x. PMID: 16603043. differences in the results of the mechanical tests of the 3. Gambarini G, Miccoli G, Seracchiani M, Morese A, Piasecki L, Gaimari G, Di Nardo D, Testarelli L. Fatigue Resistance of two instruments. In fact, according to the results of the New and Used Nickel-Titanium Rotary Instruments: a Com- present study, Reciproc showed lower flexibility and parative Study. Clin Ter. 2018 May-Jun;169(3):e96-e101. cyclic fatigue resistance than Reciproc Blue, whereas doi: 10.7417/T.2018.2061. PMID: 29938739. the latter showed lower torsional resistance than the 4. Plotino G, Grande NM, Testarelli L, Gambarini G, Castagno- former. Wave One Gold is a thermally treated (single la R, Rossetti A, Özyürek T, Cordaro M, Fortunato L. Cyclic file system) CCW reciprocating instrument designed by Fatigue of Reciproc and Reciproc Blue Nickel-titanium Reciprocating Files at Different Environmental Temperatu- Dentsply Maillefer. The primary file, tested in the cur- res. J Endod. 2018 Oct;44(10):1549-1552. doi: 10.1016/j. rent study, is 25.08 with a rectangular cross-sectional joen.2018.06.006. Epub 2018 Aug 23. PMID: 30 design and a proprietary heat treatment, the Gold Wire. 5. Plotino G, Giansiracusa Rubini A, Grande NM, Testarelli L, The dimensions are similar to the other instruments, Gambarini G. Cutting efficiency of Reciproc and waveOne but design and HT are significantly different. reciprocating instruments. J Endod 2014;40:1228–30. ht- The results of the current study showed that the behavior tps://doi.org/10.1016/j.joen.2014.01.041. 6. Grande NM, Ahmed HMA, Cohen S, Bukiet F, Plotino G. of the new instrument is slightly different from the old Current Assessment of Reciprocation in Endodontic Prepa- ones. Despite being heat-treated Direct R Gold pres- ration: A Comprehensive Review-Part I: Historic Perspecti- ents stiffness similar to the NHT Reciproc, while the HT ves and Current Applications. J Endod 2015;41:1778–83. Reciproc Blue and WaveOneGold showed significantly https://doi.org/10.1016/j.joen.2015.06.014. more flexibility. On the contrary results of the cyclic fa- 7. Plotino G, Ahmed HMA, Grande NM, Cohen S, Bukiet F. tigue tests showed no difference in terms of cyclic fa- Current Assessment of Reciprocation in Endodontic Prepa- ration: A Comprehensive Review - Part II: Properties and tigue lifespan between the Direct R Gold and the other Effectiveness. Journal of Endodontics 2015;41:1939–50. two thermally treated reciprocating instruments (HT Re- https://doi.org/10.1016/j.joen.2015.08.018. ciproc Blue and WaveOneGold), while NHT Reciproc 8. Zanza, A.; D’Angelo, M.; Reda, R.; Gambarini, G.; Testa- showed the smallest fatigue resistance. Moreover, the relli, L.; Di Nardo, D. An Update on Nickel-Titanium Rotary resistance to torsional stress was higher for Direct R Instruments in Endodontics: Mechanical Characteristics, Gold than for any other tested instruments, while NHT Testing and Future Perspective—An Overview. Bioengi- neering 2021, 8, 218. https://doi.org/10.3390/bioenginee- Reciproc was found to be significantly more resistant ring8120218 than HT Reciproc Blue and WaveOneGold. 9. DIRECT-R GOLD. Available at: https://www.directendo. Since the tip and taper dimensions are almost the same com/Product/direct-r-gold. Accessed December 9, 2023, for every instrument tested, and since the Direct R gold n.d. has the same cross-sectional design as Reciproc and 10. Testarelli L, Plotino G, Al-Sudani D, Vincenzi V, Giansira- Reciproc Blue, the explanation of these results must cusa A, Grande NM, Gambarini G. Bending properties of a new nickel-titanium alloy with a lower percent by weight be due to the proprietary thermal treatments of the in- of nickel. J Endod. 2011 Sep;37(9):1293-5. doi: 10.1016/j. struments. Direct R-Gold heat treatment allowed a sig- joen.2011.05.023. Epub 2011 Jul 16. Erratum in: J Endod. nificant increase in both torsional and fatigue resistance, 2014 Dec;40(12):2086. PMID: 21846552. which is a clinically relevant advantage in a single-file 11. Gambarini G, Miccoli G, Seracchiani M, Khrenova T, Don- technique where only one instrument is used and, as francesco O, D’Angelo M, Galli M, Di Nardo D, Testarelli L. a consequence, it is subjected to all instrumentation Role of the Flat-Designed Surface in Improving the Cyclic Fatigue Resistance of Endodontic NiTi Rotary Instruments. stresses. Materials (Basel). 2019 Aug 8;12(16):2523. doi: 10.3390/ However, to better understand the thermal treatments, ma12162523. PMID: 31398814; PMCID: PMC6720207. the martensitic and austenitic composition of the new 12. Plotino G, Grande NM, Mazza C, Petrovic R, Testarelli L, instruments other studies like a Differential Scanning Gambarini G. Influence of size and taper of artificial canals Calorimetry could be performed in the next future. More- on the trajectory of NiTi rotary instruments in cyclic fatigue over it must be kept in mind another drawback could be studies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 12 10.59987/ads/2023.4.9-13 M. Feghali et al. 2010 Jan;109(1):e60-6. doi: 10.1016/j.tripleo.2009.08.009. 15. Gambarini G, Galli M, Di Nardo D, Seracchiani M, Donfran- Epub 2009 Nov 17. PMID: 19926504 cesco O, Testarelli L. Differences in cyclic fatigue lifespan 13. Gambarini G, Miccoli G, Seracchiani M, Morese A, Piasecki between two different heat treated NiTi endodontic rotary L, Gaimari G, Di Nardo D, Testarelli L. Fatigue Resistance of instruments: WaveOne Gold vs EdgeOne Fire. J Clin Exp New and Used Nickel-Titanium Rotary Instruments: a Com- Dent. 2019 Jul 1;11(7):e609-e613. doi: 10.4317/jced.55839. parative Study. Clin Ter. 2018 May-Jun;169(3):e96-e101. PMID: 31516658; PMCID: PMC6731004. doi: 10.7417/T.2018.2061. PMID: 29938739. 16. Giansiracusa Rubini A, Plotino G, Al-Sudani D, Grande NM, 14. Zanza A, Seracchiani M, Di Nardo D, Reda R, Gambarini Sonnino G, Putorti E, Cotti E, Testarelli L, Gambarini G. A G, Testarelli L. A Paradigm Shift for Torsional Stiffness of new device to test cutting efficiency of mechanical endo- Nickel-Titanium Rotary Instruments: A Finite Element Analy- dontic instruments. Med Sci Monit. 2014 Mar 6;20:374-8. sis. J Endod. 2021 Jul;47(7):1149-1156. doi: 10.1016/j. doi: 10.12659/MSM.890119. PMID: 24603777; PMCID: joen.2021.04.017. Epub 2021 Apr 27. PMID: 33915175. PMC3948890. 10.59987/ads/2023.4.9-13 13 

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Case report Analgesic drugs in dentistry: a narrative review Bianca D’Orto* experience associated with actual or potential tissue Carmen Baldi* damage”. Vanessa Bonafede* Depending on the pathogenesis, pain can be classified Andrea Pacifici° into four main categories: Imma Ianniceli* 1. nociceptive, transient pain in response to a peripheral Matteo Nagni* stimulation. 2. inflammatory, instantaneous pain related to a painful * Dental School, Vita-Salute San Raffaele University, Mi- hypersensitivity resulting from inflammatory tissue lan, Italy and Department of Dentistry, IRCCS San Raf- damage. Depending on the site involved, it is subdi- faele Hospital, Milan, Italy vided into: °Libero Professionista PhD Sapienza University of • superficial somatic (skin or mucous membranes) Rome, Rome, Italy. • deep somatic (muscles, bones, joints) • visceral (internal viscera) 3. neuropathic, pain occurring in the peripheral or central nervous system, in the absence of a nociceptive insult. Abstract 4. psychogenic, pain caused by an abnormal interpreta- Pre- and post-operative pain are among the most dif- tion of perceptual messages, in the absence of verifi- ficult problems to manage in dental practice. There able damage to the nervous system. are various factors that could influence these condi- tions: from the patient’s susceptibility to the clinical Biochemical basis of dental pain practice performed. However, an adequate manage- ment of both allows to considerably improve the Dental pain is predominantly inflammatory and is caused patient’s compliance and, at the same time, the sat- by the release of chemical mediators from tissue cells, isfaction of the latter. All articles and reviews consid- mediators that are referred to as ‘prostanoids’. ered in this brief review, were searched on the online This category of chemical mediators, which includes a platform of scientific reading sites such as PubMed whole series of molecules such as histamine, bradykinin, and Medline, selecting the most current ones, up to thromboxane A2, prostaglandins (PGE2, PGD2, PGF2α), January 2022. Considering the keywords “Analgesic and substance P, is capable of overcoming cell mem- drugs”, “dentistry” AND “dental pain”, randomized brane defences so that it can interact with specific high- controlled trials (RCTs), prospective studies, obser- affinity protein receptors located at nerve endings (with a vational studies, reviews, and retrospective studies greater prevalence in C a-myelin fibres). were considered. As a result of trauma and surgery, prostanoids are re- The aim of this narrative review is to describe the leased into soft tissue, hard and connective tissue. several therapeutic techniques allowed to reduction Histamine, bradykinin and substance P sensitise nerve of pre- and post-operative pain during clinical dental endings, leading to oedema formation during the early practice, so as to be able to outline in a linear and stages of inflammation; prostaglandins, on the other concise way some brief clinical guidelines that can hand, protract pain sensation. Thus, it can be argued be easily consulted. that the main contributors to primary hyperalgesia (i.e. an increased response to a painful stimulus) are pros- tanoids, fatty acids derived from arachidonic acid, a Keywords: analgesic drugs, dentistry, dental pain, constituent part of membrane phospholipids. Phospho- drug-kinetics, drug-dynamics. lipase A2, after being released from membranes follow- ing trauma, converts arachidonic acid into PGH2, which leads to the release of prostanoids through the activity INTRODUCTION of a particular enzyme, COX-2 (type 2 cyclooxygenase). COX-2 is inhibited non-selectively by non-steroidal anal- Pre- and post-operative pain management appears to be gesic drugs (NSAIDs). one of the main issues that dentists have to deal with in their daily practice. To undergo dental treatment without WHO Analgesic Scale pain is the patient’s main wish. IASP (international association for the study of pain) However, pain is generally identified as a subjective no- defined pain as “an unpleasant sensory and emotional ciceptive sensation, which is why it is not easy for the 10.59987/ads/2023.4.23-29 23  Analgesic drugs in dentistry: a narrative review clinician to quantify and localise the pain stimulus. To Corticosteroids this end, the WHO has developed an analgesic pain Corticosteroids, also called cortico-adrenal hormones or scale, which is a classification of pain from one to ten corticoids, are a group of steroid hormones synthesised according to the nociceptive sensation experienced by in the cortical of the adrenal gland. They can be divided the patient, where one is the minimum pain and ten is into three categories: glucocorticoids, mineralocorticoids the maximum pain. It is a very useful and validated scale and sex hormones. and represents a guideline for pain therapy in dentistry. Corticosteroids cause important anti-inflammatory ef- Thus, the choice of drug will be related to the mecha- fects mainly through a reduction in capillary perme- nism of action and the potency of the pain. ability. The anti-inflammatory effect of glucocorticoids Analgesics are more effective in preventing the onset of (cortisol, prednisone, etc.) is mostly mediated by an pain than in relieving existing pain, as long as they are inhibition of the transcription of genes that regulate the administered regularly. production of most inflammatory cytokines and type 2 cyclo-oxygenase. MATERIALS AND METHODS The most widely used in dentistry are triamcinolone, be- tamethasone and dexamethasone, which have half-lives All articles and reviews considering the topic of pain of 24-48 hours, 36-54 hours and 36-54 hours respectively. management in dentistry were searched on the online The effectiveness of synthetic corticosteroids in oral platform of scientific reading sites such as PubMed and surgery is still controversial, as there are no protocols Medline, selecting the most current ones, up to Janu- universally accepted by the international scientific com- ary 2022, including any language. Considering the key- munity. words “Analgesic drugs”, “dentistry” AND “dental pain”, However, the active ingredients most commonly used in randomized controlled trials (RCTs), prospective stud- oral surgery and their respective dosages are: ies, observational studies, reviews, and retrospective • Methylprednisolone studies were considered. Textbooks relevant to the topic Dosage: (0.5-1 mg/kg/day) for a normal-weight adult were then examined, and the citations of each retrieved about 40 mg one hour before surgery (half-life 2.4- article and those of reviews and expert opinions were 3.5 hours) and after 12 hours. Same dosage every examined to include as much knowledge as possible. 12 hours on subsequent days for no more than 24-48 hours to avoid cortico-adrenal inhibition. LITERATURE REVIEW ON ANALGESIC • Dexamethasone Anti-inflammatory and anti-reactive activity 8-10 DRUGS IN DENTISTRY times greater than prednisolone. Dosage: 8-16 mg dexamethasone one hour before Pharmacological types surgery and 8-16 mg every six hours for no more The analgesics used in dentistry are numerous and be- than 24-48 hours to avoid cortico-adrenal inhibition. long to different categories; therefore, their use must be However, even these substances are not free of various thoughtful and specific to the individual clinical case. side effects, such as delayed wound healing, suppres- sion of adrenergic activity, hyperglycaemia, water-saline retention, hirsutism, acne, skin streaks, obesity, etc. Analgesic drugs with central mechanism All these side effects only become apparent when ad- of action ministered in large doses and over long periods of time. Paracetamol Single doses, on the other hand, are considered safe for healthy patients. Paracetamol or acetaminophen is an active ingredient Corticosteroids have therapeutic indications in dentistry with antipyretic and analgesic activity and has a weak in cases of: anti-inflammatory effect. It is considered a quite safe • non-herpetic mucosal lesions drug, so that its use, with the appropriate dosage, is also • nerve damage caused by surgery or trauma recommended for paediatric patients. • phlebitis From the chemical point of view, paracetamol is a de- • prophylaxis of preoperative surgical oedema rivative of para-aminophenol, obtained by acetylation • endodontic therapy (to relieve pain of peri-apical ori- of the latter. Paracetamol is now available by several gin) routes of administration: • prophylaxis of PONV (post-operative Nausea and • oral Vomiting) • rectal A meta-analysis by Markiewicz MR. et al. 2008, conduct- • parenteral ed to evaluate the effect of corticosteroids in the control It has a synergistic action with NSAIDs and opioids. of lockjaw, oedema, and pain following lower third molar Recommended doses should be between 1000 and surgery, revealed that peri-operative administration of 1500 mg. corticosteroids results in a reduction of post-operative The administration of paracetamol 1000 mg + codeine oedema and lockjaw. 60 mg at the end of oral surgery reduces pain intensity and prolongs postoperative analgesia. Antibiotics Side effects may possibly include liver toxicity; kidney In dentistry, antibiotics are drugs prescribed daily by the damage; allergic reactions, on the other hand, are quite clinician for both prophylaxis and therapy against bacte- rare. rial infections. Despite this, the use of antibiotics as at- Doses of paracetamol of 500 mg + codeine 30 mg are tenuators of nociceptive stimuli is still a matter of debate indicated in less severe odontostomatological pain. in the scientific community today. 24 10.59987/ads/2023.4.23-29 B. D’Orto et al. These drugs can be administered locally or systemi- structure and action. NSAIDs commercially available are cally. The systemic use of antibiotics, particularly after about 25-30. third-molar extraction, has been proposed by several It is a category of drugs with a variety of effects, including authors; however, this use does not seem to have any antipyretic, anti-inflammatory and analgesic effects, and additional effectiveness compared to local antibiotic inhibition of platelet release and free radicals. administration in preventing inflammatory oedema and NSAIDs inhibit cyclooxygenase (COX), the enzyme re- post-operative pain. sponsible for converting arachidonic acid into prosta- The use of antibiotics is indicated in the immuno-com- glandins and thromboxanes. promised patient or in cases where an active infection About anti-inflammatory therapy, the identification of two is present at the time of surgery. In such cases, the different forms of cyclooxygenase has been of funda- administration of an antibiotic can more effectively pre- mental importance: COX 1 and COX 2. vent the symptoms of infection and the resulting post- The first is involved in general homeostasis and is found operative pain. in most tissues and organs. COX 2, on the other hand, is In dentistry, the prescription of antibiotics is empirical be- not detected in tissues and only appears in response to cause the dentist does not know which microorganisms certain stimuli. Based on this difference, anti-inflamma- tory therapy has increasingly shifted to selective COX-2 are responsible for the infection, as samples from the inhibitors, referred to as coxib drugs. root canal or peri-apical region are not commonly taken NSAIDs reduce the inflammatory response to surgical and analysed. However, it has recently been seen that trauma, more or less intensely depending on the drug the additional use of PACS (portable air cleaners) dur- used. The administration of NSAIDs with predominantly ing dental practice can reduce the amount of bacterial anti-inflammatory activity should begin a few hours be- micro-particles, thus being able to help the anti-bacterial fore dental surgery to prevent the inflammatory process. action provided by antibiotics. The effectiveness of the The anti-platelet effects are mainly exerted at the site PAC is confirmed from a microbiological point of view as of the operation and on the gastric mucosa, leading, in there is a reduction ranging from 69 to 80% in profes- the latter case, to a haemorrhagic gastropathy pathol- sional dental hygiene activity and from 62 to 66% during ogy. The effects on the gastric mucosa consist of micro- simple surgery activity. bloodings which correlate with the duration of drug ther- However, the most widely used antibiotic is amoxicillin, apy. NSAID-induced gastric mucosal lesions are related due to its sufficiently broad spectrum, efficacy, low inci- to a combination of inhibition of gastric cyclooxygenase dence of resistance, pharmacokinetic profile, tolerance, and cytoprotective prostaglandin deficiency, resulting in and dosage. altered mucosal blood flow. The main antibiotics prescribed in the adult dental pa- Those most at risk of gastropathy following the use of tient have been summarised in Table 1. NSAIDs are: Adverse effects of antibiotics, particularly of the beta- • female patients over 60 years of age lactam class (the most used drugs in dentistry) include • patients on oral anticoagulant and/or antiplatelet anaphylaxis, bacterial resistance, dysentery, or other al- therapy lergic reactions, especially skin rashes, which may occur • patients with a history of gastric ulceration during or days after treatment. • poly-therapy patients Macrolides, tetracyclines, erythromycin, clindamycin • patients with previous NSAID intolerance and ketoconazole are potentially toxic and particularly Caution is required when using COXIBs in patients: contra-indicated in patients with liver disease. In addi- • diabetics tion, tetracyclines may interfere with glycaemic control in • hypertensives diabetic patients. • hyper-lipidemic • smokers Analgesic drugs with peripheral mechanism NSAIDs are contraindicated in the presence of isch- of action aemic heart disease and/or cerebrovascular disease; cardiac insufficiency; post-operative aorto-coronary by- Non-steroidal analgesic drugs (NSAIDs) pass surgery. They are called ‘non-steroidal’ because they do not have For patients with swallowing difficulties, suspensions a steroidal structure like that of cortico-steroid drugs. and granules are preferable to solid tablets. The category of non-steroidal anti-inflammatory drugs Instead, an injection formulation is recommended in pa- is extremely broad and includes many active ingredi- tients refractory to oral administration and if an immedi- ents that can be classified rendering to their chemical ate analgesic effect is desired. Table 1. Main antibiotics prescribed to the adult dental patient and dosage. ACTIVE PRINCIPLE DAILY DOSE MAINTENANCE DOSE Amoxicillin with or without clavulanic acid 1000 mg 500 mg every 8 h or 875 mg every 12 h Clindamycin 600 mg 300 mg every 6 h Clarithromycin 500 mg 250 mg every 12 h Azithromycin 500 mg 250 mg every 24 h Metronidazole 1000 mg 500 mg every 6 h 10.59987/ads/2023.4.23-29 25  Analgesic drugs in dentistry: a narrative review In addition, acetyl salicylic acid, a widely used NSAID, tion in clinical practice is lidocaine: the latter is used at a may interfere with glycaemic control in diabetic patients. concentration of 2%, often in combination with adrena- line (a vasoconstrictor drug). The combination of these Opioids two compounds (lidocaine at 2% and adrenaline diluted 1:100,000) is an effective preparation to obtain a pow- Opioids represent the treatment of choice for acute post- erful analgesic effect before dental procedures such as operative pain, both moderate and severe. Those most commonly used in dental practice include codeine and fillings, apicoectomy, devitalizations, dental extractions, tramadol, which fall into the category of weak opioids. or whatever. Morphine, and its related compounds, act as agonists Nevertheless, it too is not free from side effects, such through a stereo-selective interaction with saturable as possible mucosal reactions, skin rashes, and even membrane receptors, which are unevenly distributed anaphylactic shock, although this latter reaction occurs throughout the central nervous system. in people allergic to lidocaine, a condition extremely rare. The prescription of opioids may be indicated in acute or Local anaesthetics may be toxic in the event of over- chronic pain because of their obvious analgesic effects; dose, or in the event of incorrect intravascular injection. however, they do not exempt significant risks such as Toxic effects on the cardiovascular system are manifest- respiratory depression, altered mental status, nausea, ed by a decrease in blood pressure, up to and includ- vomiting, pruritus, constipation, urinary retention and ing ventricular fibrillation, an extremely serious but very slowed bowel movement. Moreover, the main unfavour- sporadic event. able effects seem to be dose-dependent. A further adverse reaction to local anaesthetics is met- The administration of opioids by the dentist in the pres- hemoglobinemia, the oxidation of haemoglobin from the ence of chronic pain, particularly if the pathology is un- ferrous to the ferric state, which can cause cyanosis in known, must be supported by an additional approach fetus. This is particularly attributable to prilocaine and with pain specialists. benzocaine; for this reason, the FDA advises against the use of these drugs in pregnancy. Local anaesthetics Anaesthetics with and without vasoconstrictors are sum- marized in Table 2, with the corresponding maximum This is a heterogeneous group of active ingredients dosage. which, acting at different sites and with different mecha- nisms of action, induce anaesthesia. The term “local anaesthesia” refers to the loss of sensa- Post-operative pain management tion in a specific area. These drugs can be used either A preliminary estimate of postoperative pain is useful for topically (creams, gels) or infiltrative (plexic or truncular the establishment of a predefined analgesic scheme, us- anaesthesia). ing non-opioid analgesics administered singly or in com- However, it is important to emphasise that local anaes- bination, possibly with opioid drugs. thetics do not induce analgesia because, unlike anti-in- • In the presence of mild pain, an administration of: flammatory drugs, they do not inhibit the synthesis and - Ibuprofen 200/400 mg every 4/6 hours as needed. release of pain mediators, nor do they interact with pain • In the case of mild to moderate pain, the administra- receptors. tion of: It is known, however, that long-acting local anaesthetics - Ibuprofen should be about 400/600 mg every 6 prolong the duration of post-operative analgesia, espe- hours at regular intervals for the first 24 hours; there- cially in more complex implant-prosthetic rehabilitations. after as required. Bupivacaine and ropivacaine are useful for this purpose. • Then, in the presence of moderate-to-severe pain, the Bupivacaine is widely used in oral surgery mainly for soft administration of: Ibuprofen 400/600 mg combined tissue infiltration, prolonging post-operative analgesia, with paracetamol 500 mg every 6 hours at regular especially when combined with adrenaline; this anaes- intervals for the first 24 hours; thereafter as needed. thetic drug is very effective in soft tissue infiltration after • Finally, in the presence of severe pain, an administra- oral surgery (such as extraction of third molars included) tion of: and in implantology. Bupivacaine and ropivacaine, which - Ibuprofen 400/600 mg combined with paracetamol are long-acting local anaesthetics, should only be used 500 mg and hydrocodone 10 mg every 6 hours at reg- in the adult population, as they may cause undesirable ular intervals for the first 24/48 hours; then ibuprofen reactions in children and the disabled. 400/600 mg combined with paracetamol 500 mg as Among the local anaesthetics that have a great valida- required. Table 2. Posology of main anaesthetics prescribed in dentistry. MAXIMUM DOSE WITH MAXIMUM DOSE WITHOUT VASOCONSTRICTOR VASOCONSTRICTOR LIDOCAINE 2% 7 mg/kg 4,4 mg/kg ARTICAINE 4% 7 mg/kg (adult) / 5 mg/kg (child) MEPIVACAINE 2% 6,6 mg/kg 3% 4,4 mg/kg 26 10.59987/ads/2023.4.23-29 B. D’Orto et al. Injection formulations for increasing sever- Clin Anaesthesiol. 2005 Jun;19(2):247-68. doi: 10.1016/j. bpa.2004.12.003. ity of pain • Chhabra A, Nidhi C, Jain A. Knowledge, attitudes and prac- • Paracetamol tice preference regarding drug prescriptions of resident Vials: 1,000 mg dental doctors: A quantitative study. Int J Risk Saf Med. Dosage: 1,000-2,000 mg every 6-8 hours 2019;30(2):91-100. doi: 10.3233/JRS-180021. • Chung MK. A virtual case-based learning module for pain in (Maximum daily dose 8,000 mg). dentistry. J Dent Educ. 2021 Dec;85 Suppl 3:1928-1929. doi: • Tramadol 10.1002/jdd.12567. Vials: 100 mg • Colloca L, Ludman T, Bouhassira D, Baron R, Dickenson AH, Dosage: 100 mg every 6-8 hours. Yarnitsky D, Freeman R, Truini A, Attal N, Finnerup NB, Ec- • Pentazocine lactate cleston C, Kalso E, Bennett DL, Dworkin RH, Raja SN. Neu- Vials: 30 mg ropathic pain. Nat Rev Dis Primers. 2017 Feb 16;3:17002. doi: 10.1038/nrdp.2017.2. Dosage: 30 mg every 3-4 hours. • Crincoli V, Favia G, Limongelli L, Tempesta A, Brienza N. The effectiveness of ropivacaine and mepivacaine in the CONCLUSION post-operative pain after third molar surgery. Int J Med Sci In the treatment of pain in dentistry, the clinician must 2015; 12:862-866.15. • D’Orto, B.; Polizzi, E.; Nagni, M.; Tetè, G.; Capparè, P. Full consider several key points to establish the most suitable Arch Implant-Prosthetic Rehabilitation in Patients with Type and appropriate therapy for the clinical case in question: I Diabetes Mellitus: Retrospective Clinical Study with 10 • drug-kinetics, drug-dynamics and drug-genetics of Year Follow-Up. Int. J. Environ. Res. Public Health2022, 19, the therapeutic medium used 11735. https://doi.org/10.3390/ijerph191811735. • effective, and possibly immediate, analgesic treat- • Daniel E, Becker DDS. Basic and clinical Pharmacology of ment glucocorticoids. Anesth Prog.2013;60:25-32. • Drugs and Lactation Database (LactMed) [Internet]. Bethes- • elimination of the source of the painful stimulus pos- da (MD): National Library of Medicine (US); 2006-. 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Pathogenesis, diagnosis and management of den- effects and safety of (non-aspirin) NSAIDs. Nat Rev Cardiol. tin hypersensitivity: an evidence-based overview for dental 2020 Sep;17(9):574-584. doi: 10.1038/s41569-020-0366-z. practitioners. BMC Oral Health. 2020 Aug 6;20(1):220. doi: • Schmidt J, Kunderova M, Pilbauerova N, Kapitan M. A Re- 10.1186/s12903-020-01199-z. view of Evidence-Based Recommendations for Pericoro- • Manazza, F., La Rocca, S., Nagni, M., Chirico, L., & Cattoni, nitis Management and a Systematic Review of Antibiotic F. (2021). A simplified digital workflow for the prosthetic fin- Prescribing for Pericoronitis among Dentists: Inappropriate ishing of implant rehabilitations: A case report. Journal of Bi- Pericoronitis Treatment Is a Critical Factor of Antibiotic Over- ological Regulators and Homeostatic Agents, 35(4), 87-97. use in Dentistry. 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Manual vs Mechanical Oral Hygiene Pro- ta-analysis of cannabinoids, cannabis-based medicines, and cedures: Has the Role of the Dental Hygienist in Phase 2 endocannabinoid system modulators tested for antinocicep- Post-lockdown Really Changed? Oral Health Prev Dent. tive effects in animal models of injury-related or pathological 2020;18(1):1031-1037. doi: 10.3290/j.ohpd.b871059. persistent pain. Pain. 2021 Jul 1;162(Suppl 1):S26-S44. doi: • Porporatti AL, Bonjardim LR, Stuginski-Barbosa J, Bonfan- 10.1097/j.pain.000000002269. te EA, Costa YM, Rodrigues Conti PC. Pain from Dental • St George G, Morgan A, Meechan J, Moles DR, Needle- Implant Placement, Inflammatory Pulpitis Pain, and Neu- man I, Ng YL, Petrie A. Injectable local anaesthetic agents ropathic Pain Present Different Somatosensory Profiles. J for dental anaesthesia. Cochrane Database Syst Rev. 2018 Oral Facial Pain Headache. 2017 Winter;31(1):19-29. doi: Jul 10;7(7):CD006487. doi: 10.1002/14651858.CD006487. 10.11607/ofph.1680. PMID: 28118417. pub2. • Poveda Roda R, Bagán JV, Jiménez Soriano Y, Gallud • Stanisic N, Häggman-Henrikson B, Kothari M, Costa YM, Romero L. Use of nonsteroidal antiinflammatory drugs in Avivi-Arber L, Svensson P. Pain’s Adverse Impact on Train- dental practice. A review. Med Oral Pathol Oral Cir Bucal. ing-Induced Performance and Neuroplasticity: A Systematic 2007 Jan 1;12(1): E10-8. Review. Brain Imaging Behav. 2022 Mar 18. doi: 10.1007/ • Ream-AI-Hasani, Michael R Bruchas. Molecular mecha- s11682-021-00621-6. nisms of action of opioid receptor-dependent signaling and • Statement on the use of opioids in the treatment of dental behavior. Anesthesiology 2011;115:1363-1381. pain. ADA Last updated February 2017. 28 10.59987/ads/2023.4.23-29 B. 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Spanish. doi: 10.1016/j.eimc.2008.12.001. vention of Viridans Group Streptococcal Infective Endocar- • Tecco S, Sciara S, Pantaleo G, Nota A, Visone A, Germani ditis: A Scientific Statement From the American Heart Asso- S, Polizzi E, Gherlone EF. The association between minor ciation. Circulation. 2021 May 18;143(20):e963-e978. doi: recurrent aphthous stomatitis (RAS), children’s poor oral 10.1161/CIR.000000000969. condition, and underlying negative psychosocial habits • World Health Organization. WHO normative guidelines on and attitudes towards oral hygiene. BMC Pediatr. 2018 Apr pain management. Geneva: WHO 2007. 13;18(1):136. doi: 10.1186/s12887-018-1094-y. • Yasir M, Goyal A, Sonthalia S. Corticosteroid Adverse Ef- • Tetè, G., Polizzi, E., D’orto, B., Carinci, G., & Capparè, P. fects. 2021 Jul 8. In: StatPearls [Internet]. Treasure Island (2021). How to consider implant-prosthetic rehabilitation (FL): StatPearls Publishing; 2022 Jan-. in elderly patients: A narrative review. 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A NNALI DI STOMATOLOGIA www.annalidistomatologia.eu VOLUME 14 NUMERO 3-4 - 2023 A Journal of Odontostomatologic Sciences PublyMed srls  A NNALI Annali............. DI STOMATOLOGIA EDITOR IN CHIEF D’Antò Vincenzo Ciulli Emanuele, Italy University of Naples, Italy [email protected] Gatto Roberto [email protected] University of L’Aquila, Italy Di Carlo Gabriele [email protected] Basilicata Michele University of Rome “La Sapienza”, Italy University of Tor Vergata Italy [email protected] CONSULTANT EDITORS [email protected] Falisi Giovanni University of L’Aquila, Italy Allaf Ferdi De Angelis Francesca [email protected] Turkish Aligner Society,Turchia University of Rome “La Sapienza”, Italy [email protected] [email protected] Marsili Domenico, Italy [email protected] Caruso Silvia De Nuccio Claudio University of L’Aquila, Italy University Cattolica del Sacro Cuore, Italy Nagni Matteo, Italy [email protected] [email protected] [email protected] Docimo Raffaella Yisrael Kornblit Jamal Sied University of Tor Vergata , Italy Roly Doctor, Italy [email protected] [email protected] [email protected] J.L. Parra Garcia Giancotti Aldo Doctor, Mexico Department of Clinical Sciences and Laganà Giuseppina [email protected] Translational medicine University Tor University of Tor Vergata , Italy Vergata, Italy [email protected] Pietropaoli Davide [email protected] University of L’Aquila, Italy Mohamed R.Islam [email protected] Marchetti Enrico University of Dundee, Scotland University of L’Aquila, Italy [email protected] Pistilli Roberto, Italy [email protected] [email protected] Manzo Paolo Mummolo Stefano Member of EBO-IBO, Italy Pedro Vittorini Velasquez University of L’Aquila, Italy [email protected] Universidad Autonoma Gabriel Rene [email protected] Moreno [email protected] Nota Alessandro Severino Marco University of Milan, Italy University of L’Aquila, Italy [email protected] CONTACTS [email protected] Do you need further information? Get in Tatullo Marco Pagano Stefano touch with Annali di Stomatologia for any University of Bari, Italy University of Perugia, Italy question! [email protected] [email protected] Annali di Stomatologia – Editor in Chief Scopelliti Domenico Roberto Gatto ASSISTANT EDITORS Director of the UOC Maxillofacial Surgery [email protected] ASL Roma 1 Annali di Stomatologia – Managing Editor Berdouses Elias [email protected] University of Athens, Greece Alessandro Zurli Varesi [email protected] [email protected] Valentini Valentino University of Rome “La Sapienza”, Italy Annali di Stomatologia – Managing Office Nunzio Cirulli Donatella Alonzi University of Bari [email protected] [email protected] [email protected] ASSOCIATE EDITORS Annali di Stomatologia – Sponsor & D’Addona Antonio Marketing University Cattolica del Sacro Cuore, Italy Antonangelo Carmine Claudio de Nuccio [email protected] [email protected] [email protected] ANNALI DI STOMATOLOGIA II Annali di Stomatologia 2018; IX (4): 141 Trimestrale edito da PublyMed srls, Via Treviso, 17/A - 00161 Roma - P.I. 16532301005 +39 06 44.24.99.41 - [email protected] - www.annalidistomatologia.eu Reg. Trib. Roma n. 421 18/12/2009 Editorial In the light of considerable commitment and aided by the essential support of a high-profile scientific team, I managed to restore the consequentiality of our Jour- nal, which was resumed after a few years of editorial suspension. “Annali di Stomatologia” was founded in 1971 – year of registration is to be con- sidered the “historical” dental magazine with the greatest presence on the na- tional scene. Following a complex editorial process that began in 2019, thanks to the commit- ment and professionalism of my scientific group, I managed to restore the DOI on all the scientific articles published to date. The next step, which will take place shortly, will be to be included in one of the main databases in the biomedical field: PubMed. We are currently in the process of starting the conversion of scientific works into HTML format so that the journal’s indexing practice can be perfected. First of all, I would like to thank Prof. Roberto Gatto and his staff for their commitment and high professionalism, without which I would not have been able to achieve such excellent results. A special thank you must be dedicated to the priceless commitment of the entire Editorial Board and to the authors of the articles published in recent months, who believed in the growth process of Annali di Stomatologia, submitting their valuable articles and helping me to bring the Journal back to its former glory . Finally, a special recognition is addressed to the Sponsors who in recent years have supported and still financially sup- port my entrepreneurial project, believing in the realization of what was defined as a utopian dream of mine Alessandro Zurli Varesi Annali di Stomatologia Managing Editor 10.59987/ads/2023.3.1-1 1 

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Original Article Evaluating the effect of adding 10-MDP to resin-modified glass ionomer on its dentin bond strength and fluoride release Sara Majidinia* trode. The data were analyzed by one-way and repeated Mahboobe Noori° measures ANOVA, Tukey and LSD tests (α = 0.05). Hossein Bagheri§ Maryam Hosseini^ Results Farzaneh Rakhshan” Shear bond strength in the RMGI + 10% 10-MDP group Tahereh Parhizkar< was significantly higher than that in the control group (P<0.05). There was a significant difference in the *Dental Research Center, Mashhad University of Medi- amount of fluoride released in the three groups on days cal Sciences, Mashhad, Iran 7, 14 and 28, which was higher in the control group than °Assistant professor of restorative dentistry, Zahedan other groups. university of medical sciences, Zahedan, Iran § Dental Materials Research Center, Mashhad University of Medical Sciences, Mashhad, Iran Conclusion ^Dentist, Mashhad University of Medical Sciences, The addition of 10% vol of 10-MDP to the resin-modi- Mashhad, Iran fied glass ionomer significantly improves its dentin bond ”Post graduate student of esthetic and restorative den- strength, although its long-term fluoride release is lower tistry, Mashhad University of Medical Sciences, Mash- than conventional RMGI. had, Iran < DDS, MScD Student Postgraduate student, Department of Operative Dentist- Introduction ry, Mashhad Dental School, Mashhad University of Med- Glass ionomers are one of the dental materials that were ical Sciences, Mashhad, Iran introduced in 1972 [1]. Advantages such as biocom- patibility, chemical adhesion, fluoride release, thermal Corresponding author: Tahereh Parhizkar expansion coefficients similar to that of tooth, and the E-mail: [email protected] absence of shrinkage during polymerization have made glass ionomers one of the most important restorative materials [3]. However, disadvantages such as low bond Abstract strength to tooth, long setting time, dehydration during Purpose: The aim of this study was to evaluate the the initial setting, rough surface texture, and low initial effect of adding 10-MDP to resin-modified glass iono- strength limit their widespread clinical use [4]. mer on its dentin bond strength and fluoride release. Resin-modified glass ionomers (RMGI) are a hybrid of glass ionomer and composite resin [2] that were first in- Keywords: Resin-modified glass ionomer, 10-MDP, troduced in 1989 by adding a small amount of light-acti- bond strength, fluoride release. vated resin to overcome the disadvantages of traditional glass ionomers. [5]. These materials, along with the de- sirable properties of conventional glass ionomers such Materials and Methods as chemical bonding to tooth structure and fluoride re- The occlusal surfaces of thirty caries-free human third lease, have more benefits, including: decreased setting molars were ground flat to expose dentin and randomly time, having higher initial strength, being more durable divided into three groups (n=10) according to different and improved appearance [7]. concentrations of 10-MDP used with RMGI. Group 1: Adhesion of the RMGI to dental hard tissues occurs (RMGI+0% vol 10MDP), group2: (RMGI+ 5% 10MDP) through 2 different mechanisms: and group3: (RMGI+10% 10MDP). In each group a 1) a chemical bonding between polyalkenoic acid chains cylinder of modified RMGI was bonded on each flat sur- and calcium ions in hydroxyapatite, face. Shear bond strength test was carried out using 2) a micro-mechanical retention by the infiltration of the the universal testing machine (1 mm/min). The mode of organic components into a partially demineralized den- failures was examined using a stereo microscope. Five tin surface created by the self-etching characteristic of disc-shaped samples were prepared from each group RMGIC [8]. and the amount of fluoride released was measured on Various studies have recommended different methods days 1, 7, 14 and 28 using a specific fluoride ion elec- of improving RMGI bonding to dental tissues, most of 10.59987/ads/2023.3.11-15 11  Evaluating the effect of adding 10-MDP to resin-modified glass ionomer on its dentin bond strength and fluoride release which involve surface pretreatment prior to the appli- were used for testing. The teeth were randomly divided cation of glass ionomer. Previous studies concluded into three groups(n=10): that the use of a polyacrylic-acid conditioner before the Group 1: RMGI standard (Fuji II LC GC Inc., Tokyo, Ja- application of RMGIC provided stronger dentin bond pan). This group was classified control group. strength. It cleans the surface, generates micro-poros- Group 2: RMGI involving 5% volume of 10-MDP mono- ities and improve the micromechanical bond, as well as mer. react chemically with hydroxyapatite on the tooth sur- Group 3: RMGI involving 10% volume of 10-MDP mono- face [9,10]. Although, Surface conditioning especially mer. with polyacrylic acid, is an accepted method, it has not For placing the material on teeth, a tygon tube with an in- found widespread clinical use because of adding more ner diameter of 1.5 mm and a height of 2mm was placed steps to the clinical procedure. on dentin surface next to DEJ. In each group, the materi- Some studies that evaluated chemical bond using X-ray al was placed inside the tube and cured from the occlusal have shown that the ionic bond between some function- surface for 20 seconds by Bluephase light cure device al resin monomers and calcium ions on the tooth surface (Ivoclarvivadent. Schaan, Liechtenstein) at an intensity may be stronger than the hydrogen and van der Waals of 1200 mw/cm2. After removing the tube with a razor bonds due to the mechanical integration of collagen fi- blade, the samples were incubated at 37 °C and 100% brils by resin polymerization [11,12]. humidity for 24 hours. Then the samples were examined with a 10x magnification microscope (XTL-ST2FF,Blue The most common functional monomers used in com- light USA) and those which had cracks, bubbles and de- mercial adhesives are phosphate monomers such as fects were replaced with new ones. 10-MDP and Phenyl-P [13], which react chemically with The shear bond strength test was carried out using a uni- hydroxyapatite [14]. The 10-MDP monomer etches sur- versal testing machine (Santam, STM 20, Tehran, Iran) face due to the presence of hydrogen phosphate groups at a speed of 1 mm/min. For this purpose, each tooth that form two cationic waters [15]. The ionic bond formed was placed in device, and a force perpendicular to the with 10-MDP is stable in aqueous media. Compared to junction of RMGI and tooth was applied using the de- 4-META and Phenyl-P, 10-MDP is considered to be the vice’s chisel until the samples were separated from the best monomer for chemical bonding to dentin and enam- tooth. The amount of force through fracture was record- el hydroxyapatite [16,17]. ed. After the test, the failure mode of each sample was The use of functional monomers in bonding has become determined under stereoscopic microscope. common today and has greatly reduced the limitations of To evaluate fluoride release, five disc-shaped samples dentin bonding. Their improved performance has been (3*10mm) of each material were divided into 3 groups, reported in various studies. each of them was placed in a sealed plastic container Yoshida et al. (2004) conducted a comparative study on with 7 ml of double distilled water. the performance of functional adhesives and concluded All samples were kept in an incubator at 37°C during the that 10-MDP reacted with hydroxyapatite and the bond study and released fluoride amount was measured on days appeared to be very stable [18]. Another study (2005) 1, 7, 14, and 28. Prior to each measurement, the samples on the hydrolytic stability of self-etched adhesives bond- were removed from the container and were washed twice ing to dentin found that the bond strength of adhesives with 1 ml of distilled water. Then this water was added to containing 10-MDP did not decrease after thermocycling previous solution, and the samples were transferred to a [19]. Li et al. (2010) also stated in their study that the new container of fresh solution. 7 ml of solution for each interface formed with adhesive systems containing 10- sample, along with 1 ml of water used for washing, was MDP remained stable after acid and base changes [14]. mixed with 4 ml of TISAB II buffer solution and examined Therefore, the aim of this study was to evaluate the effect for released fluoride amount. A potentiometer measured of adding 10-MDP to resin-modified glass ionomer on its Fluoride releases. The electrode (WTW, Multi 9420, Ger- bond strength and fluoride release. The null hypothesis many) was immersed in solution for measurement, while was that the addition of 10-MDP to the resin-modified the container was shaken to achieve a uniform dispersion glass ionomer has no effect on bond strength and fluo- of fluoride ions in solution. The number was recorded as ride release. soluble fluoride amount in ppm. At last, fluoride released in each period was determined in mg/cm2. Materials and Methods This study was approved by local Ethics committee of Statistical analysis school of dentistry Mashhad university, Iran with code Shapiro-Wilk test was used to determine normal distri- IR.MUMS.DENTISTRY.REC.1397.020. Thirty human bution of data. One factor analysis of variance as well as third molars without crack, decay or previous restoration Tukey test were used to analyze the data obtained from were obtained and stored in 0.5% chloramine T solution bond strength assessment. Variance analysis for repeat- until use. Using periodontal scaler debris and inorganic ed measures, as well as LSD, was used to assess the remnants were cleaned. To obtain a smooth dentin sur- fluoride release. The significance level was set to 0.05. face, the teeth were horizontally cut from 1.5 mm of their occlusal surface’s central groove, by a water-cooled di- amond saw. They were embedded in a self-cure acrylic Results resin vertically till cementoenamel junction. Based on the results, the mean shear bond strength in The teeth surface was abraded by paper discs up to 600 the group 3 (10% 10-MDP monomer) was higher than grits, to create a smear layer. An alcoholic solution of other groups, and it was significantly different from the 10-MDP (Watson International, China) was mixed with control group (P<0/05). There was no significant differ- RMGI liquid in a volume ratio of 5% and 10%, which ence between the control group and the group 2 in terms 12 10.59987/ads/2023.3.11-15 S. Majidinia et al. of bond strength. The mean shear bond strength values Discussion of all groups and the standard deviations are presented in Table 1. The frequency of failure modes in each group The results of the present study showed that the addition are shown in Table 2. Most failures were recorded as of 10-MDP monomer by 5% and 10% volumes to RMGI adhesive failures. increases its bond strength to human dentin. There was According to the results, fluoride release was higher a significant difference between the 10% volume group in the control group than the other two groups on all and the control group, while the different between the days. There was no significant difference between the 5% volume group and the control group was not signifi- three groups in terms of fluoride release on the first day cant. In terms of fluoride release, the amount was higher (p>0.05). On days 7,14 and 28, the difference between in the control group than that in the other two groups. the control group and the other groups was significant This difference was not significant on the first day, while (p<0.05) , while there was no significant difference be- it was significant on days 7, 14 and 28. Therefore, the tween group1 and group2(p<0.05). The fluoride release null hypothesis of the study was rejected and Addition of chart for all groups is shown in Figure 1. 10-MDP to RMGI increases bond strength and decreas- es fluoride release. The ability to chemically bond with specific chemical monomers including 10-MDP with hydroxyapatite has Table 1. Mean bond strengths (standard deviation) in been demonstrated [20].10-MDP forms an electrostatic MPa for different materials. (a Means followed by differ- bond with hydroxyapatite, which results in a long-term ent lowercase letters are significantly different by Tukey stable bond [21].Yoshihara et al. found that the bond test at 5% confidence level.) between this monomer and hydroxyapatite was accom- GROUP MEAN (SD) panied by a self-assembled Nano-layering feature. XRD and high-resolution TEMs of hydroxyapatite crystals at- RMGI 6.43 (2/12)a tached to 10- MDP showed the formation of a 4nm layer, each layer of which contained two 10-MDP molecules RMGI + 5% 10-MDP 7.40 (1/78)ab with their methacrylate heads facing each other and their functional hydrogen phosphate groups were far apart RMGI + 10% 10-MDP 9.57 (2/65)b and deposition of the Calcium salts between these lay- ers hold them together [22]. This Nano-layering property Table 2. Frequency of failure mode. GROUP ADHESIVE COHESIVE MIXED RMGI 10 0 0 RMGI + 5% 10-MDP 9 1 0 RMGI + 10% 10-MDP 8 2 0 Figure 1. Fluoride release of different materials on different days 10.59987/ads/2023.3.11-15 13  Evaluating the effect of adding 10-MDP to resin-modified glass ionomer on its dentin bond strength and fluoride release has not been observed in other functional monomers as the flexural strength of an RMGI is almost twice than such as 4-MET and Phenyl-P and other experimental that of conventional glass ionomer due to the addition of phosphate monomers [21]. the HEMA resin monomer, therefore the cohesive frac- Since phosphate ester monomers contain methacry- ture was rare. loxy functional groups, they can also support the adhe- Since this study was primarily performed in the laborato- sion of methacrylate-based resins to the tooth structure ry, it is recommended that RMGI with 10-MDP be tested [21,23,24]. Therefore, there is a growing interest in de- in clinical trials for more reliable results. It is also rec- veloping of new phosphate ester monomers for use in ommended in future studies to check the strength of the restorative dentistry. material itself to make sure that the internal strength of The beneficial effect of functional monomers on bond- RMGI is improved by adding 10-MDP.Furthermore, be- ing, especially universal and self-etch bonds, has been cause the 10-MDP monomer creates a stable bond to proven. Cristina et al. reported that universal Scotch dentin, we also suggest investigating the durability of the bond provides acceptable bonding performance due to RMGI bond to dentin in future studies. the presence of 10-MDP monomer, which is an acidic monomer that stimulates demineralization and infiltration of monomers and chemically establishes bonds with the Conclusion mineral tissue of the tooth. Scotchbond also contains a The present study showed that the addition of 10% polyalkenoic acid polymer (Vitrebond™ Copolymer) and volume of 10-MDP to the resin-modified glass ionomer is in fact a glass ionomer-based bonding which, accord- significantly improved its dentin bond strength, although ing to the manufacturer, provides a satisfactory bond to its long-term fluoride release is less than that of conven- dentin in dry and humid environments [25,26]. tional RMGI. Adper™ Easy Bond Self-Etch Adhesive is also a univer- sal glass ionomer-based bonding that utilizes the meth- acryloxyhexyl phosphate (MHP) functional monomer. References Functional monomers such as 4-MET, Phenyl-P, MHP, 1. Wilson AD, Kent BE. A new translucent cement for dentistry. etc. are rapidly developing. However, the 10-MDP mono- The glass ionomer cement. Br Dent J. 1972; 132(4):133-5. mer is still better than others and offers more desirable 2. Berzins DW, Abey S, Costache MC, Wilkie CA, Roberts properties because it has a longer carbon chain com- HW. Resin-modified glass-ionomer setting reaction compe- pared to others, particularly MHP. Therefore, in addition tition. Journal of dental research. 2010;89(1):82-6. to its relatively strong etching effect, it produces more 3. Glasspoole EA, Erickson RL, Davidson CL. Effect of surface stable calcium-monomer salts or nanolayer[27]. treatment on the bond strength of glass ionomer to enamel. Dent Mater. 2002;18(6):454-62. Hajizadeh et al. showed that surface etching can improve 4. Pereira LC, Nunes MC, Dibb RG, Powers JM, Roulet JF, the glass ionomer bond to dentin[10]. The capability of Navarro MF. Mechanical properties and bond strength of 10-MDP in surface etching in addition to the chemical glass ionomer cements.J Adhes Dent. 2002;4(1):73-80. bond could be another reason for its effectiveness in im- 5. Mathis RS, Ferracane JL. Properties of a glass-ionomer/ proving the glass ionomer bond to the teeth in this study. resin-composite hybrid material. Dent Mater. 1989;5(5): A recent study reported that the most effective 10-MDP 355-8. 6. Aleksiejunaite M, Sidlauskas A, Vasiliauskas A. Effect of concentration range for optimal reaction between 10- Rebonding on the Bond Strength of Orthodontic Tubes: MDP and hydroxyapatite is 5-10% [24]. In the study by A Comparison of Light Cure Adhesive and Resin-Mod- Yoshihara, concentrations of 1, 3 and 5% of 10-MDP ified Glass Ionomer Cement In Vitro. Int J Dent. 2017 monomer showed a low nano layering intensity, which 13;2017:8415979. in the case of 1% fell below the limit detectable by XRD 7. Baghalian A, Nakhjavani YB, Hooshmand T, Motahhary [21]. In our study, the bond strength of RMGI containing P, Bahramian H. Microleakage of Er:YAG laser and den- tal bur prepared cavities in primary teeth restored with 5% 10-MDP monomer was less than 10% concentration different adhesive restorative materials. Lasers Med Sci. of this monomer. In addition, we initially had a group with 2013;28(6):1453-60. a concentration of 20%. However, we excluded it from 8. Muhittin Ugurlu. Bonding of a resin-modified glass ionomer the study due to unsatisfactory results. This could be be- cement to dentin using universal adhesives Restor Dent En- cause the 10-MDP monomer is a viscose monomer and dod. 2020; 45(3):e36. its presence in high amounts can reduce the penetration 9. El-Askary FS, Nassif MS. The effect of the pre-conditioning step on the shear bond strength of nano-filled resin-modi- of adhesive into the tooth surface [28]. fied glass-ionomer to dentin.Eur J Dent. 2011; 5(2):150-6. In this study, we also examined the rate of fluoride re- 10. Hajizadeh H, Ghavamnasiri M, Namazikhah MS, Majidinia lease from RMGI. In fact, fluoride release is an important S, Bagheri M. Effect of different conditioning protocols on feature of glass ionomers [29]. Since it can promote the the adhesion of a glass ionomer cement to dentin. J Con- formation of fluoroapatite on the tooth surface [30,31]. temp Dent Pract. 2009;10:1009-16. Resin-modified glass ionomer has less fluoride release 11. Yoshida Y, Nagakane K, Fukuda R, Nakayama Y, Okazaki M, Shintani H, Inoue S, Tagawa Y, Suzuki K, De Munck J, et than conventional glass ionomer due to the presence al. Comparative study on adhesive performance of function- of HEMA, so it is expected that the addition of 10-MDP al monomers. J Dent Res. 2004; 83(6):454-8. monomer will also affect fluoride release. In this study, 12. Fukegawa D, Hayakawa S, Yoshida Y, Suzuki K, Osaka A, the rate of fluoride release in groups containing 10-MDP Van Meerbeek B. Chemical interaction of phosphoric acid was lower than that in the control group ester with hydroxyapatite. J Dent Res. 2006; 85(10):941-4. Furthermore, the major fractures in this study were of 13. Wang T, Nikaido T, Nakabayashi N. Photocure bonding agent containing phosphoric methacrylate. Dental Materials the adhesive type. There are two possible reasons for 1991;7(1):59-62. this. First, although the bond strength was increased by 14. Li N, Nikaido T, Takagaki T, Sadr A, Makishi P, Chen J, Tag- adding 10-MDP, it was still far from the bond strength ami J. The role of functional monomers in bonding to enam- of composites. Second, the addition of 10-MDP also el : acid-base resistant zone and bonding performance. J increased the bond strength of the material itself, just Dent. 2010;38(9):722-30. 14 10.59987/ads/2023.3.11-15 S. Majidinia et al. 15. Van Landuyt KL, Snauwaert J, De Munck J, Peumans M, ofintermolecular interactions of self-etch dentin adhesivep- Yoshida Y, Poitevin A, Coutinho E, Suzuki K, Lambrechts P, rimer molecules with type 1 collagen: computer modelingand Van Meerbeek B. Systematic review of the chemical com- in vitro binding analysis. ActaBiomater. 2007;3(5):705-14. position of contemporary dental adhesives. Biomaterials. 24. Tian FC, Wang XY, Huang Q, Niu LN, Mitchell J, Zhang ZY. 2007;28(26):3757-85. et al. Effect of nanolayering of calcium salts of phosphoric 16. Ikeda M, Tsubota K, Takamizawa T, Yoshida T, Miyazaki M, acid ester monomers on the durability of resin-dentin bonds. Platt JA. Bonding durability of single-step adhesives to pre- ActaBiomater. 2016 Jul 1;38:190-200. viously acid-etched dentin.Oper Dent. 2008;33(6):702-9. 25. https://multimedia.3m.com/mws/media/1279637O/3m-sin- 17. Silva e Souza MH Jr, Carneiro KG, Lobato MF, Silva e gle-bond-universal-adhesive-technical-product-profile.pdf SouazPde A, De Goes MF. Adhesive systems.important as- 26. Cristina PI, Lisia LV, Eliseu AM, Gabriela RB, Alice HP, Jülia pects related to their composition and clinical usa. J Appl KS, et al. Bond strength of a universal bonding agent and Oral Sci. 2010;18(3):207-14. other contemporary dental adhesives applied on enamel, 18. Yoshida Y, Nagakane K, Fukuda R, Nakayama Y, Okazaki M, dentin, composite, and porcelain. Applied Adhesion Sci- Shintani H, Inoue S, Tagawa Y, Suzuki K, De Munck J, Van ence, 2014; 2(1):1-10. Meerbeek B. Comparative study on adhesive performance of 27. Yoshihara K1, Yoshida Y, Nagaoka N, Hayakawa S, Okiha- functional monomers. J Dent Res.2004;83(6):454-8. ra T, De Munck J, Maruo Y, Nishigawa G, Minagi S, Osa- 19. Inoue S, Koshiro K, Yoshida Y, De Munck J, Nagakane ka A, Van Meerbeek B. Adhesive interfacial interaction K, Suzuki K, Sano H, Van Meerbeek B. Hydrolytic stabil- affected by different carbon-chain monomers. Dent Ma- ity of self-etch adhesives bonded to dentin. J Dent Res. ter. 2013;29(8):888-97. 2005;84(12):1160-4. 28. Oguri M, Yoshida Y, Yoshihara K, Miyauchi T, Nakamura Y, 20. Van Landuyt KL, Yoshida Y, Hirata I, Snauwaert J, De Munck Shimoda S, et al. Effects of functional monomers and pho- J, Okazaki M, Suzuki K, Lambrechts P, Van Meerbeek B. In- to-initiators on the degree of conversion of a dental adhe- fluence of the chemical structure of functional monomers on sive. ActaBiomater. 2012;8(5):1928-34. their adhesive performance. J Dent Res. 2008;87(8):757-61. 29. De Moor RG, Verbeeck RM, De Maeyer EA. Fluoride re- 21. Yoshihara K, Yoshida Y, Hayakawa S, Nagaoka N, Irie M, lease profiles of restorative glass ionomer formulations. Ogawa T, et al. Nanolayering of phosphoric acid ester mono- Dent Mater. 1996; 12(2):88-95. mer on enamel and dentin. ActaBiomater. 2011;7(8):3187-95. 30. Billington RW, Williams JA, Pearson GJ. Ion processes in 22. Yoshihara K, Yoshida Y, Nagaoka N, Fukegawa D, Hayaka- glass ionomer cements. J Dent. 2006; 34(8):544-55. wa S, Mine A, Nakamura M, Minagi S, Osaka A, Suzuki K, 31. Hasan AMHR, Sidhu SK, Nicholson JW. Fluoride release Van Meerbeek B. Nano-controlled molecular interaction at and uptake in enhanced bioactivity glass ionomer cement adhesive interfaces for hard tissue reconstruction. ActaBio- (“glass carbomer™”) compared with conventional and res- mater. 2010;6(9):3573-82. in-modified glass ionomer cements. J Appl Oral Sci. 2019 23. Vaidyanathan J, Vaidyanathan TK, Kerrigan JE. Evaluation 21;27:e20180230. 10.59987/ads/2023.3.11-15 15 

https://www.annalidistomatologia.eu/ads/article/view/251

Original Article Modification of cognitive function induced by a functional orthodontic device Francesco Pachì1 In the field of functional orthodontics, mastication can ac- Ruggero Turlà1 tivate specific muscular groups, influencing trophism of Anastasia Romano1 the bone segment which these muscles are inserted in Roberta Condò1 [1] or originate from [2]. Aldo Giancotti1 Furthermore, several theories suggest that the stomato- gnathic apparatus can be meant as an “access door” to 1 Department of Clinical Sciences and Translational the whole body. The lack of occlusal balance might have Medicine, University of Rome “Tor Vergata” negative repercussions on different body locations, and one may presume that recovering a proper masticatory Corresponding author: Aldo Giancotti function seems to be associated to the resolution of nu- [email protected] merous pathologies and diseases. In the last two decades, literature has sought to exam- Abstract ine the correlation between an impaired mastication and Chewing is one of the most important orofacial structural alterations of all those cerebral areas that are functions. Over the last twenty years, a number of involved during chewing. Masticatory performance could authors have examined the correlation between an be linked in a relationship of direct proportionality to ce- efficient chewing function and different aspects of rebral blood flow [3,4], to cerebral oxygenation, to gray body functions: implementation of cognitive func- volume matter (GMV) and to the number of intercon- tions, reduction of nociceptive impulse propagation, nections between different cerebral areas [5]. In elderly reduced levels of stress, reduced risk of developing individuals, with an inadequate number of dental ele- atherosclerosis and desaturation, limitation of eating ments, the cerebellar and motor cortex GMV undergoes disorders and constipation. Starting from the above a significant reduction, as well as a dorsolateral prefron- considerations, this study aims at investigating the tal cortex (DLPFC), which is physiologically involved in correlation between occlusal balance – without which cognitive processes and in the expression of personality. there would be no proper mastication – and funda- Based on findings, it is not difficult to understand how mental aspects as cognitive function, stress, arousal advancing age is, in most cases, associated with a loss and concentration. For this purpose, we used specif- of the cognitive function [6,7]. ic tools and software to observe the electrical activity The use of functional connectivity magnetic resonance of the brain in 10 healthy volunteers. All the measure- imaging (fcMRI) allows to highlight the brain areas main- ments for each participant have been carried out in ly involved during chewing. In particular, there seems to be a connection between the motor cortex and the three different phases: a first phase in which all the post-central gyrus, the cingulate and precuneus cortex, individuals were in a condition of initial occlusion; a as well as the cerebellum, with the bilateral sensory-mo- second phase in which the occlusion was modified tor cortex, the superior temporal gyrus and the superior using a functional orthodontic device; and a third cingulate left cortex. Deficient chewing can suppress the phase, in which individuals removed the device. The proliferation of dentate gyrus cells [8] and trigger hippo- variations between three phases have been evaluated campal degeneration [9], resulting in impaired spatial by using the Student’s t-test, and we considered them memory [10]. A limited number of dental elements seems significant for p<0.05. The results have highlighted a to be linked to worsened cognitive-attentive functions significant variation in terms of stress, arousal and in patients affected by Alzheimer’s disease [11]; it also concentration among the three phases. seems to be connected with impaired learning ability, re- lated to degeneration of periodontal mechanoreceptors, Keywords: cognitive function 1; elastodontic appli- with a consequential suppression of sensory feedback, ances 2; chewing 3 which becomes rather insufficient and can cause central atrophy [8]. Moreover, because of human connectome, Introduction there might be a correlation between the Broca praxic language area and the area of the motor mastication and Chewing is essential for the appropriate nutrition of every swallowing control in brain cortex; hence, language skills person, for both physical and mental well-being. Howev- and feeding quality could be interconnected [12]. er, chewing is guaranteed only by the presence of most In addition to cognitive functions, several studies have or all dental elements, by a balanced intercuspation and highlighted the interdependence between higher levels proper intraoral and extraoral muscular function. of trigeminal stress and nociception suppression, with 10.59987/ads/2023.3.23-27 23  Modification of cognitive function induced by a functional orthodontic device rising levels of serotonin and norepinephrine in the blood set; the latter must adhere to the scalp, corresponding [13,14], reduced stress and salivary cortisol [15,16], to the main brain areas (Figure 1), to allow the uptake greater alertness and concentration [17-19], alleviation of neuronal electrical signals. To monitor the percentage of depression [20] and improvement in coordination and of contact between the helmet and the scalp – which posture [21,22]. should range between 98% and 100% to be optimal and Finally, other authors have examined the relation among reliable, and to obtain useful data for experimental pur- impaired chewing and atherosclerosis [23], decreased poses - the Emotiv BCI software was used. gastrointestinal motility [24], and higher incidence of Thanks to its Performance Metrics, the function mea- chronic obstructive pulmonary disease [25]. sures six cognitive conditions on a Time-Value graph: On the other hand, an adequate number of dental ele- “stress” (FRU), “engagement” (ENG), “interest” (VAL), ments would seem to reduce obesity incidence, thanks “focus” (FOC), “excitement” (EXC), “relaxation” (MED). to the stimulation of lipolysis in the visceral adipose tis- “Stress” refers to the degree of comfort experienced sue and a better satiety state because of the activation by the individual at the time of measurement. The “en- of histaminergic fibers of the hypothalamus’ ventrome- gagement” condition indicates the extent of the state of dial [26]. Moreover, Kimura et al. have underscored the alertness and attention to external stimuli. “Interest” is reduced incidence of anorexia disorders [27]. nothing more than the amount of attraction or aversion Based on the above considerations, the following study to existing stimuli. “Focus” expresses the degree of con- aims at exploring the correlation between the use of an centration stability. “Excitement” reflects a physiological orthodontic device (i.e. functional activator) and varia- state of “arousal”, or rather activation of the sympathetic tions in terms of cognitive function, stress, alertness and nervous system. Finally, “relaxation” indicates the abili- concentration. ty to recover after an intense concentration phase. The changes in the values of such conditions were monitored Materials and Methods and recorded in three distinct phases, each lasting 10 minutes: phase 1) the subject was observed at rest, be- For the study, 10 volunteers were recruited, including fore using the activator (Figure 2); phase 2) the subject 7 males and 3 females, aged between 22 and 30, with was monitored during the use of the activator; phase 3) an average age of 27.7 yrs (± SD 2.6). At the time of data was collected at rest, after activator removal. For measurements, none of the individuals was undergoing the experiment, a U4 activator was used, at a low level, orthodontic treatment. No temporomandibular joint dis- both in the body and in the shields, for several reasons: orders nor degenerative disorders affecting the nervous to avoid bulkiness, minimize discomfort and measure- system were recorded. ment distortion, to guarantee a neutral action, thanks to Each patient was asked to wear the Emotiv Pro+ hel- its advancement wall built in class I. met, a device that can detect brain electrical activity, re- Data for each phase was recorded every 10 seconds; in turning a sort of electroencephalographic outcome. The turn, at the end of the experiment, 60 values per phase device consists of 2 sensors, which must be positioned were recorded for each subject. The value average of all in the retro-auricular region, in correspondence with the subjects enabled to obtain a single reference parameter mastoid process of the temporal bone, and 14 sponge for each cognitive condition in each phase. Hence, it was electrodes, screwed to the end of each arm of the head- possible to compare phase 1 with phase 2, phase 2 with Figure 2. The activator is a removable elastomeric materi- al device, the “fulcrum” of functional orthodontic treatment based on dentosophy. It consists of a single block which contacts both arches, and it is equipped with vestibular, pal- atal and lingual shields, through which the proper balance between extrinsic forces – i.e. perioral musculature – and Figure 1. AF3, F7, F3, FC5, T7, P7, O1, O2, P8, T8, FC6, intrinsic forces – i.e. tongue - is restored; this way, maxillary F4, F8, AF4 are the brain areas where the sponge elec- growth is properly oriented. Moreover, by using such device, trodes are positioned. DRL and CMS indicate the position of it is possible to re-educate neurovegetative functions such the control electrodes. as swallowing, phonation, chewing and breathing. 24 10.59987/ads/2023.3.23-27 F. Pachi et al. phase 3, phase 3 with phase 1. For this purpose, the “p” 2 and 3 (Table 2), although the variations in “stress”, “en- significance of variations was considered using a Stu- gagement” and “interest” were not statistically significant, dent’s t-test. To be considered significant, the variation the conditions “focus”, “excitement” and “relaxation” as- value was to be p value < 0.05. All measurements were sumed significance (p < 0.05). Also comparing phase 3 carried out by a single operator. with phase 1 (Table 3), for both “focus” and “excitement” significant values were recorded; the same cannot be Results said for the other four conditions. To compare phase 1 with phase 2, phase 2 with phase Discussion 3, phase 3 with phase 1, the average values of each cognitive condition were calculated in each of the three In particular, “relaxation” was recorded as more remark- phases. The significance of the variations between the able in phase 3 (Figure 3). A possible explanation could phase pairs was assessed by means of the Student’s be that the insertion of the activator, in phase 2, as a t-Test distribution. Comparing phases 1 and 2 (Table 1), new variable in the stomatognathic system led to an in- no significant changes were recorded across the six con- crease of the muscular function of the patient and, con- ditions (p > 0.05). On the other hand, comparing phases sequently, an impairment in terms of relaxation, though Table 1. Comparison table between T0 (phase 2) and T1 (phase 1). VARIABLES T0 T1 T1-T0 Average DV Average DV Average t Test (p) FRU 39,177 10,570 45,203 14,835 6,026 0,120 * ENG 61,812 8,281 64,403 10,096 2,591 0,414 * VAL 55,301 5,141 57,173 9,816 1,872 0,634 * FOC 25,955 9,140 28,384 11,434 2,429 0,578 * EXC 39,942 5,990 41,427 5,540 1,485 0,571 * MED 26,793 9,210 30,736 11,612 3,943 0,182 * * Student’s t-Test. Bold indicates statistically significant difference. Table 2. Comparison table between T0 (phase 3) and T1 (phase 2). VARIABLES T0 T1 T1-T0 Average DV Average DV Average t Test (p) FRU 45,169 14,825 39,177 10,570 -5,99 0,360 * ENG 58,017 7,719 61,812 8,281 3,795 0,106 * VAL 60,427 6,225 55,301 5,141 -5,126 0,112 * FOC 38,542 12,478 25,955 9,140 -12.587 0,011 * EXC 47,331 4,849 39,942 5,540 -7,389 0,026 * MED 31,870 11,740 26,793 9,210 -5,077 0,045 * * Student’s t-Test. Bold indicates statistically significant difference. Table 3. Comparison table between T0 (phase 1) and T1 (phase 3). VARIABLES T0 T1 T1-T0 Average DV Average DV Average t Test (p) FRU 45,203 14,835 45,169 14,825 -0,034 0,995 * ENG 64,403 10,096 58,017 7,719 -6,386 0,093 * VAL 57,173 9,816 60,427 6,225 3,254 0,176 * FOC 28,384 11,434 38,542 12,478 10,159 0,035 * EXC 41,427 5,540 47,331 4,849 5,904 0,052 * MED 30,736 11,612 31,870 11,740 1,134 0,727 * * Student’s t-Test. Bold indicates statistically significant difference. 10.59987/ads/2023.3.23-27 25  Modification of cognitive function induced by a functional orthodontic device Figure 3. Histogram showing the mean values of each patient for each condition. The values in phase 1 are shown in pink, those in phase 2 in yellow, those in phase 3 in blue. The conditions we are most interested in are those that have shown significance in the variations between the phases in the previous tables, i.e. “focus”, “excitement” and “relaxation”. All three significantly reduce in phase 2, but only “focus” and “excitement” significantly increase in phase 3, after removing the activator. This could support the hypothesis that the occlusal balance is correlated with the systemic one, and that the functional activator, by restoring the occlusal balance, might have some repercussions at the systemic level, specifically on the cognitive sphere. quite statistically imperceptible, at p > 0.05 comparing phases 2 and 3, as well as between phases 1 and 3. phases 1 and 2. However, after removing the activator, Hence, one can presume that the activator’s use, com- the values increased again with a significant variation, bined with the crunching muscular activity, generates as can be seen from the comparison between phase a proprioceptive stimulus that raises both “focus” and 2 and phase 3; this would indicate an increase in the “excitement”. Consequently, once activator use is com- relaxation level of the subject as the device is removed. pleted, cortical activity increases, raising attention and Indeed, most patients in the sample reported having concentration levels in turn. perceived somewhat muscle soreness by the end of the experiment, associated with a sense of relief upon Conclusions activator removal. On the other hand, “focus” and “excitement” report- Therefore, considering the collected data, the variables ed different results. Both being part of the cognitive of concentration, excitement and relaxation are the as- sphere, these conditions significantly increased from pects undergoing the most significant variation. Among phase 2 to phase 3. This would suggest that a modifi- these, the ones that draw our attention are “focus” and cation of the proprioceptive inputs, which are centrally “excitement”: they significantly increased in phase 3 – transmitted, can be associated with a variation of the compared to phase 2, in which the activator was insert- cognitive function, thus confirming a theory support- ed in the mouth, but also considering the initial situation ed by several authors, including Sakamoto. In one of represented by phase 1 – they suggest that the device his studies, the latter showed how the reaction time to can actually trigger a change in the cognitive function, the auditory oddball paradigm substantially decreased identified in the increased ability to concentrate and pay in the phase immediately after the end of a chewing attention to external stimuli. Moreover, it is possible to exercise [7]. Similarly, in a study conducted by Wilkin- continue to hypothesize a link between the use of the son, the author explained that chewing gum can raise functional activator – and the related occlusal balance a subject’s learning skills [28]. Kawakami too highlight- and benefits for brain activity. It is worth highlighting the ed a reduced reaction time to the Stroop test during fact that only 10 patients were observed in the study. a gum chewing exercise [3]. Furthermore, introducing One can assume that by expanding the sample, even the concept of dentosophy, Montaud hypothesized the those variations that have reached values not far from existence of an interdependence between occlusal bal- significance – such as “engagement” between phase 2 ance and systemic balance [29]. and phase 3 – one can reach a p < 0.05. Further studies Concerning “relaxation”, removing the device reduces are required to gain more insightful data. muscular activation due to the thickness of the utilized material. Such thickness generates greater muscular References activity while the system tends to adapt to the greater 1. Matsumoto, K.; Amemiya, T.; Ito, M.; Hayashi, Y.; Watanabe, K.; occlusal vertical dimension. On the other hand, device Dezawa, K.; Arai, Y.; Honda, K. Newly developed mastication removal reduces temporary fatigue as “relaxation” in- activity reduction procedure rapidly induces abnormal atrophic creases between phases 2 and 3. The most relevant change of the mandibular condyle in young and elder experi- difference across measurements appears upon device mental animal models. Journal of Oral Science 2020, 62(1), removal rather than during its use. This might suggest 62-66 2. Aranud-Brachet, M.; Foletti, J.M.; Graillon, N.; Chaumoître, K.; that the device’s effect manifests over time and not Chossegros, C.; Guyot, L. Could mastication modify the shape immediately. Indeed, we have recorded significant dif- of the orbit? A scannographic study in humans. Surgical and ferences in terms of “focus” and “excitement” between Radiologic Anatomy 2019, 42(1), 63-67 26 10.59987/ads/2023.3.23-27 F. Pachi et al. 3. Kawakami, Y.; Takeda, T.; Konno, M.; Suzuki, Y.; Kawano, Y.; 17. Masumoto, Y.; Morinushi, T.; Kawasaki, H.; Ogura, T.; Takigawa, Ozawa, T.; Kondo, Y.; Sakatani, K. Relationships Between Gum M. Effects of three principal constituents in chewing gum on Chewing and Stroop Test: A Pilot Study. Advances in Experi- electroencephalographic activity. Psychiatric and Clinical Neu- mental Medicine and Biology 2017, 977, 221-226 rosciences 1999, 53(1), 17-23 4. Kanzaki, H.; Wada, S.; Kumazawa, M.; Yamada, Y.; Sudo, T.; 18. Sakamoto, K.; Nakata, H.; Yumoto, M.; Sadato, N.; Kakigi, R. Ozawa, E.; Seko, T.; Akaike, S.; Murakami, M.; Oikawa, T.; Oku- Mastication accelerates Go/No-go decisional processing: An mura, S.; Nakamura, Y.; Tomonari, H. Mandibular prognathism event-related potential study. Clinical Neurophysiology 2015, attenuates brain blood flow induced by chewing. Scientific Re- 126, 2099-2107 ports 2019, 9(1), 19104 19. Shibuya, K.; Misegawa, M.; Fukuhara, M.; Hirano, S.; Suzuki, 5. Chuhuaicura, P.; Dias, F.J.; Arias, A.; Lezcano, M.F.; Fuentes, K.; Sato, N. The Response Time of the Stroop Test Is Delayed R. Mastication as a protective factor of the cognitive decline during Lemon-Flavored Gum Chewing. Journal of Nutritional in adults: A qualitative systematic review. International Dental Science and Vitaminology 2018, 64(3), 239-242 Journal 2019, 69(5), 334-340 20. Erbay, F.M.; Aydin, N.; Sati-Kirkan T. Chewing gum may be an 6. Lin, C-S.; Wu, S-Y.; Wu, C-Y.; Ko, H-W. Gray Matter Volume effective complementary therapy in patients with mild to moder- and Resting-State Functional Connectivity of the Motor Cortex- ate depression. Appetite 2013, 65, 31-34 Cerebellum Network Reflect the Individual Variation in Mastica- 21. Stanek, E. 4th; Cheng, S.; Takatoh, J.; Han, B-X.; Wang, F. tory Performance in Healthy Elderly People. Frontiers in Aging Monosynaptic premotor circuit tracing reveals neural substrates Neuroscience 2016, 7, 247 for oro-motor coordination. eLife 2014, 3, e02511 7. Sakamoto, K.; Nakata, H.; Kakigi, R. The effect of mastication 22. Maezawa, H.; Koganemaru, S.; Matsuhashi, M.; Hirata, M.; Fu- on human cognitive processing: A study using event-related po- nahashi, M.; Mima, T. Entrainment of chewing rhythm by gait tentials. Clinical Neurophysiology 2009, 120(1), 41-50 speed during treadmill walking in humans. Neuroscience Re- 8. Ono, Y.; Yamamoto, T.; Kubo, K-Y.; Onozuka, M. Occlusion and search 2020, 156, 88-94 brain function: Mastication as a prevention of cognitive dysfunc- 23. Kida, M.; Ono, T.; Kokubo, Y.; Yoshimuta, Y.; Kosaka, T.; Kikui, tion. Journal of Oral Rehabilitation 2010, 37, 624-640 M.; Yamamoto, M-A.; Ikebe, K.; Maeda, Y.; Nokubi, T.; Nishimu- 9. Quintero, A.; Ichesco, E.; Schutt, R.; Myers, C.; Peltier, S.; Ger- ra, K.; Watanabe, M.; Higashiyama, A.; Miyamoto, Y. Decreased stner, G.: Functional connectivity of human chewing: an fcMRI masticatory performance is related to increased intima-media study. Journal of Dental Research 2013, 92(3), 272-278 thickness in a general urban Japanese population: The Suita 10. Minoru, O.; Kazuko, W.; Seyed M.M.; Satoru O.; Katsuhiro N.; study. Journal of Prosthodontic Research 2020, 64(3), 346–353 Nobuyuki K.; Ikuko N. Reduced mastication stimulates impair- 24. Roslan, F.; Kushairi, A.; Cappuyns, L.; Daliya, P.; Adiamah, A. ment of spatial memory and degeneration of hippocampal The Impact of Sham Feeding with Chewing Gum on Postopera- neurons in aged SAMP8 mice. Brain Research 1999, 826(1), tive Ileus Following Colorectal Surgery: a Meta-Analysis of Ran- 148–153 domised Controlled Trials. Journal of Gastrointestinal Surgery 11. De Cicco, V. Central syntropic effects elicited by trigeminal pro- 2020, 24(11), 2643-2653 prioceptive equilibrium in Alzheimer’s disease: a case report. 25. Terashima, T.; Nakajima, T.; Matsuzaki, T.; Iwami, E.; Shibui, T.; Journal of Medical Case Reports 2012, 6, 161 Nomura, T.; Katakura, A. Chewing ability and desaturation dur- 12. Couly, G. To eat or to speak. Médecine/Sciences 2020, 36(2), ing chewing in patients with COPD. Monaldi Archives for Chest 160-16 Disease 2019, 89(3) 13. Kamiya, K.; Fumoto, M.; Kikuchi, H.; Sekiyama, T.; Mohri-Ikuza- 26. Sakata, T.; Yoshimatsu, H.; Masaki, T.; Tsuda, K. Anti-Obesity wa, Y.; Umino, M.; Arita, H.: Prolonged gum chewing evokes ac- Actions of Mastication Driven by Histamine Neurons in Rats. tivation of the ventral part of prefrontal cortex and suppression Experimental Biology and Medicine 2003, 228, 1106-1110 of nociceptive responses: involvement of the serotoninergic 27. Kimura, Y.; Iwasaki, M.; Ishimoto, Y.; Sasiwongsaroj, K.; Saka- system. Journal of medical and dental sciences 2010, 57, 35-43 moto, R.; Wada, T.; Fujisawa, M.; Okumiya, K.; Miyazaki, H.; 14. Wakayama, K.; Ohtsuki, S.; Takanaga, H.; Hosoya, K.; Terasa- Matsubayashi, K. Association between anorexia and poor ki, T. Localization of norepinephrine and serotonin transporter in chewing ability among community-dwelling older adults in Ja- mouse brain capillary endothelial cells. Neuroscience Research pan. Geriatrics & Gerontology International 2019, 19(12), 1290- 2002, 44(2), 173-180 1292 15. Hollingworth, H.L. Chewing as a technique of relaxation. Sci- 28. Wilkinson, L.; Scholey, A.; Wesnes, K. Chewing gum selectively ence 1939, 90(2339), 385-7 improves aspects of memory in healthy volunteers. Appetite 16. Tahara, Y.; Sakurai, K.; Ando, T. Influence of Chewing and 2002, 38, 235-236 Clenching on Salivary Cortisol Levels as an Indicator of Stress. 29. Montaud, M. Denti & Salute. Dalla salute della bocca alla salute Journal of Prosthodontics 2007, 16(2):129-35 del corpo; Terra Nuova Edizioni, Firenze, Italia, 2009 10.59987/ads/2023.3.23-27 27 

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Case report Guided implant-prosthetic rehabilitation: a clinical case report Oddi Carlo landmarks for surgery [4]; second, the direct transfer of Collina Giorgio implant position from the pre-surgical plane to the dental Palmacci Matteo* laboratory makes possible the pre-fabrication of an im- Sgreggia Roberto* mediate-load fixed acrylic resin complete denture. Grassi Alessia* Thus, it becomes evident that the software-guided sur- Nagni Matteo* gical-prosthetic protocol has several clinical advantages such as optimizing all available residual bone to avoid re- *Dental School, Vita-Salute San Raffaele University, Mi- generative procedures, reducing the number of surgical lan, Italy and Department of Dentistry, IRCCS San Raf- procedures, decreasing the invasiveness of the surgery, faele Hospital, Milan, Italy and shortening the time between surgery and delivery of the prosthesis, minimizing the patient’s postoperative Corresponding author: Palmacci Matteo discomfort, with good predictability of functional and aes- [email protected] thetic results [5] [6]. Therefore, flapless-guided surgery requires less time and at the same time allows reducing bleeding and post-surgi- Abstract cal complications (trismus, swelling, hematoma). The advent of new assisted design software in combi- In addition, a flapless approach maintains high osteo- nation with computed tomography (CT) has increased genic potential and blood supply to the underlying im- the possibility of rehabilitating edentulous jaws with plants, allowing intimate contact between the periosteum implant-supported fixed prostheses, allowing flapless and bone while preserving the integrity of the supra-peri- surgery and immediate loading even in the presence osteal plexus [7] [8]. of critical bone volume. Aim: The aim of the present The current work-flow for guided implant surgery incor- study is to demonstrate how the use of advanced porates new technologies such as intra-oral optical scan- technologies supported by specific software allows ners, in-office CBCT, virtual implant planning software, the design and execution of optimal implant surgery and 3D printers. Which of these advanced modalities the while going on to decrease what could be intra- and practitioner chooses to use will depend on equipment postoperative risks. availability and experience level [9]. Keywords: All-on-six, Computer guided implant sur- Materials and Methods gery, Flapless implant surgery, Dental implants, Com- The patient, a 52-year-old man in good general health, puted Tomography, Virtual implant surgery planning. presents on objective examination having several eden- tulous areas at the level of the two arches, with greater Introduction impairment of function and aesthetics at the level of the The advent of new assisted design software in combi- upper jaw. His request is to regain optimal morpho-func- nation with computed tomography (CT) has increased tional restoration by performing a fixed prosthetic solu- the possibility of rehabilitating edentulous jaws with tion; therefore, for this reason, an immediate-loaded implant-supported fixed prostheses, allowing flapless implant-prosthetic rehabilitation of the upper maxilla surgery and immediate loading even in the presence of was proposed to the patient according to the All-on-six critical bone volume [1]. CT-guided surgery has become technique. even more accessible with the increased availability of virtual implant planning software [2]. In fact, computed Results tomography (CT) or cone-beam CT (CBCT) scans and No implants were lost during the follow-up monitoring three-dimensional surgical planning software allow the period; furthermore, no intra- and postoperative compli- clinician to analyze the patient’s anatomical structures cations were recorded. and prosthetic parameters, while at the same time virtu- ally visualizing the optimal position and direction of inser- tion of each implant [3]. Conclusion Virtual prototyping makes it possible to: produce stere- Through the use of guided technology, it is therefore olitho-graphic models that, by transferring virtual plan- possible to perform implant surgery with reduced num- ning to the surgical field, are particularly useful in the ber of implants with greater precision and safety realiz- presence of edentulous portions lacking anatomical ing a durable result with a favorable prognosis. 10.59987/ads/2023.3.3-9 3  Guided implant-prosthetic rehabilitation: a clinical case report Figure 1. Pre-operative OPT. CASE REPORT 5 mg, Roche) and under local anesthesia with 2% me- pivacaine and adrenaline 1:100000 (Carbocaine, Astra- A 52-year-old male patient presents for his first visit to Zeneca, Milan, Italy). The implants were placed with a the Department of Dentistry and Prosthodontics of the flapless technique. Vita-Salute San Raffaele Hospital directed by Prof. E.F. Gherlone. The patient presents good general health; however, following a thorough intra- and extra-oral ob- FOLLOW-UP jective examination, several areas of edentulousness Follow-up visits, aimed at clinical and radiographic ex- in the four quadrants are evident, compromising proper amination, were performed one week after implant place- masticatory function. A good state of impairment of the ment. Thereafter they were performed at three months, last remaining elements of the upper arch is also evi- six months and then annually until a follow-up of one dent. In fact, the patient came to our attention with the year was reached. The patient was adequately instruct- desire to be able to regain optimal masticatory as well ed, by a dental hygienist, in mechanical plaque control as esthetic function, with a request for a fixed prosthetic through the use of the electric or manual toothbrush, in- solution. terproximal brushes, and Super Floss type floss (Oral B, With the purpose of performing accurate morpho-func- Procter & Gamble, Cincinnati, OH, USA). Whereas, pro- tional restoration, the patient was proposed an immedi- fessional oral hygiene procedures were performed every ate-loaded implant-prosthetic rehabilitation of the upper three months following implant placement. jaw according to the All-on-six technique. Planning of the surgery was carried out through the use Parameters evaluated of CREA-3D Software (BioSAFin). Through the realized surgical protocol, four axial implants were planned at the Implants survival rate level of the anterior area; the implants placed in place Implant survival rate is based on the number of implants 12 and 22 having a diameter of 3.8 mm and a length of that were not lost or removed, throughout the follow-up 6 mm; in place, instead, 14 and 24, having a diameter of period [9]. 3.8mm and a length of 9 mm. In contrast, the two tilted implants placed at sites 16 and 26 were planned with a Marginal bone loss diameter of 3.8 mm and a total length of 15 mm. Endoral radiographs, using the parallel cone technique, Cross-sections were also performed at the level of the were taken after implant placement, at three, six, and planned implant sites through the software; these al- 12 months. In order to assess the marginal bone trend, lowed us to evaluate their position in relation to the bone measurements were taken through the use of CREA-3D structure, the relevant noble anatomical structures and software (BioSAFin). First, the instrument was calibrated the related prosthetic aspects. In order to have with (pixels/mm), using the diameter of the implants as the greater clarity a visualization of the axes of implant in- unit. Next, changes in peri-implant marginal bone height sertion, an axial section was made. relative to the most coronal portion of the implant fixture The support of the CREA 3D software was of relevant and the point of contact between the implant fixture and importance as it allowed, through the use of the 3D func- the marginal ridge itself were measured. To assess the tion, a three-dimensional evaluation of the position of the trend of the bone, a line passing over the shoulder of implants, thus additionally assessing the parallelism of the implant was considered as the reference point for the EAs. measurement from which a straight line was drawn par- The surgery was performed under aseptic conditions allel to the long axis of the implant to the most coronal under oral sedation with diazepam 0.25 mg/kg (Valium point at which the bone made contact with the fixture 4 10.59987/ads/2023.3.3-9 C. Oddi et al. Figure 2. Cross-section at the site level of planned plants. 10.59987/ads/2023.3.3-9 5  Guided implant-prosthetic rehabilitation: a clinical case report Figure 3. Planning the intervention using the CREA-3D BIOSAFIN Software. both mesially and distally. The software automatically provided the distance between the two points measured in millimeters. Then, to calculate the marginal bone level, a mesial measurement was taken, a distal measurement was tak- en, and then the average of the values of the mesial, distal portion, and the average between the two values of a single implant site was quantified. RESULTS Implants survival rate The patient was monitored over one year after implant placement; what could be inferred was that no implants were lost, thus demonstrating a promising implant sur- vival rate of approximately 99% [11]. Since 2010, several reviews, including systematic ones, have been written in order to evaluate the accuracy of flapless guided sur- gery in clinical trials. In general, it can be concluded that the implant survival rate ranges from 91% to 100%, thus having confirmation of the results obtained in this clinical case [12]. Marginal bone loss Figure 4. Three-dimensional assessment of implant po- sition and parallelism of EAs using CREA-3D BIOSAFIN Axial and tilted implants revealed minimal bone loss not Software. relevant to implant stability [13]. 6 10.59987/ads/2023.3.3-9 C. Oddi et al. Figure 5. Radiography in the immediate postoperative period. Figure 6. Postoperative radiography at one year. MARGINAL Axial Implants in place Axial Implants in place Tilted implants BONE LOSS 1.2 e 2.2 1.4 e 2.4 6 months (mm) 0.53 ± 0.76 0.61 ± 0.65 0.71 ± 0.69 1 year (mm) 0.85 ± 0.87 0.85 ± 0.88 0.90 ± 0.88 10.59987/ads/2023.3.3-9 7  Guided implant-prosthetic rehabilitation: a clinical case report Discussion Jan;65(1):67-80. doi: 10.1016/j.cden.2020.09.005. Epub 2020 Nov 2. PMID: 33213716. Individually analyzed risk factors show that several pre- 3. (La Monaca G, Pranno N, Annibali S, Di Carlo S, Pompa operative factors could influence the accuracy of soft- G, Cristalli MP. Immediate flapless full-arch rehabilitation ware-guided surgery. of edentulous jaws on 4 or 6 implants according to the One advantage in accuracy is having more than seven prosthetic-driven planning and guided implant surgery: A unrestored teeth to perform CBCT and surface scan retrospective study on clinical and radiographic outcomes up to 10 years of follow-up. Clin Implant Dent Relat Res. matching. In addition, it was found that longer implants 2022 Oct 5. doi: 10.1111/cid.13134. Epub ahead of print. demonstrated more accurate guided placement of the PMID: 36197040) same. There are also variables dependent on the op- 4. Arisan V, Karabuda CZ, Ozdemir T. Implant surgery using erating system chosen, which could not be evaluated in bone- and mucosa-supported stereolithographic guides this specific study because only one system was used in totally edentulous jaws: surgical and post-operative [14] [15]. In fact, many factors would seem to influence outcomes of computer-aided vs. standard techniques. the outcome of the surgical procedure; if the accuracy Clin Oral Implants Res. 2010;21(9):980-988. doi:10.1111 data from the current study are compared with the dis- /j.1600-0501.2010.01957. tances of the matching error, it can be concluded that 5. Hultin M, Svensson KG, Trulsson M. Clinical advantages the matching error (0.2 mm on average for an experi- of computerguided implant placement: a systematic re- view. Clin Oral Implants Res. 2012;23(Suppl 6):124-135. enced user) is likely to have little influence on guided doi:10.1111/j.1600-0501.2012.02545. access, when compared with all surgical and technical 6. D’haese J, Van De Velde T, Komiyama A, Hultin M, De factors [16]. Other studies have also shown that drills Bruyn H. Accuracy and complications using computer-de- and sheaths possess some freedom of movement, and signed stereolithographic surgical guides for oral rehabili- this could easily lead to lateral deviation of implants [17]. tation by means of dental implants: a review of the litera- Last but not least, it should be emphasized that the us- ture. Clin Implant Dent Relat Res. 2012; 14(3):321-335. do er’s own individual performance may have an influence i:10.1111/j.1708-8208.2010.00275. on the accuracy of matching with an algorithm (ICP) and 7. Laleman I, Bernard L, Vercruyssen M, Jacobs R, Bornstein therefore extensive training is recommended. Matching MM, Quirynen M. Guided implant surgery in the edentulous maxilla: a systematic review. Int J Oral Maxillofac Implants. errors should be reduced if the vestibular and lingual 2016;31(Suppl): s103-s117. doi:10.11607/jomi.16suppl. surfaces of CBCT scans aided with optical scans are 8. Naeini EN, Atashkadeh M, De Bruyn H, D’Haese J. Nar- used [18]. Therefore, to avoid further possible errors, it is rative review regarding the applicability, accuracy, and recommended to separate the maxillary and mandibular clinical outcome of flapless implant surgery with or with- dentition when performing any three-dimensional CBCT out computer guidance. Clin Implant Dent Relat Res. scan. Consequently, any scan can be used for com- 2020;22(4):454-467. doi:10.1111/cid.12901 puter-guided surgery [19]. The application of a guided 9. Flugge TV, Nelson K, Schmelzeisen R, et al. Three-di- surgery procedure such as the one described simplifies mensional plotting and printing of an implant drilling guide: the possibility of transferring preoperative planning to the simplifying guided implant surgery. J Oral Maxillofac Surg surgical field [20]. This study demonstrated such simpli- 2013;71:1340–6. 10. Andrade CAS, Paz JLC, de Melo GS, Mahrouseh N, fication, as all placed implants were screwable through Januário AL, Capeletti LR. Survival rate and peri-implant direct straight occlusal access [21]. In addition, the pa- evaluation of immediately loaded dental implants in individ- tient benefits from lower morbidity due to less invasive uals with type 2 diabetes mellitus: a systematic review and surgical wounds and shorter operative times [21]. meta-analysis. Clin Oral Investig. 2022 Feb;26(2):1797- In contrast, this surgical timing advantage is counteract- 1810. doi: 10.1007/s00784-021-04154-6. Epub 2021 Sep ed by the complexity of time-consuming preoperative 29. PMID: 34586502; PMCID: PMC8479496. guided surgical planning [22]. 11. Frosch, L., Mukaddam, K., Filippi, A., Zitzmann, N., & Kuhl, S. (2019). Comparison of heat generation between guided and conventional implant surgery for single and sequential Conclusions drilling protocols‐an in vitro study. Clinical Oral Implants Re- search, 30(2), 121–130. https://doi. org/10.1111/clr.13398. Thus, computer-guided implant surgery based on scans 12. D’haese J, Ackhurst J, Wismeijer D, De Bruyn H, Tah- performed with CBCT and intra-oral scans appears to be maseb A. Current state of the art of computer-guided im- a viable surgical treatment option. plant surgery. Periodontol 2000. 2017 Feb;73(1):121-133. The protocol implemented has led to promising survival doi: 10.1111/prd.12175. PMID: 28000275. rates in the short term. However, even these guided sur- 13. Misch CE. Bone classification, training keys to implant suc- gery systems are not without minor errors that could af- cess. Dent Today. 1989 May;8(4):39-44. PMID: 2597401. fect their implant placement. It is therefore necessary for 14. Derksen W, Wismeijer D, Flügge T, Hassan B, Tahmaseb A. The accuracy of computer-guided implant surgery with there to be an ongoing improvement of the software so tooth-supported, digitally designed drill guides based on as to reduce any deviations, and it is important to know CBCT and intraoral scanning. A prospective cohort study. these limitations so as to allow for increasing accuracy, Clin Oral Implants Res. 2019 Oct;30(10):1005-1015. doi: regardless of multi-factorial agents that could alter the 10.1111/clr.13514. Epub 2019 Sep 9. PMID: 31330566. expected outcome. 15. D’Haese, J.,Vervaeke, S.,Verbanck, N., & De Bruyn, H. (2013). Clinical and radiographic outcome of implants placed using stereolithographic guided surgery: A pro- References spective monocenter study. International Journal of Oral 1. D’haese J, Ackhurst J, Wismeijer D, De Bruyn H, Tah- and Maxillofacial Implants, 28, 205–215. https://doi. maseb A. Current state of the art of computer-guided org/10.11607/jomi.2618. implant surgery. Periodontol 2000. 2017;73(1):121-133. 16. Ender, A., Attin, T., & Mehl, A. (2016). In vivo precision of doi:10.1111/prd.12175 conventional and digital methods of obtaining complete‐ 2. Chen P, Nikoyan L. Guided Implant Surgery: A Tech- arch dental impressions. Journal of Prosthetic Dentistry, nique Whose Time Has Come. Dent Clin North Am. 2021 115, 313–320. 8 10.59987/ads/2023.3.3-9 C. Oddi et al. 17. Koop, R., Vercruyssen, M., Vermeulen, K., & Quirynen, 20. Vercruyssen, M., De Laat, A., Coucke, W., & Quirynen, M. M. (2013). Tolerance within the sleeve inserts of different (2014). An RCT comparing patient‐centred outcome vari- surgical guides for guided implant surgery. Clinical Oral ables of guided sur‐ gery (bone or mucosa supported) with Implants Research, 24, 630–634. https://doi.org/10.1111 conventional implant place‐ ment. Journal of Clinical Peri- /j.1600-0501.2012.02436. odontology, 41, 724–732. https://doi. org/10.1111/jcpe.12257 18. Noh, H., Nabha, W., Cho, J. H., & Hwang, H. S. (2011). 21. Testori, T., Robiony, M., Parenti, A., Luongo, G., Rosen- Registration accu‐ racy in the integration of laser‐scanned feld, A. L., Ganz, S. D., Del Fabbro, M. (2014). Evaluation dental images into maxillofa‐ cial cone‐beam computed of accuracy and precision of a new guided surgery sys- tomography images. American Journal of Orthodontics tem: A multicenter clinical study. International Journal of and Dentofacial Orthopedics, 140, 585–591. https://doi. Periodontics & Restorative Dentistry, 34(Suppl 3), s59–69. org/10.1016/j.ajodo.2011.04.018 22. Lal, K., Eisig, S. B., Fine, J. B., & Papaspyridakos, P. 19. Parsa, A., Ibrahim, N., Hassan, B., Syriopoulos, K., & van (2013). Prosthetic outcomes and survival rates of im- der Stelt, P. (2014). Assessment of metal artefact reduc- plants placed with guided flapless surgery using stereo- tion around dental ti‐ tanium implants in cone beam ct. lithographic templates: A retrospective study. International Dentomaxillofacial Radiology, 43, 20140019. https://doi. Journal of Periodontics and Restorative Dentistry, 33, org/10.1259/dmfr.20140019 661–667. https://doi.org/10.11607/prd.1113 10.59987/ads/2023.3.3-9 9 

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Case report Deep bite and dental crowding in a growing patient treated using invisalign first: a case report Arianna Malara1 valid strategy to solve orthodontic issues such as dental Silvia Fanelli1 crowding, arch forms, and space loss for normal dental Giuseppina Laganà1,2 eruption. Furthermore, a good esthetic, proper oral hy- giene and stable results were obtained using Invisalign 1 Department of Systems Medicine, University of Rome First system. “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy INTRODUCTION 2 UniCamillus - Saint Camillus International University of Health Sciences, Rome, Italy Case report This case report describes a growing male patient with Corresponding author: Arianna Malara dentoskeletal class I, dental crowding and inadequate [email protected] space for of 1.2 e 4.2 eruption, treated successfully with aligners. Abstract Aim: the aim of this case report is to confirm that In- MATERIALS AND METHODS visalign First system is an optimal and effective ther- apeutic choice in growing patient with deep bite and Diagnosis and etiology dental crowding. A 7-year-old growing Caucasian male presented for treatment with a chief complaint of absence of Keywords: Invisalign First, deep-bite, dental crowd- 1.2 and 4.2. The general medical history was negative ing, growing patient. for illness and allergy. The patient did not receive any previous orthodontic treatment and clinical examination showed no sign of bad habits. Extra-oral photos (Fig. Materials and Methods 1) and frontal and lateral examination revealed a facial R.P., 7 years old, male, showed a dentoskeletal Class I symmetry, coincident midlines and good exposure of up- relationship with dental crowding in both maxillary and per incisors. The profile had a convex aspect. mandibular arches, inadequate space for the eruption of Intra-oral photos (Fig. 2) and clinical examination re- 1.2 e 4.2, mesial rotation of 1.6 and 2.6, coincident mid- vealed dental class I, coincident midlines, deep- bite and line and increased overbite. dental crowding with mesial rotation of 1.6 and 2.6. Peri- The treatment plan lasted 12 months and provided an odontal biotype and oral hygiene were good. esthetic orthodontic approach using Invisalign First sys- At intra-oral evaluation, the patient showed inadequate tem to expand and restore arches form, to recover space space for 1.2 and 4.2 eruption; uncoordinate upper and for the 1.2 and 4.2 eruption, to obtain crowding resolu- mandibular arches, a bilateral molar and canine Angle tion, and manage space for elements 1.3, 2.3, 3.3 and Class I relationship, increased overbite and ideal overjet 4.3 eruption. (Figure 2). Pre- and post-treatment records are presented. Lateral cephalometric radiographs and panoramic ra- diography were obtained and analyzed. The panoramic Results radiography (Figure 3A) revealed an early mixed dentition with the absence of tooth developmental anomalies of At the end of the active therapy, functional occlusion with number, size, shape and structure, a lack of bone defects, Class I molar relationship was maintained, space was no infection, no temporomandibular joint abnormalities created for the 1.2 and 4.2 eruption and dental crowd- and inadequate space for the eruption of 1.2 and 4.2. ing was solved in both arches. Spaces of 0.1 millimeters According to Steiner’s cephalometric analysis [1], Later- mesial and distal the upper and lower deciduous canines al cephalometric radiograph (Fig. XX) showed skeletal were opened for the later eruption of the permanent ca- Class I relationship (ANB= 3°; Wits= -2 mm) and a nor- nines as evident in the OPT. Good intercuspation was modivergent growth pattern (SN^GoMe=36°; FMA=26°). achieved and midlines were maintained coincident. Maxillary incisors were normally inclined (INC- SUP^PF=106°) and mandibular incisors had a correct Conclusion inclination (IMPA=90°). Overbite was increased at the In the presented case report Invisalign First system beginning of treatment (OVB= 6) and overjet had ideal combined with an appropriate treatment staging is a values. (OVJ=4mm) as reported in Table 1. 10.59987/ads/2023.3.17-22 17  Deep bite and dental crowding in a growing patient treated using invisalign first: a case report Figure 1. Extra-oral photos before the treatment. Figure 2. Intra-oral photos before the treatment. Table 1. Cephalometric analysis before the treatment. T1 V.N. SAGITTAL SKELETAL RELATIONSHIP SNA° 77 82 +/- 2° SNB° 74 82 +/- 2° ANB° 3 2 +/- 2° WITS -2 0 +/- 2 mm VERTICAL SKELETAL RELATIONSHIP FMA° 26 25 +/- 3° SN/Go-Me° 36 33 +/- 5° SN/ANS-PNS° 9 7 +/- 3° ANS-PNS/Go-Me° 28 28 +/- 6° ArGoMe° 128 130 +/- 7° DENTAL BASE RELATIONSHIP U1/PF 106 105-110° IMPA 90 94 +/- 5° L1/A-Pg 2 2 +/- 2 mm OVB mm 4 2,5 +/- 2,5 mm OVJ mm 4 2,5 +/- 2,5 mm 18 10.59987/ads/2023.3.17-22 A. Malara et al. A B Figure 3. Panoramic radiography (A) and lateral cephalometric radiography (B) before the treatment. According to the Cervical Vertebral Maturation meth- Treatment progress od [2], the patient was in a prepubertal phase without completing his craniofacial growth (between CS1- CS2) The Invisalign ClinCheck plan dictated 35 aligners for (Figure 3B). each arch. To achieve expansion and restoration of arch forms, the plan involved a sequential expansion with “molars move first” staging planning [3-5]. The plan also Treatment goals involved arches alignment and deep bite resolution. In The primary objective was expansion and restoration of order to achieve correct alignment and valid intercuspa- arch forms, space recovery for the eruption of 1.2 and tion, Invisalign attachments were planned, while no IPR 4.2, management of space for the eruption of permanent was requested in the treatment plan. The patient was in- canines, resolution of crowding and obtain ideal overbite structed to wear each aligner 22/h per day and to move using Invisalign First system. on to the next one in the series after 7 days. 10.59987/ads/2023.3.17-22 19  Deep bite and dental crowding in a growing patient treated using invisalign first: a case report Figure 4. Extra-oral photos after the treatment. Figure 5. Intra-oral photos after the treatment. RESULTS DISCUSSION The overall treatment lasted 12 months and included 35 In this clinical case, a functional occlusion with Class I aligners. The treatment objectives had been successfully molar relationship was obtained, space was created for fulfilled (Figure 4 and 5), although it will be necessary to the element 1.2 and 4.2, crowding was solved in both plan an Invisalign Phase II treatment for detailed finishing arches. Spaces were opened for the later eruption of the of the case. Follow-up panoramic radiography showed permanent canines as evident in the panoramic radiog- good position of 1.3, 2.3, 3.3 and 4.3 (Figure 6A). raphy. Good intercuspation was achieved and midlines Post-treatment lateral teleradiograph showed that the were coincident. Good esthetic and stable results were treatment guaranteed the initial skeletal and aesthetic obtained only using Invisalign First protocol. values with and improvements of dental values (Table 2 Orthodontic developments, particularly in recent years, and Figure 6B). were accompanied by an important increase in the · Skeletal outcomes: cephalometric analysis con- esthetic demands of the patients [6]. Since 1990, In- firmed the skeletal Class I relationship (ANB=3°, visalign® technology has become recognized through- Wits=-2mm). The patient presented a properly sagit- out the world as an esthetic alternative to the fixed ap- tal position between the maxillary and mandible with pliances [7]. This system uses impressions or intraoral the maintenance of the FMA angle at the end of treat- scans which are converted through stereolithographic ment (FMA=26°); technology (.stl) into virtual models and then launched · Dental outcomes: the dental cephalometric analysis with the ClinCheck software: a three-dimensional mod- revealed the maintenance of the inclination of the up- eling program that allows a virtual simulation of teeth per and lower incisors, a proper overjet (OVJ=3mm) movements. A series of aligners is then produced in or- and the overbite improvement (OVB =3mm). The der to gain the needed corrections [8]. After its launch, mandibular incisors inclination remained stable at the the system was greatly improved in several ways: new end of treatment (IMPA=90°); attachment designs and new materials [9]. · Aesthetic outcomes: the soft tissue changes in- Most recently, Invisalign First package was presented volved a good profile with the jaws proportionately to the public, for the treatment of the malocclusions in positioned in the sagittal plane. On a frontal view the growing patients. patient showed an ideal smile arc. Early orthodontic treatment in mixed dentition is recom- 20 10.59987/ads/2023.3.17-22 A. Malara et al. A B Figure 6. Panoramic radiography (A) and lateral cephalometric radiography (B) after the treatment. mended to reduce or even eliminate the need for further is less than that of a multi-bracket treatment, especially orthodontic treatment, preventing problems or functional in the first 6 months of therapy [15]. This innovative treat- anomalies [10-12]. ment enables young patients to attend all their school Orthodontic clinicians are frequently challenged to and social activities with no aesthetic limitations. In addi- promptly identify and handle early signs of malocclusion tion, CA is a removable device which allows optimal oral that, if left untreated, could lead to the development of a hygiene along with meticulous oral care. CAT prevents more severe malocclusion with skeletal compromise and the deterioration of periodontal status, tooth decalcifica- temporomandibular symptoms [10]. tion during orthodontic treatment and speech disorders Nowadays, the employment of clear aligners (CA) is in- due to the bulkiness of the removable appliance [16]. creasingly being considered over other treatment strate- gies as aesthetics, comfort and oral hygiene are greater than that of conventional fixed appliances [13-14]. CONCLUSIONS In fact, as concerns the patient’s experience, it is be- This case report confirms that Invisalign First system is lieved that the impact of clear aligners treatment (CAT) an optimal and effective therapeutic choice in growing on daily activities (oral symptoms, functional limitations) patient with deep bite and dental crowding. 10.59987/ads/2023.3.17-22 21  Deep bite and dental crowding in a growing patient treated using invisalign first: a case report Table 2. Cephalometric analysis after the treatment T1 V.N. SAGITTAL SKELETAL RELATIONSHIP SNA° 77 82 +/- 2° SNB° 74 82 +/- 2° ANB° 3 2 +/- 2° WITS -2 0 +/- 2 mm VERTICAL SKELETAL RELATIONSHIP FMA° 26 25 +/- 3° SN/Go-Me° 36 33 +/- 5° SN/ANS-PNS° 9 7 +/- 3° ANS-PNS/Go-Me° 28 28 +/- 6° ArGoMe° 128 130 +/- 7° DENTAL BASE RELATIONSHIP U1/PF 108 105-110° IMPA 90 94 +/- 5° L1/A-Pg 2 2 +/- 2 mm OVB mm 3 2,5 +/- 2,5 mm OVJ mm 3 2,5 +/- 2,5 mm The treatment objectives had been successfully fulfilled who needed refinement. Am J Orthod Dentofac Orthop. maintaining esthetics and proper oral hygiene although 2018;154(1):47–54. it will be necessary to evaluate if II phase treatment in 8. Laganà G, Malara A, Lione R, Danesi C, Meuli S, Cozza P. Enamel interproximal reduction during treatment with clear order to detail finishing of the case. aligners: digital planning versus OrthoCAD analysis. BMC Oral Health. 2021 Apr 19;21(1):199. 9. Papadimitriou A, Mousoulea S, Gkantidis N, Kloukos D. Clini- References cal effectiveness of Invisalign® orthodontic treatment: a sys- 1. Steiner CC. Cephalometrics for you and me. Am J Orthod. tematic review. Prog Orthod. 2018;19(1):37. 1953;39:729-55. 10. Staderini E, Patini R, Meuli S, Camodeca A, Guglielmi F, 2. Baccetti T, Franchi L, McNamara JA Jr. An improved ver- Gallenzi P. Indication of clear aligners in the early treatment sion of the cervical vertebral maturation (CVM) method for of anterior crossbite: a case series. Dental Press J Orthod. the assessment of mandibular growth. Angle Orthod. 2002 2020;25(4):33-43. Aug;72(4):316-23 11. Laganà G, Abazi Y, Beshiri Nastasi E, Vinjolli F, Fabi F, Divizia 3. Lione R, Cretella Lombardo E, Paoloni V, Meuli S, Pavoni C, M, Cozza P. Oral health conditions in an Albanian adolescent Cozza P. Upper arch dimensional changes with clear align- population: an epidemiological study. BMC Oral Health. 2015 ers in the early mixed dentition: A prospective study. J Orofac Jun 14;15:67. Orthop. 2023 Jan;84(1):33-40. English. doi: 10.1007/s00056- 12. Laganà G, Masucci C, Fabi F, Bollero P, Cozza P. Prevalence 021-00332-z. Epub 2021 Sep 3. PMID: 34477905. of malocclusions, oral habits and orthodontic treatment need 4. Cretella Lombardo E, Paoloni V, Fanelli S, Pavoni C, Gazzani in a 7- to 15-year-old schoolchildren population in Tirana. Prog F, Cozza P. Evaluation of the Upper Arch Morphological Chang- Orthod. 2013 Jun 14;14:12. es after Two Different Protocols of Expansion in Early Mixed 13. Duong T, Kuo E. Finishing with invisalign. Prog Orthod. Dentition: Rapid Maxillary Expansion and Invisalign® First 2006;7(1):44-55. System. Life (Basel). 2022 Aug 26;12(9):1323. doi: 10.3390/ 14. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well life12091323. PMID: 36143360; PMCID: PMC9502768. does Invisalign work? A prospective clinical study evaluating 5. Levrini L, Carganico A, Abbate L. Maxillary expansion with clear the efficacy of tooth movement with Invisalign. Am J Orthod aligners in the mixed dentition: A preliminary study with Invis- Dentofacial Orthop. 2009 Jan;135(1):27-35. align® First system. Eur J Paediatr Dent. 2021 Jun;22(2):125- 15. Miller KB, McGorray SP, Womack R, et al. A comparison of 128. doi: 10.23804/ejpd.2021.22.02.7. PMID: 34238002. treatment impacts between Invisalign aligner and fixed appli- 6. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well ance therapy during the first week of treatment. Am J Orthod does Invisalign® work? A prospective clinical study evaluating Dentofacial Orthop. 2007 Mar; 131(3):302.e1-9. the efficacy of tooth movement with Invisalign®. Am J Orthod 16. Li X, Ren C, Wang Z, Zhao P, Wang H, Bai Y. Changes in Dentofac Orthop. 2009;135(1):27–35. force associated with the amount of aligner activation and lin- 7. Charalampakis O, Iliadi A, Ueno H, Oliver DR, Kim KB. Ac- gual bodily movement of the maxillary central incisor. Korean J curacy of clear aligners: a retrospective study of patients Orthod. 2016 Mar;46(2):65-72. 22 10.59987/ads/2023.3.17-22 

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A NNALI DI STOMATOLOGIA www.annalidistomatologia.eu VOLUME 14 NUMERO 2 - 2023 A Journal of Odontostomatologic Sciences PublyMed srls  A NNALI Annali............. DI STOMATOLOGIA EDITOR IN CHIEF D’Antò Vincenzo Di Carlo Gabriele University of Naples, Italy University of Rome “La Sapienza”, Italy Gatto Roberto [email protected] [email protected] University of L’Aquila, Italy [email protected] Basilicata Michele Falisi Giovanni University of Tor Vergata Italy University of L’Aquila, Italy [email protected] [email protected] CONSULTANT EDITORS De Angelis Francesca Marsili Domenico, Italy Allaf Ferdi University of Rome “La Sapienza”, Italy [email protected] Turkish Aligner Society,Turchia [email protected] [email protected] Nagni Matteo, Italy De Nuccio Claudio [email protected] Caruso Silvia University Cattolica del Sacro Cuore, Italy University of L’Aquila, Italy [email protected] Jamal Sied [email protected] [email protected] Yisrael Kornblit Docimo Raffaella Roly Doctor, Italy J.L. Parra Garcia University of Tor Vergata , Italy [email protected] Doctor, Mexico [email protected] [email protected] Laganà Giuseppina Giancotti Aldo University of Tor Vergata , Italy Pietropaoli Davide Department of Clinical Sciences and [email protected] University of L’Aquila, Italy Translational medicine University Tor [email protected] Vergata, Italy Mohamed R.Islam [email protected] University of Dundee, Scotland Pistilli Roberto, Italy [email protected] [email protected] Marchetti Enrico University of L’Aquila, Italy Manzo Paolo Turchetta Nicola, Italy [email protected] Member of EBO-IBO, Italy [email protected] [email protected] Mummolo Stefano Pedro Vittorini Velasquez University of L’Aquila, Italy Nota Alessandro Universidad Autonoma Gabriel Rene [email protected] University of Milan, Italy Moreno [email protected] [email protected] Severino Marco University of L’Aquila, Italy Pagano Stefano [email protected] CONTACTS University of Perugia, Italy [email protected] Do you need further information? 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[email protected] Director of the UOC Maxillofacial Surgery ASL Roma 1 Annali di Stomatologia – Editor in Chief [email protected] Roberto Gatto ASSISTANT EDITORS [email protected] Berdouses Elias Valentini Valentino Annali di Stomatologia – Managing Editor University of Athens, Greece University of Rome “La Sapienza”, Italy Alessandro Zurli Varesi [email protected] [email protected] [email protected] Nunzio Cirulli ASSOCIATE EDITORS Annali di Stomatologia – Managing Office University of Bari Donatella Alonzi [email protected] Antonangelo Carmine [email protected] [email protected] Annali di Stomatologia – Sponsor & D’Addona Antonio Marketing University Cattolica del Sacro Cuore, Italy Ciulli Emanuele, Italy Claudio de Nuccio [email protected] [email protected] [email protected] ANNALI DI STOMATOLOGIA Annali di Stomatologia 2018; IX (4): 141 II Trimestrale edito da PublyMed srls, Via Treviso, 17/A - 00161 Roma - P.I. 16532301005 +39 06 44.24.99.41 - [email protected] - www.annalidistomatologia.eu Reg. Trib. Roma n. 421 18/12/2009 Editorial Digital orthodontics: 25 years after the advent of Align Technology’s trans- parent aligners, a revolution that continues. Digital dentistry is a constantly growing field, combining digital technologies with traditional dental practice. This innovative approach has revolutionized the way dental treatments are carried out, improving efficiency, accuracy and overall preci- sion. Digitalization has had a significant impact in several areas of dentistry, in- cluding diagnostics, treatment planning, design and manufacturing, as well as in patient management from all points of view, which is why the term “virtual patient” is already in use. Digital dentistry, in addition to acting in purely clinical areas, as mentioned above, also acts on the communicative sphere between patient and dentist. This happens, for example, when we use those software that, through the acquisition of patient data and images, are able to simulate a dental treatment before surgery, but as we will see later, also through devices designed for diagnostic use only. In Orthodontics the digital revolution was started by the advent of transparent aligners produced by Align Technology more than 25 years ago. Much has changed in this time, the technique has become increasingly predictable and performing and aligners have gained an important part of the market today. They are no longer used only for aesthetic corrections but also in the in- terceptive orthodontic treatment of the growing patient. The innovation was not only dedicated to the materials used for the production of aligners, but above all to the Clincheck software, a powerful diagnostic tool and to the implementation with the Itero intraoral scanner. The scannner is an integral part of the digital flow, it is able not only to help the special- ist in communicating with the patient with the various simulation software but also to be more performing in monitoring the therapy with the integrated digital monitoring tools. We can say that the constant digital evolution, not only in Or- thodontics, but also in the other branches of Dentistry, will involve not only the specialist but will guide and develop him “digitally” also broadening the views to interdisciplinary treatment and in the treatment of the growing patient. Sometimes the digital revolution may seem slow, but it is certainly tireless and more and more than we can imagine. Artificial intel- ligence will become an important integral part of development software and will increasingly support dentistry. All that remains is to live this evolution and digital revolution, in Orthodontics and dentistry in general, aware that it will change often and will not stop, but will allow us to integrate basic knowledge and clinical practice into a digital system that will al- low patients to be treated in a more predictable way and with more effective communication. My advice? Have fun being an integral part of this digital revolution and keep your mind open to continuous innovations, software and techniques, never being frightened, but absolutely fascinated, because your human intelligentsia will guide you. Prof.ssa Silvia Caruso University of L’Aquila 10.59987/ads/2023.2.1-1 1 

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Original Article The improvement of predictability in Clear Aligner treatment in conjunction with Digital Monitoring Sara Caruso*1 sential to guide the patient and follow their compliance Silvia Caruso1 in order to obtain the most beneficial results from the Mariaelena De Felice1 treatment. Dental Monitoring (DM) is a recent invention Roberto Gatto1 that combines teleodontology with artificial intelligence Vincenzo D’Antò2 (AI) and allows orthodontists to monitor their patients’ treatment progress remotely using the patient’s own 1 Department of Life, Health and Environmental Scienc- smartphone to take photographs or scans. Furthermore, es, Paediatric Dentistry, University of L’Aquila, 67100 the DM software can build three-dimensional (3D) digi- L’Aquila, Italy tal models from these scans. [7] The program consists 2 School of Orthodontics, Department of Neuroscience, of three integrated platforms: 1) a phone application Reproductive Science and Oral Science, University of for the patient, 2) a patented algorithm that evaluates Naples Federico II, 80131 Naples, Italy orthodontic movements and 3) a web platform where professionals receive updates on the evolution of their patients’ treatment. When patients take scans, the im- *Corresponding author: [email protected] ages are uploaded to the program’s servers and verified to ensure that their quality is sufficient to be processed Abstract by the Dental Monitoring algorithm, which can calculate tooth movement with high precision. [3]. In orthodon- The primary objective of this study is to evaluate the tics, the DM system allows the treating doctor to mon- Tpredictability of orthodontic treatment with clear itor the loss or detachment of brackets, tubes, bands aligners monitored by Dental Monitoring® (DM) and and buttons, injuries from broken hooks or temporary to assess if using the DM system can actually lead anchoring devices (TAD), broken ligatures, escape of to better results and shorter treatment times. A sec- the arch occlusal interference with a tooth or a brack- ondary objective is to assess whether the DM system et, oral hygiene, soft tissue inflammation, damage to can be more effective in monitoring one type of mal- the teeth, signs of aphthous stomatitis, cleanliness of occlusion over another, namely: crowding, crossbite appliances, gum recessions, and stability of fixed and and diastema. A total of 55 patients treated consec- removable retainers. In particular, during an orthodontic utively with clear aligners were selected. All patients treatment with clear aligners, monitoring can be carried were asked to use the DM system with scheduled ap- out at each aligner change, according to the protocol pointments at 7–8-week intervals. Our results show chosen by the orthodontist. [9-10]. The DM system no- that photos and scans taken in the chair correspond tifies the treating doctor of various data: the “tracking” accurately to the photos and scan taken by the patient option allows the clinician to remotely follow the treat- using the DM system. Results also show that the dif- ment at each change of aligners, to evaluate the fit of ferent malocclusions did not show any difference in the aligner. The option “loss of glued auxiliary” allows predictability when using the DM system. This study the doctor to monitor the integrity of the auxiliaries. The concluded that treatment time was indeed reduced in “auxiliary device” option can evaluate the presence and terms of total number of in-office appointments. maintenance of buttons and elastics. The “damage to aligners” option is essential to ensure proper integrity Keywords: Dental Monitoring; clear aligners; pre- of the teeth and aligners. The clear aligner system con- dictability; treatment plan. sists of custom-made aligners that perform orthodontic tooth movements by applying compression and traction Introduction forces to the periodontium. Optimal tooth movement occurs when continuous orthodontic forces are applied Teleorthodontic technology and remote monitoring of and maintained, hence, making it necessary to change patients have become an imminent reality that allows or- the aligners regularly to counter the effects of aligner thodontists to proactively monitor their patients through force degradation and loss of elasticity with in vivo use. virtual controls that are an integration with those in the Most clear aligner makers suggest that these chang- clinic. [2] es are needed on average after one to two weeks of Literature suggests that this technology leads to better wear. Regular replacement of aligners requires a high clinical outcomes and high patient and physician satis- level of patient compliance [11-12]. In patients with poor faction by dramatically reducing chair time. [1]. Since compliance, treatment times may also increase due to orthodontic treatment usually lasts for months, it is es- the need for further refinements which is due, in turn, to 10.59987/ads/2023.2.3-6 3  The improvement of predictability in Clear Aligner treatment in conjunction with Digital Monitoring less-than-ideal results.[13-14].In this retrospective study, The exclusion criteria were as follows: the primary objective is to evaluate the predictability of • need for orthognathic treatment orthodontic treatment with clear aligners monitored by • anomalies of enamel and dentin. DM, and to assess if using the DM system can actual- ly lead to better results and shorter treatment times by Patients were treated by a single orthodontist provider monitoring patients closely and more accurately, and fol- (S.C.) and all patients were asked to use the DM system lowing the treatment plan as set up using the Invisalign at the start of their treatment with scheduled appointments ClinCheck® software. at approximately 7-8week intervals. Each group changed In our study, the patients were divided into three groups aligners approximately every 10 days with an average corresponding to three different orthodontic problems: wear of 22h per day. However, this aligner change proto- crowding, crossbite and diastema. The secondary ob- col could vary based on how the DM software instructed jective is to assess whether the DM system can be more the patient as to whether to proceed to the next aligner or effective in monitoring one type of malocclusion over continue wearing the same aligner one or several days another. longer. Frontal and lateral DM scans were processed and compared at time T0 (before treatment) and at time T1 Materials and Methods (after approximately 12 months of treatment). The DM software highlights at each aligner change both the de- A total of 55 patients treated consecutively with clear gree of gingival inflammation present and the location of aligners were selected by the University of L’Aquila of the various dental misalignments. (Fig.1-2). which, 32 belonging to group A: patients with dental These measurements were verified by two doctors: crowding in both arches, 15 to group B: patients with MEDF and SA.C. multiple diastemas, 8 belonging to group C: patients with anterior crossbite, unilateral or bilateral. Patients were Results followed up with Dental Monitoring (DM) during the ap- proximately 12-month course of treatment and have the The scans obtained using the DM application at time T0 following inclusion criteria: and T1 were then compared. We found excellent corre- • treatment with at least 20 clear aligners in the first lation in the first year of therapy between clinical teeth treatment phase alignment and the planned alignment in the ClinCheck® • non-extraction treatment treatment plan. (Fig.3-8). During the course of treatment, • patients with full permanent dentition the “negative” comments provided by the DM system, • patients who did not have agenesis or other dental which indicated poor oral hygiene or a lack of aligner anomalies. tracking, made it possible to immediately identify the Figure 1. Platform of DM of the first case 4 10.59987/ads/2023.2.3-6 S. Caruso et al. Figure 2. Platform of DM of the second case Figure 3. Pre-treatment of crossbite case Figure 5. Pre treatment of diastema case Figure 4. Post treatment of crossbite case Figure 6. Post treatment of diastema case 10.59987/ads/2023.2.3-6 5  The improvement of predictability in Clear Aligner treatment in conjunction with Digital Monitoring Hansa et. al, measuring the effect of treatment monitor- ing with DM, recorded a reduction in treatment time of 1.8 months for patient using the DM system. In addition, a reduction in appointments of 33.1% over the total dura- tion of treatment was recorded in the study. Patients with crowded dentitions showed a prevalence of negative comments regarding poor oral hygiene. The first set of aligners was completed without the need to interrupt the treatment and perform a refinement ahead of schedule. Conclusions This study showed that therapy time was reduced in terms Figure 7. Pre treatment of crowding case of the number of appointments and this indicates that there is also a reduction in material costs and number of visits. In addition, there is an increase in the frequency of patient monitoring, resulting in a more accurate assessment of the treatment by the orthodontist. Furthermore, these results reveal an important precision in terms of the development of the DM system that allowed the doctor to follow the pa- tients remotely, achieving the pre-established objectives. The limit of the study refers to the lack of occlusal scans of the dental arches and therefore to a lack of overlap with the digital models processed by the 3D scanner. References 1. Mandall NA, O’Brien KD, Brady J, Worthington HV, Harvey L. Figure 8. Post treatment of crowding case Teledentistry for screening new patient orthodontic referrals. part 1: a randomised controlled trial. Br Dent J 2005; 199:659- 62: discussion 653. problem and make corrective measures. In addition, the 2. Nutalapati R, Boyapati R, Jampani N, Dontula BSK. Applica- proper wear of the aligners, and the correspondence of tions of teledentistry: a literature review and update. J Int Soc the photos taken in the dental chair with those of the Prev Community Dent. 2011;1(2):37. 3. Hansa I, Semaan SJ, Vaid NR, Ferguson DJ. Remote monitor- application were compared at each appointment, detect- ing and “Teleorthodontics”: concept, scope and applications. ing an almost total correspondence between both sets of Semin Orthod. 2018;24(4): 470–81. photographs. Our study evaluated whether there were 4. Chen JW, Hobdell MH, Dunn K, Johnson KA, Zhang J. Tele- differences in the predictability of treatment based on dentistry and its use in dental education. J Am Dent Assoc the different malocclusions. The results showed that the 2003;134:342-6. malocclusions did not show any difference in predictabil- 5. Jampani ND, Nutalapati R, Dontula BSK, Boyapati R. Applica- ity over the first year of therapy. tions of teledentistry: a literature review and update. J Int Soc Prev Commun Dent 2011;1:37-44. 6. Kravitz ND, Burris B, Butler D, Dabney CW. Teledentistry, doit- yourself orthodontics, and remote treatment monitoring. J Clin Discussion Orthod 2016;50:718-26. 7. Impellizzeri A, Horodynski M, Serritella E, et al. Threedimen- Treatment with clear aligners requires careful and sional evaluation of dental movement in orthodontics. J of thoughtful digital planning in order to achieve successful Dentalcad 2020;88(3):182-190 dental movements throughout treatment until the finish- 8. Morris RS, Hoye LN, Elnagar MH, Atsawasuwan P, Galang- ing stage and make this technique more predictable. In Boquiren MT, Caplin J, et al. Accuracy of Dental Monitoring 3D our study, the patients recruited and subjected to ortho- digital dental models using photograph and video mode.Am J Orthod Dentofacial Orthop 2019;156:420-8. dontic treatment with clear aligners were monitored using 9. Grauer D, Cevidanes LH, Tyndall D, Styner MA, Flood PM, the DM system where a sequence of scans were gener- Proffit WR. Registration of orthodontic digital models. Cranio- ated that corresponded to the various treatment phases. fac Growth Ser 2011;48:377-91. The primary objective was to evaluate the predictability 10. Grunheid T, Loh C, Larson BE. How accurate is Invisalign in of orthodontic treatment with clear aligners monitored by nonextraction cases? Are predicted tooth positions achieved? DM and to assess if using the DM system can actual- Angle Orthod 2017;87:809-15. ly lead to better results and shorter treatment times by 11. Tuncay, O.C.; Bowman, S.J.; Nicozisis, J.L.; Amy, B.D. Effec- tiveness of a compliance indicator for clear aligners. J. Clin. following patients closely and more accurately, and fol- Orthod. 2009, 43, 263–268. lowing the treatment plan as setup using the ClinCheck® 12. Schott, T.C.; Göz, G. Color fading of the blue compliance indi- software. The results obtained in our study are in agree- cator encapsulated in removable clear Invisalign Teen ®align- ment with the literature [8,3] as they demonstrated excel- ers. Angle Orthod. 2011, 81, 185–191. lent therapy control and a correspondence between the 13. Al-Abdallah, M.; Hamdan, M.; Dar-Odeh, N. Traditional vs scans performed through the application and the office digital communication channels for improving compliance with fixed orthodontic treatment: A randomized controlled trial. visits with intervals of 7-8 weeks. Furthermore, the study Angle Orthod. 2021, 91, 227–235. showed that after about 12 months, the scans obtained 14. Richter, D.D.; Nanda, R.S.; Sinha, P.K.; Smith, D.W.; Currier, using the DM application showed excellent results for G.F. Effect of behavior modification on patient compliance in all three monitored malocclusions. [4,5,6]. The study by orthodontics. Angle Orthod. 1998, 68, 123–132. 6 10.59987/ads/2023.2.3-6 

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Original Article Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs): from traditional solutions to current monolithic zirconia restorations. Concise review Andrea Berzaghi1 DDS, MSc, PhD rial combinations chosen based on clinical and economic Sergio Bortolini1 DDS, Associate Professor factors. Therapeutic options differ on the basis of reten- tion methods, framework design, combination of pros- 1 Department of Surgery, Medicine, Dentistry and Mor- thetic materials, gingiva construction methods3. In all phological Sciences with Interest in Transplant, Oncol- implant-prosthetic designs we can find advantages and ogy and Regenerative Medicine, University of Modena disadvantages related to aesthetics, strength, simplici- and Reggio Emilia (UNIMORE), Via del Pozzo 71, ty, manufacturing method, complications and cost. The 41125 Modena, Italy. choice of materials and the implant-prosthetic design are closely linked. In order to select the most advantageous therapeutic option, in the decision-making process it is Corresponding author: essential to know the strengths and weaknesses of the Andrea Berzaghi available solutions. The most current solutions make it [email protected] possible to exploit the translucency potential of the new generations of zirconia which, however, require ade- quate knowledge of the materials and a correct design Abstract evaluation. In this article we expose current knowledge Implant-supported fixed complete dental prostheses on modern full-arch implant prosthetic solutions in the (IFCDPs) can be made with different prosthetic de- light of the recent zirconia-based materials offered by the signs in a wide range of material combinations. The product sector. choice of materials and the implant-prosthetic design are closely linked. In the recent past, the combina- tions of materials used for full-arch fixed prosthetic Traditional solutions restorations were exclusively: metal-acrylic resin, Historically, resin occlusal surfaces have been used in metal-composite resin and metal-ceramic. In the last implant prosthetics to provide a “cushioning effect” to the two decades, zirconia frameworks have become in- implants in order to compensate for the resilience of the creasingly popular in the implant prosthetic field and periodontium and allow the occlusal surface to be the the introduction of CAD/CAM technology has made it weakest link in the implant prosthetic restoration5. With possible to approach full-arch restorations in a differ- the deepening of knowledge on osseointegration and a ent way. The most advanced implant-prosthetic de- greater diffusion of implant prosthesis, the use of metal signs exploit the aesthetic and mechanical strength alloy and ceramic for occlusal surfaces has spread. Cur- qualities of the latest generation monolithic zirconia. rently, there is no scientific evidence showing a link be- These solutions looks very promising. However, the tween osseointegration and the type of occlusal surface long-term outcome of these implant-supported reha- material. Furthermore, there does not appear to be any bilitations remains still unknown due to the lack of differences in terms of stresses transmitted to the bone sufficient clinical data. based on the fabrication material of the occlusal surfac- es of the restoration6. Nonetheless, fracture of the occlu- Keywords: Zirconia, monolithic zirconia, metal bar, sal material is one of the most common complications Implant-supported fixed complete dental prostheses. reported in the literature7,8. In the recent past, the com- binations of materials used for full-arch fixed prosthetic restorations were exclusively: metal-acrylic resin, met- Introduction al-composite resin and metal-ceramic. The metal-acryl- Implant-supported fixed complete dental prostheses (IF- ic resin combination (Metal framework-prefabricated CDPs) represent the therapeutic solution of excellence acrylic artificial teeth) has shown high success rates9 for total edentulism and demonstrate high clinical suc- and remains a popular choice due to its long tradition in cess rates in the literature1,2,3. IFCDPs have 95% clinical literature, simplicity, low cost, simple repair management success at 5 years in the maxilla and 97% at 10 years and a “clinicians comfort level” acquired over the years10. in the mandibular arch4 .These restorations can be made The metal-composite resin and metal-ceramic alterna- with different prosthetic designs in a wide range of mate- tives are both expensive, more laborious to manufac- 10.59987/ads/2023.2.7-11 7  Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs... ture, difficult to repair and susceptible to the manufac- tilevers must be sized with large occlusocervical thick- turing technique11. All traditional rehabilitation typologies nesses and limited extension in order to withstand high present various complications in the short and long term occlusal loads40. It is also important to ensure adequate including: fracture or detachment of resin teeth, wear of thicknesses of the framework in correspondence with occlusal surfaces, ceramic chipping, difficulty in color the access chimneys to the connection screws adjacent matching related to gingival pink, lack of passive adap- to the cantilevers33. The same attentions in the design tation, expensive prosthetic repairs10,12-21. phase are valid in the case of anterior cantilevers, a potential cause of catastrophic fracture often underes- timated and which require a safety dimensioning of the Zirconia areas with the greatest risk of failure. The advantages The recent evolution of ceramic materials in prosthet- of the monolithic screw-retained prosthesis are many. ic dentistry is aimed at increasing the mechanical and The screw-retained prosthesis traditionally represents aesthetic properties and simplifying the manufacturing the first choice in full-arch implant-prosthetic rehabilita- and decision-making processes for clinicians and tech- tion for fewer biological complications and easier man- nicians. The interest in zirconia as a framework material agement of complications41,42. Zirconia guarantees ad- derives from the possibility of advantageously exploit- vanced mechanical properties with a low complication ing the phase transition (PTT, Phase Transformation rate; excellent biocompatibility; favorable wear charac- Toughening), obtaining a ceramic material with high teristics; reduced accumulation of plaque and biofilm; resistance and fracture toughness. Until a few years satisfactory gingival and dental aesthetics associated ago, it was universally recognized in the literature that with minimal ceramization of non-functional areas; re- the most mechanically resistant ceramics offered less duced pigmentation compared to acrylic resin. The advanced aesthetic characteristics, most of the time re- CAD-CAM design and production of zirconia has led to sulting more opaque, therefore less translucent and at- further advantages: better precision of the prosthesis tractive. Thus, in recent years zirconia has undergone thanks to modern manufacturing systems; availability of changes in microstructural composition to improve a permanent digital file with the possibility of duplicating translucency while maintaining adequate mechanical the prosthetic restoration; possibility of making tempo- properties: with the third generation of zirconia, born in rary posts in PMMA. However, the monolithic zirconia 2015, and the subsequent fourth generation, structural screw-retained design remains a complex prosthetic changes have been made starting from the increase solution, in which clinical success is linked to the knowl- of the yttrium oxide content22,23,24. Furthermore, the in- edge of the materials and the high precision required troduction of monolithic zirconia for its characteristics by 3Y-TZP32,33,43. The need to guarantee the framework of reliability and practicality has led to a downsizing in suitable dimensions in areas at risk of fracture, the im- prosthetic design with indisputable advantages for cli- possibility of recovery of the structure in the event of nicians and technicians25,26. In the last two decades, zir- failure, the low tolerance to imprecisions and the opacity conia frameworks have become increasingly popular in of the high-strength material represent the current limits the implant prosthetic field and the introduction of CAD/ of this prosthesis2,33. The monolithic screw-retained de- CAM technology has made it possible to approach full- sign is not able to take advantage of the progress of the arch restorations in a different way and with promising material because it requires high-strength but opaque success rates27-30. zirconia, which needs digital cut-back procedures and ceramization of the aesthetic area34,44. Even the latest Screw-retained IFCDPs: monolithic zirconia generation multitranslucent materials do not seem to be the adequate answer to the problem as the com- restorations plex design of the screwed monoblock places too many Monolithic zirconia has recently found an indication in unknowns on the strength of the structure. However, screw-retained full-arch implant prosthetic restorations. the new generations of 4Y-TZP and multi-translucent In this prosthetic design, the reference material remains monolithic zirconia materials, incorporating 3Y, 4Y and the second generation 3Y-TZP for mechanical strength 5Y-TZP with varying translucency levels, appear to be and high success rates: recent studies have shown a promising in these designs as well. In particular, some survival rate of 99.3% with minimal technical complica- types of 4Y-TZP with high mechanical performance can tions in the medium term31. These restorations can pro- represent promising materials in this sense. vide in the CAD phase a digital “cut back” of the struc- ture in the non-functional areas in which the minimum Metal-Zirconia Implant Fixed Hybrid Full-Arch ceramicization is required limited to the aesthetic areas Prosthesis: monolithic zirconia on metal bar including the gingival part32,33,34. The elimination of the zirconia/ceramic interface from the functional surfaces To overcome these limitations, recent studies have pro- solved the clinical complications related to the delami- posed an innovative prosthetic solution that has been nation or chipping of the veneering layer3,29,35. The key defined as a metal-zirconia hybrid for the combination to the clinical success of the screw-retained monolith- of a metal framework supporting a monolithic structure ic prosthesis lies in the extreme precision and correct in zirconia45,46. This prosthetic design features a bar, design of the monolithic monoblock, particularly in the usually in titanium or Cr-Co, to support a latest gener- areas potentially most exposed to fracture. The distal ation monolithic zirconia superstructure. By exploiting cantilever, which has a long history of clinical success advanced CAD-CAM digital technologies, it is possible in full-arch implant prosthetics36,37, in the case of limit- to combine the advantages of the two materials, offer- ed prosthetic space (less than 15mm) or parafunctional ing aesthetic and reliable restorations (Figg.1-3). The habits of prosthetic components at higher risk of me- metal bar gives stiffness, excellent tensile strength, high chanical complications38,39. In zirconia restorations, can- fracture strength, passive fit and allows you to manage 8 10.59987/ads/2023.2.7-11 A. Berzaghi et al. Figure 1. Based on CAD information, we can design and fabricate temporary and definitive prosthetic restorations on a metal bar. Figure 2. Zirconia superstructure coupled to the titanium bar (Mdt Germano Rossi). In this case, the bar was made of grade 5 titanium Rematitan 5 (Dentaurum s.p.a) while zirconia Ceramotion Z Hybrid 1300/1020 Mpa (Dentaurum s.p.a) was chosen for the superstructure. Figure 3. Case concluded: gingival and dental aesthetic ceramization with Ceramotion One Touch ceramic pastes (Dentaurum s.p.a). 10.59987/ads/2023.2.7-11 9  Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs... long spans between adjacent implants and extend can- monolithic screw-retained design has encouraging tilevers. It also allows versatile use on different implant success rates in the medium term but requires further platforms, compensates for problems of unfavorable in vitro and clinical studies for a more scientific anal- angles and offers the possibility, if necessary, to be ysis of the design criteria. Recent hybrid metal-zirco- segmented. The metal frameworks obtained by laser nia solutions combine the advantages of two different sintering/melting procedures have improved the “fit”, materials such as monolithic zirconia and metal (Ti or the “bonding” and the corrosion resistance compared Co-Cr as indicated) and appear to solve the limitations to the bars obtained by casting47. Titanium is a suitable of screw-retained solutions. This innovative prosthet- material due to its high tensile strength, fracture resis- ic implant design looks very promising. However, the tance, biocompatibility and low weight. The alternative long-term outcome of these implant-supported rehabil- is Cr-Co which has recently been re-evaluated in the itations remains unknown due to the lack of sufficient implant-prosthetic field: it boasts a long experience of clinical data. exposure in the oral cavity in removable partial prosthe- ses, it is considered the first choice in the case of can- Acknowledgments tilevers or long spans, it is harder than titanium with im- proved scratch resistance and has great resistance to The authors would like to thank Dentaurum Italia S.p.a. oxidation over time. Furthermore, in case of laser weld- for supporting this article. We thank for the clinical case: ing it guarantees excellent mechanical resistance47,48. Dr. Biagio Di Giuseppe, Roseto Degli Abruzzi (Te); Dr. The monolithic zirconia in this prosthetic design rep- Roberto Secchiaroli, Senigalia (An); Mdt Germano Ros- resents the first choice solution for reasons related to si, Alba Adriatica (Te). the intrinsic characteristics of the material and to the prosthetic technologies. From an aesthetic point of view, the metal framework gives the possibility to take References full advantage of the new generations of translucent zir- conia without risk of structural failure: only minimal ce- 1. Larsson C, Vult von Steyern P. Implant-supported full-arch ramization of the gingival areas is necessary without re- zirconia-based mandibular fixed dental prostheses. Eight- year results from a clinical pilot study. Acta Odontol Scand sorting to vestibular cut-backs on the dental elements. 2013;71:1118-1122. The bar also makes it possible to simplify the clinical 2. 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Original Article Diagnostic reliability of the Digital Imaging Fiber Optic Transillumination: a review Giovanni Bruno1,2* pers published from 1990 to 2022 were included. Nine Michele Basilicata*2,3 articles comparing two different methods for early de- Alessandra Semisa1 tection of carious lesions were selected. Simona Giani7 An analysis of the existing literature seems to support Antonio Gracco1 the hypothesis that making diagnosis by using the Patrizio Bollero2,5 Digital Imaging Fiber Optic Transillumination systems Raffaella Docimo8 represents a safe and effective support for early diag- Roberto Sorrentino6 nosis of interproximal carious lesions within enamel. Alberto De Stefani1,4 However, it is still to be considered a complementary method to traditional bitewing and periapical radio- graphs. 1 Dental Clinic, Department of Neuroscience, University of Padua, 35121 Padua, Italy Keywords: DIFOTI, Digital Imaging Fiber Optic 2 Department of Experimental Medicine and Surgery, Transillumination, Caries, Pediatric Dentistry , Spe- University of Rome Tor Vergata, 00133 Rome, Italy cial Care Dentistry, Early Diagnosis, Restorative 3 UOSD Special Care Dentistry, Policlinico Tor Vergata, Dentistry. 00133 Rome, Italy 4 Department of Pharmacological Sciences, University of Padua, 35121 Padua, Italy Introduction 5 Department of Systems Medicine, University of Rome Dental caries represents nowadays the most prevalent Tor Vergata, 00133 Rome, Italy chronic disease throughout most of the world, affecting 6 Department of Neurosciences, Reproductive and approximately 97% of the population [1,2] with a prev- Odontostomatological Sciences, Univerisity “Federico alence of 21,6% among the 4-years-old children and II” of Naples, 80131 Naples , Italy 43,1% among the 12-years-old children [3]. In the last 7 Private Practice Casciago (VA), 21020 Varese, Italy decades, the prevalence of this condition tended to de- crease for the widespread use of fluoride in toothpastes 8 Pediatric Dentistry, Department of Surgical Sciences, and in foodstuffs. Due to its widespread diffusion, it is University of Rome Tor Vergata, 00133 Rome, Italy; considered a major public health problem and thus re- quiring efficient procedures for primary prevention, as Corresponding author: well as an early and correct diagnosis, with the goal [email protected] (M.B.) of minimally invasive treatments. According to World [email protected] (G.B.) Health Organization (WHO), tooth decay is defined as “an external and localized pathological process that aris- (*) These authors are equally contributed to this work. es after the eruption of the tooth and involves a softening of the hard tissues with consequent formation of cavities” [4]; more precisely it has been described by some au- Abstract thors as a progressive, destructive, irreversible, and in- This paper aims at illustrating the different diagnostic fectious disease that affects the hard tissues (i.e. enam- methods and compare the reliability of the Digital Im- el, dentine, cement) of teeth from the outermost surfaces aging Fiber Optic Transillumination (DIAGNOcamTM, to the depth, thus inducing growing demineralization and KaVo Kerr, Brea, California, US) with the use of in- dissolution of the organic substances [5]. traoral radiographs. Since the discovery of radiogra- Causal factors involved in the carious pathology are dif- phy, various methods have been introduced in order ferent (i.e. dental plaque, fermentable carbohydrates, to provide early diagnosis of caries. In this review, time factor, host receptivity, age, systemic health, intake specific keywords have been chosen on different of fluoride, degree of education, socio-economic status, search engines and medical databases. Scientific pa- previous caries), so defining a multifactorial etiology 10.59987/ads/2023.2.13-17 13  Diagnostic reliability of the Digital Imaging Fiber Optic Transillumination: a review and a pathogenesis based on the commonly accepted (this?) review through the citation searching of Scopus “chemico-parasitic” theory of Miller, who affirms the and Google Scholar. National (Italian) guidelines for ra- chemical-acid nature of the lesions caused by the acid diological diagnostics in childhood of 2018 and nation- products of bacterial metabolism of carbohydrates [5, 6]. al (Italian) guidelines for oral health promotion and oral Following the clinical course of the disease, based on pathologies prevention in childhood of 2013 have also continuous and unbalanced processes of remineraliza- been consulted. The systematic search has been carried tion and demineralization of tooth surface at the variation out by three different operators in the period between of oral pH, it is reasonable to consider its progression May 2020 and October 2022. All the articles published from early sub-clinical lesions – which are in a large before October 2022 were eligible for inclusion in the number of cases not diagnosed by traditional methods present systematic review. – to clinical evident cavities, that gradually involve den- tine and dental chamber, thus becoming more easily Search Strategy to recognize as the extension of tissue destruction in- All the articles selected for this review were acquired us- creases [7]. ing searches strategies on Since the discovery of X-rays, radiographic examination PubMed and Scopus databases up until October 2022. has increasingly become the main diagnostic instrument The search strategy was performed using Boolean op- used in the clinical practice for caries detection. erators) in combination with the following key words: For this goal, different techniques of intraoral radiogra- “Diagnocam” OR “DIFOTI” OR “transillumination”OR phy can be used, however,the mostly used in conser- “near-infrared light transillumination” OR “caries detec- vative dentistry remains intraoral bitewing radiographs tion”OR “caries diagnostics”OR “risk assessment” OR (BTW), which permits to observe adjacent teeth crowns “non cavitated caries” OR “fluorescence”. and their proximal surfaces to evaluate caries presence and their extension [8,9]. Despite the low sensibility (40-65%), the radiographic Eligibility Criteria, Study selection examination high specificity (98-99%), in combination and Methodological Quality Criteria with clinical inspection, allows to diagnose more than 90% of proximal lesions [8,9] with the major precision Inclusion and exclusion criteria have been based on for early lesions among other methods [10]. In pediatric populations, interventions, comparisons, outcomes, and dentistry, considering the early age and the usual diffi- study designs (PICOS guidelines). Details of inclusion culty to manage these young patients, there is a great and exclusion criteria are given in flowchart. Three au- interest for an early and accurate detection of carious thors reviewed independently the titles and abstracts of lesions. It can lead to an easier outpatient management, the articles that emerged from the search strategy, for allowing therefore to reduce the timing of visits and at- the inclusion in the present systematic (qui cambia se tain even more precise therapeutic results, by combining prima hai scelto narrative!) review. In case of disagree- traditional diagnostic methods and more recent sensible ment about the inclusion of possible sources for full text reading, it has been solved by discussion and mutual systems. Furthermore, young patients need even more consensus. attention regarding the radiation protection and safety The selected papers have been subjected to a full text procedures. reading from which authors excluded in-vitro and ret- Recently, a new technology has been introduced in the rospective studies. Quality assessment has been per- dental market, which is based on Digital Imaging Fiber formed on the final list, using a methodological quality Optic Transillumination (DIFOTI). It detects the laser criterion adapted from the CONSORT statement and light dispersion (i.e. scattering) differences between Jadad quality assessment scale. The selected studies healthy dental hard tissue and the decayed one, which were independently scored by 3 reviewers. appears in a shade of grays [11]. In case of disagreement, the scoring has been assigned In conclusion, the aim of this systematic review is to after discussion and mutual consensus. Each article re- point out the importance of early diagnosis of caries and ceived a score out of 11 points based on the method- highlight the in-vivo reliability of DIFOTI, by analyzing its ological quality criteria and classified as ‘good’ if higher advantages and limits in accordance with current scien- than 9 points, ‘moderate’ if between 7 and 9 points, and tific evidences. ‘poor’ if lower than 7 points. Materials and methods The present systematic review was conducted accord- RESULTS ing to the Preferred Reporting Items for Systematic Re- views and Metanalysis (PRISMA) guidelines (www.pris- StudySelection ma-statement.org) After removing duplicate articles and repetitions, the sys- tematic research through PubMed/Medline, Web of Sci- Information Sources ence, Scopus, and Cochrane Collaboration Trial retrieved The authors developed a research strategy on electronic 126 articles. In the screening phase, a total of 117 articles databases including Medline, Web of Science, Scopus, were excluded (articles were excluded after title read- and Cochrane Collaboration Trial. The electronic search ing because regarding the unrelated topic of research, has been combined with a manual one, thus controlling review articles, discussions, critical summaries, case re- the original reference lists and adding more articles to ports, research reports, case series, and animal studies). 14 10.59987/ads/2023.2.13-17 G. Bruno et al. A total of 43 articles were considered eligible according to using a DIAGNOcamTM prototype, concluding that light the inclusion and exclusion criteria and valuable for com- source intensity represents the most significant parame- plete full-text reading. After full-text reading, other 34 arti- ter for image reproducibility [11]. cles were excluded because they were in-vitro studies. In In the study by Schneiderman et al., experienced den- the end, 9 articles met the inclusion and exclusion criteria tists analyzed a sample of fifty extracted teeth, then the and thus they were included in the present review. authors compared specificity and sensitivity of both the DIFOTI technology and radiography in detecting caries Results on different tooth surfaces. From literature review, it emerged that up to December The results obtained brought out that DIFOTI sensitivity 2022, 9 studies evaluating the diagnostic qualities of in proximal caries detection is twice as high as that of DIFOTI technology were published; particularly, among radiographs, it is ten times higher for vestibular and lin- these, only 8 articles compared the use of DIAGNO- gual lesions and seven times higher for occlusal lesions, camTM to intraoral radiographs in early diagnosis of despite the lower specificity (10%) for these in compari- carious lesions. son to radiographs. By relying on this evidence, Schnei- It is interesting to note that a few studies have been con- derman et al. affirmed that observing all tooth surfaces ducted in-vivo, instead they were mostly performed on and diagnosing incipient carious lesion with the DIFOTI extracted teeth in-vitro. was simple, whereas on the contrary, it was not using Keem et al. selected 5 teeth and detected with great radiographs; furthermore the correct interpretation of de- sensitivity even small changes of the enamel surface by tected images can be considered attainable as well [12]. Identification Records identified through Additional records identified database searching through other sources (n = 126) (n = 0) Records after duplicates removed (n =126) Screening Records screened Records excluded (n = 126) (n = 83) Eligibility Full-text articles Full-text articles excluded assessed for eligibility (n = 34) (n = 43) Article not in English, Italian, Spanish (5) Case-reports and books (7) Included Studies included in Other diagnostic methods qualitative synthesis (22) (n =9) 10.59987/ads/2023.2.13-17 15  Diagnostic reliability of the Digital Imaging Fiber Optic Transillumination: a review In a study conducted by Young and Featherstone, it has novel early diagnosis approaches could aim at major been observed in vitro that DIFOTI technology does not dental tissue preservation. permit to estimate the proximal caries depth towards the For this reason, clinical diagnosis and decision-making dentine, unlike radiographs, and this was in accordance processes still represent a challenge, even after many with other authors [18]; however, it provides the advan- years of research that led to the development of inno- tage of early identification of lesions just after two weeks vative examination technologies. The persisting limits of from their start, instead of four weeks as with other clini- radiographs and DIAGNOcamTM make the early diag- cal and radiological methods [17, 18]. nosis of caries still complicated but more easily achiev- Astvaldsottir et al. evidenced on a sample of fifty-six ex- able, if these two examination systems are combined. tracted premolars that the DIFOTI technology showed The early detection of proximal lesions can be obtained a significantly better sensitivity, but a lower specificity by using DIAGNOcamTM, but radiographs still remain than radiographs for enamel lesions; on the contrary, the most suitable method to evaluate the extension of for dentine cavities the results were comparable to decayed tissues. each other, thus confirming the need for more studies In conclusion, the application of DIFOTI to pediatric den- on this topic [19]. tistry is of great interest, as it appears to be a safe and Other authors have recently affirmed that the only use of well accepted technique; nonetheless, it would be desir- DIFOTI in daily clinical practice cannot replace intraoral able to have more comprehensive literature and scientif- radiographs [13,14], since it does not provide enough ic evidences for a better understanding of its application information about conditions of dental pulp or periodon- and limits. tium, however it certainly represents a safer instrument for periodic checkups by reducing frequent and repeated x-radiation [15,16]. References 1. Fontana M, Zero DT. Assessing patients’ caries risk. J Am Discussion Dent Assoc. 2006 Sep;137(9):1231-9. doi: 10.14219/jada. archive.2006.0380. PMID: 16946427. Tooth decay represents one of the most diffused pathol- 2. McComb D, Tam LE. Diagnosis of occlusal caries: Part I. ogies nowadays and, considered its initial asymptomatic Conventional methods. J Can Dent Assoc. 2001 Sep;67 condition, the role of an early diagnosis becomes criti- (8):454-7. PMID: 11583606. cal to prevent extensive and painful tissue destruction, 3. Campus G, Condò SG, Di Renzo G, Ferro R, Gatto R, Giuca which can progressively lead to dental pulp suffering. MR, Giuliana G, Majorana A, Marzo G, Ottolenghi L, Petti S, Piana G, Pizzi S, Polimeni A, Pozzi A, Sapelli PL, Ugazio A; Therefore, periodic visits as well as the choice of an ef- Italian Society of Paediatric Dentistry. National Italian Guide- fective examination for early caries detection is of prima- lines for caries prevention in 0 to 12 years-old children. Eur J ry clinical importance. Paediatr Dent. 2007 Sep;8(3):153-9. PMID: 17919065. Visual and tactile method of diagnosis could not be suffi- 4. Huysmans MC, Longbottom C. The challenges of validat- ciently reliable to establish whether and when to intervene; ing diagnostic methods and selecting appropriate gold and on the other hand, radiographs has limits regarding standards. J Dent Res. 2004;83 Spec No C:C48-52. doi: early lesions identification. Thus, it is necessary to evalu- 10.1177/154405910408301s10. PMID: 15286122. ate the use of more sensible instrumental examinations in 5. Stefano Eramo, Paolo Negri. Sintesi storica delle teo- clinical practice, especially in pediatric dentistry. rie eziopatogenetiche sulla carie. July 2017; pp26-32. In the last years, many authors investigated the diag- doi:10.13140/RG.2.2.35375.64166. 6. Anil S, Anand PS. Early Childhood Caries: Prevalence, Risk nostic reliability of radiographs and that of DIFOTI by Factors, and Prevention. Front Pediatr. 2017;5:157. Pub- comparing the digital images produced by both the ex- lished 2017 Jul 18. doi:10.3389/fped.2017.00157 aminations. Investigations showed that DIAGNOcamTM 7. Pitts NB. Clinical diagnosis of dental caries: a European has a significant sensitivity for initial lesions but does not perspective. J Dent Educ. 2001 Oct;65(10):972-8. PMID: allow to appreciate its depth in dentine, and therefore 11699999. many authors concluded that DIFOTI cannot replace 8. Aps JKM, Lim LZ, Tong HJ, Kalia B, Chou AM. Diagnostic ef- radiographs – even if it represents an excellent comple- ficacy of and indications for intraoral radiographs in pediatric mentary diagnosis system for both occlusal and proximal dentistry: a systematic review. Eur Arch Paediatr Dent. 2020 lesions [17,18]. Aug;21(4):429-462. doi: 10.1007/s40368-020-00532-y. DIAGNOcamTM transillumination technology also offers Epub 2020 May 10. PMID: 32390073. 9. Mejàre I, Kidd E.A.M: Radiography for caries diagnosis. a reliable guide for opening cavities, a great means of Dental caries: the disease and its clinical management communication to patients, as well as a radiation-free 2nd edition. Feejerskov O, Kidd E.A.M. Oxford: Blackwell and efficient longitudinal control system for early lesions, Munksgaard, 2008; pp 69-88 especially for those the clinician decides to threat with 10. Gomez J. Detection and diagnosis of the early caries le- medical supplies to promote remineralization [15-18]. sion. BMC Oral Health. 2015;15 Suppl 1(Suppl 1):S3. doi: However, intraoral radiographs allow a more precise es- 10.1186/1472-6831-15-S1-S3. Epub 2015 Sep 15. PMID: timate of caries depth [18] and therefore many authors 26392124; PMCID: PMC4580848. suggest the advantage to associate radiological exam- 11. S. Keem and M. Elbaum, “Wavelet representations for ination and transillumination, in order to obtain better monitoring changes in teeth imaged with digital imag- ing fiber-optic transillumination,” in IEEE Transactions on diagnostic accuracy. Medical Imaging, vol. 16, no. 5, pp. 653-663, Oct. 1997, doi: 10.1109/42.64075611 Conclusions 12. Schneiderman A, Elbaum M, Shultz T, Keem S, Greenebaum M, Driller J. Assessment of dental caries with Digital Imaging Recent studies have provided sufficient evidence to af- Fiber-Optic TransIllumination (DIFOTI): in vitro study. Caries firm that a restorative approach is limiting in caries man- Res. 1997;31(2):103-10. doi: 10.1159/000262384. PMID: agement, thus a deeper biological comprehension and 9118181. 16 10.59987/ads/2023.2.13-17 G. Bruno et al. 13. Dündar, ayşe & Ciftçi, Mehmet & İşman, Özlem & Aktan, 17. Douglas A Young, John D B Featherstone. Digital imaging Ali. (2020). In vivo performance of near-infrared light transil- fiber-optic trans-illumination, F-speed radiographic film and lumination for dentine proximal caries detection in perma- depth of approximal lesions. J Am Dent Assoc. 2005 Dec; nent teeth. Saudi Dental Journal. 32. 187-193. 10.1016/j. 136 (12): 1682-7. doi: 10.14219/jada.archive.2005.0111. sdentj.2019.08.007. 18. Abdelaziz M, Krejci I, Perneger T, Feilzer A, Vazquez L. 14. Kühnisch J, Söchtig F, Pitchika V, Laubender R, Neuhaus Near infrared transillumination compared with radiogra- KW, Lussi A, Hickel R. In vivo validation of near-infrared phy to detect and monitor proximal caries: A clinical retro- light transillumination for interproximal dentin caries detec- spective study. J Dent. 2018 Mar;70:40-45. doi: 10.1016/j. tion. Clin Oral Investig. 2016 May;20(4):821-9. doi: 10.1007/ jdent.2017.12.008. Epub 2017 Dec 16. PMID: 2925885018. s00784-015-1559-4. Epub 2015 Sep 15. PMID: 26374746. 19. Á. Ástvaldsdóttir, K. Åhlund, W. P. Holbrook, B. de Verdier, 15. Schaefer G, Pitchika V, Litzenburger F, Hickel R, Kühnisch S. Tranæus, “Approximal Caries Detection by DIFOTI: In J. Evaluation of occlusal caries detection and assessment Vitro Comparison of Diagnostic Accuracy/Efficacy with Film by visual inspection, digital bitewing radiography and near- and Digital Radiography”, International Journal of Dentistry, infrared light transillumination. Clin Oral Investig. 2018 vol. 2012, Article ID 326401, 8 pages, 2012. https://doi. Sep;22(7):2431-2438. doi: 10.1007/s00784-018-2512-0. org/10.1155/2012/326401 Epub 2018 Jun 18. PMID: 29915930 16. Söchtig F, Hickel R, Kühnisch J. Caries detection and di- agnostics with near-infrared light transillumination: clinical experiences. Quintessence Int. 2014 Jun;45(6):531-8. doi: 10.3290/j.qi.a31533. PMID: 24618570 10.59987/ads/2023.2.13-17 17 

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Case Report Extraction of an upper premolar due to a root fracture and subsequent implant positioning: a case report Lara Ceresoli* then contextual to the insertion of the implant; The pro- Serena Ferri* cedure took place with the extraction of the premolar, Vittorio Pensa* which left the presence of a bone defect of the buccal Marta Todaro* alveolar wall. Subsequently, after prescribing pre-surgi- Umberto Manica* cal antibiotic therapy, (with Levofloxacin 500 mg once a Matteo Nagni** day for ten days, Medrol 0.16 mg 1 tablet on the morn- ing of surgery, 3\4 the morning following the day of sur- * Dental School, Vita-Salute San Raffaele University, gery, 1\2 two days after surgery and 1\4 three days after Milan, Italy and Department of Dentistry, IRCCS San surgery) implant insertion was carried out. A Winsix KT Raffaele Hospital, Milan, Italy implant was inserted, 3.8 mm in diameter and 11 mm in ** MSc, Dental School, Vita-Salute San Raffaele Univer- length, which has the characteristic of having a platform sity, Milan, Italy and Department of Dentistry, IRCCS with a diameter greater than the implant body (4.5 mm) San Raffaele Hospital, Milan, Italy that adapts perfectly to the post-extraction bone spac- es going to optimize prosthetic rehabilitation. A healing screw was then placed after repairing the bone defect, in Corresponding author: fact a mixture of autologous bone taken from the implant Ceresoli Lara positioning site and biomaterial, bio bone, was made, all email: [email protected] covered by a resorbable membrane in equine-derived collagen to contain the material inside the bone defect. After 3 months, a prosthetic crown was placed. Abstract Objectives: Root fracture, from an etiological point of Results and conclusions view, constitutes the progression of the incomplete At the end of the work, a perfect osseointegration of the lesion. The treatment of this type of lesion involves Winsix KT implant is observed 3.8 mm in diameter x 11 the root fragments extraction, as in the case below, mm in length with a maintenance of bone thickness, in their entirety. Vertical fractures can in fact include healing of the defect and good healing of soft tissues, the entire thickness of the root, if complete. They may even at 10 years of follow-up. involve the buccal surface, the lingual surface or both surfaces, also extending to the periodontal attach- ment. In this case there was a fistula at the buccal Introduction level, in fact the presence of fistulas in this type of The prognosis of a dental element should be evaluated lesions can be detected in 35-42% of cases of root based on various factors; Although some types of frac- fractures1. The following article presents the clinical tures are believed to have an uncertain prognosis, such case of a patient who had the fractured root residue of as incomplete fractures or fractures of the crown only, element 1.5 with vestibular fistula that required masti- there are some types of injuries, such as vertical frac- catory and element aesthetic restoration. tures of the root or fractures of the middle third of the root whose prognosis is considered poor. In fact, vertical frac- Keywords: Dental implant, root fracture, pre-surgi- tures often have periodontal ligament involvement and cal antibiotic therapy, buccal bone defect, prosthetic among the symptoms, in addition to pain and swelling, a crown. periodontal abscess can also occur in a third of cases3. For what concerns the timing of implant insertion, it is based on clinician experience and on the characteristics Materials and methods of the patient and the implant site. The consensus report A 48-year-old male patient, non-smoker and without any published in 2014, describes the timing of implant place- systemic disease, presented fractured root residue of el- ment after an extraction4. ement 1.5 requiring functional and aesthetic restoration Hammerle et al. considered necessary to develop a clas- of the element. The technique adopted in this surgical sification to describe advantages and disadvantages of procedure was “one stage”, in which the extraction was various positioning timings, based on clinical observa- 10.59987/ads/2023.2.19-23 19  Extraction of an upper premolar due to a root fracture and subsequent implant positioning: a case report tion. In particular, the decision to insert or not the im- Winsix KT implant was inserted, 3.8 mm in diameter and plant immediately after extraction is determined both by 11 mm in length, which has the characteristic of having the characteristics of soft and hard tissues and by the a platform with a diameter greater than the implant body characteristics of the healing of the alveolus. Among the (4.5 mm) that adapts perfectly to the post-extraction various timings, therefore, the positioning immediately bone spaces going to optimize prosthetic rehabilitation. after the extraction of the element is taken into consid- Buccal bone defect is then managed with the insertion of eration; the advantages include both the reduced num- both autologous bone taken from implant site mixed with ber of surgical procedures and the reduction of the time biomaterial, biobone (Fig. 4). of the treatment plan, with the possibility of making the most of the residual bone that is just extracted from the element5. The disadvantages includes the morphology of the site that could complicate the implant placement, as well as tissue biotype and lack of keratinized mucosa. It has also been argued in literature that implant place- ment after extraction could stimulate new bone forma- tion and osseointegration, as well as preserve alveolar bone tissue. It was recommended in a 2004 review by Chen et al.6 that implant insertion immediately after ex- traction helps to avoid bone atrophy. Case Report A 48-year-old male patient, non-smoker, in good sys- temic health, comes to our attention for a fistula at the level of the first quadrant. In the first instance, a careful intra- and extra-oral ob- Figure 2. Post-extraction site, with buccal bone defect. jective examination was performed, which revealed the presence of a residual root at the level of 1.5 and a buc- cal fistula (Fig. 1). Subsequently always in the first visit, first-level radio- graphic examinations were performed: Orthopantomog- raphy and Endoral Rx near the root residue. After careful evaluation of the patient’s clinical and sys- temic situation, “one stage” surgery technique was pro- posed as the operative technique, in which extraction was concurrent with implant placement. The patient was prescribed the antibiotic prophylax- is (with Levofloxacin 500 mg once a day for ten days, Medrol 0.16 mg 1 tablet on the morning of surgery, 3\4 the morning following the day of surgery, 1\2 two days after surgery and 1\4 three days after surgery). At the next appointment after signing informed consent and local anesthesia with articaine 4% and adrenaline 1: 100,000 (Ubistesin 40 mg/ml, 3M ESPE, Italy) avulsion of the element has been performed, leaving however a Figure 3. Winsix KT 3,8 mm diameter x 11 mm length in- sertion in post-extraction site. bone defect on the buccal side (Fig. 2). At the same stage, after extracting the element, revising the cavity, and raising a full-thickness flap, a Winsix KT implant is placed in the post-extraction site (Fig. 3). A Figure 1. Fractured root element with buccal fistula in Figure 4. Bone defect management using autologous bone place 1.5 and biobone biomaterial 20 10.59987/ads/2023.2.19-23 L. Ceresoli et al. Figure 5. Positioning of a resorbable membrane on the bone defect by means of the healing screw. Figure 7. Post- extraction implant healing with “one stage” technique. Figure 6. Positioning of a resorbable membrane in Paraso- rb collagen 0.3 mm thick Figure 8. Prosthetic abutment. Next, a resorbable membrane was placed on the bone defect and the healing screw was also placed at the same time (Fig. 5). To conclude the surgery, the placement of a 0.3-mm- thick Parasorb collagen resorbable membrane to cover the healing screw was also opted for, in order not to let the flap slide coronally to cover the placed and regener- ated implant and to achieve soft tissue healing (Fig. 6). Finally, flap closure was performed with a detached stitch suture with 3/0 resorbable thread (Vicryl, Ethicon, Johnson & Johnson, New Brunswick, NJ, USA). Post- operative instructions were reported to the patient. The patient was reexamined 14 days after surgery to remove the sutures, and good tissue healing could be observed. After 3 months, prosthetic rehabilitation was performed, which included removal of the healing screw with subse- quent insertion of the abutment. Impressions were taken for fabrication of the prosthetic restoration. One week later, the patient was able to receive the ceramic gold crown (Figg. 7-9). The patient was placed on a follow-up protocol with an- nual professional hygiene and radiographic checks at Figure 9. 3 months follow-up after surgery and placement the implant site. The final follow-up is at 10 years (Fig.10) of the ceramic gold crown. 10.59987/ads/2023.2.19-23 21  Extraction of an upper premolar due to a root fracture and subsequent implant positioning: a case report in this review, concerning implant positioning associated with dehiscence regeneration following the extraction of the fractured tooth. Most of the works considered used non-absorbable membranes, unlike the type of membrane used in the clinical case described above, in association or not with the insertion of biomaterial (whether it was a xenograft of bovine or autologous origin)15-16 and the suc- cess rate at a 5-year follow-up was around 76.8%17 up to 100%16-18. In 14 studies, the insertion of absorbable mem- branes for a total of 406 implants was evaluated and the success rate ranged from 95.4% to 100% with a follow-up varying between 5-7 months and 5 years19-20-21. For what concerns the decision to go to perform a “one stage” technique of implant positioning following the el- ement extraction, the patient’s age and systemic health condition can be the so called protective factors. These factors, together with the patient’s medical and dental his- tory, seem to be factors to be evaluated before implant placement. The factors that can negatively affect implant positioning following extraction can in fact be mainly ana- tomical or biological (alveolar conformation, gingival bio- Figure 10. 10 years follow-up from the implant functional type, periapical lesion or periodontal disease)22. load Conclusions At the end of the work, a perfect osseointegration of the Winsix KT implant is observed 3.8 mm in diameter x 11 Discussion mm in length with a maintenance of bone thickness, The vertical fracture of the root itself has a poor prog- healing of the buccal defect and good healing of soft tis- nosis, as reported by various scientific works, including sues, even at 10 years of follow-up. Khansis et al. 20147; vertical fractures in fact tend to in- volve the root and periodontium and involved tooth are usually extracted, although there are studies that speak References of an attempt to reunite the root but with a low or variable 1. Tsesis I, Rosen E, Tamse A, Taschieri S, Kfir A. Diagnosis of success rate. The early diagnosis of a fractured root and vertical root fractures in endodontically treated teeth based on tooth extraction can maintain the integrity of the alveo- clinical and radiographic indices: a systematic review. J En- lar bone allowing a correct implant positioning, making dod. 2010 Sep;36(9):1455-8. doi: 10.1016/j.joen.2010.05.003. optimal then the restoration of both aesthetic and masti- Epub 2010 Jul 4. PMID: 20728708. catory function. 2. Lindhe J., Niklaus P., Karring T., Clinical periodontology and implant dentistry, fifth edition In a 2014 systematic review, Corbella S.8 develops a 3. Tamse A, Fuss Z, Lustig J, Kaplavi J. An evaluation of end- classification for bone defects resulting from the ex- odontically treated vertically fractured teeth. J Endod. 1999 traction of a vertically fractured tooth and evalues the Jul;25(7):506-8. doi: 10.1016/S0099-2399(99)80292-1. PMID: existing literature on the treatment of this type of defect 10687518. analyzing dental implants in combination with regener- 4. Hämmerle CH, Chen ST, Wilson TG Jr. Consensus state- ative procedures. In cases of vertical root fractures a ments and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxil- quick decision is relevant in safeguarding the residual lofac Implants. 2004;19 Suppl:26-8. PMID: 15635943. bone. Even if, even in these cases, a conservative ap- 5. Werbitt MJ, Goldberg PV. The immediate implant: bone pres- proach can be adopted, the prognosis of these elements ervation and bone regeneration. Int J Periodontics Restorative is often poor9-10-11-12. In these circumstances, in fact, im- Dent. 1992;12(3):206-17. PMID: 1305154. plant treatment seems to be the treatment of choice. 6. Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early Even the success of the latter procedure seems to be placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral at risk if it is not performed with the correct timing and Maxillofac Implants. 2004;19 Suppl:12-25. PMID: 15635942. the right clinical evaluation of bone and soft tissues, in 7. Khasnis SA, Kidiyoor KH, Patil AB, Kenganal SB. Vertical fact it may be necessary to incur a regenerative proce- root fractures and their management. J Conserv Dent. 2014 dure13. Many studies have evaluated the success of im- Mar;17(2):103-10. doi: 10.4103/0972-0707.128034. PMID: mediate implant placement after extraction of the dental 24778502; PMCID: PMC4001262. element with vertical fracture and it has been reported 8. Corbella S, Taschieri S, Samaranayake L, Tsesis I, Nemcovsky C, Del Fabbro M. Implant treatment choice after extraction of that success rate in these cases is comparable to suc- a vertically fractured tooth. A proposal for a clinical classifica- cessful placement in an healthy site14. It is in fact known tion of bony defects based on a systematic review of literature. that communication between the root canal and the peri- Clin Oral Implants Res. 2014 Aug;25(8):946-56. doi: 10.1111/ odontal space can lead to an abscess process and rapid clr.12164. Epub 2013 Apr 8. PMID: 23560723. bone resorption, again depending on the extent and se- 9. Moule, A.J. & Kahler, B. (1999) Diagnosis and management verity of the fracture3. of teeth with vertical root fractures. Australian Dental Journal 44: 75–87. As regards the association of this type of fractures with 10. Kawai, K. & Masaka, N. (2002) Vertical root fracture treated bone dehiscences and fenestrations, twenty-three ar- by bonding fragments and rotational replantation. Dental Trau- ticles (for a total of 814 implants) have been analyzed matology 18: 42–45 22 10.59987/ads/2023.2.19-23 L. Ceresoli et al. 11. Eichelsbacher, F., Denner, W., Klaiber, B. & Schlagenhauf, U. 17. Becker, W., Dahlin, C., Lekholm, U., Bergstrom, C., van Steen- (2009) Periodontal status of teeth with crown-root fractures: re- berghe, D., Higuchi, K. & Becker, B.E. (1999) Five-year evalu- sults two years after adhesive fragment reattachment. Journal ation of implants placed at extraction and with dehiscences of Clinical Periodontology 36: 905–911 and fenestration defects augmented with ePTFE membranes: 12. Taschieri, S., Rosano, G., Weinstein, T. & Del Fabbro, M. results from a prospective multicenter study. Clinical Implant (2010a) Replacement of vertically rootfractured endodontically Dentistry and Related Research 1: 27–32. treated teeth with immediate implants in conjunction with a 18. Lorenzoni, M., Perti, C., Polansky, R.A., Jakse, N. & Wegs- synthetic bone cement. Implant Dentistry 19: 477–486. cheider, W.A. (2002) Evaluation of implants placed with barrier 13. Esposito, M., Grusovin, M.G., Polyzos, I.P., Felice, P. & membranes. A restrospective follow-up study up to five years. Worthington, H.V. (2010) Timing of implant placement after Clinical Oral Implants Research 13: 274–280. tooth extraction: immediate, immediate-delayed or delayed 19. Chen, S.T., Darby, I.B., Adams, G.G. & Reynolds, E.C. (2005) implants? A Cochrane systematic review. European Journal of A prospective clinical study of bone augmentation techniques Oral Implantology 3: 189–205. at immediate implants. Clinical Oral Implants Research 16: 14. Truninger, T.C., Philipp, A.O., Siegenthaler, D.W., Roos, M., 176–184 Hammerle, C.H. & Jung, R.E. (2011) A prospective, controlled 20. Park, S.H. & Wang, H.L. (2007) Clinical significance of incision clinical trial evaluating the clinical and radiological outcome location on guided bone regeneration: human study. Journal of after 3 years of immediately placed implants in sockets ex- Periodontology 78: 47–51. hibiting periapical pathology. Clinical Oral Implants Research 21. Siciliano, V.I., Salvi, G.E., Matarasso, S., Cafiero, C., Blasi, A. 22: 20–27. & Lang, N.P. (2009) Soft tissues healing at immediate trans- 15. Moses, O., Pitaru, S., Artzi, Z. & Nemcovsky, C.E. (2005) Heal- mucosal implants placed into molar extraction sites with buc- ing of dehiscence-type defects in implants placed together cal self-contained dehiscences. A 12-month controlled clinical with different barrier membranes: a comparative clinical study. trial. Clinical Oral Implants Research 20: 482–488. Clinical Oral Implants Research 16: 210–219 22. Blanco J, Carral C, Argibay O, Liñares A. Implant place- 16. Hassan, K.S. (2009) Autogenous bone graft combined with ment in fresh extraction sockets. Periodontol 2000. 2019 polylactic polyglycolic acid polymer for treatment of dehis- Feb;79(1):151-167. doi: 10.1111/prd.12253. PMID: 30892772. cence around immediate dental implants. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 108: e19–e25. 10.59987/ads/2023.2.19-23 23 

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A NNALI DI STOMATOLOGIA www.annalidistomatologia.eu VOLUME 14 NUMERO 1-4 - 2023 A Journal of Odontostomatologic Sciences PublyMed srls  A NNALI Annali............. DI STOMATOLOGIA EDITOR IN CHIEF D’Antò Vincenzo Di Carlo Gabriele University of Naples, Italy University of Rome “La Sapienza”, Italy Gatto Roberto [email protected] [email protected] University of L’Aquila, Italy [email protected] Basilicata Michele Falisi Giovanni University of Tor Vergata Italy University of L’Aquila, Italy [email protected] [email protected] CONSULTANT EDITORS De Angelis Francesca Marsili Domenico, Italy Allaf Ferdi University of Rome “La Sapienza”, Italy [email protected] Turkish Aligner Society,Turchia [email protected] [email protected] Nagni Matteo, Italy De Nuccio Claudio [email protected] Caruso Silvia University Cattolica del Sacro Cuore, Italy University of L’Aquila, Italy [email protected] Jamal Sied [email protected] [email protected] Yisrael Kornblit Docimo Raffaella Roly Doctor, Italy J.L. Parra Garcia University of Tor Vergata , Italy [email protected] Doctor, Mexico [email protected] [email protected] Laganà Giuseppina Giancotti Aldo University of Tor Vergata , Italy Pietropaoli Davide Department of Clinical Sciences and [email protected] University of L’Aquila, Italy Translational medicine University Tor [email protected] Vergata, Italy Mohamed R.Islam [email protected] University of Dundee, Scotland Pistilli Roberto, Italy [email protected] [email protected] Marchetti Enrico University of L’Aquila, Italy Manzo Paolo Turchetta Nicola, Italy [email protected] Member of EBO-IBO, Italy [email protected] [email protected] Mummolo Stefano Pedro Vittorini Velasquez University of L’Aquila, Italy Nota Alessandro Universidad Autonoma Gabriel Rene [email protected] University of Milan, Italy Moreno [email protected] [email protected] Severino Marco University of L’Aquila, Italy Pagano Stefano [email protected] CONTACTS University of Perugia, Italy [email protected] Do you need further information? Get in Tatullo Marco touch with Annali di Stomatologia for any University of Bari, Italy Scopelliti Domenico question! [email protected] Director of the UOC Maxillofacial Surgery ASL Roma 1 Annali di Stomatologia – Editor in Chief [email protected] Roberto Gatto ASSISTANT EDITORS [email protected] Berdouses Elias Valentini Valentino Annali di Stomatologia – Managing Editor University of Athens, Greece University of Rome “La Sapienza”, Italy Alessandro Zurli Varesi [email protected] [email protected] [email protected] Nunzio Cirulli ASSOCIATE EDITORS Annali di Stomatologia – Managing Office University of Bari Donatella Alonzi [email protected] Antonangelo Carmine [email protected] [email protected] Annali di Stomatologia – Sponsor & D’Addona Antonio Marketing University Cattolica del Sacro Cuore, Italy Ciulli Emanuele, Italy Claudio de Nuccio [email protected] [email protected] [email protected] ANNALI DI STOMATOLOGIA Annali di Stomatologia 2018; IX (4): 141 II Trimestrale edito da PublyMed srls, Via Treviso, 17/A - 00161 Roma - P.I. 16532301005 +39 06 44.24.99.41 - [email protected] - www.annalidistomatologia.eu Reg. Trib. Roma n. 421 18/12/2009 Editorial New procedures for the improvement of the SSN for a better access to dental care Innovative “prescriptions”, to improve the treatment of the citizen in need of odontosto- matological care, are published daily on dental journals. These “prescriptions” are mostly indications from The Experts who have the aim of favouring citizens’ access to dental care in the dental facilities of the Servizio Sanitario Nazionale (SSN), which is constantly grap- pling with the long-standing and never solved problems of waiting lists and staff shortages. Beyond the goodness of the initiative, the arranged action plans always need the com- mitment of financial resources, nowadays not widely available. The question then arises as to how a project is feasible without the appropriate financial backing or, better yet, how economic resources can be found. However, the reason why the suggestions are never related to structures, technologies and personnel optimization, is not known. One example among many is the appointment agendas of outpatient visits and services, which punctuate the work activity of every health professional, both public and private. Are we sure that the visits’ and services’ scheduling is calibrated based on actual staff availability and patient demand? A study conducted a few years ago by the WHO Collaborating Centre for Epidemiology and Community Dentistry showed that the average daily time spent using a dental unit in the Public Service is about 3 hours. The time spent on the dental unit turns out to be about half that of a health professionals’ work shift (7.36 hours) established for medical management by the CCNL’s health area (this is not valid for departmental chiefs). The same concept is true for the as- sistance staff, of the health care professionals, (7.12 hours) working in the dental team. In addition, once the opening time of the dental service is defined, the agendas must be set based on the time space established for each service, which is characterized by a known execution time. This execution time considers not only the average medical time but also some corrections (ancillary times). However, many times this approach is still not used, indeed, in various situations what is seen is an “agenda personal- ization”. All of this shows that only with the application of simple scheduling rules, accompanied by the system’s monitoring and control, we can ensure the delivery of the required services and expand the number of beneficiaries without the need of further monetary expenses for the structure. dr. Michele Nardone Adda district director Head of Corporate Dental Services ASST Melegnano e della Martesana (Mi) 10.59987/ads/2023.1.1-1 1 

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Original Article Squamos Odontogenic Tumor: A case report Paolo De Angelis1 The process of tissue formation and differentiation in Camilla Cavalcanti1 squamous odontogenic tumor is multifactorial; Malassez Giuseppe De Rosa1 remnants may underlie epithelial proliferation in lesions Noemi Cesaroni1 associated with the alveolar process while the dental Teresa Musarra2 lamina may be the cause of the occurrence of lesions Antonio D’Addona1 associated with unerupted or impacted teeth (4,5). Although SOT is more frequently solitary intraosseous 1 Department of Head and Neck, Oral Surgery and Im- lesion (central SOT), peripheral SOT and SOT-like pro- plantology Unit, Institute of Clinical Dentistry, Catholic liferation arising in odontogenic cyst variants have also University of Sacred Hearth, Fondazione Policlinico been described. Universitario Gemelli, 00168 Rome, Italy. Peripheral SOT is rare and affects soft tissues producing 2 Division of Anatomic Pathology and Histology, Fon- ‘saucerization’ of underlying bone. (6) dazione Policlinico Universitario A. Gemelli-IRCCS, Histologically they are typically described as mural out- Largo Agostino Gemelli, 00168 Rome, Italy. growths inside the walls of odontogenic cysts. In fact, SOT from a microscopic point of view shows large islands of benign squamous epithelium separated by a stroma Corresponding author: of collagenous material with an outer layer of squamous Antonio D’Addona cells. Some cases show calcifications both within the stro- E-Mail: [email protected] ma and within the squamous islands. These islands may undergo cystic degeneration over time. (7, 8, 9) The usual treatment is enucleation of the lesion with ap- Abstract propriate curettage of the affected site. Only one case A 40-year-old male patient presented with diffuse ra- of malignant transformation of intraosseous SOT at the diolucent lesions on the upper maxilla at the apex of mandibular level has been described in the literature, the incisors, canines, premolars, and molars. Surgi- and cases of recurrence are also quite rare. cal excision of the lesions was performed, and the Clinical signs typically reported are asymptomatic swell- biopsy specimens were submitted for histological ing associated with tooth mobility and bone resorption. analysis: the lesions of the first quadrant were found Diagnosis is made primarily during routine radiographic to be a squamous odontogenic tumor, a rare benign examinations in which predominantly unilocular radiolu- neoplasm of odontogenic origin. The purpose of this cency is evident although cases of SOT with a multilocu- article is to describe the clinical, radiographic and his- lar appearance have been described in the literature. tological aspects of odontogenic squamous tumor. Radiographically appearing with a triangular shape be- tween the roots of the teeth, the treatment of election is surgical excision with curettage of the surgical site. Keywords: Squamos Odontogenic Tumor, Radiolu- The aim of this case report is to describe the diagnostic cent lesions, Maxilla. course and surgical and squamous cell tumor treatment in a patient treated at our department. Introduction Case report Squamous odontogenic tumor (SOT) is a rare benign neoplasm that originates from the odontogenic epitheli- A 40-year-old male patient came on clinical examina- um. It was first described by Pullon in 1975 and was rec- tion with multiple cavities and root remnants of lateral ognized by World Health Organization (WHO) in 2005 incisors, canine, premolar and second molar in the first and, more recently, in 2017 (1,2) quadrant; canine, first premolar, first and second molar The recent WHO classification of odontogenic and max- in the second one. illofacial bone tumors defines SOT as “a benign epithe- Palpation of the affected area did not result in discharge lial odontogenic tumor in which the tumor cells show of purulent material, and the area appeared slightly com- terminal squamous differentiation.” SOT can manifest in pressible. Radiographic examinations (Orthopanoramic different age ranges; however, it is mainly diagnosed in and Cone Beam) showed well-circumscribed radiotrans- the fourth decade of life. The sites mainly involved are lucent lesions of spherical shape nearby all root remnants. the anterior part of the upper jaw and the posterior part In the premolar region of the first quadrant such lesions of the mandible (3). appeared overlapped. (Fig. 1-2; 3-4) 10.59987/ads/2023.1.3-8 3  Squamos Odontogenic Tumor: A case report Figure 1. Ortopantomography. Figure 2. Lateral Telecranium. 4 10.59987/ads/2023.1.3-8 P. De Angelis et al. Figure 3. Element 1.2 CBCT frames Figure 4. Element 1.6 CBCT frames. Treatment Moreover, severely compromised elements 22 and 24 and root residues 23 24 and 26 were extracted. Treatment included extraction of root remnants and In order to get primary intention healing, all the sharp compromised dental elements, removal of lesions for corners of the crest were smoothed with a diamond bur histologic analysis, and adequate curettage of the post- and silk 4/0 sutures were used. extraction cavity and washings with physiological saline. Then, the same crestal full thickness-flap was subse- The patient was treated under general anesthesia and quently made in the first quadrant from the incisal area since the lesion corresponding to elements 22 23 24 to the last molar. The dental elements and root residues was the most extensive the surgery started from the were all extracted except for 11. second quadrant: after plexus anesthesia with adrena- In this area there were multiple lesions of a cystic na- line 1:100.000, a full thickness crestal flap with distal dis- ture, the major one involving the lateral incisor and they charge was made from the second molar area up to the appeared very similar to that of the second quadrant central incisor. A mucoperiosteal flap was detached until that we had previously enucleated. Once all the lesions a good view of the areas affected by the cystic lesions had been excised, an accurate curettage was per- was obtained. formed with abundant physiological washes. The se- An osteotomy was then performed until the right cleav- verely compromised buccal cortex was smoothed and age was obtained to mobilize the cystic epithelium until made as regular as possible before the suture. It was it was completely “shelled out”. The lesion excised from not possible to completely close the flap in correspon- the surrounding bone consisted of fibrous and compress- dence of the cavity at the level of the buccal molar area ible tissue with a citrine yellow liquid content. Curettage where a dehiscence remained. All the lesions were col- of the cavity and abundant washing was then carried out. lected for histological analysis. 10.59987/ads/2023.1.3-8 5  Squamos Odontogenic Tumor: A case report After the surgery, the patient was given zitromax (500 mg) Diagnosis for three days, ibuprofen (600 mg) for four days and mouth- rinses with clorexidine 0,12 % , twice a day, for a week. Histologic analysis of the lesion from the second quadrant Sutures were removed after one week and a dehiscence revealed a cystic formation with multi-layered non-kera- was noticed on the first quadrant with bone exposure: a topoietic hyperplastic epithelial lining due to a chronic in- revision and curettage of the zone was performed and it flammatory process: it was compatible with radicular cyst. was closed by primary intention. As regards the first quadrant, three samples were ana- One week later, the area completely healed and the next lysed and they revealed a multi-layered epithelial lining step will be the rehabilitation of the upper jaw with a re- associated with surrounding nests of variably shaped movable prothesis and a follow-up at 6 months. and sized epithelial cells without atypia: the samples As regards the lower jaw, also multiple cavities, root rem- were compatible with the diagnosis of squamous odon- nants and radiolucent lesions are detectable: elements togenic tumor (SOT). (Fig. 6-7) 48,47,43,35,36,38 will be extracted and all the related lesions will be enucleated and analyzed (Fig. 5). Figure 5. Enucleation of the lesion. Figure 6. SOT 1x section stained with Hematox- ylin-Eosin. 6 10.59987/ads/2023.1.3-8 P. De Angelis et al. Figure 7. SOT 10x section stained with Hematoxylin-Eosin. Discussion Also Barbeiro et al. (2021) described a case of maxil- lary dentigerous cyst involving tooth 18 which showed Squamous Odontogenic Tumor (SOT) is a benign lesion squamous odontogenic tumor like proliferation: their with slow proliferation rate that is thought to origin from group managed to treat it by enucleation of the lesion dental lamina remnants. However, it is locally infiltrative and involved tooth and obtained complete healing and and it may cause tooth displacement or un-eruption and no recurrence after 3 year follow-up. Considering all clin- root divergency, irregular swelling and bony expansion ical differences between the two kind of lesions it is not due to the perforation of the cortical bone; other cases of possible to assert that SOT is the natural progression of mild discomfort, soreness or a feeling of pressure when SOT-LPOC. (12) the nerves are involved have been reported; sometimes, The election treatment modality is conservative enucle- it is totally asymptomatic and discovered with routine ex- ation with curettage; other cases reported in literature ams. In our case the patient did not have any kind of received a more aggressive treatment consisting on en symptom related to the growth of the lesions and was re- bloc resection, hemimaxillectomy or radical alveolecto- ferred to the oral surgery department to treat the multiple my. Moreover, it is suggested to treat multilocular, multi- cavities and dental remnants. As reported in literature, focal and/or recurrent lesions involving maxilla, which is the most common location of the SOT is the premolar- known to be more porous than mandible, with an exten- canine in maxilla or the molar region of the mandible. sive intervention. (13) Our patient showed multiple radiolucent lesions in all Cases of recurrence of SOT are reported in literature es- quadrants and we attempted to analyze the ones affect- pecially when enucleation was performed but were not ing the first and the second ones. (10) influenced by the age of the patient, location of the le- The histological analysis revealed the presence of both sion, expansion and perforation of cortical bone and loc- SOT and a radicular cyst, which come from proliferation ularity in radiological exams. Since there are no guide- of Malassez remnants after inflammatory stimulus. Also lines about the gold stardard of treatment of SOT, it is SOT is frequently associated with necrotic or unerupted suggested that the surgeon would evaluate the suitable teeth which may have cause the proliferation of dental surgical treatment for the case. lamina, thus suggesting a mild correlation between the In our case, the enucleation was completed with accu- tumor and the cyst. rate curettage and physiological washes due to the wide A review by Chrnovic and Gomez (2018) analyzed cases extension of the lesions: we preferred not to extend the of proliferation of SOT and squamous odontogenic tu- resection beyond the cavities and preserve the residual mor-like proliferation in odontogenic cysts (SOT-LPOC) bone crest to a future rehabilitation. thus concluding that they are different clinicopathological conditions since SOT showed a more aggressive growth pattern: the former had unilocular or multilocular aspect Conclusion and was associated with cortical bone perforation in 62 Our study is an additional case of intraosseos multifo- % of central lesions and tooth displacement while the cal SOT, which has been described in literature as a latter showed no signs of bone erosion or root resorption rare but locally aggressive odontogenic tumor with low and were most associated with radicular and dentiger- recurrence rate: our approach was conservative since ous cysts, as it appeared most of the times as an uni- the patient had multiple lesions and we attempted to locular lesion. (11) preserve the bone volume. The limitation of the study 10.59987/ads/2023.1.3-8 7  Squamos Odontogenic Tumor: A case report is the short follow-up, which will be updated, and the port and Review of the Literature. Head Neck Pathol. 2017 absence of a surgical protocol treatment, since in litera- Jun;11(2):168-174. ture there are still not data and guidelines to treat SOT 7. Hopper TL, Sadeghi EM, Pricco DF. Squamous odontogenic with predictable results. tumor. Report of a case with multiple lesions. Oral Surg Oral Med Oral Pathol. 1980 Nov;50(5):404-10. 8. Norris LH, Baghaei-Rad M, Maloney PL, Simpson G, Guinta J. Bilateral maxillary squamous odontogenic tumors and the References malignant transformation of a mandibular radiolucent lesion. 1. Pullon PA, Shafer WG, Elzay RP, Kerr DA, Corio RL: Squamous J Oral Maxillofac Surg. 1984 Dec;42(12):827-34. odontogenic tumor.Report of six cases of a previously unde- 9. Doyle JL, Grodjesk JE, Dolinsky HB, Rafel SS. Squamous scribed lesion. Oral Surg Oral Med Oral Pathol 40:616, 1975. odontogenic tumor: report of three cases. J Oral Surg. 1977 2. Wright JM, Devilliers P, Hille J. Squamous odontogenic tu- Dec;35(12):994-6. mor. In: El-Naggar AK,Chan JKC, Grandis JR, Takata T, 10. Jones BE, Sarathy AP, Ramos MB, Foss RD. Squamous Slootweg PJ: WHO Classification of Head and Neck Tumors. odontogenic tumor. Head Neck Pathol. 2011 Mar;5(1):17-9. France: IARC Press; 2017 11. Chrcanovic BR, Gomez RS. Squamous odontogenic tu- 3. Goldblatt LI, Brannon RB, Ellis GL: Squamous odontogenic mor and squamous odontogenic tumor-like proliferations tumor. Report of five cases and review of the literature. Oral in odontogenic cysts: An updated analysis of 170 cases Surg Oral Med Oral Pathol 54:187, 1982. reported in the literature. J Craniomaxillofac Surg. 2018 4. Baden E, Doyle J, Mesa M, Fabie M, Lederman D, Eichen Mar;46(3):504-510. M. Squamous odontogenic tumor: report of three cases in- 12. Barbeiro CO, Barbeiro RH, Silveira HA, Almeida LY, León JE, cluding the first extraosseous case. Oral Surg Oral Med Oral Bufalino A. Maxillary dentigerous cyst showing squamous Pathol 1993;75:733 – 8. odontogenic tumorlike proliferation: surgical approach and lit- 5. Philipsen HP, Reichart PA. Squamous odontogenic tumor erature review.AutopsCaseRep [Internet].2021;11:e2021302. (SOT): a benign neoplasm of the periodontium. A review of 13. Upadhyaya JD, Banasser A, Cohen DM, Kashtwari D, Bhat- 36 reported cases. J Clin Periodontol 1996; 23:922 – 6. tacharyya I, Islam MN, Squamous Odontogenic Tumor: Re- 6. Elmuradi S, Mair Y, Suresh L, DeSantis J, Neiders M, Aguirre view of the literature and report of a new case, Journal of A. Multicentric Squamous Odontogenic Tumor: A Case Re- Oral and Maxillofacial Surgery (2020). 8 10.59987/ads/2023.1.3-8 

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Original Article Bone level technique: personal technique for miofacial functional treatment Francesco Calvani1 Introduction Umberto Torre1 Alessandro Lozza3 The ageing process of the face involves a level of bone Emanuele Bartoletti2 erosion that generates a morphological change in the main features of a person’s face. Consequently, the muscular structures of facial expression also undergo 1 Calvani Multispecialty Center, street Livorno 25, 00162, changes in their functionality. Rome, Italy; Another important factor that can shift bone ageing in one E-Mails: [email protected] [email protected] district over the other is altered mimicry due to altered skeletal growth. It has been reported several times in the 2 Head of Outpatient Department of Aesthetic Medicine literature that an open bite leads to a more energetic con- Fatebenefratelli Isola Tiberina-Gemelli, Rome, Italy; traction of certain muscles such as the chin muscle, the E-Mail: [email protected] mouth angle depressor and the buccinator muscle. 3 MD Care Center for Facial Paralysis and Oral Nerves The study carried out that led to the standardisation of Studio Schiappadori Milan Italy this technique involves the restoration of the bone gap Corso Vittorio Emanuele 15 due to physiological bone ageing and bone compensa- tion in those cases where there is an alteration of nor- Corresponding author: mal maxillary and mandibular development and growth. Francesco Calvani E-Mail: [email protected] The technique involves supraperiosteal bolus infiltra- tions of 2-phase hyaluronic acid-based gels with very high cohesiveness for maximum volumetric compensa- Abstract tion with a small quantity of product. The ageing process of the face involves a level of The points we studied are strategic points with an indi- bone erosion that generates a morphological change rect dynamic action on the mimic muscles and thus on in the main features of a person’s face. Consequent- their balance with an inevitable postural change. ly, the muscular structures of facial expression also This effect produces a lifting of the skin, subcutaneous undergo changes in their functionality. tissue and some surrounding structures of the face. Another important factor that can shift bone ageing This functional treatment aims to achieve a dynamic in one district over the other is altered mimicry due and functional modification of each patient’s subjective to altered skeletal growth. physiological muscle contraction. The study carried out that led to the standardisa- The points standardised by Dr Francesco Calvani have tion of this technique involves the restoration of been studied for maximum muscular effect. The study the bone gap due to physiological bone ageing and was substantiated by a team of specialists whohigh- bone compensation in those cases where there is an lighted the changes by means of electromyographic alteration of normal maxillary and mandibular devel- and ultrasound examination and photography. opment and growth. The technique involves supraperiosteal bolus infil- trations of 2-phase hyaluronic acid-based gels with Materials and methods very high cohesiveness for maximum volumetric 32 patients were recruited for this study between the compensation with a small quantity of product. ages of 38 and 55. All patients underwent infiltrative This functional treatment aims to achieve a dynamic treatment on standardised points. and functional modification of each patient’s sub- All patients had natural and complete dentition. 26% had jective physiological muscle contraction. The study dental restorations in the posterior sectors. was substantiated by a team of specialists who high- All patients had dental alignment with skeletal classes in lighted the changes by means of electromyographic first class (12 patients), second class (16 patients) and and ultrasound examination and photography. third class (4 patients). Key words: miofacial function, miofacial treatment, No patients underwent orthognathic surgery. Skeletal anterior open bite, Orofacial myofunctional All patients had no current orthodontic treatment. status, Orofacial myofunctional therapy, Filler, An- All patients underwent infiltrations of supraperiosteal hy- thropometry; Facial beauty; Facial measurements; aluronic acid at the points standardised by the technique, Quantitative analysis. which included 3 mandibular points,2 maxillary transmu- 10.59987/ads/2023.1.9-16 9  Bone level technique: personal technique for miofacial functional treatment cosal points, 2 zygomatic points and 2 fronto-temporal 10 strategic points to restore bone thrust on muscles and points, totalling 10 points. tissues The points were studied from a bone and vascular point All patients were treated in one session. of view to allow maximum effect with minimum vascular Bolus infiltration was performed over the standardised risk. bone component. A 27G needle was used at each point. Patients were studied by means of electromyography The most important strategic point especially in patients performed in static and dynamic situations with aelec- with second dento-skeletal classis the point of chin syn- tromiography neuromian 2to record potential changes thesis called chin protuberance or gnathon. These pa- before and after treatment. The study mainly involved tients presented, after sub-muscular infiltration at the recording the orbicularis of the mouth, the chin muscle, level of the chin muscle tendon, a support of the chin the mouth angle depressor, the buccinator and ultra- muscle that produced a reduction in the autonomous sound. The ultrasound study (Mindray 23 MHz linear contraction of the patient’s dento-skeletal hindbrain. probe) was conducted in three phases. The first phase The autonomous contraction is due to the labial incom- involved the process of checking and mapping the pa- petence that the bone gap produces. tients to investigate the possible presence of previous Strategic points were ultrasound-assessed to study their treatments that could influence the study. As a matter of vascularisation and to avoid complications from com- fact, patients who had previous treatments with non-ab- pression or arterial cannulation. sorbable fillers and had no memory or knowledge of The above-mentioned infiltrations produced an improve- them were excluded from the ultrasound investigation. ment reported by the patient as a feeling of relaxation In the second phase, anatomical and especially vascular of the entire face, especially the middle and lower thirds ‘full face’ mapping of the patients was carried out in or- with a change in the functionality of muscle contraction, der to highlight any anatomical variants that might have and with a change of contraction not properly said but jeopardised the safety of the study. The third ultrasound produced by more basal support as we know thatacting phase assessed the result of the filler placement in all on the bone and increasing the physiological resorp- points but especially in the functional points both at the tion of these areas produces a feeling of relaxation and chin and jaw level (Calvani point) well-being. Electromyography was performed before the infiltration Each point provides a certain type of face dynamics. and after the infiltration to record changes at rest and 1 infiltration of the chin area comprising the chin tubercle in dynamics with a recording of each patient’s normal and the chinprotuberance where it anchors into the mus- postural and subjective contraction. cle of the same name. The change in each patient’s postural automatism was 2 Bilateral retro-masseter mandibular angle where the highlighted by recording the pre and post results and greatest mandibular bone resorption occurs due to mus- comparing them. cle stimulation and contraction. 90% of the patients experienced an improvement in 3 Calvani point located along an oblique line connect- muscle contraction resulting in a reduction in muscle hy- ing the third/fourth tooth element to the insertion of the peractivity after infiltration. zygomatic muscles (major and minor) at the level of the The affected areas were ultrasound-mapped, highlight- antero-inferior margin of the maxillary bone in its lateral ing the muscular and vascular structures with precision portion. A strategic point for the protrusion of the maxil- and safety. lary bone and acting electromyographically on the zygo- matic muscles. The technique 4 nasal root point extending mainly from the root of the nasal pyramid to the cartilaginous component The technique involves the use of hyaluronic acid in a 5 zygomatic point between the junction of the body and two-phase gel with high molecular cohesiveness and the zygomatic arch high G’. 6 lateral supraorbital point above the orbital rim, one The product was chosen on the basis of its rheological centimetre lateral to the fronto-orbital suture properties. A 1-phase product was not considered be- After infiltration all patients were evaluated by electromy- cause of its cohesiveness and duration of firmness. This ography at 3 months. technique involves the sole and exclusive use of two- phase products because it was discovered that in the medium term they leave the most stable and balanced Discussions functional result. The bone level technique involves the infiltration by The technique involves the infiltration of hyaluronic acid 2-phase hyaluronic acid of specific bone points for bone divided as follows: restoration due to ageing and compensation of those - 0.50ml in the chin area bone gaps due to altered growth in the jaw bones. - 0.25 ml in the mandibular angle area per side The study focused specifically on dynamic and static - 0.2 ml inside the supraperiosteal oral cavity on the muscle changes. maxillary bone in areas 1.4and 2.4 respectively By means of electromyographic examinations, an im- - 0.30ml in the dorsal nasal area extending between provement of these muscular districts involved in com- dorsum and tip pensation phenomena (due to a bone deficit either by - 0.25 ml at the level of the zygomatic arch per side physiological resorption due to ageing or due to impaired - 0.15 ml in the eyebrow orbital area at 1 cm lateral to development and lack of maxillofacial and orthodontic the fronto-temporal suture per side. surgical therapies)was revealed. - The variability of the quantity depends on the clinical Facial expressions and the correlation between chew- picture of the patient being analysed. ing, swallowing, skeletal class and emotionality of each - The total is2,5/ ml of hyaluronic acid individual subject is much discussed in the literature. 10 10.59987/ads/2023.1.9-16 F. Calvani et al. Figure 1. Patient 1 - pre and post. Patient with second dento-skeletal class. Pre and post treatment photos with bone level technique. Labial incompetence was filled by intramucosal infiltration below the chin muscle and the maxillary muscle. 10.59987/ads/2023.1.9-16 11  Bone level technique: personal technique for miofacial functional treatment Gallerano9 et all in a 2012 article described a myofunc- result that is not only functional but also aesthetic on tional treatment after an orthodontic surgical treatment in the muscle, tissue and skin29. a study of 30 cases, investigating the language ability The technique we adopted involves a change not of of class I,II, III subjects12;14;5 showing that 19 out of 30 contraction but of muscle axis. By changing muscle patients after surgery reported improved swallowing, axis, a change in the contractile behaviour of the mus- correct tongue tone and posture, and re-education cle was noted27. of the facial muscles. Most of the patients belonged James3 et all carried out an important study on muscle to a third dento-skeletal class with an anterior open pain related to chewing disorders especially in patients bite30;32. All these patients were re-educated using with an anterior open bite. They identified muscular ex- speech therapy sessions for muscular rehabilitation as ercises to treat this type of disorder, but also showed that the muscles underwent a change in axis and posture muscle tension especially in the treatment of myofascial during the treatment. Of the 19 patients, only 2 were pain7;8 of the masticatory muscles can only and exclu- ineffective while the rest had a restitutia ad integrum sively be alleviated by performing muscle stretching and with a reduction in the speech disorder they previously making a change in the dental occlusion, all of which had. This makes us realise that inevitably acting on results in a change in the axial muscle. Thus changing the bone by changing position and volume can have a the muscular axis results in a change of contraction33; 36; Figure 2. Patient 2 pre and post. Patient with second dento-skeletal class. Pre and post treatment photos with bone level technique. Labial incompetence was filled by intramucosal infiltration below the chin muscle and the maxillary muscle. In the frontal view, increased volume is evident at the level of the lower middle third of the face without superficial skin infiltration but only deep infiltration. The result is achieved by muscular thrust by increasing bone volume and with physiologic resorption of the bone 12 10.59987/ads/2023.1.9-16 F. Calvani et al. 25 . The facial and dental bone component in orthodontic masseter muscles. When swallowing, this results in an treatments and maxillofacial surgery change their phys- increased muscle contractility of the lower third of the iognomy. A surgical treatment is aimed at changing the face compared to the upper third. skeletal relationship between the maxilla and the mandi- This reinforces the results obtained with our technique. ble. This shift can have different degrees depending on Infiltrating under the chin parasymphysis, without involv- the planned treatment and the alteration to be correct- ing the muscle of the same name in its structure, creates ed21;. Orthodontic treatment is aimed at rebalancing the a support of the same at the tendon level and thus a sup- correct relationship of the tooth guides. The process of port for the lip especially in dento-skeletal labial incom- restoring a malocclusion to first class is a process that petencies. By means of electromyography with surface changes the occlusal, masticatory, swallowing and inev- and intramuscular electrodes, a contractile reduction itably mimic posture. from 15% to 40% was found. Naturally, the percentage The aim of the technique involves precisely this, i.e. increased significantly in dento-skeletal classes II and changing the muscular axis22;34;10. This is done with deep III. The significant reduction in contraction is of course supraperiosteal infiltrations that act on the mimic muscles, not due to the muscle itself reducing its contraction but in some cases creating different contraction axes. This rather to a change in its axis that causes the muscle to results in a change of contraction automatism that each contract differently19. patient possesses that takes time to change. Of course, It is not possible to standardise the change as the indi- there are no studies that can translate this effect into a viduals changed. functional effect at the swallowing level, but the effect is The concept of change of contraction is a broad con- certainly present at the facial mimic and indirectly aes- cept and each person has a different response, so this thetic level. All patients in this study experienced a benefit study only reported improvement in an incorrect posture translated into generalised facial muscle relaxation. In the concept. second classes, on the other hand, the patients reported Jiaxing Wang2 et all conducted a study also defining a reduction in the contraction of the chin muscle23;24, orbi- facial contraction correlated with the individual’s ethnic cularis of the mouth, lip depressor, risorius and buccinator. group. It was seen that following muscular exercise, peo- Hong Hong11 et all in 2021 carried out an important study ple of different ethnic groups contract correlated muscle on skeletal growth, showing, by means of electromyo- groups differently. It is therefore difficult to standardise graphic examination, the different contraction that oc- a result, but our observations have always shown an improvement, especially in those areas where there is curs at the level of the lower third compared to the upper hypertonus4. third of the face15;16;17. They showed that in patients with open anterior bite18;20; a greater anterior facial height and a greater degree of Third article incisional protrusion can be found.This study evolved In a study of 50 patients11;29 with TMD, taking into con- by correlating electromyography with 18 cephalometric sideration the contraction of the orbicularis muscle of the measurements and it was found that there is a differ- mouth, lips, and masticatory and lingual systems, it was ence between the contraction of the orbicularis muscles found that changing the muscle axis by pressure ma- of the mouth and chin and the anterior temporalis and neuvers with the hands showed a remaining masticato- Figure 3. The EMG recording during a maximal effort of 20 seconds shows a global reduction of the amplitude and frequency of voluntary recruitment in the right and left mental muscle after treatment. Pre-treatment: A right mental, B left mental After treatment: C right mental, B left mental 10.59987/ads/2023.1.9-16 13  Bone level technique: personal technique for miofacial functional treatment study on facial expressions related to food cravings. The article reports the change in contraction and posture due to a specific emotional stimulus. Thus, the emotion in the facial expression can lead to a change in contraction and posture of the whole face depending on the emotionality of the subject. In a subject with a tired face and a re- ceding chin, a change in masticatory posture can there- fore occur. In our technique using electromyography, we noticed a reduction in muscle contraction after the pro- posed treatment, which brought the patient a functional and indirectly aesthetic benefit. This indirectly led to an increase in self-esteem and a rebalanced contraction of all mimic muscles. Less chin and buccinatorcontraction, with evident increase in the volume of the part itself and skin rebalancing13;. Koletzi26 et all in a study of adolescents found that after muscular rehabilitation of the lower third, there was an increase in tongue thrust at the upper and lower incisors. This resulted in an increased contraction of the orbicu- laris muscle of the mouth. Thus, altered orbicular con- traction is also found in the growth phase. Our protocol provides support at the level of the chin muscle, which nevertheless brings help with the function and muscular posture of the lower third. Conclusions In light of the results obtained and the literature in use, we believe that the bone level technique can be an important aid in the contractile processes of the facial muscles. Often the discomfort of patients due to physio- logical skeletal resorption related to advancing age, loss Figure 4. Bone level points. Ten points for modulation of of dental elements or dental and skeletal malocclusions muscle contraction. can lead to an alteration of the physiological contractile harmony of the entire face. All patients underwent basic EMG examination with su- ry igloo. By acupressure both the lip and the orbicularis pramaximal voluntary contraction of individual muscles, were suspended. This resulted in a masticatory postural demonstrating full cooperation. change28;29. Y-Solution 720 was infiltrated by needle: this is the only After functional rehabilitation by means of targeted hyaluronic acid-based filler with a high G’ (517 Pa) and stretching and speech therapy exercises, a significant high cohesivity (54 gf ) that simultaneously has the best improvement in function was noted. The results after features of biphasic and monophasic fillers: it is de- physiological rehabilitation treatment were exciting26;31. scribed by its manufacturers as belonging to a new class All movements were recorded before and after treat- of products called Y-phasic. ment. The areas most affected were appearance, lip These characteristics give the gel a high versatility level: posture, cheek, tongue and jaw mobility, chewing and it can be used not only in the classic areas that need swallowing functions. volumetric increase, such as cheekbone, chin or man- After functional treatment with physiotherapy and speech dibular profile, but also in areas such as the nose: the therapy, it was ascertained that degenerative changes in gel has a superior lifting capacity, enabling it to withstand masticatory dysfunctions due to bone and muscle pro- external stresses and retain its original shape without cesses were alleviated and even stopped. The study migrating; it has a better lifting capacity that allows it shows that poor masticatory posture that inevitably in- to withstand external stresses and maintain its original volves the musculoskeletal system of both mastication shape without migrating. and mimicry can improve if treated. After 20 minutes EMG was repeated with the same se- With our technique we have proven the fact that by in- quence (right buccinator, left buccinator and chin mu- serting supraperiosteal hyaluronic acid there are no al- scle). terations to the muscles as the muscles are not affected, The result shows an overall reduction in the amplitude but by shifting their axis a valid functional result can be of the electromyographic trace with both spatial and achieved to reduce stress and accentuated contractility temporal reduction of motor unit recruitment between 25 especially in very emotional patients with work-related and 50% compared with the previous condition with the stress. same parameters. Emotionality in contraction plays a very important role. A Only two patients showed a reduction of 3-6%: these patient with an altered state of aesthetics will present an patients had a first dento-skeletal class and a third den- altered mimicry just as a patient with muscular contrac- to-skeletal class, respectively. tile alterations will present an altered aesthetics. Our electromyographic observations showed us how an Jennifer Schmidt6 in a 2017 article reported an important increase in volume at certain strategic points can restore 14 10.59987/ads/2023.1.9-16 F. Calvani et al. support to the soft tissues, inevitably triggeringa gener- 10. C M de Felício 1, A P M Medeiros, M de Oliveira Melchior alised muscular contractile rebalancing. Affiliations expand. Validity of the ‘protocol of oro-facialmyo- A principle that should not be underestimated is maxillary functionalevaluation with scores’ for young and adult sub- jects. J OralRehabil. 2012 Oct;39(10):744-53. and mandibular bone resorption. Resorption processes doi: 10.1111/j.1365-2842.2012.02336.x.Epub 2012 Aug 1. play an important role in the contractile capacity of the PMID: 22852833 DOI: 10.1111/j.1365-2842.2012.02336.x face. A face without bone support will inevitably undergo 11. Hong Hong# 1, YueZeng# 1, Xiaomin Chen1 2, CaixiaPeng1 3, Ji- a change in muscular contractility due to both the down- anqingDeng 1 4, Xueqin Zhang 1 3, Lidi Deng1 5, YongjianX- ward slide of the entire skin muscle system and the in- ie 1, Liping Wu 6 Affiliations expand. Electromyographic fea- evitable change in muscle axis. The muscles will also tures and efficacy of orofacial myofunctional treatment for skeletal anterior open bite in adolescents: an exploratory undergo stretching due to the weight of all the tissue ele- study. Oral Health. 2021 May 7;21(1):242. ments of the face with an inevitable change in their tone doi: 10.1186/s12903-021-01605-0. especially at the level of the middle third. To rebalance, PMID: 33962610 therefore, this phenomenon will produce an increase in PMCID: PMC8103572 contraction to also support the weight of all the tissues. DOI: 10.1186/s12903-021-01605-0 By rebalancing and compensating the superficial bone 12. JanvierHabumugisha1, Bo Cheng1, Shu-Yu Ma1, Min- Yue Zhao1, Wen-Qing Bu1, Gao-Li Wang1, Qiong Liu 1, volumes with the help of 2-phase hyaluronic acid, it has RuiZou 2, Fei Wang 3Affiliations expand. A non-randomized been noted that these muscles are able to rebalance concurrent controlled trial of myofunctional treatment in the their contraction. This is the most plausible explanation mixeddentition children with functional mouth breathing as- for the results obtained. sessed by cephalometric radiographs and study models PMID: 36008795 PMCID: PMC9413933 References DOI: 10.1186/s12887-022-03559-w 13. Cláudia Maria de Félicio 1, Rosana Luiza Rodrigues Gomes 1. DespinaKoletsi 1 2 3, Margarita Makou 1, NikolaosPandis 4 5. Ef- Freitas, César Bataglion Affiliations expand. The effects of fect of orthodontic management and orofacialmuscle training orofacial myofunctional therapy combined with an occlusal- protocols on the correction of myofunctional and myoskel- splint on signs and symptoms in a man with TMD-hypermo- etalproblems in developingdentition. A systematic review and bility: case study. Int J Orofacial Myology. 2007 Nov;33:21-9. meta-analysis. OrthodCraniofacRes. 2018 Nov;21(4):202- PMID: 18942478 215. doi: 10.1111/ocr.12240.Epub 2018 Aug 27. 14. A L Garretto 1 Affiliations expand. Orofacial myofunctional 2. 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Original Article Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs): from traditional solutions to current monolithic zirconia restorations. Concise review. Andrea Berzaghi1 DDS, MSc; PhD with different prosthetic designs in a wide range of mate- Sergio Bortolini1 DDS, MSc, Associate Professor rial combinations chosen based on clinical and economic factors. Therapeutic options differ on the basis of reten- 1 Department of Surgery, Medicine, Dentistry and Mor- tion methods, framework design, combination of pros- phological Sciences with Interest in Transplant, Oncol- thetic materials, gingiva construction methods3. In all ogy and Regenerative Medicine, University of Modena implant-prosthetic designs we can find advantages and and Reggio Emilia, Modena, Italy; sergio.bortolini@ disadvantages related to aesthetics, strength, simplic- unimore.it ; [email protected] ity, manufacturing method, complications and cost. The choice of materials and the implant-prosthetic design are closely linked. In order to select the most advantageous Corresponding author: therapeutic option, in the decision-making process it is Berzaghi Andrea, [email protected] essential to know the strengths and weaknesses of the available solutions. The most current solutions make it possible to exploit the translucency potential of the new Abstract generations of zirconia which, however, require ade- Implant-supported fixed complete dental prosthe- quate knowledge of the materials and a correct design ses (IFCDPs) can be made with different prosthetic evaluation. In this article we expose current knowledge designs in a wide range of material combinations. on modern full-arch implant prosthetic solutions in the The choice of materials and the implant-prosthetic light of the recent zirconia-based materials offered by the design are closely linked. In the recent past, the product sector. combinations of materials used for full-arch fixed prosthetic restorations were exclusively: metal- acrylic resin, metal-composite resin and metal-ce- Traditional solutions ramic. In the last two decades, zirconia frameworks Historically, resin occlusal surfaces have been used in have become increasingly popular in the implant implant prosthetics to provide a “cushioning effect” to the prosthetic field and the introduction of CAD/CAM implants in order to compensate for the resilience of the technology has made it possible to approach full- periodontium and allow the occlusal surface to be the arch restorations in a different way. The most ad- weakest link in the implant prosthetic restoration5. With vanced implant-prosthetic designs exploit the the deepening of knowledge on osseointegration and a aesthetic and mechanical strength qualities of the greater diffusion of implant prosthesis, the use of metal latest generation monolithic zirconia. These solu- alloy and ceramic for occlusal surfaces has spread. tions looks very promising. However, the long-term Currently, there is no scientific evidence showing a link outcome of these implant-supported rehabilitations between osseointegration and the type of occlusal sur- remains still unknown due to the lack of sufficient face material. Furthermore, there does not appear to be clinical data. any differences in terms of stresses transmitted to the bone based on the fabrication material of the occlusal surfaces of the restoration6. Nonetheless, fracture of Keywords: Zirconia, monolithic zirconia, metal bar, the occlusal material is one of the most common com- Implant-supported fixed complete dental prostheses. plications reported in the literature7,8. In the recent past, the combinations of materials used for full-arch fixed prosthetic restorations were exclusively: metal-acrylic Introduction resin, metal-composite resin and metal-ceramic. The Implant-supported fixed complete dental prostheses (IF- metal-acrylic resin combination (Metal framework-pre- CDPs) represent the therapeutic solution of excellence fabricated acrylic artificial teeth) has shown high suc- for total edentulism and demonstrate high clinical suc- cess rates9 and remains a popular choice due to its long cess rates in the literature1,2,3. IFCDPs have 95% clinical tradition in literature, simplicity, low cost, simple repair success at 5 years in the maxilla and 97% at 10 years management and a “clinicians comfort level” acquired in the mandibular arch4 .These restorations can be made over the years10. The metal-composite resin and metal- 10.59987/ads/2023.1.17-22 17  Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs)... ceramic alternatives are both expensive, more labori- chanical complications38,39. In zirconia restorations, can- ous to manufacture, difficult to repair and susceptible tilevers must be sized with large occlusocervical thick- to the manufacturing technique11. All traditional reha- nesses and limited extension in order to withstand high bilitation typologies present various complications in the occlusal loads40. It is also important to ensure adequate short and long term including: fracture or detachment of thicknesses of the framework in correspondence with resin teeth, wear of occlusal surfaces, ceramic chipping, the access chimneys to the connection screws adjacent difficulty in color matching related to gingival pink, lack to the cantilevers33. The same attentions in the design of passive adaptation, expensive prosthetic repairs10,12-21. phase are valid in the case of anterior cantilevers, a potential cause of catastrophic fracture often underes- timated and which require a safety dimensioning of the Zirconia areas with the greatest risk of failure. The advantages of the monolithic screw-retained prosthesis are many. The recent evolution of ceramic materials in prosthetic The screw-retained prosthesis traditionally represents dentistry is aimed at increasing the mechanical and aes- the first choice in full-arch implant-prosthetic rehabilita- thetic properties and simplifying the manufacturing and tion for fewer biological complications and easier man- decision-making processes for clinicians and techni- agement of complications41,42. Zirconia guarantees ad- cians. The interest in zirconia as a framework material vanced mechanical properties with a low complication derives from the possibility of advantageously exploiting rate; excellent biocompatibility; favorable wear charac- the phase transition (PTT, Phase Transformation Tough- teristics; reduced accumulation of plaque and biofilm; ening), obtaining a ceramic material with high resistance satisfactory gingival and dental aesthetics associated and fracture toughness. Until a few years ago, it was with minimal ceramization of non-functional areas; universally recognized in the literature that the most reduced pigmentation compared to acrylic resin. The mechanically resistant ceramics offered less advanced CAD-CAM design and production of zirconia has led to aesthetic characteristics, most of the time resulting more further advantages: better precision of the prosthesis opaque, therefore less translucent and attractive. Thus, thanks to modern manufacturing systems; availability of in recent years zirconia has undergone changes in mi- a permanent digital file with the possibility of duplicating crostructural composition to improve translucency while the prosthetic restoration; possibility of making tempo- maintaining adequate mechanical properties: with the rary posts in PMMA. However, the monolithic zirconia third generation of zirconia, born in 2015, and the subse- screw-retained design remains a complex prosthetic quent fourth generation, structural changes have been solution, in which clinical success is linked to the knowl- made starting from the increase of the yttrium oxide edge of the materials and the high precision required content22,23,24. Furthermore, the introduction of monolithic by 3Y-TZP32,33,43. The need to guarantee the framework zirconia for its characteristics of reliability and practicality suitable dimensions in areas at risk of fracture, the im- has led to a downsizing in prosthetic design with indis- possibility of recovery of the structure in the event of putable advantages for clinicians and technicians25,26. In failure, the low tolerance to imprecisions and the opacity the last two decades, zirconia frameworks have become of the high-strength material represent the current limits increasingly popular in the implant prosthetic field and of this prosthesis2,33. The monolithic screw-retained de- the introduction of CAD/CAM technology has made it sign is not able to take advantage of the progress of the possible to approach full-arch restorations in a different material because it requires high-strength but opaque way and with promising success rates27-30. zirconia, which needs digital cut-back procedures and ceramization of the aesthetic area34,44. Even the latest generation multitranslucent materials do not seem to Screw-retained IFCDPs: monolithic zirconia be the adequate answer to the problem as the com- restorations plex design of the screwed monoblock places too many unknowns on the strength of the structure. However, Monolithic zirconia has recently found an indication in the new generations of 4Y-TZP and multi-translucent screw-retained full-arch implant prosthetic restorations. monolithic zirconia materials, incorporating 3Y, 4Y and In this prosthetic design, the reference material remains 5Y-TZP with varying translucency levels, appear to be the second generation 3Y-TZP for mechanical strength promising in these designs as well. In particular, some and high success rates: recent studies have shown a types of 4Y-TZP with high mechanical performance can survival rate of 99.3% with minimal technical complica- represent promising materials in this sense. tions in the medium term31. These restorations can pro- vide in the CAD phase a digital “cut back” of the struc- ture in the non-functional areas in which the minimum Metal-Zirconia Implant Fixed Hybrid ceramicization is required limited to the aesthetic areas Full-Arch Prosthesis: monolithic zirconia including the gingival part32,33,34. The elimination of the zirconia/ceramic interface from the functional surfaces on metal bar solved the clinical complications related to the delami- To overcome these limitations, recent studies have pro- nation or chipping of the veneering layer3,29,35. The key posed an innovative prosthetic solution that has been to the clinical success of the screw-retained monolithic defined as a metal-zirconia hybrid for the combination prosthesis lies in the extreme precision and correct of a metal framework supporting a monolithic structure design of the monolithic monoblock, particularly in the in zirconia45,46. This prosthetic design features a bar, usu- areas potentially most exposed to fracture. The distal ally in titanium or Cr-Co, to support a latest generation cantilever, which has a long history of clinical success monolithic zirconia superstructure. By exploiting ad- in full-arch implant prosthetics36,37, in the case of limited vanced CAD-CAM digital technologies, it is possible to prosthetic space (less than 15mm) or parafunctional combine the advantages of the two materials, offering habits of prosthetic components at higher risk of me- aesthetic and reliable restorations (Figg.1-3). 18 10.59987/ads/2023.1.17-22 A. Berzaghi et al. A B Figure 1. Based on CAD information, we can design and fabricate temporary and definitive prosthetic restorations on a metal bar. Figure 2. Zirconia superstructure coupled to the titanium bar (Mdt Ger- mano Rossi). In this case, the bar was made of grade 5 titanium Rematitan 5 (Dentaurum s.p.a) while zirconia Ceramotion Z Hybrid 1300/1020 Mpa (Dentaurum s.p.a) was chosen for the superstructure. Figure 3. Case concluded: gingival and dental aesthetic ceramization with Ceramotion One Touch ce- ramic pastes (Dentaurum s.p.a). 10.59987/ads/2023.1.17-22 19  Modern concepts in Implant-Supported Fixed Complete Dental Prostheses (IFCDPs)... The metal bar gives stiffness, excellent tensile strength, Conclusions high fracture strength, passive fit and allows you to man- The introduction of monolithic zirconia for its charac- age long spans between adjacent implants and extend teristics of reliability and practicality has led to a down- cantilevers. It also allows versatile use on different im- sizing in prosthetic design in implant prosthesis. The plant platforms, compensates for problems of unfavor- monolithic screw-retained design has encouraging able angles and offers the possibility, if necessary, to be success rates in the medium term but requires further segmented. The metal frameworks obtained by laser in vitro and clinical studies for a more scientific analy- sintering/melting procedures have improved the “fit”, sis of the design criteria. Recent hybrid metal-zirconia the “bonding” and the corrosion resistance compared solutions combine the advantages of two different to the bars obtained by casting47. Titanium is a suit- materials such as monolithic zirconia and metal (Ti or able material due to its high tensile strength, fracture Co-Cr as indicated) and appear to solve the limitations resistance, biocompatibility and low weight. The alter- of screw-retained solutions. This innovative prosthetic native is Cr-Co which has recently been re-evaluated implant design looks very promising. However, the in the implant-prosthetic field: it boasts a long experi- long-term outcome of these implant-supported rehabil- ence of exposure in the oral cavity in removable partial itations remains unknown due to the lack of sufficient prostheses, it is considered the first choice in the case clinical data. of cantilevers or long spans, it is harder than titanium with improved scratch resistance and has great resis- tance to oxidation over time. Furthermore, in case of Acknowledgments laser welding it guarantees excellent mechanical re- sistance47,48. The monolithic zirconia in this prosthetic The authors would like to thank Dentaurum Italia S.p.a. for supporting this article. We thank for the clinical case: design represents the first choice solution for reasons Dr. Biagio Di Giuseppe, Roseto Degli Abruzzi (Te); Dr. related to the intrinsic characteristics of the material Roberto Secchiaroli, Senigalia (An); Mdt Germano Ros- and to the prosthetic technologies. From an aesthetic si, Alba Adriatica (Te). point of view, the metal framework gives the possibility to take full advantage of the new generations of trans- lucent zirconia without risk of structural failure: only minimal ceramization of the gingival areas is neces- sary without resorting to vestibular cut-backs on the References dental elements. The bar also makes it possible to 1) Larsson C, Vult von Steyern P. Implant-supported full-arch simplify the clinical and technical management of the zirconia-based mandibular fixed dental prostheses. Eight- provisional and definitive prosthetic phases. Starting year results from a clinical pilot study. Acta Odontol Scand from the CAD design information on the bar, we can 2013;71:1118-1122. create PMMA provisionals that act as prototype pros- 2) Carames J, Tovar Suinaga L, Yu YC, Pérez A, Kang M. theses useful in the preliminary evaluation and ap- Clinical Advantages and Limitations of Monolithic Zirconia proval phase2,33. Information and any design updates Restorations Full Arch Implant Supported Reconstruction: Case Series. Int J Dent 2015;2015:392-496. of the provisional can be CAD converted and corrected 3) Bidra AS, Rungruanganunt P, Gauthier M. Clinical out- in the zirconia prosthesis favoring a better physiologi- comes of full arch fixed implant-supported zirconia cal adaptation to the definitive restorations. The digital prostheses: A systematic review. Eur J Oral Implantol files allow the duplication of the temporary and defini- 2017;10(suppl 1):35-45. tive prosthetic restoration with immediate availability, 4) Rohlin M, Nilner K, Davidson T, Gynther G, Hultin M, Jemt ensuring easy management of all technical steps and T, Tranaeus S. Treatment of adult patients with edentu- all clinical complications. Monolithic zirconia can be lous arches: A systematic review. International Journal of Prosthodontics 2012;25:553-567. cemented or screwed to the metal framework accord- 5) Brånemark PI. Osseointegration and its experimental ing to the clinician’s preferences, allowing for practi- background. J Prosthet Dent 1983;50(3):399–410. cality and prosthetic retrievability. From an economic 6) Stegaroiu R, Khraisat A, Nomura S, et al. Influence of su- point of view, the hybrid metal-zirconia solution can be perstructure materials on strain around an implant under considered advantageous compared to pre-existing 2 loading conditions: a technical investigation. Int J Oral solutions. All traditional full-arch rehabilitation types, in Maxillofac Implants 2004;19(5):735-742. fact, have various complications in the short and long 7) Goodacre CJ, Bernal G, Rungcharassaeng K, et al. Clini- cal complications with implants and implant prostheses. J term including: fracture or detachment of resin teeth, Prosthet Dent 2003; 90(2):121-132. wear of occlusal surfaces, ceramic chipping, difficulty 8) Brägger U, Karoussis I, Persson R, et al. Technical and in color matching related to pink gingiva, lack passive biological complications/failures with single crowns and fit, costly prosthetic repairs49,50. In particular, full-arch fixed partial dentures on implants: a 10‐year prospective metal-acrylic implant-prosthetic restorations require cohort study. Clin Oral Implants Res 2005; 16(3):326-334. five to six maintenance operations in 10 years with 9) Mertens C, Steveling HG. Implant-supported fixed pros- higher numbers in cases of bi-maxillary implant-pros- theses in the edentulous maxilla: 8-year prospective re- sults. Clin Oral Implants Res. 2011 May;22(5):464-72. thetic rehabilitation. In this sense, monolithic zirconia 10) Purcell BA, McGlumphy EA, Holloway JA, Beck FM. 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https://www.annalidistomatologia.eu/ads/article/view/229

Original Article The use of botulinum toxin for medical-aesthetic purposes in dentistry: a comparative medico-legal approach in the context of the European Union G.L. Vaccaro1 BTX-A is also able to reduce facial expression lines. In G. Di Carlo2 fact, medicines based on BTX-A have been authorized A. Polimeni3 by the EMA (European Medicines Agency) for canthal and forehead wrinkles treatment [5]. BTX-A is also suc- 1 Student, Department of Oral and Maxillo-Facial Sci- cessfully administered to temporarily smooth perioral ences, Sapienza University of Rome, Viale Regina wrinkles in off-label mode. Elena 287a, 00161 Rome, Italy. The efficacy of BTX-A in both dental and perioral area 2 Assistant professor, Department of Oral and Maxillo- aesthetic treatments has raised the question if this drug Facial Sciences, Sapienza University of Rome, Viale can be legitimately administered by dentists. This issue Regina Elena 287a, 00161 Rome, Italy. is particularly important within the context of E.U. Coun- 3 Full professor, Rector, Department of Oral and Maxillo- tries because the dentistry field is subject to common Facial Sciences, Sapienza University of Rome, Viale rules. In fact, Directive 2005/36/EC has defined a homo- Regina Elena 287a, 00161 Rome, Italy. geneous context of professional competences to allow the free movement of dentists and the mutual recogni- tion of qualifications [6]. Corresponding author: The aim of this study is to highlight the existence of a A. Polimeni diversified framework of competences in the administra- E-Mail: [email protected] tion of BTX-A among E.U. member Countries. The study also revealed that the anatomical fields of dentistry pres- Abstract ent significant differences between States and the need to provide for a unification of the rules. In the last few years, the interest of dentists in aes- thetic treatments has grown considerably. For this reason, many European Union Country (E.U. Coun- Method tries) have regulated the competences of dentists in the field of aesthetic medicine. One of the most This study has taken into account the BTX-A regulation common therapies in this field is represented by for aesthetic purposes in the 27 E.U. member States. the injection of botulinum toxin type A (BTX-A). Only the regulations adopted by Institutional Bodies This study has analyzed the regulatory measures were considered significant results of the research. The on the BTX-A administration adopted by all the E.U. selection of regulatory sources has followed hierarchical member States. The search found the presence of criteria. The search has privileged the acts of primary a very varied regulatory framework and the need rank (State laws or equivalent acts, judgment of the Or- for convergence measures between legislations. dinary Judicial Authority). Failing that, steps were taken In fact, the harmonization of dental competences is first to seek measures adopted by the competent Min- one of the pillars of the freedom to provide services istries and Regulatory Agencies (secondary rank). Only under Directive 2005/36/EC. The prevision of com- if the search of primary and secondary rank acts failed mon competences is functional not only to allow were considered the acts of Dentists/Medical profes- the professionals movement among the E.U. Mem- sional Orders. ber States, but also to guarantee the health of pa- The conflicts between the normative sources of the tients and avoid market distortions. same State have been solved with the application of the following criteria: hierarchical (the higher-level source prevails), chronological (if the sources have the same Keywords: botulinum, toxin; dentistry; litigation level, the more recent prevails), specialty (between sources of the same level, the one prevails special over the general one). Introduction The issue of the anatomical boundaries of the dentists’ competence in BTX-A administration was also analyzed. In recent years, numerous studies have demonstrated In absence of indication in the regulatory sources, the the efficacy of BTX-A in the treatment of dental patholo- BTX-A administration was considered legitimate at least gies such as bruxism, temporomandibular disorders on the tissues covering the jaws (art. 5 of Council Di- (TMD), hemifacial spasm and gummy smile [1] [2] [3] [4]. rective 78/687/EEC of 25 July 1978) [7]. The search for 10.59987/ads/2023.1.23-27 23  The use of botulinum toxin for medical-aesthetic purposes in dentistry: a comparative medico-legal approach in the context of the European Union Table I. Summary table on BTX-A regulation for aesthetic reasons in the dentistry field within the E.U. E.U. Countries BTX-A Administration Anatomical boundary for Aesthetic purpose Austria Not allowed Belgium Not allowed Bulgaria Not allowed Mouth and jaw, including associated Croatia Allowed tissue (Directive 78/687/CEE) Mouth and jaw, including associated Cyprus No normative restrictions ---> Allowed tissue (Directive 78/687/CEE) Denmark Allowed (only if delegated by a MD) No restriction Mouth and jaw, including associated Estonia Allowed tissue (Directive 78/687/CEE) France Not Allowed Lips Red vermilion Germany Allowed Mouth and jaw, including associated Greece Allowed Tissue (Directive 78/687/CEE) Hungary Not Allowed Mouth and jaw, including associated Ireland Allowed tissue (Directive 78/687/CEE) Italy Not Allowed Latvia Not Allowed Lithuania Not Allowed Mouth and jaw, including associated Luxembourg Allowed tissue (Directive 78/687/CEE) Mouth and jaw, including associated Malta Allowed tissue (Directive 78/687/CEE) Netherland Allowed Head and neck dermal cover tissue Poland Allowed Craniofacial district Pourtugal Allowed Dermal tissues covering the face Republic of Czechoslovakia Allowed Head and neck dermal cover tissue Mouth and jaw, including associated Romania Allowed tissue Spain Not Allowed Slovakia No normative restrictions (de facto allowed) Slovenia No normative restrictions (de facto allowed) Allowed (only with oral and maxillo-facial Mouth and jaw, including associated Sweden specialization degree) tissue 24 10.59987/ads/2023.1.23-27 G.L. Vaccaro et al. regulatory sources was conducted with the Google® Lithuania, and Hungary the generic title of Medical Doc- search engine. The laws were retrieved from the offi- tor is not sufficient to administer BTX-A for aesthetic pur- cial databases of the Governments of the E.U. Member pose: in these States specialization in dermatology or States. The administrative authorities measures were re- plastic surgery is necessary (maxillofacial surgeons and trieved from the institutional internet portals (Ministries, ophthalmologists are also authorized in France). Differ- Regulatory Authorities, Professional Associations). The ences were also found among the States that license translation of the documents from the official language dentists to administer BTX-A. In fact, In Czech Republic into Italian was carried out with the aid of the Google ® and Sweden, only dentists specializing in oral and maxil- “Translator” function. lofacial surgery are authorized to administer BTX-A. In Croatia, Ireland, Holland, Poland, the Czech Republic and Romania, dentists can administer BTX-A only if they Results demonstrate specific training (in the Czech Republic, no further training is required only for dentists special- Significant results were found in 24 E.U. Member States izing in oral and maxillofacial surgery). In conclusion, in out of the total of 27 (which corresponds to an average 7 States out of a total of 18, the title of dentist alone is of 89%). Only in 3 cases (Cyprus, Slovenia and Slo- not sufficient for the administration of BTX-A as further vakia) it was not possible to find institutional norma- training/specialization is required (corresponding to an tive sources. In these States there are “de facto” no average of 38%). In Denmark, dentists can administer restrictions on BTX-A administration in dentistry. In 5 BTX-A only on the recommendation of a Medical Doctor cases the BTX-A administration was regulated by law, specialized in dermatology/plastic surgery or trained in act equivalent to the law and judgment of the judicial the use of the drug. authority (Belgium, France, Germany, Poland and Swe- From the analysis of the normative sources, differences den). However, only in Belgium has been adopted a also emerged in the dentistry anatomical areas of com- proper law on aesthetic medicine and BTX-A adminis- petence. tration [8]. In Germany and Poland, the BTX-A admin- In Croatia, Cyprus, Estonia, Finland, Greece, Ireland, istration has been regulated by judicial authority with Luxembourg, Malta, Romania, Slovenia, Slovakia and a judgment [9] [10] [11]. In France and Sweden, the Sweden, the administration of BTX-A is authorized at legal framework on BTX-A administration has been re- least within the anatomical boundaries established by constructed on the basis of health care laws [12] [13]. Directive 78/687/EEC (Mouth and jaw, including asso- In 14 cases the issue on the legitimacy of BTX-A ad- ciated tissue). In fact, in these States the authorization ministration has been addressed by the Health Authori- for BTX-A administration do not indicate the anatomi- ties (Austria [14], Bulgaria [15], Croatia [16], Denmark cal limits. For this reason, at least the anatomical limits [17], Estonia [18], Finland [19], Hungary [20], Italy [ 21] recognized by Directive 78/687/EEC were considered [22] [23], Latvia [24], Lithuania [25], Luxembourg [26], included. the Netherlands [27], the Czechoslovak Republic [28] In Germany, on the other hand, the anatomical bound- and Spain [29]). In all cases, except Italy and Spain, aries have been defined in a very limited way (red ver- the field of aesthetic medicine and BTX-A administra- milion of the lips). In Czech Republic, The Netherlands, tion was regulated by the Ministries of Health of each Poland and Portugal the dentistry field of operation in State. In 7 cases the legitimacy of BTX-A administration BTX-A administration is much wider instead. In fact, in in dentistry has been addressed by the Orders of Den- Czech Republic and in The Netherlands Dentists can ad- tists. In the Netherlands, Poland and Czech Republic, minister BTX-A to the covering tissues of the head and the Orders of Dentists intervened to supplement the neck. In Poland, the authorization concerns the entire ministerial legislation. In Greece [30], Ireland [31], Por- craniofacial area while in Portugal the administration of tugal [32] and Romania [33] the acts adopted by the BTX-A is authorized on tissues of the whole face. Orders of Dentists are the only source of legislation In conclusion, this analysis shows notable differences in (Table 2). the extent of the anatomical boundaries of dental com- The study showed that the BTX-A administration for petences in BTX-A administration. In fact, the dental aesthetic purposes is legitimate in 18 E.U. Member competence goes from the minimal borders of Germany States out of a total of 27 (equal to an average of 67%). (tissues associated with labial vermilion) to the very ex- In 15 States has been provided an express authoriza- tensive ones of Holland, Czech Republic, Poland and tion for the aesthetic BTX-A administration in dentistry. Portugal (the entire head and neck district). However, in In the remaining 3 States (Cyprus, Slovenia and Slova- the majority of cases (12 out of 18 States, equal to an kia) the BTX-A administration is allowed due to lack of average of 67%) it was found that the administration of explicit prohibitions. In fact, explicit bans are provided BTX-A is legally performed within the anatomical con- only by 9 Countries (Austria, Belgium, Bulgaria, France, texts of dental competence provided by Directive 78/687/ Hungary, Italy, Latvia, Lithuania and Spain) (Table 1). EEC (Mouth and jaw, including associated tissue). Discussion Conclusions The results of the analysis on BTX-A regulation have This study has highlighted the presence of an inhomo- highlighted numerous differences between the E.U. geneous framework of competences with respect to States. In about 2/3 thirds of the E.U. States, dentists the BTX-A administration for medical-aesthetic reasons are authorized to BTX-A administration for aesthetic within the E.U. On the other hand, the correct function- treatments. Only in 9 States have been provided an ex- ing of the principle of free movement of professionals plicit prohibition. Moreover, in Belgium, Bulgaria, France, requires common competences. An intervention by the 10.59987/ads/2023.1.23-27 25  The use of botulinum toxin for medical-aesthetic purposes in dentistry: a comparative medico-legal approach in the context of the European Union Table2. Summary table on normative source on BTX-A administration in dentistry for aesthetic purpose within the E.U. Normative source on BTX-A administration in dentistry for aesthetic purpose E.U. Countries Law on Systematic Judgments Measures of Measures of No Aesthetic interpretation of the judicial the National the Order of regulation medicine of health laws authority Health dentists Authorities Austria X Belgium X Bulgaria X Croatia X Cyprus X Denmark X Estonia X Finland X France X X (National Medicaments Agency) Germany X Greece X Hungary X Ireland X Italy X (National Medicaments Agency) Latvia Lithuania Luxembourg X Malta Netherland X Poland X Pourtugal X Republic of X X Czechoslovakia Romania X Spain X (National Medicaments Agency) Slovakia X Slovenia X Sweden X 26 10.59987/ads/2023.1.23-27 G.L. Vaccaro et al. proper Institutions would therefore be appropriate not dienste/vernetzung/rechtsprechung?Gericht=OVG%20Nor- only to avoid market distortions, but also to prevent dan- drhein-Westfalen&Datum=18.04.2013&Aktenzeichen=13%20 gers to the health and safety of patients/consumers. The A%201210/11”& HYPERLINK “https://dejure.org/dienste/ vernetzung/rechtsprechung?Gericht=OVG%20Nordrhein- use of the BTX-A in the dental field is in fact becoming Westfalen&Datum=18.04.2013&Aktenzeichen=13%20A%20 more and more common and accepted by the scientific 1210/11”Aktenzeichen=13%20A%201210/11 community. However, BTX-A is a drug that is not without 11. https://www.iww.de/zp/quellenmaterial/id/195656 risks and side effects. If the competent Institution wanted 12. h t t p s : / / w w w. l e g i f r a n c e . g o u v. f r / c o d e s / i d / L E G I - to include BTX-A in the field of dentistry, it will be also TEXT000006072665 necessary to provide adequate training for the operators. 13. https://www.lakemedelsverket.se/sv/lagar-och-regler/ foreskrifter/2016-34-konsoliderad An acceptable solution might be to expand university 14. h t t p s : / / w w w . r i s . b k a . g v. a t / G e l t e n d e F a s s u n g . dentistry curricula or provide mandatory post-graduate wxe?Abfrage=Bundesnormen HYPERLINK “https://www.ris. training. This kind of solution would also comply with ar- bka.gv.at/GeltendeFassung.wxe?Abfrage=Bundesnormen&G ticles 21, paragraph 6 and 36, paragraph 2 of Directive esetzesnummer=20007939”& HYPERLINK “https://www.ris. 2005/36/EC which provide that the dentist’s competenc- bka.gv.at/GeltendeFassung.wxe?Abfrage=Bundesnormen&G es and his university training can be expanded and mod- esetzesnummer=20007939”Gesetzesnummer=20007939 15. h t t p s : / / w w w. m h . g o v e r n m e n t . b g / m e d i a / f i l e r _ p u b - ified to adapt them to scientific and technical progress. lic/2021/03/18/naredba4-24-02-2021-standart-plastichna- hirurgiq.pdf 16. https://www.zakon.hr/z/499/Zakon-o-reguliranim-profesijama- References i-priznavanju-inozemnih-stru%C4%8Dnih-kvalifikacija 17. https://www.retsinformation.dk/eli/lta/2014/834 1. Kwon KH, Shin KS, Yeon SH, et al. Application of botulinum 18. https://www.terviseamet.ee/et/keskkonna-tervis/inimesele/ilu- toxin in maxillofacial field: part I. Bruxism and square jaw. Max- ja-isikuteenused/esteetilised-protseduurid illofac Plast Reconstr Surg 2019; 1;41(1):38. 19. https://www.valvira.fi/terveydenhuolto/hyva-ammatinharjoit- 2. Sipahi Calis A, Colakoglu Z, Gunbay S. The use of botulinum taminen/laakehoidon-erityistilanteita/botuliinihoidot) toxin-a in the treatment of muscular temporomandibular joint 20. https://sebeszem.hu/blog/post/ki-vegezhet-hazankban-arc- disorders. J Stomatol Oral Maxillofac Surg 2019;120(4):322- esztetikai-beavatkozasokat 325. 21. http://www.poiesisweb.eu/wp-content/uploads/down- 3. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: loads/2018/02/ok-aifa.pdf a new approach based on the gingival exposure area. J Am 22. http://www.valet.it/DOWNLOAD/SIES_comunicati/PAREREC- Acad Dermatol 2010; 63(6):1042-51. SS2019.pdf 4. Chagas TF, Almeida NV, Lisboa CO, et al. Duration of effec- 23. https://www.collegiomedicinaestetica.it/medicinaestetica/im- tiveness of Botulinum toxin type A in excessive gingival dis- ages/RETTIFICA_AIFA12916.pdf play: a systematic review and meta-analysis. Braz Oral Res 24. https://likumi.lv/ta/id/282367-arstniecibas-personu-un-arst- 2018; 32:e30. niecibas-atbalsta-personu-registra-izveides-papildinasanas- 5. https://www.ema.europa.eu/en/documents/referral/ un-uzturesanas-kartiba summary-information-referral-opinion-following-arbitra- 25. https://e-seimas.lrs.lt/portal/legalAct/lt/TAD/77b659f0308e11e tion-pursuant-article-29-council-directive/83/ec-botox-ac- a8f0dfdc2b5879561 tive-substance-clostridium-botulinum-type-neurotoxin-com- 26. https://www.lessentiel.lu/fr/story/les-injections-de-botox-reser- plex-background-information_en.pdf vees-aux-medecins-596892198588 6. h t t p s : / / e u r - l e x . e u r o p a . e u / l e g a l - c o n t e n t / I T / 27. https://www.zorginstituutnederland.nl/actueel/nieu- TXT/?uri=celex%3A32005L0036 ws/2019/11/20/kwaliteitskader-cosmetische-zorg-basis-voor- 7. h t t p s : / / e u r - l e x . e u r o p a . e u / l e g a l - c o n t e n t / I T / veilige-en-kwalitatief-goede-zorg ALL/?uri=CELEX:31978L0687 28. h t t p s : / / w w w. m z c r. c z / w p - c o n t e n t / u p l o a d s / 8. https://etaamb.openjustice.be/nl/wet-van-23-mei-2013_ wepub/16212/35290/M%C5%AF%C5%BEe%20 n2013024225.html#:~:text=Niet%2Dheelkundige%20 l%C3%A9ka%C5%99%20stomatolog%20s%20uzna- esthetisch%2Dgeneeskundige%20of%20 nou%20odbornou%20zp%C5%AFsobilost%C3%AD%20 esthetisch%2Dheelkundige%20ingrepen%20mogen,of%20 prov%C3%A1d%C4%9Bt%20kosmetick%C3%A9%20 vertegenwoordigers%20van%20de%20minderjarige. z%C3%A1kroky%20v%20oblasti%20hlavy%20a%20krku,%20 9. https://openjur.de/u/166109.html prov%C3%A1d%C4%9Bt%20b%C4%9Blen%C3%AD.pdf 10. h t t p s : / / d e j u r e . o r g / d i e n s t e / v e r n e t z u n g / 29. https://www.aemps.gob.es/informa/circulares/medicamento- rechtsprechung?Gericht=OVG%20Nordrhein-West- sUsoHumano/2010/docs/circular_02-2010_toxina-botulinica- falen HYPERLINK “https://dejure.org/dienste/vernet- A.pdf zung/rechtsprechung?Gericht=OVG%20Nordrhein- 30. https://www.osanet.gr/images/uploads/odontiatroi/iatrikos_bo- Westfalen&Datum=18.04.2013&Aktenzeichen=13%20 tox.jpg . A%201210/11”& HYPERLINK “https://dejure.org/dienste/ 31. http://www.dentalcouncil.ie/nonsurgicalcosmetics.php). vernetzung/rechtsprechung?Gericht=OVG%20Nordrhein- 32. https://www.omd.pt/2022/08/harmonizacao-facil-competen- Westfalen&Datum=18.04.2013&Aktenzeichen=13%20A%20 cias/ 1210/11”Datum=18.04.2013 HYPERLINK “https://dejure.org/ 33. http://www.cmdbuzau.ro/legislatie/61.pdf 10.59987/ads/2023.1.23-27 27 

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Original Article Use of the magnet mallet in a case of extraction and post-extraction implant site preparation, in combination with regenerative therapy on hypertensive patient: a case report and literature review Oddi C.* Keywords: Magnetic Mallet, Implant positioning, Tooth Collina G.* extraction, CBCT, Regenerative surgery Ceresoli L.* Ferri S.* Introduction Grassi A.* Nagni M.** The first electrified dental hammer was projected in 1873 by William Bonwill, in order to fill the cavities with gold [1]. Over the years this hammer has been modified and im- *Dental School, Vita-Salute San Raffaele University, proved in order to make the most of its qualities. It is a de- Milan, Italy and Department of Dentistry, vice that allows an high control and stability of the applied IRCCS San Raffaele Hospital, Milan, Italy forces, allowing to perform procedures that are as safe as possible for the patient and the surgeon himself [2-3]. **MSc, Dental School, Vita-Salute San Raffaele Magnetodynamic technology exploits the physical prin- University, Milan, Italy and Department of Dentistry, ciples of electromagnetism to be able to apply controlled IRCCS San Raffaele Hospital, Milan, Italy forces on a body, in order to minimize the impact time Corrisponding Author: Giorgio Collina [4]. Nowadays, in fact, the Magnetic Mallet (MM) is used email: [email protected] in oral surgery, in many different fields [5]. It is charac- terized by a handpiece powered by a power control de- vice, which has the ability to deliver forces according to Abstract the application time, precisely four force modes 75, 90, 130 and 260 daN with an impact time of 80 μs. Different Objectives: over the years a device has been developed, shock waves are emitted from the handpiece depending the Magnetic Mallet, which allows a very high control and on the type of surgery. In addition, on this handpiece you stability of the applied forces, able to perform procedures can go to insert different inserts according to the tech- that were the safest possible for the patient and the sur- nique / procedure that is being applied. geon himself. The handpiece has been designed so that The Magnetic Mallet is thus used in different oral surgi- different shock waves are emitted according to the type cal procedures, such as: dental extractions, in the place- of surgery, with the possibility of inserting different inserts ment of implants, in the preparation of the implant site according to the technique / procedure that is being ap- (osseodensification), in sinus lift procedures or in ridge plied. The Magnetic Mallet can be used in different sur- expansion procedures. [6-7-8-9-10] gical procedures; Dental extractions, implant placement, implant site preparation (osseodensification), maxillary sinus lift procedures or crestal expansion procedures. Materials and methods Materials and methods: In the following clinical case, In October 2022, a 58-year-old female patient, suffering the extraction of element 2.7 is conducted with the simul- from hypertension, came to our attention for pain located taneous insertion of two implant fixtures in place 2.6 and near the second quadrant. During the first visit after a 2.7 and simultaneous regenerative therapy. The implant careful intra- and extra-oral clinical examination, a first- in site 2.6 was positioned with a traditional method, with level orthopantomography (OPT) radiographic examina- the help of the implant motor, while the post-extraction tion was performed in order to evaluate the patient’s oral implant in site 2.7 was inserted with the use of the Mag- condition even more carefully (Fig. 1). netic Mallet. In the second quadrant there was a prosthetic bridge that extended from element 2.4 to element 2.7 with element Results: At one week the sutures were removed and the 2.6 bridge. The prosthetic artifact had some mobility per- tissues showed good healing. The patient is then placed haps due to the carious lesion that extended below the in a maintenance and follow-up program to monitor heal- prosthetic crown of element 2.7, previously devitalized ing after some time. and covered with a Richmond crown (Fig. 2). 10.59987/ads/2023.1.29-34 29  Use of the magnet mallet in a case of extraction and post-extraction implant site preparation Figure 1. OPT After evaluating the condition of the element and prepar- ing a treatment plan that was as predictable as possible, it was agreed to extract element 2.7 with the simultane- ous insertion of two implant fixtures in place 2.6 and 2.7 and simultaneous regenerative therapy (Fig. 3-4-5). After signing the information form, local anesthesia was carried out with 4% articaine and adrenaline 1:100,000 (Ubistesin 40 mg/ml, 3M ESPE, Italy), element 2.7 was estracted with the aid of the Magnetic Mallet (MM). This tool has allowed a safe, predictable and fast ex- traction, reducing the possible complications in which it could be incurred (Fig. 6). Subsequently, two implants were placed in place 2.6 and 2.7 at the same time as regenerative therapy, by elevat- ing a full-thickness flap with parasulcular incision and insertion of a biomaterial, a xenograft of bovine origin (Bioss collagen) (Fig. 7). [11] The implant in site 2.6 was positioned with a traditional method, with the help of the classic implant motor, while the post-extraction implant in place 2.7 was inserted with the Magnetic Mallet. The 2.6 site plant is a 3.8X11 Figure 2. Carious lesion in position 2.7. The patient was explained the situation and the fact that it was considered necessary to remove the prosthetic bridge in order to assess whether element 2.7 was sal- vageable or not. Already assuming the disastrous con- dition of the element and the difficulty in being able to save it, the patient was prescribed a second level CBCT examination in order to evaluate three-dimensionally the amount of bone for the possible insertion of implant fix- tures (Fig. 3). At the next appointment, the prosthetic artifact was re- moved and the disastrous condition of element 2.7 came to light. Figure 3. CBCT and implant treatment plan planification. 30 10.59987/ads/2023.1.29-34 C. Oddi et al. Figure 4. CBCT and implant treatment plan planification. Figure 5. CBCT and implant treatment plan planification. 10.59987/ads/2023.1.29-34 31  Use of the magnet mallet in a case of extraction and post-extraction implant site preparation Figure 6. Extraction of the element in position 2.7 and implant positioning in position 2.6. post-extractive implant positioning in association with the use of Mangnetic Mallet in position 2.7. Figure 7. Regenerative therapy on site 2.7 with insertion of Figure 8. Flap suture with detached stiches with 4/0 absorb- biomaterial (xenograft of bovine origin). able thread. Winsix TTI system, while the 2.7 on-site plant is a 4.5X9 DISCUSSION Winsix TTI. The flap closure was carried out with a suture with de- Patient’s medical hystory is foundamental to state the cor- tached stitches with 4/0 absorbable thread (Vicryl, Ethi- rect treatment plan, especially when we are talking about con, Johnson & Johnson, New Brunswick, NJ, USA) surgery. When implant surgery is performed in patients (Fig. 8-9). with cardiovascular disease, concerns are related to the possible bad consequences of the use of anticoagulants preoperatively or to changes in blood pressure caused by RESULTS vasoconstrictors contained in local anesthetics. The retrospective study by Tonini KR. et al., investigates One week after surgery, the sutures were removed and the association of hypertension and the use of antihy- the tissues were in a good state of healing. Finally, the pertensive drugs with dental implant failure rate. 1877 patient was placed within a maintenance program with implants were placed in a total of 602 patients. 71.43% periodic clinical and radiographic checks to assess heal- of the patients were normotensive, while 28.36% were ing and bone regeneration over the years. hypertensive. The success rate of implant positioning in 32 10.59987/ads/2023.1.29-34 C. Oddi et al. Figure 9. Post-surgical control OPT the normotensive group was 93.98% while in the hyper- Although in some cases the insertion of axial implants tensive group was 92.99%, and their success rate was in basal bone may be hindered by insufficient residual similar whether they had taken antihypertensive drugs bone height, the insertion of implants in native bone or not. It is possible to assume that hypertensive pathol- should be always preferred. [22] ogy, also in combination with the use of antihypertensive Type of fixtures choice and prosthetics can influence the drugs, cannot be associated with implant failure [12]. success rate in the short and long term; It follows that Wu X. et al., in their review, discuss how hypertensive pre-surgical planning represents a fundamental starting drugs such as beta-blockers, thiazide diuretics and ACE point for rehabilitation[23][24]. All the procedures were inhibitors can have a positive effect on implant survival carried out in compliance with the rules provided for the rate [13]. Covid-19 pandemic situation, to promote the safety both The use of vasoconstrictors in anesthetics do not appear of patients and staff [25]. Professional and home hygien- to be contraindicated. In fact, Montebrugnoli L. et al. ic maintenance is one of the main prerequisites for suc- showed how the presence of adrenaline does not cause cessful implants. [26][27] an increase in pressure, because its use produces less A recent systematic review of 2022 aimed to answer stress than would occur with the production of endog- the question of whether the use of Magnetic Mallet was enous catecholamines released following the adminis- effective or not used in oral surgery, in terms of tissue tration of anesthesia without vasoconstrictors [14]. healing, and complications, comparing it to the use of Failure to control intra-operative pain could create the traditional instruments. activation of important cardiovascular responses [15]. Of 252 articles, 14 were included in the review (3 for The administration of approximately two vials of local tooth extraction and 11 for dental implantology). Out of anesthetic with adrenaline 1:100,000 or 1:80,000, in a total of 619 tooth extractions (256 patients) performed hypertensive patients, does not significantly alter blood with the magnetic mallet, no complications were re- pressure [16]. Following the injection of one vial of lido- ported. The implants included were 880 (525 patients): caine (1.8 ml) at 2% with epinephrine 1:100,000 (0.018 640 in the Magnetic Mallet group (382) and 240 in the mgr), plasma levels of epinephrine increase two to three control group (133). The survival rate of the implants times without causing significant changes in blood pres- was 98.9% in the Magnetic Mallet group and 95.42% in sure and heart rate; three vials increase levels five to six the control group. Seven patients experienced benign times and are accompanied by hemodynamic changes paroxysmal positional vertigo after implant surgery, all without symptoms; on the other hand, stress itself can in- in the control group. The results are not sufficient to crease plasma levels of endogenous catecholamines 40 establish the effectiveness of the Magnetic Mallet but it times [17]. Cardiovascular response that occurs as a re- seems to be an effective option in oral and implant sur- sult of stress can be related to the dental procedure rather gery procedures [28]. than to the use of anesthetics containing vasoconstrictors The usefulness of the Magnetic Mallet had already been [18]. Becker DE et al., on the other hand, suggests that studied in 2014 by Crespi, R. et al. in a work whose pur- despite the properties of vasoconstrictors, in patients with pose was to evaluate its effectiveness in the field of tooth cardiovascular diseases and in hypertensive patients, in- extractions and in maintaining the integrity of the alveo- voluntary intravascular injection of adrenaline is associ- lar bone after the extraction. The extractions were con- ated with adverse cardiovascular effects. [19] ducted using a Magnetic Mallet, which moving the blade Dental implants are currently a successful therapeutic in a longitudinal movement along the central axis up and alternative that can also be applied in patients with sys- down towards the space of the periodontal ligament, pro- temic diseases, which are nowadays increasing with the viding a mechanism for guiding longitudinal movements. rase of average age [20][21]. No fracture or loss of cortical bone has been observed in 10.59987/ads/2023.1.29-34 33  Use of the magnet mallet in a case of extraction and post-extraction implant site preparation tooth extractions conducted with Magnetic Mallet. All the 14. Montebugnoli L, Pelliccioni GA, Borghi C. Effetti dei vaso- sockets showed complete secondary soft tissue healing costrittori durante l’anestesia locale [Effects of vasocon- 2 weeks after complete root extraction. At the follw-ups, strictors during local anesthesia]. Dent Cadmos. 1990 May 31;58(9):62-71. there were no signs of inflammation or exposed bone in 15. Becker DE. Preoperative medical evaluation: part 1: general any of the cases. A clinical study is also reported, show- principles and cardiovascular considerations. Anesth Prog. ing how maximum alveolar preservation and related gin- 2009 Autumn;56(3):92-102; quiz 103-4. doi: 10.2344/0003- gival structures can be maintained after atraumatic tooth 3006-56.3.92. extraction by Magnetic Mallet [29]. 16. Serrera Figallo MA, Velázquez Cayón RT, Torres Lagares D, In the context of oral surgery, Magnetic Mallet seems to Corcuera Flores JR, Machuca Portillo G. Use of anesthet- ics associated to vasoconstrictors for dentistry in patients be a suitable alternative, but other studies should be con- with cardiopathies. Review of the literature published in the ducted with a larger sample to confirm this hypothesis. last decade. J Clin Exp Dent. 2012 Apr 1;4(2):e107-11. doi: 10.4317/jced.50590. 17. Cáceres MT, Ludovice AC, Brito FS, Darrieux FC, Neves Conclusion RS, Scanavacca MI, Sosa EA, Hachul DT. Effect of lo- cal anesthetics with and without vasoconstrictor agent As we can see from this clinical case, the use of the in patients with ventricular arrhythmias. Arq Bras Cardiol. 2008 Sep;91(3):128-33, 142-7. English, Portuguese. doi: Magnetic Mallet (MM) in the dental field is useful in dif- 10.1590/s0066-782x2008001500002. ferent oral and implant surgery procedures, because it 18. Spivakovsky S. Injectable local anaesthetic agents for den- is a safe, predictable, fast to use and manageable tool. tal anaesthesia. Evid Based Dent. 2019 Jun;20(2):42-43. doi: 10.1038/s41432-019-0021-x. 19. Becker DE, Reed KL. Essentials of local anesthetic phar- References macology. Anesth Prog. 2006 Fall;53(3):98-108; quiz 109- 10. doi: 10.2344/0003-3006(2006)53 1. The Bonwill Electro-Magnetic Mallet. Am J Dent Sci. 1881 20. D’Orto, B.; Polizzi, E.; Nagni, M.; Tetè, G.; Capparè, P. 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Int J Oral Maxillofac Implants. implant prosthodontic score of a one-year prospective study on three different connections for single-implant 2013 May-Jun;28(3):869-74. doi: 10.11607/jomi.2679. restorations. Journal of Osseointegration, 10(4), 130-135. 7. Crespi R, Capparè P, Gherlone E. Sinus floor elevation by doi:10.23805/JO.2018.10.04.04. osteotome: hand mallet versus electric mallet. A prospec- 24. Gherlone, E. F., Capparé, P., Pasciuta, R., Grusovin, M. G., tive clinical study. Int J Oral Maxillofac Implants. 2012 Sep- Mancini, N., & Burioni, R. (2016). Evaluation of resistance Oct;27(5):1144-50. against bacterial microleakage of a new conical implant- 8. Crespi R, Capparè P, Gherlone E. Electrical mallet provides abutment connection versus conventional connections: An essential advantages in maxillary bone condensing. A pro- in vitro study. New Microbiologica, 39(1), 59-66. spective clinical study. Clin Implant Dent Relat Res. 2013 25. Capparè, P., D’ambrosio, R., De Cunto, R., Darvizeh, A., Dec;15(6):874-82. doi: 10.1111/j.1708-8208.2011.00432.x. Nagni, M., & Gherlone, E. (2022). The usage of an air pu- Epub 2012 Jan 11. rifier device with HEPA 14 filter during dental procedures 9. Crespi R, Capparè P, Gherlone EF. Electrical mallet pro- in COVID-19 pandemic: A randomized clinical trial. Inter- vides essential advantages in split-crest and immediate im- national Journal of Environmental Research and Public plant placement. Oral Maxillofac Surg. 2014 Mar;18(1):59- Health, 19(9) doi:10.3390/ijerph19095139 64. doi: 10.1007/s10006-013-0389-2. Epub 2013 Jan 18. 26. Tecco, S., Grusovin, M. G., Sciara, S., Bova, F., Pantaleo, 10. Crespi R, Capparè P, Gherlone E. A comparison of manual G., & Capparé, P. (2018). The association between three and electrical mallet in maxillary bone condensing for imme- attitude-related indexes of oral hygiene and secondary im- diately loaded implants: a randomized study. Clin Implant plant failures: A retrospective longitudinal study. Internation- Dent Relat Res. 2014 Jun;16(3):374-82. doi: 10.1111/j.1708- al Journal of Dental Hygiene, 16(3), 372-379. doi:10.1111/ 8208.2012.00485.x. Epub 2012 Aug 15. idh.12300. 11. Bassir, S. H., El Kholy, K., Chen, C. Y., Lee, K. H., & Intini, 27. Cattoni, F., Tetè, G., D’orto, B., Bergamaschi, A., Polizzi, E., G. (2019). Outcome of early dental implant placement ver- & Gastaldi, G. (2021). Comparison of hygiene levels in metal- sus other dental implant placement protocols: A systematic ceramic and stratified zirconia in prosthetic rehabilitation on review and meta-analysis. Journal of periodontology, 90(5), teeth and implants: A retrospective clinical study of a three- 493–506. https://doi.org/10.1002/JPER.18-0338 year follow-up. Journal of Biological Regulators and Homeo- 12. Tonini KR, Hadad H, Egas LS, Sol I, de Carvalho PSP, Pon- static Agents, 35(4), 41-49. doi:10.23812/21-4supp1-4. zoni D. Successful Osseointegrated Implants in Hyperten- 28. Bennardo, F.; Barone, S.; Vocaturo, C.; Nucci, L.; Antonel- sive Patients: Retrospective Clinical Study. Int J Oral Maxil- li, A.; Giudice, A. Usefulness of Magnetic Mallet in Oral lofac Implants. 2022 May-Jun;37(3):501-507. doi: 10.11607/ Surgery and Implantology: A Systematic Review. J.Pers. jomi.9425. Med.2022,12,108. https:// doi.org/10.3390/jpm12010108 13. Zhou W, Wang F, Monje A, Elnayef B, Huang W, Wu Y. 29. Crespi, R., Bruschi, G. B., Capparé, P. & Gherlone, Feasibility of Dental Implant Replacement in Failed Sites: E.   (2014).   The Utility of the Electric Mallet.   Journal A Systematic Review. Int J Oral Maxillofac Implants. 2016 of Craniofacial Surgery,   25 (3),   793-795.   doi: 10.1097/ May-Jun;31(3):535-45. doi: 10.11607/jomi.4312. SCS.0000000000000523 34 10.59987/ads/2023.1.29-34 

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Editorial Dentistry and the elderly patients: A challenge for the future! The average age and life expectancy of the population is constantly increasing, and a great challenge for the healthcare systems around the globe will be to ensure a healthy aging for the future generations. The dentist must also be prepared and trained to know how to enhance and maintain a “healthy” smile in the different age groups and promote all the actions necessary to im- prove the health of the oral cavity and dental solutions effective from a biological point of view but also financially sustainable. So far, oral health has been largely neglected on the global health agenda. Yet, most dental disorders are mostly preventable and treatable. A good prevention campaign will have to play an increasingly indispensable role, thus allowing huge economic sav- ings and improving the quality of life of the population. A new approach to “senior” dentistry is being born and will need to be developed, with solutions designed specifically for the resolution of functional problems, but increasingly also aesthetic. It should not be forgotten that among professionals, doctors and dentists, we notice the same effects of the aging of the general population, with an increasingly high average age. Professional updating, new technologies and different models in the interpretation of medicine are outlining the study of the future: an interconnection of numerous profes- sionals who will exchange information on the state of health and well-being of their patients. The change is also taking place on management models that, in the near future, will have to integrate with modern technologies and new forms of communication and relationship with patients. Ensuring effective treatment in a safe and controlled environment is equivalent to ensuring “longevity” also to our studies. Prof. Luigi Paglia Annali di Stomatologia 2022; XIII (1-4): 1 1 

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Article Traditional versus digital impression: compliance and preference in pediatric patients- review Valeria Luzzi1 tients and children, for whom it represents a moment of Gabriele Di Carlo1 discomfort. It can also be complex for the clinician. The Elvira Crupi1 possibility of effectively replacing the traditional physi- Ester Quarta1 cal detection of the impression represents the main ad- Francesca De Angelis1 vantage of the optical impression. In orthodontics this Stefano Di Carlo1 has a fundamental importance both from a clinical and Antonella Polimeni1 diagnostic point of view. Traditional orthodontic study Gaetano Ierardo1 models have also been replaced by digital study mod- els, through which the orthodontist can perform all the 1 Department of oral and Maxillo-Facial Sciences, Sapi- measurements he or she made on the plaster model enza University of Rome, Via Caserta 6, 00161 Rome, [2]. In orthodontics, a first attention was paid to the first Italy; scanners capable of transforming plaster models into 3D images, but with the appearance on the market of intraoral scanners, there was a real revolution [3]. In the most recent literature there are many studies that focus *Corresponding author: on the main features of intraoral scanners, such as the Francesca De Angelis - University of Sapienza Italy accuracy and precision of measurements, but very few [email protected] or almost non-existent studies evaluate the patient’s compliance. For this reason, through this research we want to understand which method is most appreciated Abstract for taking impressions in the field in the pediatric ortho- The purpose of this article is to compare the alginate dontic field. impression with digital impression using the introral scanner Carestream 3600 and understand which is preferred by patients. 50 young orthodontic patients Materials and methods (25 boys and 25 girls) who had no previous experi- 50 pediatric patients, 25 females and 25 males with an ence of impressions were enrolled in the study. Af- age between 6 and 9 years (Table 1), who made the first ter the impressions the patients were subjected to a dental visit at the Department of Pediatric Dentistry of questionnaire for both types of impressions. They the La Sapienza University. The parents of the young pa- were asked about feelings of nausea and breathing tients were informed about the purposes of the research issues related to whether a digital or alginate im- and signed informed consent. In order to be included in pression was taken. As for the feeling of nausea, 24 the study, patients had to meet two requirements to par- girls and 22 boys did not have this feeling with digital ticipate in the study: impressions; as regards breathing, 19 girls and 23 - They never had impressions procedures before the boys did not find respiratory problems with the intra- study; oral scanner. At the end, patients were asked which - Make an impression to have study models for orth- method they preferred. About 75% both for girls and boys preferred the intraoral scanner. Therefore, the odontic purposes. digital method was found to be the most comfortable Each of them was first subjected to impression taking for the patients. with alginate and occlusion wax, sent to the technician to be able to develop the plaster models and later with Key words: children, digital impression, alginate the CareStream 3600 intraoral scanner, thus obtaining impressions, patient comfort, patients’ preferences, 50 plaster models and 50 corresponding digital models. orthodontics patient, feeling of nausea, problems in Each patient was administered an illustrated question- breathing. naire, before and after taking the impression. It con- tained three questions, made more pleasant in the eyes of the children by the replacement of the boxes where Introduction to place the X with three smiley, happy, sad or indiffer- Nowadays with the advancement of progress and tech- ent faces (Table 2). The outcomes that have been cho- nology, dentistry is increasingly facing, embracing all sen were studied through an assessment of the sense its branches to the third dimension [1]. The traditional of nausea, ease of breathing and any other problems impression is an unwelcome phase both for adult pa- related to the two techniques. Only in the final analysis Annali di Stomatologia 2022; XIII (1-4): 3-8 3  Traditional versus digital impression: compliance and preference in pediatric patients- review Table 1. Breakdown of patients by age. 50 children 25 girls 25 boys 5 6 YEARS OLD 3 6 7 YAERS OLD 7 7 8 YEARS OLD 8 7 9 YEARS OLD 7 Table 2. Satisfaction questionaire submitted to each Table patient. of patients by age 1: breakdown SATISFACTION QUESTIONNAIRE IMPRESSION SATISFACTION QUESTIONNAIRE DURING THE IMPRESSION IMPRESSION WITH CAMERA DURING - DIDTHE YOUIMPRESSION WITH CAMERA COME TO THROW UP? - DID YOU COME TO THROW UP? - COULD YOU BREATHE QUIETLY? - COULD YOU BREATHE QUIETLY? - I HAVEN’T ANY PROBLEMS - I HAVEN’T ANY PROBLEMS DURING THE IMPRESSION WITH PONGO - DID YOU COME TO THROW UP? DURING THE IMPRESSION WITH PONGO - DID YOU COME TO THROW UP? - COULD YOU BREATHE QUIETLY? - COULD YOU BREATHE QUIETLY? - I HAVEN’T ANY PROBLEMS - I HAVEN’T ANY PROBLEMS WHICH METHOD DO YOU PREFER? - CAMERA WHICH METHOD DO YOU PREFER? - GEL - CAMERA - NO PREFERENCE - GEL 4 Annali di Stomatologia 2022; XIII (1-4): 3-8 V. Luzzi et al. was the participant asked to express a preference for swered that they had no breathing problems, while 6 in one or the other method. The language that was used in an uncertain manner. The data vary by analyzing the the questionnaires is a simple jargon easily understood response with the conventional method. Only 10 girls by the young patients. The word “pongo” was used in- replied that they could breathe quietly, 8 were uncertain stead of alginate and the word “camera” instead of scan- and 7 had problems with breathing (Figure 2). ner. All procedures were carried out by an operator and In graph number 3, the answers of the female patients to over a period of a month. the third question regarding the possibility of having had other problems were analyzed. Regarding fingerprints Results for 18 girls there was no problem. Two answered had problems and the remaining 5 answers are uncertain. As graph one shows, through which the responses con- Regarding the conventional method, it can be observed cerning the feeling of nausea were analyzed, 24 girls re- that an equal number of girls responded in the affirma- plied that they had no sensation, while only one girl gave tive and neutral way, while 3 of them have definitely en- a “short” answer regarding the taking of impressions with countered problems (Figure 3). the scanner. While, for conventional impressions, 6 girls The responses of the children were assessed and in had to vomit, for 10 the experience was uncertain and at chart 4. The feeling of nausea was analyzed from the last 9 girls had no vomiting reflex (Figure 1) scanner - 22 children had no problems, 3 remained neu- In the second graph, the answers from female patients to tral and no child gave an affirmative answer. the second question ofNO thePREFERENCE questionnaire were analyzed On the contrary, during taking the alginate impressions, -- NO PREFERENCE regarding the possibility of having difficulties in breathing. only 5 children did not have the vomiting reflex, 9 per- Regarding Table 2:the Table 2: impression satisfaction satisfaction with submitted questionaire questionaire the scanner, submitted each19 to each to girls an- patient patient ceived it and finally 11 remained neutral (Figure 4). QUESTION 1: QUESTION 1: DID DID YOU YOU COME COME TO TO THROW THROW QUESTION 3: I HAVEN'T ANY PROBLEMS UP? UP? 30 30 20 25 18 QUESTION 3: I HAVEN'T ANY PROBLEMS 25 16 20 24 24 14 20 20 12 15 18 15 10 16 18 8 14 10 10 6 12 11 11 10 99 10 4 55 10 11 66 28 18 5 00 2 3 00 06 11 11 SCANNER 24 SCANNER 18 5 2 SCANNER 24 11 00 4 ALGINATE ALGINATE 11 5 11 3 ALGINATE 99 10 10 66 2 2 3 0 SCANNER 18 5 2 Figure 1. Feeling of nausea Figure Figure feelinginof 1: feeling 1: ofgirls. nausea in nausea in girls girls Figure 3. Others problems Figure inproblems 3: others girls. in girls ALGINATE 11 11 3 QUESTION 1: DID Figure 3: others YOU problems COME TO in girls QUESTION 2: QUESTION 2: COULD COULD YOU YOU BREATHE BREATHE THROW UP? QUIETLY? QUIETLY? QUESTION 1: DID YOU COME TO 20 25 THROW UP? 20 18 18 20 16 16 25 22 14 14 15 20 12 12 22 10 10 10 15 19 19 88 5 11 10 9 66 5 0 10 10 3 0 11 44 88 5 66 77 SCANNER 22 3 09 22 5 0 00 ALGINATE 0 5 3 11 9 00 SCANNER 22 3 0 SCANNER SCANNER 19 19 66 00 ALGINATE 5 11 9 ALGINATE ALGINATE 10 10 88 77 Figure 4: feeling of nausea in boys Figure 2. Breathing Figure pproblems Figure 2: 2: in girls. in breathing pproblems breathing pproblems in girls girls Figure 4. Feeling of nausea Figure 4: feeling in boys. in boys of nausea Annali di Stomatologia 2022; XIII (1-4): 3-8 5  Traditional versus digital impression: compliance and preference in pediatric patients- review In graph 5 the answers to question number 2 were an- alyzed, which concerned the possibility of breathing peacefully. While using the digital method, 23 children QUESTION 2: DID YOU BREATHE QUIETLY? were able to breathe quietly, 2 responded uncertainly 25 while no negative response was obtained. While using 23 QUESTION 2: DID YOU BREATHE QUIETLY? the alginate, on the other hand, 9 children responded in 20 25 an affirmative way, 4 in a negative way and most, that is, 23 12 children, responded in an uncertain / hesitant manne 15 20 (Figure 5). Finally, in chart number 6, the answers to the question 10 15 on the possibility of having had other problems were analyzed. During the impression with the scanner, there 12 were no problems for 20 children and five answered 105 9 hesitantly. With the alginate impression, 5 children re- 4 2 12 0 plied that they had problems, 12 replied hesitantly while 50 9 for 8 of them experienced no problem (Figure 6). SCANNER 23 2 0 4 The last questionnaire that was completed asked the ALGINATE 0 9 2 12 0 4 children to express a preference for one or the other SCANNER 23 2 0 method. From chart ° 7 for boys and ° 8 for girls it can ALGINATE 9 12 4 be highlighted how in equal percentage (75%), in both Figure 5. Breathing problems in boys. figure 5: breathing problems in boys sexes, the scanner is preferred. Alginate is the pre- ferred method to a greater extent by boys (20%) than girls who choose this option (12%). At last, 5% of boys figure 5: breathing problems in boys and 12% of girls do not prefer any of the two methods QUESTION 3: I HAVEN'T ANY PROBLEMS (Figure 7). 25 QUESTION 3: I HAVEN'T ANY PROBLEMS Discussion Study models, therefore, represent an essential form of 20 25 orthodontic documentation for documentation and anal- ysis of the case. With the advent of digital impression, 15 20 many of the limits that were had with conventional im- pression were overcome. They are not subject to phys- 10 15 20 ical damage, do not create dust or other disorders and 12 require negligible storage space. The digital information 105 20 8 can be stored on the computer’s hard drive, on storage 5 0 5 12 devices such as CDs or on a central server. Recovery is 50 fast and efficient because the models are stored by the SCANNER 20 8 5 0 5 0 5 patient’s name and number. They also make it possible ALGINATE 0 8 12 5 to reduce time and expense of duplicating the models SCANNER 20 5 0 to be transferred to colleagues or laboratories and, at ALGINATE Figure 86: other problems12 in boys 5 last, they are an excellent case presentation tool [5]. But digital models also have disadvantages. The high initial Figure 6: other problems in boys cost to which is added the cost of constant technologi- Figure 6. Other problems in boys. WHICH METHOD DO YOU WHICH METHOD DO YOU PREFER? PREFER? NONE NONE 4% 12% ALGINATE ALGINATE 20% 12% SCANNER SCANNER 76% 76% SCANNER ALGINATE NONE SCANNER ALGINATE NONE Figure 7. Preference of boys and girls. Figure 7: preference of boys and girls 6 Annali di Stomatologia 2022; XIII (1-4): 3-8 V. Luzzi et al. cal updating. There learning time that the clinician needs and the time required to obtain the impressions was re- to effectively master the system and familiarize with the corded. Data indicated that subjects receiving intraoral hardware and software. Some patients are more difficult scans preferred digital impression and that subjects to manage, for example the inability to hold their tongue receiving alginate impressions were neutral, while effi- still or to remain motionless with mouth open. Finally it ciency varied based on the impression method. The au- is difficult to scan very pronounced emergence profiles, thors eventually concluded that intraoral scanners are interproximal areas with severe misalignment, upper ret- accepted by orthodontic patients and have an efficiency romolar areas in proximity to the coronoid process and comparable with conventional impression methods de- data overlap of the antero-superior palate-occluded-ves- pending on the type of scanner [9]. tibular sector [6]. In 2018 a study conducted by Mangano A. et al exam- According to the numerous advantages of digital im- ined 30 young orthodontic patients (15 male and 15 fe- pressions, there are some studies in the literature which male) who had never had experience with the impres- show, like our study, that young patients prefer these. sions. Conventional impressions for orthodontic study In a 2014 study conducted by Yuzbasioglu E. et al the models were taken using an in alginate and fifteen days traditional impression was compared with the digital im- later, the impressions were taken, using an intraoral pression to understand what was preferred by the pa- scanner (CS3600®, Carestream Dental, Rochester, NY, tients. 24 young patients, 12 male and 12 female, who USA). Immediately after taking the impression, the ac- had never taken the impression neither in alginate nor ceptability, comfort and stress of the patients were mea- digitally, were examined. After taking the impressions sured using two questionnaires and the State-Trait Anxi- the patients’ preferences, their perceptions and working ety Inventory. The data showed no difference in terms of times were assessed through a questionnaire. Statisti- anxiety and stress; however, patients preferred the use cal analyzes were performed using the Wilcoxon Rank of digital systems rather than conventional impression test and P <0.05 was considered positive. The results techniques [10]. showed significant differences between the groups in In a 2019 study conducted by Ylmaz H. et al the fin- terms of total working time and processing phases, but gerprints were compared with alginate and digital ones, patients still preferred the digital technique over the assessing the comfort, preference and time required to conventional one in terms of comfort [7]. make the impression. 28 children were assessed and In a 2015 study by Lukasz B. et al, the alginate impres- comfort was examined by both patients and the clini- sion technique was compared with two digital techniques cian during the impression taking; the necessary chair and the preference was assessed in young orthodontic times were also assessed. For statistical analysis, the patients. Thirty-eight subjects aged 10 to 17 years requir- t test and Mann-Whitney U test were used and P <.05 ing impressions for orthodontic treatment were randomly was considered significant. In terms of comfort, digital allocated to 3 groups that differed in the order that an impression were the ones most preferred by children, alginate impressions and 2 different intraoral scanning while in terms of time, no significant differences were procedures were administered. After each procedure, found between digital and alginate impressions [11]. patients were asked to evaluate their perceptions on a Despite this literature supporting the purpose of this re- 5-point Likert scale for reflex of vomiting, nausea, diffi- view, the study has some limitations. In fact, only one culty breathing, feeling of discomfort, perception of scan type of intraoral scanner was used, so other intraoral time, anxiety and the use of a powder , and select the scanners with their workflows could lead to different preferred impression system. The presidential time and results. In addition, the two types of impressions were maximum mouth opening were also recorded. During taken by a single operator, to avoid errors between dif- the alginate impression taking in the upper arch, greater ferent operators. nausea (P = 0.00) and discomfort (P = 0.02) were per- ceived compared to scans with CEREC Omnicam (Siro- na Dental Systems, Bensheim, Germany); while there Conclusions were no significant differences in perceptions between the impression taking in alginate and the Lava C.O.S. The following study showed that young orthodontic pa- (3M ESPE, St Paul, Minn) and between the 2 scanners. tients prefer digital impressions, although alginate 51% of subjects preferred digital impressions, while 29% impressions required the shortest chairside time. These preferred alginate ones and 20% expressed no prefer- results is also confirmed by the literature review not only ence. Therefore, it was possible to conclude that young in terms of patient comfort, but also for all the advantag- orthodontic patients prefer digital techniques over algi- es of intraoral scanners. More well-designed research nate impressions, although these require less time in the is needed in the future to increase our knowledge of pa- chair [8]. tients’ experiences with digital impressions. Burzynskia J. A. et al in 2017 conducted an initial pilot study through which a valid and reliable survey tool was created that can measure 3 areas of patient satisfaction References for taking the impression. A visual analog scale survey 1. Three dimensional surface acquisition systems for the study was developed and administered to 180 orthodontic pa- of facial morphology and teir application to maxillofacial sur- tients receiving 1 of 3 types of impressions: gery. Kau CH, Richmond S, Incrapera A, English J, Xia JJ. - iTero Element intraoral scan (Align Technologies, San s.l.: Int J MedRobot 2007;3(2):97-110. Jose, Calif), n = 60; 2. Single tooth modeling for 3d dental model. Int J Biomed Imaging. Yuan T, Liao W,Dai N,Ceng X,Yu Q. 2010;2010. - TRIOS Color intraoral scan (3Shape, Copenhagen, Doi:pii:535329. 10.1155/2010/535329. Denmark), n = 60; 3. A comparison of plaster,digital and reconstructed study mod- Conventional alginate impression (imprEssix Color el accuracy. Keating AP, Knox J,Bibb R,Zurov Al. s.l. : JOrtod Change; Dentsply Sirona, York, Pa), n = 60. 2008;3583):191-201. Annali di Stomatologia 2022; XIII (1-4): 3-8 7  Traditional versus digital impression: compliance and preference in pediatric patients- review 4. Dental models in 3D. MB, Stewart. s.l.: Orthod Prod Feb:21- Wouter Kerdijk, Wicher Joerdvan der Meer, YijinRen. s.l.: 24,2001. American Journal of Orthodontics and Dentofacial Orthope- 5. Ortho bytes Am J Orthod Dentofac Orthop 117:240-241, dics, August 2016 , Vol. Volume 150, Issue 2 . 2000. Redmond WR, Redmond WJ, Redmond JR. 9. Comparison of digital intraoral scanners and alginate impres- 6. Scanning accuracy and precision in 4 intraoral scanners: an sions: Time and patient satisfaction. s.l.: American Journal of in vitro comparison based on 3-dimensional analysis. Nedelcu Orthodontics and Dentofacial Orthopedics, April 2018 , Vol. RG, Persson AS. s.l.: J Prosthet Dent 2014 ; 112: 1461-71. . Volume 153, Issue 4, April 2018, Pages 534-541. 7. Comparison of digital and conventional impression tech- 10. Conventional Vs Digital Impressions: Acceptability, Treat- niques: evaluation of patients’ perception, treatment comfort, ment Comfort and Stress Among Young Orthodontic Pa- effectiveness and clinical outcomes. Yuzbasioglu E, Kurt H, tients. Mangano A, Beretta M, Luongo G, Mangano C, Man- Turunc R, Bilir H. s.l. : BMC Oral Health. 2014 Jan 30;14:10. gano F. 31;12:118-124., s.l.: Open Dent J. , 2018 Jan . doi: 10.1186/1472-6831-14-10. 11. Digital versus conventional impression method in children: 8. Treatment comfort, time perception, and preference for con- Comfort, preference and time. Hakan Yilmaz, Merve Nur ventional and digital impression techniques: A comparative Aydin. s.l.: International Journal of pediatrric dentistry, July study in young patients. Lukasz Burhardt, Christos Livas, 2019. 8 Annali di Stomatologia 2022; XIII (1-4): 3-8 

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Article COVID19-Personal Protective Equipment ergonomic improvements: necessary considerations for the dental team health Giulia Fantozzi1 Key words: COVID-19; prevention & control; dentist- Mauro D’Agostino2 ry; dental hygiene; occupational exposure. Sara Bernardi3 Serena Bianchi3 Introduction Ettore Lupi4 The coronavirus disease (COVID-19) caused by the Fabiola Rinaldi5 SARS-CoV-2 coronavirus has had an unprecedented Roberto Gatto3 impact worldwide1. However, the nature of the virus Gianluca Botticelli3* spreading modality, no single strategy could limit the pandemic diffusion, requiring a continuous struggle by 1 Private Dental Hygienist, 65100, Pescara, Italy. even the most advanced healthcare systems to address 2 Private Architect, 65100, Pescara, Italy. the challenges of COVID-19. 3 Department of Life, Health and Environmental Scienc- COVID-19 disease began in December 2019 in the Wu- es, University of L’Aquila, 67100 L’Aquila, Italy han fish market in China and then rapidly spread to Thai- 5 Department of Innovative Technologies in Medicine land, Japan, South Korea, Singapore, and Iran. Subse- & Dentistry, University of Chieti—Pescara ‘Gabriele quently, the viral spread affected Italy, Spain, the USA, d’Annunzio’, 66100 Chieti, Italy the UAE, and the UK2. Therefore, the rapid spread of the 4 Maxillofacial Surgery Unit, San Salvatore Hospital, disease led the World Health Organisation (WHO) to de- 67100, L’Aquila, Italy. fine COVID-19 as a pandemic on 11 March 20203. Sig- * Corresponding Author nificant challenges have followed since then, with virus isolation, an effective vaccine development towards the *Corresponding author: multiple variants, and appropriate disease management Gianluca Botticelli as the main objectives. In terms of structure, COVID-19 is an RNA virus, thus more prone to changes and mutations than DNA viruses, which are single-stranded positive with an envelope. Abstract The viral genome has a 5’ terminal rich in open read- The coronavirus disease (COVID-19) caused by the ing frames that encodes proteins essential for virus SARS-CoV-2 coronavirus impacted worldwide with- replication. Instead, the 3’ terminal includes five struc- out any precedents, including the dental world, tural proteins, Spike protein (S), membrane protein (M), from the education to the advanced cares. The nucleocapsid protein (N), an envelope protein (E), and co-existence with the virus circulation imposed haemagglutinin-esterase protein (HE). The Spike protein the use of personal protection equipment such as is mainly responsible for pathogenesis in the human spe- respiratory protective equipment. The aim of this cies because its receptor-binding domain (RBD) binds to paper is to report the modifications made to a Pow- the human cell surface receptor protein Angiotensin-con- er Air Power Respirator to improve the quality of verting enzyme - 2 (ACE - 2), encoded by the ACE2 work during dental hygiene procedures. The device gene4. It then binds to the transmembrane protease is composed of a hood and a power-air unit. The serine-2 (TMPRSS2), a cell surface protein expressed power-air unit is equipped with a strap to secure by epithelial cells of specific tissues4. The ubiquitous dis- the filters and battery at the waist. The hood and the tribution of ACE - 2 in organs means that SARS-CoV-2 power-air unit presented visibility, weight, and use infection may mainly affect the lungs, leading to respira- issues during dental hygiene procedures. The mod- tory failure. However, this infection involves several or- ifications to the hood made the shield more resis- gans, from the kidneys to the heart, blood vessels, liver, tant and allowed the place for magnifying loupes. In pancreas, and immune system. Moreover, virus entry addition, placing the battery-unit in a backpack, the into host cells enhances the immune response, produc- weight was better distributed. Further innovations ing a profound secretion of inflammatory cytokines and in PPE, barrier devices to minimize aerosol con- chemokines, inducing acute respiratory distress and tamination, air purification systems, antiviral adju- multi-organ failure2,4,5. vants, chairside screening for COVID-19, changes SARS-CoV-2 has been found in nasopharyngeal se- in clinical techniques could be envisaged to mini- cretions and saliva. Thus, the infection spreads mainly mize the spread of COVID-19, possibly adapted, through respiratory droplets and direct contact with in- and adopted in future pandemics. fected individuals and inanimate objects6. Annali di Stomatologia 2022; XI (1-4): 9-14 9  COVID19-Personal Protective Equipment ergonomic improvements SARS-CoV-2 can likely spread through aerosols (usu- by the user. These devices have been considered during ally defined as small airborne particles <5μm) gener- the early stages of the pandemic, also by the dental ated during dental procedures, reaching considerable workers, due to the shortages of PPE supplies16,17. How- distances and even remaining suspended in the air for ever, the ergonomics and the costs lower the quality of several hours, making the dental office environment a life of the dental professionals during the procedures. high-risk area for nosocomial spread7–12. This paper aims to report the modifications made to a Until the development and delivery of an effective vac- PAPR to improve the quality of work during dental hy- cine against COVID-19, the first measures affected den- giene procedures. tal care treatments, which were limited to emergency treatment in most developed countries13,14. For the protection of patients and all the dental team, PAPR defects and proposed solutions in-office consultation was restricted to a selected group The device is composed of a hood and a power-air unit. of patients after appropriate risk assessment. In addition, The power-air unit is equipped with a strap to secure the appropriate physical and temporal separation measures filters and battery at the waist. The hood and the pow- have been implemented in dental practices, and ade- er-air unit presented visibility, weight, and use issues quate time was set aside for clearance and decontam- during dental hygiene procedures. The power-air unit ination of the working field between patients15. aims to filter the air in the hood to guarantee protection The global protocols for clinical dentistry during against the external droplets generated during the aero- COVID-19 showed a widespread and broad consensus sol procedures. However, the air outlet led to two prob- on the observance of proper and thorough hand hygiene lems: 1) the device would go into alarm when catching and appropriate personal protective equipment (PPE)16. the hair (even under the cap), 2) the air was directed Recommended PPE included disposable gowns, gloves, over the neck and sometimes into the ear. FFP2 or FFP3 masks or N95 masks, and appropriate eye protection13,17. Additional measures suggested during operational pro- cedures included using high-volume suction devices, The hood rubber dam isolation, and mouthwashes with 0.2% ch- The object of the study is the product ‘K20 hood 0326003’ lorhexidine before the procedure to reduce the viral load manufactured by KASCO SRL (Reggio Emilia, Italia), in the oral cavity18. which conditions were found to improve its durability. The adopted measures have been proved effective in After short periods of use, indeed, cracks appear along limiting the virus diffusion19. the perimeter path from the transparent visor (Figure1) According to dental procedures, different types of PPEs and scratches on the inside due to friction on the inner are required. For example, the procedures generating surface from magnifying glasses (Figure 1). Therefore, aerosol, such as dental hygiene procedures, require the two essential features of the usage: the separation with use of a cap, protective glasses or face shield, FFP2 or the outside and its unfiltered, positive-pressure leakage FFP3 mask, Uniform, Fluid-resistant gown, Gloves, from the front (perimeter cracking) and blurring of visi- Clinical footwear, and shoe covers13. Dental health care bility (scratch marks from magnifying glasses). professionals have also considered the Powered Air-Pu- The two critical points are due to the considerable light- rifying Respirator (PAPR) as alternative PPE when in ness and flexibility of the cover that provides comfort shortages of FFP2 masks14,20. and considerable deformation in operation, inducing The PAPRs usually are composed by a hood which can creases in the visor and impacts with the glasses. be loose or tight fit type, or a rigid helmet, and by a bat- Although a material of remarkable plasticity, the trans- tery-powered unit which filter and purify the air, breathed parent polycarbonate shield is weakened by the seam Figure 1. A. Cracks on the edge of the v sor and B. scratches due to magn fy ng g asses. 10 Annali di Stomatologia 2022; XIII (1-4): 9-14 G. Fantozzi et al. 2 mm from the edge, binding it to the rest of the device. entrusted with the anchorage of the support for wearing It also takes on the burden of anchoring the support for (Figure 2). wearing. Moreover, the construction system does not This modification provides excellent stability in the dis- provide for the visor replacement by the operator. A re- tance from the face during the movements, avoiding placement or any other intervention leads to the loss of abrasions due to impact from the glasses magnifying certification (EN 529:2006). Therefore, the user has to glasses (Figure 3). Furthermore, leakage to the outside resort to a new and costly purchase. is ensured with a thin rubber gasket compressed by the The goal is to make the visor less perishable and re- pressure of the visor transparent polycarbonate visor placeable simply and efficiently to make the general on the frame, an action exerted by a series perimeter maintenance exclusively based on sanitization. of M3 nylon screws (Figure 2). However, this stiffen- To obtain our prototype, we thought of providing the vi- ing creates problems with air intake at the rear. More- sor with a PETG frame as slender as possible to pro- over, with the helmet’s oscillation reduction, the tube vide stiffening and anchorage in strict mode towards the becomes stiffened at the outlet and can find an obstacle fabric of the cover and in removable by screws towards in the hair or the cap. To overcome this latter handicap, the transparent visor. Furthermore, the same frame is the inner ring nut of the inlet pipe with a radial diffuser Figure 2. Exp oded v ew of the construct on deta s re at ng to the mod ficat on (exc ud ng the band for the wear ng that comes reused) Annali di Stomatologia 2022; XIII (1-4): 9-14 11  COVID19-Personal Protective Equipment ergonomic improvements Although the use of this device on conscious patients in plant Guided Surgery Procedures Coatings 2022;12(2) dental practices is unlikely in its current form, it opens doi:10 3390/coatings12020240 the door to innovation in the development of barrier sys- 11 Mummolo S Botticelli G Quinzi V Giuca G Mancini L Marzo G mplant safe test in patients with peri implantitis J tems23. For example, in the study by Alì and Raja24 fluo- Biol Regul Homeost Agents 2020;34(3):147 153 rescein dye and ultraviolet (UV) light were used to limit 12 Botticelli G Severino M Ferrazzano GF et al Excision of aerosol diffusion during operative dentistry. lower lip mucocele using injection of hydrocolloid dental im Further innovations in PPE, barrier devices to minimize pression material in a pediatric patient: A case report Appl aerosol contamination, air purification systems, antivi- Sci 2021;11(13) doi:10 3390/app11135819 ral adjuvants, chairside screening for COVID-19, and 13 Melo P Afonso A Monteiro L Lopes O Alves RC COV D 19 Management in Clinical Dental Care Part : Personal Pro changes in clinical techniques could be envisaged to tective Equipment for the Dental Care Professional Int Dent minimize the spread of COVID-19, possibly adapted, J 2021;71(3):263 270 doi:10 1016/j identj 2021 01 007 and adopted in future pandemics. 14 Estrich CG Gurenlian JAR Battrell A et al nfection Pre vention and Control Practices of Dental Hygienists in the United States During the COV D 19 Pandemic: A longitudi Conflict of Interest nal study J Dent Hyg JDH 2022;96(1):17 26 15 Chasib NH Alshami ML Gul SS Abdulbaqi HR Abdulka None reem AA Al Khdairy SA Dentists Practices and Attitudes Toward Using Personal Protection Equipment and Associa References ted Drawbacks and Cost mplications During the COV D 19 Pandemic Front Public Heal 2021;9(November):1 7 1 Varvara G Bernardi S Bianchi S Sinjari B Piattelli M doi:10 3389/fpubh 2021 770164 Dental education challenges during the covid 19 pandemic 16 Gallagher JE Johnson Verbeek JH Clarkson JE nnes N period in italy: Undergraduate student feedback future per Relevance and paucity of evidence: a dental perspective on spectives and the needs of teaching strategies for profes personal protective equipment during the COV D 19 pande sional development Healthc 2021;9(4):1 15 doi:10 3390/ mic Br Dent J 2020;229(2):121 124 doi:10 1038/s41415 healthcare9040454 020 1843 9 2 Umakanthan S Sahu P Ranade A V et al Origin transmis 17 Darwish S El Boghdadly K Edney C Babbar A Shem sion diagnosis and management of coronavirus disease besh T Respiratory protection in dentistry Br Dent J 2019 (COV D 19) Postgrad Med J 2020;96(1142):753 2021;230(4):207 214 doi:10 1038/s41415 021 2657 0 758 doi:10 1136/postgradmedj 2020 138234 18 Basso M Bordini G Bianchi F Prosper L Testori T Del 3 Bianchi S Gatto R Fabiani L EFFECTS OF THE SARS Fabbro M Efficacy of preprocedural mouthrinses to prevent COV 2 PANDEM C ON MED CAL EDUCAT ON N TALY : SARS CoV 2 (COV D 19) transmission: narrative literature CONS DERAT ONS AND T PS Euromediterranean Bio review and new clinical recommendations Utilizzo di col med J 2020;15(24):100 101 doi:10 1111/eje 12542 10 lutori preoperativi contro il virus SARS CoV 2 (COV D 19): 4 Lu R Zhao X Li J et al Genomic characterisation and epi revisione della letteratura e racc Quintessence Int (Berl) demiology of 2019 novel coronavirus: implications for virus 2020;1:10 24 origins and receptor binding Lancet 2020;395(10224):565 19 onescu AC Brambilla E Manzoli L Orsini G Gentili V Rizzo 574 doi:10 1016/S0140 6736(20)30251 8 R Efficacy of personal protective equipment against corona 5 Torge D Bernardi S Arcangeli M Bianchi S Histopatho virus transmission via dental handpieces J Am Dent Assoc logical Features of SARS CoV 2 in Extrapulmonary Organ 2021;152(8):631 640 doi:10 1016/j adaj 2021 03 007 nfection: A Systematic Review of Literature Pathogens 20 Oakes LA Chi WJ Welch RH Report of a Powered Air Pu 2022;11(8):867 doi:10 3390/pathogens11080867 6 Matuck BF Dolhnikoff M Duarte Neto AN et al Salivary rifying Respirator and ts Use in the Dental Setting Med J glands are a target for SARS CoV 2: a source for saliva (Fort Sam Houston, Tex) 2021;(PB 8 21 01/02/03):97 103 contamination J Pathol 2021;254(3):239 243 doi:10 1002/ 21 Akbari N Salehiniya H Abedi F Abbaszadeh H Compa path 5679 rison of the use of personal protective equipment and in 7 Giovannetti F Lupi E Di Giorgio D et al mpact of CO fection control in dentists and their assistants before and V D19 on Maxillofacial Fractures in the Province of L A after the corona crisis J Educ Health Promot 2021;10:206 quila Abruzzo taly Review of 296 Patients Treated with doi:10 4103/jehp jehp 1220 20 Statistical Comparison of the Two Year Pre COV D19 22 Petrone P Birocchi E Miani C et al Diagnostic and surgical and COV D19 J Craniofac Surg 2022;33(4):1182 1184 innovations in otolaryngology for adult and paediatric pa doi:10 1097/SCS 0000000000008468 tients during the COV D 19 era Acta Otorhinolaryngol Ital 8 Marchetti E Mummolo S Mancini L et al Decontamina organo Uff della Soc Ital di Otorinolaringol e Chir Cerv facc tion in the dental office: a comparative assessment of a 2022;42(Suppl 1):S46 S57 doi:10 14639/0392 100X sup new active principle Dent Cadmos 2021;89(3):200 206 pl 1 42 2022 05 doi:10 19256/d cadmos 03 2021 06 23 Carter J Doorgakant A Rigby M Robb C A space suit 9 Falisi G Paolo CD Rastelli C et al Ultrashort mplants Al modification for the COV D 19 era Ann R Coll Surg Engl ternative Prosthetic Rehabilitation in Mandibular Atrophies 2020;102(9):756 757 doi:10 1308/RCSANN 2020 0197 in Fragile Subjects: A Retrospective Study Healthcare 24 Ali K Raja M Coronavirus disease 2019 (COV D 19): 2021;9(2):1 9 doi:10 3390/healthcare9020175 challenges and management of aerosol generating pro 10 Falisi G Foffo G Severino M et al SEM EDX Analysis cedures in dentistry Evid Based Dent 2020;21(2):44 45 of Metal Particles Deposition from Surgical Burs after m doi:10 1038/s41432 020 0088 4 14 Annali di Stomatologia 2022; XIII (1-4): 9-14 

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Article Graphene: excursus of the evolution of processes and products M. Covelli1 material with a thickness of a single atom: the graphene. A. Cusanno2 Scientists successfully separated graphene from graph- E. Aiello3 ite through micromechanical stripping and this discovery A. Greco Lucchina4 led them to win the Nobel Prize for Physics 2010 togeth- A. Mastroianni 5 er. The graphene, a basic constitutive element of graphic F.M. Ceruso5 materials, is a two -dimensional material consisting of 6 G. Palumbo2° tied sp2 carbon atoms that are strictly packed in a bee honeycomb network with an entire distance of 1.42 Å1. 1 CIRPAS, University of Bari, Italy Among all sp2 to carbon allotropes, the graphene shows 2 Department of Mechanics Management and Math- the most remarkable and interesting chemical and phys- ematics (DMMM), Politecnico di Bari, Italy ical properties such as an ultraelected electronic mobility 3 Marrelli Health, Tecnologica Research Institute, Italy (~ 2 × 10.5 cm2/vs), high thermal conductivity with an 4 Saint Camillus International University of Health and exceptional value of 3,500–5,000 W/MK (superior to any Medical Science, Rome, Italy. other material) and an electric conductivity with a critical 5 Department of Dentistry “Fra G.B. Orsenigo” – Osped- current density of 108 A/cm2. In summary, it can there- ale San Pietro F.B.F., Rome, Italy fore be said that this material has high chemical and me- ° Co-Last Authors chanical resistance, an excellent thermal and electrical transport and a high transparency2. *Corresponding author: Elisabetta Aiello; e-mail: [email protected] Process Evolution: Production Techniques Graphene was isolated for the first time in 2004 using Abstract a very simple and inexpensive technique, namely, the mechanical exfoliation of graphite by means of a scotch OBJECTIVE: Graphene and derived materials are a tape. Since that time, other production techniques have new class of fundamental nanomaterials. Thanks to been studied and tested, each aimed at producing sam- the unique characteristics as excellent electrical con- ples suitable for different applications and uses. Cur- ductivity, biocompatibility and thermal properties, rently, various methods for producing graphene have this material has aroused a considerable interest been developed, with different approaches based on in the scientific community from its discovery. The size, shape of the flakes, quality and quantity. Although, purpose of this work is to pursue the various steps in addition to their possible applications, the techniques chronologically that led from discovery to single pro- are limited to: mechanical exfoliation, liquid phase ex- duction and in series of graphene, focusing on the foliation suitable for mass production, chemical vapour advantages and disadvantages of the techniques go- deposition (CVD), chemical reduction of graphene ox- ing to underline the validity and importance of each, ide. One of the main challenges currently appears to on the basis of the searches to be carried out and the be the mass production of high quality graphene with products finished to be obtained. In the second sec- few or no contaminants and / or defects and large par- tion of this work, however, we focused on the evolu- ticle size at an almost low cost. Commonly, the meth- tion of the applications of this super material over ods used for the synthesis of graphene from different time. In fact, graphene and bidimensional materials sources can be divided into top-down (exfoliation and in graphene have been significantly used in various reduction) and bottom-up (chemical vapour deposition) areas of biomedical research such as fabric engi- approaches. neering, regenerative medicine, bioimaging with ap- plication in neural engineering and in the clinic, with different future perspectives still to be completed. Mechanical Exfoliation Key words: Graphene, Graphene oxide, Bioimag- The first preparation method used, whose first attempts ing, Regenerative medicine, Quantum points of gra- were made in 1998, is mechanical exfoliation. It is the phene. simplest method that made it possible for the first time to synthesize graphene. In this technique, a piece of graphite was subjected to repeated exfoliation and then Introduction transferred to a substrate; specifically, there is the appli- In 2004 two physicists A. Gem and K. Novoselov of the cation of a force to the surface of highly oriented graphite University of Manchester areolated for the first time a crystals to detach and divide the crystalline layers to ob- Annali di Stomatologia 2020; XIII (1-4): 15-20 15  Graphene: excursus of the evolution of processes and products tain a single one. Initially, the interaction of AFM (atom- suspension is then subjected to mixing through ultra- ic force microscope) and STM (tunnelling microscope) sonic waves, or high shear mixer. These processes analysis tips with the graphite surface was exploited to create both shear and cavitation forces inside the liq- provide sufficient energy to overcome inter-plane attrac- uid that cause the graphite crystals to break, reducing tion forces and lead to removal and isolation. of the crys- them to ever thinner sheets, therefore, single sheets of talline monoatomic layer. Later, a much simpler method graphene. The suspension resulting from the process is was developed, called the scotch-tape method, which then purified by ultracentrifugation. Higher spin speeds used simple masking tape to exfoliate graphite. The result in thinner flakes but with a small lateral dimen- technique consisted of placing the surface of a graph- sion, which reduce utility for applications such as com- ite crystal on the adhesive tape, peeling off the tape posites. The number of graphene layers (N), i.e. the and thus peeling a few layers of material. The tape with thickness of the exfoliated graphite material, is usually the graphite imprint was then folded back on itself and determined by transmission electron microscopy (TEM) this action was carried out several times. At the end of and atomic force microscopy (AFM). This method is the process, the thin adhered flakes were easily trans- more promising from the point of view of scalability and ferred to an insulating substrate. Mechanical exfoliation allows to obtain large quantities of excellent material. is the simplest and most accessible method of isolating In contrast, graphene flakes turn out to be small as side graphene flakes of the size of a few square microns, dimensions. In addition, the use of reactive solvents useful for basic research and laboratory scale experi- could increase costs and the process itself is not very ments producing very high quality crystals, but unfortu- ecological due to the heavy use of solvents, given the nately, it is not suitable for a production industrial as it is low solubility of graphene6. not possible to increase the process3. Chemical Vapour Deposition (CVD) Chemical Reduction of Graphene Oxide (GO). Subsequently, in 2008-2009, the chemical vapour depo- Until now, all studies had focused on the exfoliation of sition (CVD) method was reported, which is one of the graphite oxide and subsequent reduction to graphene. most useful methods for preparing high quality structur- From after 2006, however, graphene was synthesized al monolayer graphene to be used for different devices. by reduction of graphene oxide. Various chemical and To date, several types of CVD methods are available thermal reduction methods have been tested which such as plasma enhanced CVD, thermal CVD, hot / have produced materials with conductivity in the order cold wall CVD and many others. Large samples can of 102 S/cm. The chemical synthesis of graphene, via be prepared by exposing a metal to various hydrocar- the reduction of graphene oxide (GO), is a methodol- bon precursors at high temperatures. The mechanism ogy that has the advantage of having high yields and of formation of graphene depends, in detail, on the ample opportunity to carry out the process on a large growth substrate and generally begins with the growth scale. However, the quality of the chemical synthesis of carbon atoms that nucleate on the metal after the product is rather poor, due to a partial reduction of the decomposition of hydrocarbons and the nuclei subse- GO and an abundance of defects in the crystal lattice, quently grow in large domains. In addition to gaseous which makes the product more suitable for applications hydrocarbons such as methane, ethylene or acetylene, that do not strictly require qualitative graphene, such liquid precursors such as hexane and pentane have as ‘use in polymeric composites. In fact, the quality of also been used7. Transferring the graphene from the the material produced cannot be considered high since growth substrate to one of interest can be quite diffi- it contains both intrinsic defects (such as edges or de- cult due to the chemical inertia of graphene generating formations) and extrinsic defects (such as groups con- defects in the material, just as thermal variations can taining O and H). In general, this process is strongly affect the stability of the material. CVD, generically, re- influenced by the choice of solvent, reducing agent (hy- mains one of the most successful methods for produc- drazine monohydrate, hydroquinone and compounds ing graphene over a large area even if the process ap- containing sulfur), and surfactant, which are combined pears complex and a high amount of energy is required to maintain a stable suspension4. for the execution of the method. Since CVD is a valid candidate for the production of high quality graphene in Liquid Phase Exfoliation large quantities, several research groups have focused in this direction. Bae et al8, used a roll-to-roll (RTR) pro- Subsequently, around 2008, the method of exfoliation in cess for the production of 30 inches and subsequently the liquid phase was studied, which is based on the use the technique was applied for the continuous produc- of the pressure forces that are generated inside a liquid. tion of graphene. One of the latest attempts, carried Currently, it appears to be a widely used method for the out in 2015, made it possible to produce high quality production of graphene and involves 3 different steps: monolayer graphene using cold wall CVD with resistive 1. dispersion in a solvent or surfactant; heating, which was also 100 times faster than conven- 2. exfoliation; tional CVD9. In conclusion, it can be stated that CVD 3. purification to separate the exfoliated from the allows to synthesize graphene on surfaces of several non-exfoliated material and, if supplied in powder square centimetres, obtaining high crystalline quality form, to completely remove traces of solvent5. (large crystalline grains, low presence of contaminants Powdered graphite is mixed with a solvent with specif- and defects and continuity of surfaces), being able to ic physical qualities such as surface tension and / or easily transfer the material produced. on a wide range viscosity or in a mixture of water and surfactant. The of substrates for different applications. 16 Annali di Stomatologia 2020; XIII (1-4): 15-20 M. Covelli et al. Additional Techniques ing a potential to graphite bars used as electrodes in a conductive solution, which gradually flake off and gener- There are also graphite thermal exfoliation techniques ate graphene nanosheets in solution. The most signifi- that almost completely provide single-layer graphene cant advantage of this method is that it allows to produce as a product. These are methods that have many ad- graphene with modulable properties simply by changing vantages over mechanical exfoliation: first of all the time the starting material and the process conditions. Conse- required to complete the process. In fact, high tempera- quently, graphene can be tailor-made, depending on the ture exfoliation processes can last even a few seconds. specific application10. In addition, most thermal exfoliation methods produce Below in Table I the summary of the advantages and dis- graphene in a gaseous environment, thus avoiding the advantages of graphene production techniques. use of liquids. When graphite oxide is used as a pre- cursor, thermal exfoliation simultaneously leads to the Product Evolution: Application of Graphene reduction of graphene. During heating, the functional groups bonded to the graphite layers decompose and The extraordinary properties of graphene, including its produce gases that generate pressure between adjacent conductivity, transmittance, flexibility and strength, allow layers. Exfoliation takes place when the pressure ex- it to be used in various applications such as electronics, ceeds the attractive forces between the layers. For this composites, membranes and next generation renew- reason, graphite oxide, expanded graphite and graph- able energy technologies (e.g. solar cells). Specifically, ite intercalation compounds are preferably used as raw however, among the emerging nanomaterials used for materials for thermal exfoliation instead of simple graph- biomedical applications, graphene-based biomaterials ite. In addition to the mechanical, chemical and thermal have attracted a lot of scientific and technological inter- methods described above, there are other more recently est in recent years, showing great future prospects as developed methods which are equally promising. The antibacterial agents, biosensors, bioimaging tools and electrochemical method, for example, consists in apply- as components of engineering. of stem cells and tissues. Table I. Advantages and disadvantages of graphene synthesis and production techniques Synthesis techniques Advantages Disadvantages Top down 1. Mechanical exfoliation - Simple method - Not suitable for business and industrial production - Easily accessible - Inability to increase the process. - Suitable for graphene flake insulation - It allows to produce graphene crystals of the highest quality - Suitable for basic and laboratory research 2. Chemical reduction of - Very high yield - Very poor quality of the product graphene oxide (GO) - Possibility of carrying out the process on - Synthetic product suitable only for a large scale applications that do not require a qualitative graphene. 3. Liquid phase exfoliation - Synthesis of excellent material - Very small side dimensions of the product - High costs for the use of reactive solvents - Not very ecological process 4. Thermal exfoliation - Very fast processing times - Product not of excellent quality - Gaseous and non-liquid environment 5. Electrochemical - High quality product exfoliation - Considerably higher yield - Ecological choice - Production of graphene with modulating properties. Bottom-up 1. Chemical vapour - Useful for preparing high quality - Very complex process deposition (CVD) structural graphene - High energy quantity - Easy material transfer on a wide range of substrates. Annali di Stomatologia 2020; XIII (1-4): 15-20 17  Graphene: excursus of the evolution of processes and products Antibacterial Agents molecules and improve selectivity13. In 2017, a new bio- sensor was reported, specific for the detection of human Around 2016, an all Italian research obtained promising papillomavirus (HPV), where the graphene-polyanalin- results aimed at designing nanomaterials for new an- ia (G-PANI) electrode is modified using a pyrrolidinyl timicrobial therapies. This research analyzed the anti- nucleic acid probe (anthraquinone-labeled peptide) microbial effects of graphene oxide on various human and printed with the inkjet printing method. And it is pathogens such as: E. coli, C.albicans, E.faecalis and through electrostatic attraction that the response of the S.aureus. The scholars have evaluated how coating electrochemical signal on the synthetic oligonucleotide medical instruments with this material can help reduce target is measured14. Promising results were shown in infections, especially after surgery, also allowing to re- the same year by studying and creating graphene mi- duce the use of antibiotics. Initially, the studies were croelectrodes integrated with bilayer lipid membranes. very contradictory in this regard, but the Italian team Under these conditions the biosensor achieves good analyzed how the size and concentration of graphene reproducibility, reusability, high selectivity, fast re- oxide sheets affect its antimicrobial action on import- sponse times, long life and high sensitivity. In addition, ant human pathogens. This effectiveness depends on the use of graphene microelectrodes in the detection its size, the agent’s exposure to the material and other of various toxic substances such as toxins, diagnosis parameters; examining the graphene oxide in sheets of D-dimers, urea and cholesterol has been reported15. of about 200 nanometers it was studied how, in aque- As a consequence of these promising results, in 2020 ous solution it is able to eliminate about 90% of S. au- a biosensor made on field effect transistors was pre- reus and E. faecalis, and about 50% of E. coli in one sented, that is, a graphene-FET used to detect clinical time equal to about two hours. It was explained how samples of SARS-CoV2 through the spike protein, with graphene oxide sheets can cut bacterial membranes promising results. These devices exploit the change in acting almost like a “nano-knife”, they can envelop bac- surface potential induced by binding to biomolecules. teria and block their growth or oxidize the cellular com- When some charged molecules bind to the gate they ponents of bacteria. The action against the C. albicans change the charge distribution in the semiconductor fungus was also discovered, with an efficacy similar to and this results in a change in the conductivity of the E. Coli. In addition, the possibility of mixing graphene transistor. Typically, these Bio-FETs include the classic oxide with different biocompatible polymers was evalu- FET structure with source, drain and gate to which the ated to obtain an antibacterial coating suitable for med- sensitive biological element is added, often a film with ical devices susceptible to bacterial colonization11. Sub- binding sites for the analyte. In this new technology the sequently in 2019 Elia et al12, studied a nanotechnology basic operation is the same as the classic FET but a strategy consisting of graphene oxide or carbon nano- thin graphene channel, tens of microns thick, has been fibers (CNF) combined with the irradiation of light-emit- added between the electrodes of the two main compo- ting diodes (LEDs) as novel nano-weapons against two nents. Typically, graphene behaves as an inert material Gram-positive pathogens. multidrug-resistant, clinically but under certain conditions it can absorb different mol- relevant: methicillin-resistant Staphylococcus aureus ecules and bind easily, this allows the graphene-FET (MRSA) and methicillin-resistant Staphylococcus epi- to be functionalized with biologically sensitive systems dermidis (MRSE). Several tests and studies on other such as enzymes, DNA, RNA or antigens16. pathogens such as viruses, fungi and other resistant bacteria are still ongoing. Bioimaging Biosensors Around 2014, graphene quantum dots (GQDs) were first defined as a new class of fluorophores17. The GQDs In biomedical applications, graphene-based nano- showed great photophysical properties and good bio- structures with highly sensitive and selective perfor- compatibility, with characteristics very similar to a mol- mance as biosensors have recently been reported. ecule compared to other quantum dots, therefore to be The studies concerning this specific applications date used in various applications of life science and in bio- back to the period 2015-2017 up to 2021 with studies medicine. Until before, all the fluorophores used in bio- on graphene-based biosensors for the detection of imaging were organic dyes with not very relevant char- COVID-19. Graphene is a semi-metal with ultra-high acteristics such as the tendency to photo-bleaching. charge mobility capable of offering excellent electronic On the contrary, GQDs have unique optical properties properties and of being functionalized on its surface, directly linked to their shape, size and surface chem- and it is for these reasons that graphene-based mate- istry, so that they are considered suitable for bioim- rials have been exploited in bio-sensing applications. aging. In addition, even with femtosecond laser (NIR) The functionalized area of graphene is able to direct- excitation in the near infrared, GQDs show very little ly detect the biomolecules from its oxide components photo bleaching. Their small size allows them to easily due to the synthesis in which many epoxide, hydroxyl cross biological barriers, targeting specific areas and and carboxyl groups are formed on the edges and on anatomical regions that are difficult to access18. Over the surface sites. In addition, functionalized graphene time, several in vivo and in vitro studies have made it allows the binding of heteroatoms, antibodies, en- possible to know the different characteristics and ca- zymes, DNA, proteins and several specific molecules. pabilities of GQDs. In fact, in 2015, Kumar et al19, syn- Graphene provides a high possibility of active sites for thesized functionalized green GQDs, highly biocom- charge-biomolecule interactions thanks to the large patible with dimensions between 3 and 14 nm through specific surface area that leads to improved detection the acid treatment of graphite powder. In vivo studies, and supports the desired functionalization to target bio- on the other hand, date back to very recent times 18 Annali di Stomatologia 2020; XIII (1-4): 15-20 M. Covelli et al. thanks to the fact that many researchers had carried cial neural implants. The first studies were conducted at out studies on nanoparticles of 40 nm and therefore the University of Manchester and the Catalan Institute of the same size as GQDs. In recent times, however, of Nanosciences and Nanotechnology in Spain, where Fan et al20, have exploited the lower Ph of solid tumors graphene and related materials were examined for the compared to that of normal tumors, therefore a pH of design of devices for neural implants to record and stim- 6.5 compared to a pH of 7.0-7.4. pH -sensitive GQDs ulate electrical activity in conjunction with a targeted ad- were prepared capable of changing their emission ministration of certain drugs. These neural implants ap- from green (pH <6.8) to blue (pH> 6.8). These GQDs pear to be a very promising approach for the detection, were injected subcutaneously into tumors and adja- monitoring and treatment of a range of different sensory cent muscles in mice carrying various tumors, such as and motor disorders of the central and peripheral ner- glioblastoma multiform. Evaluated the images under vous systems. the microscope, after 24 hours it was shown how the These implants have the function of creating a connec- tumors emitted green light and the muscles blue light. tion and interaction between neural tissue, nerve fibers The ability of GQDs to reach tumor regions by measur- or individual neurons and external devices, used to re- ing fluorescence was tested by intravenous injection. cord, monitor and stimulate brain activity to intervene It was possible to see how quantum dots successfully in the functions of the central nervous system. Start- crossed the blood brain barrier, being able to classify ing from this, it can be said that graphene is a versatile them as potential probes for fluorescence-guided can- substrate that can take different shapes with different cer surgery but also for diagnosis. properties and proves to be excellent for generating 2D materials used for stimulation and recording devices. Stem Cell and Tissue Engineering Monolayer graphene nanosheets facilitate the recording of electrical activity in neuronal tissue, while reduced In the field of regenerative medicine and tissue engi- graphene oxide has been selected for electrical stimu- neering, graphene has been regarded as a versatile lation of the nervous system, capable of providing stim- “nano-platform”. The application of graphene in this ulation for long periods. This research group also looked context of biomedicine is to be associated with mod- at the technology to develop a retinal implant for people ern times, starting from 2019 onwards. In fact, in 2019, who have lost their lives due to retinal diseases. In addi- Jagiello et al21, demonstrated the impact of graphene- tion, graphene can be modulated and functionalized with based substrates (reduced graphene oxide and oxide) oxygen allowing the administration of anti-inflammatory on the biological properties of mesenchymal / stromal drugs and neurotransmitters released at different rates stem cells. Their results underline that both graphene after implantation, thanks to the hydrogel coating of the oxide and reduced graphene oxide-based scaffolds graphene sheets. Hence the research for the biomedi- show potential applicability as novel, biocompatible, cal applications of graphene and 2D materials has ex- safe materials for use in biomedicine. In 2020, howev- panded into various fields, even reaching the diagnosis er, other studies made it possible to combine graphene of cancer25. with bioceramics to recreate a 3D printable scaffold Conclusions with specific characteristics for bone regeneration, also studying how carbon affects cell proliferation and dif- In conclusion, graphene thanks to the structure made ferentiation in vitro. Through this study it was proposed of carbon atoms has extraordinary properties hence the to add carbon-based material for a new biocompatible name “material of wonders” or even “miraculous mate- 3D scaffold that could become the key structural ma- rial”. Graphene has a higher resistance than steel and terial for bone regeneration22. Also in the same year it a somewhat unique electronic and thermal conduction was shown how a graphene oxide scaffold stimulated capacity. Looking towards the future, research and in- the proliferation of myogenic progenitor cells and en- dustry need to collaborate to drive innovations and di- docrine functions of differentiating cells, thus actively rect research towards the most promising applications participating in the construction of muscle tissue23. In also from a commercial point of view, evaluating the addition, in the same year, studies were carried out on significant progress that has been made in the last 8-9 the potential application of graphene oxide in the man- years. The most promising discoveries as seen in the ufacture of electrodes for retinal prostheses, used for previous sections were those in the field of engineer- retinopathies. Graphene was chosen as the material ing and regenerative medicine thanks to the physical, for the electrodes due to its superior chemical-physi- chemical and biological properties of graphene, paying cal characteristics compared to other materials. These particular attention to its use as a vehicle for the deliv- prostheses provide excellent assistance in the treat- ery of genes / drugs. It is also expected that, thanks ment of age-related macular degeneration (AMD) and to the combination of graphene (but also derivatives) retinitis pigmentosa. From here we can understand how with other compositions, the future possibility of gener- this specific material can be applied in the field of cell ating and manufacturing new intelligent and multifunc- and tissue regeneration associated with nanotechnolo- tional materials. It is obvious that this biomaterial is not gies and electrical and electronic engineering24. only positive but also problems related, above all, to cytotoxic and genotoxic effects. At the moment there Applications in the Neural Field is no gold standard to overcome the problems asso- ciated with graphene, it is thought, in fact, to continue Health services require more and more innovative solu- with more in-depth investigations on this material and tions to meet the growing demands and graphene in its derivatives by developing new experimental models 2018 paved the way in the treatment and management on which to base before proceeding with further clinical of diseases of the nervous system with the help of spe- applications. Annali di Stomatologia 2020; XIII (1-4): 15-20 19  Graphene: excursus of the evolution of processes and products Informed Consent Statement: Not applicable. 14 Prinjaporn T Weena S Adisorn T Charles SH Tirayut V Orawon C Electrochemical paper based peptide nucleic Conflicts of Interest: The authors declare no conflict acid biosensor for detecting human papillomavirus Anal of interest. Chim Acta 2017; 952: 32 40 15 Nikoleli G P ; Siontorou C ; Nikolelis D ; Bratakou S ; Karapetis S ; Tzamtzis N Biosensors Based on Lipid Mod References ified Graphene Microelectrodes C 2017; 3: 9 16 Seo G Lee G Kim MJ Baek SH Choi M Ku KB Lee CS 1 Novoselov KS Geim AK The rise of graphene Nat Mater Jun S Park D Kim HG Kim SJ Lee JO Kim BT Park 2007; 6: 183 191 EC Kim S Rapid Detection of COV D 19 Causative Virus 2 Murali R Yang Y Brenner K Beck T Meindl JD Breakdown (SARS CoV 2) in Human Nasopharyngeal Swab Speci current density of graphene nanoribbons Appl Phys Lett mens Using Field Effect Transistor Based Biosensor ACS 2009; 94: 243114 Nano 2020; 14: 5135 5142 3 Papageorgiou DG Kinloch A Young RJ Mechanical prop 17 Zheng P Wu N Fluorescence and Sensing Applications of erties of graphene and graphene based nanocomposites Graphene Oxide and Graphene Quantum Dots: A Review Progr Mater Sci 2017; 90: 75 127 Chem Asian J 2017; 12: 2343 2353 4 Stankovich S Dikin DA Piner RD Kohlhaas KA Klein 18 Palmieri V Bugli F Cacaci M Perini G De Maio F Delogu hammes A Jia Y Wu Y Nguyen ST Ruoff RS Synthesis G Torelli R Conti C Sanguinetti M De Spirito M Zanoni R of graphene based nanosheets via chemical reduction of Papi M Graphene oxide coatings prevent Candida albicans exfoliated graphite oxide Carbon 2007; 45: 1558 1565 biofilm formation with a controlled release of curcumin load 5 Niu L Coleman JN Zhang H Shin H Chhowalla M Zheng ed nanocomposites Nanomedicine 2018; 13: 2867 2879 Z Production of two dimensional nanomaterials via liq 19 Kumar V Singh V Umrao S Parashar V Abraham S uid based direct exfoliation Small 2016; 12: 272 293 Singh AK Nath G Saxena PS Srivastava A Facile rapid 6 Emtsev KV Bostwick A Horn K Jobst J Kellogg GL Ley L and upscaled synthesis of green luminescent functional Towards wafer size graphene layers by atmospheric pres graphene quantum dots for bioimaging RSC Adv 2014; 4: sure graphitization of silicon carbide Nat Mater 2009; 8: 21101 21107 203 207 20 Fan Z Zhou S Garcia C Fan L Zhou J Punti quanti 7 Zhang Y Zhang L and Zhou C Review of Chemical Va ci di grafene fluorescente PH Responsive Fluorescent por Deposition of Graphene and Related Applications Acc Graphene Quantum Dots for Fluorescence Guided Surgery Chem Res 2013; 46: 2329 2339 and Cancer Diagnosis Nanoscale 2017; 9: 4928 493 8 Bae S Kim H Lee Y X Xu Park JS Zheng Y Balakrishnan 21 Jagiełło J Sekuła Stryjewska M Noga S Adamczyk E J Lei T Kim HR Song Y Kim YJ Kim KS Özyilmaz B Ahn Dźwigońska M Kurcz M Kurp K Winkowska Struzik M JH Hong BH and ijima S Roll to roll production of 30 inch Karnas E Boruczkowski D Madeja Z Lipińska L Zu graphene films for transparent electrodes Nat Nanotechnol ba Surma EK mpact of Graphene Based Surfaces on the 2010; 5: 574 578 Basic Biological Properties of Human Umbilical Cord Mes 9 Close TH Bointon MD Barnes S Russo MF Craciun High enchymal Stem Cells: mplications for Ex Vivo Cell Expan quality monolayer graphene synthesized by resistive heat sion Aimed at Tissue Repair nt J Mol Sci 2019; 20: 4561 ing cold wall chemical vapor deposition Adv Mater 2015; 22 Memarian P Sartor F Bernardo E Elsayed H Ercan B 27: 4200 4206 Delogu LG Zavan B sola M Osteogenic Properties of 10 Othman NH Alias NH Shahruddin MZ Marpani F & Aba 3D Printed Silica Carbon Calcite Composite Scaffolds: ND Synthesis methods of graphene n Graphene Nano Novel Approach for Personalized Bone Tissue Regenera tubes and Quantum Dots Based Nanotechnology Wood tion nt J Mol Sci 2021 ;22: 475 head Publishing 2022: 19 42 23 Wierzbicki M Hotowy A Kutwin M Jaworski S Bałaban J 11 Palmieri V Papi M Bugli F Lauriola M Conti C Ciasca Sosnowska M Wójcik B Wędzińska A Chwalibog A Sa G Maulucci G Sanguinetti M De Spirito M TOWARDS wosz E Graphene Oxide Scaffold Stimulates Differentiation A “GREEN ANTIMICROBIAL THERAPY: STUDY OF and Proangiogenic Activities of Myogenic Progenitor Cells GRAPHENE NANOSHEETS INTERACTION WITH HU nt J Mol Sci 2020; 21: 4173 MAN PATHOGENS Biophysical Society 60th Annual 24 Yang JW Yu ZY Cheng SJ Chung JHY Liu X Wu CY Lin Meeting 2016 Los Angeles SF Chen GY Graphene Oxide Based Nanomaterials: An 12 Elias L Taengua R Frígols B Salesa B Serrano Aroca Á nsight into Retinal Prosthesis nt J Mol Sci 2020 ;21: 2957 Carbon Nanomaterials and LED rradiation as Antibacte 25 Bramini M Alberini G Colombo E Chiacchiaretta M Di rial Strategies against Gram Positive Multidrug Resistant Francesco ML Maya Vetencourt JF Cesca F nterfacing Pathogens nt J Mol Sci 2019; 20: 3603 graphene based materials with neural cells Front syst neu 13 Li D Zhang W Yu X Wang Z Su Z Wei G When biomol rosci 2018; 12 ecules meet graphene: From molecular level interactions to material design and applications Nanoscale 2016; 8: 19491 19509 20 Annali di Stomatologia 2020; XIII (1-4): 15-20 

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Article Classification system for partial edentulism: ABC classification Sergio Bortolini1, DDS, Associate Professor Conclusions: The ABC classification represents a Andrea Berzaghi1, DDS, PhD rapid pre-diagnostic tool capable of identifying 3 Alessandro Bianchi1, DDS, PhD levels of difficulty of the clinical case: progressively, Alfredo Natali2, DDS proceeding from green to red, the clinician can ide- Frugone-Zambra Raul3, DDS, MHSc, DHSc, Professor ally foresee the series of pretreatments and the level Mario Barbano4 DDS, MDS Full Professor of difficulty in prosthetic acceptance of every single Jorge Biotti4 DDS, MDS Associate Professor individual. The classification is proposed as a gen- Maurizio Franchi5, MD, DDS, Associate Professor eral guideline with which to analyze advantages and Ugo Consolo1, MD, DDS, Full Professor disadvantages of different therapeutic alternatives, but also as an effective communication tool with the patient. 1 Department of Surgery, Medicine, Dentistry and Mor- phological Sciences with Interest in Transplant, Onco- logy and Regenerative Medicine, University of Mode- Keywords: Partial edentulism, masticatory function, na and Reggio Emilia, Modena, Italy; sergio.bortolini@ functional unit, prosthetic acceptance. unimore.it ; [email protected]; alessandro. [email protected] [email protected] 2 DDS, Prosthodontist, private practice in Carpi, Mode- Introduction na, Italy The functional tooth unit is a concept described by Eich- 3 Faculty of Dentistry, San Sebastián University, San- ner, accepted and applied constantly up to the pres- tiago, Chile. University Autónoma de Chile, Temu- ent day. The functional units are a pair of premolars co, Chile; [email protected] or molars of intact anatomy in correct inter-arch rela- 4 School of Dentistry, Universidad Mayor, Santiago, Chi- tionship1-2. Eichner’s classification of edentulism, in its le. [email protected] full version, was born for epidemiological purposes in 5 Department of Biomedical and Specialty Surgical the pre-implant era and, although it still represents an Sciences, University of Ferrara, Ferrara, Italy; mauri- effective and appreciated tool, it requires high prosthet- [email protected] ic skills to be converted into a clinical method of daily work. Furthermore, it has recently been criticized for Corresponding author: the modest level of scientific evidence it offers2. The Berzaghi Andrea, [email protected] classification proposal is based on critical analysis of functional units in partial edentulism and is the result of Abstract the observation of the growth of subjective prosthetic dissatisfaction manifested by numerous patients reha- Objectives: This article proposes a classification bilitated with removable prosthetic therapy, mainly in system for partial edentulism according to criteria of Emilia Romagna, after 2012. In a short time we real- patient’s efficiency, sufficiency and functional deficits ized that we had higher prosthetic failure rates with the same objective prosthetic parameters; moreover, the Methods: The ABC classification is based on a crit- phenomenon appeared almost independent of the lev- ical analysis of functional units premolars and mo- el of clinical experience of the operators. Patients with lars in antagonism between them. The indispensable prosthetic dissatisfaction or rejection showed common diagnostic tools are the visit of patient, diagnostic characteristics, summarized with typical clinical histo- imaging tests and model analysis in antagonism to ries, identifiable both on the basis of psychosocial pa- each other. rameters and on anatomical indications3-5. In this paper Results: Classification proposal. The classification we aim to report the salient points of the classification recognizes and classifies three distinct functional system for partial edentulism according to criteria of levels identifying them with a letter and a standard- patient’s efficiency, sufficiency and functional deficits ized color code. Class A (green) represents an an- with the intention of proposing a useful and immediate atomical condition that allows bilateral masticatory tool in defining the complexity of the clinical case and function; Class B (yellow) identifies bilateral eden- the predictability in terms of therapeutic success. The tulous conditions and represents a condition of result is a simple analysis model, merged into the “The- functional sufficiency. Class C (red) represents the ory of Simplified Models” and summarized by the ABC condition of functional insufficiency. classification, described below. Annali di Stomatologia 2022; XIII (1-4): 21-26 21  Classification system for partial edentulism: ABC classification Methods simplified models: A1: condition of intact dentition in nor- mal occlusion with maximum number of functional units The classification system for partial edentulism is based bilaterally. A2: unilateral intercalated edentulous (premolar on a critical analysis of functional units premolars and or molar) in the absence of occlusal collapse, diastema, molars in antagonism between them. Implant-prosthetic dental migration or passive extrusion of the antagonist crowns and fixed prosthetic restorations of natural ele- elements. A3: unilateral distal molar edentulous. Series ments are also considered functional units. No acrylic or B identifies bilateral edentulous conditions and is distin- ceramic tooth of partial or total removable prosthesis can guished by the yellow color. It represents a condition of be assimilated to an occlusal unit. It is conventionally es- functional sufficiency hierarchically submitted to series A tablished that an occlusal unit molar (i.e. a pair of molars in (Fig.2). The B series is also summarized in three distinct antagonism physiological) has value 2 and a premolar has simplified models: B1: edentulous intercalated with signs value 1, while a natural tooth abraded, rotated, ectopic or of occlusal collapse, mono or bilateral, diastemas, migra- summarily rehabilitated with disfigurement of the normal tions of the border elements or passive extrusions of the anatomy, has a value of 0. The third molars, when they antagonists. B2: bilateral molar edentulous or “shortened meet the functional requirements indicated above, are dental arch” (S.D.A.). B3: bilateral distal edentulous with considered similarly to the first and second molars6. Final- last active functional unit. The C series represents the con- ly, it is established that the central incisors, the lateral ones dition of functional insufficiency, is characterized by the red and the canines have a value of 0 in terms of functional color and represents the condition of maximum risk of PRS unit. The diagnostic tools essential to the case study are (“Prosthesis Rejection Syndrome”). It too identifies three the visit of patient, diagnostic imaging tests and the anal- distinct simplified models, all marked by no functional unit ysis of the plaster models in antagonism with each other. in antagonism (Fig. 3). C1: residual maxillary and / or man- The classification recognizes and classifies three distinct dibular dental elements not in antagonism with each other. functional levels, defined as “classes” or “series”, identify- C2: “Single Denture Syndrome” and related syndromes. ing them with a letter and a standardized color code. C3: total edentulous outcome of one of the previous con- ditions (C1 and C2). ABC identifies, through the study of these nine models, a general guideline, with immediate Results visualization of the level of effectiveness and functional The first class, coded by the letter A, is marked green in efficiency; moreover, it allows to advance a forecast of the color and identifies the conditions of functional excellence. evolution of the clinical case, both in anticipation of dental The subject in class A by definition presents an anatom- extractions with the resulting downgrading and in the case ical condition that allows bilateral masticatory function of fixed implant prosthesis to restore the physiological den- (Fig. 1). Series A identifies three distinct conditions called tal formula, with the advantages we know7-10. Figure 1. Series A, green color. Functional excellence. Small intercalated or distal unilateral edentulism. No signs of occlusal collapse. Simultaneous bilateral or alternating unilateral chewing. It requires urgent compensation therapy. Minimal clinical difficulty even for inexperienced operators. 22 Annali di Stomatologia 2022; XIII (1-4): 21-26 S. Bortolini et al. Figure 2. Series B, yellow color. Functional Sufficiency. Long-standing intercalated or distal mono or bilateral edentulism attrib- utable to occlusal collapse outcomes. Ipsilateral chewing. Medium prosthetic difficulty. C1 C2 C3 Figure 3. Series C, red color. Functional deficit. No intermaxillary relationship preserved. Non-acceptance syndrome of remov- able prosthesis for the patient who has never been a prosthesis wearer. The dentate patient with complete loss of occlusal anatomy should also be considered as series C (e.g. extreme bruxist). Maximum difficulty even for experienced operators. Annali di Stomatologia 2022; XIII (1-4): 21-26 23  Classification system for partial edentulism: ABC classification Discussion Syndrome” seem to have a value predictive of the phe- nomenon. Furthermore, these cases have some pecu- The ABC classification allows to perform some clinical liarities: when treated with fixed implant prostheses, considerations of general value such as: a rapid diag- such as conventional Implant Bridge or Toronto Bridge, nostic semiotic analysis of the oral cavity of a partially they concentrate most of the technical complications in edentulous patient; an intuitive biomechanical reason- the short-medium term, highlighted as fractures or de- ing on the patient’s preferred chewing side, by looking tachment of replacement teeth, chipping or loosening for signs of parafunction; educates the clinician to read of the screws8-10. In these cases it seems prudent to the clinical and radiographic changes of a patient who adopt some precautions, such as adequate provision- has undergone tooth extractions not compensated by al times and the promotion of a rehabilitation process prosthetic replacements in accordance with the mod- that includes personalized oral physiatry instructions, els reported in literature, allowing to advance prog- to be continued even after the delivery of the definitive nostic hypotheses for the prediction of medium-long prostheses21-23. It is therefore clear that the dentist’s term complications; offers a clear, simple and effective work in prosthetic rehabilitation should not be limited communication tool with the patient; analyzes the anat- to measurement mathematics of bone volumes, to the omy according to guidelines common to all operators positioning of dental implants or to the delivery of the in the sector (dentists, dental hygienists, dental tech- prosthetic restoration in the hope that the patient gets nicians) and validates some psychosocial aspects of used to it by himself. An additional effort is needed chronic edentulism; proposes a census of the classic for the recovery of neuromuscular coordination and syndromes of edentulism and an immediate differential self-image that neuroscience has described as “over- analysis relating to the most common complications coming of acquired paralysis”24. In all this reasoning, reported in the literature; it allows an immediate data the operator is required to have a cultural background collection, suitable for a first visit screening and cata- in the neurological, physiological and physiatric fields logable in any clinical record using a dental alert formu- which seems to push prosthetic dentistry towards oral la about the difficulties of accepting conventional pros- medicine. theses. The moment of incorporation of a removable prosthesis is the result of a complex combination of factors and recognizes subjective, objective and psy- Conclusions chosocial aspects11-13. The literature has analyzed this complexity in detail and all dentists have experienced The ABC classification represents a rapid pre-diagnos- the frustration of some cases in which high levels of tic tool capable of identifying 3 levels of difficulty of the satisfaction are not achieved despite the procedures clinical case: progressively, proceeding from green to being consistent with the state of the art, while in oth- red, the clinician can ideally foresee the series of pre- er cases mobile prostheses highly incongruous for the treatments and the level of difficulty in prosthetic ac- dentist are considered excellent by patients11-13. These ceptance of every single individual (Fig. 4). The clas- are obviously problems of poor acceptance of the res- sification system represents a didactic screening tool toration in the first case and over-acceptance in the without epidemiological purposes. It also constitutes second. The phenomenon has been widely described an alert approach on some frequently observed clinical and recognizes a psychosocial origin. The clinician scenarios, potentially insidious in prognostic terms. It must therefore be able to read the patient from an an- represents an invitation to the analysis and census of atomical but also a psychological point of view, and some classic syndromes of partial edentulism and of- must have a clear picture of the predisposing, favoring fers some prognostic and biomechanical insights that and triggering conditions of prosthetic rejection11,14,15. can be useful to all categories related to dentistry, from This diagnostic sensitivity, which recognizes in clinical dental hygienist to dental technician. The concept of dy- experience some antidotes to prosthetic refusal, it can namic edentulism and the medium-long term tendency be supported in terms of communication with the eden- to concentrate the worsening of the clinical conditions tulous patient by a few rules proposed by the ABC clas- of the oral cavity on the non-working side of the pa- sification. It is clear, a fact widely reported in the liter- tient, invites the clinician to re-evaluate the concept of ature, that implant-supported prosthesis can represent prevention of occlusal collapse. The dental extractions a valid therapy for this “inability to adapt to the prosthe- of the posterior sectors not compensated by the re- sis”. The study of some peculiar models of edentulism placement of the lost elements are the real key factor of (the so-called partial edentulous syndromes described the reasoning proposed by the ABC classification. The in the early decades of the 1900s) seems particularly techniques to compensate for edentulism can be differ- indicative in identifying subjects at risk of dissatisfac- ent, from orthodontics to fixed prostheses to implantolo- tion or prosthetic rejection7-10. The explanations of this gy, and the differential diagnosis is left to the clinician’s phenomenon are not completely known, but it is evi- decision. Fixed prosthetic therapy for edentulous gaps, dent that removable prostheses have non-negotiable performed according to the state of the art, is the most limits, which makes them particularly disadvantageous effective prevention tool we have. The ABC classifica- in some categories of patients compared to fixed pros- tion has proved to be a tool simple but effective work in theses16-20. In our clinical experience, some anatomi- communication with patient and in the pre-diagnosis of cal and clinical conditions such as “Kelly’s Syndrome”, partial edentulism in a particular context of social den- the “Single Denture Syndrome”, “Combination-like tistry that it has followed by the 2012 Emilia Romagna Syndromes”, the “Eagle’s Syndrome” or the “Ernest’s earthquake. 24 Annali di Stomatologia 2022; XIII (1-4): 21-26 S. Bortolini et al. Figure 4. Chronology of the progression of partial edentulism not prosthetically compensated. From left to right, excellence, sufficiency and functional deficits. Implantology represents the tool to be able to reverse the direction of the arrow, offering the operator the possibility of deciding at which functional level to rehabilitate the patient. References 10. Veyrune JL, Opé S, Nicolas E, Woda A, Hennequin M. Changes in mastication after an immediate loading implan- 1. Klineberg I, Kingston D, Murray G. The bases for using a tation with complete fixed rehabilitation. Clin Oral Investig. particular occlusal design in tooth and implant-borne re- 2013 May;17(4):1127-34. construction and complex dentures. Clin Oral Implants 11. Shala KS, Dula LJ, Pustina-Krasniqi T, Bicaj T, Ahmedi EF, Res. 2007 Jun;18 Suppl 3:151-67. Lila-Krasniqi Z, Tmava-Dragusha A. Patient’s satisfaction 2. Yamashita S, Sakai S, Hatch JP, Rugh JD. Relationship be- with removable partial dentures: a retrospective case se- tween oral function and occlusal support in denture wear- ries. Open Dent J. 2016 Dec 9;10:656-63. ers. J Oral Rehabil. 2000 Oct;27(10):881-6. 12. Bessadet M, Nicolas E, Sochat M, Hennequin M, Veyrune 3. Liang S, Zhang Q, Witter DJ, Wang Y, Creugers NH. Ef- JL. Impact of removable partial denture prosthesis on chew- fects of removable dental prostheses on masticatory per- ing efficiency. J Appl Oral Sci. 2013 Sep-Oct;21(5):392-6. formance of subjects with shortened dental arches: a sys- 13. Arce-Tumbay J, Sanchez-Ayala A, Sotto-Maior BS, Senna tematic review. J Dent. 2015 Oct;43(10):1185-94. PM, Campanha NH. Mastication in subjects with extremely 4. Moore C, McKenna G. In patients with shortened dental shortened dental arches rehabilitated with removable par- arches do removable dental prostheses improve mastica- tial dentures. Int J Prosthodont. 2011 Nov-Dec;24(6):517-9. tory performance? Evid Based Dent. 2016 Dec;17(4):114. 14. Hatch JP, Shinkai RS, Sakai S, Rugh JD, Paunovich ED. 5. Mousa MA, Lynch E, Sghaireen MG, Zwiri AM, Baraka OA. Determinants of masticatory performance in dentate adults. Influence of time and different tooth widths on masticatory Arch Oral Biol. 2001 Jul;46(7):641-8. efficiency and muscular activity in bilateral free-end sad- 15. Tumrasvin W, Fueki K, Yanagawa M, Asakawa A, Yoshimu- dles. Int Dent J. 2017 Feb;67(1):29-37. ra M, Ohyama T. Masticatory function after unilateral distal 6. Yanagawa M, Fueki K, Ohyama T. Influence of length of food extension removable partial denture treatment: intra-indi- platform on masticatory performance in patients missing uni- vidual comparison with opposite dentulous side. J Med lateral mandibular molars with distal extension removable Dent Sci. 2005 Mar;52(1):35-41. partial dentures. J Med Dent Sci. 2004 Jun;51(2):115-9. 16. Sarita PT, Witter DJ, Kreulen CM, Van’t Hof MA, Creu- 7. Al-Omiri MK, Sghaireen MG, Alhijawi MM, Alzoubi IA, gers NH. Chewing ability of subjects with shortened Lynch CD, Lynch E. Maximum bite force following unilat- dental arches. Community Dent Oral Epidemiol. 2003 eral implant-supported prosthetic treatment: within-subject Oct;31(5):328-34. comparison to opposite dentate side. J Oral Rehabil. 2014 17. Al-Omiri MK. Muscle activity and masticatory efficien- Aug;41(8):624-9. cy with bilateral extension base removable partial den- 8. Gonçalves TM, Campos CH, Gonçalves GM, de Moraes tures with different cusp angles. J Prosthet Dent. 2018 M, Rodrigues Garcia RC. Mastication improvement after Mar;119(3):369-76. partial implant-supported prosthesis use. J Dent Res. 2013 18. Gonçalves TM, Vilanova LS, Gonçalves LM, Rodrigues Dec;92(12 suppl):189S-94S. Garcia RC. Effect of complete and partial removable 9. Nogawa T, Takayama Y, Ishida K, Yokoyama A. Com- dentures on chewing movements. J Oral Rehabil. 2014 parison of treatment outcomes in partially edentulous Mar;41(3):177-83. patients with implant-supported fixed prostheses and re- 19. Mizuuchi W, Yatabe M, Sato M, Nishiyama A, Ohyama T. movable partial dentures. Quintessence Publishing Co Inc. The effects of loading locations and direct retainers on 2016;31(6):1376-82. the movements of the abutment tooth and denture base Annali di Stomatologia 2022; XIII (1-4): 21-26 25  Classification system for partial edentulism: ABC classification of removable partial dentures. J Med Dent Sci. 2002 tex control of orofacial movements. Arch Oral Biol. 2007 Mar;49(1):11-8. Apr;52(4):334-7. 20. Tumrasvin W, Fueki K, Ohyama T. Factors associated with 23. Boudreau S, Romaniello A, Wang K, Svensson P, Ses- masticatory performance in unilateral distal extension re- sle BJ, Arendt-Nielsen L. The effects of intra-oral pain on movable partial denture patients. J Prosthodont. 2006 Jan- motor cortex neuroplasticity associated with short-term Feb;15(1):25-31. novel tongue-protrusion training in humans. Pain. 2007 21. Abarca M, Van Steemberghe D, Malavez C, De Ridder J, Nov;132(1-2):169-78. Jacobs R. Neurosensory disturbances after immediate 24. Abarca M, Van Steemberghe D, Malavez C, Jacobs R. loading of implants in the anterior mandible. An initial ques- The neurophysiology of osseointegrated oral implants. tionnaire approach followed by a psycophysical assess- A clinically underestimated aspect. J Oral Rehabil. 2006 ment. Clin Oral Investig. 2006 Dec;10(4):269-77. Mar;33(3):161-9. 22. Sessle BJ, Adachi K, Avivi-Arber L, Lee J, Nishiura H, Yao D, Yoshino K. Neuroplasticity of face primary motor cor- “The authors declare that there is no conflict of interest.” 26 Annali di Stomatologia 2022; XIII (1-4): 21-26 

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Article Platelet-rich plasma (PRP): history of the platelets’ concentrates and current applications in medicine M. Covelli1 ered the gold standard treatment1 . The biotechnologies A. Cusanno2 used to recreate bone tissue and optimize the biolog- C. Benincasa3 ical substrate can be identified in: bone morphogenic R. Ruggiero3 proteins (rhBMP), autologous growth factors contained C. Annichiarico3 in platelet-enriched plasma (PRP), mesenchymal stem B. Marrelli3° cells and scaffolds; these can be used alone and / or G. Palumbo2° in combination 2. Platelet Rich Plasma (PRP) is a blood product and presents as an autologous concentrate of 1 CIRPAS, University of Bari, Italy platelets suspended in a small volume of plasma3. The 2 Department of Mechanics Management and Mathe- PRP has an autologous origin 4 and exploits the biologi- matics (DMMM), Politecnico di Bari, Italy cal properties of platelets5. Platelets play a fundamental 3 Marrelli Health, Tecnologica Research Institute, Italy role in haemostasis and have pro-inflammatory, regu- ° Co-Last Authors latory and regenerative properties and release growth factors (GFs), chemokines and other regulatory mole- Corresponding Author: cules6. Research now shows that platelets also release Caterina Benincasa; e-mail: [email protected] many bioactive proteins responsible for the attraction of macrophages, mesenchymal stem cells and osteoblasts that not only promote the removal of degenerated and necrotic tissues, but also improve tissue regeneration Abstract and healing7-8. Numerous experimental and clinical stud- Over the years, regenerative medicine has been im- ies carried out in recent years have made it possible to proved thanks to new therapies and new innovative thoroughly investigate the effectiveness of the platelet clinical protocols. The purpose of this work was to concentrate and the possibility of using it frequently and evaluate the efficacy of Platelet-rich Plasma by re- on a daily basis as a therapeutic support for various dis- tracing the history of the evolution of the preparation eases of both the oral cavity and bone tissue in general9. technique, enhancing the role of platelets in tissue This is because the use of PRP has advantages: the su- healing, as well as its use in various sectors of medi- praphysiological concentration of growth factors which cine. At the same time, through a critical review of appears to be able to increase the speed of wound re- recent innovations in the field of bone regeneration, pair, reduce inflammation associated with trauma and was paid attention to new clinical protocols obtained minimize the production of scar tissue 10. from second generation platelet concentrates. Key words: Platelet-rich Plasma, Preparation Tech- History of the Use of PRP nique, Platelets, Regenerative Medicine, Tissue Healing, PRF, PRGF. The use of lyophilized fibrin, bank or autologous, dates back to the seventies, in particular in orthopedic surgery Introduction where it was useful in grafts for the effect of conglobation of the particulate bone tissue and for a better neo-osteo- Pathologies affecting the bone tissue have always been genesis, then attributed to a generic effect osteoconduc- of great interest both for the high incidence with which tor of fibrin. Tayapongsak et al11 who first adopted autol- they occur and for the difficulty of having a complete ogous fibrin in maxillofacial surgery (1994), adhered to healing and therefore a full functional recovery of the this explanation. In 1995, Slater et a 12 found that adding structures involved. The therapeutic protocols currently platelets to an osteoblast culture in vitro accelerated its in use in the treatment of these diseases are far from development. In the field of oral and maxillofacial sur- a real returned ad integrum. Current research is there- gery, the PRP technique has been the subject of numer- fore converging towards the study of therapies that aim ous publications13. In 1997, on the other hand, Whitman to stimulate endogenous repair and the formation of a et al14 studied the efficacy of “Platelet Gel” in accelerating tissue with morpho-functional characteristics similar to the wound healing process15. those of healthy tissue. Research has increasingly al- The use of PRP begins with the publications of Robert E. lowed the implementation of non-surgical treatments. Marx who in 1998 demonstrated the beneficial effects of For this reason, scientists have focused their research an amplification of PDGF and TGF-β on bone regenera- on the enhancement of some biological substances tion. Described as a quick, safe, inexpensive and easy- active on alternative healing processes to autologous to-obtain product, PRP is the subject of ever-increasing bone transplantation, which for many years was consid- clinical interest16-17. Annali di Stomatologia 2022; XIII (1-4): 27-32 27  Platelet-rich plasma (PRP): history of the platelets’ concentrates and current applications in medicine Marx et al16 in their work dated 1998, compared, in 88 of myoblasts. The increase of all parameters survival, cases in which mandibular restriction occurred, the re- proliferation and differentiation also occurred in C2C12 generative and maturative results obtained by doing a / BM-MSC co-cultures in the presence of PRP compared regenerative with ground bone taken from the iliac crest to treatment with PRP alone22. with those deriving from bone grafting iliac creast added However, the use of PRP in long bones seems to be with PRP. The results obtained showed that in the cases somewhat controversial. In a randomized clinical study treated with bone graft added with PRP there was a fast- carried out in 2007, a lower healing capacity was shown er bone regeneration and maturation and, consequent- in subjects treated with PRP, about 60% of the testers, ly, a better quality and quantity of bone trabeculae with both against BMP-7 and autograft transplant23. the higher density of the regenerated bone tissue. they were also evaluated through histological examinations PRP in Plastic Surgery and histomorphometric data showed a greater exten- sion of the bone trabeculae in cases with bone and PRP In recent years, the use of treatment in cosmetic surgery compared to that found in samples with only bone grafts. has also grown considerably. The use of platelet concen- Another confirmation came from immunohistochemical trate for non-transfusional use, in particular in regenera- examinations: by treating the samples with monoclonal tive medicine or dermatology, is an internationally estab- antibodies for the growth factors PRGF and TGF-R, their lished practice. The PRP is, in fact, indicated for these presence was detected in the platelets of the PRP and applications as a facilitator in the biorevitalization treat- in numerous cells of the bone tissue taken for grafting 16 . ment. Numerous clinical studies have been conducted to The first studies were carried out in the field of maxillofa- evaluate its application in the field of aesthetic medicine cial surgery, however the most sensational results were in particular for hair loss conditions, skin rejuvenation, obtained first on experiments on the jaw of goats and scarring and dispigmentation conditions24. then on the vertebral column in humans. Fennis et al17 A meta-analysis and randomized clinical trials aimed at reports in its article dated 2002 how the use of PRP im- quantifying hair density in subjects with androgenic alo- proves healing in physiological and timing terms; in fact, pecia show a hair density of 0.58 with a 95% confidence in 28 goats mandibular defects were created, 14 goats interval in subjects treated with PRP compared to pla- were treated with only bone graft while the remaining cebo25. with PRP added with particulate bone. The latter showed excellent healing in a short time. Lowery et al18 demon- PRP in Uro-Gynecological Disorders strates a percentage of positive results of 30% of the use of PRP in lumbar spinal fusions. PRP was used with A search of the literature, carried out in 2021, also re- hydroxyapatite. The results obtained in the 39 treated vealed an excellent use with excellent results in the patients confirmed the excellent properties: chemotac- treatment of uro-gynecological disorders26: PRP could tic and mitogenic effect on mesenchymal stem cells and be used in alternative protocols for the management of osteoblasts. vaginal atrophy, in some subjects it also led to an im- Even more recent studies confirm the efficacy of PRP in provement in the symptoms of stress urinary inconti- vertebral and non-vertebral surgery. In fact, from a sys- nence27. tematic review on PUBMED, in 2020, considered 274 patients undergoing meniscus reconstruction, it stated PRP in Gynecology a lower failure rate in subjects treated with PRP than in those cases treated without PRP19. By recreating critical The use of PRP in gynecology and in particular in assist- size defects in rabbits, Leng et al20 believes that PRP ed fertilization techniques is also spreading to address can compensate for the porous DBM deficiency. In fact, both the problem of thin endometrium and to improve the radiographic evaluation and the histological analysis implantation rates in women with previous failures. Im- revealed a greater formation of new bone after implan- portant scientific works report interesting success rates tation in the DBM group added with PRP at 6 and 12 in patients treated with PRP and with previous repeat- weeks compared to the DBM group without PRP. ed embryonic implantation failures, due to insufficient endometrial growth. In a recent publication, dated July 2022, the net increase in implantation rates in participat- PRP in Muscle Tissue Repair ing women undergoing PRP treatment is confirmed, but Recent studies are trying to identify strategies aimed no efficacy on abortion rates28. Another study conduct- at improving endogenous muscle repair potential. The ed by Tremellen et al29 considered 20 female patients administration of bone marrow-derived mesenchymal under the age of 45, with severe decreases in ovarian stromal cells (BM-MSC) together with the effect of PRP reserves. Treatment with PRP showed an increase in represents a very promising strategy. Although there are the number of embryos generated but an insignificant in- clinical results, they are very controversial for therapeu- crease in the number of oocytes generated. The results tic application in skeletal muscle injuries21. Vallone et are to be considered excellent compared to the results al22, in their study, evaluated the viability, survival, prolif- obtained in untreated women. eration and myogenic differentiation induced by PRP on C2C12 and BM-MSC myoblasts and at the same time Evolution of Technique also the effect of PRP in combination with BM-MSC in the induce myogenic differentiation. Assays of incorpo- The mode of action of the PRP exploits the role of action ration of MTS and EdU, expression of Ki67 and signaling of platelets. The preparation techniques of the product, of Akt and Notch-1 have decreed how the treatment with therefore, must keep the platelets unaltered and intact30. PRP increased the survival, viability and proliferation It is during the inflammatory phase that platelets play 28 Annali di Stomatologia 2022; XIII (1-4): 27-32 M. Covelli et al. different roles: antimicrobial effect, induces the coagu- bone regeneration before dental implant rehabilitation, in lation cascade and retroactive the clot, releases growth liquid form in order to soak sponges of fibrin and implant factors and cytokines. The secretion of growth factors is wires15. stimulated by the coagulation cascade, therefore PRP However, in a recent study there is talk of lyophilized must be obtained from blood treated with anticoagulant, PRP. Such platelet concentrate in titanium scaffolds so that the platelets remain viable long enough to allow most strongly promoted cell viability and osteogenic dif- treatment31. ferentiation of BMSCs39. PRP treated with anticoagulant lasts for about eight hours. The preparation of the PRP must take place in such a way as to effectively separate the platelets from PRP vs PRF the erythrocytes and concentrate them without dam- PRP represents a source of bioactive growth factors, aging the platelets themselves. The method chosen is however optimal preparation, activation, as well as important since the growth factors contained within the quantification of the various growth factors present is a alpha granules are activated when the granules them- controversial and still unclear topic40. selves merge with the platelet membrane31-32. Recently, it has attracted widespread attention for its According to Marx’s protocol, the one described above regenerative potential in soft tissues, however, the in- and the one used to date, the PRP is prepared from au- fluence on bone healing and dental tissue regeneration tologous blood starting from a centrifugation which, us- is still unclear41. In fact, the literature reports the use of ing the different density gradients, can collect and con- fibrin as an osteonic material, to be used alone or to be centrate platelets during surgery. The collection of PRP compacted with bone grafts: the importance of growth is done in 20-30 minutes through a gradient density cell aids in the process of tissue repair, cell proliferation and separator (Medtronics). This cell separator draws 400 to chemotaxis is emphasized42. The protocol for the reali- 450 mL of autologous whole blood through a central ve- zation of the PRF is a single centrifugation of the tubes nous catheter placed during surgery. With a spin speed without coagulant. The absence of the coagulant allows of 5600 RPM, whole blood is drawn at a rate of 50ml / the activation of coagulation and therefore the formation min. Citrate phosphate dextrose (CPD) is then added to of a fibrin clot is expected that contains all the platelets the centrifugate in a ratio of 1 ml of CPD to 5 ml of blood and leukocytes. While PRP is considered a plasma de- to achieve anticoagulation. The PRP is then activated rivative with two consecutive centrifuges and can be with calcium chloride and bovine thrombin in order to cryopreserved, PRF is an autologous scar that cannot have a platelet gel then added with both spongy and cor- be preserved43. tical autogenous bone and with synthetic bone matrix32. Several studies have analyzed how osteoid tissue is In fact, literature data have shown that when calcium and present in the PRF graft area for 4 months and the ab- thrombin are added to PRP, platelets are activated and sence of anticoagulant means that the platelets are fully can thus release the content of their granules a, which activated and used for a long-term effect44. include both PDGF and TGF-ß33-34. The fibrin network that forms after the PRF protocol is Over the years have been examined different methods three-dimensionally more homogeneous than the one for the preparation of PRP, starting in 1994 when Tay- that forms with the PRP protocol; in fact, in the PRP apongsak et al35 produced an autologous fibrin adhe- protocol, the addition of bovine thrombin and calcium sive, from a whole blood unit with its plasma fraction, to chloride determines a more rapid polymerization of fibrin be used in the following 2 -3 weeks. with a three-dimensional structure that is less elastin and In 1999, Anitua studied an open cycle technique of sin- more disordered45. The absence of manipulations during gle centrifugation for the preparation of PRP in order to the PRF preparatory phase and a front of a greater num- obtain a platelet concentration 2-3 times higher than the ber of intrinsic growth factors makes the PRF protocol classic one: it used a protocol characterized by a 160 g safer than the old PRP preparation protocols46. centrifugation for 6 minutes , subsequently changed to 270 g for 7 minutes36. The author suggests the use of calcium chloride to activate the product with the possibil- ity of accelerating the gelling process by also associating PRP vs PRGF autologous bone36. The evolution of platelet concentrates is aimed at pro- In 2000, Sacchi et al37 Described a double centrifugation moting the regeneration process. Today we talk about technique, respectively at 180 rpm and 580 rpm for a du- PRGF, plasma rich in growth factors, growth factors that ration of 20 minutes each in open cycle and for outpatient initiate the migration of undifferentiated stem cells to- use, involving an enrichment of the PRP of 3.57 times wards the site and to induce their differentiation as well compared to the basal concentration. subsequently to be as their growth47-48 . activated with calcium chloride and Botropase. For the realization of the product only one centrifugation Landesberg et al38, in 2005, proposed an alternative of 8 minutes is foreseen. From centrifugation there will protocol for the preparation of PRP: compares samples be two fractions. Fraction 2 (F2) is defined as the 2 mL of with the addition of the classic bovine thrombin used as plasma just above the Buffy coat and Fraction 1 (F1) is anticoagulant to the thrombin receptor agonist peptide-6 the plasma column above F2. Adding 10% calcium chlo- (TRAP) samples. Thrombin caused rapid clotting of the ride to F1 can form a fibrin barrier membrane to acceler- PRP with clot formation within 3.25 minutes. Adding ate soft tissue healing and adding to F2 can form a fibrin TRAP at 100 μmol / L took 9.25 minutes for the clot to so- clot. F2 can also be mixed with bone graft materials in lidify completely. The author himself therefore proposes order to accelerate the healing processes and resorption the use of TRAP as a valid alternative to bovine thrombin. of degradable bone graft materials. In 2012 Inchingolo et al15 shows the effectiveness of a A study from 2022 confirms its use in in vitro regenera- method that involves the use of PRP as graft material in tive medicine. In this study, were evaluated the chromo- Annali di Stomatologia 2022; XIII (1-4): 27-32 29  Platelet-rich plasma (PRP): history of the platelets’ concentrates and current applications in medicine somal stability of the gingival and fibroblasts at the same blood. Am J Vet Res 2004 ;65: :924-930. time alveolar osteoblasts after long-term culture. Cul- 4. Giusti I, Rughetti A, D’Ascenzo S. Identification of tured cells were expanded with PRGF or fetal bovine se- an optimal concentration of platelet gel for promot- rum (FBS) as a culture medium supplement. The results ing angiogenesis in human endothelial cells. Trans- showed a higher cell proliferation rate in PRGF-treated fusion 2009;49:771-778. cells. Analysis of the CGH array (Genomic Hybridization 5. Maia L., de Souza M.V., Ribeiro J.I., de Oliveira Assay) to consider chromosomal stability did not reveal A.C., Silveira Alves G.E., Benjamin L., Silva Y.F.R., genetic instability. The autologous PRGF technology, ac- Zandim B.M., Moreira J. 2009 Platelet-rich plasma cording to Anitua et al., Preserves the genomic stability in the treatment of induced tendinopathy in horses: of the cells and represents a valid alternative to the FBS histologic evaluation Journal of Equine Veterinary culture medium and therefore a good supplement for cell Science 29(8), 618-626 therapy49. 6. Haigler MC, Abdulrehman E, Siddappa S, Kishore R, Padilla M, Enciso R. Use of platelet-rich plasma, platelet-rich growth factor with arthrocentesis or ar- Conclusions throscopy to treat temporomandibular joint osteoar- thritis: Systematic review with meta-analyses. J Am The mechanisms of bone formation and repair have Dent Assoc 2018; 149:940-952. been rapidly investigated and elucidated over the past 7. Sampson S, Gerhardt M, Mandelbaum B. Platelet decade. Although many problems still remain open, it is rich plasma injection grafts for mu-sculoskeletal in- clear for now what the gold standard is for tissue restitu- juries: a review. Curr Rev Musculoskelet Med 2008; tion ad integrum but it is only clear that numerous cyto- 1: 165-174. kines and GFs as well as polypeptides play an essential 8. Cieslik-Bielecka A, Bielecki T, Gazdzik TS, Arendt role in these processes. . The GFs and BMPs regulate J, Król W, Szczepanski T. Autologous platelets and the proliferation and differentiation of mesenchymal cells leukocytes can improve healing of infected high-en- and play a role of primary importance in the remodel- ergy soft tissue injury. Transfus Apher Sci 2009; ing, regeneration and healing phases of both tissues. 41:9-12. A prospect that has become interesting in the last de- 9. Rose LF, Rosenberg E. 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Autologous Platelet Rich Plasma (PRGF) J Extra Corpor Technol 2004; 36: 28-35 Preserves Genomic Stability of Gingival Fibroblasts 48. Van Den Dolder J, Mooren R, Vloon AP, Stoelinga and Alveolar Osteoblasts after Long-Term Cell Cul- PJ, Jansen JA. Platelet-rich plasma: quantification ture. Dent J (Basel) 2022;10:173. 32 Annali di Stomatologia 2022; XIII (1-4): 27-32 

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Editorial Digital dentistry: myth or reality? In an age in which digital overspreads in every area of the social, personal, and working life, the dental field is certainly not an exception. What, not so long ago, seemed to be “the future”, now constitutes the “present” of our daily work. The digital revolution has undergone a rapid development up to our days, in which we can make use of a real digital workflow, which changes totally what was the used to be plan, from the first steps of data collection to the diagnosis and design of a plan, to the diagnos- tic and communicative simulation, up to the realization of the treatment. In other words, digital dentistry is today a mature and complete workflow that leverages multiple tools and systems to create 3D models of the patient’s dental anatomy and it can produce accurate digital dental restorations leading to a huge paradigm shift in all aspects of dentistry. In contemporary dentistry, digital technologies such as conical beam computed tomography (CBCT), mandibular movement scanning, intraoral 3D scanning, facial scanning, 3D printing, and personalized treatment planning have taken on an important role in both research and clinical practice toward the goal of precise medicine. These technologies are having a major impact on processes and procedures, as well as workflows and time spent in clinical procedures, resulting in more personalized, predictable, and effective treatment by reducing iatrogenic complications. Fingerprints with intraoral scanners (IOS), digitally made prostheses, augmented reality and virtual patients have become a reality today. All this information interconnects with each other, making it much easier to include all the dental specialties involved in multidisciplinary treatments and even to make use of advanced artificial intelligence (AI) and Machine Learning (ML) tools in the planning process of the treatment. The current digital revolution is different from the previous ones, because we find the emergence of artificial intel- ligence as an element that seeks to complement or replace the human factor. Many healthcare professionals have already integrated digital technologies into practical workflows, which reduce reliance on manual skills and visual recognition. Although the principles on which clinical decisions are based remain the same, the incorporation of digital technology is bringing about radical changes in the relationship and communication with the patient and with other members of the working group, in procedures and in clinical materials. Today we can say that every branch of dentistry has been strongly influenced by digital technology and has had a significant impact on dentistry like never before, and this has led to a radical change in the way we work by facilitating care and improving the results of clinical treatment. Also in dental research, we can see the continuous growth of many new articles and the birth of new journals focused on digital dentistry and this is favoring the constant discovery of new therapeutic possibilities. Despite all this, even today among dentists there is a certain confusion and perplexity when it comes to introducing new tools and digital processes in their clinics. As industry professionals we should always make sure that our knowl- edge and skills are up to date to improve our ability to care for our patients. The digitalization of dentistry is having a huge impact on workflows and time spent on clinical procedures. Make no mistake: The digital revolution has now reached dentistry, it is not the future, it is now the present. Enter the world of Digital Dentistry now! Massimo Frascaria DDS, Ph. D Annali di Stomatologia 2021; XII (1-4): 1 1 

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Original article Burning mouth syndrome: a literary review and an uptade Matteo Mazzuka1 Keywords: Burning mouth syndrome, xerostomia, Gianluca Botticelli2* dysgeusia, glossodynia; oral pain; burning tongue. Enrico Ivagnes1 Antonino Spagnolo1 Introduction Sara Caruso2 Roberto Gatto2 Definition Burning mouth syndrome (BMS) is an enigmatic, idiopathic, chronic and often painful clinical form for which 1 Private practice no validated and standardized definitions, diagnostic crite- 2 Pediatric Dentistry, Department of Life, Health and En- ria or classifications have yet been established. It was first vironmental Sciences, University of L’Aquila, 67100 described by Fox in 1935 (1). The American Academy of L’Aquila, Italy (pediatric dentistry) Orofacial Pain defines BMS as a burning sensation in the * Corresponding Author oral mucosa despite the absence of clinical findings and abnormalities in laboratory tests or imaging (2,3). The International Association for the Study of Pain Corresponding author: (IASP) defines BMS as a burning pain of the tongue Roberto Gatto or other oral mucosal membrane associated with nor- mal signs and laboratory findings lasting at least 4 to 6 months. The current version of the World Health Organ- ization International Classification of Diseases uses the term glossodynia, which includes additional terms such Abstract as glossopyrosis and painful tongue, and describes the Burning mouth syndrome is a debilitating condition of condition as painful sensations in the tongue, including chronic oral pain and/or burning, which mainly affects burning sensations (2,4 ). pre and postmenopausal women. It can be character- The epidemiology of BMS is difficult and imprecise since ized by the presence of other symptoms, such as a there are no universally accepted definitions, the differ- sensation of dry mouth (xerostomia), a bitter or metallic ent epidemiological studies often refer to different clinical taste (dysgeusia) and tingling. BMS can be classified entities in which there are no lesions of the oral mucosa. into two clinical forms: primary and secondary BMS. Therefore, the prevalence varies greatly from one study The primary BMS is essential or idiopathic, in which the to another, probably in relation to the diagnostic criteria. organic local/systemic causes cannot be identified. The prevalence of glossodynia in the general population The secondary BMS is caused by local, systemic, and/ is estimated at 2.5 to 5.1% (5). In a study by Bergdahl or psychological factors; thus, its diagnosis depends and Bergdahl (6), the prevalence was estimated at 3.7% on identification of the exact causative factor. of 1,427 subjects aged between 20 and 69 years ,espe- Its etiology is complex and not well defined, suggest- cially postmenopausal women (7). ing neuropathic mechanisms. Its diagnosis continues to be a challenge for the clinician since there are no sufficiently objective and universally accepted criteria. Etiology This disease is usually characterized by presenting Primary BMS is essential or idiopathic, in which the many symptoms, but without clinical signs, which causes cannot be identified, and it is probable that there makes its diagnosis difficult as it excludes lesions in is a neuropathological cause that manifests itself with the oral mucosa by its own definition. sensory alterations (hypoesthesia), is due to the reduc- Therapy has been found to be effective for reducing tion of the nociceptive trigger threshold, or due to neuro- the oral burning or pain symptom in some BMS pa- physiological where there are no defined findings. tients previous clinical trials found that drug thera- Secondary BMS is caused by systemic,local and psy- py with capsaicin, alpha-lipoic acid, clonazepam, and chological nature factors like, anemia, vitamin B defi- antidepressants may provide relief of oral burning or ciency, folic acid and zinc, diabetes, thyroid disease, pain symptom but given the complexity of this syn- drugs such as angiotensin-converting enzyme inhibitors drome, there are currently no widely accepted guide- and hypoglycemic agents, irritations, parafunctional hab- lines for its treatment. its and oral infections. At the immunological level, there Aim :Update knowledge on burning mouth syndrome could be those of allergic origin, such as the hypersen- treatment, pathophysiology, analyzing current and in- sitivity reaction to dental materials. In fact, it is possible novative therapeutic procedures and assessing their that allergies may play a role in the development of burn- effective efficacy. ing mouth syndrome (2,8). Annali di Stomatologia 2021; XII (1-4): 2-5 2  Burning mouth syndrome: a literary review and an uptade Among the psychological factors that predispose to suf- interdisciplinary approach for the proper management fering from BMS are psychiatric disorders of anxiety and of these patients. Although many drugs have been pro- severe depression. In fact, in one study Suresh et al. posed, none of them prove to be a number one stand- Identified anxiety and depression as the most common ard. Treatment planning must be personalized for each disorders presented by patients with BMS (9). patient. If local, systemic, or psychological factors are evident, treatment or elimination should be attempted (17). A complete clinical examination of the oral muco- Pathophysiology sa is crucial in these patients to define a treatment. The lack of pathology of the oral mucosa is mandatory for Patients with BMS usually show a series of typical symp- the diagnosis of BMS. Details related to quality, onset, toms of alteration of the trigeminal nerve: altered percep- persistence, intensity, onset, duration, relieving factors, tion of pain, alteration of neural transmission, increased course, sites involved in pain symptoms are essential. excitability and finally, a negative affectation of the trigeminal-vascular system, which shows the presence of a multifactorial component (10). Non-pharmacological treatment Recent studies such as those by Feller et al. 2017 (11), Silvestre et al. 2015 (12), and Coculescu et al. 2015 (13), The initial treatment will be non-pharmacological, trying where neurophysiological, psychophysical and neu- to treat those medical processes that can give rise to ropathological factors are included, have clarified that discomfort or burning in the mouth, managing all those several neuropathic mechanisms, mostly subclinical, act irritative situations that can give rise to small traumas at different levels and contribute to the pathophysiology on the tongue or lips, such as fractures or very promi- of primary BMS. Demonstration of loss of small-diame- nent dental cusps, as well as as areas of hyperpressure ter nerve fibers in the epithelium of the tongue with an of the prosthesis on the mucous membranes. The pa- upregulation of the TRPV1 and P2X3 receptor accounts tient should be informed about her situation, avoiding all for the thermal hypoesthesia and increased taste detec- doubts that could increase her level of anxiety. Mucous tion thresholds seen on quantitative sensory testing. As protectors can be used, which protect against friction, in neuropathic pain, decreased brain activation to heat rubbing and thermal changes (2,14,15). stimuli has been shown in patients with primary BMS. Pharmacological treatment The use of Capsaicin is an alternative that has been Diagnosis used to control neuropathic pain. It is based on the de- The clinical diagnosis is fundamentally based on the dis- sensitization of thermal, chemical and mechanical stim- comfort reported by the patient, also taking into account uli by acting on C fiber receptors. It is used as a gel or that the typical profile will be that of an older woman, be- mouthwash with which a certain degree of improvement tween the 5th and 7th decades of life, accompanied by a can be obtained, but with a limited effect over time (2) . significant anxious component (14,15). In the oral exam- The use of topical Clonazepam has had very good short- ination, it is necessary to rule out the presence of lesions term results, being effective in 2/3 of patients. This drug that demonstrate the existence of some local or systemic acts by inhibiting pain transmission and suppressing process that can explain the appearance of symptoms. central neuronal hyperactivity in cases of deafferenta- Parafunctional habits and alterations secondary to them tion. In patients resistant to clonazepam, Gabapentin can only be seen occasionally. can be used, but its results are contradictory (2). Other According to the studies by Zakrzewska et al. (2016) and types of treatments used have been Amilsupride, Parox- Sun et al. (2013) the criteria to be taken into account when etin and Sertraline. At low concentrations it has an anal- diagnosing a patient with BMS are based on (15,16) pres- gesic action, but the studies carried out do not provide a ence of symptoms including daily deep burning sensation sufficient level of efficacy and evidence. of the oral mucosa (bilateral),pain for at least 4-6 months, In traditional medicine, the first-line treatment of choice with variable intensity during the day that do not interfere for BMS generally consists of selective serotonin reup- with sleep. take inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs). As an alternative treatment, the traditional Japanese medicine (kampo) Rikkosan Treatment was also used. Rikkosan consists of five raw herbs (Asiasarum root (saishin), Cimicifuga rhizome (shoma), There are several therapeutic methods that are used Saposhnikovia root (boufu), Glycyrrhiza (kanzou), and in BMS. From a clinical perspective, clinicians should Japanese Gentian (ryutan)) and are indicated as natural initially determine signs and symptoms consistent with pain relievers (18).They observed Rikkosan mouthrinse primary (essential/idiopathic) BMS or with secondary produces pain relief lasting approximately 1 hour. BMS in which symptoms are caused by underlying local The treatment of BMS requires an interdisciplinary ap- or systemic conditions. Secondary BMS requires proper proach for the proper management of these patients. In diagnosis and treatment of such conditions. this regard, low-level laser therapy (LLLT) has been con- In primary BMS, the cause is unclear, so management sidered as an alternative for the treatment of SBA due options are based on the patient’s symptoms, often to its analgesic and regenerative action on peripheral leading to unsatisfactory results (16). The complex and nerve fibers. The results of the studies are highly satis- multifactorial etiology of BMS requires a systematic and factory and show a significant improvement in symptoms 3 Annali di Stomatologia 2021; XII (1-4): 2-5 M. Mazzuka et al. after treatment. According to Ana Liz Pereira de Matothe satisfactory response or remission rate and stabilize ef- best energy dosage should be between 0.5 and 8 J / ficacy (22). cm 2 because it can reduce inflammation and accelerate According to Daniel L. Neuman the use of variable dos- wound healing. LLLT has an analgesic effect; however, age naltrexone up to 4.4 mg has been shown to relieve the application it must be successive, continuous and in symptoms after 8 weeks, the patient reported a reduc- several sessions tion of at least 50% in the severity of subjective pain as- The therapy that the low-level laser has is described sociated with the symptoms of burning mouth syndrome minimal side effect and has a reduction in symptoms in and the improvements remained consistent during the BMS (19). follow-up visits at 11 months, with no need for modifica- Alpha-lipoic acid (ALA), which is an antioxidant that can tion. the dosage (23). scavenge free radicals and exert nerve repair activity, has also been studied. Clinical trials have investigated Psychological treatment the efficacy of this substance in the treatment of BMS, but the results are conflicting (19). Likewise, Komiyama et al. (24) have investigated the According to Wenqing Zhang photobiomodulation (PBM) effectiveness of group cognitive behavioral treatment can help relieve pain, speed up the resolution of inflam- to improve pain and anxiety in patients with BMS. They mation process and promote healing of damaged tissues. designed a brief group CBT intervention to provide dis- By stimulating mitochondrial cytochromes and then ini- ease self-management skills and introduce behavioral tiating secondary cell signaling pathways. Studies have strategies to manage chronic and persistent BMS pain. shown that PBM was effective in many parts of the body, Pain intensity and disturbance in daily life decreased sig- such as for the treatment of musculoskeletal injuries, de- nificantly from the first to the second CBT session. The generative diseases and dysfunctions.A single treatment state anxiety score also decreased after the CBT ses- is generally sufficient for acute and postoperative ther- sion and approached the control value. They report that apy. However, up to 10 treatments may be needed for individual and group cognitive therapy has been shown chronic pain and degenerative diseases presenting min- to be equally effective in managing chronic pain, since imal side effects with improvements over clonazepam there were no significant differences between the two. in reducing pain sensation over the 12-week follow-up But according to the patients’ narrative impressions, the period (21). CBT group intervention may be more useful to control According to daniela adamo et all. Vortioxetina is well persistent pain in patients with BMS, since it provides tolerated and effective in the treatment of BMS, suggest- mutual psychological support. Therefore, they conclude ing a new frontier in the management of this disease and that a brief cognitive-behavioral intervention group is ef- other chronic pain conditions by offering good safety fective in reducing pain and anxiety in patients with BMS. and tolerability, with lower latency of action, especially in Likewise, the reduction of anxiety can also be useful to middle-aged or elderly patients. with medical comorbidi- reduce the intensity of pain in these patients. Although ties, also offering improved cognitive function. Treatment studies of the effect of duration of CBT therapies on should be performed for at least 12 months to achieve burning sensation complaints are needed. Annali di Stomatologia 2021; XII (1-4): 2-5 4  Burning mouth syndrome: a literary review and an uptade Conclusion and perspective 7. Dahiya, P., Kamal, R., Kumar, M., Niti, Gupta, R., & Chaud- hary, K. Burning mouth syndrome and menopause. Inter- The treatment of SBA 1 it”s difficult, therapies are var- national journal of preventive medicine. 2013; 4(1), 1520. ied, none show overwhelming results, and almost all re- 8. Coculescu EC, Radu A, Coculescu BI. Burning mouth syn- drome: a review on diagnosis and Treatment. Journal of quire more larger randomized clinical trials, and longer Medicine and Life. 2014; 7(4):512-515. duration. 9. Skoglund A, Egelrud T. Hypersensitivity reactions to den- Therefore, since there is not a single drug capable of tal materials in patients with lichenoid oral mucosal lesions solving this pathology alone, today the recommendation and in patients with burning mouth syndrome. Scand J Dent Res. 1991; 99(4):320–8. is to use a combination of drugs gradually adapting them 10. Jaaskelainen SK, Woda A. Burning mouth syndrome. Cepha- to the patient’s symptomatic response taking into ac- lalgia. 2017; 37(7) 627–647. doi: 10.1177/0333102417694883. count that Gabapentin and ALA, administered together, 11. Feller L, Fourie J, Bouckaert M, Khammissa RAG, Ballyram were more useful. in reducing burning in the mouth. R, Lemmer J. Burning Mouth Syndrome: Aetiopathogenesis and Principles of Management. Pain Research and Man- The topical and systemic use of clonazepam has been agement. 2017; Article ID 1926269, 6 pages. https://doi. found to be advantageous, with the precaution of tak- org/10.1155/2017/1926269 ing individual measures with the chronic diseases they 12. Silvestre FJ, Silvestre-Rangil J, López-Jornet P. Síndrome present. It can be associated with laser therapy (LLLT) de boca ardiente: revisión y puesta al día. Rev Neurol. which reduces the symptoms of patients by offering 2015; 60: 457-63. 13. Coculescu EC, Manole G, Coculescu BI, Purcărea VL. slightly more consistent therapeutic results compared to Burning mouth syndrome: controversial place as a symp- those obtained solely with clonazepam, without negative tom of Oro-dental pathology. Journal of Medicine and Life. effects. Special Issue. 2015; 8, pp.34-37. Cognitive behavioral therapy is effective in reducing pain 14. Odell EW. Cawson. fundamentos de medicina y patología oral. 9ª edición. España: Elsevier; 2018. and anxiety, reducing pain intensity and should always 15. Zakrzewska J, Buchanan JA. Burning mouth syndrome. accompany drug treatment. BMJ Clin Evid 2016;7;2016. pii: 1301. Other alternative therapies such as: gargling with Rik- 16. Sun A, Wu K-M, Wang Y-P, Lin H-P, Chen H-M, Chiang kosan, Acupuncture may be effective but alone may not C-P. Burning mouth syndrome: a review and update. Jour- nal of Oral Pathology & Medicine. 2013;42(9):649–55. doi: be sufficient to obtain satisfactory results. 10.1111/jop.12101 17. Wardrop RW, Hailes J, Burger H, Reade PC. Oral discom- In the future, with the proper use of diagnostic tests, pa- fort at menopause. Oral Surg Oral Med Oral Pathol 1989; tients with BMS may benefit from interventions specifi- 67: 535–40. 18. Nakazawa S, et al. Effectiveness of rikkosan gargling for cally targeting the underlying pathophysiological compo- burning mouth syndrome. Traditional & Kampo Medicine. nents and thus apply better procedures. It is necessary 2017;4(2):121–3. to encourage the scientific community to continue with 19. Daniela Adamo,Giuseppe Pecoraro,Noemi Coppola,Elena this line of research, which will benefit both the experts Calabria1,Massimo Aria,Michele Mignogna .Vortioxetine and the patients who suffer from this syndrome. versus other antidepressants in the treatment of burning mouth syndrome: An open-label randomized trial.Oral Dis . 2021 May;27(4):1022-1041. doi: 10.1111/odi.13602. 20. Barbosa NG, et al. Evaluation of laser therapy and alpha - lipoic acid for the treatment of burning mouth syndrome: References a randomized clinical trial. CrossMark. 2018; 33(6):1255– 1262. https://doi.org/10.1007/s10103-018-2472-2 1. Fox H. Burning tongue glossodynia. N Y State J Med. 1935; 21. Guarneri F, Guarneri G, Marini H. Contribution of neuroin- 35:881–4. flammation in burning mouth syndrome: indications from 2. Bagán Sebastián JV. Medicina Bucal. 4ta edición. Lugar de benzodiazepine use. Dermatologic Therapy. 2008; Vol. 21: publicación: Medicina oral; 2008. S21–S24. 3. Klasser GD, Grushk M, Su N. Burning Mouth Syndrome. 22. Wenqing Zhang,Lijun Hu,Weiwei Zhao,Zhimin Yan. Ef- Oral Maxillofacial Surg Clin N Am; 2016; 28:381–396 fectiveness of photobiomodulation in the treatment of pri- 4. Headache Classification Committee of the International mary burning mouth syndrome-a systematic review and Headache Society (IHS). The International Classification meta-analysis. Lasers in Medical Science volume 36, pag- of Headache Disorders, 3rd edition (beta version). Cepha- es239–248 (2021). lalgia. 2013;33(9):629–808. 23. A-L Matos,P-U Silva,L-R Paranhos,I-T Santana,F-R Matos 5. Coculescu EC, Tovaru S, Coculescu BI. Epidemiological .Efficacy of the laser at low intensity on primary burning oral and etiological aspects of burning mouth syndrome. Journal syndrome: a systematic review.Med Oral Patol Oral Cir Bucal of medicine and life. 2014; 7(3), 305-9. . 2021 Mar 1;26(2):e216-e225. doi: 10.4317/medoral.24144. 6. Bergdahl M, Bergdahl J. Burning mouth syndrome: prev- 24. Komiyama O, et al. Group cognitive-behavioral intervention alence and associated factors. J Oral Pathol Med. 1999; for patients with burning mouth syndrome. Journal of Oral 28:350- 354. Science. 2013; Vol. 55, No. 1, 17-22. 5 Annali di Stomatologia 2021; XII (1-4): 2-5 

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Case report Are ministerial recommendations sufficient to avoid bisphosphonate related osteonecrosis of the jaw? A case report A. Massaria1 Introduction M.V. Bartolucci1 R. Baldi1 Bisphosphonate related osteonecrosis of the jaw (BRONJ) M. Messi1 is an adverse effect characterized by a progressive bone necrosis of the jaws in patients intaking bisphosphonates or resorption inhibitors without previous exposition to radia- 1 U.O.C. (Complex Operative Unit) Oral Surgery & Odon- tion therapy. Table 1 reports diagnostic criteria for BRONJ. tostomatology A.V.2 Ancona (Provincial Administration) The reason of the exclusive occurrence of BRONJ in the - A.S.U.R. Marche (Regional Healthcare Agency) -Italy jaws is unknown. To this regard some hypotheses were proposed: • the bone turnover is physiologically faster in the jaws; Corresponding author: • the lower jaw has a terminal vascularization M. Messi • presence of a thin mucoperiosteal layer that protects the underlying bone tissue; • oral biofilm Abstract • dento-alveolar interface that predispose to bone expo- Bisphosphonate related osteonecrosis of the jaw sition in case of oral surgery. (BRONJ) can occur in patients affected by malignan- cy associated hypercalcemia, bone metastases of Table 1. BRONJ Diagnostic criteria. solid tumors or multiple myeloma intaking amino-bi- Diagnostic Criteria sphosphonates or other bone resorption inhibitors. BRONJ occurs initially with alveolar bone radio- Current or previous therapy with: graphic alterations, with peripheral facial neurolog- • Bisphosphonates ical symptoms and thereafter with bone exposition • Denosumab • Antgiogenesis inhibitors and necrosis • Clinical or radiological diagnosis of progressive Drug related ONJ were also reported in oncologic bone destruction or bone necrosis patients intaking angiogenesis inhibitors or mono- Exclusion Criteria clonal antibodies that inhibit bone resorption (e.g. Denosumab). • Previous or simultaeous radiation theraphy head In the present case report, Denosumab has been ad- and neck region ministered to treat bone lesions related to invasive Doubt Criteria ductal breast cancer. Before starting therapy with Denosumab, in order to • Primary bone neoplasm primitiva and/or bone jaw restore oral and periodontal health, dental extrac- metastasis tions were performed without any modifications to surgical protocols and waiting the complete healing The literature Medication-related ONJ as (1-8) : of extraction sites (6 weeks). 1) BRONJ Even if ministerial recommendations were followed, 2) NON BRONJ: ONJ related non-bisphosphonates drugs. even if we waited the biologic healing and even if Two groups of resorption inhibitor drugs are described: denosumab therapy started without symptoms, bisphosphonates and denosumab. Bisphosphonates bind BRONJ occurred in this patient. to the hydroxyapatite crystals of bone and include amin- The mistake made in the management of the pres- obisphosphonates and non-aminobisphosphonates. Am- ent case is that we did not carefully evaluated early inobisphosphonates were mainly associated to BRONJ radiological signs (alveolar crest thickening, bone (56). These drugs are prescribed to treat bone metastases sclerosis, persistent alveolar post-extraction socket, secondary to solid neoplasms o multiple myeloma and os- periodontal space widening, formation of bone se- teo-metabolic deseases. questrum) that could bring the clinician to the diag- Aminobisphosphonates are also prescribed to prevent nostic suspect of BRONJ before the onset of clinical drug induced osteoporosis after hormonal therapy for signs (fistula, and bone exposure). breast or prostate cancer (61-63). Identifying early radiological signs could bring the Denosumab is monoclonal antibody that temporary inhib- clinician to an early diagnosis and consequently a its osteoclasts recruitment and activation with a conse- better prognosis. quent bone turnover reduction. Annali di Stomatologia 2021; XII (1-4): 6-11 6  Are ministerial recommendations sufficient to avoid bisphosphonate related osteonecrosis of the jaw? A case report First cases of denosumab related ONJ were described in patients with a suspect of ONJ. The CT provides detailed 2010 (26-99-100-132-13). information about the number and the nature of osteolytic Three studies compared ONJ prevalence between deno- osteosclerotic lesions (188-192). The CT permits to inves- sumab and zoledronic acid treatment in patients with bone tigate cortical and spongious bone and to discern between metastases secondary to solid tumors (26-99-100). These healthy and pathologic bone giving information about the studies showed that ONJ prevalence after the intake of extension of pathologic process (193-186-192-198-199- these drugs is similar (1-2%) (27-70-24-135-134). The 200). Table 3 reports the radiological criteria for the diag- Italian society of Maxillo-Facial Surgery (SICMF) and the nosis of medication-related ONJ. Italian society of oral medicine and pathology (SIPMO) no- ticed the need of defining the medication-related ONJ on Table 3. radiological criteria for the diagnosis of medica- the basis of clinical and radiological criteria different from tion-related ONJ. the only observation of exposed necrotic bone (39-173). Even if necrotic bone exposition remains the main indica- Medication-related ONJ non-specific signs tor of ONJ, the clinician should identify other clinical and OPM instrumental signs that can place the suspect of ONJ also without bone exposition (175-178) These signs are report- Early signs Increased thickness of alveolar crest ed in table 2. SICMF e SIPMO stated that X-rays exams Lamina dura sclerosis are fundamentals to a diagnostic confirm of medication-re- Post-extractive site presistance. lated ONJ (mainly without bone exposition). Sequestrum Without x-rays imaging and only following classifications Widening of periodontal space based on clinical signs, there are 25% of false negative with negative consequences on prognosis and on world Late signs health care cost (40). Pathologic fracture Increased thickness of alveolar nerve canal Table 2. Clinical criteria for the diagnosis of medica- Widespread osteosclerosis tion-related ONJ. Radiopacity maxillary sinus Periostal reaction Symptoms and clinical signs CT • Halitosis • Dental abscess Early signs Cortical Erosion • Mandibular asymmetry Increased thickness of alveolar crest and lamina dura • Pain originated form teeth or bone Increased thickness of spongious bone • NECROTIC BONE EXPOSITION Focal midollar osteonecrosis • Mucous Fistola Post-extractive site presistance. • Extra-oral Fistula Sequestrum • Hyperemic mucosae Widening of periodontal space • Absence of complete healing of extraction sites • Dental mobility Late signs • Abnormal mandibular range of motion Oro-antral, oro-nasal and muco-cutaneous fistula • Labial Paresthesia/disesthesia Pathologic fracture Increased thickness of alveolar nerve canal • Exudate emission from the nose Osteolysis extended to maxillary sinus. • Purulent secretion Widespread osteosclerosis • Bone fragments spontaneous Sequestrum Zygomatic and hard palate osteosclerosis • Trisma Periostal reaction • Soft tissues tumefaction Sinusitis The ONJ suspect should induce the clinician to perform a Nowadays the preventive approach represents the more complete anamnesis with first and second line x-rays in- effective strategy in the management of patients that will vestigations. intake ONJ-related drugs (4-10). Orthopantomography (OPM) and endoral x-rays are the The aim of primary prevention is the control of risk factors first line investigations (190-191), while the computed in order to reduce the chance to develop infections and tomography (CT) represents the second lie investigation inflammatory events that do not respond to conservative (192-193). First line investigations are useful in order to therapy, while secondary prevention is based on the ear- identify bone sequestrum and osteolytic areas. These in- ly diagnosis throughout clinical and radiological signs and vestigations permit to evaluate some osteonecrosis sub- associated symptoms identification clinical signs such as periodontal space widening, lamina Following current ministerial recommendations (19) the dura sclerosis and alteration of spongious bone, but do not patients that are candidates to therapy with ONJ-related permit to discern between generic osteolytic lesions and drugs must undergo a dental examination and to treatment bone metastases. of oral pathologies before starting drug therapy. With the OPM it is possible to identify an osteolytic lesion If dental surgical therapies are indicated to solve oral only when there is a bone mineral loss over 30-40% (192- pathologies (e.g. dental extractions), the onset of the 194). However, the OPM is very useful as first approach in ONJ-related drugs therapy should be 4-6 weeks after the 7 Annali di Stomatologia 2021; XII (1-4): 6-11 A. Massaria et al. surgical procedures or however not before the complete 07.01.2019 Complete healing of the tissues. Absence of epithelialization of extraction site. symptoms. The therapy with Denosumab started. In the clinical case the we will present despite all the min- isterial recommendations have been followed, some mis- 14.06.2019 Dental evaluation: absence of acute or takes brought to a bad management of the patients with chronic inflammation. Further x-rays investigations were consequent late diagnosis. not prescribed. The aim of the present case report is to underline that following the ministerial recommendation should be not 10.10.2019 The patient refers pain during chewing in the sufficient in order to avoid the ONJ risk. Furthermore the 4th quadrant. The clinician decided to modify the low- present work aims at the importance of early radiologi- er removable prostheses in order to eliminate areas of cal signs that should bring the clinician to the suspect of pressure. ONJ before the onset of clinical signs in order to have 15.11.2019 After an initial improvement, the symptoms an early diagnosis and a consequent better prognosis. get worse and a new OPM was prescribed. Case report The OPM is significant concerning early ONJ signs. In A female aged 70 affected by bone metastases second- this case these signs were misinterpreted by the dentist ary to ductal invasive breast cancer was waiting to start and the radiologist and were confused with root residu- the therapy with resorption inhibitor drugs (DENOSUM- als in the 43-44 area. In 41-42 area a late healing was AB) and undergone a dental clinical evaluation that un- detected (the extractions were performed 1 year before). derlined the need of some dental extractions (1.2-2.2- Endoral x-rays were performed in order to confirm the ra- 3.2-3.3-4.2-4.3). diological suspect (presence of root residuals) but these 26.11.2018: dental extractions were performed following investigations show the presence of a bone thickening appropriate surgical protocols (29-79-89) and prescrib- caused by the denosumab therapy. ing antibiotic therapy (Amoxicillin 1gr 3 times a day start- Therefore, we decided to further modify the lower pros- ed 3 days before the surgery and stopped 1 week after thesis in order to remove pressure areas. the surgery) (29-79-82-84-85-88-90). Dental extractions Actually, the OPM and the endoral x-rays show evident were performed after a rinse with a 0.2% chlorhexidine signs of ONJ: post-extractive socket persistence after mouthwash without alcohol for 1 minute. After the local more than 1 year from the extraction; widespread os- anesthesia, the extractions of teeth were performed with teosclerosis and spongious thickening in the extraction the minimum intrusiveness for the bone after removing areas; bone sequestrum in 44-45 areas. granulation tissue. The wounds were sutured in order to The progressive bone thickening is more clear if this obtain a healing by primary intention. area of osteosclerosis is compared to the bone density of adjacent or contralateral areas (187-203). 03.12.2018 After one week the sutures were removed and These radiological signs were ignored or misinterpret- the post-surgical control was planned after one month ed as late healing caused by resorption inhibitors drugs. OPM 16.11.2018 Annali di Stomatologia 2021; XII (1-4): 6-11 8  Are ministerial recommendations sufficient to avoid bisphosphonate related osteonecrosis of the jaw? A case report OPM 15.11.2019 OPM 15.11.2019 (detail) This contributed to a delayed diagnosis and to a conse- Conclusion quent worst prognosis. 28.11.2019 After about 2 months the patient come back In this case the pain referred by the patient was underes- for a dental control because of persistent pain. The clin- timated and misinterpreted. Furthermore, since all steps ical examination showed the presence of a fistula in the of the management protocols were followed, the early 43-44 area. Therefore we decided with the oncologist to radiological signs were not recognized. suspend the therapy with Denosumab and to refer the The results of the present clinical experience aim to un- patient to the maxilla-facial section in order to treat a derline that detecting early signs of medication-related possible medication-related ONJ. ONJ could be difficult. Furthermore, we would like to OPM 14-04-2020 ENDORAL x-rays: FISTULA 9 Annali di Stomatologia 2021; XII (1-4): 6-11 A. Massaria et al. highlight that this pathology can occur even if all ministe- Bisphosphonate-Related Osteonecrosis of the Jaw? J Oral rial recommendation are followed. Maxillo-fac Surg 2010 16. Fedele S., Bedogni G., Scoletta M., Favia G., Colella G., Osteonecrosis diagnosis and treatment need a specific Agrillo A., et al. Up to a quarter of patients with osteonecro- knowledge and a careful evaluation of clinical and radio- sis of the jaw associated with antiresorptive agents remain logical signs (even if not specific). undiagnosed. Br J Oral Maxillofac Surg 2015. The management of the oncologic patient require a coor- 17. Hillner BE., Ingle JN., Chlebowski RT., Gralow J., Yee GC., Janjan NA., et al. American Society of Clinical Oncology dination among different specialists in order to intercept 2003 Update on the role of bisphoshonates and bone healt this pathology in the early stage and to improve the treat- issues in women with breast cancer. J Clin ONcol 2003. ment that could be invasive. The specialists involved 18. Saad F., Abrrahamsson P-A., Miller K.,Preserving bone should be: the oncologist (management of oncologic healt in patients with hormone-sensitive prostate cancer: the role of Bisphoshonates. BJU Int 2009. pathology), the dentist (management of oral pathology), 19. ItoK., ElkinEB., GirotraM., MorrisMJ.Cost-effectivenessof- the general physician and the radiologist (management fracture prevention in men who receive androgen deprivation of the comorbidity). therapy for localized prostate cancer. Ann Intem Med 2010. 20. Fusco V., Bedogni A., Addeo A., Campisi G., Definition and estimation of osteonecrosis of jaw ( supplementary data from the denosumab extension study? Support Care Can- References cer 2017, 21. Fizazi K., Carducci M., smith M., Damiao R., Brown J., 1. Ruggiero SL., Dodson TB., Fantasia J., Goodday R., Karsh L., et al. Denosumab versus zoledronic acid for treat- Aghaloo T.,Mehrotra B., et al. American associacion of oral ment of bone metastases in men with castraction-resistant and maxillofacial surgeons position paper on medication-re- prostate cancer: A randomised, double-blind study. Lancet lated osteonecrosis of the jaw-2014 update. J Oral Maxillo- 2011. fac Surg 2014. 22. 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Case report Management of lingual nerve injury: a case report P. Tiriduzzi1 and sublingual salivary glands, the latter follow the fibers L. Gentili of the lingual nerve to the taste buds. Once separated C. Vianale from the mandibular nerve, it runs between the internal M. Coloccini pterygoid muscle and the medial wall of the mandibular M. Messi M. ramus. At the retromolar trigone and molar (particular- ly the third) level, the nerve runs on the upper medial margin of the alveolar ridge and can be very superficial. 1 U.O.C. (Complex Operative Unit) Oral Surgery & Odon- The LN then runs into the oral floor and terminates in the tostomatology A.V.2 Ancona (Provincial Administration) lingual pelvis (1). - A.s.u.r. (Regional Healthcare Agency) Marche, Italy. Anatomical studies of the LN mainly focus on its course at the oral cavity floor and the retromolar trigone level, as it is most susceptible to injury during surgical proce- Corresponding author: dures (2-6). In a cadaver dissection study, 669 LNs were Dr Paolo Tiriduzzi. [email protected] analyzed. 14.05% were located above the lingual crest, 0.15% in the retro molar trigone and 85.80% in the typ- ical position, i.e. at a vertical distance from the lingual crest of 3.01±0.42 mm and at a horizontal distance from Neurological lesions of the lingual nerve (LN), during the lingual plate of 2.06 ± 1.10 mm (7). general dentistry and oral surgery practice, are still fre- In its typical position, the LN, in 23.27% of the cases, is quent nowadays, despite the existence of three-dimen- directly in contact with the lingual plate of the alveolar sional diagnostic radiology, stereolithography, up-to-date process. However, when the LN is located in the retro- surgical techniques and instruments with sonic and pie- molar area, it runs between the mandibular ramus and zoelectric technology resulting in a gentler treatment of the medial pterygoid muscle, instead of proceeding in soft tissues. its normal course along the medial surface of the mandi- ble and lying near the roots of the third molars. It heads Abstract towards the retromolar trigone, then it runs posterior to the third molar and, finally, it descends at an acute angle One of the most common complication associated in the direction of the medial surface of the mandible, with oral surgical procedures are iatrogenic injuries resuming its normal course (8). to lingual branch of trigeminal nerve. Lingual nerve damage may result in permanent lingual sensory deficit leading to symptoms, including lost or altered sensation and the development of unpleasant neuro- Aetiology of lingual nerve injury pathic pain, with consequent impaired quality of life. The most frequent cause of LN lesion is to be sought The surgical removal of mandibular third molars is in the extraction surgery of the lower third molars: LN one of the most common oral surgical procedures is, in fact, damaged during 0.6-2% of extractions of and it is associated with a number of perioperative these tooth elements (9, 10). However, implant surgery, complications, including nerve injuries. This paper removal of calculi from the Warton’s duct, treatment of show how to manage lingual nerve injuries. ranula located in the postero-lateral portion of the mouth floor, removal of mandibular cysts, of impacted or su- pernumerary teeth, of benign lesions or demolition for Keywords: lingual nerve injury, third molar extrac- malignant neoformations, orthognathic surgery, osteora- tion, paresthesia, neurorrhaphy. dionecrosis, osteomyelitis and maxillofacial trauma may also be among the causes of LN injury (11, 12). Performing truncular anaesthesia can also cause neuro- logical injury. The incidence of temporary injuries of the Anatomy LN following the performance of truncular anaesthesia The LN is a sensory branch of the third trigeminal branch ranges between 0.15% and 0.54%, while permanent and provides tactile and thermal sensitivity of the oral ones range 0.01% approximately (13, 14). floor and the anterior two-thirds of the tongue. This nerve The etiopathogenetic mechanism may be related to a also distributes the visceral efferent and visceral afferent needle injury, to the potential neurotoxicity of the anaes- fibers of the intermediate facial nerve transmitted through thetic agent and its ischaemic effect with possible subse- the chorda tympani: the former reach the submandibular quent degeneration of axons (15). 12 Annali di Stomatologia 2021; XII (1-4): 12-21 P. Tiriduzzi et al. Classification of nerve injuries Symptomatology of neurological lesions The most widely used classification for assessing neu- The International Association for the Study of Pain rological impairment is Seddon’s classification of 1943, (IASP) distinguishes the symptoms resulting from a which identifies three types of nerve injury: nerve injury into: - Neuropraxia: consisting of a conduction block, re- - Anaesthesia: complete absence of sensitivity in the lated to compression or stretching of a nerve trunk innervation territory. during surgery or postoperative perineural edema. - Paresthesia: altered sensitivity. Stimulating the axon in the proximity of the lesion - Hypoesthesia: a decrease in normal sensation (to causes no distal response, while stimulation down- either tactile, thermal and painful stimuli). stream gives a completely normal response. Neu- - Hyperesthesia: an abnormal increase in sensitivity roapraxia allows spontaneous and relatively rapid to stimuli. In the case of a painful stimulus, it is de- healing. scribed as hyperalgesia. - Axonotmesis: characterized by anatomical inter- - Dysesthesia: altered sensitivity associated with burn- ruption of the axons, while preserving the nerve ing/pain. This sensation, most unpleasant for the sheaths. The distal nerve stump undergoes Wal- patient, can be either spontaneous or triggered by a lerian degeneration, while the proximal stump de- stimulus that is not typically pain-inducing (Allodynia). generates as far as the first node of Ranvier. Nerve The altered sensitivity of the tongue involves only the regeneration is possible and restarts from the intact affected half that is related to the injured nerve. The proximal stump at a rate of about 1 mm per day, fol- patient reports a feeling of “swollen tongue” deter- lowing the guide shown by the intact nerve sheaths. mining eventual discomfort: a frequent morsicatio of Functional recovery can be achieved upon com- the lingual margin with consequent traumatic lesions, plete regeneration. However, it may also require a while the decreased proprioceptive capacity with- few months. in the oral cavity may compromise food distribution - Neurotmesis: consisting of interruption of both the between the dental arches and the act of deglutition, axons and the nerve sheaths. In this way, sponta- phonatory difficulty, and partial taste alteration. When neous regeneration is not possible and surgery is the main symptom is pain, and not anaesthesia, the required (16-18). In 1951, Sunderland considered it quality of life is greatly impaired because the patient appropriate to divide axonotmesis into two degrees experiences spontaneous pain despite the absence of severity, based on the nerve’s ability to recover of tactile and gustatory sensitivity of the tongue. full or partial function, and neurotmesis into two fur- ther levels, based on the continuity or discontinuity Timing and injury management of the nerve, thus proposing a classification into five degrees of injury (19). In 1989 Mc Kinnon added a In the case of a confirmed LN injury, there are two pos- sixth degree, in relation to an injury involving sever- sibilities. The first is the immediate repair, through micro- al fascicles in the same nerve (20). surgical procedure, of the iatrogenic damage occurred The patterns of LN injury in oral surgery are hetero- accidentally during another scheduled treatment. This geneous and depend on both the type of surgery per- particular situation requires the surgeon to be skilled in formed and the instruments used. They can be sum- microsurgery, as well as the available suitable instru- marized into a few groups: compression damage, mentation, high-magnification loupes, or, even better, stretch-induced damage, partial or complete resection a surgical microscope. In addition, it is essential to be damage. Compression of the LN can occur as a direct able to perform the surgery under balanced general an- consequence of an improper use of surgical instru- esthesia, in order to ensure complete anesthesia of the ments such as retractors, elevators, malleable spatu- affected nerve and immobility of the patient throughout las, specifically employed to protect this nerve struc- the procedure. If the above conditions are not feasible, ture. The prognosis is generally good and restitutio ad the microsurgical repair should be performed as soon as integrum usually occurs within a couple of weeks to a possible, preferably within a month. couple of months. However, it is not always possible to make an immedi- Stretch injury is caused by the traction of the nerve ate diagnosis of a confirmed LN injury, as such an inci- along its major axis and the consequent extension of dental event may occur during noninvasive procedures. the same nerve. In this case, the resolution of symptoms The pain felt by the patient in the intraoperative phase may occur within 6 months. Partial and total resections is therefore often mistaken for a failure of local anaes- occur through accidental trauma with surgical instru- thesia during dental treatment, thus making it difficult to ments or through displacement of the lingual plate of the diagnose neurotmesis from compression or stretch. In alveolar process, e.g. during extraction of mandibular addition, it is often the patient, during the days following third molars. In the case of partial resection, recovery, the treatment, who reports to the dentist discomfort or albeit partial, may require up to 12 months. On the con- altered sensitivity of the tongue. trary, a clean cut of the nerve results in the formation of Once the diagnosis of nerve damage has been made, two stumps, and the prognosis is poor, as spontaneous a follow-up period of at least three months is needed in functional recovery is not possible. This is due to the re- order to assess any possible improvement in the symp- traction of the two stumps and the frequent formation of tomatology, or to decide if surgical procedure is neces- an amputation neuroma near the proximal stump, com- sary. During the follow-up period, subjective assessment posed of axonal fibers and scar tissue, which generates tests of sensitivity should be performed, stimulating the spontaneous pain or touch-evoked pain. tongue with pressure stimuli at different points and re- Annali di Stomatologia 2021; XII (1-4): 12-21 13  Management of lingual nerve injury: a case report cording any eventual improvement. If the anaesthesia subsequent pain and sensation loss of the auricle. To does not disappear after 3 months or if the hypoaesthe- overcome these problems, it is possible to employ a sia does not improve within 8 months, surgical treatment homologous graft, using a deantigenated and sterilised of the lesion should be considered (21). donor-derived nerve tissue that, while maintaining the The repair of nerve damage in case of anaesthesia can natural epineural sheath, acts as a scaffold for possible be performed using different techniques, depending on guided axonal regeneration (22-28). the overall clinical situation. A further possibility is the use of synthetic biological con- The neurorrhaphy technique consists of reconstructive duits and guides (first generation), resorbable collagen suture of the two nerve stumps. There are four types of type I conduits (second generation), or conduits contain- peripheral nerve reconstruction: epineural, perineural, ing stem cells (third generation) which are currently being epi-perineural and fascicular suture. Neurorrhaphy is studied and tested (29, 30). When painful symptoms of performed using epineural sutures, in a circumferential severe dysesthesia without regression occur a few weeks manner. The lingual nerve, in fact, has a diameter rang- after the traumatic event, intervention by performing neu- ing from 1.5 to 3 mm and the individual nerve fascicles rolysis is necessary. This consists of freeing a compressed are not distinguishable within it. Therefore, perineural nerve from a pathological adhesion, e.g. scar tissue, to or fascicular suture cannot be performed. Such proce- allow the recovery of its functionality. There are two tech- dures are more suitable for larger nerves or well-defined niques of neurolysis. Troncular neurolysis is a procedure nerve bundles, as for example the brachial plexus. The that involves the liberation of the nerve from compression suture of the two nerve ends must be performed without alongside its entire circumference. It is performed when any tension with 8-0 sutures made of a perfectly toler- the nerve is suffused with fibrous tissue attributable to an ated and non-absorbable material, in order to avoid for- injury in neighboring tissues. Fascicular neurolysis is per- eign-body reactions along with scarring and subsequent formed on an injured nerve visualized under a microscope failure of the procedure. and consists of removing the fibrous tissue surrounding Once the two nerve ends have been identified among each individual filament. the soft tissues, obtaining a tension-free juxtaposition should not be very complex, as it is possible to slide Management of lingual nerve injury: them and reapproximate the two ends. It must be con- Case report sidered that at the lesion site there may be a neuroma, either traumatic or resulting from amputation, which T.I., a 30-year-old female patient, underwent an extrac- must necessarily be resected, in order to allow the juxta- tion surgery of the mandibular lower left third molar un- position of the two ends with exposed healthy non-scar der local anaesthesia (Fig. 1). During the extraction, the tissue. This manoeuvre may not allow the execution of a distal root of the lower left third molar was accidentally tension-free suture and make it necessary the use of a dislocated into the soft tissue on the lingual side. After connecting graft. attempting an intra-alveolar recovery of the remnant, the The graft used may be autologous and taken from the procedure was suspended and a suture performed, as greater auricular nerve. This technique involves an in- a significant amount of time had passed since the ex- crease in surgical time, greater morbidity in the patient, traction. In addition, the excessive bleeding of the site possible formation of a neuroma at the donor site with and the consequent impossibility of having a clear view Figure 1. Preoperative orthopantomography of the lower left third molar extraction surgery. 14 Annali di Stomatologia 2021; XII (1-4): 12-21 P. Tiriduzzi et al. to identify the fragment, the increase in perceived pain, cial Administration) of Ancona where she was exam- the consequent state of agitation of the patient and the ined. The objective oral examination revealed injuries increasing stress for the dentist, led to a picture that was from biting. Moreover, complete lack of sensitivity of no longer manageable in an outpatient dental clinic envi- the left tongue was ascertained using the three assess- ronment of basic level. ment tests: puncture test, tactile test and proprioceptive The days following the extraction, the patient immedi- discrimination test. Dysesthesia and persistent burning ately reported classic symptoms of anaesthesia of the sensation also made normal oral hygiene manoeuvres tongue in the left side, followed by periods of dysesthe- painful for the patient. A CTA and a new orthopanto- sia and burning. However, she was treated for the first mography were conducted (Fig. 2). Radiographic ex- six months using NSAIDs, cortisone, and B-complex aminations showed the presence of the root remnant vitamins, probably hoping for a resolution of the dam- and a discontinuity of the lingual alveolar wall of the age despite the root remnant being dislocated in the soft lower left third molar (Fig. 3-8). Surgery to remove the tissues. root remnant, along with the concomitant attempt to The patient arrived at the U.O.C. (Complex Operative repair the nerve lesion, was then scheduled under bal- Unit) of Oral Surgery and Odontostomatology A.S.U.R. anced general anaesthesia, although the recommend- Marche (Regional Healthcare Agency), A.V. 2 (Provin- ed timing had already passed. Figure 2. Postoperative orthopantomography of the lower left third molar extraction surgery. Figure 3. CBCT. Annali di Stomatologia 2021; XII (1-4): 12-21 15  Management of lingual nerve injury: a case report Figure 4. CBCT. Figure 5. CBCT. Figure 6. CBCT. 16 Annali di Stomatologia 2021; XII (1-4): 12-21 P. Tiriduzzi et al. Figure 7. CBCT. Figure 8. CBCT. Annali di Stomatologia 2021; XII (1-4): 12-21 17  Management of lingual nerve injury: a case report Once the state of narcosis had been induced, the left the upright branch of the mandible and part of the root retromolar trigone and the left oral floor, both distally and remnant up to the premolar region. mesially, were infiltrated with adrenaline to achieve opti- At first, the root remnant had to be located through the mal bleeding control (Fig.9). soft tissues by the maxillofacial surgeon, who dissected A full-thickness incision was performed using an electro- them using blunt dissection technique. Once located, the surgical unit, in the attempt to follow, as much as possi- fragment was removed by a Klemmer forcep (Fig.10-11). ble, the scars of the previous surgery. The surgical field Performing again the atraumatic blunt dissection tech- was widened lingually in order to clearly expose part of nique, the ends of the injured LN were isolated. The ma- Figure 9. Preoperative image. Figure 10. Operative phase of isolation and extraction of the dislocated root Figure 11. Detail of the removed root remnant. in soft tissue. 18 Annali di Stomatologia 2021; XII (1-4): 12-21 P. Tiriduzzi et al. noeuvre proved to be complex, as the nerve had actually sue constituting the amputation neuroma and free them been cut in two parts, a diagnosis which was never cer- from the fibrous tissue that covered them, surrounding tain, because - as aforementioned - such lesion occurred the neuroma. At this point microsurgical neurorrhaphy during a noninvasive procedure, and this resulted in the technique was performed using 8-0 polypropylene su- consequent sliding and distancing of the two ends. In tures (Fig. 12). After the subsequent washing of the order to provide an effective recovery, an intraoperative surgical field, the operation was terminated by suturing microscope (under 16X magnification) was employed. the flaps of the incision (Fig. 13). Once discharged, the Once the two ends were identified, a few millimetres of patient continued home treatment for three weeks, being them were surgically removed to eliminate the scar tis- administered antibiotic coverage therapy, together with Figure 12. Detail of the suture of the neurorrhaphy. Figure 13. Suture. Annali di Stomatologia 2021; XII (1-4): 12-21 19  Management of lingual nerve injury: a case report NSAIDs and corticosteroids anti-inflammatory therapy on the ipsilateral lingual margin and dorsum, although and L-acetylcarnitine. far from being considered a restitutio ad integrum, it al- Eight months have passed since the neurorrhaphy lowed her to resume normal chewing and physiological surgery was performed, and during check-ups the pa- tongue mobility (Fig. 14). A delayed intervention has tient no longer presents dysesthesia, hyperesthesia, most certainly lowered the percentage of chances of a burning pains, and the traumatic biting lesions have successful neurorrhaphy, nevertheless, performing this disappeared. Furthermore, she has resumed perform- type of surgery has eliminated all that algic symptoma- ing oral hygiene manoeuvres without any symptoms of tology reported by the patient and this, in neurology, can discomfort. She reports an improvement in sensitivity be considered a success. Figure 14. Control at eight months after surgery. References 3 Nov 2011 EPUB https://www.ildentistamoderno.com/ lesione-del-nervo-linguale-in-seguito-a-chirurgia-dei-terzi- 1. Manuale di Chirurgia Orale SICOI. Elsevier - Masson molari. 2011; 924:9. 9. Schwartz LJ. Lingual anaesthesia following mandibular 2. Kim SY, Hu KS, Chung IH et al. Topographic anatomy of odontectomy. J Oral Surg 1973;31:918-20. the lingual nerve and variations in communication pat- 10. Walter JM Jr, Gregg JM. Analysis of postsurgical neurologic tern of the mandibular nerve branches. Surg Radiol Anat alteration in the trigeminal nerve. J Oral Surg 1979;37:410- 2004;26:128-135. 4. 3. Graff-Radford SB, Evans RW. Lingual nerve injury. Head- 11. Ellies LG, Hawker PB. The prevalence of altered sensation ache 2003;43:975-983. associated with implant surgery. Int J Oral Maxillofac Im- 4. McGeachie JK. Anatomy of the lingual nerve in relation to plants 1993;8:674-9. possible damage during clinical procedures. Ann Australas 12. Tursun R, Green JM 3rd. Immediate microsurgical bone Coll Dent Surg 2002;16:109-110. and nerve recostruction in the irradiated patient: a case re- 5. Lauretano AM, Li KK, Caradonna DS et al. Anatomic lo- port. J Oral Maxillofacial Surg. 2017;74:1-13. cation of the tongue base neurovascular bundle. Laryngo- 13. Haas DA, Lennon D. A 21 year retrospective study of re- scope 1997;107:1057-1059. ports of paresthesia following local anaesthetic adminis- 6. Yang HM, Woo YJ, Won S-Y, Kim DH, Hu KS, Kim H-J. tration. J Can Dent Assoc 1995;61:319-30. Course and distribution of the lingual nerve in the ven- 14. Harn SD, Durham TM. Incidence of lingual nerve trauma tral tongue region: anatomical considerations for frenecto- and postinjection complications in conventional mandibu- my. Journal of Craniofacial Surgery 2009;20(5):1359-1363.) lar block anaesthesia. J Am Dent Assoc 1990;121:519-23. 7. Behnia H, Kheradvar A, Shahrokhi M. An anatomic study of 15. Hillerup S, Jensen R. Nerve injury caused by mandibular the lingual nerve in the third molar region. Journal of Oral block analgesia. Int J Oral Maxillofac Surg. 2006 May; 35 and Maxillofacial Surgery, June 2000;58:649-651) (5): 437-43. 8. Carini F, Lomartire G, Paleari J, Pirrone F, Santagada V. 16. Seddon HJ. Three types of nerve injury. Brain 1943;66:237-88. Lesione del nervo linguale in seguito a chirurgia dei terzi 17. Brunelli GA, Brunelli GR. Pathofisiology of Peripheral Nerve molari: una review della letteratura. Il Dentista Moderno. repair and regeneration G.I.O.T. 2001;27:155-62. 20 Annali di Stomatologia 2021; XII (1-4): 12-21 P. Tiriduzzi et al. 18. Chiapasco M. Manuale illustrato di Chirurgia Orale. Masson nerve allografts from a multicenter registry study. J Reconstr ed. Milano 2001. 423: 394-395. Microsurg. 2015;31:384–390. 19. Sunderland S. A classification of peripheral nerve injury pro- 26. Means KR Jr, Rinker BD, Higgins JP, et al. A multicenter, ducing loss of function. Brain 1951;74:491-516. prospective, random- ized, pilot study of outcomes for 20. Risitano G, Santoro G. Knowledge about peripheral digital nerve repair in the hand using hollow conduit com- nerve repair: true and false. Acta Orthopedica Italica. Vol. pared with processed allograft nerve. Hand (N Y). 2016;11: 41- Anno 2018. 144-151. 21. Biglioli F. Diagnosi e terapia delle lesioni nervose del cavo 27. Safa B, Buncke G. Autograft substitutes: conduits and pro- cessed nerve allografts. Hand Clin. 2016;32:127–140. orale. Dentista Moderno 2010;4:39-59. 28. Brooks DN, Weber RV, Chao JD. Processed nerve allografts 22. Biglioli, Federico & Colombo, V.. (2010). Le lesioni del nervo for peripheral nerve reconstruction: a multicenter study of linguale in chirurgia orale. Dental Clinics. 4. 9-20. utilization and outcomes in sensory, mixed, and motor nerve 23. Wolford LM, Rodrigues DB. Autogenous grafts/allografts/ reconstruction. Microsurgery. 2012;32:1–14. conduits for bridging peripheral trigeminal nerve gaps. At- 29. Gaudin R, Knipfer C, Henningsen A, et al. Approaches to las Oral Maxillofac Surg Clin North Am. 2011;19:91–107. peripheral nerve repair: generation sofbiomaterial conduits 24. Whitlock EL, Tuffaha SH, Luciano JP, et al. Processed al- yielding to replacing autologous nerve grafts in craniomaxil- lografts and type I collagen conduits for repair of peripheral lofacial surgery. Biomed Res Int. 2016;2016:3856262. nerve gaps. Muscle Nerve. 2009;39:787–799. 30. Lundborg G. A 25-year perspective of peripheral nerve sur- 25. Rinker B, Ingari J, Greenberg J, et al. Outcomes of short- gery: evolving neuroscientific concepts and clinical signifi- gap sensory nerve inju- ries reconstructed with processed cance. J Hand Surg Am. 2000;25:391–414. Annali di Stomatologia 2021; XII (1-4): 12-21 21 

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Case report Cone beam CT and stereolithographic model in primary dentition Giancarlo Barraco1 pathogenesis of triple tooth can be traced to fusion, gemi- Stefano Pagano nation or concrescence5. Bennett described the first case Stefano Eramo1 in the late 1880s6 and only five cases were reported until Stefano Eramo 1984 when Knapp and McMahon reported one case and reviewed the topic2-5 and coined the term describing this anomaly in children. Shilpa and Nuvvula8 proposed the 1 Ordinary Professor, Department of Medicine and Sur- first classification9-11 recognized by the international sci- gery, University of Perugia, Perugia, Italy entific community: • Type I: three pulpal chambers and three root canals due to fusion: Corresponding author: - Type Ia: fusion of two normal teeth with one super- Prof Stefano Eramo numerary tooth; Ordinary Professor, Department of Medicine and Sur- - Type Ib: fusion of three normal teeth. gery, University of Perugia, Perugia, Italy • Type II: two pulpal chambers and two root canals: - Type IIa: a combination of a twin tooth (double tooth) and a supernumerary tooth; Abstract - Type IIb: one twinned tooth (double tooth) and one normal tooth. There are many recognized dental anomalies, among In order to study complex dental situations, 3D printed ana- the least common being the “triple tooth”, with a preva- tomical replicas, already widely used in other medical fields lence of 0.02% in the primary dentition. However, such (such as orthopedics, cardiac and oncologic surgery, neu- malformation can more easily lead not only to carious rosurgery and transplants), have been proposed. Thanks pathology, due to dental dysmorphisms, and pulpal to stereolithography (SLA), an additive manufacturing lesions, but also to rhizalysis and agenesis of the per- technology12 anatomical structures visible in radiological manent elements, causing eruption alterations and images can be reproduced13. The latest technologies can malocclusions. Therefore, techniques such as CBCT be useful to study complex preoperative treatment plans, and 3D anatomical replicas have been proposed to be reducing surgery duration with fewer complications using able to study complex clinical situations such as the intra-operative surgical guides, improving doctor-patient triple tooth in its entirety, in order to analyze anatom- communication and reducing medical-legal conflicts14. ical structures and identify the best treatment plan. In SLA would also find a wide horizon in the medical train- this paper we propose a clinical case of a triple tooth ing for simulation techniques. Bioprinting15 represents the in a 6-year-old child in the left mandible with fusion of desirable advancement of such technology, with no longer incisor with a supernumerary tooth associated with the anatomical replicas in resin but in tissues and/or organs lateral incisor fusion. created “ad personam,” starting from the same cells as the recipient individual. This paper aims to make an accurate grading of the triple Keywords: Cone Beam; Stereolithography; Ortho- tooth anomaly and obtain a complete anatomical and mor- dontics; 3D printing. phological evaluation for a correct prognosis and a suita- ble treatment plan minimizing iatrogenic risks. The clinical Introduction oral examination alone is not adequate for a correct and complete treatment program, while CBTC radiodiagnostic Teeth malformations can be classified in size abnormal- techniques, ities (microdontics and macrodontics), shape (such as dens in dente, dens invaginatus, fusion or gemination), number (such as agenesis, oligodontia, hypodontia or hy- Methods perodontia), position (ectopia, heterotopia or transposition) or structure (dysplasia and hypoplasia). Primary dentition We report a case of “triple tooth” of a 6-year-old child abnormalities are frequently pathogenetic of cosmetic and in the left mandible (fusion of incisors with supernumer- functional, transient or permanent problems such as ab- ary tooth) associated with the lateral incisor succedant normal eruption or development of the permanent teeth fusion. The patient was evaluated in the Department of either in the chronology or site of eruption. Surgical and Biomedical Sciences, Section of Orthodon- “Double teeth”, resulting from fusion or gemination, are tics and Reconstructive Dentistry. History of trauma or relatively frequent with an incidence between 0.1% and special pathology and family history were not relevant. 1.55%1, while the union of the three teeth, or “triple tooth” Examination showed irregular tooth morphology in the is rarely reported in the primary dentition2-7. The etio- patient’s anterior region, and there was fusion of the left Annali di Stomatologia 2021; XII (4): 22-25 22  Cone beam CT and stereolithographic model in primary dentition maxillary central incisor with a supernumerary tooth and Results of this with the lateral incisor (Figure 1). The fused teeth were caries-free, the succedant tooth 3.1 was partially CT scan enabled a 3D reconstruction that highlights var- erupted but placed in a lingualized location. Based on ious anatomical structures, such as the course of the in- the clinical and radiological features, we can describe ferior alveolar nerve and the site of the chin foramen and our present case as Type IIa according to the classifi- the realization of the stereolithographic replica (Figure 3). cation of Shilpa and Nuvvula8, a case of fusion of two The parents were informed about the abnormality of the normally developed teeth with a supernumerary tooth triple tooth and reassured that element 3.1 was erupting and an endodontic anatomy characterized by two pulpal and already visible in the arch, even if lingualized, and the chambers and two root canals. The remaining primary germ of lateral incisor 3.2 was developing normally. Con- teeth in both arches were normal. Periapical radiography sidering the clinical examination and the CT findings, the revealed fusion of the central and supernumerary tooth triple tooth was extracted. Parents were also made aware with the deciduous lateral incisor without a clear distinc- of the concomitant problems and advised to perform reg- tion of the root canal in the supernumerary tooth with the ular follow up, consult an orthodontist for potential erup- central canal. A cone beam CT scan was performed to tion alterations. The dysmorphism of the tooth can make make a prognostic assessment of the subsequent clin- it more subjected to carious lesions, with possible pul- ical picture and to evaluate the correct presence of the popathy-related problems that may interfere with permu- permanent elements, their morphological structure, and tation, inducing malocclusion or agenesis of the perma- the relationships between the triple tooth roots and the nent succedant as reported in the literature 5,6,10,11,16. permanent tooth buds in relation to the planning of the The examinations showed a physiological rhizalysis, the triple tooth extraction (Figure 2). presence of permanent tooth 3.2, and sufficient distance Figure 1. Triple tooth in the left mandible with a fu- sion of incisor and a supernumerary tooth associated with the lateral incisor succedant fusion. Figure 2. Cone beam CT scan of the triple tooth. 23 Annali di Stomatologia 2021; XII (1-4): 22-25 G. Barraco et al. Figure 3. Anatomic replica of the 6-years-old child mandible situation. between the roots of the triple tooth and the underlying but progressively fused endodontic units at the apex19. permanent teeth; this allowed us to confidently schedule Iis clear that the presence of an apical lesion makes en- the extraction of the pathological element without any dodontic therapy very hostile, considering endodontic complications. At the follow-up visit one month after the variability and dysmorphisms, orienting therapy toward extraction, the soft tissues were in good trophic condition extraction20. It should be noted that the literature con- and 3.1 had spontaneously repositioned in the arch. cordantly reported a high prevalence of agenesis of re- placement permanents8,9,19,21, this leads to the fact Discussion that it is essential to perform a CBTC examination in or- der to make a correct prognostic and identify a suitable The few cases reported does not allow a meaningful treatment plan. assessment, but it can be stated that the prevalence of Currently, there is no agreement among researchers on triple teeth in the primary dentition is rare (0.02%)2 and the mechanism by which triple dentition develops. Some more frequent in the male sex and Asian populations as believed that it is the derivation of three dental buds of reported by M. Lagarde et al.17 stating how “triple tooth” the primary dental lamina fused together6,8, however, is more frequent in males than females (2:1), and that most cases described a union between a supernumerary the age of affected children ranged from 1 year and 11 tooth and the central or lateral incisor. Additional hypoth- months to 10 years (mean age 4.9 years). Regarding the eses are related to gemination events associated with site, maxillary triple teeth are more common than man- fusion of primary and secondary lamina and the high dibular ones18. There is a preponderance in the left side prevalence of permanent tooth agenesis5,8,19,22. compared to the right side (4:3), while Shultz-Weidner Performing a CBTC is essential for a 3D and/or stereo- also reported the presence of a bilateral maxillary triple lithographic reconstruction of the loco-regional situation tooth11. Few cases in the literature evaluated the anat- in order to assess not only the size of the roots and the omy of chamber and root endodontium, however Knapp resulting anatomical relationships with the bud of the and McMahon described how each tooth element of the underlying permanent, but also potential agenesis and triple tooth possessed its own root canal but converged rhizalysis23. With these information an intervention can into a shared chamber4. Deepti et al.16 presented a case be planned, which may include an immediate extraction in which the pulpal canals of 6.2 and a supernumerary or a period of observation using preventive techniques, tooth are largely fused with an hourglass figure, the canal fluoroprophylaxis and topical fluoride therapy of dysmor- of 6.1 is deformed and a communication or otherwise dys- phic grooves9,24,25. However, triple-tooth cases require plasia of dentin between 6.1 and the supernumerary can collaboration between conservative dentist, orthodontist be glimpsed. Aguilo L. et al.10 in a CT histology and mor- and oral surgeon to achieve a complete resolution and phology study of a triple tooth highlighted an endodontic avoid cosmetic and functional complications26,27. anatomy showing three autonomous pulpal chambers whose canals however merge into a single canal within Conflict of Interest Statement the three fused roots. Other Authors have described cas- es of fused crowns and roots presenting three separate None Declared. Annali di Stomatologia 2021; XII (4): 22-25 24  Cone beam CT and stereolithographic model in primary dentition References 16. Deepti T, Jatinder KD, Mridula G. Images in Medicine: Trip- licated Primary Anterior Teeth - A Report of Two Cases. 1. Kramer PF, Feldens CA, Ferreira SH, Spiguel MH, Feldens JCDR. 2016;10:ZJ03-ZJ04 EG. Dental anomalies and associated factors in 2- to 5-year- 17. Lagarde M et al. Simultaneous occurrence of triple teeth old Brazilian children. Int J Paediatr Dent. 2008;18:434–40. and double teeth in primary dentition: A rare case report and 2. Ravn JJ. Aplasia, supernumerary teeth and fused teeth in review of the literature. Clinical Case Reports. 2020 the primary dentition. An epidemiologic study. Scand J Dent 18. Gellin ME. The distribution of anomalies of primary anterior Res. 1971;79:1–6. teeth and their effect on the permanent successors. Dent 3. Brook AH, Winter GB. Double teeth. A retrospective study Clin North Am. 1984;28:69‐ 80. of ‘geminated’ and ‘fused’ teeth in children. Br Dent J. 19. Mohapatra A, Prabhakar AR, Raju OS. An unusual triplica- 1970;129:123–30. tion of primary teeth-A rare case report. Quintessence Int. 4. Knapp JF, McMahon JI. Treatment of triple tooth: Report of 2010;41:815–20. case. J Am Dent Assoc. 1984;109:725–7. 20. Giuca MR, Carli E, Lardani L, Pasini M, Miceli M, Fambrini 5. Dhooria HS, Badhe AG. An unusual fusion of three teeth. A E. Pediatric Obstructive Sleep Apnea Syndrome: Emerging case report. J Indian Dent Assoc. 1983;55:327–8. Evidence and Treatment Approach. Scientific World Jour- 6. Long O. Gemination of three deciduous lower incisors. Br nal. 2021;2021:5591251. Dent J. 1951;91:324. 21. Giuca MR, Pasini M, Drago S, et al. Influence of Vertical 7. Burley MA, Reynolds CA. Germination of three anterior Facial Growth Pattern on Herbst Appliance Effects in Pre- teeth. Br Dent J. 1965;118:169–70. pubertal Patients: A Retrospective Controlled Study. Int J 8. Shilpa G, Nuvvula S. Triple tooth in primary dentition: A pro- Dent. 2020;2020:1018793. posed classification. Contemp Clin Dent. 2013;4:263–267. 22. Wu CW, Lin YT, Lin YT. Double primary teeth in children 9. Rao A. Synodontia of deciduous maxillary central and later- under 17 years old and their correlation with permanent al incisors with a supernumerary tooth. J Indian Soc Pedo successors. Chang Gung Med J. 2010;33:188‐ 193. Prev Dent. 2000;18:71–5. 23. Gultekin IM, Uysal S, Turgut MD, Dural S, Tekcicek M. A 10. Aguilo L, Catala M, Peydro A. Primary triple teeth: Histolog- rare triple tooth in primary dentition: CT findings. Pediatr ical and CT morphological study of two case reports. J Clin Dent J. 2017;27:157‐161. Pediatr Dent. 2001;26:87–9 24. Bagattoni S, Lardani L, D’Alessandro G, Piana G. Oral 11. Schultz-Weidner N, Ansari F, Mueller-Lessmann V, Wetzel WE. Bilateral triplicated primary central incisors: Clinical health status of Italian children with Autism Spectrum Disor- course and therapy. Quintessence Int. 2007;38:395–9. der. Eur J Paediatr Dent. 2021;22(3):243-247. 12. Prince JD. 3D printing: An industrial revolution. J Electron 25. Graziani F, Izzetti R, Lardani L, Totaro M, Baggiani A. Ex- Resour Med Libr. 2014;11:39‑45. perimental Evaluation of Aerosol Production after Dental 13. Mitsouras D, et al. Medical 3D Printing for the Radiologist. Ultrasonic Instrumentation: An Analysis on Fine Particu- Radiographics. 2015;35:1965–88. late Matter Perturbation. Int. J. Environ. Res. Public Health 14. Pagano S, Lombardo G, Coniglio M, et al. Autism spec- 2021;18:3357. trum disorder and paediatric dentistry: A narrative overview 26. Juneja S, Verma KG, Singh N, Sidhu GK, Kaur N. Clinical of intervention strategy and introduction of an innovative course and treatment of a triplication defect: a case report. technological intervention method. Eur J Paediatr Dent. J Dent. 2015;12:385‐388. 2022;23:54-60. doi:10.23804/ejpd.2022.23.01.10 27. Colombo S, Gallus S, Beretta M, et al. Prevalence and de- 15. Chia HN, Wu BM. Recent advances in 3D printing of bio- terminants of early childhood caries in Italy. Eur J Paediatr materials. Journal of biological engineering, 2015;9(1),4. Dent. 2019;20(4):267-273. 25 Annali di Stomatologia 2021; XII (1-4): 22-25 

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Editorial In the recent years I have witnessed the constant growth of some young colleagues who, thanks to a widespread, open, and constant sharing of experience, have actively entered our editorial project and today constitute a key figure and are surely part of the esprit de corps that led us to the publication of the second issue of Annali di Stomatologia. Joining our working group means sharing its values but, not only! “The more people who share knowledge, the more the community benefits from it” and it is in this spirit, that we want to give back to our readers this final product of a high-level research that aims to represent a point of reference in the affirmation of knowledge in our sector. Including many young people in our team of researchers has been a challenge, but it is returning a great satisfaction, indeed. A great number of people, motivated to increase their knowledge without fear of discussion, sometimes even in opposition to the traditional techniques and rules, has given new life to new debates. And it is from there that we have started, walking together the path of a shared plan and a mutual exchange of ideas and knowledge, aiming to the excellence without ever taking anything for granted. Young editors who question them- selves about their knowledge, lead us to a great challenge with ourselves, sometimes breaking down barriers that open us and new possible horizons of research. As part of our goals, we enhance the quality of information, we favor the cultural growth of the Dental community and we open to the principles of modernity and technical evolution, improving a change in action while also maintaining constant attention on possible translations with respect to the current practices. Scenarios in a swift and constant evolution are for us a further stimulus to continue with passion and perseverance and while we are about to start a new chapter of our work, I would like to address a thank you to all the professionals who have worked with incessant commitment and have renewed daily their will to guarantee us a spot on the inter- national level. Happy reading! Prof. Roberto Gatto Annali di Stomatologia 2020; XI (1-4): 1 1 

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Original article Clinical and histomorphometric comparison of autologous dentin graft versus a deproteinized bovine bone graft for Socket Preservation Gallusi Gianni1 thickness to allow their insertion, primary stability, and os- Quinzi Vincenzo1 seointegration. If such thickness is not present, implant Grilli Filippo1 treatment may be possible only through regenerative Memè Lucia2 surgery techniques, the success of which is linked to an Rasicci P.1 accurate diagnosis involving the correct choice of graft Mummolo Stefano1 material, which is crucial for adequate bone formation. In current times, when implant placement is the favored 1 Department of Life, Health and Environmental Scienc- option for replacing a missing tooth, preservation of the es, University of L’Aquila, Italy alveolar ridge is vital. After tooth extraction, dimensional 2 Università Politecnica delle Marche , Ancona, Italy changes in the residual alveolar ridge are inevitable, which pre-existing pathologies such as periodontal dis- *Corresponding author: ease and periapical lesions accelerate3. Filippo Grilli: [email protected] When a tooth is lost, the lack of stimulation of residual Stefano Mummolo: [email protected] bone causes a decrease in trabeculae and bone density in the edentulous socket, along with a loss of width in the buccal bone and a subsequent loss of height in the vol- ume of the alveolar process. These risks are particularly Abstract significant during the first 8 weeks4. Within the first 6 months after tooth extraction, the alveo- Dentin has been an important topic of study for its lar ridge loses height and width ≥50%5-6. Therefore, to potential use as a bone substitute because it has maintain the bone volume useful for optimal functional a higher mineral content than any material derived and esthetic outcomes of a dental implant, it is neces- from bone. Furthermore, dentin is similar to autolo- sary to intervene conteporary or immediately after ex- gous bone in two ways: it is both osteocompatible traction. Placement of various grafting materials within and osteoconductive, thus providing a physical ma- the postextraction socket is supported by numerous trix for the sediment of new bone. studies as a “ridge preservation technique.” 5- 6-7-8-9 In this comparative study, we evaluated the osteoin- Techniques for alveolar ridge preservation using autog- ductive and osteoconductive possibilities of various enous, allogeneic, and xenograft graft materials have materials normally used in “socket preservation” or been mentioned in the literature. alveolar ridge preservation. For most favorable results, an ideal bone graft should From the results obtained, it can be seen that autol- have the properties of osteoconduction, osteoinduction, ogous dentin matrix and bovine-derived xenografts and osteoproliferation10-11. Among all available op- (Bio-Oss) achieved better bone regeneration with a tions, allografts and xenografts demonstrate only osteo- greater amount of newly formed bone (expressed by conduction (except allograft with demineralized freeze- the BV/TV parameter) and less fibrous bone, which dried bone, which is osteoinductive). Considering that has unfavorable characteristics for implant biome- autologous bone possesses all three ideal properties, chanics. it is still considered the gold standard. However, infec- tion hazard from the donor site, limited availability, and Key words: dentin, socket preservation, osteocon- marked resorption are some of the shortcomings of au- ductive tologous bone grafting. Advances in tissue engineering and stem cell science Introduction are leading to the development of new techniques for The human body has intrinsic mechanisms that allow bone regeneration in the maxillofacial area constituting self-healing, but ‘restitutio ad integrum’ is not recurring, an additional therapeutic possibility. particularly in the oral cavity and at the level of the al- Dentin has been an important topic of study for its poten- veolar bone. Biomaterials can promote and enhance tial use as a bone substitute because it has a higher min- the natural capacity for healing and can be successfully eral content than any material derived from bone. Further- used to restore certain structures in the human body 1-2. more, dentin is similar to autologous bone in two ways: it Dental implants represent a method with predictable is both osteocompatible and osteoconductive, thus pro- results for rehabilitating chewing function in edentulous viding a physical matrix for the sediment of new bone. For patients as long as there is an adequate residual bone the above reasons, dentin is considered an ideal bioac- Annali di Stomatologia 2020; XI (1-4): 2-9 2  Clinical and histomorphometric comparison of autologous dentin graft versus a deproteinized bovine bone graft for Socket tive material for hard tissue regeneration 12-13-14. As a quantitative technique, histomorphometry may also The literature agrees that proteins with a weight similar find wider application in “measuring” the response of to bone morphogenetic proteins (BMPs) are abundant in bone to biomaterials implanted during surgery. 29 dental substance. BMPs help promote the differentiation of mesenchymal cells into odontoblasts and ameloblasts Materials and methods 15-16-17-18-19. These proteins can improve the osteoinductive proper- In this comparative study, we evaluated the osteoinduc- ties of bone substitutes if they can be successfully re- tive and osteoconductive possibilities of various mate- tained during the processing of the graft material. The rials normally used in “socket preservation” or alveolar idea of being able to use the tooth as a bone substitute ridge preservation. The study was carried out on a single dates back to studies on the identification of growth fac- patient to get rid of all the variables that inevitably may tors known as bone morphogenetic proteins (Bmps). In arise when evaluating a larger audience of subjects. The 1967, U.S. orthopedic surgeon Marshall Urist, discov- patient, a volunteer, of the present study, is a candidate erer of Bmps, first demonstrated their presence in dentin for treatment and rehabilitation with implant-prosthetic as well. Subsequently, Bmps in the dentin matrix were therapy at the Dental Clinic of the University of L’Aquila. isolated and characterized 17-18-19. In addition, the candidate patient required dental extrac- Autogenous dentin grafting has been developed and tions for periodontal reasons. The patient included in the clinically applied in Korea from 2008 onward. study met the following exclusion criteria: The patient’s extracted tooth represents the ideal bioma- - History of systemic disease that would make surgery terial because it is autologous, does not require a sec- contraindicated ond harvest site, has high osteoconductive and osteoin- - Long-term therapy with nonsteroidal anti-inflamma- ductive properties, and is remodeled and fully replaced tory drugs by new bone. - Lack of antagonistic elements in the area being ex- The osteoinductive properties are due to the presence tracted and thus of implant placement of significant amounts of Bmp within the dentin structure. - Oral therapy with bisphosphonates These proteins are preserved even long after extraction - Lack of elements adjacent to the site undergoing and are unaffected by storage conditions: consider that therapy intact Bmps have been identified even in fossil human - Inability to present at subsequent follow-ups teeth. The complete or partial demineralization treat- - Subject smoker of more than 10 cigarettes per day. ment that is carried out by some of the current methods Before participating in the study, the patient received increases the bioavailability of dentin Bmps, which are clear explanations and signed the informed consent. otherwise constrained by the high degree of crystallinity In addition, he or she was carefully evaluated through of hydroxyapatite. This makes dentin the most biologi- analysis of diagnostic patterns and panoramic/periapical cal and osteoinductive material available, with the sole radiographs, and data such as age, sex, smoking hab- exception of autologous bone. In this regard, it should its, indication for dental extraction based on both clini- be kept in mind that in theory enamel also has good os- cal and radiographic data, location of the tooth element, teoconductivity characteristics but, having a higher inor- and presence/absence of adjacent teeth were acquired. ganic component (96% compared to 60-70% of dentin), Once informed consent was performed, it was possible it is less easily resorbed even after demineralization 19. to proceed with the surgical procedure. Many studies on the use of autogenous dentin as a graft The clinical situation of the patient examined presented have shown good clinical and histological results 20-21- the dental arches with edentulousness of numerous ele- 22-23-24. However, there is a paucity of data supporting ments. the use of autogenous tooth graft (ATG) in clinical ap- To study the effectiveness of autogenous dentin in pre- plications. serving the alveolar ridge, the following experimental Avoiding autogenous bone harvesting by opening an- protocol was established. other surgical site is advantageous in all cases where The patient had extracted eight elements in the two the need to increase bone volumes is accompanied by arches. the extraction of dental elements. It also helps with the The post-extraction sites were divided into 3 groups: cost savings associated with the use of an autologous GROUP 1: in which the alveolus was filled with freshly material compared with those of animal or synthetic ori- prepared autologous dentin matrix; gin. 25-26-27-28 GROUP 2: in which deproteinized bovine bone (Geistlich The primary objective of the present study is to evalu- Bio-Oss) was used; ate clinically and radiographically the efficacy of an au- GROUP 3: control, in which the alveolar bone defect was tologous dentin graft versus a deproteinized bovine bone graft in the technique of alveolar ridge preservation in not filled, reproducing natural post-extraction conditions. post-extraction sites. The secondary purpose was to determine histologically the bone formation potential of Surgical protocol ATG (Autogenous Tooth Graft). - Antibiotic prophylaxis. The data obtained were evaluated by histomorphometry, Following the latest guidelines about antibiotic prophy- or quantitative histology, which allows the acquisition of laxis in oral surgery, the patient received prophylactic an- the most important bone parameters, including the bone tibiotic therapy with 2g amoxicillin 1 hour before extrac- remodeling index. Indeed, suffice it to say that it is used for the diagnosis of metabolic diseases of the skeleton tion and continued therapy in the postoperative period (on bicortical biopsies from the iliac crest). with 1g amoxicillin twice daily for 4 days. 3 Annali di Stomatologia 2020; XI (1-4): 2-9 G. Gallusi et al. Figure 1. Condition of the dental arches immediately following multiple extractions. - Anesthesia Lidocaine-based local-regional and plexic anesthesia was performed, with adrenaline 1:50000 where possible. - Dental extractions Elements 1.4, 1.2, 2.2, 2.4, 3.4, 3.2, 4.2 and 4.4 were extracted with manual syndesmotomes or extraction for- ceps. The atraumatic extraction and subsequent grafting for the alveolar ridge preservation technique were per- formed without dislodging a full-thickness flap using the flapless technique. Great care was taken to minimize trauma to the buccal bone surface and to maintain the integrity of bone mor- phology. - Curettage of the alveolus Figure 2. Grinding and sorting process completed. For proper performance of this study, it was necessary to ensure the removal of all root fragments, fibers, and soft tissues from the alveolus prior to the insertion of graft The first step was to select teeth for treatment. Endodon- material. tically treated elements were excluded. Curettes were used to remove these tissues in the post- A high-speed handpiece and an ultrasonic scaler were extraction socket. used to remove all cavities, artificial materials (crowns or fillings of any kind, amalgam or composites), and de- - Preparation of autologous dentin matrix bris until completely clean elements remained. It was not Parallel to curettage, according to the manufacturer’s necessary to remove the crown or enamel. recommendations, treatment of the extracted teeth for The prepared teeth were dried and introduced into the the creation of the autologous dentin matrix graft was grinding chamber, they were then ground and sorted performed. through the machine functions obtaining particles be- The Smart Dentin Grinder manufactured by KometaBio tween 300 and 1200 microns in size. Particles smaller was chosen for the preparation of the autologous material. than 300 microns were discarded. Annali di Stomatologia 2020; XI (1-4): 2-9 4  Clinical and histomorphometric comparison of autologous dentin graft versus a deproteinized bovine bone graft for Socket heal naturally. The graft material was condensed into the socket by gently pressing it while the patient’s blood was used as the preferred medium to blend it. The use of collagen membrane is mandatory to ensure the protection of the site from gingival proliferation (tent- ing effect) to allow graft rooting and osteogenesis, as well as to allow optimal retention of the material. For this purpose, the membrane was appropriately shaped ac- cording to the dimensions of the socket and then adapt- ed with the ends gently pushed underneath the adjacent soft tissues previously unglued (envelope technique). - Sutures Mucosal margins were fixed in situ, using sutures with- out achieving complete soft tissue closure. Collagen membranes remained exposed to the oral cav- ity with healing by the second intention. Removal of the sutures was scheduled after 10 days. Figure 3. KometBio’s Smart Dentin Grinder with the ex- The patient was recommended to continue antibiotic tracted and cleaned teeth inserted into the grinding cham- ber. prophylaxis and take, as an anti-inflammatory, naproxen sodium in 550 mg tablets twice daily as long as needed, in addition to the use of a chlorhexidine 0.2% mouth- wash twice daily. Drawer with particle sizes between 300 and 1200 mi- crons following the shredding and sorting process. - Sample Next, the sterilization step was carried out with substanc- After about 6 months, the implants were placed by taking es provided by the manufacturer (NaOH with ethanol the bone to be analyzed from the alveolar site by full- 20%), respecting the timing and procedures. thickness flap and the use of core drills (hollow toothed, This process resulted in the organic residues dissolution internally cooled, handpiece-mounted drills) in the area of, bacteria, and toxins in the dentin, leaving the dentin where the biomaterial graft had been placed. particles ready for use. Subsequently, the implant was placed. The patient received the same drug therapy at the time - Grafting of biomaterials of the initial surgery. The retrieval was left in a tube with In group 1, which includes the post-extraction sites of el- a fixative for 9 days to preserve and stabilize its con- ements 1.2, 2.2, 3.2, and 4.2, the freshly prepared dentin stituents. matrix was placed as an autogenous graft. The purpose of fixation is to prevent the postmortal de- In group 2 comprising sites 3.4 and 4.4, a deproteinized generative processes that occur in tissues while preserv- bovine bone graft (Bio-Oss. Geistlich) was placed, and ing their morphology, structure, and reactivity as best as in group 3, comprising sites 1.4 and 2.4, no graft was possible by obtaining as extensive and truthful informa- placed and the postextraction socket was allowed to tion as feasible about the “in vivo” condition of the tissue specimen under examination81. Indeed, the fixative allows instant blocking of enzyme activity, and preservation of all tissue components and does not alter the structure or allow tissue dislocation. In the present study, formaldehyde (or formalin) used in 4% dilution pH7 was chosen as the fixative. This was followed by the inclusion step, which consists of allowing a substance to permeate the tissue under ex- amination, which, as it solidifies, allows it to be cut with a microtome into thin sections a few microns (μm) thick. The inclusion material chosen was methacrylate. The resulting piece was then placed for longitudinal cut- ting using the microtome. Histological sections, on the order of 5 microns (μm), were thus made for staining and analysis. The sections, arranged on object slides, were immersed in xylol, the inclusion solvent, to allow rehydration and subsequent staining. Once the slide was stained, depending on the need for investigation, the section was sealed using Canada bal- sam and coverslip. Figure 4. Drawer with particle sizes between 300 and 1200 Several sections were made of each sampling, of which, microns following the shredding and sorting process. some were stained with methylene blue/blue II, for anal- 5 Annali di Stomatologia 2020; XI (1-4): 2-9 G. Gallusi et al. Figure 5. Placement of Group 1 grafting material (dentin) in the post-extraction socket. ysis of structural parameters, and the remaining with parameter) and less fibrous bone, which has unfavor- TRAcP staining for analysis of bone cell parameters. able characteristics for implant biomechanics. This assessment resulted not only from histomorpho- - Histomorphometric analysis metric examination but also from histological sections Histomorphometric analysis involved the entirety of the analyzed by light microscopy. sectioned specimen, and the following were mea- The percentage of residual material, examined by his- sured: tomorphometry, was also found to be higher for the - osteoclast number/bone surface area (number/ first two groups than for the third, an important finding mm2), to allow its replacement with newly formed bone tissue - osteoclast surface area/bone surface area (percent), (osteoconduction). For group I, with autogenous dentin - osteoblast surface area/bone surface area (percent), grafting, the following parameters were examined: - bone volume/total volume (percent). - BV/TV, expressing the percentage of newly formed The nomenclature, symbols, and measure units of the bone, histomorphometric indices were expressed as recom- - OC.N/micron, expressing the number of osteoclasts mended by the Histomorphometry Nomenclature Com- per micron, mittee of the American Society for Bone and Mineral - OCS/BS, expressing the number of total osteoclasts Research. observed on bone volume. Cells were fixed in 3% paraformaldehyde in cacodylate The results obtained were as follows: buffer 0.1 M for 15 min, then washed with the same buffer. • BV/TV (Bone volume/Tissue Volume) %. TRAcP activity was detected histochemically using Sig- ma- Aldrich kit #386, following the manufacturer’s sug- gested instructions. Site Section 1 Section 2 Section 3 Average ± SEM Results 1 27% 30% 28% 28.3 ± 0.88 From the results obtained, it can be seen that autolo- 2 55% 61% 58% 58.0 ± 1.73 gous dentin matrix and bovine-derived xenografts (Bio- 3 21% 17% 23% 20.4 ± 1.76 Oss) achieved better bone regeneration with a greater amount of newly formed bone (expressed by the BV/TV 4 80% 83% 88% 83.7 ± 1.30 Annali di Stomatologia 2020; XI (1-4): 2-9 6  Clinical and histomorphometric comparison of autologous dentin graft versus a deproteinized bovine bone graft for Socket • OC.N/micron surrounded by newly formed, mature, and compact bone tissue, with no bone gaps along with the interface. Site Section 1 Section 2 Section Average ± The bone was always found to be in close contact with 3 SEM the particles themselves. In addition, no inflammatory in- 1 8μm 11μm 5μm 8μm filtrate was evident. Histomorphometry showed that the newly formed bone was 38%± 1.6%, the intertrabecular 2 21μm 22μm 20μm 21μm spaces 33%±1.6%, and the residual material was 30%± 3 5μm 8μm 6μm 6μm 1.4%. 4 1μm 0μm 2μm 1μm Regarding the sites without any graft, where there was natural healing, there was evidence of neoformation of bone tissue with wide gaps. • OCS/BS No inflammatory infiltrate was found. The neoformed bone was 37%± 3.2%, the intertrabecular Site Section 1 Section 2 Section 3 Average ± spaces 44% ±1.3%, and the residual material was 0%. SEM 1 15% 20% 18% 17.6% Discussion 2 35% 32% 42% 36.3% The presence of neoformed bone was observed in all 3 13% 16% 21% 16.6% samples examined. Therefore, it can be stated that the biomaterials consid- 4 3% 0% 2% 1.6% ered in this study resulted in bone neoformation. However, the phenomena of bone neoformation are not Regarding on group 2, which included xenograft with sufficient to clarify the greater usefulness of one bioma- deproteinized bovine bone (Bio-Oss), and group 3, in- terial over another. Therefore, the amount of mineralized cluding sites left to heal naturally, the following were ex- bone, the amount of intertrabecular spaces, and the amined: amount of residual biomaterial were also considered in - BV/TV, expressing the amount of newly formed bone, our study. - The percentage of intertrabecular spaces, Based on the parameters analyzed, there are differenc- - The percentage of residual material. es between the various biomaterials, particularly in the The results obtained were as follows: amount of residual biomaterial. No fillers Bio-Oss Autologous dentin matrix turns out to be the most stable “biomaterial” in comparison with Bio-Oss and traditional New bone 37%±3.2% 38%±1.6% healing whose residual percentage is higher, given the Inter-trabecular spa- 44%±1.3% 32%±1.6% same elapsed time (in agreement with the international ces literature and concerning Bio-Oss identified as the “gold Residual material 0% 30%±1.4% standard” among grafting biomaterials). Regarding the type of material replacement, in bone tis- As for Bio-Oss, sections of some samples showed os- sue or fibrous tissue, we can argue that traditional heal- teoblastic activities with affixation of bone directly on the ing was the process that gave the highest percentage of surface of the particles, most of which appeared to be fibrous tissue formation. Figure 6. Transverse section of patient’s jaw bone. TRAcP histochemical staining highlighting cells expressing the enzyme tartrate-resistant acid phosphatase enzyme. 40X magnification. Red arrows = osteoclasts \ o = bone tissue. 7 Annali di Stomatologia 2020; XI (1-4): 2-9 G. Gallusi et al. Figure 7. Longitudinal section of patient’s maxillary bone. 2.5X magnification. Methylene blue II staining. Images are representative of at least 3 sections analyzed at different depths. O = bone tissue \ red arrows = osteoblasts \ black arrows = osteocytes Nevertheless, differences, even considerable ones, Further randomized clinical trials are needed to establish were still found among the various retrievals, even with its regenerative potential in various periodontal weak- the same material used, in the type of tissue regener- nesses. ated. These disparities are related to individual patient factors that play an equally important role such as: - general health conditions of the same, References - anatomical conditions, 1. A. Martinez, J. Franco, E. Saiz, F. Guitian: Maxillary sinus - amount of residual bone. floor augmentation on humans: Packing simulations and 8 It is inferred, in fact, through the radiological study per- months histomorphometric comparative study of anorganic formed before and after surgery, how the anatomical bone matrix and β- tricalcium phosphate particles as graft- ing materials. Mater Sci Eng C Mater Biol Appl. 2010 June shape of the post-extraction site and the thickness of 15; 30(5): 763–769. residual bone are determining factors for the surgery to 2. Adell R, Erikson B, Lekolm U, Branemark PI, Jemt T. Along be succesfull. –term follow- up study of osseointegrated implants in the As far as anatomy is concerned, we can state that there treatement of the totally edentulous jaw. Int J Oral Maxil- are types of anatomy that facilitate graft rooting as they lofac Implants 1990;5:347-359. are characterized by greater irrigation, in which the neo- 3. Araujo, M.G. & Lindhe, J. 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Original article Antibiotic prophylaxis in dentistry B. D’Orto*1 growth of a pathogen (Bacillus anthracis) responsible Lara Ceresoli* for an infectious disease (KI., 2016). The action of the Serena Ferri* antibiotic on the bacterium can be of two types: bacte- Costanza Ferraro* riostatic or bactericidal; in the first case, the drug allows M. Nagni*2 bacterial replication to be stopped, while, in the second case, it causes its death (Kohanski, (2007)). * Dental School, Vita-Salute San Raffaele University, The most commonly prescribed antibiotics in dentistry Milan, Italy and Department of Dentistry, IRCCS San are Amoxicillin 250 mg three times a day, Ampicillin 500- Raffaele Hospital, Milan, Italy; 1000 mg four times a day, Penicillin 500 mg four times 1 D’Orto Bianca, DDS, fellow MSc, Dental School, Vita- a day, Cephalexin 250-1500 mg four times a day, Ce- Salute San Raffaele University, Milan, Italy and De- phradine 250-1000 mg four times a day, Metronidazole partment of Dentistry, IRCCS San Raffaele Hospital, 200-250 mg three times a day, Clarithromycin 250-500 Milan, Italy; Corresponding author: [email protected] mg twice a day, and finally Doxycycline 200 mg initially, 2 Nagni Matteo; DDS, MSc, Dental School, Vita-Salute then 100 mg daily. (Ramu C. et al., 2012). San Raffaele University, Milan, Italy and Department According to the World Health Organization, antibiotics of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy. are abused drugs. This inappropriate use has led to the problem of resistance which is becoming a serious glob- al threat. It is estimated that antibiotic resistance causes 25,000 deaths per year. (Morehead MS et al., 2018). Abstract Prescribing antibiotics for prophylactic purposes are a very common practice among dentists, although the use The aim of the present narrative review was to sum- of antibiotic prophylaxis in implantology and oral surgery marize the main indications of antibiotic prophylaxis is controversial. (Schwartz AB et al., 2007). in dentistry. Prophylactic treatment is prescribed to avoid an infection A search was performed via the search engines that could occur if staphylococci and streptococci con- Pubmed, Scopus and Web of Science. All types of taminate the surgical wound. Broad-spectrum antibiotics articles were included in the study except for those such as Amoxicillin are usually prescribed. (Dar-Odeh found in the various search engines and publica- NS et al., 2010). tions not related to the topic addressed, which were The antibiotic prophylaxis protocol involves the admin- excluded. istration of 2 g of amoxicillin 30 to 60 minutes before With the limitations of this study, antibiotic prophy- surgery, according to guidelines published in 2018 by laxis could play a decisive role in avoiding post-op- the National Institute for Health and Clinical Excellence erative infections, especially in more invasive sur- (NICE). In case of possible allergy to amoxicillin, the an- geries and in compromised patients. Further clinical tibiotic most frequently administered turns out to be clar- studies could be useful to further investigate the ithromycin (500g) or clindamycin (600 mg). (National In- role of antibiotic prophylaxis according to individual stitute for Health and Clinical Excellence (NICE), 2008). systemic diseases. Antibiotic prophylaxis appears to be extremely safe ex- cept for small cases of hypersensitivity and allergic re- Kewords: antibiotic prophylaxis, systemic diseases, actions. Beta-lactams are the class of antibiotics that oral surgery, dental implants. cause a higher percentage of adverse reactions, about 20%; followed then by sulfonamides with 2-10%, fluoro- quinolones, macrolides, tetracyclines and glycopeptides. Introduction to antibiotics used in dentistry (Macy E. et al., 2012) Waksman SA., defined an antibiotic as ‘’a chemical sub- The literature shows that among the female and male stance, produced by microorganisms, which can inhibit population those who most frequently develop allergy to the growth and even destroy bacteria and other micro- antibiotics turn out to be the female population. (Sousa- organisms’’. (Waksman SA, 1956). Nowadays, the term Pinto B et al.,2017) antibiotic refers to a chemical substance of natural or The literature review by K de Leeuw et al, 2019, suggests synthetic origin that inhibits or kills pathogenic bacteria prescribing antibiotic prophylaxis for dental procedures (KI., 2016). The first antibiotic was described by Bartolo- in high-risk immunocompromised patients who may de- meo Gosio, an Italian physician, microbiologist and bio- velop systemic infections when undergoing procedures chemist, who succeeded in isolating a substance (Peni- such as extractions or implant placement. These are cillium brevi) from a mould, capable of preventing the patients with severe neutropenia, primary immunodefi- Annali di Stomatologia 2020; XI (1-4): 10-15 10  Antibiotic prophylaxis in dentistry ciency or patients taking high doses of immunosuppres- obstruction, is quite high. In these patients, the current sants. (de Leeuw K et al., 2019). recommendation is to undertake implant surgery with- Oral surgery, periodontal and endodontic treatments and out modification of anticoagulation therapy provided that implant placement are dental procedures that may pro- the INR is less than 3 or 3.5 and the surgery does not mote the occurrence of infective endocarditis (IE). (Ci- include the opening of an extended flap and insertion of urus M, 2021). a graft. In general, consultation with the treating physi- Infective endocarditis is a rare infection that affects 5-10 cian is recommended, especially in congenital bleeding people per 100,000 per year. Morbidity is high, requires disorders. (Diz P. et al., 2013). prolonged courses of antibiotics and patients often un- The placement of dental implants over the years has be- dergo surgery to replace the valve. Mortality is high. It come, after ascertaining their success over time, a rou- is therefore necessary to prevent this disease with ap- tine procedure (Ng P. et al., 2011) with a 2% failure rate propriate antibiotic prophylaxis before the patient under- in case of fibrointegration (Troiano et al., 2018) often as- goes invasive dental procedures. (Hoen B et al., 2013). sociated with both bacterial contamination of the implant Amoxicillin reduces the frequency of bacteremia but is and the trauma of the surgery itself, in addition to the not 100% effective. (Limeres P. et al., 2016). primary stability of the implant and variants related to the post-operative phase (Sakka S. et al., 2012). There are several protocols involving antibiotics The first bacterial species to colonise the implant surface before and after dental procedures, most of these and therefore associated with implant failure are strepto- describe the use of Amoxicillin and Amoxicillin cla- cocci, both gram-positive and gram-negative (anaerobic) vulanate. (Mombelli A. et al., 1987). In particular the Stein et al. protocol (Stein, et al., A recent systematic review evaluates the use of preop- 2018, ), which stands Amoxicillin posology; erative Amoxicillin and argues that systemic antibiotic amoxicillin should be taken 1 h before surgical pro- administration for a single implant placement surgery cedures (2 g) and than, 500 mg every 8 h after sur- does not particularly affect its success (Romandini M. gery for 7 days. et al., 2019). Amoxicillin clavulanate has two methods of som- Nevertheless, an effective standard prophylaxis protocol ministration; that reduces the degree of implant failure to 2% has been 500 + 125 mg 2 days before surgery and 500 + 125 proposed several times and by several studies (Lund B. mg every 12 h for another 4 days (paediatric use) or et al., 2015), this consists of a single dose of Amoxicillin 875 + 125 mg 2 days before surgery and 875 + 125 one hour before surgery (Rodrìguez S., 2018) (Roman- mg every 12 h for another 4 days. dini et al., 2019). Indeed, in terms of implantation failure, both prophylaxis, pre- and post-operative, proved to be as effective as the Indications for antibiotic prophylaxis single-dose prophylaxis. In agreement with this, a pro- in implantology phylaxis involving the administration of multiple doses of antibiotic seems to be an overprescription (Romandini et Systemic antibiotic prophylaxis is frequently prescribed al., 2019) (Esposito M. G., 2013). by dentists before implant surgery to avoid both implant Moreover, the incorrect use of antibiotics can cause vari- failure and the risk of post-operative infection. Indeed, ous adverse reactions as well as lead to antibiotic resis- bacterial contamination during oral implant surgery is tance, from diarrhoea to allergic reactions, and this risk thought to be responsible for early implant loss. Infected should always be considered when going to administer dental implants cannot always be recovered. (Esposito antibiotic prophylaxis (Surapaneni H. et al., 2016). M. et al., 2008) Although at this point it seems essential to outline a cor- The scientific literature suggests that as far as the rect method of prophylaxis, the literature on this subject healthy patient is concerned, a single dose of antibiotic is conflicting on the preoperative or postoperative use of prior to surgery is sufficient. (Barnabeu-Mira et al., 2021) antibiotic prophylaxis in the clinically healthy patient, and On the other hand, in the case of patients with systemic its subsequent correlation with implant failure and suc- diseases there are cases in which implant treatment is cess rates. (Surapaneni H. et al., 2016). contraindicated (patients undergoing chemotherapy or being treated with intravenous bisphosphonates), while in some cases patients can be treated by following cer- Indications for antibiotic prophylaxis in oral tain precautions. (Hwang D et al., 2006). surgery To avoid septicaemia in an immunocompromised patient it is necessary, in agreement with the general practitio- Dental infections affect both the soft and hard tissues ner, to prescribe antibiotic prophylaxis prior to implant of the oral cavity and can occur because of dental car- procedures. (Scully C. et al., 2007) ies, pulpal necrosis, dental trauma, and periodontal dis- This indication is also valid for uncontrolled diabetic ease. There is swelling and pain at the affected site. If patients, as the literature reports a high risk of implant not treated quickly, serious complications such as os- failure compared to patients with controlled diabetes, as teomyelitis, brain abscess, airway obstruction, carotid well as for patients treated with corticosteroids. (Wang F. infections, sinusitis, septicemia, meningitis, cavernous et al., 2010) (Bencharit S. et al., 2010)Patients with co- sinus thrombosis, orbital abscess and loss of vision can agulation disorders have no contraindications to implant develop (Igoumenakis D. et. al. 2014). treatment, but the possibility of intra-operative compli- If the infection occurs systemically, the possibility of cations such as haemorrhage, with subsequent airway administering intravenous antibiotics emerges from the 11 Annali di Stomatologia 2020; XI (1-4): 10-15 B. D’Orto et al. literature. According to current guidelines, antibiotic abscesses with systemic compromise (localised fluctuat- therapy should be administered only once the infectious ing swelling, fever above 38°C, general malaise, lymph agent has been removed and should be continued for node swelling and muscle lockjaw); infections with a rapid approximately 2-3 days after surgery (Koyuncuoglu CZ. and progressive onset within 24 hours, cellulitis and os- et. al. 2017). teomyelitis; re-implantation of the tooth element, where Dental procedures in which antibiotic therapy is con- topical antibiotics are sometimes recommended (Hinck- sidered necessary, regardless of the patient’s medical fuss SE. et. al 2009) (Andersson L. et al., 2012) and soft health, are risk of infection after extraction of a tooth el- tissue trauma from surgery (Diangelis AJ. et al., 2012). ement (included or not included), after periodontal sur- gery, after implant placement, after tooth reimplantation, after endodontic procedures with periapical lesions or Indications for the use of antibiotic therapy endodontic surgery (Salmerón-Escobar JI. et. al. 2006). in periodontology On the other hand, in the case of a patient with systemic Antibiotic administration in periodontal surgery is indicat- disease, the literature suggests that antibiotic prophy- ed in periodontal, regenerative and Guided Bone Regen- laxis is a necessary option to prevent possible complica- eration (GBR) bone surgery. The literature shows that, tions (Ahmadi H. et al., 2021). in periodontal bone surgery, the prescription may be Specifically, if oral surgery is to be carried out, both in postoperative (Powell CA. et al., 2005) Mohan RR. et al., the case of transplanted patients and patients on hae- 2014) on the contrary some studies report that the pre- modialysis, antibiotics are necessary to protect them scription is only necessary in the presence of an already from possible bacteraemia (Bayraktar G. et al., 2009) ongoing infectious process (Tseng CC. et al., 1993). (Pereira-Lopes O. et al., 2019). In regenerative surgery, the most commonly used anti- In case of necrotising ulcerative gingivitis, acute periapi- biotics are the penicillin family (69.5%) or doxycycline cal abscess, cellulitis, pericoronitis, peri-implantitis, in- (24.2%), while only 2.3% use other types of antibiotics. fections of the deep fascial layers of the head and neck, The same recommendations also apply to GBR (Linde- and in case of fever, antibiotic prescription is recom- boom JA. et al., 2003) (Powell CA. et al., 2005). mended. Antibiotic prophylaxis is crucial for the control of dental infections following surgery involving incisions, drainage, and pulpal organ involvement (Gutiérrez JL. Use of antibiotics in pediatric dentistry et. al. 2006). Dentists prescribe different types of drugs in order to Indications for antibiotic prophylaxis manage specific oral diseases and conditions (Goel D. in extractive surgery et al., 2020). Poor knowledge of the appropriate clinical indications for prescribing antibiotics contributes to the Dental extractions are performed for various reasons: formation of antibiotic-resistant strains; in fact, children destructive caries, included elements, orthodontic treat- as young as four years old have been found to have ment, periodontal treatment, or trauma (McCaul LK et multi-resistant bacteria in their oral cavities (Ready D. al., 2001). et al., 2003). The prescription of antibiotics to prevent alveolitis and Some complications that can be found when inappropri- surgical site infections during third molar extraction is a ate prescriptions are made in the pediatric population are: widespread practice among dentists (Cervino G. et al., the risk of developing diabetes from sugar-containing 2019), although the literature is ambiguous, as the use antibiotics, the risk of developing allergies and asthma of antibiotics for prophylactic purposes does not signifi- (Droste JH. et al., 2000). In addition, early exposure to cantly reduce the presence of infections at the surgical antibiotics is also thought to change the gut microbiota, site (Lee JY et al., 2013). with long-term adverse effects such as obesity and Can- In the randomised controlled trial by Dios et al., 2006, dida Albicans infections (Al-Shayyab MH. et al., 2015). microbiological analysis of postoperative bacteremia Enamel development defects on the first permanent mo- was performed to determine the effectiveness of anti- lars and maxillary central incisors may be correlated with biotic prophylaxis in dental extraction. Amoxicillin and Amoxicillin intake during early childhood (Hong L. et al., moxifloxacin prophylaxis showed high efficacy, whereas 2005). clindamycin prophylaxis did not. Thus, the results of the There are several clinical situations that should be appro- study suggest that amoxicillin and moxifloxacin are two priately considered when prescribing antibiotics in pediat- antibiotics that can reduce postoperative infections fol- ric patients. Facial lacerations and puncture wounds may lowing dental extraction (Diz Dios P. et. al 2006). simply require topical antibiotic agents, but when these Given the low risk of infection, there is no evidence to appear to be contaminated and the risk of infection is high support antibiotic prophylaxis for healthy people under- enough, then systemic antibiotics can be administered going third molar extraction surgery (Martín-Ares M. et (American Academy of Pediatric Dentistry). al. 2017). In cases of irreversible pulpitis, necrotic pulp, and local- ized acute apical abscesses, but without systemic signs and symptoms, antibiotics are not indicated (Segura- Indications for antibiotic prophylaxis in en- Egea JJ. et al., 2017). In addition, on pain associated dodontics with dento-alveolar infection, antibiotics have no effect; The administration of antibiotic prophylaxis is indicated in in these cases it is sufficient to prescribe analgesic/anti- the following cases (Segura-Egea JJ. et. al 2017): acute inflammatory drugs (Palmer NO., 2006). apical abscesses in unhealthy patients; acute periapical Antibiotic prescription should be made when acute odon- Annali di Stomatologia 2020; XI (1-4): 10-15 12  Antibiotic prophylaxis in dentistry togenic abscess is associated with pyrexia in the last 24 health in peritoneal and hemodialysis patients. Int J Dent. h (Palmer NO., 2006). Antibiotic prescription is also re- 2009;2009:159767. doi: 10.1155/2009/159767. Epub 2009 quired in cases of facial cellulitis, associated with sys- Mar 10. PMID: 20309409; PMCID: PMC2837468. 7. Bencharit S, Reside GJ, Howard-Williams EL. Complex temic signs and symptoms (Dar-Oden N. et al., 2018). prosthodontic treatment with dental implants for a patient In these cases, the antibiotic of choice is amoxicillin (2-3 with polymyalgia rheumatica: a clinical report. Int J Oral days, max 5 days) or phenoxymethyl penicillin (2-3 days, Maxillofac Implants. 2010 Nov-Dec;25(6):1241-5. PMID: max 5 days (American Academy of Pediatric Dentistry). 21197503. Whereas the antibiotic regimen to be administered, when 8. Bernabeu-Mira, J., Peñarrocha-Diago, M., & Peñarrocha- patients are allergic to penicillin, involves metronidazole Oltra, D. (2021). Prescription of Antibiotic Prophylaxis for Dental Implant Surgery in Healthy Patients: A System- (3 days), or clarithromycin (7 days) (American Academy atic Review of Survey-Based Studies. 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Original article The Orthodontic-Periodontal Risk Assessment (OPRA) in developing Periodontal Disease Marino Musilli1 maintenance of the corrected periodontal condition [3]. Sherry Lee2 Lang and Tonetti [4] described the Periodontal Risk As- Mauro Farella3 sessment (PRA) through the use of a functional diagram, Guerino Paolantoni4 evaluating factors which influence the risk of disease progression at an individual level. It would be useful to 1 Private practice in Salerno have a similar diagram for an Orthodontic-Periodontal 2 Dental House Surgeon of University of Otago, Dunedin interdisciplinary approach for guidance in choosing the 3 Department of Oral Sciences appropriate orthodontic treatment plan to preserve the 4 Private practice in Naples periodontal health. As suggested and underlined by sev- eral Authors[5-8-9-10-11], there is evidence indicating Corresponding Author that orthodontic appliances can alter this delicate bal- Dr. Guerino Paolantoni ance between defense and host. Address: Via Francesco Giordani, 30, 80122 Napoli NA However, we can only infer a negative influence of risk Phone: +39 081 681418 factors related to the accuracy of the forces exerted on Fax: +39 081 681418 the tissues by orthodontics appliances [12-15]. Email: [email protected] In patients with high susceptibility to periodontal disease, these orthodontics risk factors need to be considered and managed appropriately or they have the potential Abstract to cause an imbalance in the orthodontic-periodontal in- terface [16]. Fifty percent of the adult population suffers from periodontal disease. Patients with Stage IV peri- odontal disease have altered physiological dental Methods relationships such as masticatory dysfunction, sec- In order to explain the adverse effects occurring on ondary occlusal trauma, increased tooth mobility, patients susceptible to periodontitis during orthodontic bite collapse, tooth migration and flaring. Occlusal treatment, we hypothesized that some factors common forces can alter and adversely affect the outcome to periodontitis (device cleanability and periodontitis sus- of periodontal therapy, thus orthodontic treatment ceptibility) combined with those specific to orthodontics can be considered to re-store occlusal harmony as (treatment duration, device force system accuracy and well as improve smile aesthetics. The objectives of device extension and gingival phenotype) may influence this article were 1) to underline the possible factors periodontal health conditions in interdisciplinary ortho- involved in the relationship between systemic con- perio therapy: ditions and periodontal disease during orthodontic A. Periodontal anchorage teeth preservation treatment in patients with periodontal issues; 2) to B. Device cleansability propose an Orthodontic-Periodontal Risk Assess- C. Treatment time ment model (OPRA) to account for risk factors as- D. Force system accuracy sociated with orthodontic treatment, estimating their E. Gingival Phenotype impact on periodontal health in susceptible patients. F. Patient susceptibility to periodontitis Keywords: Interdisciplinary therapy, risk assess- The Alveolar Bone Housing [17] has not been directly in- ment, Ortho-Perio strategies, periodontal diseases, cluded amongst the previous factors for several reasons orthodontics, orthodontic appliances, dental plaque, later explained in the discussion, but is still indirectly biofilms considered within the Gingival Phenotype. For simplicity, these factors can be categorized into three areas: Introduction A) Device (related to the infectious stimulus group) B) Load (related to the mechanical stimulus group) As highlighted by the new periodontal classification, C) Periodontal aspect (related to the involved periodon- secondary occlusal trauma can negatively influence the tal teeth group) course and expression of periodontal disease, attributing to it a greater degree of complexity of treatment (Stage IV Interdisciplinary approach) [1,2]. In an interdisciplin- a. Periodontal anchorage teeth preservation ary orthodontic-periodontal approach, treatment aims to Orthodontic movement of teeth alters the homeostatic rebalance occlusal function and facilitate the long-term environment in both a healthy and reduced (healed) Annali di Stomatologia 2020; XI (1-4): 16-27 16  The Orthodontic-Periodontal Risk Assessment (OPRA) in developing Periodontal Disease periodontium. During orthodontic treatment, it would be on patients with an average age of fourteen years [8,29, desirable to move only the teeth that are planned to be 30], but we know that the peak in incidence of severe moved, and avoid placing additional stress on the other chronic periodontitis is around 38-40 years of age [31]. teeth, especially if there is already reduced periodontal From a biological point of view, it is easier for the peri- support. odontium of younger patients to revert back to a healthy Orthodontic appliances commonly incorporate all teeth condition after debonding. in both dental arches, as dental arches must be coordi- Clear aligners and other types of minimally invasive ap- nated. As a result, position of all teeth changes in order pliances have recently appeared in the orthodontic land- to facilitate this. The orthodontic management of seg- scape. It has been shown that clear aligners simplify oral ments with reduced residual periodontium presents con- hygiene measures for both the individual and profession- siderable difficulties with regards to the force intensity al [32]. Minimally invasive orthodontics use wires with or and direction of movement. Errors are often made, cre- without brackets bonded in a limited area within the den- ating periodontal disorder as seen in occlusal trauma. tal arches by which precise forces through a statistically Careful planning and selection of teeth to be moved will determined system can be applied [33, 34]. help avoid unwanted and undesirable movement on the teeth we do not want to move or stress with high-risk c. Treatment Time force systems. Despite decreasing the magnitude of It is best to minimize the duration of orthodontic treat- force application in teeth with reduced periodontal sup- ment in patients susceptible to periodontitis as orthodon- port, there will still be a vertical extrusive effect (due to tic treatment is considered a sterile inflammatory pro- the “cone effect”) [18] as well as unpredictable move- cess. Not only do orthodontic devices lead to a greater ments (due to the sudden change in position of the accumulation of biofilm, but they also result in a biofilm Center of Resistance). Physiologic bone resorption on composition change towards periodonto-pathogenic the already thin and fragile cortical bone in periodon- bacteria. Therefore, a prolonged period of orthodontic tally-compromised dentitions can occur in orthodontic therapy becomes a co-factor in the risk for periodontal tipping movements due to the concentration of tensile recurrence [35]. and compressive stresses on the alveolar margins and The duration of orthodontic therapy also represents the root apex [19]. period in which the periodontium of a patient susceptible With the introduction of mini-screws in orthodontics [20, to periodontal disease is exposed to mechanical stimuli 21], undesirable forces and movement of anchor units – further activating the inflammatory mediators impli- have been reduced. Mini-screws, mini-plates or con- cated in orthodontic tooth movement. The duration of ventional implants are recommended for better control treatment is associated with the complexity of the initial of three-dimensional tooth movements [22]. Through malocclusion, the effectiveness of the orthodontic appli- time and development, the use of these anchoring de- ances chosen and the desired treatment outcomes. vices have become more specific, limiting the exten- In conventional orthodontic therapy, the goal is to obtain sion of orthodontic appliances as well as minimizing the an Angle Class I occlusion, in line with the Andrew’s Six duration of treatment. Thus with the use of TADs, it is Keys of Occlusion [36]. The achievement of this treat- now possible to avoid unnecessary biological stimuli ment outcome is one of the most used reference param- or round-tripping movements on compromised anchor eters by orthodontic institutions around the world where teeth without undermining efficacy on the reactive unit the ideal occlusion is perceived as the most aesthetic (teeth that need to be moved). and most stable. Meta-analysis has shown that the av- erage duration of orthodontic treatment is approximately b. Cleansability of Device 24.9 months [37] with no major differences between ado- This is based on the assumption that the increase in bac- lescents and adults [38]. In the context of fixed devices, terial mass on tooth surfaces can easily lead to the wors- treatment which include dental extractions are often of ening of periodontal health - gingivitis and recurrence of longer duration than those without dental extractions [39]. periodontitis [23, 24]. In reality, this concept is changing, as many studies The most widespread orthodontic device is the fixed have shown that post-orthodontic stability is not guar- multi-bracket appliance. A single wire (with or without anteed [40]. For this reason, orthodontic treatment out- loops) or several wires involving different sectors of the comes involving a compromised occlusion may need to arch can be inserted into the brackets. Maintenance be considered, as long as the occlusion is stable. In the of oral hygiene with fixed metal appliances is very dif- orthodontic-periodontal interface, longer treatment dura- ficult and without proper hygiene, the increase in bacte- tions are associated with greater periodontal stimulus rial load around the brackets leads to a higher gingival from prolonged orthodontic forces and pro-inflammatory bleeding index [25-27]. Greater oral hygiene problems factors within the periodontium. including plaque deposits were also found with the lin- gual bracket system [28]. d. Accuracy of Force Systems Previous reports show that clinical periodontal pa- Different orthodontic appliances create different force rameters partly normalized in three months following vectors on the periodontium [41]. Ideally, knowledge of the removal of fixed appliances [11]. However, it can the magnitude and direction of the force systems act- sometimes take between six months to two years post- ing on the teeth will lead to treatment with more pre- treatment for levels of supra- and subgingival Colony dictable outcomes [42, 43], however in reality, it is not Forming Units (CFU) to reach pre-treatment values. It possible to know or maintain the applied force vector for is worthwhile noting that these studies were conducted most orthodontic appliances between appointments. As 17 Annali di Stomatologia 2020; XI (1-4): 16-27 M. Musilli et al. a result, there is an automatic variability in orthodontic phenotype when the necessary orthodontic tooth move- force systems, capable of changing the direction of den- ment will compromise the bony housing. Similarly, soft tal movement (the phenomenon of “dental fluctuation”) tissue PhMT may be needed to perform CAOT (Corticot- [44], leading to treatment not completely identical to the omy-assisted orthodontic therapy), or in conjunction with programmed alignment (“indiscriminate alignment”) [44]. bone grafting. Thus, there are clinical situations in which Among these variables, we can mention the anchorage both bone and soft tissue augmentation are necessary value deriving from the occlusion and the musculature of [51]. A study also explored the labial gingival thickness the patient, the soundness of the residual periodontium using CBCT imaging and found a moderate association and the occlusal sensitivity of the patient to the occlusal with the underlying bone radiographically [53]. changes occurring during tooth movements. Swinging It is important to clinically assess and record findings movement of the teeth (jiggling) linked to the unpredict- regarding the gingival phenotype prior to commencing able creation of occlusal prematurities in patients with orthodontic treatment as it is not only to reduce the risk a reduced vertical pattern results in tooth mobility very of gingival recession, but also to be aware of the alveolar similar to those present in secondary occlusal trauma bone housing and the boundaries of orthodontic tooth [45]. This method of managing orthodontic movements movement. is the prerogative of a group of techniques that we could classify as “continuous arch techniques”. The name is f. Patient susceptibility to periodontitis inspired by the fact that there is often only a single wire Periodontitis is a complex, chronic inflammatory disease engaging all the brackets of each arch. Clear aligners as a result of an imbalance of the oral microbiota and work with a similar force system treating entire dental the host response leading to inflammation and destruc- arches with a single device with the same characteristics tion of the periodontium in susceptible individuals [54]. of elasticity. Although bacterial presence is essential, there are also An alternative to this approach is the “segmented arch other contributing factors such as individual susceptibil- technique” [46-48]. This is characterized by brackets ity, certain systemic diseases (i.e. diabetes), smoking on all teeth connected by different wire segments (also and the presence of excessive occlusal stress. These with different Load/Deflection characteristics). With a can all act as co-factors for the disease onset and pro- segmented arch approach, we tend to differentiate the gression [55, 56]. In recent years, there has been greater active units (teeth to be moved) from the reactive units attention from the international scientific consensus on (teeth that are stationary), using carefully applied forces occlusal aspects and masticatory dysfunction, where for more predictable movements. these factors are now included and characterize the A third method of working with more calculated, accurate staging of the new periodontal classification [57]. In ad- and longer-lasting force systems, allowing extremely dition to periodontopathogenic bacterial elimination and delicate movements is the Statically Determined System lifestyle changes, therapeutic strategies must also focus [49]. A statistically determined system implies “that the on controlling malpositioning of the dental elements and law of statics (equilibrium) is sufficient to solve” and they abnormal occlusal forces. At each stage of inter-disci- provide us with the most predictable knowledge of force plinary treatment, the lack of control can affect treatment systems [41, 44-49]. Therefore, this force system could outcome [58]. be the most suitable for teeth or groups of teeth with very In 2018 a new Classification scheme for periodontal and small residual periodontium. peri-implant diseases was proposed as part of the World Workshop on Classification of Periodontology [1, 54], e. Gingival Phenotype establishing the stage, extension, complexity and sever- Gingival phenotypes are distinguished into three cat- ity of periodontitis through the attribution of the grade, egories - thin, medium or thick but currently, a simple risk of progression and susceptibility of the disease. This method to identify gingival phenotype in patients does new classification incorporates many factors that were not exist. The available evidence indicates that subjects previously evaluated in other procedures (Periodontal with thin and narrow gingiva tend to have more gingi- Risk Assessment) [56], designed to monitor and evalu- val recession compared with those with thick and wide ate health and/or disease characteristics of the patient. gingiva. [50, 51]. This risk is increased with orthodontic In order to reflect on the intrinsic periodontal characteris- therapy and may be clinically apparent over time after tics of the orthodontic patient, this periodontal parameter orthodontic treatment [2]. To prevent gingival recession, has also been included in the synoptic table. The work many authors have suggested modifying the gingival of Heitz-Mayfield et al 2020 [59] placed the least com- phenotype prior to, or during orthodontic treatment. promised values (with the least risk of progression [1A])​​ The benefits of phenotype modification therapy involving towards the center of the polygon and those with greater soft tissue augmentation (PhMT-s) during orthodontic impairment of the periodontal status (with an increased treatment remain undetermined due to the limited num- risk of progression ([4C]) towards the external part. We ber of studies available in the literature, however, PhMT propose to quantify the six discussed variables to cre- via corticotomy with particulate bone grafting (PhMT-b ate a functional diagram which will help clinicians in their along with corticotomy-assisted orthodontic therapy - treatment with regards to the orthodontic-periodontal in- CAOT) may provide clinical benefits. Augmenting peri- terface (Figure 1). odontal phenotypes expand the scope of incisor move- Scores for the Orthodontic-Periodontal Risk Assessment ment [52]. Furthermore, Kao et al. suggests that Bone In order to make the following graph more availabe and phenotype modification therapy (PhMT) should be pur- easier to reproduce, a numerical scale from 1 to the 10 sued prior to orthodontic treatment in patients with thin has been chosen, attributing the value 10 to a maximum Annali di Stomatologia 2020; XI (1-4): 16-27 18  The Orthodontic-Periodontal Risk Assessment (OPRA) in developing Periodontal Disease Figure 1. Ortho-Perio Risk Assessment: I) TOP view. The chart is on a plane with macro areas: A) DEVICE (belonging to the infectious stimulus group), B) LOAD (belonging to the mechanical stimulus group, C) PERIODONTAL ASPECT (belonging to Involved periodontal teeth group). Inside there are five vectors that describe the risk factors associated with the orthodontic de- vice: a) Periodontal anchorage teeth preservation, b) Kind of Orthodontic Appliance (device cleanliness), c) Orthodontic Treat- ment Time, d) Force System Accuracy, e) Gingival Phenotype. The following PERSPECTIVE view (II, III, IV, V and VI) show the sixth vector and how it can increase the vertical dimension of the 3D chart: f) Periodontal Susceptibility. risk, the value 5 to an average risk and the value 1 to a e) Gingival Phenotype minimum risk. 10: Thin phenotype 5: Medium phenotype a) Periodontal anchorage teeth preservation 1: Thick phenotype 10: all reactive forces are applied to teeth with reduced but healthy periodontium (no miniscrews are used) f) Patient’s susceptibility to periodontitis (Stage and 5: the side effects on the anchorage teeth are limited Grade) by the use of miniscrews (use of biomechanically ori- 4C: Up to Stage 4, Grade C ented skeletal anchorage) OR anchorage teeth are not 3C/4: Up to Stage 3, Grade C involved with the orthodontic appliance OR if anchorage 3A/B: Up to Stage 3 Grade A/B teeth are involved, they have intact periodontium 2A/B: Up to Stage 2 Grade A/B 1: the teeth with healed but reduced residual periodon- 1A: Stage 1 Grade A tium that we do not want to move are not involved by the orthodontic device (Minimally invasive therapies with the The assignment of values of the first five vectors of use of miniscrews) OPRA defines an area whose extension is directly pro- portional to the risk this device can induce a recurrence b) Cleansability of Device of periodontal disease in periodontally susceptible pa- 10: when the appliance is placed on the lingual side tients. It is important to note that the grading includes 5: when the appliance is placed on the labial side (splints patients with different periodontal susceptibility, as indi- on lingual side included) cated in the new periodontal disease classification [1]. 1: when the appliance is a Clear Aligner or Minimally In- Thus, it is empirical to pay attention to the first five OPRA vasive Orthodontics vectors (related to the appliance) in relationship with the sixth OPRA vector (related to the host susceptibility to c) Treatment time periodontal disease). 10: for therapies with an expected duration beyond two years Calculating the patient’s orthodontic-periodontal risk as- 5: for therapies with an expected duration greater than sessment one year and less than two years The OPRA is a three dimensional chart where the first 1: for therapies with an expected duration of less than five vectors lie on a flat polygon and the Periodontal a year Susceptibility (PS), the sixth vector lies in the centre. The first five vectors considered are exclusively related d) Accuracy of force systems to the device and they potentially express nociceptive 10: continuous archwire and aligners stimuli capable of influencing the state of periodontal 5: segmented archwire approaches health. 1: Minimally Invasive Orthodontics (statically determined General results from the first five vectors (Fig 2): systems) - Low-risk: all parameters in the low-risk category (Fig 2c) 19 Annali di Stomatologia 2020; XI (1-4): 16-27 M. Musilli et al. - Moderate-risk: at least one parameter in the moder- odontic appliance without fixed brackets with a statically ate-risk category (Fig 2b) determined system with use of skeletal anchorage in a ­ High-risk: at least one parameter in the high-risk cat- patient with a Stage 4 grade C, presenting all vectors in egory (Fig 2a) the low-risk category. In order to fully express its potential and simplify orth- General considerations following integration of all six odontic treatment decisions, the OPRA must address the vectors: patient’s existing periodontal health status as well as the When PS (the sixth vector) is 1A (Stage 1 grade A), teeth undergoing orthodontic displacement. all the other parameters are on the flat plane (Fig 2a), meaning a high-risk orthodontic approach is possible Results with low periodontal susceptibility. On the other hand, when PS (the sixth vector) is 4C (Stage 4 grade C) the Although this procedural algorithm (OPRA) is based centre is raised (the PS vector) (Fig 2c); meaning that it partly on scientific evidence and partly on the opinion of is advisable to treatment plan using a low risk orthodon- authoritative clinicians, it has allowed us, in the last few tic approach due to the high periodontal susceptibility of years of our clinical activity, to simplify the therapeutic the patients in developing periodontal disease. choices in Orthodontic-Periodontal stage IV cases, mak- ing them more effective while reducing the risk of pro- Figure 2 shows three types of OPRA related to three dif- gression and recurrence of periodontal disease in this ferent types of orthodontic devices and three different particular type of patient. type of periodontal susceptibility. In Figure 2a, a fixed The three types of sample patients shown below have vestibular orthodontic appliance on both arches accord- the sole purpose of making the international scientific ing to the continuous arch technique without the use of consensus understand what options they can take in skeletal anchorage, in a patient with a Stage 1 grade A. carrying out these complex clinical cases. It presents three of the five vectors (Periodontal anchor- That is, the sample shows how the patient’s periodontal age teeth preservation, Accuracy, Gingival phenotype) characteristics at the systemic level, at the tooth level in the high-risk category, one vector (Cleanliness) in and at the site level have influenced orthodontic choices the moderate-risk category and one vector (Treatment in terms of choice of device, direction and duration of time) in the low-risk category. Figure 2b shows a fixed the forces. orthodontic appliance on a single arch according to the segmented technique with the use of skeletal anchor- Explanatory Clinical Case age in a patient with a Stage 2 grade B. It presents four of five vectors (Periodontal anchorage teeth preserva- The three clinical cases presented in Figures 4, 5 and 6 tion, Cleanliness, Accuracy and Gingival phenotype) in show the importance of selecting the appropriate orth- the moderate-risk category and one vector (Treatment odontic appliance with regards to the patient’s periodon- Time) in the low-risk category. Figure 2c shows an orth- tal status. Figure 2. a) Fixed vestibular orthodontic appliance on both arches according to the continuous arch technique, without the use of skeletal anchorage, in a patient with a Stage 1 grade A. b) Fixed orthodontic appliance on a single arch according to the segmented technique, with the use of skeletal anchorage, in a patient with a Stage 2 grade B. Miniscrews help to reduce side effects on anchorage teeth that have a reduced but healed periodontum c) Orthodontic appliance without brackets with a stati- cally determined system with use of skeletal anchorage (Minimally Invasive Orthodontics), in a patient with a Stage 4 grade C. Due to the use of miniscrews, no anchorage teeth with a reduced but healed periodontum are involved. Annali di Stomatologia 2020; XI (1-4): 16-27 20  The Orthodontic-Periodontal Risk Assessment (OPRA) in developing Periodontal Disease Figure 3. Procedural flowchart summarizing all the diagnostic and therapeutic steps of the interdisciplinary approach in peri- odontal patients who must undergo orthodontic therapy. When and how to evaluate orthodontic therapy. OPRA gives us a tool to evaluate various orthodontic ap- notype. The most recent orthodontic techniques have pliances and their effect on periodontal relapse. When instead decreased dental extractions as a procedure for the patient has a Stage 1 Grade A periodontitis or a low relieving crowding by expanding the dental arches both PRA, we can use any orthodontic device - high, medium sagittally and transversely, in the hope of an expansive or low OPRA (Figure 2a). If the patient has a Stage 4 remodeling effect of the buccal alveolar bone. The con- Grade C periodontitis or a high PRA it is preferable to cept is similar to that of the growth induced by functional use an orthodontic device with low OPRA (Figure 2c). It appliances but with a lack of evidence in the literature would be better to choose an appropriate OPRA to peri- [63, 64]. Subsequent studies by Melsen and Coll [65] odontitis Stage and Grade of the patients but in some have verified with pre and post CBCT imaging that this cases this is not possible, especially when there are effect cannot be guaranteed. As a result, it is increas- problems associated with the cleansability of the device ingly believed that tooth movement in the labial direction or accuracy of the force system. In situations where it must be contained within the thickness of the alveolar is not possible to avoid involving teeth with healthy but bone, even if its pre-therapy evaluation cannot be rou- reduced periodontium, a solution could be to increase tinely performed on all patients, for evident ethical rea- the frequency of professional oral hygiene, decreasing sons related to excessive radiation exposure. Ultimately, the magnitude of delivered forces or more frequent orth- it is once again the common sense of the orthodontist to odontic appointments. For example, Case 1 (Figure 4) avoid excessive expansions, perhaps referring clinically and Case 2 (Figure 5) have the same periodontal stage to the gingival phenotype [62 - 67]. with a minor difference in Grade. The solution from the Since Alveolar Bone Housing is not an easily parameter- OPRA point of view is to apply a medium risk appliance izable factor, nor is it valuable for all patients (due to radi- as shown in Case 2 (Figure 5). When it is not possible ation and ethical reasons) [68] as the regulation of dental to select the most appropriate appliance, it is recom- movement within its scope is linked to the sensitivity and mended to increase the frequency of orthodontic ap- prowess of the clinician, the authors have decided not pointments and professional hygiene visits. to include it amongst the elements of the OPRA chart, intending that tooth movement beyond the boundaries of Discussion the basal bone is limited as much as possible. Instead of The Alveolar Bone Housing is an important factor which an Alveolar Bone Housing vector, we intended to use the warrants some discussion. This concept, previously sug- Gingival phenotype as a vector as it is more frequently gested by Tweed, refers to the positioning of teeth above related to the Alveolar Bone Thickness and is more eas- the basal bone [60, 61] and is quite well demonstrated ily detectable by the clinicians [69]. by Wennstrom’s primate studies [62]. It is understood With the new Periodontal Diseases classification [1] we that moving the teeth beyond the thickness of the alveo- can consider a number of parameters that will allow us lar bone is strongly correlated to the onset of gingival to easily attribute the stage of impairment and the risk of recession, especially in conditions of thin gingival phe- periodontitis progression. 21 Annali di Stomatologia 2020; XI (1-4): 16-27 M. Musilli et al. Figure 4. CASE 1: Periodontitis: STAGE III - GRADE B. Relationship of Class I on both sides. Need for interdisciplinary treat- ment to correct the misalignment and extrusion of the 21 that caused functional disorders. The initial Scores (included Full Mouth Plaque Score [FMPS] and Full Mouth Bleeding Score [FMBS]) are too high to proceed with an orthodontic therapy. At the re-evaluation after 3 months from Step 1 and 2, we proceeded with regenerative surgery from 13 to 23 to correct the periodontal defects. We waited about 1 year (until all periodontal scores indicate stable healthy conditions), and then orthodontic therapy began using a Definitive Orthodontic treatment plan: Alignment on both arches and OVB correction. At the end of the move which lasted about 12 months, the patient was given an increase in the volumes of the incisors, using a composite to improve the aesthetics of the smile. OPRA scores: Periodontal anchorage teeth preservation = 10 (all teeth are involved including teeth with reduced but healed peridontium, no miniscrews were used); Cleanliness = 5 (fixed appliances placed on labial surfaces of the teeth on both arches); Treatment Time = 1 (expected duration of less than 1 year); Accuracy = 10 (continuous archwire approach used through bracket free fixed appliance); Gingival phenotype = 5 (medium phenotype). Given the complexity in the management of patients with The most complex Orthodontic-Periodontal steps are periodontal disease [22], it is essential to intervene with characterized by: an extremely cautious interdisciplinary approach using 1- Choosing the most appropriate orthodontic strategy. a procedural algorithm such that all required multi-dis- 2- Timing of orthodontic tooth movements. ciplinary treatment is performed with the correct timing. 3- Maintaining good periodontal control during orthodon- Therefore, we consider it useful to implement the guide- tic therapy. lines of Stage I-II-III [70] with additional steps, presenting these cases a degree of complexity of the major treat- Choosing the appropriate orthodontic strategy ment (Figure 3). To establish an individualized therapeutic plan, it is es- It should be noted that in the PRELIMINARY Phase, sential to know the periodontal status of patients at the any orthodontic and gnathological strategies are envis- initial consultation appointment. From this information aged in order to evaluate the ideal approach to control we can develop a Preliminary Orthodontic Treatment malocclusion, mobility and para-functions in periodontal Plan (Figure 3), evaluating the occlusal relationships and patients. identifying factors that may hinder the normal conduct of It is only in the phase of the DEFINITIVE interdisciplin- therapy. Examples include: ary treatment plan following comparison of the patient’s - the presence or absence of tooth mobility [71] periodontal risk profile with characteristics of the ideal - the presence or absence of parafunctions (wear fac- orthodontic device and stabilisation of all inflammatory ets or muscle pain) parameters can the most appropriate orthodontic treat- We should firstly state our “ideal orthodontic goal”. This ment modality be ascertained. will be dependent on the patient’s periodontal status. In During active orthodontic therapy, important procedures this phase, any necessary stabilization of hypermobile are performed to control the inflammatory values of the elements with the use of a splint, as well as occlusal ad- periodontal patient undergoing orthodontic treatment. justments in patients with increased tooth mobility [72] Monthly reassessment of periodontal vestments, me- is carried out. This may allow for any necessary non- chanical control of risk factors (if necessary) and moti- surgical periodontal therapy to be performed more easily vational reinforcement to correct home plaque control. and reduce the risk of worsening periodontal health [73]. Annali di Stomatologia 2020; XI (1-4): 16-27 22  The Orthodontic-Periodontal Risk Assessment (OPRA) in developing Periodontal Disease Figure 5. CASE 2. Periodontitis: STAGE IV - GRADE C. Class I Relationship on both sides, with increased OVB (due to lower frontal teeth extrusion), increased OVJ with flared upper frontal teeth on the left side and diastema between them. Over-erupted 26 as a result of the missing 36. Need for interdisciplinary treatment to correct the misalignment of both the upper and lower arches. The initial Scores (including FMPS and FMBS) are too high to proceed with an orthodontic therapy. After Step 1 and 2, the residual defects were corrected at Step 3 with regenerative surgery using amelogenins and synthetic biomaterial scaf- folds. We waited only one month (until all periodontal scores indicated stable healthy conditions) to proceed from the surgery as movements began in the lower arch, without initially involving the upper arch affected by the surgery. Only after one year did we proceed with the move to the upper arch (mature healing achieved after surgery). The case finished with an additive ameloplasty in composite to reduce the imperfection of the lack of papilla between the 21 and 22. . OPRA scores: Periodontal anchorage teeth preservation = 5 (use of skeletal anchorage bio-mechanically oriented); Cleanliness = 5 (placement of fixed splints on lingual surfaces of the teeth); Treatment Time = 5 (expected duration greater than one year and less than two years); Accuracy = 5 (segmented arch wire approach); Gingival phenotype = 1 (thick phenotype) Orthodontic treatment should only commence following It is also important to note that there are variations in the the active phase of periodontal therapy and then deter- maturation and healing following different periodontal mining the most appropriate orthodontic strategy using procedures. These range from a few days for Resective the value of the OPRA (Figure 3). Surgery (ORS), to six months for Scaling, Root Planing Example: when a patient needs correction of the ante- and Access Flap (AF), and up to one year for Regenera- rior deepbite, if posterior anchorage will compromise tive Surgery (GTR and EMD) [71, 77-79]. the posterior dentition (due to teeth with poor residual periodontal support), clinicians can opt for the exclusion Maintaining good periodontal control during orthodontic of these sectors by using skeletal anchorage (temporary therapy anchorage devices). The presence of orthodontic appliances induces a If more than one treatment method is available to treat a change in the normal saprophytic bacterial flora towards more pathogenic species [80] and increases the difficulty malocclusion, clinicians should choose the shorter treat- for patients to maintain good oral hygiene [81]. During ment option as well as one that facilitates easier oral orthodontic treatment, there are simultaneously areas hygiene. of bone neo-apposition and bone resorption in the peri- odontium around teeth that are being moved. In the ab- Timing of orthodontic tooth movements sence of plaque and inflammation, bony apposition and The literature remains unclear and somewhat contro- resorption is defined as a sterile pseudo-inflammatory versial on the exact timing to start tooth movement after process. The mediators RANK, RANKL, OPG, IL-1 / IL- periodontal therapy [74]. However, there is clear clinical 6, MMPs that regulate these movements also intervene evidence showing tooth movement enhancing the rate during the inflammatory processes of bone lysis as a re- of inflamed connective tissue attachment destruction for sult of the inflammatory response [35]. teeth with infra bony pockets [75, 76] and thus orthodon- There is a need to formulate an individualized profes- tic treatment should only be performed on periodontally- sional plaque control program for patients undergoing stable patients. orthodontic treatment to avoid the recurrence of peri- 23 Annali di Stomatologia 2020; XI (1-4): 16-27 M. Musilli et al. Figure 6. CASE 3. Periodontitis: STAGE IV - GRADE C. Class I relationship on both sides misaligned upper frontal teeth, 11 over-erupted. Need for interdisciplinary treatment to correct the extrusion of 11 that caused functional disorders. The initial Scores (included FMPS and FMBS) are too high to proceed with an orthodontic therapy. The 11 was necrotic with considerable mobility. We proceeded initially with splinting of the frontal group at the same time as the endodontic treatment of the 11. In this case, steps 1 and 2 were sufficient to eliminate periodontal defects. Therefore, only 4 months after the start of therapy (all periodontal scores indicated stable healthy conditions), the orthodontic shift was carried out using a bracket free segmented approach with a Minimally Invasive Orthodontic appliance. A cantilever (statically determined system) on implant as anchorage on the upper right side and a 10 gram single force on tooth 11 with a stainless steel rigid splint on the labial surface of the front teeth, preventing proclination on 11 during the intrusive movement. OPRA scores: Periodontal anchorage teeth preservation = 1 (orthodontic anchorage on implant); Cleanliness = 1 (Minimally Invasive Orthodontics); Treatment Time = 1 (expected duration of less than a year); Accuracy = 1 (statically determined system); Gingival phenotype = 1 (thick phenotype). odontal disease (Figure 3). Our experience leads us to Conclusions suggest regular 30-minute hygiene appointments once a month, especially for patients with Grade B and C Periodontal procedures are based on robust scientific periodontitis. The following procedures should be car- evidence whereas expert opinions are often relied on ried out: in the orthodontic field. The intrinsic limits of the OPRA - Periodontal re-examination are currently linked to the arbitrariness of the selected - Supra and subgingival instrumentation factors as they are based only on years of clinical expe- - Reinforcement of oral hygiene motivation rience. We hope to be able to share its long-term effec- During these monthly evaluations, if periodontal param- tiveness in the future. eters such as Full Mouth Bleeding Score (FMBS) are Author Contributions: Conceptualization, methodology, greater than ten percent and probing depths of orthodon- M.M and G.P..; validation, data curation, G.P., M.M.; tically-involved teeth show increased values, there is a writing—original draft preparation, M.M. G. P.; writing— risk of periodontitis progression [82]. We will implement a review and editing, M.M, G.P., G.S., S.L.; supervision, procedure defined by us as “STOP and GO” whereby the G.S., M.M, G.P. All authors have read and agreed to the orthodontic treatment is stopped, motivational oral hy- published version of the manuscript. giene is reinforced, and professional re-instrumentation is Funding: This research received no external funding. performed by the dental hygienist. Orthodontic treatment only restarts when the periodontal parameters return to Institutional Review Board Statement: Not applicable. ideal conditions. This will make it possible to establish Informed Consent Statement: Not Applicable an individualized interdisciplinary procedure with extreme Data Availability Statement: The data sets used and/or precision, reducing the risk of recurrence or unexpected analyzed during the current study available from the cor- clinical events. Following treatment, patients should be responding author on reasonable request. placed on individualized maintenance programmes that include three month recalls in patients with high PRA and Conflicts of Interest: The authors declare no conflict of six month recalls in patients with low PRA [83]. interest. Annali di Stomatologia 2020; XI (1-4): 16-27 24  The Orthodontic-Periodontal Risk Assessment (OPRA) in developing Periodontal Disease References 18. Verna, C.; Bassarelli, T. 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Van Gastel, J.; Quirynen, M.; Teugels, W.; Coucke., W.; lean, A.; Lang, N. P.; Salvi, G.E. Time between recall visits Carels, C. Longitudinal changes in microbiology and clinical and residual probing depths predict long-term stability in peridontal variables after placement of fixed orthodontic ap- patients enrolled in supportive periodontal therapy. J Clin pliance. J Periodontol 2008, 79, 2078-2086. Periodontol 2019, 46, 218–230. 27 Annali di Stomatologia 2020; XI (1-4): 16-27 

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Original article Ultrashort implant in the upper jaw, an alternative therapeutic procedure after the failure of the sinus lift: a case report Gianluca Botticelli 1 a female patient presenting with atrophic posterior Ennio Calabria2* maxilla which was rehabilitated with an implant of Marco Severino1 3 millimeters in length after the failure of a previous Giordano Foffo3 surgical maxillary sinus lift through lateral window Pierpaolo Petrelli4 approach and with a total follow-up of 36 months. Massimo Galli5 Calabria E6 Key words: ultrashort implants, sinus lift, bone re- Giudice A7 generation failure Gatto R1 Giovanni Falisi1 Introduction Implant-supported fixed prostheses represent a highly 1 Department of Life Health and Environmental Scienc- reliable therapeutic option and one of the most predict- es, University of L’Aquila,67100, l’Aquila, Italy able dental procedures for treating partial posterior jaw 2 Department of Neuroscience, Reproductive Sciences edentulisms1-3. and Dentistry, University of Naples Federico II, Na- The rehabilitation of posterior jaws may be clinically ples, Italy challenging, especially when the residual bone volume 3 Private practicer, L’Aquila, Italy does not allow the proper insertion of implants with a 4 Department of Innovative Technologies in Medicine standard length of at least ten mm4. & Dentistry, University of Chieti—Pescara ‘Gabriele In these situations, the placement of implants may pres- d’Annunzio’, 66100 Chieti, Italy ent an anatomical issue due to the potential damage to 5 Department of Oral and Maxillofacial Sciences, Uni- noble anatomical structures such as the inferior alveolar versity of Rome La Sapienza, Rome, Italy nerve or the maxillary sinus5. 6 Private practicer, Lamezia Terme, Catanzaro, Italy In addition, the implant rehabilitation of the posterior re- 7 Department of Health Sciences, School of Dentistry, gions of the upper maxilla may be even more compli- University of Catanzaro “Magna Grecia”,Catanzaro cated by the volume reduction of the available bone due Italy. to the loss of dental elements and the maxillary sinus pneumatization 6-10. *Corresponding author: When the volume of the bone is inadequate for the Elena Calabria, DDS, PhD placement of standard implants, bone augmentation pro- [email protected] cedures are generally performed to provide the correct bone volume quantity11. Abstract According to Misch, to perform an implant rehabilitation of the posterior maxilla in case of a width of bone < 5mm The rehabilitation of the posterior sites of the maxilla - category SA4, it is recommended to perform a maxillary with dental implants is a therapeutic procedure of- sinus augmentation procedure through a lateral window ten influenced by the atrophy of the maxillary bone, approach with a delayed positioning of the implant fix- caused by either the loss of dental elements or by ture12-13. Complications of this procedure are perforation the maxillary sinus pneumatization. of the Schneiderian membrane (25.7%), rhino-sinusitis Bone loss in the upper maxillae which prevents the (4.2%-8.4%), exposure of the bone graft (3.1%), and placement of implant fixture, may be fixed with sur- loss of the graft (1.6%)14-19. gical bone regenerations techniques, such as the Another approach in the case of maxillary atrophy is us- sinus lift, or with the placement of zygomatic and/or ing zygomatic implants. However, studies have demon- pterygoid implants. Although the proved effective- strated a higher number of complications with zygomatic ness of these invasive therapeutic approaches, the surgery compared to traditional sinus lift and implant po- biological and economic costs may be high. Also, sitioning procedures 20-21. the failure of these procedure, may further prevent In recent years, the use of short (5-10 mm) and ultrashort the possibility of a second implant rehabilitation. In implants (< 5 mm in length) has been suggested as an this scenario, the use of the short and ultra-short alternative therapy to such surgical options for prosthetic implants may be considered a valid minimally in- restoration in resorbed jawbones 4,5,22. Patients treated vasive alternative for the rehabilitation of the atro- with short and ultrashort implants may benefit from a phic edentulous crests. Here, we describe a case of rehabilitation based on fewer surgical procedures, with Annali di Stomatologia 2020; XI (1-4): 28-32 28  Ultrashort implant in the upper jaw, an alternative therapeutic procedure after the failure of the sinus lift: a case report less invasiveness and minor postoperative discomfort or per left molar extracted (tooth 2.6- figure 1) because of a complication23.   vertical fracture following the endodontic treatment. We report the case of a female patient presenting with The patient reported that about four months following the severe maxillary atrophy, which was rehabilitated by in- tooth extraction, she underwent a maxillary sinus aug- serting an ultra-short implant of 3 millimeters associated mentation through the lateral window approach, with the with the technique of a minimal invasive crestal sinus lift insertion of biomaterial grafting. However, she further re- after the failure of a previous maxillary sinus lift. 28,29,30 ported having developed acute sinusitis of the left maxil- lary sinus after two weeks as complications of the surgi- cal procedure, requiring a second surgery to remove the Case report grafting material. After 18 months, the clinical situation A female patient, 47 years old, a smoker with an un- was an atrophy degree of < 5mm - category SA4 (Figure remarkable medical history, was referred to the dental 2), so we first proposed the second procedure of sinus clinic of the University of L’Aquila (Italy) to rehabilitate floor elevation. the partial posterior edentulism in the upper left maxilla. However, the patient was looking for an alternative, less She reported that two years before, she had the first up- invasive solution. Figure 1. OPG of the patient referring to the period when the first upper left molar was still present. Figure 2. OPG of the patient which highlights the absence of the dental element 2.6 and the severe maxillary atrophy. 29 Annali di Stomatologia 2020; XI (1-4): 28-32 G. Botticelli et al. Since the residual maxillary bone height measured 3 was prepared (with a reduced depth to that one needed), mm, we suggested positioning an ultra-short implant a pellet of equine collagen (Congress - Smith&Nephew) in association with a minimal invasive crestal sinus lift. was placed inside the prepared surgical site. Afterward, Then, using the same implant as the residual bone com- the implant was placed in the preparation site to deter- paction tool along with its insertion, without performing mine a greenstick fracture of the maxillary sinus floor. further bone increase. The implant surgical site was prepared with a diameter An ultra-short implant of 3 mm and 5.1 mm in diameter equal to that of the ultrashort implant; thus, the implant was placed. The implant was made of Titanium of grade placement was performed by giving a simple and con- 4, with a sandblasted and etched surface, and character- trolled push to the fixture. The surgical site was sutured ized by a conometric connection with 4° degree, with a with VICRYL TM - Ethicon (caliber: 4/0, color: purple, complete tubular section, hollow inside (IM Maco, Maco shape: cylindrical, needle length: 17.4 mm, gauge: 21). International). This fixture is characterized by a flat, self- The sutures were removed seven days later. The patient taping apical portion with a plateau. The coronal platform was provided with postoperative instructions, including is inclined with a trapezoidal section to increase the bone antibiotic therapy as indicated, the use of non-steroidal contact surface. The implant-abutment presents a trans- anti-inflammatory drugs as needed, and the intake of mucosal length of 3 mm. a liquid diet for three days. In addition, the patient was Antibiotic prophylaxis was scheduled based upon admin- recommended to use chlorhexidine spray 0.2% for four istering two gr/day of amoxicillin starting 1 hour before days, cleansing with 10% hydrogen peroxide using a the surgical intervention and continuing for the next three sterile hydrophilic gauze to be passed over the sutures. days every 12 hours24. Before the surgery, oral disinfec- After about four months after the first operation, the sec- tion was performed with chlorhexidine (0.2% solution for ond surgical procedure was performed to expose the one minute). Local anesthesia (OPTOCaIN®, 20 mg/m head of the implant and remove the healing screw. A Ti- with adrenalin 1:80,000. Molteni Dental— Italy) was ad- tanium abutment of grade 5 was placed, and a provision- ministered on both vestibular and palatal mucosa. First, a al prosthesis was made in acrylic resin and then applied. total-thickness mucoperiosteal flap was raised to reveal After two months, the final crown in layered zirconium the underlying alveolar bone. The protocol preparation was cemented (Figure 3a). phase of the implant site consisted of a first perforation The patient attended a clinical follow-up twice a year of the bone using a lanceolate burr, maintaining intact as part of her routine oral hygiene program. The radio- the cortex of the sinus floor, and proceeding sequentially graphic follow-up at 12 and 36 months from the mastica- by using the preparation burrs to obtain a slightly less tory load highlights a good osteointegration of the fixture deep implant site. Once the planned diameter of the site (Figures 3b and 3c).   Figure 3. A. Orthopanto- mogram showing the defini- tive crown visible in the sec- ond quadrant B. periapical x-ray one year after implant loading. C. periapical x-ray examination three year af- ter implant loading. Annali di Stomatologia 2020; XI (1-4): 28-32 30  Ultrashort implant in the upper jaw, an alternative therapeutic procedure after the failure of the sinus lift: a case report Discussion References Even with modern technology for guided bone regen- 1. Tomasi C, Wennström JL, Berglundh T. Longevity of teeth eration, the insertion of implants within a resorbed bone and implants: a systematic review. J Oral Rehabil 2008; 35 may not be predictable4. (Suppl 1):23–32. The surgical procedures aiming at obtaining the bone 2. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. A systematic review of the 5-year survival and augmentation, or the use of a zygomatic implant, are complication rates of implant-supported single crowns. Clin generally invasive, expensive, often requiring a higher Oral Implants Res. 2008;19(2):119-130. number of surgical procedures, associated with post- 3. Misch CE, Perel ML, Wang HL, et al. Implant success, sur- operation complications, and require more extended pe- vival, and failure: The International Congress of Oral Im- riods (up to 1 year) for the prosthetic load4. plantologists (ICOI) Pisa Consensus Conference. Implant Dent 2008; 17(1):5–15. The predictability of short and ultra-short implants in 4. Bernardi S, Gatto R, Severino M, et al. Short Versus Longer implant-supported prosthetic rehabilitations has been Implants in Mandibular Alveolar Ridge Augmented Using debated in the last years. Also, the definition of short im- Osteogenic Distraction: One-Year Follow-up of a Random- plant presents disagreements; some researchers define ized Split-Mouth Trial. J Oral Implantol. 2018; 44(3):184- them as fixtures ranging from 7 to 10 mm, whereas oth- 191. ers consider them to be “short” implants with a length < 8 5. Falisi, G., Bernardi, S., Rastelli, C., et al. “All on short” prosthetic-implant supported rehabilitations. ORAL and Im- < 7 or of 6 mm. Finally, researchers agree on considering plantology, 2007; 10 (4): 477-487 ultra-short implants length of 4 millimeters or less23. 6. Atwood DA. Reduction of residual ridges: a major oral dis- Das Neves et al. reported that short implants are advis- ease entity. J Prosthet Dent. 1971; 26 (3):266-279. able as an alternative approach to advanced surgical 7. Atwood DA, Coy WA. Clinical, cephalometric and densito- procedures for bone augmentation due to lower mor- metric study of reduction of residual ridges. J Prosthet Dent. bidity, reduced operation time, and lower costs for the 1971; 26(3) :280-295. 8. Tallgren A. The continuing reduction of the residual alveolar patient25. ridges in complete denture wearers. A mixed longitudinal Another study conducted in 2014 comparing the long- study covering 25 years. J Prosthet Dent. 1972; 27 (2):120- term outcomes between short and long implants (with 132. sinus lift) reports no evident differences in the survival 9. Berg H, Carlsson GE, Helkimo M. Changes in shape of of the implants and prosthetic failures26. A recent retro- posterior parts of upper jaws after extraction of teeth and prosthetic treatment. J Prosthet Dent. 1975; 34(3) :262-268. spective study evaluating the implant success rate of 50 10. Chanavaz M. Maxillary sinus: Anatomy, physiology, surgery, ultra-short dental implants after a follow-up of 8-10 years and bone grafting related to implantology: Eleven years of reported a success rate of 94% and that the ultra-short surgical experience, J Oral Implantol 1990; 16(3):199–209. implants proved to be a reliable solution for prosthetic res- 11. Scarano A, Bernardi S, Rastelli C, Mortellaro C, Vittorini toration in patients with severe alveolar bone atrophy 23. P, Falisi, G. Soft tissue augmentation by means of silicon Another study reported that in patients who underwent expanders prior to bone volume increase: A case series. J Biol Regul Homeost Agents 2019;33(6 Suppl. 2):77-84. the rehabilitation of the complete arch using ultrashort DENTAL SUPPLEMENT implants, the critical rehabilitation issues occur in the first 12. Misch CE. Treatment plans for implant dentistry. Dent To- week and after four months following implant placement day. 1993; 12(12): 56-61. together with the prosthetic load 22. 13. Misch CE. Maxillary posterior treatment plans for implant The presented a case showed a patient successfully dentistry. Implantodontie. 1995; 19(4):7-24. 14. Adell R, Eriksson B, Lekholm U. A long-term follow-up treated with an ultra-short implant of 3 millimeters after study of osseointegrated implants in the treatment of totally the failure and complication of a sinus lift, with a total edentulous jaws. Int J Oral Maxillofac Implants 1990 5(4): follow-up of 36 months, confirming the reliability of the 347–359. ultra-short implant as a valid and effective therapeutic 15. Tatum H. Maxillary and sinus implant reconstruction, Dent option for severe atrophy bone. If confirmed by in vivo Clin North Am 1986; 30(2) :207–229. studies, this option may be chosen in case of the gen- 16. Hall HD. Bone graft of the maxillary sinus floor for Brane- mark implants, Oral Maxillofac Surg Clin North Am 1991; eral poor health of the patients or contraindications to the 3(4):869–875. major surgical procedures, and those patients willing to a 17. Raghoebar GM, Onclin P, Boven GC, Vissink A, Meijer HJA. minimally invasive approach27. Long-term effectiveness of maxillary sinus floor augmenta- Using an ultra-short implant of 3 millimeters was a practi- tion: A systematic review and meta-analysis. J Clin Peri- cal approach in rehabilitating a posterior edentulism in odontol. 2019;46 (Suppl 21):307-318. severe maxillary bone atrophy after the failure of a sinus 18. Moreno Vazquez JC, Gonzalez de Rivera AS, Gil HS, Mifsut RS. Complication rate in 200 consecutive sinus lift proce- lift. However, further research involving a large sample of dures: guidelines for prevention and treatment. J Oral Maxil- patients with a longer follow-up must confirm the results. lofac Surg. 2014;72(5):892-901. 19. Kayabasoglu G, Nacar A, Altundag A, Cayonu M,    Muhtarogullari M, Cingi C. A retrospective analysis of the Acknowledgements relationship between rhinosinusitis and sinus lift dental im- plantation. Head Face Med. 2014;10:53. We wish to thank Doctor Ennio Calabria for his collab- 20. Balaji SM, Balaji P. Comparative evaluation of direct sinus oration in the execution of the surgical procedure and lift with bone graft and zygoma implant for atrophic maxilla. Indian J Dent Res. 2020; 31(3):389-395. prosthesis rehabilitation of the case presented. 21. Pieri F, Caselli E, Forlivesi C, Corinaldesi G. Rehabilita- tion of the Atrophic Posterior Maxilla Using Splinted Short Conflict of Interest Implants or Sinus Augmentation with Standard-Length Im- plants: A Retrospective Cohort Study. Int J Oral Maxillofac None. Implants. 2016;31(5):1179-88. 31 Annali di Stomatologia 2020; XI (1-4): 28-32 G. Botticelli et al. 22. Falisi G, Di Paolo C, Rastelli C, et al. Ultrashort Implants, Al- 26. Perelli M, Abundo R, Corrente G, Saccone C. Short (5 and 7 ternative Prosthetic Rehabilitation in Mandibular Atrophies mm long) porous implants in the posterior atrophic maxilla: in Fragile Subjects: A Retrospective Study. Healthcare (Ba- a 5-year report of a prospective single-cohort study. Eur J sel). 2021;9(2):175. Oral Implantol. 2012;5(3):265-272. 23. Malchiodi L, Ricciardi G, Salandini A, Caricasulo R, Cuc- 27. Calabria Ennio. Short Implant di Ultima Generazione, Nu- chi A, Ghensi P. Influence of crown-implant ratio on im- ove Prospettive. Edizione Martina 2021 plant success rate of ultra-short dental implants: results 28. Intercepting of Class III Malocclusion with a Novel Mecha- of a 8- to 10-year retrospective study. Clin Oral Investig. nism Built on the Orthopaedic Appliance: A Case Report- 2020;24(9):3213-3222. PMID: 35740723 24. Botticelli G, Severino M, Ferrazzano GF, Vittorini Velasquez 29. Impact of molar teeth distalization with clear aligners on oc- P, Franceschini C, Di Paolo C, Gatto R, Falisi G. Excision of clusal vertical dimension: a retrospective study. Caruso S, Lower Lip Mucocele Using Injection of Hydrocolloid Dental Nota A, Ehsani S, Maddalone E, Ojima K, Tecco S.BMC Impression Material in a Pediatric Patient: A Case Report. Oral Health. 2019 Aug 13;19(1):182. Applied Sciences. 2021; 11(13):5819. 30. Temporomandibular Joint Anatomy Assessed by CBCT Im- 25. das Neves FD, Fones D, Bernardes SR, do Prado CJ, Neto ages. Caruso S, Storti E, Nota A, Ehsani S, Gatto R.Biomed AJ. Short implants--an analysis of longitudinal studies. Int J Res Int. 2017;2017:2916953. doi: 10.1155/2017/2916953. Oral Maxillofac Implants. 2006; 21(1):86-93. Epub 2017 Feb 2.PMID: 28261607 Annali di Stomatologia 2020; XI (1-4): 28-32 32 

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Editorial Why Negotiation is the most critical business skill for dentists. Dentistry in Italy have been through many changes during the last 20 year. Dental tourism and dental clinics and social media have totally inverted the patients’ focus on dental care. Moreover, toaday dentistry is not only a matter of clinical approach, but also manage- ment, intended as financial, human resources and patient’s of course, which is the den- tists’ main asset. However, this is the fact: dentists are not trained on management during the dental school. Nowadays, to achieve coherence between results and busy agenda, dentists need to put clinical training right aside management one, empowering 2 of the master soft skills, able to generate a meaningful difference both for the dentist practice as well as the patient experience. We are referring to Communication and Negotiating. Between them, negotiation represents a crucial skill to be trained and acted throughout the dental office, since it is meant to bring a brand new approach to dental treatment presentation and patient experience. Negotiation allows dentists to differentiate from their competing collegues in the field. Some dentists are successful thanks to their personal talent in treating and giving care to their patient, simply because they have naturally developed such communicating and negotiating skills. For those who do not have such talent, there is a way: the so called negotiation protocol. These are the main features of the negotiation protocol: 1. It is indipendent from any personal talent, since it implies a scientific approach to negotiation, due the specific steps to be held; 2. It allows the dentist have a more specific patient profile; 3. It allows the dentist communicating the treatment to the patient with a deepest clearness and fullfilling comprehen- sion. 4. It allows the dentist access to a detailed financial planning of the cures towards the patient’s commitment; 5. The protocoll make it possible to hire new personnel or change it if necessary, guaranteeing continuity with the pro- cess itself, thank to the scientific approach. It is remarkable how negotiation itself is a process, asking to involve the whole human resources working on and for the patient in the office: dentist, lab operators, assistants and of course the dental office secretary. Negotiating protocol enphasizes the role of the dentist and his team, acting to give the patient the best medical result and human experience ever, and yet allowing the dentist as manager to get hold on those precious data, able to develop the dental office performances. Annibale Ferrante Annali di Stomatologia 2019; X (1-4): 1 1 

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Original article Maxillary sinus infection related to Aspergillus: case report and recent updates Pierpaolo Petrelli1 Introduction Fabiola Rinaldi1* Sofia Rastelli2 Aspergillus sinusitis, firstly reported by Katzenstein et Gianluca Botticelli2 al. in 1983, is an infectious disease that, despite its dif- fusion, still presents a challenge in diagnosis, manage- 1 Department of Innovative Technologies in Medicine ment, classification, and characterization (1). & Dentistry, University of Chieti—Pescara ‘Gabriele The first organs affected by aspergillosis in the case of d’Annunzio’, 66100 Chieti, Italy the Head and Neck region are the nasal cavity and para- 2 Department of Life, Health and Environmental nasal sinuses. Sciences, University of L’Aquila, 67100 L’Aquila, Italy Aspergillus species are more than 185, but Aspergillus Fumigatus, Aspergillus Flavus, and Aspergillus Niger are responsible for over 95 % of all infections (2). Symptoms *Corresponding author: include anterior and posterior nasal discharge, epistax- Fabiola Rinaldi is, nasal polyps, nasal obstruction, headache, proptosis, DDS, Oral Surgery Post-Graduate Student, Depart- anosmia, and snoring (3). Aspergillus genus includes ment of Innovative Technologies in Medicine & Dentistry, pathogens without keratolytic enzymes and, therefore, University of Chieti—Pescara ‘Gabriele d’Annunzio’, cannot actively penetrate undamaged and intact mucus 66100 Chieti, Italy, [email protected], membrane or skin (4). 08713554220. Diagnosis is based on infiltrative or non-infiltrative fungal hyphae, sinonasal polyposis, and histopathology with a Abstract positive fungal culture of the tissue sampled from surgi- cal intervention (5). An early diagnosis, appropriate pre- Aspergillus related sinusitis is a fungal infectious and post-operative pharmacological steroids and antifun- disease that, despite its diffusion, is still not well ac- gal molecules, an accurate surgical debridement of the knowledged to dental operators. Due to the anatomo- polyps, and adequate drainage represent the successful physiology characteristics of the maxillary sinus, the key points of the aspergillosis sinusitis treatment (6). diagnosis of non-invasive aspergillus sinusitis relies The anatomical position of the paranasal sinus can on clinical and imaging signs, and on the medical his- eventually lead to the spread of the infection into the cra- tory of the patient. Here, we present a clinical case de- nial cavity, representing a life-threatening complication scribing a fungus ball, which diagnosis resulted par- of the aspergillus sinusitis. In particular, the infection can ticularly difficult, due to the presence of concomitant spread to orbit due to the bone erosion of the fungal pol- dental interventions in the same maxillary area. A 50 yps. The infection can run into the middle cranial fossa years-old woman, without any medical issue, came to from the superior orbital fissure and optic canal (7). the private dental practice complaining about nasal Classification of paranasal sinus Aspergillosis includes discharge from the left side. Dental arch were sub- invasive (acute fulminant, chronic invasive, granuloma- jected to several treatments; to better understand the tous invasive) and non-invasive (fungus ball and allergic working plan, an orthopantomogram was performed, fungal rhinosinusitis) forms, which differ in pathophysiol- revealing a radiopacity in the left sinus. The cone- ogy and clinical signs (8). beam computed tomography showed the obstruction Due to the anatomical structure of the maxillary sinus of the maxillary sinus, and clarified the presence of and the physiology of Schneider’s Membrane, diagnosis mycetoma calculus. The patient underwent surgical of non-invasive aspergillus sinusitis relies on clinical and Caldwell-Luc intervention and mycetoma sampling; imaging signs and the medical history of the patient. the following in-vitro investigations revealed the Here we present a case of fungus ball, which diagnosis presence of Aspergillus Niger. The one-year follow- resulted particularly tricky due to the presence of con- up showed no recurrence of the infection. The re- comitant dental interventions in the maxillary area. ported case is aimed to underline how mycetoma is a benign condition, still unknown to dentists despite its Case report large diffusion. Moreover, the authors want to high- 50 years - old woman, resulted with no pathological con- light that an endodontic treatment can offer a favour- dition in her medical history, came to the private dental able environment to mycetoma formation. practice complaining about nasal discharge from the left side. Beyond the nasal discharges, no other symptoms Keywords: mycetoma, aspergillosis, sinuses, fungal were referred. sinusitis. The left side maxillary teeth presented several treat- Annali di Stomatologia 2019; X (1-4): 2-5 2  Maxillary Sinus infection related to Aspergillus: case report and recent updates ments, so an orthopantomogram (OPG) was taken to Successively, the cone-beam computed tomography overview the situation. (CBCT) showed the thickening and obstruction of the The OPG revealed a radiopacity in the left sinus, well maxillary sinus and clarified the presence of mycetoma demarked and defined but unusual and inconsistent with calculus (Figure 2). Therefore, the patient was referred the dental situation, so any endodontic material and den- to the local maxilla-facial department for surgical treat- tal fixture were excluded (Figure 1). ment. Surgical treatment included a Caldwell-Luc inter- Figure 1. Initial OPG. On the left side, it is possible to appreciate the sinus opacity as well as the presence of a material strongly hyperdense, indicated by the arrow. The teeth of the correspondent arches present fixed prosthesis and the presence of several endodontic treatments. Figure 2. CBCT reconstruction. Cross sections confirmed the complete sinus obstruction and the presence of an hyperdense material. 3 Annali di Stomatologia 2019; X (1-4): 2-5 P. Petrelli et al. Figure 3. One Year follow-up. Teeth have been extracted due to inadequacy to support the crowns and substituted with fixed prosthetis-implant supported. There was no recurrence of the lesion. vention with the sinus revision and mycetoma sampling tis. Innovation in medical technology, including advance- for culture, which revealed the presence of Aspergillus ments in radiological imaging and diagnostic endoscopy, niger. allowed to define the disease classification, diagnosis, The OPG performed at a one-year follow-up showed no and management (8). recurrence of the infection (Figure 3). The mycetoma or fungal ball consists of a slow but con- Successively the patient revealed she worked in the tinuous deposition of purulent non-invasive fungal calculi countryside, and the source of infection was probably in the paranasal cavities (14). It can present more often the hay. unilateral, which is the main difference with allergic fun- gal sinus, even though cases of more cavities have been Discussion reported (15). Mycetoma generally occurs in adults, with a preference for the female gender. The anatomy of the maxillary sinus, which is a cavity, Mycetoma’s localization usually is more frequent in the and the histology of the Schneider membrane, make maxillary sinus and more rarely (5%) in the sphenoid si- clinical signs of infectious, iatrogenic, or endogenous nus (16). Patients suffering from mycetoma do not pres- disease quite similar and challenging for the specialists ent a compromised immune system nor significant alter- of the maxillofacial area (dentists, ENTs, maxillofacial ations in the levels of immunoglobulin or IgG subclasses surgeons). (17). However, the slow development of the disease, Indeed, cysts can expand until they occupy the entire the quality of the symptoms, and the characteristics of volume of the sinus (9); an iatrogenic disease caused by not-invasiveness, make the diagnosis of mycetoma late. the presence of materials irritating the sinus mucosa pre- Berry et al. reported 29% of patients receive the diagno- sents with nasal discharge and unilateral sinusitis (10). sis within a year from the symptom onset (18). Indeed, In contrast, infectious diseases cause the thickening of the quality of the symptoms, which include headache, the membrane, nasal discharge, and usually present as cough, and facial pain, are similar to chronic bacterial bilateral (11). rhinosinusitis; therefore, instrumental diagnosis is funda- Recently, fungal rhinosinusitis incidence increased mental for a differential diagnosis (19). due to the spread of different pathogens, the aging of Risks factors associated with the mycetoma are rep- the population, and the presence of comorbidities and resented by systemic diseases which can playe a key chronic diseases, such as diabetes and immunological role in the onset of the fungal ball, such as anatomi- diseases requiring long-term steroid therapy immuno- cal variants (deviation of the nasal septum), Wegener’s suppressive treatments (12). granulomatosis, asthma, lymphoproliferative diseases, In a study by Loidolt et al. (13), approximately the fre- and diabetes (18). In addition, the previous root canal quency of fungal rhinosinusitis was 10% of all patients treatments are the dental conditions that can predispose who underwent surgical treatment due to chronic sinusi- to mycetoma (4). Annali di Stomatologia 2019; X (1-4): 2-5 4  Maxillary Sinus infection related to Aspergillus: case report and recent updates The instrumental diagnostic tool of the first level for 5. Almomen A, Albaharna H, AlGhuneem AA, AlZahir BZ. mycetoma diagnosis is the orthopantomogram (OPG), The Endonasal Endoscopic Approach to Different Si- nonasal Fungal Balls. Int J Otolaryngol. 2022;2022:1-6. which allows appreciating the opacification of the max- doi:10.1155/2022/6721896 illary sinus as well as focal radiopacity (50% of cases) 6. Singh N, Bhalodiya NH. Allergic fungal sinusitis (AFS)--ear- pathognomonic signs of mycetoma (20). lier diagnosis and management. J Laryngol Otol. Computed tomography (CT) imaging represents the 2005;119(11):875-881. doi:10.1258/002221505774783412 second level of radiological exam. Its accuracy allows to 7. Mauriello JAJ, Yepez N, Mostafavi R, et al. Invasive rhinosi- gather information about the nature and the dimensions no-orbital aspergillosis with precipitous visual loss. Can J Ophthalmol. 1995;30(3):124-130. of the lesion and plan the surgical approach. CT signs of 8. Grosjean P, Weber R. Fungus balls of the paranasal mycetoma are heterogeneous material in the involved si- sinuses: A review. Eur Arch Oto-Rhino-Laryngology. nus, sinus obliteration, and the presence of spot strongly 2007;264(5):461-470. doi:10.1007/s00405-007-0281-5 radiopacity (21). The sensitivity and specificity of CT in 9. Bernardi S, Scarsella S, Di Fabio D, et al. Giant follicu- the presence of these findings were calculated respec- lar cysts extended in pterygo-maxillary fossa, antro-na- tively in 62% and 99% (22). so-ethmoidal and orbital space associated to exophtalmos and diplopia in young patients. Oral Maxillofac Surg Cases. In the reported case, the patient did present the symp- 2018. doi:10.1016/j.omsc.2018.02.002 toms of chronic rhinosinusitis, with purulent nasal dis- 10. Manchisi M, Bianchi I, Bernardi S, Varvara G, Pinchi V. Max- charge, and previous endodontic treatments in the illary sinusitis caused by retained dental impression materi- maxillary sinus involved. Therefore, the instrumental di- al: An unusual case report and literature review. Niger J Clin agnostic tools, OPG and CBCT, allowed performing the Pract. 2022;25(4):379-385. doi:10.4103/njcp.njcp_1662_21 diagnosis of mycetoma, confirmed by the subsequent 11. van Duijn NP, Brouwer HJ, Lamberts H. Use of symp- toms and signs to diagnose maxillary sinusitis in gen- histological exam. eral practice: comparison with ultrasonography. BMJ. The treatment of mycetoma is surgical, consisting of a 1992;305(6855):684-687. doi:10.1136/bmj.305.6855.684 Caldwell-Luc intervention, as in our case, using endo- 12. Fanucci E, Nezzo M, Neroni L, Montesani L, Ottria L, Gar- scopic techniques5. The outcome depends on continu- gari M. Diagnosis and treatment of paranasal sinus fungus ous follow-up and patient compliance. In our case, being ball of odontogenic origin: Case report. ORAL Implantol. the infection’s source, the patient was prescribed to stay 2014;6(3):63-66. doi:10.11138/orl/2013.6.3.063 13. Loidolt D, Mangge H, Wilders-Truschnig M, Beaufort F, away from the countryside. Schauenstein K. In vivo and in vitro suppression of lympho- Garofalo et al. in 2016 reported how the pure endoscopic cyte function in Aspergillus sinusitis. Arch Otorhinolaryngol. technique might be hard and difficult to perform given the 1989;246(5):321-323. doi:10.1007/BF00463585 usual position of the fungal ball, in the anterior recess, 14. Ferguson BJ. Fungus balls of the paranasal sinuses. Oto- proposing the gauze technique as safer and easier sur- laryngol Clin North Am. 2000;33(2):389-398. doi:10.1016/ gical treatment for the mycetoma (23). s0030-6665(00)80013-4 15. Mitsimponas KT, Walsh S, Collyer J. Bilateral maxillary si- However, in the study, it is reported how the difficult posi- nus fungus ball: report of a case. Br J Oral Maxillofac Surg. tion of the lesion, and therefore a difficult removal, might 2009;47(3):242. doi:10.1016/j.bjoms.2008.08.023 lead to the relapse (23). 16. Sethi DS. Isolated sphenoid lesions: diagnosis and man- The reported case offered an occasion to underline how agement. Otolaryngol neck Surg Off J Am Acad Otolaryn- mycetoma is a benign condition still unknown to dentists gol Neck Surg. 1999;120(5):730-736. doi:10.1053/hn.1999. despite its diffusion and how accurate should be an en- v120.a89436 17. Jiang R-S, Hsu C-Y. Serum immunoglobulins and IgG sub- dodontic treatment which can offer an environment fa- class levels in sinus mycetoma. Otolaryngol neck Surg Off vorable to mycetoma formation. J Am Acad Otolaryngol Neck Surg. 2004;130(5):563-566. doi:10.1016/j.otohns.2003.07.014 Conflict of Interest 18. Barry B, Topeza M, Géhanno P. [Aspergillosis of the parana- sal sinus and environmental factors]. Ann d’oto-laryngologie None. Chir cervico faciale Bull la Soc d’oto-laryngologie des Hop Paris. 2002;119(3):170-173. 19. Wu PW, Lee TJ, Yang SW, et al. Differences in clinical and References imaging presentation of maxillary sinus fungus ball with and without intralesional hyperdensity. Sci Rep. 2021;11(1):1-8. 1. Agarwal S, Kanga A, Sharma V, Sharma DR, Sharma doi:10.1038/s41598-021-03507-1 ML. INVASIVE ASPERGILLOSIS INVOLVING MULTIPLE 20. Stammberger H, Jakse R, Beaufort F. Aspergillosis of the PARANASAL SINUSES – A CASE REPORT. Indian J Med paranasal sinuses x-ray diagnosis, histopathology, and Microbiol. 2005;23(3):195-197. doi:https://doi.org/10.1016/ clinical aspects. Ann Otol Rhinol Laryngol. 1984;93(3 Pt S0255-0857(21)02595-0 1):251-256. doi:10.1177/000348948409300313 2. Khan MA, Rasheed A, Awan MR, Hameed A. Aspergillus 21. Morino T, Kuroyanagi H, Yanagihara T, Ohto H. Sinus My- infection of paranasal sinuses. J Taibah Univ Med Sci. cetoma. Intern Med. 2021;60(19):3183-3184. doi:10.2169/ 2010;5(2):60-65. doi:10.1016/S1658-3612(10)70134-7 internalmedicine.6688-20 3. Saravanan K, Panda NK, Chakrabarti A, Das A, Bapuraj 22. Dhong HJ, Jung JY, Park JH. Diagnostic accuracy in sinus RJ. Allergic fungal rhinosinusitis: an attempt to resolve the fungus balls: CT scan and operative findings. Am J Rhinol. diagnostic dilemma. Arch Otolaryngol Head Neck Surg. 2000;14(4):227-231. doi:10.2500/105065800779954446 2006;132(2):173-178. doi:10.1001/archotol.132.2.173 23. Garofalo P, Griffa A, Dumas G, Perottino F. “Gauze Tech- 4. Urs AB, Singh H, Nunia K, Mohanty S, Gupta S. Post endo- nique” in the Treatment of the Fungus Ball of the Maxillary dontic Aspergillosis in an immunocompetent individual. J Clin Sinus: A Technique as Simple as It Is Effective. Int J Otolar- Exp Dent. 2015;7(4):e535-e539. doi:10.4317/jced.52247 yngol. 2016;2016:4169523. doi:10.1155/2016/4169523 5 Annali di Stomatologia 2019; X (1-4): 2-5 

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Original article Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report Matteo Nagni*1 the basal bone, homologous bone is placed in addition to Luca Arduini** a small amount of autologous bone in the upper part of Daiana Zuccaro** the elevation supported by collagen. After 4 months from Tania Arduini* surgery with a bone height of 9 mm, a 3.8x11 mm implant Raffaele Vinci*2 fixture (Winsix, Biosafin, Ancona, Italy) was placed and then prosthetically restored by deferred load method. 1 DDS, MSc, Dental School, Vita-Salute San Raffaele University, Milan, Italy and Department of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy; Conclusion 2 MD, MFS, Associate Professor, Director of Oral Sur- The Magnetic Mallet could be a valuable aid to support gery School Specialization, Dental School, Vita-Salute implant procedures in the absence of adequate residual San Raffaele University, Milan, Italy and Department of bone height. Dentistry, IRCCS San Raffaele Hospital, Milan, Italy; * Dental School, Vita-Salute San Raffaele University, Milan, Italy and Department of Dentistry, IRCCS San Introduction Raffaele Hospital, Milan, Italy; ** DDS. With the increase in average age, the placement of den- tal implants to replace missing teeth could be a success- *Corresponding author: ful practice in all categories of patients (1-3). Matteo Nagni The loss of teeth, in addition to other factors (4,5), caus- DDS, MSc, Dental School, Vita-Salute San Raffaele Uni- es bone resorption which, in posterior maxilla, increases versity, Milan, Italy and Department of Dentistry, IRCCS due to pneumatization of maxillary sinus (6,7). San Raffaele Hospital, Milan, Italy. When residual bone height is too reduced for traditional axial implants placement, maxillary sinus elevation pro- cedures could be indicated in rehabilitation of edentu- Abstract lous posterior atrophic maxilla, proving excellent long- Aim: The objective of this paper was to show a case term (≥5 years) implants survival rate (8-10). report of maxillary sinus lift with crestal access us- The main approaches are lateral window technique and ing the Magnetic Mallet technique and bio-material osteotome mediated technique (OSFE). placement. The first can be employ when residual bone height is less then 5 mm, the second, requires a minimum of 5 Keywords: Magnetic Mallet, bone condensation, re- mm to be applied (11-13). sidual bone height, dental implant. Lateral window approach was introduced for the first time by Tatum in 1977 (14) and then was described by Boyne and James in 1980 (15). Materials and Methods The surgical procedure provided the creation of a bony A 46-year-old woman, required the replacement of a window on lateral sinus wall to allow sinus membrane prosthetic bridge on natural teeth (from 2.4 to 2.7), which elevation and biomaterials insertion. Implants placement caused her pain when chewing and thermal input. The could be performed at the same time of surgery or after elements supporting the rehabilitation needed endodon- bone healing (approximately 4 months later) (16). tic treatment. The Osteotome mediated technique (OSFE) was intro- In addition to conservative treatment of the residual tooth duced by Summers in 1994 as less invasive alternative: abutments, it was decided to restore tooth 26 by implant osteotomes of progressive diameter concurrently allowed placement. Schneider’s membrane elevation and bone compaction, allowing an immediate insertion of the implants (17). Results According with several complications associated with According to the insufficient residual bone height for the traditional maxillary sinus augmentation procedures insertion of the fixture, the osteotome sinus floor eleva- (18,19), the aim of this paper was to show a case report tion technique was performed. of maxillary sinus lift with crestal access using the Mag- Subsequently, since the elevation is greater than 30% of netic Mallet technique and bio-material placement. Annali di Stomatologia 2019; X (1-4): 6-16 6  Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report Case report At the first visit, the patient already expressed her specific request for a prosthetic restoration with single elements. The patient, a 46-year-old woman, required the re- Objective and radiological examination showed the pres- placement of a prosthetic bridge on natural teeth, which ence of prosthetic bridges from 2.4 to 2.7 and a scarce caused her pain when chewing and thermal input, and amount of basal bone in the area to be rehabilitated with in fact the elements supporting the rehabilitation needed implant fixtures in site 2.6. (Fig. 1-4) endodontic treatment. Figure 1. Figure 2. Figure 3. Figure 4. 7 Annali di Stomatologia 2019; X (1-4): 6-16 M. Nagni et al. In agreement with the clinical and radiographical diag- tached to assess its correct mobility and avoid any injury nosis it was decided to perform a sinus lift with crestal during the insertion of biomaterial. access using a minimally invasive biphasic technique. Once mobilized, the collagen is placed in direct contact Before surgery, diagnostic tests are performed to choose with the displaced bone. It allows blood to be drawn in and the technique to be performed and the amount of bioma- stabilize the clot. It has been shown that the creation of a terial to be placed. space between the sinus membrane and the residual bone Under local anaesthesia, a full-thickness access flap is promotes the migration of stem and mesenchymal cells performed to expose the cortical bone. within the blood clot; the differentiation of these cells into Once the cortical bone is exposed, preparation begins osteoblasts and the formation of new bone then occurs. through compaction with a 300 flat osteotome. The corti- Subsequently, since the elevation is greater than 30% of cal bone is fractured and displaced apically using the con- the basal bone, homologous bone is placed in addition cave osteotome 200 until the sinus floor is broken. The to a small amount of autologous bone in the upper part compacted bone is invaginated during the simultaneous of the elevation supported by collagen. elevation of the Schneiderian membrane. The osteotome In this case, since a rise of at least another 6 mm was in the photo was the angled prototype of the new easy-in required, 4.5 cc of osteoconductive material was placed kit bent to simplify the procedures in posterior sectors. according to the estimate described above 0.6x6= Once the sinus cortical is broken, the membrane is de- 3.6+30%=4.68. (Figure 5-15) Figure 5. Figure 6. Figure 7. Figure 8. Figure 9. Figure 10. Annali di Stomatologia 2019; X (1-4): 6-16 8  Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report Figure 11. Figure 12. Figure 13. Figure 14. Figure 15. 9 Annali di Stomatologia 2019; X (1-4): 6-16 M. Nagni et al. After 4 months from surgery a radiological control is per- Once the bone had matured and stabilized through com- formed to evaluate the extent of the elevation obtained. paction, the implant site was prepared. (Fig. 18-26) With a bone height of 9 mm, it was decided to place a The operative sequence of the sharp concave tip oste- 3.8x11 mm implant fixture (Winsix, Biosafin, Ancona, It- otomes of the AZ easy-in kit was: aly). (Fig. 16-17) 100-160-200. The step with the first osteotome 100P Figure 16. was omitted due to the lack of mature cortical bone being newly angiogenic bone. The site preparation was taken up to a length of 11 mm thus proceeding with a new mini sinus lift. Follow-up visits were performed one week after surgery, at 3 and 6 months and then once a year for the next years (5 years follow-up - Fig. 29-31). The patient was inserted in a professional oral hygiene program to avoid possible complications (20, 21) and monitoring dental implant. The final prosthesis was performed, according with the healing time of the upper jaw, about four months after surgery. Discussion As reported by several Authors, both Sinus Floor Eleva- tion Techniques could have many complications as Sch- neider membrane perforation (22), bone graft infections (23), acute or chronic sinus infection (24), vascular lesions (25), paroxysmal positional benign vertigo (PPBV) (26), wound dehiscence, bone graft and implants loss (27). Membrane perforation represents the most common issue both for lateral and transcrestal approach, with a prevalence of 3.6% to 56% and 23.6 to 44% respectively (28, 29). If this complication occur, bone graft migration into the sinus antrum could cause an acute or chronic sinus in- Figure 17. fection (23). Annali di Stomatologia 2019; X (1-4): 6-16 10  Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report Figure 18. Figure 20. Figure 19. Figure 21. 11 Annali di Stomatologia 2019; X (1-4): 6-16 M. Nagni et al. Figure 22. Figure 23. Figure 24. Figure 25. Al-Dajani et Al. in a Meta-Analysis concerning incidence, risk factors, and complications of Schneiderian mem- brane perforation in sinus lift surgery, also described the role of membrane thickness and sinus septa on this is- sue. (30) According with Ardekian et Al. (31), there was a significant correlation between membrane perforation and sinus membrane <1 mm thick, with a higher preva- lence in presence of bony septa. Another possible complication of sinus floor elevation’ procedures could be the injury of alveolar antral artery (AAA), which could have either an intraosseous or in- trasinusal course (as minority) (32). The consequence could be a several bleeding, which could increase according to vessel diameter (33). To reduce these possible issues, as suggested by Torel- la et Al. (34) and Vercellotti et Al. (35), piezoelectric in- Figure 26. struments should be preferred: during the creation of bony window on lateral sinus wall they could prevent both Schneider’s membrane perforation and AAA lesion. Moreover, a Cone-Beam Computed Tomography per- formed before surgery is necessary to evaluate position and features of these anatomical structures (36). Another possible complication of sinus floor elevation is Annali di Stomatologia 2019; X (1-4): 6-16 12  Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report Figure 27. a postoperative maxillary sinusitis, with an incidence rate of up to 20% (37). The possible consequence is a partial or complete ob- struction of the ostium-meatal unit, altering the physio- logical activity of the mucosal airway system (38). Concerning benign paroxysmal positional vertigo (BPPV), it was related only with transcrestal sinus floor elevation. BPPV can be described as a vestibular end organ disorder often characterized by episodes of ver- tigo. (39) Although the symptoms involved within about a month, if not identified properly and managed correctly they could be enough severe to hinder patients from carrying out normal daily activities (13). To reduce the incidence of complications, which is much higher in lateral approach breast augmentation, in the last few years we have tried to extend the indications for transcrestal augmentation also in case of residual bone height below 5 mm (40, 41). With the new minimally invasive transcrestal elevation techniques, the frequency of perforation has decreased to an average of 3.8% for transalveolar elevation (42), whereas it is about 5 times more frequent for lateral el- evation (43). Membrane integrity is a key determinant of bone graft and implant survival: perforation is associated with a Figure 28. higher incidence of postoperative complications, such as graft failure and infection; furthermore, the size of the perforation is inversely proportional to implant survival (44). Sinus lift performed with magneto-dynamic osteotomes could be performed in total safety, with a survival rate of 98.9%, as confirmed by the present clinical case (45,46). 13 Annali di Stomatologia 2019; X (1-4): 6-16 M. Nagni et al. Figure 29. Figure 31. Conclusion Within the limitations of this study, this case report could represent significant evidence of the efficacy of maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement. Figure 30. Annali di Stomatologia 2019; X (1-4): 6-16 14  Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report References 20. 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Original article Clinical management of a severe case of positional obstructive sleep apnea syndrome Venza Nicolò1 tem control over ventilation (3). The presence of some Malara Arianna1 syndromes also predisposes the onset of sleep disor- Palmacci Daniel1 ders (4). Brain dysfunctions might also manifest, such as Laganà Giuseppina1,2 excessive daytime sleepiness and lack of concentration and these are the most common causes of traffic ac- 1 Department of Systems Medicine, University of Rome cidents (5). The prevalence of OSA has been estimat- ‘Tor Vergata’, Via Montpellier 1, 00133 Rome, Italy ed to be 14% of men and 5% of women (6). Despite 2 UniCamillus - Saint Camillus International University its prevalence, OSA is still an underdiagnosed medical of Health and Medical Sciences via Sant’ Alessandro condition, and more than 85% of patients with clinically 8, 00131 Rome, Italy significant OSA are never diagnosed (7). The presence of sleep disturbances is often associated with the pres- ence of sleep bruxism (8). Positional Obstructive Sleep Corresponding author: Apnoea Syndrome (POSAS) is a sub-type of OSAS in Nicolò Venza which obstructive apneas occur mainly in the supine Department of Systems Medicine, University of Rome sleeping position (more than 50% of apnea episodes). ‘Tor Vergata’, Via Montpellier 1, 00133 Rome, Italy. Polysomnography is the gold standard diagnostic test Email: [email protected] for the diagnosis of OSA in whom there is a concern for OSA based on a comprehensive sleep evaluation that Abstract include informations on sleep posture (9). The apnea-hy- popnea index (AHI) is used to diagnose OSAS, and it is Obstructive sleep apnea syndrome (OSAS) is a com- calculated as the number of apneas and hypopneas per mon disorder which involves upper airway collapse hour during sleep (10). Mandibular advancement devic- during sleep. Positional Obstructive Sleep Apnoea es (MAD) are recommended as first-line therapy for mild Syndrome is a sub-type of OSAS characterized by to moderate OSA or as second-line treatment for severe obstructive apneas mainly in the supine sleeping po- OSA for patients who do not tolerate or respond to CPAP sition. Mandibular advancement devices (MAD) are (11). Specifically, MADs interact with the mandible to recommended as first-line therapy for mild to moder- the tongue, pharyngeal dilator muscles, and indirectly ate OSA or as second-line treatment for severe OSA the soft palate. By moving the mandible forward, these for patients who do not tolerate or respond to CPAP. structures that make up the lumen of the oropharynx are A case report of severe positional OSAS (AHI/h 34.7) extended forward as well, thereby increasing the up- is presented. The clinical case was studied by CBCT per airway space (12). According to the literature Cone head and neck scan and nocturnal polysomnography Beam Computed Tomography (CBCT) with its low effec- and treated with a mandibular advancement device, tive radiation dose and low scanning time represents an positional therapy, dietary adjustments and instruc- effective technique for a 3D complete evaluation, when tions for proper sleep hygiene. After the treatment the utilizing a large field of view protocol, for a comprehen- patient’s AHI decreased to 5.1 and his general health sive head and neck evaluation (13). improved. The MAD appliance represents a valid therapeutic alternative in subjects with severe OSAS A case report of severe OSAS in a middle age man, who do not tolerate CPAP. A combined approach to studied by CBCT head and neck scan and nocturnal pol- the pathology can improve the patient’s overall health ysomnography and treated by customized and titrabled and quality of life. MAD, is presented. Keywords: OSA, Mandibular advancement devices, polysomnography, computed tomography. Clinical case and therapeutic approach A 41 years old Caucasian male, M.M., from the Depart- Introduction ment of Orthodontics referred by the Neurophysiopa- thology Department of Tor Vergata Hospital, with a chief Obstructive sleep apnea syndrome (OSAS) is a com- complaint of snoring, numerous episodes of nocturnal mon and treatable disorder, which involves upper airway apnea and daytime sleepiness. The patient had histo- collapse during sleep and results in intermittent hypox- ry of arterial hypertension and depression. The patient aemia and sleep fragmentation (1,2). This disorder is was undergoing pharmacological treatment for his de- the result of a complex interaction between anatomic pressive state. He had previously been treated for sleep factors, sleep-related factors, and central nervous sys- apnea with CPAP. This treatment had not shown satis- Annali di Stomatologia 2019; X (1-4): 17-21 17  Clinical management of a severe case of positional obstructive sleep apnea syndrome factory results due to the patient’s poor tolerance to the ADVANCER (Leone orthodontic products, Sesto Fior- therapy. The patient’s body mass index was 27,13 (over- entino, Firenze, Italy). Bimaxillary device with lateral weight) with a neck circumference of 45 cm, and he was connectors composed of a tube and piston mechanism being treated by a nutritionist to improve alimentation with the possibility of adjusting the protrusion very accu- and lose weight. The patient was also instructed in prop- rately, with 7 mm of maximum elongation. Vestibular pin er sleep hygiene to improve his habits. The upper airway for elastic bands were added to the device to prevent appeared normal in ear-nose-throat and laryngoscopy the patient from keeping his mouth open while sleeping examinations. The patient’s neck and tongue muscles (Fig. 1a). were enlarged. Moreover the patient shows a reduced The MAD was periodically adjusted during monthly patency of the nasal airways passages due to hypertro- checks in order to obtain the maximum possible mandib- phy of the nasal turbinates. The patient does not have ular advancement in the absence of patient discomfort. any voluptuous habit. At the oral examination the patient After six months of using MAD and NS Sleep Positioner, showed right and left full class I with dentoalveolar bi- the patient’s apnea improved the patient reports a clear retrusion and increased OVB, signs of dental bruxism improvement in symptoms (ESS = 1), restful sleep, ab- and normal-shaped arches. The patient besides shows sence of asthenia upon awakening, absence of snoring macroglossia (Mallampati grade 3), normal size of the and / or apneic episodes. The patient does not show uvula and soft palate, type 1 tonsillar grading. Epworth any kind of discomfort, absence of signs or symptoms sleepiness score (ESS) was 11. CBCT examinations was about temporomandibular dysfunctions. The second pol- performed with NewTom VGi EVO unit (NewTom 3G, QR ysomnographic examination with MAD in situ revealed s.r.l.; AFP Imaging, Elmsford, NY, USA). The 3D recon- only nine apnea episodes and no one were central. The struction and evaluation of the upper airways showed an patient’s AHI decreased to 5.1 (Fig. 2). Moreover, the anatomical narrowing of the hypopharynx which predis- patient’s overall health improved owing to dietary adjust- poses the collapse of the airways during sleep. Written ments. The patient appeared satisfied with the results consent was obtained from the patient. of the therapy. A second TCCB with MAD in situ scan Upon polysomnographic examination, the subject was showed an increased dimension of the hypopharynx diagnosed with positional preference OSAS. During the (Fig. 3). test, he had 141 apneas, 1 of which were central. The patient’s apnea hypopnea index (AHI) was 34.7, a value Discussion that meets the criterion for severe sleep apnea. Because the patient refused CPAP therapy due to dis- The patient was treated using a mandibular advance- comfort and considering the strong positional compo- ment device, positional therapy, dietary adjustments and nent of apneas, treatment options for reduction of the instructions for proper sleep hygiene according with the OSAS included a customized and titrabled MAD (Figure existing evidenced-based clinical practice guidelines 1a) and a NS Sleep Positioner (Advanced Brain Moni- (14, 15). The patient presented in the basal PSG an AHI toring, Carlsbad, CA) composed of a plastic device fas- of 34.7 events/h. Before starting the therapy with the tened on the back of the neck with an adjustable rubber MAD, the patient tried CPAP for a few nights, once it strap secured by a magnetic clasp (Fig. 1b). is the primary treatment indication for severe sleep ap- Customized MAD was obtained through the Gorge nea. Nevertheless, he abandoned it as the discomfort Gauge at maximum advancement without muscular pain was the no-compliance reason. After titrating the MAD, for patients. The MAD chosen was the TELESCOPIC the results of the control polysomnographic, with the a b Figure 1. (a) Intraoral views of the MAD appliance with vestibular elastic bands (b) Night Shift Positioner. 18 Annali di Stomatologia 2019; X (1-4): 17-21 V. Nicolò et al. a b Figure 2. (a) Polysomnographic report before treatment (b) after treatment. Annali di Stomatologia 2019; X (1-4): 17-21 19  Clinical management of a severe case of positional obstructive sleep apnea syndrome a b Figure 3. (a) 3D CBCT initial reconstruction and evaluation of the upper airways (b) with MAD in situ. oral appliance in situ, showed an objective decrease in position is not only important to avoid the simple fall the rates of respiratory obstructive events. The full night of the soft tissues by gravity but also for the effects PSG showed an AHI = 5.1 events/h. Patients with severe on chest pressure. Joosten S.A. and colleagues (23) OSA have an increased cardiovascular risk, showing in- demonstrated a 13% functional residual capacity (FRC) creased prevalence of hypertension, stroke, arrhythmia, decrease in the OSA group when moving from lateral to and aortic events, although these findings are not always supine. This reduction of FRC influences upper airway consistent (16-18). Without CPAP adherence, they must collapsibility with resultant changes in upper airway be treated with alternative therapies. As suggested in the pressure (24). The reduction in lung volume causes an literature, the efficacy of the OSAS therapy must be eval- increase in critical pressure (Pcrit) which influences the uated in relation to the patient’s compliance (19). The collapse of the upper airways causing the apnea event. main objective of MAD therapy is to reduce or normalize Additionally, a reduced lung volume increases the ring the AHI. There are some predictors that help dentists in gain of the ventilatory control system during reduced the attempt to identify which patients will benefit more sleep lung oxygen and carbon dioxide deposits which from the treatment. However, the predictors are still not can then function of respiratory instability in the supine fully clinically reliable (20). In the present case the pa- position of sleep (25). tient was 41 years old, overweight and higher AHI. This In this case report, the patient was placed on a weight- outcome was not compatible with some strong predic- loss program with a nutritionist in order to manage the tors such as lower AHI, lower age, lower BMI and higher BMI. Although the effect of weight-loss on OSAS out- mandible protrusion (21). Despite this, the patient had an comes is not well studied, weight management is rou- excellent response to MAD therapy. tinely recommended. A decrease in BMI is associated In this study the patient wore a NS Sleep Positioner in with improved metabolic outcomes in obese subjects order to avoid supine position. Van Kesteren et al. (22) and should be routinely encouraged notwithstanding is demonstrated that, especially in POSA patients, the potential benefits regarding OSAS (26). Chirinos JA et head position has a fundamental role in the genesis al. (27) in his study has shown that CPAP, associated of apnoeas. Simply with head rotation, the anteropos- with a weight-loss program, increases insulin sensitivity terior collapse of the tongue due to gravity forces can and reduces serum triglyceride levels, but no improve- be avoided and the airway can be stiffened. The body ment was observed with CPAP treatment alone, which 20 Annali di Stomatologia 2019; X (1-4): 17-21 V. Nicolò et al. raises the important issue of the usefulness of adding 12. Kerbrat A, Vinuesa O, Lavergne F, Aversenq E, Graml A, weight-loss programs to CPAP treatment in order to Kerbrat JB, Trost O, Goudot P. Clinical impact of two types of mandibular retention devices - A CAD/CAM design and a improve the cardiovascular risk factor profile of obese traditional design - On upper airway volume in obstructive patients with OSA. The same considerations can cer- sleep apnea patients. J Stomatol Oral Maxillofac Surg. 2021 tainly also be made in the association between MAD Jun 9:S2468-7855(21)00125-7 and weight loss. A meta-analysis that included four ran- 13. Alsufyani NA, Al-Saleh MA, Major PW. CBCT assessment domized controlled trials assessing the effect of inten- of upper airway changes and treatment outcomes of ob- structive sleep apnoea: a systematic review. Sleep Breath. sive lifestyle interventions on weight change and AHI 2013;17(3):911–923. reduction found that a weight loss of 14 kg was associ- 14. Epstein LJ, Kristo D, Strollo PJ Jr, et al.; Adult Obstruc- ated with a reduction in AHI of 16 events/h (28). tive Sleep Apnea Task Force of the American Academy of Sleep Medicine . Clinical guideline for the evaluation, man- agement and long-term care of obstructive sleep apnea in Conclusion adults. J Clin Sleep Med. 2009;5(3):263-276. 15. Ranieri S, Laganà G, Cretella Lombardo Elisabetta, Cozza The mandibular advancement device associated with P. Le problematiche respiratorie nel sonno in età adulta: il positional therapy, weight-loss program and instruc- ruolo dell’ortodontista. Dental Cadmos. 2018; 86. 10.19256 tions for proper sleep hygiene improved the polysomno- 16. Kimura, H.; Ota, H.; Kimura, Y.; Takasawa, S. Effects of In- graphic parameters in a case of severe OSA. The MAD termittent Hypoxia on Pulmonary Vascular and Systemic Dis- appliance represent a valid therapeutic alternative in eases. Int. J. Environ. Res. Public Health 2019, 16, 3101. subjects with severe OSAS who do not tolerate CPAP. 17. Kohler, M.; Pitcher, A.; Blair, E.; Risby, P.; Senn, O.; Forfar, C.; Wordsworth, P.; Stradling, J.R. The impact of obstructive A combined approach to the pathology can improve the sleep apnea on aortic disease in Marfan’s syndrome. Respi- patient’s overall health and quality of life. ration 2013, 86, 39–44. 18. Laganà G, Venza N, Malara A, Liguori C, Cozza P, Pisano C. Obstructive Sleep Apnea, Palatal Morphology, and Aortic References Dilatation in Marfan Syndrome Growing Subjects: A Retro- 1. Iber C, Ancoli-Israel S, Chesson A, et al. The AASM Manual spective Study. Int J Environ Res Public Health. 2021 Mar for the Scoring of Sleep and Associated Events: Rules, Ter- 16;18(6):3045. minology and Technical Specifications. 1st ed., Westches- 19. Vanderveken OM, Dieltjens M, Wouters K, De Backer WA, ter, IL: American Academy of Sleep Medicine; 2007. Van de Heyning PH, Braem MJ. Objective measurement of 2. Azagra-Calero E, Espinar-Escalona E, Barrera-Mora compliance during oral appliance therapy for sleep-disor- JM, et al. Obstructive sleep apnea syndrome (OSAS). dered breathing. Thorax. 2013 Jan;68(1):91-6. Review of the literature. Med Oral Patol Oral Cir Bucal 20. Guimarães MLR, Hermont AP, Guimarães TM, Dal-Fabbro 2012;17(6):e925. C, Bittencourt L, Chaves Junior CM. Severe obstructive 3. Susarla SM, Thomas RJ, Abramson ZR, Kaban LB. Bio- sleep apnea treatment with mandibular advancement de- mechanics of the upper airway: changing concepts in the vice: A case report. Sleep Sci. 2018 Mar-Apr;11(2):118-122. pathogenesis of obstructive sleep apnea. Int J Oral Maxillo- 21. Sutherland K, Takaya H, Qian J, Petocz P, Ng AT, Cistulli fac Surg 2010; 39: 1149-59. PA. Oral Appliance Treatment Response and Polysomno- 4. Obstructive sleep apnea in children with Marfan syndrome: graphic Phenotypes of Obstructive Sleep Apnea. J Clin Relationships between three-dimensional palatal morphol- Sleep Med. 2015;11(8):861-8. ogy and apnea-hypopnea index. Paoloni, V., Cretella Lom- 22. Van Kesteren ER, Van Maanen JP, Hilgevoord AAJ, et bardo, E., Placidi, F., ...Cozza, P., Laganà, G. International al. Quantitative effects of trunk and head position on the Journal of Pediatric Otorhinolaryngology, 2018, 112, pp. 6–9 apnea hypopnea index in obstructive sleep apnea. Sleep 5. Guimarães MLR, Azevedo PG, Barros-Vieira S, Elbaz M, 2011;34:1075-1081. Leger D, Hermont AP. When adherence to CPAP fails, how 23. Joosten SA, Sands SA, Edwards BA, et al. Evaluation do we treat workers with obstructive sleep apnea? Sleep of the role of lung volume and airway size and shape in Sci. 2022 Jan-Mar;15(Spec 1):135-142. supine-predominant obstructive sleep apnoea patients. 6. Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Meh- Respirology 2015;20:819-827. ra R, Ramar K, Harrod CG. Clinical Practice Guideline for 24. Rowley JA, Permutt S, Willey S, et al. Effect of tracheal and Diagnostic Testing for Adult Obstructive Sleep Apnea: An tongue displacement on upper airway airflow dynamics. J American Academy of Sleep Medicine Clinical Practice Appl Physiol 1996;80:2171-2178. Guideline. J Clin Sleep Med. 2017 Mar 15;13(3):479-504 25. Edwards BA, Sands SA, Feeney C, et al. Continuous pos- 7. Kato M, Adachi T, Koshino Y, et al. Obstructive sleep apnea itive airway pressure reduces loop gain and resolves peri- and cardiovascular disease. Circ J. 2009;73 (8):1363–1370. odic central apneas in the lamb. Respir Physiol Neurobiol 8. 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Sutherland K, Vanderveken OM, Tsuda H, Marklund M, 28. Mitchell LJ, Davidson ZE, Bonham M, O’Driscoll DM, Ham- Gagnadoux F, Kushida CA, et al. Oral appliance treatment ilton GS, Truby H. Weight loss from lifestyle interventions for obstructive sleep apnea: an update. J Clin Sleep Med and severity of sleep apnoea: a systematic review and me- 2014;10:215–27 ta-analysis. Sleep Med. 2014;15(10):1173–1183 Annali di Stomatologia 2019; X (1-4): 17-21 21 

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Editorial It is with a great deal of satisfaction and pride that I present, as Editor in Chief, the first new edition of Annals of Stomatology. A scientific magazine, founded in 1959, which after a period of pause, is ready to return pursuing its original mission with passion and renewed enthusiasm; seeking growth, im- provement, and innovation. Our magazine offers itself, in the international scene, as a tool for Research, analysis, and scientific dissemination, thanks to the knowledge and contribute of many scholars and re- searchers in the Sector. With a solid base of teamwork, sharing the same goals and purposes, exchanging dynamic and transversal knowledge, we will work with commitment, determination and constancy to deliver a great magazine to support Research and Innovation. Thanks to our professional background, we will be able to offer the consulting of updated and rigorous works as well as the dwelling on the in-depth treatment of individual clinical cases, received and characterized by elements of greater interest. Through a screening of carefully analyzed data we will evaluate a selection of papers, these will also include a study review from dental schools. On top of that we will present protocols and treatment procedures, also done through the most modern technologies; we aspire to possible new development and innovation projects. Being an editor puts forward numerous possibilities, but above all, it offers a privileged approach to Research. I am grateful for this role and certificate of esteem, that I wish to be able to honor and share with the entire team. My fellow colleagues returned a great deal of enthusiasm, starting from the beginning of the project and along the route of our path. We hope for an ever more widespread participation, openness to discussion and constructive exchange; if we will man- age to turn our work into a tool of support and cultural and scientific enrichment, then we will have achieved our goal! Enjoy this reading! Editor in Chief Roberto Gatto Annali di Stomatologia 2018; IX (4): 141 141 

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Original article A rare case of double whartin parotid tumor. Parapharyngeal intraoral surgical approach. Paolo Arangio1 Introduction Edoardo Cerbelli2 Alessandro Agrillo3 Parapharyngeal space tumors account for about 0.5% Domenico Scopelliti4 of all head and neck cancers; the majority of these rare tumors are benign (about 80%) (1). 1 San Filippo Neri Hospital, Rome The most frequent parapharyngeal space tumor origi- [email protected] nates in the salivary glands and pleomorphic adenoma 2 San Filippo Neri Hospital, Rome represents the most common histological type. General- [email protected] ly, most tumors originating from the retro-styloid space 3 San Filippo Neri Hospital, Rome are neurogenic, while tumors coming from salivary [email protected] glands usually fill the pre-styloid space (2). 4 Chief of Maxillo-Facial Surgery, San Filippo Neri, The parapharyngeal space, also called maxillary or lat- Rome Italy, Vice-president Operation Smile Italy eral pharyngeal space, is a challenging area for cancer [email protected] treatment. It is an inverted cone-shaped space extending from the hyoid bone to the basicranium, bounded medi- ally by the pre-tracheal fascia and laterally by pterygoid Corresponding author: muscles and the mandible. It is frontally bounded by the Domenico Scopelliti sub-mandibular space and posteriorly by the pre-man- Chief of Maxillo-Facial Surgery, San Filippo Neri, Rome dibular space (3). Italy, Vice-president Operation Smile Italy. In most cases patients are asymptomatic, at least the [email protected] mass reaches 3 cm size, and tumors are discovered as an incidental finding examining patients for an unrelated problem. Abstract The most frequent symptoms reported were pain, dys- Parapharyngeal space tumors account for about phagia, odynophagia, a sense of hearing loss and mid- 0.5% of all head and neck cancers; the majority of dle ear effusion due to Eustachian tubes obstruction these rare tumors (about 80%) are benign (1). and, in case of an enlarged tumor, clinical examination The most frequent parapharyngeal space tumor may also reveal intraoral asymmetry and protrusion of originates in salivary glands and the pleomorphic the anterior tonsillar pillar and/or palate (4-5). adenoma represents the most common histological Surgery is the main approach for the management of type. Generally, most tumors originating from the parapharyngeal masses except for lymphoproliferative retro-styloid space are neurogenic, while tumors diseases (6). coming from salivary glands usually fill the pre-sty- Several surgical strategies have been described for the loid space. management of parapharyngeal space masses, and an We present a case report of combined cervical accurate surgical planning is mandatory, considering pa- trans-parotid and intraoral access in patient with tients’ nature, and neoplasm position (7). double neoplasms, starting from superficial and We present a case report of combined cervical trans-pa- deep parotid spreading in the parapharyngeal space. rotid and intraoral access in patient with double ne- After superficial parotid neoformation removal oplasms, starting from superficial and deep parotid through a pre-tragal preauricular approach, we per- spreading in the parapharyngeal space. formed an intraoral incision laterally to the left tonsil pillar. We detached the neoformation with its capsule, Clinical case and surgical approach showing no neurovascular structure placed anterior- A 72-year-old male showed to our hospital with a ly to the neoplasm. 10-months history of a left-sided parotid mass associat- Through intraoral approach, thus, it is possible to ed with an intraoral foreign body sensation. access to MPS in safety, avoiding excessively inva- He also reported temporomandibular joint pain, spread- sive incisions and approaches, in selected cases of ing in the cervical area, recurrent headaches and difficul- well-defined neoformations, regardless of dimen- ties in swallowing. sions. During clinical examination we appreciated a palpable swelling in the left latero-cervical region, not sore nor Keywords: multidisciplinary team care, oral medi- painful during palpation; the same clinical finding was cineand maxillofacial surgery, oral potentially malig- present in the oral cavity. nant disorders, oro-pharyngeal cancer. MRI showed two neoformations, the first one arising in Annali di Stomatologia 2018; IX (4): 142-145 142  A rare case of double whartin parotid tumor. Parapharyngeal intraoral surgical approach Figure 1. Axial CT Figure 2. Sagittal CT Figure 3. Coronal CT the left parotid area and the remaining spreading from tached the neoformation with its capsule, showing no the deep lobe of the homolateral parotid gland, facing neurovascular structure placed anteriorly to the neo- the oral cavity and causing a compression of the homo- plasm, as expected by MRI images (Fig. 4). lateral airways. (Figg.1-3) Thus, we cleaved the whole neoformation, safely, from In particular, this last lesion occupied the middle par- the surrounding planes, exposing the neurovascular apharyngeal space (MPS) and the pre-styloid space, structures placed posteriorly. causing a neurovascular structure (internal jugular vein The two neoformations, one deriving from the superficial and internal carotid artery) posterior displacement; the lobe of the parotid gland and the other spreading from features made the intraoral access the most appropri- the deep pole, measure respectively 2.3 and 3 cm in di- ate approach, able to minimize the risk of aesthetic and ameter (Fig. 5). functional damage. The patient was released in good conditions and the After superficial parotid neoformation removal, through convalescence was carried out regularly. Neither com- a pre-tragal preauricular approach, we performed an plications nor sensitive defects were reported in the intraoral incision laterally to the left tonsil pillar. We de- post-operative period. Figure 4. Intraoperative view of the lesion Figure 5. Intraoperative view after lesion removal 143 Annali di Stomatologia 2018; IX (4): 142-145 P. Arangio et al. Figure 6. Patient two weeks after surgery Headaches and TMJ disorders disappeared after sur- opsy. The surgical removal of these tumors is the best gery, with a total recovery within 1 month (Fig. 6). treatment; several surgical approaches, classified as transoral, transcervical, transparotid–transcervical, tran- Discussion scervical–transmandibular or infratemporal, have been described in the literature according to the position and The para-pharyngeal space represents a challenging type of neoformation. area to access, for the maxillofacial surgeons, due to the As described by Prasad et al., parapharyngeal space depth of the location, the complex anatomy and the pres- can be divided into three portions: ence of adjoining vital structures. - Upper parapharyngeal space (UPS), from the crani- The fascia, arising from the styloid process to the tensor al base to the axial plane passing through the lower veli palatine muscle, splits the parapharyngeal fossa into edge of the lateral pterygoid muscle two compartments: the pre-styloid and the retro-styloid - Middle parapharyngeal space (MPS), from the axial sections (8). plane bounded above by the UPS and below by the This space is bounded antero-superiorly by the maxil- insertion of the medial pterygoid muscle lary sinus, continuing supero-laterally with the infratem- - Lower parapharyngeal space (LPS), bounded at the poral fossa, which is separated from the medial ptery- top by the MPS and below by the hyoid bone (16). goid fascia (9). The goal of surgery is to ensure a complete enucleation The retro-styloid PPS contains: IX-XII cranial nerves, minimizing aesthetic and functional damage. internal carotid artery (ICA), internal jugular vein (IJV), In our patient the intraoral portion of the neoplasm oc- paraganglia, ectopic salivary glands and lymph nodes. cupies the pre-styloid space and the MPS, displacing Due to the deep location, parapharyngeal space tumors posteriorly the neurovascular structures represented by are usually asymptomatic until the lesion reaches a di- IJV and ICA. mension greater than 2,5-3 cm. Among the intraoral approaches, we distinguish: For this reason, in most cases, these are diagnosed in- - Transantral sublabial cidentally, with an imaging exam, performed for other - Transoral transvestibular reasons (10). - Transoral transpharyngeal (our approach) The vast majority of PPS lesions are benign salivary - Transmandibular transoral gland tumors of which pleomorphic adenoma is the most As described by Ferrari et al., one of the conservative common (11). techniques, able to adequately expose the neoplasms Warthin tumor extending from the deep lobe to the par- placed on the MPS, is represented by the transoral apharyngeal space represents a very rare occurrence, trans-pharyngeal approach: which consists in an incision accountant for about 1% of all histotypes involving this placed on the front tonsil pillar (17). region (12). Although it is discredited by some authors (18) for the Preoperative CT, MRI and angiography are the most greater risk of capsule rupture, dissemination in case of common tools used to diagnose PPS tumors, investigat- malignant tumors and infection due to contamination by ing the relationship with major neurovascular structures, the germs present in the oral cavity, intraoral approach is glandular tissue, and craniofacial skeleton. a valid alternative, from a functional and aesthetic point CT and MRI are both valid options, although the latter of view. gives more information about the lesion’s feature (13). This was described by Goodwin and Chandler, who first Angiography is recommended if imaging shows a wid- presented a series of transoral parapharyngeal tumors ening of the carotid bifurcation (14), however, PET CT is removal (19). recommended too when the presence of metastases is As described by Betka et al., in case of selected tumors, suspected (15). an intraoral approach allows the access to PPS minimiz- If malignancy is suspected, histological diagnosis should ing side effects and ensuring a good ability to eradicate be obtained using fine needle aspiration cytology or bi- the disease (20). Annali di Stomatologia 2018; IX (4): 142-145 144  A rare case of double whartin parotid tumor. Parapharyngeal intraoral surgical approach Conclusion 9. Maheshwar AA, Kim EY, Pensak ML, et al. Roof of the para- pharyngeal space: defining its boundaries and clinical impli- Through intraoral approach, thus, it is possible to access cations. Ann Otol Rhinol Laryngol. 2004;113:283 was 288. to MPS in safety, avoiding excessively invasive incisions doi: 10.1177/000348940411300405. 10. Dimitrijevic MV, Jesic SD, Mikic AA, Arsovic NA, Tomanovic and approaches, in selected cases of well-defined ne- NR. Para- pharyngeal space tumors: 61 case reviews. Int J oformations, regardless of dimensions. Oral Maxillofac Surg 2010;39:983 was 989. An accurate imaging is required for a correct surgical ap- 11. Parapharyngeal Space Pleomorphic Adenoma: A 30-Year Review Abie H. Mendelsohn, MD; Sunita Bhuta, MD; Thom- proach to show possible displacement of neurovascular as C. Calcaterra, MD; Hubert B. Shih, BS; Elliot Abemayor, structures. MD, Phd; Maie A. St. John, MD, PhD. Postoperative course is free of significant complications, 12. Shaw CK, Sood S, Bradley PJ, Krishnan S. Unusual mass in with no discomfort reported by the patient; headaches the parapharyngeal space: a Warthin’s tumour. ANZ J Surg. 2006 Mar;76(3):193-4. PubMed PMID: 16626365. Takashi- and TMJ pain disappeared after surgery. ma S, Sone S, Honjho Y, Horii A, Yoshida J. Warthin’s tumor of the parotid gland with extension into the parapharyngeal space. Eur J Radiol. 1997 May;24(3):227-9. PubMed PMID: References 9232394. 1. Dallan I, Seccia V, Muscatello L, et al. Transoral endoscopic 13. Dimitrijevic MV, Jesic SD, Mikic AA, Arsovic NA, Tomanovic anatomy of the parapharyngeal space: a step-by-step logi- NR. Para- pharyngeal space tumors: 61 case reviews. Int J cal approach with surgical considerations. Head Neck 2011; Oral Maxillofac Surg 2010;39:983 was 989. 33:557-561. 14. (Surgical managment of parapharingeal space tumours: 2. Excision of tumors in the parapharyngeal space using an results of 10-year follow up 14 F Bozza, MG Vigili,1 P Rusci- endoscopically assisted transoral approach: a case series to,2 A. Marzetti,1 and F Marzetti2. Surgical management of and literature review Zhe Chen1, Ya-Lian Chen1, Qi Yu1, parapharyngeal space tumours: results of 10-year follow-up. Shui-Hong Zhou1, Yang-Yang Bao1, De-sheng Shang2 and 15. Parapharyngeal Space Tumor: Submandibular Approach Ling-Xiang Ruan2. Without Mandibulotomy Kuauhyama Luna Ortiz1 • Oscar 3. Fakhry, Nicolas (25 July 2016). “A proposal for a level Villa-Zepeda1 • Jose F. Carrillo1 • Ernesto Molina-Frias1 • for parapharyngeal extension of parotid gland”. Europe- Antonio Go ́mez-Pedraza1. an Archives of Oto-Rhino-Laryngology. 273 (10):3455. 16. Prasad SC, Piccirillo E, Chovanec M, La Melia C, De Dona- doi:10.1007/s00405-016-4226-8. PMID 27455864. to G, Sanna M. Lateral skull base approaches in the man- 4. Jansen JC, et al. Estimation of growth rate in patients with agement of benign parapharyngeal space tumors. Auris head and neck paragangliomas influences the treatment Nasus Larynx. 2015;42(3):189-198. proposal. Cancer. 2000;88(12):2811. 17. Surgical anatomy of the parapharyngeal space: A multiper- 5. Surgical Approaches to Benign Parapharyngeal Space spective, quantification-based study Marco Ferrari MD1 | Al- Tumors-5-Year Experience Keyvan Aghazadeh1, MD; Mo- berto Schreiber MD, Phd1 | Davide Mattavelli MD1 | Davide hammadtaghi Khorsandi1,MD; Mohamamadjavad Rikhte- Lombardi MD1 | Vittorio Rampinelli MD1 | Francesco Dogli- gar1,MD; *Amirsina Sharifi1,MD; Arsalan Hashemiagh- etto MD, Phd2 | Luigi Fabrizio Rodella MD, Msc3 | Piero dam2,MD; Arezou Hashem Zade2,MD. Nicolai MD1. 6. Case report: extranodal non-Hodgkin’s lymphoma of the 18. Parapharyngeal Space Tumor: Submandibular Approach parapharyngeal space Fatma Tulin Kayhan, Naif Ozkul, De- Without Mandibulotomy Kuauhyama Luna-Ortiz1 • Oscar partment of Otolaryngology, Head and Neck Surgery, Vakif Villa-Zepeda1 • Jose F. Carrillo1 • Ernesto Molina-Frias1 • Gueha Hospital, Istanbul, Turkey. Antonio Go ́mez-Pedraza1. 7. Parapharyngeal Space Pleomorphic Adenoma: A 30-Year 19. Goodwin WJ Jr, Chandler JR (1988) Transoral excision of Review Abie H. Mendelsohn, MD; Sunita Bhuta, MD; Thom- lateral parapharyngeal space tumors presenting intraorally. as C. Calcaterra, MD; Hubert B. Shih, BS; Elliot Abemayor, Laryngo- scope 98:266=269. MD, PhD; Maie A. St. John, MD, PhD. 20. Eur Arch Otorhinolaryngol. 2010 May;267(5):765-72. doi: 8. Maheshwar AA, Kim EY, Pensak ML, et al. Roof of the para- 10.1007/s00405-009-1071-z. Epub 2009 Aug 28. Transoral pharyngeal space: defining its boundaries and clinical impli- and combined transoral-transcervical approach in the sur- cations. Ann Otol Rhinol Laryngol. 2004;113:283 was 288. gery of parapharyngeal tumors. Betka J1, Chovanec M, Klo- doi: 10.1177/000348940411300405. zar J, Taudy M, Plzák J, Kodetová D, Lisý J. 145 Annali di Stomatologia 2018; IX (4): 142-145 

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Original article Intra-oral scanning and CAD/CAM prosthesis fabrication Enrico Moglioni1 3. Manufacturing of the appliance. Luca dal Carlo2 An intraoral scanner can capture the optical impres- Mike Shulman2 sion of soft and hard tissue intraorally. Alternatively, Marco Pasqualini2 models fabricated from analog (traditional) impres- Franco Rossi2 sions can be scanned and digitalized with a scanner. Carlo Cosma2 Doctors will transfer accumulated data to the den- Flavio Lico2 tal laboratory, where dental technicians design and Paolo Diotallevi3 manufacture the prosthesis. Especially in electro-welded immediate load implan- tology (characteristic of the Italian school of implan- 1 Presidente ARASS (Associazione per la Ricerca e le tology) the digital flow optimized the entire rehabili- Attività Sociali in Stomatologia) tation process. Association for Research and Social Activity in Stoma- The Benefits of Using a CAD-CAM technology. tology Rome Italy - Effective communication with the patient. 2 Medico odontoiatra - Greater patient comfort. 3 Medico radiologo - Better diagnosis. - Easy storage of data. - A scanner is far less invasive compared to tradi- Corresponding author: tional dental impressions. Enrico Moglioni - The possibility of creating and reproducing high Presidente ARASS (Associazione per la Ricerca e le At- quantities dental models. tività Sociali in Stomatologia) - The fast transfer of files via the internet to a lab- Association for Research and Social Activity in Stomato- oratory situated far away. logy Rome Italy - The reduction of corrections and remakes, high 3388752989 production workflow. [email protected] - Saving time and costs of the entire restoration process. - The decrease in non-recyclable materials. Abstract - The possibility of planning and simulating im- The acronym Cad-Cam stands for Computer-Aid- plant surgery using designated software, merg- ed Design and Computer-Aided Manufacturing. In ing the intraoral scanning data is 3D CAT radiog- 1970, Dr. Francois Duret and his colleagues were raphy (DICOM). the first to develop a Cad-Cam dental system, later Limitations of Using a CAD-CAM technology: named the Sopha system (Sopha BioConcept, Inc. - Initial Investment. Los Angeles). In the early 80s, a Swiss dentist, Dr. - Learning Curve. Werner Mörmann, and an Italian electronic engineer, - Continuous software updating. Eng. Marco Brandestini developed the first Cad- Computer-aided design (CAD) and computer-aided Cam chairside system for dental use, known as the manufacturing (CAM) are innovative digital systems Cerec system (Chairside Economical Restoration of capable of scanning prepared teeth intended for re- Esthetic Ceramics). Anderson and his colleagues ceiving crowns, bridges, inlays, and other restora- attempted to create titanium caps using Cad-Cam tions. With the advent of technologies and potential technology. In 1983, they introduced a Cad- Cam applications, dentistry is one application area that has technology to mill implant restorations in titanium gained the highest market share in the last few years. and cover it with ceramic or composite. This system CAD/CAM systems offer a better, faster, and more con- later became known as the Procera system. Comput- venient method for fabricating dental restorations. er-Aided Design (CAD) technology of computerized Many dental schools adopted CAD/CAM technology systems to create, modify, analyze and enhance the intended for education and clinical patient care. CAD/ design process. Computer-Assisted Manufacturing CAM technology improves the experience of both the (CAM) is an automated system that organizes man- professional and patient by reducing patient visits, ages, and controls manufacturing process. increasing efficiency, and contributing to a positive Together Cad-Cam process has three cycles: practice environment and clinical productivity. Such 1. The data acquisition. factors ultimately contribute to the overall market 2. Data elaboration and design processing. growth and revenue during the forecast period. Annali di Stomatologia 2018; IX (4): 146-161 146  Intra-oral scanning and CAD/CAM prosthesis fabrication Keywords: CAD/CAM, Intraoral Scanner, One-piece, 1. The data acquisition. Immediate loading, Intraorally welded, Implants 2. The data elaboration, design processing. Surgical Guides. 3. Manufacturing of the appliance. Introduction The traditional method The acronym Cad-Cam stands for Computer-Aided De- The traditional method. sign and Computer-Aided Manufacturing. For a fixed metal-ceramic prosthesis manufacturing: Computer-Aided Design (CAD) technology is applied to - Dental Impression computerized systems to facilitate the creation, modifi- - Plaster Model cation, analysis and enhancement of a design. - Modeling of substructure in wax Computer-Assisted Manufacturing (CAM) is an automat- - Casting ed system that organizes, manages and controls manu- - Metal preparation facturing operations (1). - Ceramic application In 1970, Dr. Francois Duret and his colleagues were the All these stages are 100% manual operations. All work first to develop a Cad-Cam dental system, later named the depends on technicians and all of them can potentially Sopha system (Sopha BioConcept, Inc.Los Angeles) (2). flaw the final product. With different quality control lev- In the early 80s, a Swiss dentist, Dr. Werner Mörmann, els, these defects could be detected relatively late; this and an Italian electronic engineer, Eng. Marco Brandes- might prolong the production times. tini developed the first Cad-Cam chairside system for when detected and corrected (Fig. 2). dental use, known as the Cerec system (Chairside Eco- Collateral damage or side-effects of inappropriately pro- nomical Restoration ofEsthetic Ceramics) (3). duced laboratory work: Anderson and his colleagues attempted to create tita- - open margins cause secondary decay and gingival nium caps using Cad-Cam technology. In 1983, they inflammation, decreasing the teeth and prosthesis’s introduced a Cad- Cam technology to mill implant res- lifespan, ultimately bone loss; torations in titanium and cover it with ceramic or com- - the nonpassive fit of the prosthesis can move teeth posite. This system later became known as the Procera to compensate for the deficiency. system (4). However, overloaded implants will react differently than Computers are substitutes for regular hand-operated the teeth, active lateral forces will cause bone loss and activity, and trained dental technicians, making the work- ultimately even implant loss. flow more expeditious, cost-effective, and predictable. Natural teeth can move axially by 25-100µ and 56-108µ Cad-Cam has three cycles (Fig. 1): laterally (5). Prostheses on implants move more than Figure 1. Acquisition of data, elaboration of data and manufacturing of the device. 147 Annali di Stomatologia 2018; IX (4): 146-161 E. Moglioni et al. Figure 2. Dimensional changes in elastomer impression materi- al can be duplicated as plaster modeling errors, ultimately pro- ducing prostheses with defects. 3-5µ in an axial direction and 10-50µ in a lateral direc- tion; implants will fail if moving further (6). An incorrect prosthesis fit generates stress that can negatively affect the bone-implant interface and, therefore, become the first step towards an implant’s dis-integration (7). The most common prosthetic complications, the screw loos- ening or fracture, can be related to a nonpassive, forced prosthesis insertion (8). If a titanium bar is seated with extra stress (nonpassive fitting) on welded abutments, it will cause an unbalanced forces distribution (9) Figure 4. Scan of one-phase implant abutments level. Analog, Traditional intraoral impressions The dental impression material can inaccurately impress CHART 1. Compares manufacturing processes for a dif- a titanium bar welded to the monolithic implants’ abut- ferent type of restoration. Traditional workflow compared ments. This mono-block structure has undercuts (10). to CAD-CAM technology. Elastomeric materials impressing the undercut, are de- CAD-CAM technology eliminates some steps as well as formed upon withdrawal, may not ideally resemble the 70% manual labor (Fig. 5). contour, and when it is reproduced on the model, it will create inaccuracies. Digital flow in implant prosthetics The time between taking the impressions and casting Reverse Engineering the plaster model also can affect the accuracy because of the material’s dimensional stability. The term “reverse engineering” refers to the techniques Small and thin abutments may give the technicians a and technologies which enable a virtual product to be hard timereproducing them on the model (11). created from a real one. Reverse-engineering can rec- When comparing analog to digital impressions, the au- reate the object or create a similar object with added en- thors suggest that most of the challenges described hancements to reconstruct an existing object’s virtual or above areeliminated (12) CAD model (13). In dentistry, these techniques are used to transfer a patient’s anatomy into a calculator. Three general steps are common to all reverse-engineering Intraoral scanners efforts. They include: Intraoral scanners (IOS) are devices used for capturing - Information extraction. The reverse-engineered ob- direct optical impressions. The hard and soft tissues im- ject is studied, information about its design is extract- ages, captured by imaging sensors and scanning soft- ed and it is examined to determine how the pieces fit ware, generatea 3D model. together. Taking dental impressions and the fabrication models can - Modeling. The collected information is summarized be done with an intraoral scanner and 3D printer (Fig. 3). into a model. Information is specific to the original Digital dental impressions are the first step (Fig. 4). and abstracts it into a general model that can design new objects. - Review. Reviewing the model and testing it in various scenarios ensures a realistic abstraction of the origi- nal object or system. Once it is tested, the model can be implemented to reengineer the original object. Computer-aided design (CAD) is a reverse-engineering technique used to recreate a manufactured part. It in- volves producing 3D images of the part so it can be remanufactured.A coordinate measuring machine meas- ures the part, and as it is measured, a 3D wireframe image is generated using CAD software and displayed on a monitor. Reverse-engineering techniques eliminate Figure 3. Intraoral Scanner. some of the guesswork. Annali di Stomatologia 2018; IX (4): 146-161 148  Intra-oral scanning and CAD/CAM prosthesis fabrication Figure 5 The main manufacturing processes for the creation of metal-ceramic ormetal-free crowns. Digital dental workflow Dentists scan the dental/implant surfaces and/or of the scan-body implants and adjacent anatomical structures, - Digitalization done by the dentist; the digital impres- the scanner reproduces the morphology of the dental sion of the patient’s soft and hard tissue. Scanning arch with elements. Typically, hundreds of scans are of the preparation. Implant/abutment direct scan or a necessary to capture all of the information from vari- scanning body. Scanning by the dental technician ous sides and angles. These scans are then integrated a plaster model obtained from a traditional impres- through a common reference system known as align- sion or scanning the impression also transferring ment/registration. articulated models into the virtual articulator in the Finally, the individual scans are merged to re-create the laboratory. final model. This entire process of bringing together the - CAD designing of a prosthesis. individual scans and merging them is known as a 3D - The technician is milling the substructure or mono- scanning pipeline. The dotted image reproduces the lithic prosthesis. morphology of the scanned dental arch. At this point, it - Application of the veneering material, finishing, and is necessary for the cloud of points to transform into a polishing. surface. To do this, the software undertakes the joining - Dentist delivers the prosthesis to the patient. of the single discrete points, according to a mathemati- cal formula, measuring the distance between them and 3D Scanner reconstructing a grid formed by a series of minuscule All 3D scanners are instruments to scan an object and polygons (generally triangles) (Fig. 6). uselight and specific sensors to convert optical data, the so-called “cloud of points” converting it into a 3D model. The basic principle is the emission of a light signal (Laser or structured light) by an emitter and the receiver’s return signal’s reception (14). In dentistry, the most common scanners are the so- called “triangulation scanners.” Typically, a 3D scanner consists of a source of light, one or more video cameras. 3D scanners essentially create a digital copy of a real-world object. This digital copy of the 3D file can then be edited and 3D printed. Also, a 3D file can be used for further 3D modeling processes. Nowadays, in this 21st-century, Engineers are using this technology for reverse engineering processes. 3D scan- Figure 6. The software connects the points in the cloud, re- ner files are generally compatible with CADsoftware and constructing a grid formed of triangles, calculating the area, 3D printing slicer software. and defining its filling in. 149 Annali di Stomatologia 2018; IX (4): 146-161 E. Moglioni et al. It is possible to calculate the three-dimensional position. When the scanner recognizes a curved surface, such as The light is reflected through trigonometry, measuring the cylindrical bar welded to the implant abutments, it the angle and distance between the video and the light immediately increases the number of triangles. Although source (which forms the scanner head). This principle of a large number of points, on one hand, better define the measurement is known as “triangulation.” It is possible to scanned area, on the other hand, this does not neces- obtain an in-depth image through scanning. sarily guarantee accuracy and precision. Having a series of polygons created by a wireframe, the Accuracy: represents the error/discrepancy between the software can calculate the single triangles’ area and fill recorded measurement and its true value (accepted as themin. The in-depth image is an image in which the 3D accurate). It is an error that supersedes the acquired coordinatesof the object’s surface are memorized. data; where measurements of the same value are re- A solid structure is recreated and forms the virtual model, peated, it can be considered the distance between the and accuracy depends on the dimensions and number of average and truemeasurements. triangles. Therefore, it is based on the number of refer- Precision: is represented by the dispersion of the meas- ence points initially recorded by the scanner—the more urements around their average. It enables an estimation detailed the scan, the more detailed reconstruction. of the casual error component, considering several re- STL file formats encode information in order to store it peated measurements. Precision means the ability to on a computer. When it comes to 3D printing, the STL repeat the same measurement several times. So, an (Standard Triangulation Language) file format is the already precise machine simply needs to be set accord- most commonly used. ingly to achieve maximum accuracy (Fig. 7). The scanners that are available on the market are con- tactless optical technologies, such as: Transfer of digital data to the laboratory - Confocal microscopy. - Photogrammetry. Once the optical impression is recorded and filed, the - Active and passive stereo display. STL file is sent directly to the designated laboratory - Triangulation. (Fig. 8). Figure 7. Examples of accuracy and precision (trueness and precision) with three different scanners. Scanner precision The international standards regarding the international regulations ISO 10360-1-9 2013 (15) Geometrical Product Specifications (GPS) (Quality control Test for coordination of the measuring machines (CMM); while for dentistry, the regulation is ISO 12836:2012 (16) (Dentistry - Digitizing devices for Cad-Cam systems for indirect dental restora- tions- test methods for assessing accuracy). The parameters linked to three-dimensional measuring are resolution, accuracy, and precision; that is, measurement uncertainty. These can be defined in the following way: (Maximum) Resolution: generally consists of the most minute variations in measurement possible to measure. The cloud density of points is proportional to the resolu- tion: it affects the distance between the recorded points Figure 8. Enhanced impression sent by internet to the lab- and describes geometrical details of small dimensions. oratory. Annali di Stomatologia 2018; IX (4): 146-161 150  Intra-oral scanning and CAD/CAM prosthesis fabrication The optical impression of welded/unwelded one phase immediate load implants We are working with the one-piece implant/abutment (17). Preparation of implant abutments During the preparation, it is necessary to increase the in- terproximal space so that the cameras’ light can stream freely and, therefore, precisely record the details. The one-piece implant/abutments, smaller than two-piece abutments, facilitates the camera capturing (Fig. 9-10). Gingival retractions Once the implants placements, preparation, and ad- justments of the abutments are completed, the gingival margin needs to be verified and recorded; the gum needs to be repositioned or retracted. Gingival retrac- tion can be accomplished using retraction cords; in some cases, a laser can be a helpful instrument. Figures 11 and 12. Three implants, one submerged, and two one-piece implants were welded together in this clin- ical case. After integration, the welded bar was removed, and the three implants were prepared for impressions. Gingival cord/retractors were placed, and digital impres- sions were taken. The upper jaw was scanned pre-operatively, where the abutments were positioned; this area was cropped from Figure 11. Removing the welded bar, verifying the implant the image. The prepped abutments are scanned, and stability and the refining margins of the abutments. the software will re-impose the abutments into the previ- ously cropped area (Fig. 13). Figure 12. The two gingival retractors/cords were left during the digital impression acquisition (clinical case of figure 11). Figure 9. Intra-oral scanning of the abutment portion of the one- piece implants was prepared similar to natural teeth. Figure 10. The structure of the one-piece implant abutment Figure 13. The eliminated area will be reproduced through provides easier access for scanning. the rescanning of the area with the placed abutments. 151 Annali di Stomatologia 2018; IX (4): 146-161 E. Moglioni et al. The acquired image part is cropped, and this area Digital impressions of implants (cropped) is rescanned; It saves time because the sec- ond scan does not include the entire jaw. As this The digital impression of the implants connected with a area is rescanned, the new partial second scan will bar is a challenging procedure in the restorative stage re-impose the previously cropped part of the digital im- (18). pression. Temporary PMMA prosthesis cemented on immediately The full upper jaw impression, with the implant abut- inserted and connected implants. It will provide a tempo- ments and soft tissue, is reconstructed as a model. Once rary patient’s function for the duration of the integration the second scan is complete, it can be articulated with of the implant (19-21) (Fig. 15). the opposing jaw, the occlusion is scanned and sent The digital impression of the temporary prosthesis is tak- (emailed) to the laboratory (Fig. 14). en for record-keeping purposes. It can be used as a part Working with an intraoral scanner, taking digital records of the permanent impression later on (Fig. 16). gives us: This model will be used in the laboratory as a perma- The entire upper and lower jaw with the functional tem- nent prosthesis guideline. Occlusion, horizontal and porary prosthesis. vertical overjets are verified, and the technician can The recording confirmed occlusion. build the final prosthesis with the outline based on the The possibility for the second fragment impression to be provided data. re-imposed and to be taken any time later (a day or a The temporary is removed and the implant abutments week or longer). modifiedas needed to define the finishing line (Fig. 17). The bite registration taken for the full mouth without the need to be retaken. Once the fragment is re-imposed, Size control theocclusal record used is the one saved before. The preoperative model, the temporary prosthesis mod- The full-arch impression/model can be duplicated and el, will be used in the laboratory as a permanent prosthe- saved. sis prototype. Figure 14. Bite registration record. Annali di Stomatologia 2018; IX (4): 146-161 152  Intra-oral scanning and CAD/CAM prosthesis fabrication Occlusion, horizontal and vertical overjects are verified, and the technician can create the final prosthesis out- line based on provided data (Fig. 18). We can verify that both abutments and the welded bar are within limits to maintain a proper prosthesis outline. If the bar position is compromised, the bar can be re- welded and the impression retaken. Intraoral scanning can verify the miss- angulated abutment, the compro- mised path of insertion and even the presence of an undercut; all these can be corrected and the impres- sion retaken. This correction can be done with almost no time wasted, unlike using an analog, older technique (Fig. 19). With a welded bar (22, 23) on the abutments, undercuts are frequent, especially junction points. With the digital impression, it can be detected and eliminated almost instantly. Design of closing margins Digital/optical impression reveals the finishing line imme- diately, and if it needs to be redefined, it can be done at that time (Fig. 20). Another function of the software is to personally trace the prosthesis finishing line, the margins of the resto- Figure 15. ration. Figure 16. The optical impression/ model of the temporary prosthesis after healing. The margin is highlighted with a colored line, memoriz- ing and saving it as a file. The welded bar is rested on the edentulous area, and we can draw the equatorial margin on the bar. The equator indicates the line which the prosthetic structure must not bypass. Continuing with the digital flow, the software will visual- ize the acquired data in 3D; the technician will design a dental restoration in 3D (Fig. 21). The Benefits of Using an Intra-Oral Scanner - Effective communication with the patient. - Greater patient comfort. - Better diagnosis. - Easy storage of data. Figure 17. Illustration of the optical impression with welded - A scanner is far less invasive compared to traditional one-phase implants at the laboratory, the workflow continues. dentalimpressions. 153 Annali di Stomatologia 2018; IX (4): 146-161 E. Moglioni et al. Figure 18. Control and immediate verification of the available sizes for the correct illustration of the prosthesis. Figure 19. Assessing the presence of an undercut when it is determined can be immediately eliminated. Figure 20. Outlining the finishing line or the restoration mar- Figure 21. Design and illustration of the prosthetic resto- gins on the implant abutments. rations. Annali di Stomatologia 2018; IX (4): 146-161 154  Intra-oral scanning and CAD/CAM prosthesis fabrication - The possibility to create and reproduce high quan- As artificial intelligence algorithms become more and titiesdental models. more advanced, the increasing precision of the elements - The fast transfer of files via the internet to a built with AI’s help and its reliability make it irreplaceable laboratorysituated many kilometers away. in today’s life. - The reduction of corrections and remakes, high Today, the practitioners are divided into a few groups, productionworkflow. utilizing surgical guides, as computer-guided procedures - Saving time and costs of the entire restoration pro- and computer-assisted ones. cess. Once the CBCT acquisition was completed, the operator - The decrease in non-recyclable materials. studied the radiographic images, checking for possible - The possibility of planning and simulating implant pathologies, examining vital structures. surgery using designated software, merging the in- To eliminate any possible misreading, it is recommend- traoral scanning data is 3D CAT radiography (file ed that the Maxillofacial radiologist evaluates the image. DICOM). The software used to design and illustrate the treatment There are some Limits: planning, including implant placements and bone aug- - Initial Investment. mentations, usually comes with CBCT. Various third-party - Learning Curve. softwares offer comprehensive CBCT review, 3D recon- - Continuous software updating. struction, treatment planning, and surgical guides design. - The camera’s light may have limitations when a To transfer the data, build surgical guides or temporary shiny object needs to be scanned. Oral fluids and restorations, we need to merge radiographic data. It gen- gum covering the margin line have to be eliminated. erally comes in DICOM format files, with hard and soft tissue images obtained from the optical intraoral scan in CAD technology, the different components of the pros- STL format. To merge these files (generated from CBCT thesis processing, two distinct working techniques: radiographic data, 3D anatomical model and soft and The subtractive technique - CNC. hard tissue scanned with optical scan) and fabricate pa- The milling machines are equipped with different drills tient-matched surgical guides, an additional software is for various materials. They can be used to cut solid needed. With software, one can merge the digital radio- disks. Alternatively, a soft disk (a green stage) will later graphic scan with the optical intraoral scan by choosing besintered to become hard (24). close matching points. The software will re- impose and The additive technique - AM merge the images. The structure is built layer by layer, known as Additive Treatment planning is implemented in one of many Manufacturing (25). methods. The suggested one includes placing the miss- Today, CAD/CAM technology has become irreplaceable, ing tooth or teeth on the virtual model, then placing an yet the last word is human intellect and the human hand. implant and abutment. Surgical guides Once implants are placed into the desired position, an operator can build a surgical guide using different reten- As Oral Implantology is becoming a standard treatment tion methods. modality, more and more doctors are adding it to their The guide can be teeth retained or bone retained de- treatment choices. pending on the patient’s condition. The bone retained Artificial intelligence has also become part of our pro- surgical guard has to be fixated with pins, slots, or pin- fessional and social lifestyles. Bringing elements of ar- holes; they are a part of the surgical guide design. tificial intelligence into our everyday lives changed it at The operator builds a surgical guide over the implants, vir- different levels. As we are implying in oral implantology, tually placed on the reconstructed radiographic image and one can say that 3D treatment planning and treatment soft and hard tissue model obtained from the optical scan. performance has improved dramatically. Surgical sleeves are incorporated into the surgical guide. Treatment times, accuracy, and outcome benefited from Different companies offered their surgical kits with corre- artificial intelligence engagement. sponding surgical sleeves and implant drivers for a fully As we move along with new technologies, one should guided procedure. understand the benefits and limitations, to guarantee the In a case, the operator chose computer-assisted tech- proper application. niques; the surgical guide is utilized for partial guidance: Different synopses are as follow: computer-guided sur- like osteotomy positioning. gery, computer-assisted surgery. The operator will be thoroughly guided from the first oste- It is up to an operator to decide who is what. Without otomy to the final depth, width and implants (abutments prejudice we study the main principles to cover both optional) placement in the complete computer-guided options, and the operator will have to choose. surgery. CBCT, initially used for diagnostic purposes, is the best In the situation where bone augmentation is required, for assessment, diagnosis, treatment planning and operator-guided techniques are preferred by the authors. guiding the surgical and prosthodontic means. The tolerance of surgical instruments has advanced and The 3D reconstruction becomes more and more precise the drills’ lateral movements (vibrations) were significant- and predictable in education, fabricating surgical and ly reduced. The software imaging devices and printing prosthetic appliances. devices improved further, all ameliorating a lot the pro- Virtual treatment planning, implant placement, bone re- cedure’s accuracy. duction, or bone augmentation can be guided or con- Prediction: soon most of the procedures will be fully trolled with the surgical guide’s utilization. computer- guided with high clinical success (Fig. 22-30). 155 Annali di Stomatologia 2018; IX (4): 146-161 E. Moglioni et al. Figure 22. The software can evaluate and illustrate the treatment planning, implant placements and bone augmentations, usually included with CBCT. Figure 23. CBCT for diagnostic purposes. Annali di Stomatologia 2018; IX (4): 146-161 156  Intra-oral scanning and CAD/CAM prosthesis fabrication Figure 24. Virtual treatment planning on a generated model. Implants are placed into the desired position. Figure 25. The operator builds a surgical guide. 157 Annali di Stomatologia 2018; IX (4): 146-161 E. Moglioni et al. A B Figure 26. A. Designed surgical guide. B. Surgical guide Figure 27. Surgical sleeve. Figure 28. Implant drivers (mount). (RealGUIDE 5.0, 3DIEMME Srl, Italy) (RealGUIDE 5.0, 3DIEMME Srl, Italy) Figure 29. The report, the estimated bone quality and possible collision situations. Annali di Stomatologia 2018; IX (4): 146-161 158  Intra-oral scanning and CAD/CAM prosthesis fabrication Figure 29. Continua. Figure 29. Continua. 159 Annali di Stomatologia 2018; IX (4): 146-161 E. Moglioni et al. Figure 30. Completed surgical part References 11. P. Oral Implantology today: Surgical protocol, Historical facts, Diagnostic imaging, Biomechanical notes. Implants 1. Carfagna G. CAD/CAM 3D. Studi di progettazione e produz- n° 4 – 2016 44-51. ione di un componente meccanico Edizioni Savine (2010). 12. Picton DC, Creasey SJ Some causes of failure of crowns, 2. Duret F.,Preston J.D. (1991). “CAD/CAM imaging in dentist- bridges and dentures. J Oral Rehabil. 1989 Mar;16(2): ry.” Curr Opin Dent 1(2): 150-154. 109-18. 3. Mormann W.H. (2004). “The origin of the Cerec method: a 13. Christensen GJ (2008) Will digital impressions eliminate the personal review of the first 5 years.” Int J Comput Dent 7(1): current problems with conventional impressions? J Am Dent 11-24. Assoc 139(6): 761– 763. 4. Andersson M., Carlsson L., Persson M.,Bergman B. (1996). 14. Guidi G., Russo M., Beraldin JA. Acquisizione 3D e model- “Accuracy of machine milling and spark erosion with a CAD/ lazione poligonale 2010 McGraw-Hill Companies srl Milano. CAM system.” J Prosthet Dent 76(2): 187- 193. 15. Persson A, Andersson M, Oden A, Sandborgh-Englund G 5. Sahin S, Cehreli MC. The significance of passive framework A three- dimensional evaluation of a laser scanner and a fit in implant prosthodontics: current status. Implant Dent touch-probe scanner. 2006, The Journal of Prosthetics Den- 200110: 85-92. tistry, Vol. 95, issue 3 p. 194-200. 6. Kim Y, Oh TJ, Misch CE, Wang HL. Occlusal considerations 16. ISO 10360-9:2013 Geometrical product specifications in implant therapy: clinical guidlines with biomechanical ra- (GPS) -- Acceptance and reverification tests for coordinate tionale. Clinical Oral Implants Res 2005;16: 26-35. measuring systems (CMS) -- Part 9: CMMs with multiple 7. Sahin S, Cehreli M, Yalcin E. The influence of functional probing systems. forces on the biomechanics of implant-supported prosthe- 17. ISO 12836:2012 specifies test methods for the assessment ses. A review J Dent 2002;30: 271-282. of the accuracy of digitizing devices for computer-aided de- 8. Sones AD. Complications with osseointegrated implants. J sign/computer-aided manufacturing (CAD/CAM) systems Prosthet Dent 1989;62: 581-585. for indirect dental restorations. 9. Moglioni E, Diotallevi P, Pezzuti E, Pasqualini M, Ferrante 18. Moglioni E, Diotallevi P, Pierazzini A, Pezzuti E, Lagana’ G. G, Floris Pl. Success rates in subjects rehabilitated with im- L’implantologia orale oggi: protocolli chirurgici, cenni storici, mediate loading technique on according to AISI guidelines. diagnostica per immagini e note di biomeccanica. 2005 Boll. Ann. Stom. 2008; LVII (1-2):19-23. SMO 25:4-9. 10. Moglioni E, Pezzuti E, Grotowski T, Dal Carlo L, Shulman 19. Dal Carlo L, Pasqualini Me, Mondani P.M, Rossi F, Moglioni M, Diotallevi E, Shulman M. Mondani intraoral welding: historical process Annali di Stomatologia 2018; IX (4): 146-161 160  Intra-oral scanning and CAD/CAM prosthesis fabrication and main practical applications. Journal of Biological Reg- of periodontal disease. Journal of Biological Regulators & ulators & Homeostatic Agents. Vol. 31,n°2 (S1), 233-239 homeostatic Agents. Vol. 32, n°2 /S1), 27-34 (2018). (2017). 23. Dal Carlo L, Pasqualini Me, Rossi F, Meynardi F, Moglioni 20. Rossi F, Pasqualini Me, Moglioni E, Meynardi F. Impianti E, Riccardi L, Fanali S, Shulman M. Saldatrice endorale di postestrattivi one-piece a carico immediato nel settore fron- Mondani. Principali applicazioni pratiche. Doctor Os 2017 tale superiore con deficit osseo vestibolare. Doctor Os XIII XXVIII;05:36-47. (7) Sett. 2013:779-787. 24. Dal Carlo L, Squillantini P. Shulman M, Winkler S, Moglioni 21. Rossi F, Pasqualini Me, Carinci F, Meynardi F, Diotalle- E, Donati R, Pasqualini Me, Rossi F. Case Report: Imme- vi P, Moglioni E, Fanali S. “One-piece” immediate-load diate loading of intraorally welded implants. Implants n° 3 post-extraction implants in labial bone deficient upper – 2016 – 8-13. jaws. Annals of Oral &Maxillofacial Surgery 2013 Apr 25. Van Noort R. “The future of dental devices is digital.” Dent 01;1(2):14. Mater 2012; 28(1): 3-12. 22. Meynardi F, Lauritano D, Pasqualini Me, Rossi F, Griv- 26. Beuer F., Schweiger J.,Edelhoff D.. “Digital dentistry: an et-Brancot L, Comola G, Dal Carlo L, Moglioni E, Zampetti overview of recent developments for CAD/CAM generated P. The importance of occlusal trauma in the primary etiology restorations.” Br Dent J 2008 204(9): 505-51. 161 Annali di Stomatologia 2018; IX (4): 146-161 

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Original article Bone regeneration/repairing with an innovative bone substitute Antonio Scarano1 of fundamental importance in the study of bone regen- Francesco Inchingolo2 eration and in the assessment of all the methods to be Gianna Dipalma2 implemented, in order to guide this process in a profit- Maura Boggian3 able way. Luca Signorini4 Following the loss of the tooth, in fact, various events take place and lead to a variable amount of bone re- 1 Department of Innovative Technologies in Medicine sorption due to the qualitative and quantitative changes and Dentistry, University of Chieti-Pescara, 66100 that occur in the alveolar bone itself, around the ex- Chieti, Italy. traction site (the alveolar process and more generally 2 Department of Interdisciplinary Medicine, University of the bone). Alveolar tooth-dependent structure (1) un- Medicine Aldo Moro, 70124 Bari, Italy. dergoes remodeling that is definitely characterized by 3 Scientific Consultant, Ubgen Research Unit a marked reabsorption. Chronologically, during the first 4 School of Dentistry, Saint Camillus University of Health year following tooth extraction, large portions of cortical Science, 00198 Rome, Italy. bone are replaced with trabecular and medullary bone (2-4) and there is a marked reduction in the size of the Corresponding: extraction site both in the apico-coronal and in the buc- Prof. Luca Signorini co-lingual direction. In particular, some data are high- lighted in the literature: after the first six months there is a reduction of about 30% of the vestibular volume of Abstract the residual alveolar ridge, but at the same time, new bone is formed which fills the post-extraction defect. In The healing of a post-extraction socket and the final a radiographic study Tan et al. (2012) quantified the re- remodeling of the residual ridge represent a moment absorption, this was about 1.24mm vertically and 3.8 of fundamental importance in the study of bone re- mm horizontally, 6 months after the extraction. Some generation and in the assessment all the methods authors have pointed out that bone loss is more marked to be implemented in order to guide this process in on the buccal side and leads to a shift of the alveolar a profitable way. The purpose of this clinical eval- ridge 2/3 lingually/palatally compared to the original po- uation is therefore to assess the effectiveness of a sition. In order to delay the processes of modification granular bovine bone (RE-BONE bone substitute, of the alveolar ridge (horizontally and vertically) and of Ubgen System, Vigonza-PD, Italy) in promoting the volumetric reduction, that begin at the same time as the formation of new bone and preserving the volume healing process due to dental extraction, it is consid- of the pre-existing one at the extraction site. 30 pa- ered appropriate to preserve the post-extraction alve- tients were involved in this study, involving a total olus to allow a subsequent implant-prosthetic rehabili- of 30 alveolar sockets treated with new medical de- tation (4-7). To date, there are various techniques that vices. Each patient was treated 4g of bovine bone preserve the post-extraction socket. These employ the in granular form. Our pilot study, carried out on the use of grafting materials (or biomaterials) with or without samples considered suitable by the operator, iden- the association with biological membranes. tified the presence or absence of mineralized bone, The purpose of this clinical evaluation is therefore to as- soft tissue and graft material, through a qualitative sess the effectiveness of a granular bovine bone (RE- and quantitative percentage assessment. BONE bone substitute, Ubgen System, Vigonza-PD, The results showed an optimal percentage of new Italy) in promoting the formation of new bone and pre- bone formation, with a prevalence of hard tissue. The serving the volume of bone at the extraction site. presence of grafting material constituted only a small percentage in most of the analyzed samples, demon- Materials and Methods strating that the substituted material was optimally resorbed and replaced with new mature bone tissue. All medical devices used in this study are approved for commercial use and are freely provided by UBGEN, to carry on the aims of this study. The supply of materials Keywords: Dental Implants; Implantology has been stored in an appropriate and safe place, and Introduction is accessible only to people authorized to carry out this protocol. Medical devices are: The healing of a post-extraction socket and the final - BMrebone01B (0,5g – 0,25-1 mm) remodeling of the residual ridge represents a moment - BMrebone01C (1g – 0,25-1 mm) Annali di Stomatologia 2018; IX (4): 162-166 162  Bone regeneration/repairing with an innovative bone substitute Patient sample size a fragment of Condress Collagen on suture with horizon- 30 patients were involved in this study, involving a to- tal “U” or “8” (silk 4-0). Finally, 600 mg of ibuprofen was tal of 30 alveolar sockets treated with the new medical given every 8 hours, as needed, on a full stomach. devices. Each patient was treated 4g of bovine bone in granular form in the following quantities: Visit 3 - Suture Removal. • BMrebone01B (0,5g - 0,25-1 mm) Removed the sutures after 12 days. • BMrebone01C (1g - 0.25-1 mm) Visit 4 - Check-up at 30 days Criteria for admission to the study The check has been performed. Inclusion criteria Visit 5 - Checkup at 60 days Patients involved in the study, and which therefore re- The check has been performed. sponded to the inclusion criteria, were aged between 20 and 70 years with one or more teeth to be extracted Visit 6 - Checkup at 90 days and substituted with implants. Those presented a med- The check has been performed. ical history without significant pathologies and were not using drugs that could condition the bone metabolism. Visit 7 - Check-up at 120 days These are healthy subjects, at most, with the presence The patient underwent antibiotic coverage (Amoxicillin of compensated arterial hypertension and / or compen- Clavulanate 1000 mg: 1 tablet every 8 hours for 7 days sated hypercholesterolemia. The patients selected in before intake, 1 tablet 3 hours before surgery). the study presented post-extraction sockets with buc- Infiltration anesthesia (Articaine with 1/100K vasocon- cal wall and the simultaneous presence of upper pre- strictor) was administered on site. Bone biopsy was per- molars with chronic periapical pathologies refractory to formed with a drill (internal diameter 2 mm) and subse- orthograde orthodontic treatment and / or with reduced quent implant placement. Finally, the site was sutured. coronal support. Because of the impossibility to find cases with premolars Visit 8– after 4/5 months prosthetic finalization to be extracted, subjects with upper incisors and canines The check has been performed. to be removed were also included in the study for the aforementioned reasons. Biopsy Samples until processing were stored by neutral buff- Exclusion criteria ered formalin fixation process in a dark glass bottle and Smoking patients, pregnant women, patients with chron- bakelite cap. ic systemic diseases (e.g. diabetes) and neoplastic of the facial district, patients using bisphosphate were ex- Fixation cluded from the study. Equally, all those subjects who The sample was fixed in neutral buffered formalin and presented any sites already implant failure localized, un- placed in the glass bottle with stopper provided at the treated periodontitis, sites with acute infections, chronic start of the clinical trial. inflammatory diseases of the oral cavity. Finally, subjects with autoimmune diseases (taking cortisone), declared Identification allergy to one or more medications to be used during An identification tag was placed on each bottle with the treatment and finally alcoholics and /or drug addicts patient identification code. were also excluded. Processing Plan of the study The biopsy samples were dehydrated in order to include The study plan was divided into eight visits. them in paraffin to obtain sections prepared on special slides subjected to staining with hematoxylin-eosin. Visit 1 - Pre-surgical evaluation Patients were evaluated according to the inclusion and Histological and histomorphometric analysis exclusion criteria. To start the recruitment, informed con- In order to carry out histological and histomorphomet- sent was signed, and an identification code was gener- ric analysis, the various samples taken were analyzed ated and assigned for each patient. and photographed, at various magnifications; an optical microscope, with digital image reconstruction, with a Visit 2 - Extraction and filling of the site with bone sub- transmitted and polarized illumination, was used. In the stitute REBONE various sections, the tissues and materials present, such The patient underwent antibiotic coverage with Amoxicil- as mineralized bone, medulla and grafting material, were lin Clavulanate 1000 mg: 1 tablet every 8 hours for 7 days identified. Therefore, we proceeded with the qualitative before intake, 1 tablet 3 hours before surgery. Infiltration and quantitative evaluation of each sample with dedi- anesthesia was administered on site (Articaine with 1 / cated software and finally, the data were analyzed for 100K vasoconstrictor) and an extraction as atraumatic statistical purposes. as possible (odontotomy) was performed. The sockets Results were cleaned, the granulation tissue was removed and a local bleeding was stimulated. The site was filled with Our pilot study, carried out on the samples considered RE-BONE® pre-hydrated with sterile physiological solu- suitable by the operator, identified the presence or ab- tion (without overfilling), the graft was then covered with sence of mineralized bone, soft tissue and graft mate- 163 Annali di Stomatologia 2018; IX (4): 162-166 A. Scarano et al. rial, through a qualitative and quantitative percentage Also, the clinical findings showed how the healing of the assessment (Table1). The results showed an optimal sockets treated with RE-BONE at the initial time (T0) and percentage of new bone formation, with a prevalence at a control time (after 120 days) was excellent locally of hard tissue. The presence of grafting material con- and macroscopically (Figg. 2, 3). stituted only a small percentage in most of the analyz- The samples taken from the biopsy were dehydrated, ed samples, demonstrating that the substituted material embedded in paraffin to obtain sections, stained with was optimally resorbed and replaced with new mature hematoxylin-eosin, prepared on special slides. The sam- bone tissue (Fig. 1). ples were photographed and analyzed accordingly at various magnifications; an optical microscope, with dig- Table 1. ital image reconstruction, with a transmitted and polar- Histological samples of post-extraction alveolar ized illumination, was used. The results show that after bone treated with RE-BONE 30 days (Figure 3) an intense osteogenic activity was present. The bone was immature but already present Bone (%) Soft tissue (%) Graft (%) to ensure clinical support. After 90 days (Figure 4) the Sample 1 20.87 25.33 53.80 mineralization was almost completed and the bone had replaced most part of REBONE material. Sample 2 68.76 3.30 27.95 Sample 3 15.27 50.39 34.34 Discussion Sample 4 Regenerative medicine is a discipline aimed at tissue 45.87 31.61 22.64 regeneration that uses external means to improve or re- Sample 5 48.99 10.46 40.66 store the natural healing capacity of our body. Immedi- ate implant placement does not prevent the resorption Sample 6 30.30 22.75 46.95 of the buccal bone crest (1) and several oral tissues Sample 7 54.49 12.42 33.08 may have more difficulties in triggering their own repair mechanisms. These situations are hampered by condi- Sample 8 0 39.43 60.57 tions such as: the absence of oxygen and nutrients, a Sample 9 24.58 20.59 54.83 chronic inflammatory state, a particularly complex tis- sue matrix to remodel. From a clinical point of view, the Sample 10 30.30 22.75 46.95 preservation of the ridge and the socket often needs a Sample 11 22.41 19.32 58.27 bone tissue graft for the proper management of defects in the buccal bone before insertion of implants (2). The Figure 1. Annali di Stomatologia 2018; IX (4): 162-166 164  Bone regeneration/repairing with an innovative bone substitute A B Figure 2. A. (T0). B. After 120 days. Figure 3. After 30 days. Figure 4. After 60 days. 165 Annali di Stomatologia 2018; IX (4): 162-166 A. Scarano et al. REBONE bone substitute, thanks to the high surface/ immediate implant placement and ridge preservation tech- volume ratio, is an ideal scaffold for osseointegration niques: review of morphometric studies in animals. Implant and osteoinduction, furthermore, the highly porous and Dent 2013,22,155-160. 2. Wang, R.E.; Lang, N.P. Ridge preservation after tooth ex- interconnected structure carries out an osteoconductive traction. Clin Oral Implants Res 2012,23,147-156. action capable of promoting cell colonization, the circu- 3. Hämmerle, C.H.; Araújo, M.G.; Simion, M. Evidence-based lation of substances nutrients and rapid vascularization. knowledge on the biology and treatment of extraction sock- After having carried out the function of filling, support ets. Clin Oral Implants Res 2012,23,80-82. and osteoconduction, the bone substitutes used in this 4. Darby, I.; Chen, S.T.; Buser, D. Ridge pres-ervation tech- study are completely degraded by osteoclastic activity niques for implant therapy. Int J Oral Maxillofac Implants 2009,24,260–271. and physiologically remodeled into new vital bone tis- 5. Barone, A.; Ricci, M.; Calvo-Guirado, J.L.; Covani, U. Bone sue already after 60 days. remodelling after regen-erative procedures around implants placed in fresh extraction sockets: an experimental study in Beagle dogs. Clin Oral Implants Res 2011, 22,1131–1137. Conflicts of Interest: “The authors declare no conflict 6. Feller, L.; Khammissa, R.A.; Bouckaert, M.; Lemmer, J. Al- of interest.” veolar ridge preservation immediately after tooth extraction. SADJ 2013,68,408-410. 7. Sbordone, L.; Levin, L.; Guidetti, F.; Sbordone, C.; Glikman, A.; Schwartz-Arad, D. Apical and marginal bone alterations References around implants in maxillary sinus augmentation grafted 1. Viña-Almunia, J.; Candel-Martí, M.E.; Cervera-Ballester, J.; with autogenous bone or bovine bone material and simul- García-Mira, B.; Calvo-Guirado, J.L.; Peñarrocha-Oltra, D.; taneous or delayed dental implant positioning. Clin Oral Im- Peñarrocha-Diago, M. Buccal bone crest dynamics after plants Res 2011,22, 485–491. Annali di Stomatologia 2018; IX (4): 162-166 166 

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Original article All-on-four rehabilitation in patient with type II diabetes mellitus: case report and literature review Francesco Orlando*1 Results Irene Cusenza* Serena Ferri* No implants were lost during the follow-up period. The Costanza Ferraro* marginal bone loss was comparable to literature results Matteo Nagni*2 related to implant-retained prosthetic rehabilitations in healthy patients. No intra- and postoperative complica- * Dental School, Vita-Salute San Raffaele University, tions were reported. Milan, Italy and Department of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy Conclusion 1 Fellow MSc, Dental School, Vita-Salute San Raffaele Maintaining a good glycemic control, able to favor the University, Milan, Italy and Department of Dentistry, compensation of diabetes, the insertion of implants can IRCCS San Raffaele Hospital, Milan, Italy be considered a safe procedure. The constant monitor- 2 MSc, Dental School, Vita-Salute San Raffaele Univer- ing of the patient and his adherence to a strict hygiene sity, Milan, Italy and Department of Dentistry, IRCCS protocol are fundamental to promote implant survival San Raffaele Hospital, Milan, Italy and early identification of complications. Corrisponding author: Introduction Matteo Nagni The increase in the average age of the population leads [email protected] to an increase in the incidence of various systemic dis- eases such as diabetes. At the same time fixed rehabili- tation of partial or total edentulous patients with systemic Abstract diseases, associated with the increase in the average AIM: The increase in the average age of the popula- age, could be increasingly required (1, 2). tion leads to an increasing incidence of many differ- Diabetes mellitus is a complex metabolic disease, de- ent systemic diseases, often associated with partial fined by the ADA (American Diabetes Association) as a or total edentulism. In particular, diabetes plays a group of metabolic diseases characterized by elevated significant role in patients’ implant-prosthetic reha- blood glucose levels (hyperglycemia) that result from the bilitation, as it has a direct effect on the oral cavity. body’s inability to produce or use insulin (3). There are The aim of this case report is to illustrate the rate of four types of diabetes: type I diabetes, an autoimmune implant survival, marginal bone loss and any intra- disease characterized by an absolute deficiency of in- and post-operative complications in patients with sulin, caused by destruction of pancreatic ß-cells, that type II diabetes, undergoing fixed prosthetic reha- affects approximately 5-10% of the population and tends bilitation according to the All-on-Four method, in a to occur at a young age; type II diabetes, caused by the two-years of follow-up. association between a peripheral resistance to the ac- tion of insulin and an inadequate secretory response Keywords: All-on-Four, systemic diseases, immedi- of pancreatic ß-cells (“relative insulin deficiency”), rep- ate loading, diabetes, hyperglycemia. resents the majority of cases of late-onset diabetes; drug- or chemical-induced diabetes; and gestational di- Materials and methods abetes (4). Diabetes has a direct effect on the oral cav- ity, manifesting itself through microangiopathy, altered The patient, suffering from type II diabetes, presented immune response and changes in salivary composition edentulous regions and compromised residual teeth (5). In cases of implant rehabilitations, diabetes, could in both arches. Considering the need for a fixed reha- interfere with the normal processes of osseointegration, bilitation and, on the other hand, a severe bone loss as the state of hyperglycemia has a negative effect on in the posterior maxillary and mandibular sectors, we osteoblastic regulation and BIC (Bone Implant Contact) opted for a rehabilitation based on a reduced number values (6, 7). of implants, according to the “All-on-Four” method. Fol- The diabetic patient’s treatment may exhibit two differ- low-up examinations, aiming at assessing implant sur- ent types of complications: the intra operative and the vival and marginal bone loss, were performed one week post-operative ones. The former group includes hy- after surgery, after six months and then once a year for poglycemic crisis, while the latter includes mucositis, the following 24 months. Any intra- and postoperative peri-implantitis, lack of implant osseointegration and complications were noted to evaluate and monitor the poor wound healing (8). Hypoglycemic crisis is defined patient. Professional hygiene was performed every four as an acute consequence of diabetic disease and usu- months after surgery. ally occurs when the patient had not taken their medi- Annali di Stomatologia 2018; IX (4): 167-174 167  All-on-four rehabilitation in patient with type II diabetes mellitus: case report and literature review cations regularly and had not adequately eaten before the appointment (9). Mucositis and peri-implantitis are defined as inflammatory lesions of the tissues surround- ing an implant. Peri-implant mucositis is defined as an inflammatory lesion limited to the surrounding mucosa of an implant, whereas peri-implantitis is defined as an in- flammatory lesion of the mucosa affecting the supporting bone resulting in a loss of osseointegration, thus causing a likely decrease in implant success (10). The failure to osseointegrate the implant is another occurring post-op- erative complication. Osseointegration implies a firm, di- rect, and lasting connection between the vital bone and the titanium implants (11). In conclusion, we recall the Figure 2. Intraoral photo: presence in the mandible of an incomplete soft tissue healing, caused by high blood glu- incogruous prosthesis anchored to dental elements. cose levels and non-enzymatic protein glycation, leading to AGE formation (12) which alters the permeability of the endothelium, releases inflammatory cytokines and ative complications, determined by her general state of growth factors, and increases the expression of adhe- health. A professional oral hygiene session was carried sion molecules and chemokines, thus leading to delayed out during the preoperative phase; subsequently, con- wound healing (13,14). ventional impressions were taken for the study models; The aim of this case report was to illustrate implant sur- these were also used for the prosthetic component of vival rate, marginal bone loss and possible intra- and the treatment. This was followed by radiographic inves- post-operative complications in patients with type II dia- tigations including an OPT (orthopantomography, a first betes undergoing fixed prosthetic rehabilitation, accord- level examination) which allowed an overall assessment ing to the All-on-Four method, at two years follow-up. of the jaws (Fig. 3). But, only after performing a CBCT (Cone Beam Computed Tomography, second level ex- Case report amination), it was possible to evaluate the bone volume of the maxilla. After carefully classifying the patient’s A 60-year-old woman came to the Department of Den- bone density, defined as D3, and attentively performing tistry of the IRCCS San Raffaele Hospital with the wish all preoperative procedures, surgery could be sched- to have an implant-prosthetic rehabilitation of the lower uled. One hour before surgery, 2g of Amoxicillin and arch. The patient was submitted to an anamnestic ques- Clavulanic Acid (Augmentin, GlaxoSmithKline, Brussels, tionnaire which showed that she suffered from type II Belgium) were administered as a preventive measure. diabetic pathology. To assess the state of the disease, it The surgical phase was performed under local anaes- was decided to perform laboratory tests in which the val- thesia (Optocaine 20 mg/ml with adrenaline 1:80,000; ues of Hba1c 7% (glycosylated haemoglobin) and gly- Molteni Dental, Florence, Italy). Some dental elements caemic levels <180 mg/dl were analysed. The tests’ re- considered hopeless were avulsed (Fig. 4). sults were normal and her diabetes resulted to be under control, making the patient an excellent candidate for im- plant therapy. The frontal view of the patient’s smile can be observed in Figure 1. Intraoral examination revealed the presence of an incongruous prosthesis anchored to dental elements that functioned as prosthetic abutments (Fig. 2). Among the various treatment options, given the presence of edentulous areas, the placement of implants according to the “All-on-Four” method was considered the most valid. After the signing of the informed con- sent and the implant-prosthetic treatment, the patient was made aware of the possible intra- and post-oper- Figure 3. Orthopantomography that shows the condition of the jaw bones and residual elements. Figure 1. Extraoral photo. Figure 4. Post-extractive socket. 168 Annali di Stomatologia 2018; IX (4): 167-174 F. Orlando et al. Figure 5. Crestal incision and bilateral release incisions. Figure 7. Tilted implant. Figure 6. Full-thickness buccal flap. Figure 8. Axial and tilted implants. The mandibular edentulous ridge was incised with a crestal incision and bilateral release incisions from the first molar region to the contralateral side and a sub- periosteal dissection was performed on the lingual and buccal surfaces (Fig. 5). A full-thickness buccal flap was then lifted to expose the buccal bone wall and to get an optimal view of the mental foramen (Fig. 6). Once the incisions had been made and the flaps lifted, implant placement was possible. In the mandible, the two posterior implants (dimensions length and diame- ter) (TTx, Winsix, Biosafin, Ancona, Italy) were placed Figure 9. Placement of abutments. bilaterally immediately anteriorly to the mental foramen (Fig. 7). It is important to underline that, following the All-on-Four protocol, the posterior implants are inserted following an inclined trajectory of about 25-30 degrees with respect to the occlusal plane. In fact, they emerge at the level of the second premolar, in order to decrease the length of the cantilever and maintain a large distance between the implants. The central implants, on the other hand, are inserted following a trajectory perpendicular to the occlusal plane (Fig. 8). The insertion torque was between 30 and 40 Ncm before final implant placement, thus achieving high primary sta- bility and immediate functionality. Figure 10. Flap repositioning and suture. To compensate for the lack of parallelism between the posterior implants and the prosthetic screw, angled Then the prosthetic phase started, which included the abutments (Extreme Abutment, EA Winsix, Biosafin) delivery of a provisional prosthesis and the taking of were placed at 30°. The anterior implants, on the other impressions for the fabrication of the definitive one: a hand, were fixed at 17° to allow optimal access for the few hours after surgery, a screw-reinforced, metal-rein- prosthetic screw ((Fig. 9). After these steps, which were forced, acrylic provisional prosthesis with ten teeth was essential for the prosthetic part, the previously lifted flap delivered (no cantilevers were used in the provisional was repositioned and adjusted with 4-0 nonabsorbable prostheses). suture (Vicryl; Ethicon, Johnson & Johnson, New B run- The torque for the tightening the prosthetic screws was swick, NJ, USA), ((Fig. 10). Immediately after surgery, 20 N. Eventually the screw access holes were covered an OPT was performed to verify the correct placement of with temporary resin (Fermit, Ivoclar Vivadent, Naturno, the implants ((Fig. 11). Bolzano, Italy) ((Fig. 12). Annali di Stomatologia 2018; IX (4): 167-174 169  All-on-four rehabilitation in patient with type II diabetes mellitus: case report and literature review Figure 11. OPT to check implants placement. Figure 12. Provisional prosthesis. Figure 13. Mucosa after suture removal. Approximately four months after surgery, the definitive Follow-up prosthesis will be delivered and, unlike the provisional prosthesis, the latter will have an occlusion reproducing Follow-up visits, aimed at clinical and radiographic ex- the patient’s natural dentition, i.e. it will have a cantilever amination, were performed one week after implant distal to the first molar. placement. Subsequently, at three months, six months Post-surgical indications included the use of a post-sur- and then annually until a two-year follow-up was at- gical dressing and rinsing with a solution containing tained. The patient was instructed, by a dental hygienist, chlorhexidine digluconate (0.12% or 0.2%), twice a day in mechanical plaque control using an electric or manual for 10 days. In addition, the use of 1 g Amoxicillin and toothbrush, interproximal brushes and Super Floss (Oral Clavulanic Acid (Augmentin, GlaxoSmithKline) twice dai- B, Procter & Gamble, Cincinnati, OH, USA). While, pro- ly for 7 days after surgery and non-steroidal anti-inflam- fessional oral hygiene procedures were performed every matory drugs (Ibuprofen 600 mg, Brufen, Abbott Labo- three months, after implant placement. ratories, Chicago, IL, USA) was recommended should it be deemed necessary. Lastly, the patient was advised to Parameters evaluated eat a liquid diet and to avoid any brushing trauma to the surgical site, as well as smoking. The patient underwent Implants survival rate. Implant survival rate is based a follow-up visit after one week and the sutures were on the number of implants that were not lost or removed, removed at the same time (Fig. 13). during the follow-up period (15). 170 Annali di Stomatologia 2018; IX (4): 167-174 F. Orlando et al. Marginal bone loss. Intra oral radiographs, using the Intra- and post-operative complications. The patient, parallel cone technique, were taken after implant place- thanks to adequate glycemic control (20), did not suffer ment, at three, six, twelve months and once a year for from hypoglycemic crisis during the surgical procedure. the following two years of follow-up. To evaluate mar- No clinical signs of mucositis and peri-implantitis were ginal bone progression, the measurements were per- observed during the two-year follow-up. This was made formed using Digora 2.5 software (Soredex, Tuusula, possible by the patient’s inclusion in a maintenance Finland). First, the instrument was calibrated (pixel/ program of professional oral hygiene and control of the mm), using the diameter of the implants as the unit. diabetic pathology (21). The literature suggests that mu- Then, changes in the height of the peri-implant mar- cositis is caused by the accumulation of biofilm that inter- rupts host-microbe homeostasis at the implant-mucosal ginal bone with respect to the most coronal part of the interface, resulting in an inflammatory lesion. Mucositis implant fixture and the contact point between the im- is a reversible condition, so the clinical implication is that plant fixture and the marginal crest were measured. To optimal biofilm removal is a prerequisite for the preven- evaluate bone, a line passing over the shoulder of the tion and management of mucositis (22). Based on these implant was considered as a reference point for meas- considerations, it was agreed that periodic clinical and urement from which a straight line was drawn parallel radiographic controls should always be performed after to the long axis of the implant to the most coronal point implant placement to allow for the possible diagnosis of where the bone made contact with the fixture, both me- mucositis and peri-implantitis. Intra-oral radiographs, sially and distally. The software automatically provided taken during the follow-up period, confirmed that os- the distance between the two points measured in milli- seointegration had taken place. They showed intimate meters. To reduce human error, this measurement was contact between bone and implant, with an apparent ab- made by different operators, and the mean of the three sence of interposed fibrous tissue. The osseointegration measurements was considered. of the patient’s implants was promoted by the correct Then, to calculate the marginal bone level, a mesial implant placement, based on the primary stability, which measurement was taken, a distal measurement was was obtained by an insertion torque of 30 N (23). taken and then the average of the mesial, distal and the average between the two values of a single implant site Discussion was calculated. According with the clinical considerations examined, it will be necessary to follow an adequate diagnostic path- Intra-operative and post-operative complications. way, to obtain a predictable result of the implant-pros- thetic therapy of the diabetic patient. During the first visit, Intra-operative Post-operative in fact, the general medical and dental history plays a complications complications crucial role and allows the clinician to reach an adequate knowledge of the patient’s general and dental health sta- Mucositis and peri-implantitis tus (24). An anamnesis is followed by an extra- and in- Hypoglycaemic crisis Lack of osseointegration tra-oral examination; the latter paying particular attention not only to the dental elements present in the oral cavity Insufficient wound healing but also to the soft tissues surrounding the tooth or locat- ed on the edentulous ridges (25, 26). Before a diabetic patient undergoes oral surgery, it is Results necessary to establish the type of diabetes and the de- Implant survival rate. In the clinical case presented, the gree of glycaemic control. Robertson C et al., in a review diabetic patient who received implant rehabilitation, pre- of the literature, describe the criteria to establishing the sented laboratory tests appropriate for implant insertion. diagnosis of diabetes and to identifying individuals at high No implants were lost during the follow-up period. It is risk of developing the disease. They suggest that if pa- stated that the survival rate, two years after surgery, was tients with controlled diabetes maintain a Hba1c value of 100% (16,17). <7%, then it will be possible to proceed with surgery (27). In the literature review, by Ramu C. et al., the indications Marginal bone loss. Both axial and tilted implants for antibiotic prophylaxis in dental practice are stated. For patients with uncontrolled diabetes, antibiotic proph- showed marginal bone loss comparable to that of the ylaxis is considered mandatory as they are more sus- healthy patient (17-19). ceptible to oral infections. On the other hand, antibiotic prophylaxis is recommended for patients with controlled MARGINAL diabetes, both in the case of minor and major surgery BONE Axial implants Tilted implants (28). For these reasons, in agreement with the authors, LOSS the patient was given 2g of Amoxicillin and Clavulanic acid one hour before surgery, as a preventive measure. 6 months (mm) 0.61 ± 0.75 0.66 ± 0.58 The most serious complication, that a diabetic patient can experience during oral surgery, is a hypoglycemic 1 year (mm) 0.85 ± 0.83 0.86 ± 0.91 crisis. To prevent this fact, it is important to make sure that the patient has taken their usual medication and 2 years (mm) 0.86 ± 0.78 0.88 ± 0.64 eaten regularly before the appointment (29). If the pa- tient has lost consciousness due to hypoglycemic crisis, Annali di Stomatologia 2018; IX (4): 167-174 171  All-on-four rehabilitation in patient with type II diabetes mellitus: case report and literature review medical assistance should be sought; a solution of 25-30 to micro-vascular complications and delayed wound ml 50% dextrose or 1 mg glucagon should be injected healing (41). intravenously; glucagon can also be administered intra- In the retrospective study by Alberti et al., no difference muscularly or subcutaneously (30). According to Kidam- in implant survival (survival rate) after 10 years was bi S. et al., patients receiving oral antidiabetics have a shown in patients with diabetes (survival rate 96.5%), lower risk of developing hypoglycemic crises than those compared to patients without diabetes mellitus (surviv- receiving insulin therapy (31). al rate 94.8%) (42). According to the literature review, Holmstrup P. et al. state that, since diabetes mellitus by Naujokat H. et al., in the first years after implant is a systemic inflammatory state, often associated with placement, the survival rate of implants in patients periodontitis, in case of implant rehabilitation, the patient with controlled diabetes does not differ from that of may have an increased risk of developing mucositis and non-diabetics. However, when observed in the long peri-implantitis (32). In the literature, the correlation be- term, about twenty years, the implant survival rate is tween hyperglycemia and the risk of peri-implantitis is reduced in patients with controlled diabetes compared still a matter of discussion. Alberti A. et al., in their ret- to non-diabetic patients (43). rospective study, evaluated the influence of diabetes on Lorean A et Al., in their retrospective study, reported peri-implantitis and implant failure. They considered 204 that patients with high HbA1c values (8.1% to 10.0%) patients, treated with 929 implants. Of these, 19 were had greater marginal bone loss than those with lower diabetic patients and most of them showed good control HbA1c values (44). In agreement with this, Souto-Maior of their diabetic disease at the time of implant surgery. JR et al., through a systematic review of the literature, Among the diabetic patients only one showed peri-im- state that it is possible to observe marginal bone loss plantitis and another one showed increased implant that affects osseointegration (45). The factors that can failures. The results of these authors showed no asso- contribute to implant failure, as already described, are ciation between peri-implantitis, diabetes mellitus and many. However, according to the scientific review by implant failure (33). In contrast, Rekawek P. et al, in their Mombelli et al., bacterial plaque has a negative role in retrospective cohort study, examined 286 patients treat- the health of peri-implant oral tissues; in fact, the basis ed with 748 implants and found that diabetic patients had of a correct management of the bacterial flora is home an increased risk of peri-implantitis. However, this risk oral hygiene supported by professional services (46). It can be counteracted by placing patients on a mainte- is necessary to underline how fundamentally important nance regimen with regular visits and professional oral the synergy between the dental professional and the hygiene sessions (34). dental hygienist is in the context of successful implant Another clinical aspect affected by diabetes is implant rehabilitation, which, even more so in the treatment osseointegration. In the retrospective case-control study and monitoring of patients with systemic pathologies, by Sghaireen MG et al. 257 subjects were included, 121 must be expressed because of the potential risks of with and 136 without diabetes; diabetes was defined as any preoperative, intraoperative, and postoperative well controlled with a HbA1c of less than 8%. Implant complications (47, 48). failure in the osseointegration process was observed in 17 cases in the diabetes group (4.5%) and in 16 cases in the control group (4.4%), so that a non-significant differ- Conclusion ence (p = 0.365) was concluded (35). Schwarz F. et al., This case report could demonstrate that implant-pros- in their retrospective cohort study, evaluated immediate thetic rehabilitations in the totally edentulous patient loading in a patient with type II diabetes. In 108 diabetic with compensated diabetes could be safely applied. patients, immediately loaded implants showed identical Clinical studies should be performed to confirm this survival to those placed after 3 months (100% each) result. (36). In diabetic individuals, persistent hyperglycaemia suppresses osteoblastic activity and alters the response of parathyroid hormone which regulates calcium and References phosphorus metabolism (37), decreases collagen formation, induces apoptosis in bone lining cells and 1. Tetè G, Polizzi E, D’orto B, Carinci G, Capparè P. How to consider implant-prosthetic rehabilitation in elderly patients: increases osteoclastic activity resulting in bone loss a narrative review. J Biol Regul Homeost Agents. 2021 Jul- (38). The reduction in bone-implant contact confirms Aug;35(4 Suppl. 1):119-126. doi: 10.23812/21-4supp1-11. that diabetes inhibits osseointegration, unless hyperg- PMID: 34425667. lycemia is therapeutically treated, and normal glucose 2. 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Original article Rapid maxillary expansion in OSA children: Cone Beam CT skeletal and nasomaxillary complex airway volume changes evaluation and correlation Paola Pirelli* Conclusion Valeria Fiaschetti** Aldo Giancotti* Enlarged Posterior suture, pterygoideus process, maxil- Roberta Condò* lary width and Nasal cross-sectional width (PNS) showed Gianluca Mampieri* a direct correlation to increased airways volume, bring- ing a functional improvement. The increase in volume * Department of Clinical Sciences and Translational of the nasal cavity and nasopharynx, with expansion of Medicine, University Tor Vergata, Rome, Italy the nasal osseous width and maxillary width causing by ** Department of Biomedicine and Prevention, University RME treatment had a positive effect on children affected Tor Vergata, Rome, Italy by chronic snoring and OSA. The results show that the RME therapy can restore and improve a normal nasal airflow with disappearance of obstructive sleep breath- Corresponding author: ing disorder. Aldo Giancotti Department of Clinical Sciences and Translational Medi- Introduction cine, University Tor Vergata, Rome, Italy The Orthodontic treatment options in OSAS children have emerged in the past decade for children with Abstract OSAS (1-3). The nasomaxillary complex provides ante- rior bony support for the upper airways, and orthodontic Objective: evaluate the correlation between skeletal treatment affects these structures, causing changes in changes in 2D dimensions and volume changes of the airways to some extent. RME can help to increase the upper airways before and after rapid maxillary nasopharyngeal and oropharyngeal space for children expansion (RME) therapy in children with obstruc- with upper jaw restriction. This means that orthodontists tive sleep apnoea (OSA) by Cone Beam computed have the responsibility to understand the physiology of tomography (CBCT) and between volume of the up- upper airways (2-3). Katyal et al (4) showed how children per airways and clinical data. with narrow dentoalveolar transverse width and reduced Methods: 23 children with OSA and malocclusion nasopharyngeal and oropharyngeal sagittal dimensions underwent CBCT scans with a Dentascan and 3D had a high risk for sleep-disordered breathing. Many reconstruction program before (T0) and 4 months studies have reported the influence of RME on the upper after (T1) RME. Patients underwent an ENT visit with airways, though the results were different due to various auditory and respiratory tests, including a daytime subjects and expansion methods (5). sleepiness questionnaire, a 19-channel polysom- Imaging 3D software programs have been extremely nography, and an orthognatodontic examination. useful in assessing the benefits of RME. In recent times Results: in all cases opening of the mid-palatal su- a three-dimensional method of investigation (3D-CT) ture was demonstrated. Nasal osseous width, vol- ume of the total upper airways, nasal cavity and na- has been used to study the effects of RME treatment (6- sopharynx and oropharynx increased significantly 8) using low dose protocol (9). The same author (9, 10) (P, .05), and enlarged nasopharyngeal volume was studied the treatment and post-treatment skeletal effects correlated to increased nasal width at the PNS plane of RME, using low dose CT in growing subjects. (P, .05). Posterior suture, pterygoideus process, The CBCT systems are operated at a lower patient dose maxillary width and Nasal cross-sectional width than the MDCT systems, which are used for wide ranges (PNS) (W-PNS) have an excellent and statistically of exposure protocols in dental clinics (11) and have significant correlation coefficient with Total upper become a standard technique for dentomaxillofacial CT airway volume (V-TA) Nasal cavity volume (V-NC) imaging (12-14). (Nasopharyngeal airway volume (V-NPA) Oropha- They have also proven vital for structural comparisons ryngeal airway volume (V-OPA), while Anterior and between pre and post-clinical treatment and for the middle suture have an excellent and statistically sig- evaluation of the morphological changes caused by nificant correlation coefficient only with Oropharyn- the treatment, because they improved the visualization geal airway volume (V-OPA). of anatomical structures by rendering unnecessary the superimposition of conventional radiographs (15). Fur- Keywords: Rapid Maxillary Expansion, OSA chil- thermore, these programs enhance the accuracy of re- dren, Computed tomography. search findings, besides improving the effectiveness of Annali di Stomatologia 2018; IX (4): 175-183 175  Rapid maxillary expansion in OSA children any techniques applied, while facilitating the use of com- The patients were scanned in orthostatic position with puter tools for 3D image manipulation, be it by itself or the Frankfurt plane perpendicular to the floor, keeping the associated with other software (14, 15). teeth in centric occlusion and the tongue in the position The purpose of this study was to evaluate the correlation at the end of swallowing (against the palate), breathing between skeletal changes in 2D dimensions and volume smoothly, and no swallowing. The digital imaging and changes of the upper airways before and after rapid communications in medicine (DICOM) data were import- maxillary expansion (RME) therapy in children with ob- ed into Dolphin Imaging software (Chatsworth, CA, USA) structive sleep apnoea (OSA) by Cone Beam computed and used for the measurements described. Volumetric tomography (CBCT) and between volume of the upper measurements were carried out with the aid of Dolphin® airways and clinical data. Imaging v. 11.7 software, using the “Airways Volume” tool, and density was set at 55 for all patients. The images were evaluated in three views (sagittal, coro- Materials and methods nal and axial), thus delimiting the nasomaxillary complex, Subjects and then calculating the volume in cubic millimetres. Numerical evaluation of the various parameters was 78 children were selected from a sample of 120 patients based on the identification and registration of a group of presenting malocclusion (45 boys and 33 girls) with the reference points, identified on the CT images reformat- average age of 8.5 years (range: 5-12 years) present- ted on different planes. ing oral breathing, snoring and OSA symptoms. Patients Before landmark identification, the three-dimensional presenting adeno-tonsillar hypertrophy and body mass volumetric images were oriented with the Dolphin imag- index more than 24 kg/m2 were excluded from this sam- ing software as follows: coronal plane (horizontal line ple. Furthermore, a subsequent selection excluding the through orbital bilaterally), sagittal plane (Frankfurt hori- younger population was made: in order to reduce the zontal), and axial plane (Crista galli to basion). The Dol- probabilistic effects of ionizing radiation ―the stochas- phin software allowed automatic volume calculation after tic radiation effect― children between 5 and 9 years of segmenting the area of interest by setting the threshold age were excluded. Moreover, only patients with a good value of 55. polysomnography were selected, and patients who did The material was measured twice by the same author, not undergo second CT control or who had image arti- with at least one week interval between T0 and T1. facts in the first or second control were excluded. At the The following parameters were measured in millimetres: end of the screening the selected sample for the study (1) Suture opening was measured at three levels on the consisted of 23 patients with mixed dentition, an aver- axial plane: anterior edge, middle and posterior na- age age of 10.5 years (range 9 e12 years), an average sal spine. At T0 the measurement of the midpalatal apnoea/hypopnea index (AHI0) of 14.1 (±2.4), and an suture at three different levels was considered equal average minimum oxygen saturation of 75.8 (±8.3) %. to 0 in order to level the different values before RME Selection criteria included: malocclusion with upper jaw treatment that were in the range of 0-0.3. contraction, oral breathing, snoring and OSA symptoms (2) Maxillary base width was calculated on the axial (documented by polysomnography), no adenotonsillar plane between the vestibular border of buccal corti- hypertrophy, body mass index less than 24kg/m2. cal plate (left and right respectively). The points were Patients underwent an ENT visit with auditory and respira- joined using a line tangent to the dental root of the tory tests, including a daytime sleepiness questionnaire, first molar. a 19-channel polysomnography, an orthognatodontic ex- (3) The distance between the apices of the pterygoid amination and CB CT scans with a Dentascan and 3D processes (left and right) was calculated on the axial reconstruction program, before (T0) and 4 months after plane. (T1) RME. All the clinical investigations were carried out (4) Nasal cross-sectional (ANS) height (H-ANS): The before orthodontic therapy (T0), after 2 months (T1) with height of nasal cavity at the cross-section passing the device still on, and 4 months after the end of the through ANS on Coronal plane reconstruction. orthodontic treatment (T2). (5) Nasal cross-sectional (ANS) width (W-ANS): The This study was approved by Ethical Committee and greatest width of nasal cavity at the cross-section the informed consent was obtained from the parents or passing through ANS on coronal plane reconstruction. guardians of all patients. (6) Nasal cross-sectional height (midpoint) (H-mid): The Specific evaluations were made regarding the following height of nasal cavity at the cross-section passing parameters: maxillary suture width at anterior, middle though the midpoint between ANS and PNS on coro- and posterior level; nasal width; right and left molar an- nal plane reconstruction. (Fig. 1) gulation and pterygoid processes distance. Vertical and (7) Nasal cross-sectional width (midpoint) (W-mid): The horizontal dimensions and volume of the nasal cavity, greatest width of nasal cavity at the cross-section nasopharyngeal, oropharyngeal and the total pharynge- passing through the midpoint between ANS and PNS al airway volume were compared before and after RME. on coronal plane reconstruction. (Fig. 1) Correlations between changed volume and dimensions (8) Nasal cross-sectional height (PNS) (H-PNS): The were explored. height of nasal cavity at the cross-section passing through PNS on coronal plane reconstruction. Data collection (9) Nasal cross-sectional width (PNS) (W-PNS): The CBCT scans examinations (Newtom 5GXL) were per- greatest width of nasal cavity at the cross-section formed before expansion (T0) and after 4 months’ reten- passing through ANS on coronal plane reconstruction. tion (T1) by the same operator. The cavity volume was measured in mm3 by 3D images 176 Annali di Stomatologia 2018; IX (4): 175-183 P. Pirelli et al. Figure 1. (1) Nasal cavity volume (V-NC) bound by lines connect- Results ing the anterior nasal spine (ANS) to the tip of the nasal bone, then to nasion (N), then to sella (S), then The table 1 summarizes the results. to posterior nasal spine (PNS). In all the 23 cases, an opening of the midpalatal suture (2) Nasopharyngeal airways volume (V-NPA): The line was obtained, with resulting effects at different levels. passing through PNS and S is its anterior border, the line parallel to the Frankfurt horizontal plane (FHP) Midpalatal suture passing through PNS point is the inferior border, In all cases we obtained the opening of the midpalatal pharyngeal posterior wall is the posterior border. suture. The increase at the anterior level of the suture (3) Oropharyngeal airways volume (V-OPA): The line showed an average opening of 4.1 mm. This increase is parallel to FHP passing through the tip of the uvula evident with the appearance of an interincisive space, is the inferior border pharyngeal anterior wall is the the hallmark of the midpalatal suture opening that was anterior border and pharyngeal posterior wall is the always present in all cases; 3.1 mm at the medium level posterior border. of the suture; 1.95 at the posterior level of the suture. (4) Total upper airway volume (V-TA): The line passing (Fig. 2) through PNS and S is its anterior border, the top of the epiglottis is its inferior border, pharyngeal ante- Maxillary width rior wall is the anterior border and pharyngeal poste- rior wall is the posterior border added to nasal cavity RME therapy is responsible for the expansion of the volume (V-NC). maxilla with an average cross-sectional increase of Rhinomanometric and polysomnography was performed 3.5 mm. There were individual variations, although all before, after 2 and 4 months from RME. values showed clear differences between T0 and T1, The following parameters of the polysomnography test indicating that, in all patients, the manoeuvre had an were evaluated: Obstructive AHI Range, Nadir SPO2 expansive effect. (%), Duration of Longest Obstructive Apneas, Duration of Desaturation (S302<92%) ass% TST and Sleep Ef- Pterygoid processes ficiency (%). From the study of the pterygoid processes distance, we Statistical Analysis found an average increase of 2.6 m. W-ANS, W-mid, W-PNS, H-ANS, H-PNS and H-mid The normality of the data was evaluated using the Shap- We found an average increase respectively of 6.3mm, iro-Wilk test. Measurements for each patient before and 2.43mm, 3.1mm, 3.9mm, 0.5mm and 1.7mm. after treatment were compared with Wilcoxon’s paired In summary, the midpalatal suture was opened in all pa- matched test. Values are expressed as mean ± standard tients. A statistically significant difference was observed deviation. As a threshold of statistical significance, a between the measurements of the maxillary, nasal cavi- value of p _ 0.05 was used. ties, and pterygoid processes distance width, performed The Spearman coefficient, ⍴, was calculated for inter- before and after treatment. relationships between 2D and 3D measures. W-ANS, W-mid, W-PNS, showed a significant increase, The statistical treatment of the data was performed with while H-ANS, H-PNS and H-mid showed a non-statisti- the Statistical Package for the Social Sciences (SPSS), cally significant increase. version 22 for Windows. Annali di Stomatologia 2018; IX (4): 175-183 177  Rapid maxillary expansion in OSA children Table 1. Changes in the Volumes and Dimensions of the Upper Airway and Changes of Skeletal Widths Before (T0) and After (T1) Rapid Maxillary Expansion. Parameters T0 Mean (SD) T1 Mean (SD) (T1-T0) Mean (SD) P value* Anterior suture 0 4,1 4,1 <.001* Middle suture 0 3,1 3,1 <.001* Posterior suture 0 1,95 3,1 <.001* Pterygoideus processes 51,7 54,3 2,6 <.001* Maxillary width 51,6 55,1 2,6 .021* Total upper airway volume 60.8 (11.5) 70.3 (11.5) 9.4 (5.4) .012* (V-TA) Nasal cavity volume (V-NC) 32.3 (6.1) 39.5 (6.3) 7.2 (6.3) .014* Nasopharyngeal airway volume 8.8 (4.2) 10.8 (4.1) 2.0 (4.3) .003* (V-NPA) Oropharyngeal airway volume 11.37 (2.4) 14.94 (2.9) 3.57 (5.1) .004* (V-OPA) Nasal cross-sectional height 24.8 (6.3) 28.7 (6.5) 3.9 (6.1) .062* (ANS) (H-ANS) Nasal cross-sectional width 15.4 (6.2) 21.7 (6.4) 6.3 (6.3) .008* (ANS) (W-ANS) Nasal cross-sectional height 29.2 (2.1) 30.9 (2.2) 1.7 (2.3) .082* (midpoint) (H-mid) Nasal cross-sectional width 29.7 (2) 31.5 (2) 1.8 (2) .006* (midpoint) (W-mid) Nasal cross-sectional height 19.4 (2.4) 19.9 (2.6) 0.5 (2.2) .078* (PNS) (H-PNS) Nasal cross-sectional width 20.7 (4.4) 23.8 (4.7) 3.1 (4.2) <.001* (PNS) (W-PNS) Figure 2. The increased V-NPA was closely linked to the enlarged mm3 with a standard deviation of 6,3mm3, the mean na- W-PNS. sopharynx volume was 10.8 mm3 (DS = 4.1 mm3), the At T0 the mean total upper airways volume was 60.8 mean oropharynx volume was 14.9 mm3, with a standard mm3 (SD = 11,5 mm3), the mean nasal volume was 32.3 deviation of 2.9mm3. mm3 with a standard deviation of 6,1mm3, the mean na- The study shows an increase T0/T1: the total upper air- sopharynx volume was 8.8 mm3 (DS = 4.2 mm3), the ways volume of 9.4mm3 (SD = 5.4 mm3), the nasal vol- mean oropharynx volume was 11.3mm3, with a standard ume of 7.2 mm3 with a standard deviation of 6,3mm3, the deviation of 2.4 mm3. nasopharynx volume of 2.0 mm3 (DS = 4.3 mm3), the At T1 the mean total upper airways volume was 70.3 oropharynx volume of 3.5 mm3, with a standard devia- mm3 (SD = 11,5 mm3), the mean nasal volume was 39.5 tion of 5.1mm3. 178 Annali di Stomatologia 2018; IX (4): 175-183 P. Pirelli et al. Figure 3. The results confirmed the evidence obtained in the de- tal upper airway volume (V-TA) (respectively p .014,.023, scriptive analyses, meaning that the increase in total up- .033, .038; ρ.84,.87,.78,.78), Nasal cavity volume (V-NC) per airways volume (p < 0.05), nasal volume (p < 0.05), (respectively p .018,.027, .034, .032; ρ.82,.86,.81,.87), nasopharynx volume (p < 0.05) and oropharynx (p < Nasopharyngeal airway volume (V-NPA) (respectively p 0.05), were statistically significant. (Fig. 3) .018,.038, .036, .031; ρ.89,.88,.82,.91), and Oropharyn- Enlarged nasopharyngeal volume was correlated to in- geal airway volume (V-OPA) (respectively p .021,.042, creased nasal width at the PNS plane (P, .05). Posterior .039, .039; ρ.87,.89,.81,.72). While Anterior and middle suture, pterygoideus process, maxillary width and Nasal suture have an excellent and statistically significant corre- cross-sectional width (PNS) (W-PNS) have an excellent lation coefficient only with Oropharyngeal airway volume and statistically significant correlation coefficient with To- (V-OPA) (respectively p .047,.031; ρ.78,.75). (Table 2) Table 2. Correlation Coefficient Between Significant Changes of Upper Airway Volume and Other Variables. Total upper Nasopharyngeal Oropharyngeal Nasal cavity PARAMETERS airway volume airway volume airway volume volume (V-NC) (V-TA) (V-NPA) (V-OPA) p value* ρ p value* ρ p value* ρ p value* ρ Anterior suture 0.676 .37 0.721 .42 0.684 .43 0.047 .78 Middle suture 0.564 .46 0.642 .41 0.691 .38 0.031 .75 Posterior suture 0.014 .84 0.018 .82 0.018 .89 0.021 .87 Pterygoideus processes 0.023 .87 0.027 .86 0.038 .88 0.042 .89 Maxillary width 0.033 .78 0.034 .81 0.036 .82 0.039 .81 Nasal cross-sectional height 0.326 .24 0.289 .27 0.295 .31 0.542 .12 (ANS) (H-ANS) Nasal cross-sectional width 0.321 .52 0.332 .58 0.298 .57 0.284 .52 (ANS) (W-ANS) Nasal cross-sectional height 0.415 .26 0.435 .22 0.447 .21 0.479 .14 (midpoint) (H-mid) Nasal cross-sectional width 0.124 .54 0.147 .57 0.165 .58 0.197 .56 (midpoint) (W-mid) Nasal cross-sectional height 0.235 .25 0.224 .22 0.264 .24 0.297 .18 (PNS) (H-PNS) Nasal cross-sectional width 0.038 .78 0.032 .87 0.031 .91 0.039 .72 (PNS) (W-PNS) * Represents a significant correlation, P, .05. Annali di Stomatologia 2018; IX (4): 175-183 179  Rapid maxillary expansion in OSA children Table 3. Polysomnographic data. Note the significant improvement in all the functional parameters achieved at T2. All data are displayed as mean _ standard deviation. Abbreviations: TST, total sleep time; T0, before any orthodontic ther- apy; T1, after 4 weeks with the device; T2, 4 months after the end of the orthodontic treatment. T0 T1 T2 Range 6.1-22.4 Range 0-9.1 Range 0-26 OBSTRUCTIVE AHI Averange 16.3 2.5 Averange 8.3 2.3 Averange 0.8 1.3 Nadir SPo2 (%) 77.9 ± 8.4 90.2 ± 5.7 95.4 ± 1.4 Duration of longest 39.8 ± 17.2 24.3 ± 12.3 12.1 ± 6.5 obstructive apneas Duration of desaturation 18.5 ± 3.2 5.8 ± 1.3 1.3 ± 1.4 (S302 < 92%) ASS % TST Sleep efficiency (%) 88.5 ± 9.1 88.9 ± 5.7 89.8 ± 8.5 These CBCT changes were associated with changes in CT), has been used to study the effects of RME treat- PSG findings with an AHI ¼ 0.5 (±1.3) and lowest satura- ment (19) and imaging software programs have been ex- tion ¼ 96.1 (±1.8) %. tremely useful in assessing the benefits of RME (20, 21). The Table 3 shows polysomnography data in terms of Respiratory problems associated with transverse maxil- average of obstructive AHI Range, Nadir SPO2 (%), Du- lary deficiency have been widely discussed by orthodon- ration of Longest Obstructive Apneas, Duration of De- tists and otolaryngologists, given the relation between saturation (S302<92%) ass% TST and Sleep Efficiency causes, effects and treatment. (%) at T0, after 2 and 4 months from RME. RME anchored on teeth is performed more and more Polysomnography presents a normalization of recording in young children with OSA, as the presence of an ab- in the AHI in all patients at the end of 4 months. normal narrow palate is frequently noted with or without The baseline rhinomanometric data showed a statisti- enlarged adenotonsils (22), particularly after the dem- cally significant difference between those measured at 2 onstration of incomplete results of tonsillectomy and ad- and 4 months (Wilcoxon Z 5–4.86, P5 .000; Wilcoxon Z enoidectomy (T&A) surgery and reoccurrence of abnor- 5 –5.39, P 5 .000, respectively). The difference between mal breathing during sleep post T&A (23, 24). rhinomanometric data at 2 and 4 months was also statis- Today, rapid maxillary expansion is regarded as an im- tically significant (Wilcoxon Z 5 –4.86, P 5 .000). portant method to correct maxillary deficiency and this The difference between baseline AHI and that at 2 and 4 technique has been validated by many other authors months was statistically significant (Wilcoxon Z 5 –4.0, P as it makes the splitting of the midpalatal suture pos- 5 .000; Wilcoxon Z 5 –5.15, P 5 .000, respectively). sible while producing certain changes in the nasal cavity, The difference between AHI at 2 and 4 months was also which improves breathing (25-27). statistically significant (Wilcoxon Z 5 –2.0, P 5 .046). Increases in nasal width and height, and changes in Four months after the end of the orthodontic treatment nasal volume between pre and post-RME, assessed by (T2), all tests showing a normalization of functional ex- Cone Beam computed tomography, have been observed aminations were confirmed. by several authors (28, 29). This was also among the goals of this study, which were confirmed by the results. Discussion It is no doubt that an improved breathing pattern is an important clinical achievement, as observed in this A lot of studies have demonstrated the accuracy of the study immediately following RME. Our patients showed CBCT and its low radiation dose on pediatric patients an increase in nasal cavity volume after RME, with this (14-16). The need to reduce the radiation dose also outcome being confirmed by an image manipulation pro- arose to fully adhere to both the Italian regulatory frame- gram with 3D images, and by quantification of the mea- work and the European dosimetric levels, reported by sured areas. the International Commission on Radiological Protec- The same results were observed in all measures of the tion, for which the use of ionizing radiation in the health nasomaxillary complex. field must be justified by the advantages that can derive We found clear orofacial skeletal modifications related to from it. This meant that exposure had to be be kept as RME, including the changes of the pterygoid processes low as reasonably possible, consistently with diagnos- in our subjects. tic needs (17, 18) (a principle of primary importance in Imaging is only a part of a sleep-disordered-breathing in- particular in the pediatric patients). Usage of 3D-CB CT vestigation, and had to be integrated into the overall re- is not new when considering changes in upper-airways sults, including those obtained during sleep with nocturnal morphology following RME. DiCarlo et al. (18) performed polysomnography; but the 3D-CT provided valid informa- a systematic review for coherent protocols with CBCT to tion on the skeletal changes obtained with treatment. measure airways dimensions and morphology. In recent The results we obtained show that the RME therapy times a three-dimensional method of investigation (3D- widens nasal fossa, thus restoring a normal nasal air- 180 Annali di Stomatologia 2018; IX (4): 175-183 P. Pirelli et al. flow with disappearance of obstructive sleep-disordered polysomnography presented a normalization of record- breathing. ing in the AHI in all patients at the end of the 4 months, The improvement can be clearly linked to the skeletal and the baseline rhinomanometric data showed a statis- expansion caused by the manoeuvre performed on the tically significant difference between those measured at suture. 2 and 4 months. CBCT images before and after RME therapy confirm that Several methods have been proposed to evaluate the expansion occurs not only in the maxillary arch but changes in respiratory efficiency as a result of RME. also in the nasal cavity. This anatomic change brings De Filippe et al (36), through the use of morphometric 3D about an increased patency of the upper airways, re- analysis and acoustic rhinometry, showed an increase in storing normal airflow. This patency is the basis for the cross sectional in the area of the nasal cavities, followed positive effects induced by the manoeuvre, and it acts by a 34% decrease in nasal resistances. In fact a follow- on air exchange, with a net improvement of breathing up to 60 months confirms the stability of the treatment. disorders during sleep (30-32). Enoki et al (37) evaluated changes in respiratory func- Increasing of upper jaw cross section also clearly affects tion in 29 children through the use of three otolaryngol- the nasal cavities, and it is a true anatomic change that ogy examinations: nasofibroscopy, acoustic rhino-metria brings about an increased patency of the upper airways. and rhinomanometry, carried out before, immediately af- This increase is also the basis for the positive effects ter and 90 days after rapid expansion. Rhinonomanome- induced by the RME manoeuvre on the respiratory func- try showed a progressive decrease in resistance to both tion. Associated orthodontic movements can also indi- inhalation and extraction. rectly improve the oropharyngeal space by modifying the Iwasaki et al. (38) investigated the effects of RME on resting posture of the tongue. (20) nasal respiratory flow in terms of pressure and speed in Several (33, 34) studies demonstrate an increase in the 22 subjects of average age of 9 years. Eighteen patients volume of the upper airways as a result of lateral dis- treated with RME benefitted from a 66.7% reduction in placement of the walls of the nasal cavity, caused by the nasal resistance and a 46.5% decrease in blood pres- rapid expansion of the palate. Over the past decade the sure. In 2015 Fastuca et al (39) evaluated respiratory re- volumetric airways analysis with CBCT was investigated sponse following RME on 15 subjects (average age 7.5) as well as the effects of RME on respiratory function. and observed a significant correlation between respira- In our series volume of the total upper airways, the nasal tory volume and blood oxygen saturation level (spO2). cavity, the nasopharynx and the oropharynx showed sig- These results correlate the expansion of the jaw to an nificant increases, consistent with some previous studies increase in the diameter of the airways, a decrease in (29-32). Kim et al (35) demonstrated that volume of the respiratory resistance, and an improvement in the pa- nasal cavity increased continuously from pre-expansion tient’s respiratory pattern. Through polysomnography to immediately after expansion, and to 1 year after ex- (PSG) the same authors found an improvement in the pansion. They reported that nasopharyngeal volume Apnea-Hypopnea Index (AHI) with a reduction in apneic showed a significant increase 1 year after expansion, episodes of 4.2 per hour. compared with the initial volume. In the same year Ghoneima (40) showed how RME had In addition, we found a correlation between increased positive effects in terms of pressure reduction, speed nasal osseous width at the PNS plane and expansion of and airway resistance, and these changes were capable nasopharyngeal volume: in fact the cross-sectional area of changing the airflow pattern from turbulent to laminar. of the upper airways at the PNS plane enlarged with the All the effects on respiratory function mentioned above increase of maxillary width. we also demonstrated in our make RME the therapy of choice in the case of patients study how enlarged nasopharyngeal volume was corre- with OSAS without obvious upper airways obstructions. lated to increased nasal width at the PNS plane (P, .05), In fact, under physiological conditions, the nose contrib- how posterior suture, pterygoideus process, maxillary utes 50% of respiratory resistance, and RME is able to width and Nasal cross-sectional width (PNS) (W-PNS) significantly decrease these resistances (37). was correlated to increased total upper airway volume The authors suggest careful evaluation of the maxillary (V-TA), Nasal cavity volume (V-NC), Nasopharyngeal skeleton base status as a possible common cause of airway volume (V-NPA) and Oropharyngeal airway vol- OSAS and recommend resorting to RME therapy. ume (V-OPA) , while Anterior and middle suture was RME can improve nasal airflow, leading to better ventila- correlated to increased Oropharyngeal airway volume tory function through increased upper airways volume, (V-OPA). so it could be a therapeutic option for nasal obstruction. Referring to a previous study, the upper airways were Orthodontists may play an important role in the interdis- divided into more segments in this study, resulting in sig- ciplinary treatment of OSAS because a high percentage nificant changes in all its parts. of patients with OSAS suffer from maxillary narrowness. Kim et al (35) also showed no changes in volumes of the The authors’ experience shows that RME treatment has inferior section of the upper airways and MCA, in accor- a positive effect on children affected by chronic snoring dance with the data reported in the literature. and OSA (41, 42). By changing the anatomic structures, Many studies agree that the expansion of the nasal cav- RME brings a functional improvement. It is always im- ity and the increased distance between the side walls portant to assess the condition of the upper jaw to con- and the septum caused a reduction in air resistance (36- sider RME therapy in the multidisciplinary treatment of 40), facilitating physiological breathing. In our series, OSAS in children. Annali di Stomatologia 2018; IX (4): 175-183 181  Rapid maxillary expansion in OSA children Conclusions 15. Van Acker JWG, Pauwels NS, Cauwels RGEC, Ra- jasekharan S. Outcomes of different radioprotective pre- Enlarged Posterior suture, pterygoideus process, maxil- cautions in children undergoing dental radiography: a sys- lary width and Nasal cross-sectional width (PNS) showed tematic review. Eur Arch Paediatr Dent. 2020 Aug;21(4): a direct correlation to increased airways volume, bring- 463-508. 16. ICRP. Retrieved 18 November 2020 ing a functional improvement. The increase in volume 17. Direttiva 2013/59/Euratom , GU Serie Generale n.201 del of the nasal cavity and nasopharynx, with expansion of 12-08-2020 - Suppl. Ordinario n. 29 the nasal osseous width and maxillary width causing by 18. Di Carlo G, Saccucci M, Ierardo G, et al. Rapid-maxillary- RME treatment had a positive effect on children affected expansion and upperairways morphology: a systematic review on the role of cone beam computed tomography. by chronic snoring and OSA. The results show that the BioMed Res Int 2017:546-49. RME therapy can restore and improve a normal nasal 19. Hakan E, Palomo JM. Three-dimensional evaluation of up- airflow with disappearance of obstructive sleep breath- per airways following rapid maxillary expansion. A CBCT ing disorder and 3D reformatting CBCT confirmed the study. Angle Orthod 2014;84:265-73. real remodeling of craniofacial structure and nasomaxil- 20. Iwasaki T, Saitoh Y, Takemoto Y, et al. Tongue posture im- provement and pharyngeal airways enlargement as sec- lary complex airway volume, ondary effects of rapid maxillary expansion: a cone-beam computed tomography study. Am J Orthod Dentofacial Or- thop 2013;143:235-45. References 21. Villa MP, Rizzoli A, Miano S, et al. Efficacy of rapid maxil- 1. Pirelli P, Saponara M, Guilleminault C. Rapid maxillary ex- lary expansion in children with obstructive sleep apnea syn- pansion (RME) for pediatric obstructive sleep apnea: a 12- drome: 36 months of follow-up.Sleep Breath 2011;15:179-84. year follow-up. Sleep Med 2015;16: 933-5. 22. Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, et al. 2. Pirelli P, Fiaschetti V , Fanucci E , Giancotti A , Condo’ R , Adenotonsillectomy outcomes in treatment of obstructive Saccomanno S , Mampieri G. Cone beam CT evaluation sleep apnea in children: a multicenter retrospective study. of skeletal and nasomaxillary complex volume changes af- Am J Respir Crit Care Med 2010;182:676-83. ter rapid maxillary expansion in OSA children . Sleep Med . 23. Huang YS, Guilleminault C, Lee LA, et al. Treatment out- 2021 Oct;86:81-89. doi: 10.1016/j.sleep.2021.08.011. comes of adenotonsillectomy for children with obstruc- 3. Pirelli P, Saponara M, Guilleminault C. Rapid maxillary ex- tive sleep apnea: a prospective longitudinal study. Sleep pansion in children with obstructive sleep apnea syndrome. 2014;37:71-6. Sleep 2004;27:761-6. 24. Guilleminault C, Monteyrol PJ, Huyhn NT, et al. Adeno- 4. Vandana Katyal , Yvonne Pamula, Cathal N Daynes, James tonsillectomy and rapid maxillary distraction in prepubertal Martin, Craig W Dreyer, Declan Kennedy, Wayne J Samp- children: a pilot study. Sleep Breath 2011;15:173-7. son . Craniofacial and upper airways morphology in pediat- 25. Chuang, Li-Chuan; Hwang, Yi-Jing; Lian, Yun-Chia; Hervy- ric sleep-disordered breathing and changes in quality of life Auboiron M., Pirelli P.,Huang Y.,Guilleminault C. Changes with rapid maxillary expansion Am J Orthod Dentofacial in craniofacial and airways morphology as well as quality Orthop . 2013 Dec;144(6):860-71. of life after passive myofunctional therapy in children with 5. Camacho M, Chang ET, Song SA, et al. Rapid maxil- obstructive sleep apnea: a comparative cohort study. Sleep lary expansion for pediatric obstructive sleep apnea: a and breathing 2019; 23 (4): 1359-1369 systematic review and meta-analysis. Laryngoscope 26. Baratieri C C, Alves Jr M, De Souza MMG, et al. Does rapid 2017;127:1712-9. maxillary expansion have long-term effects on airways di- 6. Fanucci E, Leporace M, Di Costanzo G, et al. Multidetec- mensions and breathing? Am J Orthod Dentofacial Orthop tor CT and Dentascan software: dosimetric evaluation and 2011;140:146-56. technique improvement. Radiol Med 2006;111:130-8. 27. Lin, Cheng-Hui; Chin, Wei-Chih; Huang, Yu-Shu; Wang,P; 7. Fanucci E, Fiaschetti V, Ottria L, Mataloni M, Acampora Li,K; Pirelli,P; Chen,Y; Guilleminault C. Objective and sub- V, Lione R, Barlattani A, Simonetti G. Comparison of dif- jective long term outcome of maxillomandibular advance- ferent dose reduction system in computed tomography ment in obstructive sleep apnea Sleep Medicine   2020; for orthodontic applications. Oral Implantol (Rome). 2011 ‫‏‬74:289-296 28. Zeng J, Gao X. A prospective CBCT study of upper airways Jan;4(12):14-22. changes after rapid maxillary expansion. Int J Pediatr Oto- 8. F Ballanti , R Lione, V Fiaschetti, E Fanucci, P Cozza rhinolaryngol 2013;77:1805-10. Low-dose CT protocol for orthodontic diagnosis Eur J 29. Luciana Duarte Caldas1, Wilton M. Takeshita2, André Wil- Paediatr Dent . 2008 Jun;9(2):65-70. son Machado3, Marcos Alan Vieira Bittencourt. Effect of 9. Ballanti F, Lione R, Bacetti T, et al. Treatment and post- rapid maxillary expansion on nasal cavity assessed with treatment skeletal effects of R.M.E. investigated with cone-beam computed tomography. Dental Press J Orthod. low-dose computed tomography in growing subjects. Am J 2020 May-June;25(3):39-45 Orthod Dentofacial Orthop 2010;138:311-7. 30. Mario Cappellette Jr.1, Fabio Eduardo Maiello Monteiro 10. Pirelli, Paola; Fanucci, Ezio; Giancotti, Aldo; Di Girolamo Alves1, Lucia Hatsue Yamamoto Nagai1, Reginaldo Rai- M, Guilleminault C et al. Skeletal changes after rapid max- mundo Fujita1, Shirley Shizue Nagata Pignatari1 Impact illary expansion in children with obstructive sleep apnea of rapid maxillary expansion on nasomaxillary complex evaluated by low-dose multi-slice computed tomography. volume in mouth-breathers. Dental Press J Orthod. 2017 Sleep Medicine 2019 ; 60: 75-80   May-June;22(3):79-88 11. Guijarro-Martínez R, Swennen GR. Three-dimensional 31. 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Review article Surgical management of acute retrograde peri-implantitis: a review of current literature li na Bianca Di Murro DDS peri-apical lesion was observed in 34/36 implants Piero Papi DDS (94.5%), with complete radiographic bone fill and Giorgio Pompa MD, DDS absence of further symptomatology. io Conclusions: Several surgical techniques have been reported for lesions, with proper endodontic Oral Surgery Unit, Department of Oral and Maxillo- evaluation of adjacent teeth. Surgical and chemi- az Facial Sciences, “Sapienza” University of Rome, cal debridement of the implant associated with Rome, Italy GBR considered the preferred treatment option. Key Words: retrograde peri-implantitis, apical rn Corresponding Author: peri-implantitis, surgical treatment, surgical man- Bianca Di Murro agement, review. Oral Surgery Unit Department of Oral and Maxillo-Facial Sciences te “Sapienza” University of Rome Introduction Via Caserta 6 00161 Rome, Italy In recent years, implant placement has become E-mail: [email protected] In widespread in clinical practice (1), with long-term suc- cess and survival rates reported in literature (2). Its massive use, however, has resulted in different types Summary of complications, divided in mechanical (3,4) and bio- logical (5-7). When, after implant placement, localized ni Aims: Periapical implant lesions, also named api- pain develops in the apical area, with or without radio- cal peri-implantitis or retrograde peri-implantitis, graphic changes, a periapical implant lesion should be were described since 1992, and are characterized suspected (8). Periapical implant lesions, also named io by progressive bone loss at the periapex of the apical peri-implantitis or retrograde peri-implantitis, implant. Several case reports have suggested were described, for the first time, by McAllister et al. these lesions are possible causes for early im- (9) in 1992. These lesions are characterized by pro- iz plant failure. The aim of this article was to review gressive bone loss at the periapex of the implant and the Literature to identify current knowledge on several case reports have suggested they are the surgical management of acute retrograde peri-im- possible cause of early implant failure (10-12). Ed plantitis. The retrograde peri-implantitis (RPI) has a preva- Methods: The Authors conducted an independent lence (13) of 0.26%, significantly lower than marginal search of the literature, for reports published peri-implantitis; although its incidence may increase from 1st January 2008 up to 1st December 2018 in up to 7.8% when teeth adjacent to the implant exhibit English in several databases: Pubmed, Web of an endodontic infection (14). Science, SciVerse, MEDLINE and through The It seems positively correlated with the presence of a IC Cochrane Database of Systematic Reviews. Only small distance between an implant and its adjacent articles reporting data on the surgical treatment tooth and a shorter time elapsing from the endodontic of dental implants affected by retrograde peri-im- treatment of the adjacent tooth to the implant place- plantitis were included. Articles with unclear or ment (13). The aetiology of this lesion is still unclear. C unavailable data or with less than 6 months of fol- According to several Authors, the most likely cause is low-up were excluded. the endodontic pathology of the tooth replaced by the Results: A total of 47 records was identified implant or of the adjacent tooth (15,16). Among other through database searching. After removal of du- factors hypothesized, contamination of the implant © plicates, twenty-three studies were selected for ti- surface (17), bone overheating, pre-existing bone dis- tle and abstract analysis, with 14 articles consid- ease, presence of root fragments or foreign bodies ered for detailed screening. Eight studies were in- were reported in literature (10,18-20). The diagnosis cluded in the present review: four case series and of RPI is both clinical and radiological, with lesions four case reports. A total of 36 dental implants classified into two groups: inactive and active forms was treated, with follow-up ranging from 6 (17). The inactive lesions show no symptomatology months to 6 years. Successful resolution of the and are radiologically represented as a radiolucency 106 Annali di Stomatologia 2018;IX (3):106-110  Treatment of retrograde peri-implantitis: a review around the apex of the implant. These lesions do not Search strategy need further treatment, although these patients The following search strategy was performed: “retro- should be inserted in a proper follow-up program: grade peri-implantitis” OR “periapical peri-implantitis” standardized periapical X-rays every 6 months. If an OR “periapical implant lesion” OR “apical peri-implan- expansion of radiolucency occurs, it may indicate ac- titis” AND “treatment” OR “surgical treatment” OR li tivation and needs surgical intervention. On the con- “surgical management”. trary, active lesions usually showed symptoms (17) na such as: persisting pain at the mucosa correspondent Study selection to the implant (19), inflammation, suppuration by fis- Only articles in English and reporting data on the sur- tula discharge, mobility and dull percussion (21, 22). gical treatment of at least one dental implant affected According to Pennarrocha- Diago et al. (23), the evo- by retrograde peri-implantitis were included. Random- lution stage of the periapical lesion should be divided io ized clinical trial, prospective or retrospective cohort in three parts, promptly individuated and included in studies, case-control studies, case series or case re- the diagnosis to determine the best suitable treatment ports were included. Articles with unclear or unavail- strategy. able data or with less than 6 months of follow-up az Acute periapical lesion staging can be divided into were excluded. three parts: 1. Non-suppurated: there are no radiographically de- Quality and risk of bias assessment tectable changes in bone density around the apex To evaluate methodological quality of case reports rn of the implant, but a spontaneous and localized and case series included, a recently modified version pain at the implant mucosa is present. of the Newcastle-Ottawa Scale was used (24). This 2. Suppurated: an appreciable radiolucency is pre- tool is divided into four sections: selection (1 item), sent as a result of purulent collection around the te ascertainment (2 items), causality (4 items) and re- apex of the implant, with an active process of porting (1 item). As suggested by the Authors (24), bone reabsorption. results of the items are not summarised to obtain an 3. Suppurated-fistulized: there is a visible radiolu- aggregate score to evaluate methodological quality: In cency, a fistulous tract from the apex of the im- on the contrary, an overall judgment is expressed for plant is detectable in the buccal plate or in coro- each article (low-medium-high). The Cochrane Col- nal direction. Diagnosis of retrograde peri-implan- laboration’s two-part tool for assessing risk of bias titis, and therefore its prevalence, may also be in- was used. Bias is assessed as a judgment (high, low, fluenced by the limits of two-dimensional radi- ni or unclear) from five domains (selection, perfor- ographic imaging systems, with an underestima- tion that can be solved by the use of three-dimen- mance, attrition, reporting, and other). sional cone beam. io The aim of this article was to review the Literature to identify current knowledge on surgical management Results of acute retrograde peri-implantitis. iz Study selection Two reviewers (BDM, PP), independently from each Materials and methods other, extracted pertinent data (year; study design; Ed number of implants; surgical technique; outcome and To address the research purpose, the Authors (BDM, follow-up time) from selected studies. A total of 47 PP) conducted an independent electronic search of records was identified through database searching. the literature for reports published from 1st January After removal of duplicates, twenty-three studies were 2008 up to 1st December 2018 in English in several selected for title and abstract analysis, with 14 arti- databases: Pubmed library, Web of Science (Thom- cles considered for detailed screening (Fig. 1). The IC son Reuters), SciVerse (Elsevier), MEDLINE (OVID) kappa agreement between reviewers was 0.9. and through The Cochrane Database of Systematic Reviews (CDSR). In addition, a manual search was Population performed in the databases of the following journals: A total of 36 dental implants was treated, with follow- C Implant Dentistry; Clinical Oral Implants Research; up ranging from 6 months to 6 years. Successful res- Clinical Implant Dentistry and Related Research; Eu- olution of the peri-apical lesion was observed in ropean Journal of Oral Implantology; International 34/36 implants (94.5%), with complete radiographic Journal of Oral & Maxillofacial Implants; Journal of bone fill and absence of further symptomatology. © Oral Implantology; International Journal of Oral and Maxillofacial Surgery; International Journal of Oral Quality assessment and Maxillofacial Surgery; Journal of Periodontology; Eight studies were included in the present review: Journal of Clinical Periodontology; International Jour- four case series and four case reports. All articles nal of Periodontics and Restorative Dentistry; Journal were classified as low-quality studies, in accordance of Prosthetic Dentistry; International Journal of En- with the adapted version of the Newcastle-Ottawa dodontics; Journal of Endodontics. Scale. Annali di Stomatologia 2018;IX (3):106-110 107  B. Di Murro et al.
*)('&%$+#%)"!# #)%+!&'+%!$)+ $)&(#"+ 
 %%#!#'"+&)('&%$+#%)"!# #)%+ "+++ !&'+'!)&+$'&()$+ "+++++ li . na *)('&%$+ !)&+%#(!)$+&)')%+ "+++  io *)('&%$+$(&))")%+ *)('&%$+) (%)%+ "++++ "++ + az +  !) !+&!#()$+$$)$$)%+  !) !+&!#()$+) (%)%+ '&+)####! + #!+&)$'"$+     rn + "+++++ "+++ + te !%#)$+#"(%)%+#"+#!!#)+$ "!)$#$+ "+++ In   ni Figure 1. PRISMA Flow-chart of study selection. io Surgical treatment options: disappearance of the apical radiolucency. Follow- -Surgical and mechanical debridement of the apical up time ranged from 12 to 36 months. - Quaranta et al. (27) (2014, case report): Surgical iz part of the implant. -Surgical and mechanical debridement of implant with and mechanical debridement was performed on 1 Guided Bone Regeneration (GBR) of the defect. implant with application of tetracycline paste. Ed -Implant apex resection. Then, placement of a bioabsorbable pericardium membrane over the defect. Resulted in complete Risk of bias radiographic bone fill and absence of clinical All 8 studies included were classified as having a symptoms. Five years follow-up. high-risk of bias (Tab. 1). - Mohamed et al. (28) (2012, case report): Surgical and mechanical debridement was performed on 1 Study results dental implant, then Guided Bone Regeneration IC Based on the analysis of studies included, the follow- (GBR) with a xenograft and Platelet Rich Fibrin ing surgical options are presented in detail: (PRF). Furthermore, endodontic retreatment of - Dahlin et al. (25) (2009, case series): Implant adjacent teeth. Resulted in complete radiographic apex resection was performed on 2 implants. Re- bone fill and absence of clinical symptoms. One C sulted in complete healing without further sympto- year follow-up. matology and complete radiographic bone fill into - Penarrocha-Diago et al. (29) (2013, case series): the resected area. Follow-up period ranged from Surgical and mechanical debridement was per- 1 to 3 years. formed on 22 dental implants, with an implant sur- © - Zhou et al. (26) (2012, case series): Surgical and vival rate of 91% with no radiologic or clinical al- mechanical debridement of periapical lesion was terations. Follow-up period from 1 to 6 years. performed on 6 implants, trepanation and curet- - Chan et al. (30) (2011, case series): Surgical and tage of the apical part of the implant within irriga- mechanical debridement was performed on 2 im- tion by natural saline and chlorhexidine, further plants. Furthermore, irrigation with 0.12% application of tetracycline paste. Uneventful heal- chlorhexidine gluconate and GBR using an allo- ing resulted for all patients treated, with complete graft mixed with 250 mg tetracycline powder and 108 Annali di Stomatologia 2018;IX (3):106-110  Treatment of retrograde peri-implantitis: a review Table 1. Risk of bias of studies included (-: high risk of bias; +: low risk of bias). Author Random Allocation Blinding Incomplete Selective Other sequence concealment outcome data reporting bias generation li Dahlin, et al. - - - - - + Zhou, et al. - - - - - + na Quaranta, et al. - - - - - + Mohamed, et al. - - - - - + Penarrocha-Diago, et al. - - - - - + io Chan, et al. - - - - - + Sarmast, et al. - - - - - + az Soldatos, et al. - - - - - + rn an absorbable membrane. Healing was unevent- just prescribing an antibiotic therapy to the patient ful and significant radiographic resolution of the with/without endodontic treatment of the adjacent lesions was observed. Six months follow-up. tooth, resection of the apical part of the dental im- - Sarmast et al. (31) (2017, case report): Surgical plant, endodontic re-treatment and apicoectomy of te and mechanical debridement was performed on 1 the adjacent tooth to surgical/chemical debridement dental implant, irrigation with 0.9% sodium chlo- of the apical part of the implant with/without guided ride and chemical debridement using EDTA/ bone regeneration (GBR) procedures (36). chlorhexidine 2%, tetracycline. GBR with freeze- In This systematic review included only case series and dried bone allograft (FDBA) 50/50 and an ab- case reports, which are considered to be of the sorbable membrane. Healing was characterized lowest scientific evidence, with absence of higher by absence of symptoms and radiographic bone quality studies. Another limitation is represented by filling. One year follow-up. the limited follow-up available, with only one study ni - Soldatos et al. (32) (2018, case report): Surgical with long-term evaluation (>5 years), and by the very and mechanical debridement was performed on 1 low amount of dental implants included (n=36). dental implant, with implant surface decontami- Peri-implant diseases are well documented condi- io nated by means of an air-abrasive device with tions in literature, with a still unclear etiology (37, 38), amino acid glycine powder and Er,Cr:YSGG laser however the available scientific evidence on retro- (wavelength of 2,780 nm) at 1.5 W/25 Hz. GBR grade peri-implantitis is very limited, with only case iz performed with FDBA and a collagen membrane. reports or case series present in literature (35). Resulted in complete remission of symptomatol- Based on the findings of this review, surgical and me- ogy and radiographic bone fill. Thirty-three chanical debridement of the apical part of the implant Ed months follow-up. associated with GBR with allograft and absorbable membrane was the surgical treatment option most used. Several chemical agents were used to decon- Discussion taminate the implant surface, with irrigation by means of physiologic saline solution and chlorhexidine as Retrograde peri-implantitis aetiology is still controver- the most performed. Only one article reported data on IC sial and this leads to a large underestimation of the apex resection of the implant affected by RPI. pathology (17). In the past 20 years, various surgical techniques have been used and further studies with a longitudi- Acknowledgements C nal design are needed to identify a proper clinical management (31). Treatment for RPI depends both The Authors declare they have no conflict of interest on clinical presentation and radiological findings: di- related to this study. agnosis range between 1 week and 4 years after im- © plant placement (33, 34). If there is a radiolucent area around the apex of the implant, not present immedi- References ately after surgery, without pain, a strict follow-up of 1. De Angelis F, Papi P, Mencio F, Rosella D, Di Carlo S, Pom- the lesion is recommended, without other treatment pa G. Implant survival and success rates in patients with risk (35). If patient develops pain or radiolucency increas- factors: results from a long-term retrospective study with a es in size, medical and surgical treatment is indicated 10 to 18 years follow-up. Eur Rev Med Pharmacol Sci. 2017; (35, 36). Therapeutic modalities usually range from 21:433-7. Annali di Stomatologia 2018;IX (3):106-110 109  B. Di Murro et al. 2. 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Review article Clinical efficacy of systemic antibiotics as an adjunctive therapy to one stage full mouth disinfection (OSFMD) and full-mouth scaling and li root planning in the treatment of chronic na periodontitis: a systematic review of randomised clinical trials io Eman Elhassan1 DDS disinfection in treatment of chronic periodontitis. az Iole Vozza2 DDS, PhD Alessandro Quaranta3 DDS, PhD Key Words: antibiotics, randomised clinical trials, disinfection, periodontitis. rn 1 Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia Introduction 2 Department of Oral and Maxillo-facial Sciences, “Sapienza” University of Rome, Rome, Italy Periodontitis is a chronic inflammatory disease that te 3 Griffith Health Centre, Griffith University, results from a complex polymicrobial infection, lead- Gold Coast Campus, Australia ing to tissue destruction as a consequence of the per- turbation of the homeostasis between the subgingival In microbiota and the host defenses in susceptible indi- Corresponding Author: viduals (1). Initial phase of treatment should aim to Iole Vozza reduce or eliminate the pathogenic microorganisms Department of Oral and Maxillo-facial Sciences associated with disease. Treatment strategies involve ni “Sapienza” University of Rome scaling and root planing. This can be achieved in var- Via Caserta 6 ious visits or as full mouth scaling and root planing 00161 Rome, Italy within 48 hours. Full mouth scaling and root planing E-mail: [email protected] has been associated with additional clinical and mi- io crobiological benefits (2, 3). Full mouth disinfection as suggested by Quirynen et al. (4) differs from the Summary full mouth scaling and root planing. It is a protocol iz that involves full mouth scaling and root planing with- Periodontitis is a chronic inflammatory disease in 24 hours, subgingival irrigation of all pockets with a that results from a complex polymicrobial infec- 1% chlorhexidine gel in order to kill remaining subgin- Ed tion. The purpose of this review was to assess the gival bacteria, tongue brushing with the chlorohexi- efficacy of systemic administered antibiotics as dine 1% gel for 1 min, mouth rinsing with a 0.2% an adjuvant to full mouth scaling and root planing chlorhexidine solution for 2 min to reduce the flora in with antiseptics (full mouth disinfection) and the saliva and on the tonsils before and after scaling without the use of antiseptics in conjunction with and root planing and optimal oral hygiene, supported systemic antibiotics in the treatment of chronic for the first 2 weeks by mouth rinsing with 0.2% IC periodontitis. The following systemic review was chlorhexidine solution. The conventional form of conducted in agreement with the recommenda- staged nonsurgical periodontal therapy involves scal- tions of the Cochrane Collaboration and the prin- ing and root planing (SRP) has been shown to result ciples of the PRISMA (Preferred Reporting Items in clinical improvements of periodontal health (5, 6). It C for the Systemic Reviews and Meta Analyses has been suggested that it carries the risk for recont- statement). The search resulted in 31 studies. On- amination of already-treated areas from untreated ly 6 studies fulfilled the inclusion criteria and sites still harbouring large amounts of periodontal were eligible to be included in this systemic re- pathogens (7). Based on this hypothesis, Quirynen © view. Further, long term randomised control trials introduced the protocol of one-stage full mouth disin- with careful case selection of specific treatment fection (OSFMD) in order to reduce the bacterial load protocols as well as standardised regimens for in pockets and intraoral niches, prevent the intra-oral antibiotic use is required to obtain sufficient sci- transmission of periodontal pathogens from periodon- entific evidence based treatment clinical guide- tal pockets to recently instrumented and healing peri- lines for adjuvant use of systemic antibiotics with odontal sites and therefore produce a less pathogenic full mouth scaling and root planing and full mouth subgingival environment (4). Annali di Stomatologia 2018;IX (3):111-122 111  E. Elhassan et al. Systemic antibiotics have been used as an adjuvant findings in patients with advanced chronic periodonti- to full mouth scaling and root planning to achieve fur- tis. They compared the OSFMD protocol using ther clinical improvements. Different antibiotic regi- chlorhexidine for 2 months against conventional SRP. mens have been indicated in the treatment of moder- There was a significant reduction in bleeding scores, ate to advanced chronic periodontitis including peni- plaque, a probing depth reduction in probing depths li cillins (amoxicillin), tetracyclines (doxycycline, especially in deep pockets (>7 mm) in the test group. minocycline, tetracycline), macrolides (azithromycin, Microbiologically, there was reduction in the putative na clarithromycin, spiramycin, clindamycin), quinolones periodontal pathogens in both groups however the full (moxifloxacin, ciprofloxacin) and nitroimidazole mouth disinfection group was always significantly (metronidazole, ornidazole) (8, 9). The rationale for higher. It was concluded that OSFMD was effective the use of systemic antibiotics in combination with on medium term at improving the clinical outcomes non-surgical periodontal therapy is to suppress path- associated with periodontal health (3). Mongardini et io ogenic bacteria to levels that are associated with al. (15) investigated the clinical results of OSFMD in health (9). The purpose of this review was to assess comparison to scaling and root planning per quadrant the efficacy of systemic administered antibiotics as at 2-week intervals, in the control of severe periodon- az an adjuvant to full mouth scaling and root planing titis over an 8-month period in 40 subjects using a with antiseptics (full mouth disinfection) and without randomised control trial. Significant additional im- the use of antiseptics in conjunction with systemic an- provements were reported in the OSFMD group in tibiotics in the treatment of chronic periodontitis. terms of plaque, bleeding scores, and probing depth rn reduction (1.2 mm for single-rooted and 0.9 mm for One-stage full mouth disinfection (OSFMD) multi-rooted teeth, with corresponding additional The various steps in the original protocol for OSFMD gains in attachment of 1.0 mm and 0.8) in patients of the oral cavity propagated by the Leuven group (4) with advanced chronic periodontitis. The Authors con- te included full-mouth scaling and root planing within 24 cluded that OSFMD results in significant clinical im- hours; in order to reduce the total number of subgin- provements over conventional periodontal therapy for gival pathogenic bacteria (10, 11); subgingival irriga- an 8-month period in the treatment of severe adult In tion of the pockets with chlorhexidine gel to further and/or generalized early onset periodontitis, especial- eliminate bacteria (12); tongue brushing with ly when treating deep pockets. Many theories were chlorhexidine and mouth rinsing & gargling with proposed for the reported success of the OSFMD in chlorhexidine mouthwash to reduce the bacterial load these studies through the reduction of the transloca- ni in saliva and tonsils. The protocol also included oral tion of periodontopathogens. The exact mechanism rinses twice daily for 1 min with chlorhexidine for 2 however was unknown. It was hypothesized that it weeks, during the initial healing phase to deplete the could be due to the reduction of the bacterial over- supragingival plaque deposits and prevent biofilm for- load in a short period and prevention of re-infection. It io mation (13). The research group at the Catholic Uni- could be due to the indirect impact of change in the versity at Leuven, Belgium conducted a series of clin- supra gingival plaque which may extend sub gingival- ical trials to explore the effectiveness of one stage full ly as suggested by several studies (10, 18). The role iz mouth disinfection protocol, (3, 7, 14, 15), and they of antiseptics in OSFMD was explored in 2006 by consistently demonstrated a superior clinical out- Quirynen (19). He compared the effects of full mouth come. This was in contrast with other groups findings disinfection, with and without concomitant use of dif- Ed which didn’t report any difference using this protocol ferent types and durations of antiseptics in compari- (16). In 1995, Quirynen et al. (4) compared full-mouth son with quadrant scaling and root planning in chron- disinfection with quadrant wise periodontal therapy in ic periodontitis, over 8 months. Again, he demonstrat- 10 patients with advanced periodontal disease. Re- ed superior clinical outcomes for the OSFMD group. duction of plaque and probing depths, as well as In subsequent study (20), use of a strong antiseptic in pathogenic species, was significantly greater at 1 the OSFMD was found to play a significant role com- IC month for the OSFMD group. The deep pockets (7 - 8 pared to full mouth scaling and root planning. These mm) exhibited a better response than the moderate results were inconsistent with findings from other re- pockets (5 to 6 mm). Culture analyses showed that search groups which conducted research involving samples from the test group harboured significantly the full mouth disinfection concept (2, 16, 21-23). C fewer pathogenic species at 1 month and significantly These researchers were able to observe some statis- more beneficial bacteria at 2 months post-treatment. tically significant improvements in some outcome P gingivalis was eliminated from the test group. Long- variables; however concluded that these improve- term results of this pilot study were reported later (17) ments, whilst statistically significant; were not of a © which demonstrated statistically significant greater re- significant amount to be of clinical relevance (2). duction of probing depth in full mouth disinfection up They considered the Leuven studies “proof of princi- to 1 mm. Therefore, they concluded that one-stage ple “experiments which provoked the recolonization in full-mouth disinfection demonstrated significant clini- the control group. They argued that they had long cal and microbiological advantages over conventional time intervals before completion of debridement (6 treatment on a short-term basis. Bollen et al. con- weeks), no oral hygiene instructions were advised for ducted a randomised clinical trial with microbiological the untreated quadrants and only 7 patients with ad- 112 Annali di Stomatologia 2018;IX (3):111-122  Clinical efficacy of systemic antibiotics as an adjunctive therapy to one stage full mouth disinfection (OSFMD) and full- mouth scaling and root planning in the treatment of chronic periodontitis: a systematic review of randomised clinical trials vanced periodontal disease and significant calculus are all possible hypothesizes. OSFMD requires less deposits were selected for the studies. This generat- time to complete the treatment than multiple visits ed an ongoing debate as to whether full-mouth disin- without any disadvantages to the patient which is also fection should be the treatment of choice. It must be an important factor. More research is needed to fur- noted that none of these studies followed the original ther explore the scientific concepts related to it as li protocol of full mouth disinfection, originally suggest- well as the use of other adjuvants such as antibiotics ed by Quirynen (4) concerning the use of antiseptics with the full mouth disinfection protocol in treatment na in the Full Mouth Disinfection protocol. Some studies, of chronic periodontitis. (21, 22) employed antiseptics, but they used less po- tent povidone iodine. Systematic reviews published in 2008 (22,23), substantiated that OSFMD with and Materials and methods without antiseptics found only minor differences be- io tween the treatment strategies for adults with chronic The following systemic review was conducted in periodontitis. The studies compared for the OSFMD agreement with the recommendations of the with antiseptics did not consider the different proto- Cochrane Collaboration (27) and the principles of the az cols and different types of antiseptics used in the PRISMA (Preferred Reporting Items for the Systemic OSFMD protocols. In 2009, (24) Swierkot reviewed Reviews and Meta Analyses statement) (28). the OSFMD concept by conducting a study to com- pare clinical and microbiological effects of the original Focused question (PICO) rn OSFMD protocol, full mouth scaling and root planning The focused question that has been used was: “Do as well as conventional quadrant scaling and root systemic antibiotics combined with full mouth scaling planning in 28 patients with chronic periodontitis at 1, and root planing vs full mouth scaling and root plan- 2, 4 and 8 months. It concluded that all the different ing alone in treatment of chronic periodontitis have an te modalities resulted in significant clinical effects at any additional effect on the clinical outcomes”? time. OSFMD displayed higher reduction in probing depths and bleeding on probing sites after 1 and 2 PICO Criteria months. However, a major limitation in the study was In Participants: participants of any age with chronic peri- the reduced number of probing depths >7 mm in this odontitis receiving full mouth scaling and root planing study which could lead to incomparable results to the or full mouth disinfection protocol (within 48 hours). Leuven group studies that noticed statistical differ- Intervention: the intervention evaluated the use of ni ences mainly in moderate to deep probing depths. systemic antibiotics with or without chlorohexidine Considering the advantages of OSFMD technique, (antiseptics). patient and operator comfort, systemic effects and its Comparison: comparison of results with or without cost-effectiveness, the use of this technique in peri- use of systemic antibiotics. io odontitis patients is recommended. The most recent Outcomes: primary outcomes is PD (probing depth) meta-analysis by Fang (25) showed that even though reduction, CAL (clinical attachment level) gain. Sec- OSFMD had modest statistically insignificant addi- ondary outcomes included reduction in full mouth iz tional clinical benefits over quadrant scaling and root bleeding scores, plaque scores and microbiological planing in pocket depth reduction and clinical attach- changes. ment level gain, they recommend OSFMD as the first Ed choice for the treatment of adult chronic periodontitis. Search strategy A recent comprehensive study published in by Fonse- The PubMed database was searched from their earli- ca (26), which also compared different treatment est records until January 2019. The following search modalities for chronic periodontitis, compared terms were used: Periodontal diseases [MESH]/ OSFMD, Quadrant conventional therapy, and Full (TEXT)OR chronic Periodontitis AND Full mouth scal- mouth scaling and root planning with and without use ing and root planing [MESH]/(TEXT) OR Full mouth IC of systemic azithromycin. It reported a significant re- disinfection [MESH] /(TEXT) AND Antibiotics duction in all clinical parameters in all treatment [MESH](TEXT) AND Prospective Clinical trial. In ad- modalities however the OSFMD group with chloro- dition, a manual search was performed on issues hexidine showed higher reductions in probing depths, from the past 10 years of the Journal of Clinical Peri- C percentage of diseased sites as well as lower bacteri- odontology and Journal of Periodontology and bibli- al counts than all the other groups at a 180 days ographies of all the retrieved papers. which again reenforces the superiority of the OSFMD protocol with concomitant use of chlorhexidine. The Study inclusion and exclusion criteria © OSFMD protocol results in significant additional clini- The following eligibility criteria were imposed for in- cal and microbiological improvements with nonsurgi- clusion in the systemic review: 1. Studies were limit- cal periodontal therapy. The scientific basis of the im- ed to randomised controlled clinical trials, sample proved results with this protocol are yet to be com- size of at least 20 patients, with follow-up of at least pletely understood. Reduction in the probability of more than three months duration; 2. The population bacterial cross contamination, combination of anti- was limited to subjects in good general health with septics (chlorhexidine) and or Schwartzman reaction chronic periodontitis; 3. The interventions of interest Annali di Stomatologia 2018;IX (3):111-122 113  E. Elhassan et al. were full mouth disinfection (SRP within 24 hours, quence generation; II. Allocation concealment; III. FMSRP with use of chlorohexidine) or full mouth scal- Blinding of personnel and outcome assessors; IV. ing and root planning (SRP within 48 hours) with or Handling of incomplete outcome data. Assessment of without the use of systemic antibiotics; 4. No specific methodological study quality was performed by the systemic antibiotics were excluded; 5. Clinical para- reviewer using the criteria proposed by the Cochrane li meters of interest of PD and CAL as primary outcome Reviewer’s Handbook (Higgins and Green 2009) (27). parameters, with BOP and FMPS as secondary out- Included articles were evaluated through methodolog- na come parameters, data presented by means of pre- ical RCT aspects into “Low risk”, “High risk”, or “Un- and post-treatment data, incremental data or both; 6. clear” (27). These included a. Selection bias (Ran- Only papers in the English language were included. dom sequence generation, Allocation concealment); Only studies that met all the inclusion criteria were b. Performance bias (Blinding of the participants and analysed. personnel); c. Detection bias (Blinding of the outcome io Exclusion criteria: assessment); d. Attrition bias (Incomplete outcome 1) History of refractory periodontitis data); e. Reporting bias (Selective reporting); f. Other 2) Combination of local and systemic antibiotics bias (Other sources of bias). To be included articles az 3) Primary outcome of interest was not analysed had to be considered adequate in all six aspects. 4) Duplicated studies. Characteristics of the study design Outcome variables All selected studies were randomised controlled clini- rn The primary outcome variables in the studies were cal trials. The evaluation period varied between the reduction in probing depth, changes in clinical attach- studies from 6 months to 5 years. A considerable het- ment level. Secondary outcomes included differences erogeneity in the design, duration (evaluation period), in bleeding on probing (BOP). Other outcome vari- and regimen of SRP was present in the studies. The te ables included were microbiological changes due to number, sex, and age of the participants and the peri- treatment. odontal diagnosis also varied among the studies. Risk of bias: Risk of bias was evaluated through qual- Selection strategy In ity analysis performed by the reviewers. Quality Eligibility assessment was performed through titles analysis of the RCT was done according to the and analysis of the abstracts and full text. If the Cochrane Handbook risk assessment. Four included search key words and the relevant information to the studies estimated risk of bias is “Low Risk” according eligibility criteria were present in the title, the ab- ni to the Cochrane Handbook criteria for judging risk of stract, or both, the study was selected for full-text bias assessment tool. This includes assessment if six reading. Titles and abstracts of the search results 10 RCT issues: randomisation, concealment, incomplete were screened independently by two reviewers (AQ, outcome data, selective reporting, other bias. All the io EE, IV), for possible inclusion in the literature review. size criteria were assessed as adequate, inadequate Studies without abstracts but with titles suggesting or unclear. they were related to the objectives of this review were iz also selected for full-text screening to avoid excluding potentially relevant articles. A hand search of the ref- Results erence lists of all selected studies for additional rele- Ed vant articles was completed. The full text articles of Search and selection all the selected studies were included in the full text The search resulted in 31 studies. Only 6 studies ful- analysis. The full text of all the studies with possible filled the inclusion criteria and were eligible to be in- relevance was assessed by two reviewers (EE, AQ). cluded in this systemic review. Most of the studies After selection, full-text studies were read in detail by were excluded because the completion of SRP oc- reviewer. Those studies that fulfilled all the selection curred in a period greater than 48 hours or because IC criteria were processed for data extraction. Data of many studies reported on cases of aggressive peri- the included articles were extrapolated. The full texts odontitis (Fig. 1). All five studies included in the sys- of all studies of possible relevance were obtained for tematic review were randomised clinical control trials independent assessment by the reviewers. Any dis- that assessed clinical parameters before and after in- C agreement was resolved by discussion. Data were tervention at different time points after treatment. All extracted independently by the reviewers using a da- the studies assessed the clinical parameters for 6 ta extraction form. Disagreement regarding data ex- months, except one study that extended the results to traction was resolved by consensus. 1-year post treatment. The length of follow-up ranged © from 6 months to 5 years in the studies included. De- Quality assessment tailed information regarding the selected study char- Assessment of methodological study quality was per- acteristics and the Authors’ conclusions are present- formed combining the proposed criteria by the ed in Table 1. Two studies had a high risk of bias due Cochrane hand book for systemic reviews for inter- to the inclusion of patients in the analysis despite the ventions (27). It compromises evaluating quality discontinuation of the intervention. Detailed analysis through four methodological RCT aspects: I. Se- is presented in Table 2. 114 Annali di Stomatologia 2018;IX (3):111-122  Clinical efficacy of systemic antibiotics as an adjunctive therapy to one stage full mouth disinfection (OSFMD) and full- mouth scaling and root planning in the treatment of chronic periodontitis: a systematic review of randomised clinical trials Outcomes: In the present review, the reduction in mean pocket depth after intervention ranged from 2- 3 mm in all the studies. The length of follow-up was 6 months in all studies except one study that reported up to 5 years post intervention. li Results of individual studies: The comparison of the na findings in the selected studies is difficult due to the heterogeneity of the data, different protocols followed in each study therefore it was decided to report the type of intervention of each study and specific methodology used. The articles are reported in chronological order. io Primary outcomes Ribeiro (29). Reported results at 6 months showed an az additional reduction in PD depth was noted in the test group (0.83 mm) in PD [P2 mm at 43.52% of sites (control) compared to 53.03% (test)]. However, both groups had similar RAL gain [1.68 (control) and 1.88 rn mm (test) group]. It was therefore concluded by the group that both treatments resulted in significant clini- cal improvements. te Cionca (30). Clinical results obtained at 3 months were maintained at 6 months, the mean PD reduction in test group was 3.0 mm in test group, and 3.1 in Figure 1. Flowchart of literature search and inclusion. In placebo group. Sites presenting with pockets initially >6 mm showed a mean decrease in mean PD from Intervention 7.3 -+0.3 mm at baseline to 3.6+-0.8 mm at 3 months All six studies compared full mouth scaling and root and 3.7+- 0.6 mm at 6 months in the test group unlike planning and/or full mouth disinfection with or without ni the placebo group that showed a decrease from 7.2+- the use of systemic antibiotics. Different regimes of an- 0.7 mm to 5.2+- 1.1 mm at 3 months and 4.9 mm +- tibiotics were used in each study (Tab. 1). Data from 1.4 mm at 6 months, which shows a clear 16 advan- each article were collected, and a descriptive report was tage of use of systemic antibiotics in these sites. The io generated about the type of study, number of patients, results of the study show a significant improvement in mean follow-up period (Tab. 1), and clinical parameters: the clinical outcomes of full mouth nonsurgical peri- bleeding on probing, pocketing depth, clinical attach- odontal debridement with antibiotics and significantly iz ment level and microbiological assessment. Data from reduced need for additional therapy. each study was analysed and information about the type of study, number of participants, Mean PD (pocket Preus (31). No statistically significant differences were Ed depth) reduction, Mean CAL (clinical attachment level) noted between the different groups at baseline, 3 and gain, changes in BOP in each group after intervention, 12 months. All the groups displayed significant im- and length of follow-up, is recorded in Table 1. provements in all the analysed parameters. Mean Clinical attachment level (CAL) ranged 1.06 to 1.29 mm at 3 and 12 months, mean PD was around 2.20 to Characteristics of included studies 2.28 mm at 3 and 12 months in all four groups. The IC mean gain in CAL from baseline to 1 year was slightly Participants more in groups with antibiotics {0.72, (0.60 to 0.85) The included studies involved a total of 440 partici- and 0.81 (0.67 to 0.96) compared to 0.61 (0.51 to pants (Tab. 1). 0.72) and 0.64 (0.52 to 0.76) in groups with no antibi- C otics. Metronidazole treatment was significantly influ- Quality analysis: Quality analysis was completed util- ential of the mean probing depth (PD) reduction which ising the GRADE approach outlined in the Cochrane ranged from 0.81 to 1.03 mm. Metronidazole was hand book, which specifies four levels of quality. All found to exert an adjunctive effect on the mechanical © studies included in the review were randomised trials periodontal therapy for <= 12 months after treatment. with a high-quality rating. Limitations in the imple- It resulted in additional gain of CAL, reduction in PDs mentation of the study design in two studies which and more frequent eradication of the pockets >=5 mm, have the same design as one reported 12 months [Absence of pockets >= 5 mm at 1 year was found to while the other reported 5 years had a high risk of be 72.7% (FDIS group +met) and 62.2% (SRP + met) bias, this eventually reduced the quality of the body compared to 42.2% (Displace) and 39.1% (SRP+ of evidence from high to moderate quality evidence. placebo) in groups without metronidazole]}. Annali di Stomatologia 2018;IX (3):111-122 115  © Table 1. Characteristics of included studies in literature review. 116 Study C Design and Diagnosis, No of Regimen as Regimen Follow-up Conclusion of the Authors Bias Assessment Evaluation Subjects (end), Age Adjunct to SRP for Antiseptics use Bias (Cochrane “Risk of period bias” assessment tool) (29) E. Elhassan et al. IC Ribeiro, et al. RCT Parallel Ch P 25 patients, 12 Amoxicillin Nil 6 months Both groups showed a reduction Low risk Double masked =c, 13 = T 375 mg, in PD, and gain in RAL. Mean age= 46 metronidazole Mean Decrease in PD 2.45 250 mg 3 times mm+- 0.5 mm in control group daily for 7 days and 3.28+-0.41 mm in test group Ed At 6 m, lower Bo P and additional reduction (0.83 mm) iz in PD Similar RAL Gain in Antibiotics group io Cionca, et al. RCT Single centre Ch P 47 patients 24=C, Metronidazole Subgingival 6 months Systemic metronidazole + Double masked, 23=T Mean Age 50.5 500 mg, irrigation with 0.1% amoxicillin improved 6 month Placebo controlled amoxicillin 375 chlorhexidine clinical outcomes of full mouth RCT mg 3 times daily solution rinse Rinse with non-surgical periodontal ni for 7 days 0.25 CHX twice debridement daily (10 days) .0.4 ± 0.8 persisting pockets were still present in test group In compared to 3.0 +-4.3 in control Preus, et al. RCT Four arm Ch P 180 patients Metronidazole Subgingival 12 months Metronidazole has a significant High risk (Patients te parallel group, G1=44 (FDIS+ Met) 400 mg, 3 times irrigation with 1% adjunctive effect on clinical discontinued intervention in double masked G2= 45 (FDIS daily for 10 days CHX gel tongue parameters of CAL, PD and all groups were still included clinical trial +placebo) G3=45 (SRP brushing with CHX absence of pockets >=5 mm in the analysis) rn +Met) G4=46 (SRP + gel 1 minute every placebo) night (9 days) -0.2% CHX mouthwash every morning (9 az days) To be continued io Annali di Stomatologia 2018;IX (3):111-122 na li  © continue from Table 1 C Fonseca, et al. RCT Four arm Ch P 186 participants FAZ + QSAZ FC=Subgingival 6 months Adjuvant use of azithromycin did Low risk parallel group, (6 groups) G1=15 (Azithromycin irrigation with 0.12% not provide any significant double masked (FAZ) G2=15 (FC) 500 mg once CHX gel for improvement on clinical and clinical trial G3=15 (FNC) G4=14 daily for 3 days) 1 minute microbiological parameters. IC (QSAZ) G5=13 (QSC) The adjuvant use of CHX G6= 13 (QSNC) Mouthwash 0.12% especially in FMD protocol (FC) CHX for 30 secs at followed by QS showed more beginning and end significant improvement of each session + CHX 0.12% mouthwash twice Ed Annali di Stomatologia 2018;IX (3):111-122 daily for 2 weeks QSC=daily used of CHX 0.12% for 60 iz days Preus, et al. RCT Four arm Ch P 161 (7 lost at Metronidazole Subgingival irrigation 5 years Metronidazole increased the High risk (Patients io parallel group, initial treatment, 16 at 400 mg, 3 times with 1% CHX gel highest CAL recording discontinued intervention in double masked 5-year follow-up. daily for 10 days Tongue brushing statistically insignificantly by 0.17 all groups were still included clinical trial Patient G1 (FDIS+ with CHX gel 1 mm while FDIS decreased it by in the analysis) Met) G2 (FDIS + minute every night 0.12 mm small statistically placebo) G3 (SRP + (9 days) significant differences, too small ni Met) G4 (SRP + 0.2% CHX to recommend metronidazole placebo) mouthwash every treatment as an adjuvant morning (9 days) treatment In Cosgarea, et al. RCT Three arm Ch P 102 patients (33 Amoxicillin + All groups. PPDs>4 6 months Patients with severe chronic Low risk parallel group, groups), 91 patients metronidazole mm rinsed with periodontitis SRP in conjunction te double masked only completed. G1- 500 mg TID for 3 Chlorhexidine with amoxicillin and clinical trial =30 (SRP + placebo) days amoxicillin + digluconate solution. metronidazole 500 mg lead to G2=30 (SRP + AMX + metronidazole Chlorohexidine greater clinical improvements. rn MET 3 days) G3=31 500 mg TID for 7 digluconate solution No statistical difference between (SRP + AMX + MET 7 day 0.2% rinse twice 3 and 5-day regimen days) daily for 14 days Legend of abbreviations: RCT, Randomised control trials; AZ, Azithromycin; FAZ, Full mouth SRP within 24 hrs with AZ; FC, FMD with CHX (FMD protocol + CHX 0.12% twice daily for az 2 weeks); BOP, Bleeding on Probing; CHX, chlorhexidine; QSC, SRP per quadrant with CHX (daily 0.12% for 60 days); FNC, Full mouth SRP without CHX; PD, Pocket depth; SRP, Scaling and root planning; QSNC, SRP per quadrant without CHX; QSAZ, SRP per quadrant with AZ; CAL, Clinical attachment Level; Ch P, Chronic periodontitis; FMD, Full mouth Clinical efficacy of systemic antibiotics as an adjunctive therapy to one stage full mouth disinfection (OSFMD) and full- Disinfection (FMD protocol + CHX 0.12% twice daily for 2 weeks); RAL, Relative attachment level, measured from fixed point occlusal splint to base of pocket. io mouth scaling and root planning in the treatment of chronic periodontitis: a systematic review of randomised clinical trials 117 na li  E. Elhassan et al. Table 2. Risk of bias assessment according to Cochrane Handbook Risk of Bias Assessment (27) (H= HIGH, L=LOW). Ribeiro, Cionca , Cionca, Preus, Preus, Fonseca, Fonseca, Preus, Preus,et al. Cosagrea, Cosagrea, et al. (29) et al. et al. (30) (30) etetal.al.(31) (31) et al. al. (26)et (26) et al.(32-34) (32-34) et al. et al. (33) (33) Random sequence L L L L L L li generation (selection bias) na Allocation L L L L L L concealment (selection bias) io Blinding of participants L L L L L L and personnel (performance bias) az Blinding of outcome L L L L L L assessment (detection bias) Incomplete outcome L L L L L L rn data (attrition bias) Selective reporting L L L L L L (reporting bias) te Other bias L L H L H L In Preus (32). This study is the follow treatment of the regimen. CAL gain was statistically significantly in- previous study for 5 years, 161 patients only were creased in the antibiotic groups (1.63+-0.5 mm) and available for the 5-year review. Statistically significant (1.7+-0.53 mm) in the 3 and 7-day AB regimen com- ni additional changes in CAL with adjuvant metronida- pared to 1.13+-0.74 mm in the placebo group. zole were found at 5 years of 0.40 mm in the SRP group and 0.06 mm in full mouth disinfection group. Secondary outcomes io However additional benefit with use of systemic Ribeiro (29). 6 months resulted in lower bleeding on metronidazole was small and doesn’t justify use of probing (BOP) (7,755 at test sites, compared to antibiotics. No mention of. 21.11% at control sites). Real time PCR and Elisa iz failed to identify any significant differences between Fonseca (26). All groups in this study presented sig- the groups. However only the test treatments group nificant reduction in the percentage of periodontal reduced the numbers of all microorganisms below the Ed diseases sites, gingival index, plaque score, and levels of detection. Both groups presented statistical- CAL gain at 90 days, demonstrating all treatment ly significant reduction of PG and Tf only. modalities were effective. However, the FC group [Full mouth disinfection (FMD) with chlorhexidine Cionca (30). The number of persisting bleeding pock- (CHX) for 2 weeks] showed a higher reduction in ets was 7.5 times greater if the subjects had not re- probing depth reduction (from 2.10 +- 0.50 to 1.53 ceived the antibiotics after full mouth scaling and root IC +- 0.41 mm) and percentage of periodontal disease planing. The mean PS, GI, REC, were not significant- sites (from 6.58+- 7.95 to 2.13+- 3.90) as well as ly different. lower total bacterial counts at 90 and 180 days. The full mouth scaling and root planing group plus Preus (31). The distribution of sites with plaque at 12 C azithromycin in this study unlike other studies in the months was like baseline, however the percentage of literature demonstrated less reduction in probing sites with BOP reduced in all groups. depth compared to the full mouth disinfection group. Therefore, it was concluded that adjuvant used of Preus (32). The 5-year results reported reduced © azithromycin did not provide any significant benefit. plaque score and BOP in all groups that was main- tained at 5 years. Cosgarea (33). All groups presented significant clini- cal improvement. Average pocket reduction at 6 Fonseca (26). All groups in this study presented signifi- months in the placebo group (1.90 +-0.69 mm) was cant reduction in the percentage of periodontal diseases significantly smaller compared to 3-day antibiotic sites, gingival index, and plaque score at 90 days, (AB) (2.5+-0.62) and (2.76+-0.62) for the 7-day AB demonstrating all treatment modalities were effective. 118 Annali di Stomatologia 2018;IX (3):111-122  Clinical efficacy of systemic antibiotics as an adjunctive therapy to one stage full mouth disinfection (OSFMD) and full- mouth scaling and root planning in the treatment of chronic periodontitis: a systematic review of randomised clinical trials Cosgarea (33). All groups presented similar decrease and microbiological changes. It must be noted that in BOP at 6 months, there was more reduction of the participants in this trial had moderately deep peri- BOP in AB groups (9.47+-5.34 and 7.75 +- 6.64) odontal probing depths, and results were diluted by compared to placebo group (13.07+-9.02). FMPS was the mean value of the healthy sites. It was noted in 5 similar in all treatment groups. studies that the probing depth reduction was more li noticeable in deep (PD >6 mm) and percentage of diseases sites which were sites with 4 mm and BOP na Discussion decreased significantly in all patients receiving sys- temic antibiotics, which decreased the need of further There is a lot of evidence in the literature which sug- periodontal therapy, assumed to be surgery in these gests that systemic antibiotics in combination with patients. Microbiological results were recorded in 2 scaling and root planing result in additional clinical studies only with conflicting results, as one study io benefits compared to scaling and root planing alone, demonstrated significant reductions with the use of (29, 30) most of the studies compare the effect of systemic antibiotics while the other showed no conventional scaling and root planing carried out in changes with the use of antibiotics but significant re- az staged visits that could be weeks apart. Since the duction with use of the full mouth disinfection proto- proposal of the full mouth disinfection protocol, by col. No changes were found with regards to the in- Quirynen et al. (4) which suggest that additional clini- flammatory markers in the one study that analysed cal benefits were compared to conventional scaling them in GCF before and after intervention. All the rn and root planning, many studies have revealed better studies reported on the 6 months, except two studies clinical and microbiological outcomes with this new by Preus et al. which reported results up to 12 protocol (3, 4, 15, 34). Other studies have failed to months (31) and 5 years (32). They reported positive demonstrate such results (21-23). A review by Lang outcomes with the use of systemic antibiotics which te et al. (22) on the effects of full mouth scaling and root was maintained up to 5 years in those studies, how- planing with or without chlorohexidine and conven- ever it noted that the different was minimal despite tional scaling and root planing has shown statistically being statistically significant. significant differences between the full mouth de- In bridement with and without antiseptics and conven- tional scaling and root planing however, they were in- Limitations consistent and small and therefore concluded both ni treatment modalities were effective, it also delineated Outcome level that full mouth scaling and root planning provided ad- This present review only reported on the data pre- ditional benefits in terms of time as treatment is car- sented by 6 studies (RCT Studies) to estimate the ried out in less time. The aim of this review is to treatment effects of the use of systemic antibiotics io analyse the additional effects provided by systemic with full mouth scaling and root planing with or with- use of antibiotics in the non-surgical treatment of out antibiotics. The excluded publications are listed in chronic periodontitis using full mouth scaling and root Table 3 (35-46). The studies included used different iz planing with or without use of antiseptics. Only 6 regimens of antibiotics for different duration. The out- studies fulfilled the criteria to be included in this re- come of the review depending on the studies includ- view, which is a very limited number, most of these ed was influenced by the patient population, the data Ed studies were randomised controlled trials with a low collection, the type and regimen of the systemic an- risk of bias. Different systemic antibiotics 18 and regi- tibiotic used and the analyses that differed between mens were used in each of the studies, which studies. ranged, from combination (amoxicillin and metronida- zole, metronidazole alone and azithromycin). It must Study and review level be noted that in the literature there is no recommen- The main limitation of the present systematic review IC dations for a specific antibiotic regimen to be used in was the heterogeneity in the design, intervention, da- the treatment of chronic periodontitis. Probing reduc- ta collection, and analyses. The limited number of tion, CAL changes were the primary outcome of all studies that fulfilled the criteria also limited the the studies, 2 studies analysed the microbiological amount of data to be analysed as well as the different C outcomes after treatment as well and one study regimens of systemic antibiotics used and short fol- analysed the levels of inflammatory mediators low-up duration of only 6 months in most studies. (PGE2, IL and interferon) after treatment. 3 of the Therefore, more well designed, multicentre studies studies demonstrated significant probing depth reduc- with long follow-up are required to obtain evidence © tion with relation of systemic antibiotics when com- based guidelines. pared to full mouth scaling and root planing without antibiotics. One study reported no significant changes with the use of systemic antibiotics compared to full Conclusions mouth scaling and root planing and reported more significant changes with the full mouth disinfection Implications for practice protocol instead in terms of PD reduction, CAL gain In the present systematic review, despite the limited Annali di Stomatologia 2018;IX (3):111-122 119  E. Elhassan et al. Table 3. List of publications excluded in methodological assessment. Publication Ref no Reason for exclusion Gomi, et al. 2007 (35) SRP was completed within 7 days Pradeep, et al. 2012 (36) SRP was not completed within 24 hours li Matarazzo, et al. 2008 (37) Patient selection was smokers only (10 cigarettes per day for 5 years) na Smith, et al. 2012 (38) SRP was carried out within 3 weeks Jentsch, et al. 2016 (39) No control group. Both groups received different types of antibiotics (azithromycin or amoxicillin + metronidazole) Haffajee, et al. 2004 (40) Patients had previous periodontal therapy and only local antibiotics was used as io well Winkel, et al. 2001 (41) SRP was carried out in 3 to 6 sessions Silva, et al. 2011 (42) Treatment was carried out in 4- 6 visits not within 24 hours az Harks, et al. 2015 (43) Aggressive periodontitis patients were included in the study Lopez, et al. 2006 (44) SRP was completed in 2 sessions 3 days apart Faveri, et al. 2014 (45) All patients received SRP+ systemic metronidazole and groups were categorised according to smoking status rn Haffajee, et al. 2007 (46) SRP was completed quadrant wise in weeks te number of studies reviewed, it was nevertheless pos- 2. Apatzidou DA, Riggio MP, Kinane DF. Quadrant root plan- sible to conclude that the use of adjuvant antibiotics ing versus same-day full-mouth root planing - II. Microbio- with full mouth scaling and root planing and full logical findings. Journal of Clinical Periodontology. 2004;31(2):141-148. mouth disinfection provided additional clinical bene- fits in terms of PD reduction, CAL gain especially in In 3. Bollen CML, Mongardini C, Papaioannou W, Van Steen- berghe D, Quirynen M. The effect of a one-stage full-mouth PDs >6 mm. Even though one study did not demon- disinfection on different intra-oral niches - Clinical and mi- strate its superiority compared to other treatment pro- crobiological observations. Journal of Clinical Periodontol- tocols, it was an effective clinical modality of treat- ogy. 1998;25(1):56-66. ni ment (26). Use of antibiotics should be approached 4. Quirynen M, Bollen CML, Vandekerckhove BNA, Dekeyser with caution as to prevent bacterial resistance to sys- C, Papaioannou W, Eyssen H. Full-vs partial-mouth disin- temic antibiotics. More research is required to further fection in the treatment of periodontal infections - short-term io verify these results. clinical and microbiological observations. Journal of Dental Research. 1995;74(8):1459-1467. 5. Badersten A, Nilvéus R, Egelberg J. Effect of nonsurgical pe- Implications for research riodontal therapy. Journal of Clinical Periodontology. iz Further, long term randomised control trials with care- 1981;8(1):57-72. ful case selection of specific treatment protocols as 6. Cobb CM. Clinical significance of non-surgical periodontal well as standardised regimens for antibiotic use is re- therapy: an evidence-based perspective of scaling and root Ed quired to obtain sufficient scientific evidence based planing. J Clin Periodontol. 2002;29(Suppl2):6-16. on treatment clinical guidelines for adjuvant use of 7. 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Moher D. Corrigendum to: Preferred reporting items for sys- 43. Harks I, Koch R, Eickholz P, Hoffmann T, Kim TS, Kocher Annali di Stomatologia 2018;IX (3):111-122 121  E. Elhassan et al. T, et al. Is progression of periodontitis relevantly influenced 45. Faveri M, Rebello A, de Oliveira Dias R, Borges-Junior I, by systemic antibiotics? A clinical randomized trial. Journal Duarte PM, Figueiredo LC, et al. Clinical and microbiologic of Clinical Periodontology. 2015;42(9):832-842. effects of adjunctive metronidazole plus amoxicillin in the 44. Lopez NJ, Socransky SS, Da Silva I, Japlit MR, Haffajee treatment of generalized chronic periodontitis: smokers ver- AD. Effects of metronidazole plus amoxicillin as the only sus non-smokers. J Periodontol. 2014;85(4):581-591. therapy on the microbiological and clinical parameters of 46. Haffajee AD, Torresyap G, Socransky SS. Clinical changes li untreated chronic periodontitis. J Clin Periodontol. 2006; following four different periodontal therapies for the treatment 33(9):648-660. of chronic periodontitis: 1-year results. J Clin Periodontol. na 2007;34(3):243-253. io az rn te In ni io iz Ed IC C © 122 Annali di Stomatologia 2018;IX (3):111-122 

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Review article Temporomandibular disorders and cervical spine: a systematic review li na Emanuele Chisari MD Student1 list check, we selected n=25 articles following Enrico Buccheri MD Student1 previously written criteria. Giuliana Cubisino MD Student1 Conclusions: The literature available on the asso- io Federica D’Arma MD Student1 ciation between TMD and CSP presents major lim- Erika Catania MD Student1 itations in terms of great heterogeneity. Although Carlo Di Paolo MD, DDS2 a lot of studies focused on the genetic, biome- az Piero Cascone MD, PhD2 chanical, and radiological background of the dis- ease there is lack of consensus on one or multi- ple major actors. However, based on our analysis an association between TMD and cervical pain-re- rn 1University of Catania, Medical school, Catania, Italy lated symptoms (headache, cervical pain, back 2 Oral and Maxillo Facial Sciences Department, pain) can be assumed. More studies are needed “Sapienza” University of Rome, Rome, Italy to understand the complex and multifactorial gen- esis of the association. te Key Words: cervical spine, myofascial, pain, tem- Corresponding Author: poromandibular disorders, temporomandibular Emanuele Chisari In joint. Department of General Surgery and Medical Surgical Specialties Section of Orthopaedics and Traumatology AOU Policlinico-Vittorio Emanuele, University Introduction ni of Catania 95123 Catania, Italy Temporomandibular disorders (TMD) are a wide E-mail: [email protected] group of clinical conditions affecting the temporo- io mandibular joint and the surrounding neuronal and musculoskeletal components (1). TMD prevalence is attested to be higher than 5% (1). Lipton et al. (2) in iz Summary 1993 reported an evidence of a prevalence between 6 and 12%. Today recent epidemiological studies Aims: Temporomandibular disorders (TMD) are a support an higher prevalence up to 25-30% or even Ed wide group of clinical conditions affecting the higher (3-6). This group of disease is present in a temporomandibular joint and the surrounding broad group of ages, with a peak of prevalence in 20- neuronal and musculoskeletal components. Cer- 40 aged woman (7). While its wide presence among vical spine pain (CSP) has been proposed as a general population, only 5-10% of patients requires risk factor. Thus, the aim of this review is to anal- treatment (8). yse the available literature to document anatomi- The etiology is often multifactorial and can be usual- IC cal, pain and postural association between TMD ly be associated with traumatic or atraumatic patient and cervical spine. history. While there is evidence of genetic predispo- Methods: A systematic review of the literature sition mainly related to catechol-O-methyltrans- was performed on TMD and cervical spine, using ferase (COMT) low activity, adrenergic receptor C the following inclusion criteria: studies of any lev- polymorphisms (9-11), sexual dysmorphism, proba- el of evidence, reporting clinical or preclinical re- bly associated to the distribution of estrogen recep- sults and dealing with the anatomical, pain and tors (12), the exact pathogenesis of the disorder postural association between TMD and cervical seems to be heterogenous and mainly unknown. © spine. Cervical spine pain (CSP) has been proposed as a Results: A total of n=1150 articles was found. Af- risk factor to develop TMD. In 1996 De Wijer et al. ter duplicates exclusion, n=947 articles were se- (13) investigated this relationship in two subgroups lected. At the end of the first screening, following of patients: 103 with CSP and 111 with TMD. They the previously described selection criteria, we se- reported an overlap of the symptoms and suggested lected n=55 articles eligible for full-text reading. to conduct further studies. Instead, Bevilaqua- Ultimately, after full-text reading, and reference Grossi et al. (14) conducted a study in 2007 involv- Annali di Stomatologia 2018;IX (3):97-105 97  E. Chisari et al. ing one hundred woman and they reported how editorials and expert opinions were excluded. The there is a lack of evidence of an higher risk for CSP study selection was performed independently by patients to develop TMD. However, they have con- three Authors (E.B., G.C., F.D.), any discrepancies in firmed the pathological connection between TMD the selection process were resolved by discussion and CSP: this study demonstrates that TMD patients amongst all the Authors. The senior investigators li often develop CSP related symptoms and signs. In (P.C. and E.C.) were consulted to revise all the selec- addition, TMD seems to be linked with severity of tion process. na CSP clinical presentation. Even though it could be possible a relationship between TMD and cervical Data extraction and criteria appraisal spine disorders (CSD), it is unclear the real associa- All data were extracted from article texts, tables and tion with clinical aspects of disease. The aim of this figures. Three independent Authors reviewed each review is to analyse and report all the up-to-date ev- article (E.B., G.C., F.D.). Discrepancies between the io idence (1) determining the presence of a clinically four reviewers were resolved by discussion and con- relevant association between cervical spine and sensus. The results of every stage of selection were TMD, (2) identifying risk factors associated with this reviewed by the senior investigators (P.C. and E.C.). az condition, (3) evaluating anatomical pain and postu- ral association. Risk of bias and quality assessment Risk of bias assessment of all in vivo selected full- text articles was performed according to the ROBINS- rn Materials and methods I tool for non-randomized studies (16). The ROBINS-I tool consists of three stage assessment of the studies Literature search strategy included. First stage regards the planning of the sys- This systematic review was conducted according to tematic review, the second stage is the assessment te the guidelines of the Preferred Reporting Items for of the common bias possibly found in these studies Systematic Reviews and Meta-Analyses (PRIS- and the latter is about the overall risk of bias (Supple- MA) (15). A comprehensive search was performed on mentary material and Table 1). This assessment used four medical electronic databases (PubMed, Embase, In “Low,” “Moderate” and “High” as judgement keys: and Cochrane Library) by three independent Authors “Low” indicated a low risk of bias, “moderate” indicat- (E.B., G.C., F.D.) from their date of inception to the ed that the risk of bias was moderate, and “High” indi- 20th of May 2018. Our main aims were: (1) determin- cated a high risk of bias. In vitro and review studies were excluded by the risk assessment. �The assess- ni ing the presence of a clinically relevant association between cervical spine and TMD, (2) identifying risk ments were performed by 2 Authors (E.B., G.C.,) in- factors associated with this condition, (3) evaluating dependently. Any discrepancy was discussed with anatomical, pain and postural association. Articles the senior investigator (E.C. and P.C.) for the final io from the inception of the databases to the 20th of May decision. All the raters agreed on the results of every 2018 were searched using the following key words: stages of the assessment. Studies that were evaluat- [(Temporomandibular disorders OR TMD) AND (“cer- ed at high overall risk of bias were excluded during iz vical spine OR upper spine”)]. The reference lists of screening process after discussion with the senior in- all included articles, previous literature reviews on the vestigator (P.C.). topic and top hits from Google Scholar were reviewed Ed for further identification of potentially relevant studies Statistical methods and analysis and were assessed using the inclusion and exclusion Due to the heterogenous nature of the studies, the criteria. In addition, a search strategy document was different outcomes evaluated, the lack of controlled added as supplementary material. studies, metanalysis and statistical analysis can not be done. Therefore, descriptive synthesis was under- Selection criteria taken. IC Eligible studies for the present systematic review in- cluded those investigating the use of single-stage surgery for the revision of infected TKA. Primary Results screening of the titles and abstracts were made using C the following inclusion criteria: English language, and Study selection studies of any level of evidence published in peer-re- A total of n=920 articles was found according to the viewed journals reporting clinical or preclinical re- previous described search strategy. Overall, after du- sults. Exclusion criteria included: articles written in plicates exclusion n=798 articles were screened © other languages or studies with a focus on surgical through abstract and title reading after the removal of treatment. Additionally, we excluded studies in which the duplicates. We selected n=55 articles eligible for data was not accessible, missing, without an avail- full text reading. Ultimately, after full text reading, and able full text, or not well reported. We also excluded reference list check, we selected n=25 articles to the all the remaining duplicates, and those with poor sci- purpose of the present manuscript. A PRISMA (15) entific methodology, assessed as high risk of bias. flow chart of the selection process and screening is Abstracts, case reports, conference presentations, provided (Fig. 1). 98 Annali di Stomatologia 2018;IX (3):97-105  Temporomandibular disorders and cervical spine: a systematic review Supplementary material. Risk of bias assessment using ROBINS-I tool. Study Confounding Selection Measurement Missing Measurement Reported Overall of Intervention Data of Outcomes Result Wu et al. Moderate Low Moderate Low Moderate Low Moderate li Muñoz-García et al. Low Low Moderate Low Moderate Low Moderate na Nielsen et al Low Low Low Low Low Low Low Plesh et al. Low Low Low Low Low Low Low Fejer et al. Low Low Low Low Low Low Low Vissher et al. Low Low Low Low Low Low Low io Munhoz et al. Moderate Low Moderate Low Moderate Low Moderate La Touche et al. Moderate Moderate Low Low Low Low Moderate az De Farias Neto et al. Moderate Low Moderate Low Moderate Low Moderate Coskun Benlidayi et al. Moderate Low Moderate Low Moderate Low Moderate Greenbaum et al. Low Low Low Low Low Low Low rn Ries et al. Low Low Low Low Low Moderate Moderate Halmova et al. Moderate Moderate Low Low Low Moderate Moderate te Calixtre et al. Moderate Low Low Low Low Low Low Da Costa et al. Moderate Low Low Low Low Low Low Santander et al. Moderate Moderate In Low Low Low Moderate Moderate Inoue et al. Moderate Moderate Low Low Low Low Moderate Testa et al. Low Moderate Low Low Low Low Low ni Guarda-Nardini et al. Moderate Low Low Low Low Low Low Von Piekartz et al. Moderate Low Low Low Low Low Low Note: Moderate, the study is sound for a non-randomized study with regard to this domain but cannot be considered io comparable to a well-performed randomized trial; Low, the study is comparable to a well-performed randomized trial with regard to this domain. iz Included studies tous and tendinous connections constituting a func- The included articles (13-38) mainly focus on tional compound who moves as a single unit (43). In anatomical, postural and pain relationship between addition, what emerges from the recent literature is a Ed cervical spine and TMD. The main findings of the in- possible involvement of common neurological affer- cluded articles were summarized (Tab. 1). ences mainly related to C1 and C2 segment which Of the included studies, one is a cohort study (17), may act as one integrative functional unit to process three are prospective studies (18-20), one is an animal cutaneous, deep, and visceral nociceptive information study (21), seven are retrospective studies (22-28), two from craniofacial and afferent inputs (21). are twin retrospective studies (29, 30), two are cross- In a study conducted by de Wijer et al. (13) was con- IC sectional studies (31, 32), six are previous reviews (33- cluded that TMD with a myogenous involvement 39) and three are case-control studies (40-42). should no longer be viewed as a local disorder of the While all the studies analyse the different aspect of stomatognathic system and need an evaluation also the relationship between cervical spine and TMD, the of cervical spine and shoulder girdle. In 2016, anoth- C outcome evaluated are heterogenous. However, in er study (31) involving 86 patients with chronic neck order to undertake a descriptive analysis, our primary pain or TMD, reported how chronic pain of one of outcome was pain, both as referred and objectively these anatomical regions can spread hyperalgesia evaluated during clinical outcome, secondary out- and pain in the other one. © comes were results of patient referred information through surveys and questionnaires as descripted in Postural more details in the studies. Patient with TMD can often present cervical pain and postural asymmetry in the cranio-cervical area, that Anatomic influence the general posture of the body and the As regards anatomical associations, it is clear how clinical significance of the temporomandibular disor- the two regions are linked through muscular, ligamen- der (41). A systemic review of the 2009 confirmed Annali di Stomatologia 2018;IX (3):97-105 99  E. Chisari et al. ?>=<;:98:?7;:6>54:3425410:/.:-7;:54,<+2;2:>*-5,<;0:>*;:*;)/*-;28 Study Study design Subjects involved Relationship Results investigated (+':;-:><8 &456><:0-+2% $#:4/,5,;)-5";:4;+*/40:.*/6: &4>-/65,>< >4%:9:>42::(:4/,5,;)-5";: li ! :>2+<-:)*>1+;:><;%: 4;+*/40:*;,;5";2:6;,7>4/0;4- *>-0 05-5";:,/4";*1;4-:>..;*;4-:54)+-0: na .*/6:,;*"5,><:>42:,*>45/.>,5><: 2;;):-500+;0 +/>*,>': */000;,-5/4><: :>2+<-0:5-7:?:/*: >54:7%);*><- ?: : :)>*-5,5)>4-0:7>2:6/*;: ;-:><8 0-+2% ,7*/45,:4;,:)>54: 1;05> >*;>0:/.:)>54:>42:><0/:07/;2: io 52;0)*;>2:)>54:7%);*><1;05> 5;<0;4':;-:><8 %0-;6>-5,:*;"5; !:0-+25;0 ;4;-5, >54:54:?:>42::0;;6:-/: =;:>00/,5>-;2:=%:)>--;*4:/.:547;*- az 5->4,; 500,7;*':;-:><8 %0-;6>-5,:*;"5; 9:0-+25;0 ;4;-5, ?7;:<5-;*>-+*;:6>54<%:0+11;0-0:1;- 4;-5,:,/4-*5=+-5/40:.*/6:,>4252>-;: 1;4;0:-7>-:;4,/2;:)*/-;540:54- rn "/<";2:54:-7;:)*/,;00541:/.:)>54.+<: 0-56+<5:.*/6:-7;:0;*/-/4;*15,:>42: ,>-;,7/<>654;*15,:0%0-;6 <;07':;-:><8 ;-*/0);,-5";:*;1- 9':6/4/%1/-5,:>42:!$: ;4;-5, ?7;0;:)*;<5654>*%:3425410:0+1- te 50-*%:0-+2% 25%1/-5,:.;6><;:-54:)>5*0 1;0-:-7>-:-7;:>00/,5>-5/4:=;-;;4: ?:)>54:>42:651*>54;:7;>2>,7;: 54:/6;4:6>%:=;:)>*-5><<%:2+;:-/: In >:6/2;0-:07>*;2:1;4;-5,:*50:./*: =/-7:,/425-5/40 ;;*':;-:><8 */000;,-5/4><: :'$ #:-540:/.:2>4507: ;4;-5, ;4;0:)<>%:>:051453,>4-:*/<;:54: 0+*";% *;150-*% 4;,:)>54':)>*-5,+<>*<%:54:/6;4 ni 5007;*':;-:><8 ?54:0-+2% ':>2+<-:.;6><;:-540 ;4;-5, >*5>-5/4:54:?:)>54:>42:4;,: )>54:,>4:54:)>*-:=;:>--*5=+-;2:-/: io 1;4;0 >42=;*1':;-:><8 >**>-5";:*;"5; :0-+25;0:/4:?:>42:>: &4>-/65, >-5;4-0:5-7:?:>42:-*>+6>: 75)<>07:54+*% 750-/*5;0:250)<>%:6/*;:0;";*;: iz 0+=;,-5";':/=;,-5";':>42:)0%,7/- </15,><:2%0.+4,-5/4:,/6)>*;2:5-7: -%)5,><:)>-5;4-0:5-7:?0 Ed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© 1;654><:4/,5,;)-5";:)*/,;00541:54: 25..;*;4-:,*>45/,;*"5,><:)/0-+*;0 ;:>*5>0: ;-/': */0);,-5";:0-+2% !:>2+<-:?:)>-5;4-0 /0-+*>< ?7;:0%6)-/6>-5,:?:)>-5;4-0: ;-:><8 )*;0;4-;2:>:
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3)4('(/%$4+.#'/(**+ '$/)1' iz that there is a probable relationship between the with temporomandibular joint and muscle disorder Ed stomatognathic system and the general body posture. (TMJMD). The 59% of people with TMJMD had two The main alteration of subjects with TMD was a cervi- or more comorbid disorders like headache, neck or cal extensor muscle tension that can increase the low back pains. In particular, the 54% of the patients pain perceived, the body posture and the clinical out- with TMJMD had neck pain (22). come of the patients (38). IC Pain Discussion Guarda-Nardini et al. (20) described a reduction of pain after an intra-articular injection with hyaluronic Genetic and environmental factors seem to contribute acid into temporomandibular joint (TMJ) in patients to the pathogenic threshold of the TMD and neck dis- C with TMJ osteoarthritis and concomitant cervical spi- orders. In particular different twin studies reported ne pain. The pain improved in both areas after 3 and strong evidence of this association, even though the 6 months. Patients with chronic neck pain (CNP) and underlying mechanism were not investigated (29, 30, TMD presented more widespread pain, hyperalgesia 33-35). © in different regions of the body than patients with only The reported evidence of the association between CNP or only TMD even though psychosocial factors history of whiplash and TMD (36), the anatomical seems to be associated too (31). Pain and posture in connections (43), the association of the postural al- the cervical spine/neck region should be assessed teration affecting TM and cervical spine lack of high prior and after surgery for TMD to further clear this profile studies (37). In contrast to this, available evi- relationship (32). A high-profile study that included dence seems to support also a postural connection. 189,977 people in US analysed the pain in subjects This relationship could affect the clinical practise and 102 Annali di Stomatologia 2018;IX (3):97-105  Temporomandibular disorders and cervical spine: a systematic review li na io az rn te In ni Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) flowchart of the systematic litera- ture review. io should be known by al the medical professionals. atognathic system after being treated with cervical A study of 2014 (23) reported how the cervical pos- mobilization and stretching technique (19). Another ture (in particular the degree of cervical lordosis) cor- study showed how myofascial pain in patients with iz relate with the severity of functional pathologies of TMD affects masticatory and neck muscles (42). In temporomandibular system (FPTS). Another study addition, a recent review (39) on manual therapy on held by La Touche et al. (17) confirmed the anatomi- myofascial pain in TMD reported a strong evidence of Ed cal relationship by nociceptive innervation of trigemi- its use in patients with TMD in both head and neck nal nerve and its influence on the relationship be- regions. tween cervical spine and temporomandibular joint. In Another pilot study (26), involving 22 subjects with particular, they reported how cervical posture change TMD, showed how the rehabilitation can provide a affected maximal mouth opening (MMO) and the good effect in the cervical posture after a combination pressure pain threshold (PPT). Another study of De protocol of six months of continuous mandibular ad- IC Farias correlated the symptoms of TMD group pa- vancement appliance (MAA) and a program of postu- tients with a specific cervical posture alteration (i.e. ral re-education. flexion of the Atlas) resulting in an hyper-lordosis of The reported pain is another chapter of the relation- the cervical spine (18). This was further supported by ship between the temporomandibular joint, and in C other similar studies on cervical spine lordosis (24) general the orofacial region, and the cervical or and the cervical ROM in patients with TMD (40). neck/shoulder region. These alterations are probably the main reason be- The results of this literature review seem promising. hind the success of rehabilitation therapy in these pa- In particular in one study (27), involving 171 patients © tients. Indeed, the cranio-cervical rehabilitation, espe- with TMD, showed a relationship between the pain in cially if supported by manual therapy, seems to im- the temporomandibular joint with disk displacement prove the pain in the patients with myofascial tem- and ipsilateral muscle tenderness in orofacial and poromandibular disorders (25). In 2016, a study in- neck/shoulder region. The EMG (electromyography) volving twelve women affected by TMD reported sig- alterations of masseter muscles in people with non- nificant changes in pain-free maximum mouth open- specific neck pain evidenced how a cervical disease ing, self-reported pain, and functionality of the stom- can develop a TMD or orofacial pain (28). Annali di Stomatologia 2018;IX (3):97-105 103  E. Chisari et al. While the rationale behind this relationship is still un- 8. Levitt SR, McKinney MW. Validating the TMJ scale in a na- clear, we can assume that the anatomical and neuro- tional sample of 10,000 patients: demographic and epi- logical connections between cervical spine and TMD demiologic characteristics. J Orofac Pain [Internet]. 1994 [cit- ed 2018 Jun 20];8(1):25-35. Available from: http://www. are clinically significant. TMD seems to be a risk factor ncbi.nlm.nih.gov/pubmed/8032327 to develops myofascial pain, hyperalgesia and chronic 9. Nackley AG, Tan KS, Fecho K, Flood P, Diatchenko L, Maixn- li neck pain. In addition, TMD seems to intensify CVP er W. Catechol-O-methyltransferase inhibition increases pain and associated symptoms. Studies on posture relation- sensitivity through activation of both β2- and β3-adrenergic na ship require more high-profile studies. A complete receptors. Pain [Internet]. 2007 Apr [cited 2018 May evaluation of both these clinical conditions must in- 5];128(3):199-208. Available from: http://www.ncbi.nlm.nih. clude an accurate physical exam of both regions. gov/pubmed/17084978 Since there is a lack of evidence about of the possible 10. Diatchenko L, Nackley AG, Slade GD, Bhalang K, Belfer I, Max common etiology and pathogenesis of these disorders, MB, et al. Catechol-O-methyltransferase gene polymor- io phisms are associated with multiple pain-evoking stimuli. Pain we strongly encourage further clinical and molecular [Internet]. 2006 Dec 5 [cited 2018 May 5];125(3):216-24. studies on patients affected by these disorders. 11. Diatchenko L, Anderson AD, Slade GD, Fillingim RB, Sha- az balina SA, Higgins TJ, et al. Three major haplotypes of the Abbreviations β2 adrenergic receptor define psychological profile, blood TMD, temporomandibular disorders. pressure, and the risk for development of a common mus- CSP, cervical spine pain. culoskeletal pain disorder. 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Original article Microhardness and cervical microleakage of healthy and periodontally involved dentin at class II cavities restored with conventional and bulk-fill resin li composites na Horieh Moosavi1 DDS, MS ed. A standardized box-only cavity was prepared in io Sara Majidinia2 DDS, MS every tooth. The samples of each group were ran- Seyed Ali Banihashem Rad3 DDS, MS domly allocated to two subgroups of 10 and re- Mohammad Jafari Giv4 DDS stored as follows: in the experimental group, the Fatemeh Namdar5 DDS, MS az cavities were filled by a 4-mm layer of Tetric N-Cer- am bulk-fill resin composite (BRC). In the control group, the conventional resin composite (Tetric N- 1 Associate Professor, Department of Restorative and Ceram) was inserted incrementally and then light Cosmetic Dentistry, School of Dentistry, Mashhad Uni- cured. After 1000 cycles of thermocycling, cervical rn versity of Medical Sciences, Mashhad, Iran microleakage was evaluated by dye extraction tech- 2 Assistent Professor, Department of Restorative and nique. Data were submitted to ANOVA, t-test, and Cosmetic Dentistry, School of Dentistry, Mashhad Uni- Mann-Whitney U test (α = 0.05). te versity of Medical Sciences, Mashhad, Iran Results: VHN values of healthy dentin at all depths 3Associate Professor, Department of Periodontics, were more than periodontally involved dentin. The School of Dentistry, Mashhad University of Medical most microleakage was seen in periodontally in- Sciences, Mashhad, Iran In 4 Dentist, Dental Research Center, Mashhad University volved teeth filled with conventional composite, but there were no significant differences between dif- of Medical Sciences, Mashhad, Iran ferent groups. 5 Assistant Professor, Dental Materials Research Cen- Conclusions: Although periodontal disease had a ter, Mashhad University of Medical Sciences, Mashhad, significant effect on the reduction of VHN, but no ni Iran significant effect was observed on the cervical mi- croleakage after using different resin composites. io Corresponding Author: Key Words: bulk-fill composite, dentin, micro- Fatemeh Namdar hardness, microleakage. Dental Materials Research Center, iz Mashhad University of Medical Sciences Vakil-Abad Blvd, Mashhad 91735, Iran Introduction Tel.: +989155081447 Ed Fax:+985138829500 Free radical polymerization of methacrylate-based E-mail: [email protected]; resin composites leads to volumetric shrinkage (1) [email protected] and defect formation at the interface between tooth and restoration, recurrent caries, increased sensitivity and cuspal deflection (2). Recently, bulk-fill resin Summary composites (BRCs) have been introduced by en- IC hanced mechanical properties and time-saving (3). Aims: The purpose of this in-vitro research was to These composites are claimed to be used for incre- compare microhardness and cervical microleakage ments of up to 4 mm thickness, without adverse ef- of healthy and periodontally involved dentin after fects on the degree of conversion (4). C restoration with conventional and bulk-fill compos- Mechanical and chemical properties of root dentin ex- ites. posed to periodontal disease may present significant Methods: For microhardness test, 20 human molars alterations considering the difference in microbial flo- were collected (10 healthy and 10 for periodontal ra involved in cervical dentin caries and therefore af- © reasons). Dentinal disks from cemento-enamel fect dentin bond strength in cervical areas (5). Be- junction were prepared. Each specimen received 9 cause of the modifications in the tooth structures ex- indentations (3 for each superficial, median and posed to periodontal diseases, the microhardness deep dentin) and an average of them was recorded value is thought to be different between normal and as the Vickers hardness number (VHN) of each periodontal involved dentin. area. For microleakage test, 20 healthy teeth and 20 The lack of enamel at the deep gingival margin of extracted for the periodontal disease were collect- class II cavities leads to unstable adhesion of com- Annali di Stomatologia 2018;IX (3):123-129 123  H. Moosavi et al. posite resin to dentin or cementum. Also, dentin has microhardness. Dentinal discs were obtained just less mineralized content and more water when com- from cemento-enamel junction (CEJ) area with 2 mm pared to enamel (6). Furthermore, in the gingival mar- thickness using a low-speed diamond saw (IsoMet gin of class II cavities, polymerization shrinkage and 4000, Buehler, USA) (Fig. 1). After polishing by sili- shrinkage stresses may exceed the adhesive-dentin con paper of 1000, 1500, 2000 grit, Vickers indenta- li bond strength which leads to gap formation and mi- tions (Sinowon Manual, China) were performed for croleakage (7). Although BRCs have shown low poly- dentin surfaces (superficial, median and deep) with a na merization shrinkage and high curing depth, concerns force of 100 g for 20 s (Fig. 2). Each specimen re- are about the ability of these composites to complete- ceived 9 indentations (3 for each superficial, median ly adapt to cervical cavosurface margins and internal and deep dentin) and an average of the readings of surfaces of class II cavities (3). each area at different groups was recorded as the Previous researches have shown that collagenous Vickers hardness number (VHN) of a region. io matrix breakdown by Host-derived dentinal matrix proteinases following periodontal disease, especially Microleakage assessment chronic periodontitis, can affect the adhesive proper- As previously stated, forty extracted teeth (20 healthy az ties of composite resin to dentin (8-10). Additionally, and 20 extracted due to severe chronic periodontitis due to different microbial flora in periodontal disease, disease) were used for this test. A standardized box mechanical and chemical properties of radicular only cavity was prepared on the mesial surface of dentin exposed to oral cavity can be different from each tooth with a new fissure diamond (008) bur rn healthy dentin and this influences the bond strength mounted in a high-speed dental handpiece and air to cervical dentin. Since the use of bulk-fill compos- and cooling water spray. The buccolingual extension ites are expanding and also the overall age of the and axial depth of the cavities were 3 mm and 1.5 community and the presence of cervical lesions fol- te lowing periodontal diseases are increasing, therefore we conducted this laboratory research to evaluate whether a bulk filling technique affects gingival mi- croleakage in healthy and periodontally involved In dentin of class II cavities. Null hypotheses of this study were: 1) there wouldn’t be any significant differ- ence in microhardness of the healthy and periodon- ni tally involved dentin; 2) type of dentin (healthy and periodontally involved) and composite resin (bulk-fill or conventional) wouldn’t influence the cervical mi- croleakage of class II cavities. io Materials and methods iz Sixty extracted, caries-free human permanent molars without cracks and restoration (30 healthy human third Ed molar teeth, 30 ones extracted due to severe chronic periodontitis disease) were collected in this study. Ten samples of each group were randomly allocated for measurement of Vickers microhardness and 20 speci- mens for microleakage assessment. After extraction, all teeth were stored in thymol solution at 4°C for less IC than one month. Healthy impacted or semi-impacted third molars were obtained by surgery. Also, perma- nent molars suffering from severe chronic periodontitis with more than 5 mm periodontal pockets were select- C ed from individuals with age 41 to 50 years. After re- moving residual periodontal tissues, the specimens were cleaned with pumice. An informed consent was obtained from donors under the protocol approved by © the Ethics Committee for Human Studies and registry no.IR.mums.sd.REC. 1394. 68. Measurement of Vickers microhardness Twenty extracted teeth (10 healthy human third mo- lars and 10 extracted due to severe chronic periodon- titis disease) were used for measurement of Vickers Figure 1. Dentinal discs obtained from CEJ area. 124 Annali di Stomatologia 2018;IX (3):123-129  Periodontally involved teeth and bulk-fill composites am resin composite (Ivoclar vivadent, Schaan, Liecht- enstein) was inserted incrementally in preparations of the control subgroup while the thickness of each layer was approximately 2 mm and photo-activated for 40 seconds. Materials’ details and manufacturers’ speci- li fications are shown in Table1. The restored specimens were then subjected to artifi- na cial aging. The samples were immersed in distilled water baths at the temperature of 5°C and 55°C for 1000 cycles. The storage period in each temperature was 20 seconds and the transferring period was 10 seconds. io Dye extraction technique All restored teeth were covered by two layers of nail az polish up to one millimeter from the cervical margin Figure 2. Cross sectional view of dentin surfaces (a) super- and then were submerged in methylene blue solution ficial, (b) median and (c) deep dentin for evaluation of Vick- for two days. Subsequently, the root of each speci- ers microhardness. men was cut just a lower level from the penetration rn area by a diamond saw mounted on the low speed cutting machine (IsoMet, Buehler, USA) (Fig. 3) and mm, respectively. The cervical margin was left as a the remaining crown was then stored in a bottle con- butt joint and located 0.5 mm below the CEJ. All di- te taining 1000 μl of nitric acid (65% by weight) for three mensions were checked with the periodontal probe days. Then the bottles were centrifuged (Versatile and digital caliper to ensure uniformity among prepa- SIGMA, Montreal Biotech, Montreal, Quebec, CA) for rations. The cavities were prepared uniformly by an 5 minutes at 14,000 rpm, and 100 μl of every speci- expert operator. The dentin and enamel surfaces In men was evaluated by using the spectrophotometer were conditioned with 37.5% phosphoric acid (Ivoclar (CECIL Instruments, Cambridge, UK) at 550 nanome- Vivadent, Schaan, Liechtenstein) for 30 and 15 sec- ter. The spectrophotometer findings indicate the light onds, respectively. Rinsing was done for 15 seconds absorption of the methylene blue in the interface of ni and the remaining water was eliminated by absorbing dentin and resin that present the microleakage score cotton. The adhesive Tetric N-Bond (Ivoclar Vivadent, of the restoration. Schaan, Liechtenstein) was applied based on the manufacturer’s instruction and photo-activated for 20 io Statistical analysis seconds using the light curing device (1200 mW/cm2, The differences in hardness measurements were an- Bluephase C8, Ivoclar Vivadent, Schaan, Liechten- alyzed with two-way ANOVA and Tukey test. Statisti- stein). Matrix application was done with Tofflemire iz cal analysis of microleakage was done by indepen- stainless steel matrices. Then the samples of each dent-samples t-test and Mann-Whitney U test using group of healthy and periodontally involved dentin SPSS version 14.0 (Chicago, Illinois, USA). The sig- were randomly divided to two subgroups of 10 and Ed nificance level was considered 0.05. restored as follows: In the experimental subgroup, a 4-mm layer of Tetric N-Ceram BRC (Ivoclar vivadent, Schaan, Liechten- Results stein) was placed into the cavity and packed against the metallic matrix and then light activated for 40 sec- Vickers microhardness values onds in continuous mode. Conventional Tetric N-Cer- IC Average VHN values of healthy dentin at all depths Table 1. Materials’ details and manufacturers’ specifications. C Name Composition Filler wt%, vol% Tetric N-Ceram Dimethacrylates (Bis-GMA, Bis-EMA, UDMA), barium glass, 80% (including 17% Bulk fill Ytterbium itterbium trifluoride, mixed oxide and prepolymer, additives, prepolymers), 60% © catalysts, stabilizers, pigments Tetric N-Ceram Bis-EMA,UDMA, TEGDMA, Ba-Al-Fl-borosilicat Glass, Ba 80-81%wt Conventional Glass, YbF3 Bis-GMA, Bisphenol-A diglycidyl ether dimethacrylate; Bis-EMA, Bisphenol-A ethoxylated dimethacrylate; TEGDMA, Triethylene glycol dimethacrylate; UDMA, urethane dimethacrylate. - Prepolymer includes monomer, glass filler and ytterbium fluoride. Annali di Stomatologia 2018;IX (3):123-129 125  H. Moosavi et al. Figure 3. Representation of the penetration area after covering the specimen with two layers of nail varnish. li na io az rn te In ni Table 2. Comparison of VHN values (Mean±SD) between different depths of dentin. Dentin Type VHN P-value io Superficial Healthy 89.3±19.4b 0.071 iz Periodontally involved 75.3±11.9a Median Healthy 78.0±18.8a 0.096 Ed Periodontally involved 65.2±12.5c Deep Healthy 78.0±7.9a 0.288 Periodontally involved 74.7±10.3a The same letters indicate no significant differences. IC were more than periodontally involved dentin, but the the differences between two resin composites were C differences between them were not statistically signif- not statistically significant (Fig. 4). Additionally, peri- icant (Table 2). VHN values at superficial area of odontally involved dentin showed higher microleak- healthy dentin were more than other depths, but influ- age scores compared to healthy dentin but statistical ences of dentin depth were not statistically signifi- analysis presented no significant differences between © cant. In periodontally involved teeth, superficial and two groups. deep dentin showed the same microhardness values. Microleakage assessment Discussion However cervical microleakage scores of convention- al resin composite bonded to both healthy and peri- The results of this research showed that the VHN val- odontally involved dentin were more than BRC, but ues of superficially dentin were significantly higher 126 Annali di Stomatologia 2018;IX (3):123-129  Periodontally involved teeth and bulk-fill composites li na io az rn te In Figure 4. Cervical microleakage of two resin composites (conventional and bulk fill) at healthy and periodontally involved dentin. than median and deep healthy dentin. Previous stud- with exposure of cementum (17, 18). They presented ies have shown that the microhardness values of that the microhardness values had reverse relation- ni dentin must be demonstrated in terms of the region in ship with periodontal pocket depth (17, 18). Lee et al. dentin. Some studies have reported that the superfi- showed that the host-activated dentin proteinases cial dentin was harder than the inner dentin and the causes the destruction of collagen matrix following io hardness decreased from the dentino-enamel junc- periodontal disease and may reduce the dentin hard- tion (DEJ) to the pulp (11, 12). Kinney et al. demon- ness of periodontally involved teeth (10). strated that the hardness reduction as a function of The results of this study validated the second re- iz depth was related to the lower stiffness of inter-tubu- search hypothesis, as there were not any significant lar dentin because of non-homogeneous distribution differences in cervical microleakage of class II cavi- of the inorganic content within the organic matrix ties concerning the type of dentin (healthy or peri- Ed (12). Pashley et al. reported that the enhanced tubu- odontally involved teeth) and placement techniques lar density at interior dentin corresponded to de- (bulk-fill or incrementally). Least cervical microleak- creased hardness (13). Another study stated that age was also observed at healthy dentin of class II hardness reduction with the location might be related cavities filled with Balk-fill resin composite. to differences in the hardness of intertubular dentin, Polymerization shrinkage and contraction stress can not to more quantity of tubules (14). Fuentes et al. induce adhesive failure and gap formation in the com- IC (11) reported VHN=63 for deep sound dentin and posite restorations. Also, placement technique, pho- stated since that the dentin tubules are not oriented to-activation method, stress relieving capacity and C- randomly, properties may depend on their direction. factor are effective on the magnitude of the stress (4). The mean VHN scores reported in this study for El-Damanhoury et al. showed a significant reduction C healthy dentin were in ranging from 78 to 89.3 and in shrinkage stress of BRC compared to conventional were somewhat higher than previous studies (57-62 resin composites while maintaining the depth of cur- VHN). The dissimilarity between reported values is ing at the 4 mm thickness. They concluded that this due to the method of specimen preparation and in- could support the use of these composites to fill deep © dentation techniques employed (5, 15, 16). cavities with high C-factor (4). Based on our findings, the dentin of teeth suffering The mechanisms used to decrease contraction stress from severe chronic periodontitis showed less VHN and to enhance the curing depth are different be- compared to healthy dentin. In agreement with our re- tween bulk-fill resin composites. Some manufacturers sults, Riffle et al. and Emslie et al. found that the cer- enhance light transmission through the resin compos- vical root dentin showed less microhardness scores ite by using monomers, pigments, fillers with the in patients who suffer from periodontal disease or same refractive indices. Others decrease the inorgan- Annali di Stomatologia 2018;IX (3):123-129 127  H. Moosavi et al. ic content to enhance the light transmission and ate microleakage in the current research. In spite of depth of curing, although this approach compromises the restrictions of this investigation, although peri- the mechanical properties (19). Another approach to odontal disease had a significant effect on the dentin achieve deeper polymerization is the use of the addi- microhardness reduction, but no significant outcome tional or photo initiators like Ivocerin that is the patent- was observed on the cervical leakage after the use of li ed light activator of Tetric N-Ceram BRC and is re- conventional and BRCs. More research about long- sponsible for complete curing of the restoration. Ivo- term clinical evaluation of BRCs and periodontally in- na cerin is more light reactive than camphorquinone, acts volved teeth are required. as a polymerization booster and allows polymerization in deeper increments without compromising the physi- cal properties of the resin composite (20, 21). Conclusions Tetric N-Ceram BRC has the specially patented filler io that relieves contraction stresses (20). The manufac- VHN values of healthy dentin were more than peri- turer of this material claimed that due to the low elas- odontally involved teeth at all depths. Conventional tic modulus of this patented filler, the shrinkage resin composite showed more cervical microleakage az stress reliever expands slightly during polymerization than BRCs bounded to both healthy and periodontally and plays like a spring amongst the glass fillers with involved dentin, but the differences between two resin the higher modulus of elasticity. Also, Tetric N-Ceram composites were not statistically significant. Addition- bulk fill has prepolymerized fillers which attenuate ally, periodontally involved dentin showed higher mi- rn elastic modulus and their translucency helps to pass croleakage scores compared to healthy dentin, al- the photons through the substance. Finally, polymer- though statistical analysis showed no significant dif- ization shrinkage and contraction stress in Tetric N- ferences between them. Ceram BRC decrease during polymerization, obtain a te good marginal seal and allow increments up to 4 mm to be inserted (20, 22, 23). However, in our research References none of the two resin composites was able to inhibit perfectly cervical microleakage. In 1. Bagis Y, Baltacioglu I, Kahyaogullari S. Comparing mi- In line with our findings, some research concluded that croleakage and the layering methods of silorane-based resin any significant differences were not recorded in the composite in wide Class II MOD cavities. Operative Dentistry. 2009;34(5):578-585. cervical microleakage scores for incrementally com- 2. Phillips RW, Avery DR, Mehra R, Swartz ML, McCune RJ. ni pared to the bulk fill composites restored teeth (7, 24). Observations on a composite resin for Class II restorations: Most class II cavities extend up to or beyond the CEJ three-year report. The Journal of prosthetic dentistry. so that the cervical margins will be placed at the 1973;30(6):891-897. dentin surfaces and may cause a weak marginal seal io 3. Leevailoj C, Cochran M, Matis B, Moore B, Platt J. Micro- and microleakage between the dentin and composite leakage of posterior packable resin composites with and with- resin (25). Cavosurface margins restricted to enamel out flowable liners. Operative Dentistry. 2001;26(3):302-307. can preserve marginal seal of cavity preparation be- 4. El-Damanhoury H, Platt J. Polymerization shrinkage stress iz cause of the strong adhesion between the enamel kinetics and related properties of bulk-fill resin composites. Operative dentistry. 2014;39(4):374-382. and resin adhesive. Additionally, the internal stress of 5. Rautiola C, Craig R. The microhardness of cementum and the composites materials at dentin surfaces are often Ed underlying dentin of normal teeth and teeth exposed to pe- more than the bond strength and subsequently gap riodontal disease. Journal of Periodontology. 1961;32(2):113- formation occurs at the resin-dentin interface (26). 123. Past investigations have demonstrated that the min- 6. Demarco F, Ramos O, Mota C, Formolo E, Justino L. Influ- eral substance of dentin plays an essential role in the ence of different restorative techniques on microleakage in bond strength of composite to dentin (27). Yoshiyama class II cavities with gingival wall in cementum. Operative den- et al. explained that when the dentin was undergoing tistry. 2001;26(3):253-259. IC chemical and structural changes naturally, fewer 7. Patel P, Shah M, Agrawal N, Desai P, Tailor K, Patel K. Com- parative evaluation of microleakage of class II cavities restored resin tags formed because of the existence of mineral with different bulk fill composite restorative systems: An in sclerotic casts in the dentin tubules. Also, a limited vitro study. J Res Adv Dent. 2016;5(2):52-62. resin infiltration layer was seen at the external mar- C 8. Shinkarenko T, Rumiantsev V, Egorova E, Eliseeva T. Ma- gins of the natural lesions. They explained that the trix metalloproteinases in periodontitis. Stomatologiia. lower bond strength between resin and dentin struc- 2013;92(2):77. tures in natural lesions was because of the long term 9. Sorsa T, Tjäderhane L, Konttinen YT, Lauhio A, Salo T, Lee exposure to the oral cavity and, thereby, the pres- HM, et al. Matrix metalloproteinases: contribution to patho- © ence of unknown substances in dentin and thinner genesis, diagnosis and treatment of periodontal inflamma- tion. Annals of medicine. 2006;38(5):306-321. hybrid layer (28). 10. Lee W, Aitken S, Sodek J, McCulloch C. Evidence of a di- Dye extraction technique has employed to assess the rect relationship between neutrophil collagenase activity and marginal integrity and the ability of dental materials to periodontal tissue destruction in vivo: role of active enzyme seal the cavosurface margins. This method is simple in human periodontitis. Journal of periodontal research. and presents the characteristic of micro-leakage 1995;30(1):23-33. quantitatively (29). Therefore it was utilized to evalu- 11. Fuentes V, Toledano M, Osorio R, Carvalho RM. Micro- 128 Annali di Stomatologia 2018;IX (3):123-129  Periodontally involved teeth and bulk-fill composites hardness of superficial and deep sound human dentin. Jour- resin. Operative dentistry. 2015;40(2):172-180. nal of Biomedical Materials Research Part A: An Official Jour- 21. Furness A, Tadros MY, Looney SW, Rueggeberg FA. Effect nal of The Society for Biomaterials, The Japanese Society of bulk/incremental fill on internal gap formation of bulk-fill for Biomaterials, and The Australian Society for Biomateri- composites. Journal of dentistry. 2014;42(4):439-449. als and the Korean Society for Biomaterials. 2003;66(4):850- 22. Scientific documentation of Tetric N-Ceram Bulk Fill. Retrieved 853. online 11 September 2018. http://www.ivoclarvivadent.in/en- li 12. Kinney J, Balooch M, Marshall S, Marshall G, Weihs T. Atom- in/p/all/tetric-n-ceram-bulk-fill ic force microscope measurements of the hardness and elas- 23. Hirata R, Clozza E, Giannini M, Farrokhmanesh E, Janal M, na ticity of peritubular and intertubular human dentin. Journal Tovar N, et al. Shrinkage assessment of low shrinkage com- of biomechanical engineering. 1996;118(1):133-135. posites using micro‐computed tomography. Journal of 13. Pashley D, Okabe A, Parham P. The relationship between Biomedical Materials Research Part B: Applied Biomateri- dentin microhardness and tubule density. Dental Trauma- als. 2015;103(4):798-806. tology. 1985;1(5):176-179. 24. Moorthy A, Hogg C, Dowling A, Grufferty B, Benetti AR, Flem- io 14. Marshall Jr GW, Marshall SJ, Kinney JH, Balooch M. The ing G. Cuspal deflection and microleakage in premolar teeth dentin substrate: structure and properties related to bond- restored with bulk-fill flowable resin-based composite base ing. Journal of dentistry. 1997;25(6):441-458. materials. Journal of Dentistry. 2012;40(6):500-505. 15. Chuenarrom C, Benjakul P, Daosodsai P. Effect of inden- 25. Litonjua LA, Andreana S, Bush PJ, Tobias TS, Cohen RE. az tation load and time on knoop and vickers microhardness tests Noncarious cervical lesions and abfractions: a re-evaluation. for enamel and dentin. Materials Research. 2009;12(4):473- The Journal of the American Dental Association. 2003; 476. 134(7):845-850. 16. Yassen GH, Eckert GJ, Platt JA. Effect of intracanal medica- 26. Feilzer A, De Gee A, Davidson C. Setting stress in composite rn ments used in endodontic regeneration procedures on mi- resin in relation to configuration of the restoration. Journal crohardness and chemical structure of dentin. Restorative of Dental Research. 1987;66(11):1636-1639. dentistry & endodontics. 2015;40(2):104-112. 27. Spencer P, Wang Y, Walker M, Swafford J. Molecular struc- 17. Riffle A. The dentin: its physical characteristics during curet- ture of acid-etched dentin smear layers-in situ study. Jour- te tage. The Journal of Periodontology. 1953;24(4):232-241. nal of Dental Research. 2001;80(9):1802-1807. 18. Emslie R, Stack M. The micro hardness of roots of teeth with 28. Yoshiyama M, Sano H, Ebisu S, Tagami J, Ciucchi B, Car- periodontal disease. Dent Pract Dent Rec. 1958;9:101-113. valho R, et al. Regional strengths of bonding agents to cer- 19. Corral-Núnez C, Vildósola-Grez P, Bersezio-Miranda C, Cam- vical sclerotic root dentin. Journal of dental research. In pos A-D, Fernández Godoy E. State of the art of bulk-fill resin- 1996;75(6):1404-1413. based composites: a review. Revista Facultad de Odontología 29. NIK IR, NASERI EB, Majidinia S, NIK SR, GIV MJ. Effect of Universidad de Antioquia. 2015;27(1):177-196. Chlorhexidine and Ethanol on Microleakage of Composite 20. Jang J, Park S, Hwang I. Polymerization shrinkage and depth Resin Restoration to Dentine. Chin J Dent Res. 2017;20 of cure of bulk-fill resin composites and highly filled flowable (3):161-168. ni io iz Ed IC C © Annali di Stomatologia 2018;IX (3):123-129 129 

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Original article A multidisciplinary team for the management of oral cancer: a project called MoMax li na Umberto Romeo MD distinctive definition and principles of MDTC for Gianluca Tenore DDS, PHD OC patients and to analyse efficacy, costs and Andrea Cassoni MD time delay. io Federica Rocchetti DMD, PHD Ahmed Mohsen DMD, PHD Key Words: multidisciplinary team care, oral Giorgio Pompa MD medicine and maxillofacial surgery, oral potential- az Valentino Valentini MD ly malignant disorders, oro-pharyngeal cancer. Antonella Polimeni MD, DDS Introduction rn Department of Oral and Maxillo-Facial Sciences, “Sapienza” University of Rome, Rome, Italy The management route of cancer frequently requires the contribution of many qualified health care providers (1), which results in pushing the patients to te Corresponding Author: move among different specialists in order to be ade- Federica Rocchetti quately treated. Thus, the achievement of efficient Department of Oral and Maxillo-Facial Sciences, coordination between these specialists is the corner- “Sapienza” University of Rome In stone of providing a high and uniform level of special- Rome, Italy ist care. Tel.: 320 2847201 The Multidisciplinary Team Care (MDTC) approach E-mail: [email protected] has become the care model for cancer patients worldwide (2) and recently has been extended to oral ni cancer (OC) and oral potentially malignant disorders Summary (OPMD). MDTC can be achieved in many formats in the present healthcare systems. These formats may io Introduction: Currently, the management of can- include a comprehensive patient treatment, a devel- cer, from the detection of clinical and radiograph- opment of wide multidisciplinary cancer programmes, ic characteristics to the final diagnosis and treat- a creation of multidisciplinary diagnosis and treat- iz ment, is becoming more complex. The Multidisci- ment protocols, and a formation of cancer collabora- plinary Team Care (MDTC) approach has become tive services or multidisciplinary tumour conferences, the care model for cancer patients worldwide. The which are known as tumour boards (1, 3). Ed MDTC approach is a tool to improve the survival The advantages of MDTC may include psychological rate of cancer patients by providing them with the benefits for patients, efficient treatment decisions by best treatment plan for the prevention and/or the diverse specialists, improved clinical integration of treatment of adverse events. care for medical centres and healthcare providers, Materials and methods: This paper describes the education for practitioners, caregivers and partners management algorithm of our MDTC called Mo- and increased patient contribution in clinical trials (4). IC Max (Oral Medicine and Maxillofacial Surgery) at The MDTC approach is a tool to improve the survival the Department of Oral and Maxillo-Facial Sci- rate of cancer patients through providing them with ences, “Sapienza”, University of Rome. the best treatment plan together with the prevention Discussion and Conclusions: The efficacy of or treatment of adverse events (5). The team compo- C MDTC on oral cancer (OC) management in the lit- sition varies according to the cancer site and institu- erature is still elusive due to the absence of a tion (1, 3). consistent definition for MDTC, the complexity of The literature agrees that the MDTC approach for OC the management of OC, the non-effective con- should include a core team consisting of oral patholo- © struction and nature of the multidisciplinary team gists, general dentists, maxillofacial surgeons, oncol- and the poor communication between different ogists, radiotherapists, radiologist and anatomy- cancer centres nationally and internationally. To pathologists. If necessary, the patient can be referred date, the MoMax project has yielded good results to other specialists, such as speech therapists, dieti- in shortening the time of managing patients with cians or psychologists. In fact, most of the patients OC and increasing good patient therapeutic com- affected by OPMD or OC undergo an oral pathologist pliance. Further research is needed to achieve a and/or maxillo-facial surgeons at a late stage, when 134 Annali di Stomatologia 2018;IX (3):134-140  A multidisciplinary team for the management of oral cancer: a project called MoMax their lesions become symptomatic, which may lead to Materials and methods an important negative influence on the diagnosis and the prognosis of the pathology. For OC, the delay in MoMax Clinical Pathway patient management is basically related to three main MoMax was created and implemented at the Depart- factors: patient delay, professional delay and treat- ment of Oral and Maxillo Facial Sciences, at “Sapien- li ment delay. The consequence of increased waiting za” University of Rome in June 2014. The MoMax time is tumour growth, clinical upstaging, deteriorated core team is formed by oral pathologists, prosthodon- na prognosis and worsening of the quality of remaining tists, dental hygienists and maxillofacial surgeons life. The MDT serves as a point of reference for the who meet once a week in the same surgery to treat patients, accompanying them from diagnosis to treat- patients. Furthermore, once a week, the core team ment. meets with radiotherapists, oncologists, otorhino- We are going to report the management algorithm laryngologists, an anatomy-pathologist and a radiolo- io (Fig. 1) for OC in a specialist multidisciplinary team gist to discuss the patients at Head-Neck Tumour called MoMax (Oral Medicine and Maxillo Facial Sur- Board (HNTB) in order to plan the best personalized geon) to facilitate daily clinical decision-making of all treatment for each patient (Fig. 2). az health-care specialists involved, in order to reduce The MoMax group takes care of patients from the di- patient waiting time and to guarantee the most effec- agnosis to the treatment through cytological exams tive therapy and benefits from this type of approach. (brush and oropharyngeal swabs), histological exams rn te In ni io iz Ed IC C © Figure 1. Clinical pathways algorithm of MoMax project. Annali di Stomatologia 2018;IX (3):134-140 135  U. Romeo et al. li na io az rn Figure 2. Head and Neck Tumour Board organization. te (scalpel and laser biopsy), pharmacological thera- tal history in an unified clinical chart of all the referred pies, maxillofacial surgery and prosthetic rehabilita- patients (Fig. 3). tions. Specifically, the choice of the second level X-ray ex- The MoMax project consists of 3 pathways: preven- In amination depends on the anatomical localisation of tion, diagnosis and treatment. These pathways run the tumour: in the case of lesions close to the bone, through 4 steps. The first step is established through such as the alveolar bone or gingivobuccal bone, it is carrying out a full clinical examination in conjunction preferable to perform a contrast-enhanced and non- with the recommended investigations (brush biopsy, enhanced computed tomography (CT) scan of the ni oropharyngeal swabs, excisional and incisional biop- maxillo-facial area, jaw and neck. For areas not di- sies and X-rays) after recording the medical and den- rectly connected to the bone (i.e., the tongue and the io iz Ed IC C ©
Figure 3. Chart of MoMax project. 136 Annali di Stomatologia 2018;IX (3):134-140  A multidisciplinary team for the management of oral cancer: a project called MoMax floor of the mouth) it is preferable to perform a mag- Discussion and conclusions netic resonance imaging (MRI) of the maxillo-facial area, jaw and neck with and without contrast. A high- OC represents the sixth most common cancer in the definition chest X-ray is always required to evaluate world (8). In Italy, cancer registries reveal that OC the presence of distant metastases. represents approximately 3% of all cancers in males li In the case of early oral cancer (T1, according to and 1% in females (9). OC represents approximately UICC TNM staging system) with a thickness less than 85% of all head and neck cancers and is traditionally na 8 mm, both the CT and MRI lack of specificity and defined as a Squamous Cell Carcinoma, because sensitivity, and in case of the presence of dental 90% of these cancers are histologically originated amalgam reconstructions that can cause artefacts, an from the squamous cells of the oral cavity (8). intraoral ultrasound (US) with a very small transduc- OC is a preventable disease. The multifactorial na- er, such as a toothbrush, is performed. This examina- ture of OC results in a complex interaction between io tion allows identifying the size and the vascularity of genetics, the environment and behavioural factors the cancer, the tumour depth and the tumour thick- (i.e. tobacco and alcohol) (8). Less common risk fac- ness in order to eventually plan, pre-operatively, the tors include human papilloma virus and chronic mu- az requirement of neck-dissection. Furthermore, in this cosal trauma (Fig. 4). first step, trained dental hygienists assist smoking pa- OPMDs have been introduced in the literature and tients to quit tobacco use by providing information describe the precancerous lesions of the oral mucosa and supporting them with questionnaires and with the in recent years (10). These lesions include oral leu- rn “5A” intervention model (6). coplakia, oral erythroplakia, palatal lesions in reverse The second step is the selection and the submission smokers, oral submucous fibrosis, actinic keratosis, of the cases to the Head-Neck Tumour Board in order oral lichen planus and discoid lupus erythaematosus to achieve the most effective and suitable treatment (11). Oral leucoplakia, oral submucous fibrosis and te plan. This submission is performed through the oral oral erythroplakia have the highest malignant trans- presentation of the cases with the use of photos, CT, formation rates. Atrophic and erosive subtypes of oral MRI and US imaging. lichen planus also have the greater malignant trans- In The third step is the application of the Tumour Board- formation rate compared to other subtypes. The aeti- recommended treatment plan: surgery, radiation ther- ology is not fully understood for most OPMDs (10). apy (RT) or chemotherapy (ChT). Patients scheduled OPMDs can be considered as risk indicators of likely to receive radio and or chemotherapy that involves future malignancies in the oral mucosa (11) (Fig. 5). ni the mandible, maxilla or salivary glands are referred Therefore, one of the prevention methods for OC that to MoMax for a comprehensive dental consultation, can be effective is the early diagnosis and manage- assessment and clearance before therapy begins in ment of these disorders. order to treat, eventually, dental infections. Patients Only half of newly diagnosed OC patients has more io are also informed of the adverse events of these than 5-year survival rate (12). The low survival rate treatments such as mucositis and osteoradionecrosis and poor prognosis of OC were commonly a result of and are motivated to establish a good standard of late diagnosis rather than being hard to diagnose. iz oral hygiene (7). One of the means of prevention of Thus, early diagnosis and treatment remains the key the adverse events of radiotherapy are the delivery of of improving the survival rate (8). fluoro-prophylaxis masks to patients, to limit the de- The late diagnosis of OC is due to three factors: pa- Ed velopment of decay due to xerostomia. tient delay, professional delay and treatment delay. The fourth step includes the controls, follow-up and Patient delay can largely be attributed to the un- modification of treatment plan by the multidisciplinary awareness of the signs and symptoms of disease and team if needed. For the following year, at the end of oral symptoms being rarely attributed to cancer and radiotherapy, patients undergo professional oral hy- frequently interpreted as minor oral conditions. A lack giene sessions and controls every three months in or- of understanding of the clinical presentation of these IC der to maintain a good level of oral hygiene and to diseases and confidence on the part of health profes- avoid the onset of periodontitis or caries. Further- sionals has been suggested as a barrier for suspect- more, during this stage, patients can be rehabilitated ing cancer and dealing promptly with an appropriate with traditional prosthesis or implants to maintain referral or arranging a follow-up visit (13). The diag- C function and aesthetics. nosis of oral and pharyngeal cancers at their early Regarding patient management time, in the case of stage can be easily achieved through clinical exami- clinically suspicious lesions, many times we proceed nation (9). to biopsy immediately or maximum in a week. In the Villa et al. conducted a study to investigate patients’ © case of pre-radio and/or pre-chemotherapy dental knowledge regarding OC risk factors and to explore consultation, we proceed with the necessary treat- communication between clinicians and patients at- ments such as teeth extractions in a maximum of 10 tending dental departments within Italian university days, excluding the biological tissue healing time af- hospitals by sending out 2200 questionnaires (14). ter the surgery. The results revealed the majority (approximately 94%) of individuals had knowledge of the clinical signs associated with OC; this knowledge was more Annali di Stomatologia 2018;IX (3):134-140 137  U. Romeo et al. Figure 4. Intraoral aspect of verrucous carcinoma of the buccal mucosa. li na io az rn te In improved in individuals who had a family history of receiving counselling about OC from their physicians OC compared to individuals with no family history or dentists (14). In this study, most smokers knew ni (11). Furthermore, the Authors noticed that the pa- that smoking was a risk factor for OC (87%) and yet tients’ knowledge did not appear to be provided by continued to smoke (14). clinicians, as less than 15% of participants reported Colella G et al. (9) performed an epidemiological in- io iz Ed IC C © Figure 5. Intraoral aspect of lichen planus of the buccal mucosa. 138 Annali di Stomatologia 2018;IX (3):134-140  A multidisciplinary team for the management of oral cancer: a project called MoMax vestigation in Italy to examine the dental health care myriad of psychosocial factors necessitate the opti- providers’ knowledge of OC prevention and detection. mization of patient care with a systematic approach The results were greatly surprising that only one-third based on MDTC (16, 17). Nutritional and swallowing can correctly recognize the most common form of OC evaluation, dental evaluations and treatments, and and early OC lesions. The Authors stated that these pain management are mandatory before, during, and li values were considerably lower than those observed after concomitant treatment. in recent surveys in other countries (6). Different Finding evidence of the relation between the MDTC na studies (9) reported that a lower risk of death in can- and patient outcomes, even with this controversy, is cer patients has been achieved by treating them in the key for exerting more time and finances to sup- hospitals or by physicians serving high numbers of port this approach (1). Our MoMax project, to this patients, as both provide multidisciplinary knowledge day, has been giving good results with the short man- and management to the patients, which are needed aging time of patients and good patient therapeutic io to solve the complexity of OC diagnosis and manage- adhesion. Further research with larger cohorts of pa- ment. Given that a goal of MDTs is to improve patient tients is needed to assess whether our MDTC may care, it would be important to demonstrate that pro- positively influence the general patients’ survival rate az viding care within the MDT structure does not nega- and their quality of life. tively affect waiting times. Patil, et al. demonstrated retrospectively that the im- plementation of MDTC at University of Cincinnati Vet- Acknowledgements rn eran’s Administration Hospital (Cincinnati, Ohio, Unit- ed States) reduced the time from initial consultation The Authors thank Dr. Di Carlo, Dr. Brauner, Dr. Bat- to being seen in the otolaryngology clinic from 27.5 to tisti and Dr.ssa Montori for performing clinical assi- 16.5 days (P<0.0001), and the time from the positive stance. te biopsy to the beginning of the treatment decreased from 35 to 27 days (P=0.04) (15). Our time management, compared to the literature, is References In good. It is relevant to shorten the period between the first visit and the biopsy in OC cases, to about one 1. Hong NJ, Wright FC, Gagliardi AR, Paszat LF. Examining week, leading to an appropriate evaluation in the the potential relationship between multidisciplinary cancer HNTB in a very short time. Interesting results were al- care and patient survival: an international literature review. J Surg Oncol. 2010;102(2):125-134. ni so registered in the preparation of patients for 2. Lamb BW, Brown KF, Nagpal K, Vincent C, Green JS, Sev- radio/chemotherapy with the resolution of all the dalis N. Quality of care management decisions by multidis- problems in less than 3 weeks. ciplinary cancer teams: a systematic review. Ann Surg On- The relation between cancer patient survival rates io col. 2011;18(8):2116-2125. and MDTC is still controversial. However, there is in- 3. Carlson ER. Collective wisdom and multidisciplinary tumor ternational support of this approach (3). This contro- boards. J Oral Maxillofac Surg. 2014;72(2):235-236. versy may be due to two causes; the first is there is 4. Licitra L, Bossi P, Locati LD. A multidisciplinary approach to iz no single consistent definition of MDTC (1); the sec- squamous cell carcinomas of the head and neck: what is new? Curr Opin Oncol. 2006 May;18(3):253-257. ond is the complex care pathway of diagnosis, stag- 5. U.S. DEPARTMENT OF HEALTH AND HUMAN SER- ing, case discussion, patient consultation, treatment, Ed VICES, (National Institutes of Health, National CancerI nsti- and follow-up of cancer patients (3). tute). Common Terminology Criteria for Adverse Events (CT- Few studies stated that MDTC was expensive, and its CAE). 2017. benefits in improving the outcome of the manage- 6. Parker DR. A dental hygienist’s role in tobacco cessation. ment of OC have not been widely studied. Therefore, Int J Dent Hyg. 2003 May;1(2):105-109. some doctors believe that the early-staging of head 7. Schiødt M, Hermund NU. Management of oral disease pri- and Neck cancer can be successfully managed out- or to radiation therapy. Support Care Cancer. 2002 Jan;10 IC side the MDTC. They refer patients with only ad- (1):40-43. 8. Rivera C. Essentials of oral cancer. International Journal of vanced malignancy (13). In contrast, an Australian Clinical and Experimental Pathology. 2015;8(9):11884- study stated that the principle-based approach to 11894. MDTC may have the potential to reduce the mortality C 9. Colella G, Gaeta GM, Moscariello A, Angelillo IF. Oral can- and healthcare costs and to improve the quality of life cer and dentists: knowledge, attitudes, and practices in Italy. in women with early-stage breast cancer. The Au- Oral Oncology. 2008;44(4):393-399. thors recommended their approach to all types of ma- 10. Yardimci G, Kutlubay Z, Engin B, Tuzun Y. Precancerous le- lignancy (14). sions of oral mucosa. World Journal of Clinical Cases: WJCC. © Additionally, studies from Taiwan, the United States, 2014;2(12):866-872. 11. Warnakulasuriya S, Johnson NW, Van der Waal I. Nomen- Germany, and United Kingdom have demonstrated clature and classification of potentially malignant disorders that the MDTC has the ability to improve the quality of the oral mucosa. J Oral Pathol Med. 2007;36:575-580. of life for cancer patients, lower healthcare costs and 12. Wang YH, Kung PT, Tsai WC, Tai CJ, Liu SA, Tsai MH. Ef- to increase the survival rate (9). The management of fects of multidisciplinary care on the survival of patients with OC remains a complex challenge for health care oral cavity cancer in Taiwan. Oral oncology. 2012;48(9):803- providers. The disease process, comorbidities, and a 810. Annali di Stomatologia 2018;IX (3):134-140 139  U. Romeo et al. 13. Warnakulasuriya S, Diz Dios P, Lanfranchi H, Jacobson JJ, squamous cell carcinoma: a multidisciplinary team’s approach. Honghua, Rapidis A. Understanding gaps in the oral cancer Laryngoscope. 2016;126:627-631 continuum and developing strategies to improve outcomes. 16. Friedland PL, Bozic B, Dewar J, Kuan R, Meyer C, Phillips Global Oral Cancer Forum (Group 2). 2016 M. Impact of multidisciplinary team management in head and 14. Villa A, Kreimer AR, Pasi M, et al. Oral cancer knowl- neck cancer patients. British Journal of Cancer. 2011;104 edge: a survey administered to patients in dental depart- (8):1246-1248. li ments at large italian hospitals. J Cancer Educ. 2011;26: 17. Zorbas H, Barraclough B, Rainbird K, Luxford K, Redman 505-509. S. Multidisciplinary care for women with early breast cancer na 15. Patil RD, Meinzen-Derr JK, Hendricks BL, Patil YJ. Improving in the Australian context: what does it mean? Med J Aust. access and timeliness of care for veterans with head and neck 2003;179:528-531. io az rn te In ni io iz Ed IC C © 140 Annali di Stomatologia 2018;IX (3):134-140 

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Case report A rare case of intraparotid facial nerve schwannoma li na Claudio Ungari1 MD, PhD schwannomas arises from the neural structures of the Matteo Gualtieri1 MD head and neck, and thus also the facial nerve (CN Emiliano Riccardi1 MD VII) can be affected (1). io Fabio Filiaci1 MD Facial nerve schwannomas (FNS) mostly (90%) af- Bruna Cerbelli2 MD fect the intracranial and intratemporal course of the nerve and more rarely (9%) involve the intraparotid az area, accounting for 0.2 to 1.5% of all parotid gland 1 Oral and Maxillo Facial Sciences Department, tumors (1-5). Out of a total of 3722 patients with “Sapienza” University of Rome, Rome, Italy schwannoma retrospectively reviewed over 38-year 2 Department of Radiological, Oncological and Patho- period by Caughey et al., only 29 were related to fa- rn logical Sciences, Policlinico Umberto I, “Sapienza” cial nerve and only 8 involved the parotid segment of University of Rome, Rome, Italy the facial nerve (4). Intraparotid FSN usually appears as asyntomatic, painless, slow-growing mass, even if facial nerve dys- te Corresponding Author: function, hemifacial paresis or paralysis can be pre- Matteo Gualtieri sent. Department of Odontostomatology and Maxillofacial The lack of clinical and radiographic pathognomonic Surgery, Policlinico Umberto I In features makes difficult to diagnose the tumor preop- “Sapienza” University of Rome eratively. The definitive diagnosis is exclusively based Via Lorenzo il Magnifico 110 on histopathological and immunohistochemical exam- 00162 Rome, Italy inations (5). Tel.: +39 3288750884 This report describes a case of a 76-year-old female ni affected by intraparotid facial nerve schwannoma of the right parotid gland. Summary io Facial nerve schwannomas are benign, encapsu- Case report lated, slow-growing tumors arising from Schwann iz cells of seventh cranial nerve, rarely found in the A 76-year-old female was referred to the Department parotid gland. Clinical diagnosis is usually diffi- of Maxillofacial Surgery of “Policlinico Umberto I” cult because other unilateral parotid tumors, such (“Sapienza” University of Rome) for evaluation of a Ed as the pleomorphic adenoma, Warthin’s tumor or slow-growing and painless swelling in the right preau- mucoepidermoid carcinoma, occur as an asymp- ricular area, present since 10 months, without any tomatic slow-growing mass. symptoms of facial weakness, twitching or numbness. This report describes a case of a 76-year-old fe- Medical history and general physical examination male affected by asymptomatic intraparotid facial were non-contributory. Extraoral examination re- nerve schwannoma. vealed a swelling approximately 5x4 cm in size, local- IC Morphological characteristics, clinical course, ra- ized in the right parotid gland. The mass had a soft diographic and histopathological features, and consistency and was non-tender to palpation. The fa- surgical therapy are discussed. cial nerve functioning evaluation was regular. No cer- vical adenopathy was evident. C Key Words: Schwann cells, facial nerve, parotid Ultrasonografy (US) showed a 48x33x31 mm sized, gland, neoplasm, schwannoma. well defined, oval, anechoic mass in the superficial lobe of the right parotid gland. The anechoic signal was evocative of fluid component. Color Doppler ex- © amination didn’t detect any vascular structure. Introduction Fine-needle aspiration cytology (FNAC) was incon- clusive and reported “grouping of blood cells and lym- Schwannomas (also named neurilemmomas) are un- phocytes. Negative research for neoplastic cells”. common, benign, slow-growing tumors that originate Magnetic resonance imaging (MRI) revealed a homo- from Schwann cells of myelinated peripheral or cra- geneous lesion 45x35 mm in size, involving the su- nial nerves (1, 2). Approximately 25-40% of all perficial lobe of right parotid gland. The mass was 130 Annali di Stomatologia 2018;IX (3):130-133  A rare case of intraparotid facial nerve schwannoma li na io az rn te Figure 1. MRI showed a homogeneous mass into the right parotid gland superficial lobe. The mass was characterized by a In hypointense signal in T1- weighted images (A) and hyperintense signal in long TR-weighted images with a peripheral en- hancement (B). characterized by a hypointense signal in T1-weighted ing encapsulated tumors with a neuroectodermal ori- ni images and hyperintense signal in long TR- weighted gin, which may arise from the nerve sheath of any images with a peripheral enhancement (Fig. 1). cranial or peripheral nerves (1, 2). Surgical exploration was planned under general FNS originate from Schwann cells along the course io anesthesia. Intraoperatively, the facial nerve branch- of seventh cranial nerve and most of them arise from es were identified and carefully isolated from the yel- the intracranial course of the nerve, while they were low encapsulated mass (Fig. 2), which was localized rarely seen in the parotid gland (2). iz deep into the parotid superficial lobe. The tumor was Intraparotid FNS affects more frequently the fifth and excised along with the superficial lobe of the parotid sixth decade of life and no clear sex predilection was gland, preserving facial nerve fibers. The frozen sec- reported (2). The tumor usually presents as solitary, Ed tion examination was not performed because the unilateral, slow-growing, painless and mobile mass. nerve was not adherent to the tumor and the dissec- The facial nerve function is generally unaffected, be- tion was possible. cause the eccentric growth of the tumor tends to The immediate postoperative was uneventful and fa- move away the nerve fibers (1). The incidence of in- cial nerve functions were preserved. No adverse ef- traparotid facial nerve partial palsy is low (20-27%) fects or recurrence were reported at 6-month follow- (1). IC up. Intraparotid FNS is a diagnostic challenge due to Histological examination (Fig. 3) showed an encapsu- non-specific findings of some diagnostic modality, lated mass, characterized by areas of hypercellularity such as FNAC, which is usually inconclusive as in our with occasional nuclear palisading (Antoni A pattern) case, US showing an anechoic mass and computer- C and hypocellular zones of indistinct cytoplasm and ized tomography, in which soft tissue structures and hyperchromatic nuclei (Antoni B pattern). Immunohis- the facial nerve are not well visualized (1, 2, 5-9). tochemistry confirmed the diagnosis of schwannoma, The most appropriate exam to determine schwanno- showing diffuse and intense S100 protein immunore- ma along the course of the facial nerve is MRI with © activity of neoplastic cells. gadolinium, although the same findings may be found in other neurogenic tumors (1, 2, 8, 9). In MRI FNS appears as well-circumscribed lesion characterized Discussion by a hypointense signal in T1-weighted images and hyperintense signal T2- weighted images. The target Schwannomas (or neurilemmomas), first described sign is central low and peripheral higher signal inten- by Virchow in 1908, are rare, benign and slow-grow- sity on T2 sections (1, 2, 5-9). Annali di Stomatologia 2018;IX (3):130-133 131  M. Gualtieri et al. Figure 2. Intraoperative view of the yellow encapsulated tumor mass, localized deep into the parotid superficial lobe. li na io az rn te In ni io iz Ed Figure 3. Histopathological and immunohistochemical findings: A) in the histological exam hypercellular areas consisting of spindle cells arranged in short, interlacing fascicles (Antoni A) were alternated with hypocellular areas (Antoni B). Neoplastic cells were characterized by hyperchromatic nuclei and indistinct cytoplasmic borders. Nuclear whorling and palisading (Ve- rocay bodies) were present (Hematoxylin and eosin, original magnification, 4X); B) in the immunohistochemical exam IC widespread and intense S100 protein immunoreactivity of neoplastic cells were observed (S100 immunostaining, original magnification, 2X). C Histopathologically, intraparotid FNS is a well-encap- Facial nerve fibers are not involved in the tumor sulated mass lesion, composed by elongated nucle- mass, which tends to push away the nerve axons, ate spindle cells arranged in two types of patterns, due its origin from the Schwann sheath. which are usually present in different proportions in Immunohistochemical profile is essential to establish © the same tumor (2, 3, 5). In the Antoni A pattern cells the origin of the tumor: positive immunostaining for S- and cytoplasmic processes are arranged in hypercel- 100 confirms the diagnosis of schwannoma and neg- lular areas with little stromal matrix and their nuclei ative smooth muscle antigen (SMA) stain rules out often lying in parallel rows or in a palisading arrange- leiomyoma (1, 2, 5, 11). Intraoperative frozen section ment (Verocay body). In the hypocellular Antoni B examination may also be useful in order to make di- pattern irregular cells with no nuclei definable pal- agnosis and exclude malignancy (1, 10). isading are scattered in a loose connective tissue. In the management of intraparotid schwannoma two 132 Annali di Stomatologia 2018;IX (3):130-133  A rare case of intraparotid facial nerve schwannoma different approaches have been reported in the litera- any public or private organizations. ture (1, 2, 5, 8, 10-13). Conservative surveillance is advocated in patients with minimal or absent facial Funding nerve dysfunction or tumor localized to the parotid gland without intratemporal extension, due to the This research did not receive any specific grant from li slow and indolent growth of the tumor and the risk of funding agencies in the public, commercial, or not-for- nerve damage (2). Instead, surgical approach is rec- profit sectors. na ommended and considered the gold standard treat- ment, because in same cases complete tumor exci- sion with nerve preservation is technically possible Conflict of interest and leads to cure (1, 2, 5, 10-13). In 2007 Marchioni et al. proposed a classification of The Authors declare that there are no conflicts of in- io intraparotid FNS into four types, based on the mass terest in regard to this work. extent and involvement of the facial nerve, in order to evaluate whether the tumor resection should involve az or not the nerve (3). In type A the facial nerve is pre- References served (4.3%); in type B the partial sacrifice of one of the peripheral branches is needed (10.8%) and im- 1. Damar M, Dinç AE, Şevik Eliçora S, et al. Facial Nerve mediate reconstruction with a nerve graft or neuror- Schwannoma of Parotid Gland: Difficulties in Diagnosis and rn Management. Case Rep Otolaryngol. Epub 2016 Jan 20. rhaphy can be performed; in type C the main trunk of 2. McCarthy WA, Cox BL. Intraparotid schwannoma. Arch Pathol the facial nerve over the temporofacial or cervicofa- Lab Med. 2014;138:982-985. cial branches is sacrificed (34.7%); in type D the re- 3. Marchioni D, Ciufelli MA, Presutti L. Intraparotid facial nerve section of the main trunk and at least of one of the te schwannoma: literature review and classification proposal, temporofacial or cervicofacial branches is needed Journal of Laryngology and Otology. 2007;121:707-712. (13%). 4. Caughey RJ, May M, Schaitkin BM. Intraparotid facial According to the above classification, the reported nerve schwannoma: diagnosis and management. Oto- case was considered as type A and then surgical ex- In 5. laryngol Head Neck Surg. 2004;130:586-592. Jaiswal A, Mridha AR, Nath D, et al. Intraparotid facial nerve cision of the tumor mass allowed to preserve adja- schwannoma: A case report. World J Clin Cases. cent facial nerve fibers. 2015;16:322-326. 6. Gritzmann N, Rettenbacher T, Hollerweger A, et al. Sonog- ni raphy of the salivary glands. Eur Radiol. 2003;13:964-975. Conclusion 7. Jäger L, Reiser M. CT and MR imaging of the normal and pathologic conditions of the facial nerve. Eur J Radiol. The clinical findings in the present case were consis- 2001;40:133-146. io tent with the literature and confirms the difficulty of a 8. Alicandri-Ciufelli M, Marchioni D, Mattioli F, et al. Critical lit- erature review on the management of intraparotid facial nerve preoperative diagnosis of intraparotid FSN. Indeed, schwannoma and proposed decision-making algorithm. the rarity of the tumor and the non-specific findings of iz Eur Arch Otorhinolaryngol. 2009;266:475-479. diagnostic examinations make difficult differential di- 9. Kapila K, Mathur S, Verma K. Schwannomas: a pitfall in the agnosis with parotid benign tumors (4-6, 10-13). The diagnosis of pleomorphic adenomas on fine-needle aspira- definitive diagnosis is histopathological and immuno- tion cytology. Diagn Cytopathol. 2002;27:53-59. Ed histochemical (10). 10. Seo BF, Choi HJ, Seo KJ, Jung SN. Intraparotid facial nerve In the management of intraparotid schwannoma the schwannomas. Arch Craniofac Surg. 2019 Feb;20(1):71-74. decision-making should be based on the tumor ex- 11. Gross BC, Carlson ML, Moore EJ, et al. The intraparotid fa- tent, preoperative facial nerve function, nerve repair cial nerve schwannoma: a diagnostic and management co- nundrum. Am J Otolaryngol. 2012;33:497-504. achieving and patient’s preferences. 12. Mehta RP, Deschler DG. Intraoperative diagnosis of facial IC nerve schwannoma at parotidectomy. Am J Otolaryngol. 2008;29:126-129. Disclosure 13. Kree A, Schellekens PPA, Leverstein H. Intraparotid facial nerve schwannoma. What to do? Clinical Otolaryngology. The Authors no funding received for this work from 2007;32:125-129. C © Annali di Stomatologia 2018;IX (3):130-133 133 

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Original article Torque expression of a customized lingual appliance according to different elastomeric ligatures over time: an in vitro study li na Marco Migliorati1 DDS, MS, PhD Results: No significant differences were found in Daniela Poggio1 DDS angle values between ligatures or timepoints Sara Drago1 MSc, DDS when the complete set of data was tested Alberto Lagazzo2 MEng, PhD (p>0.01). io Roberto Stradi3 DDS, MS Conclusions: The ligature type and stretching by Fabrizio Barberis2 MEng use did not affect torque efficiency during the Armando Silvestrini-Biavati1 MD, DDS first month. az Key words: orthodontics, torque, efficiency. 1 Orthodontics Department, School of Dentistry, University of Genova, Genova, Italy Introduction rn 2 Section of Materials Engineering, Department of Civil, Chemical and Environmental Engineering (DICCA), University of Genova, Genova, Italy The demand for an aesthetic orthodontic treatment 3 School of Orthodontics and Temporomandibular has increased and more attention has been payed to te disorders, University of Naples, Naples, Italy “invisible” orthodontic techniques, such as clear align- ers and lingual orthodontics. Lingual orthodontics is a reliable option for clinicians who want to fully accom- In Corresponding author: plish therapeutic targets, because of the possibility of Sara Drago treating every malocclusion the same as the labial Orthodontics Department, School of Dentistry, approach, from extraction cases to orthognathic pa- University of Genova tients, and other nonextraction treatments (1, 2). Largo Rosanna Benzi 10 The functionality and the aesthetics of the outcome ni 16132 Genova, Italy are achieved by three-dimensional control of teeth E-mail: [email protected] during all the phases of the therapy; this control is particularly important for upper anterior teeth and it is io obtained by using biomechanics that are different Summary from the labial technique. In fact, in lingual orthodon- tics biomechanical changes are due to a different ap- iz Aim: Torque control in lingual orthodontics is es- plication point of the force, which affects the vertical sential to obtain optimal aesthetic results, never- position of teeth. Particularly, in all extraction cases, theless three dimensional control of anterior teeth the space closure can determine considerable prob- Ed depends on many factors and the role of ligatures lems in incisors inclination. in establishing the engagement of the wire into Torque expression is affected by many factors, in- the slot is considered as a key point. The aim of cluding the bracket position, the size of the wire, the this in vitro experimental study was to evaluate alloy of the wire, the friction between the wire and the how different ligatures exposed to usage degra- brackets, the tensile properties of + different elas- dation perform in maintaining torque control in a tomeric ligatures and the procedures adopted to man- IC customized lingual bracket appliance using two age third order movements (3-6). The effect of force differently sized wires. decay on elastomeric ligatures is important as well, Materials and methods: A typodont with eight ex- because the engagement of the wire into the slot de- tracted human teeth was created and a set of cus- termines the force which is transmitted to the tooth C tomized lingual brackets was obtained. Lingual and the degradation of ligatures could make this en- ligatures and ordinary ligatures were tested on gagement sub-optimal at some stage. the 0.016x0.022 NiTi and the 0.016x0.024 SS wires Force decay of elastics and ligatures is not an un- using a compression/traction machine to calcu- known effect in orthodontic practice: patients are rec- © late the efficiency in torque control. For each wire ommended to daily change orthodontic elastics and and type of ligature, the typodont was stored in doctors are invited to establish an initial force with physiological saline Sodium- Chloride 0.9%, pH about 8 to 14% of compensation above the force for 5.5 to simulate the oral environment for one the desired movement, because of the significant month and then the mechanical test was repeat- force degradation presented during the first twelve ed. A statistical analysis was performed. hours by most products (7). The force delivered by Annali di Stomatologia 2018;IX (2):59-64 59  M. Migliorati et al. elastomeric chains decays rapidly over time as well, dried for 20 seconds. Customized lingual 0.022 x 0.022 with consequences on their mechanical properties brackets (Incognito®,3M Unitek, Monrovia, Calif) in and clinical efficacy (8-10). their indirect bonding tray were then bonded with an However, a limitation of many in vitro studies on this orthodontic composite (RelyX™ Unicem 2 Automix; 3M subject is that they are based on measurements of Unitek, Monrovia, Calif). After the composite was the force and of the extension of ligatures which are cured, all samples were extracted from the resin block stretched until rupture (11, 12), whereas a better clini- and tied to a 0.018x0.025 SS archwire (Incognito®, 3M li cal simulation may be obtained by focusing on how Unitek, Monrovia, Calif) one by one. Then the teeth na the ligature influences the behavior of the entire slot- crowns were included in a block of soft wax to stay wire system. The measure of torque moment is a fea- integral with each other. Once more, the lateral surface sible laboratory observation and represents an out- of the resin block was dug over with a denture bur in a come which is strongly related to the appliance per- straight handpiece, and the teeth roots were put along formance. a straight line in the pit and encased in fluid transparent io The aim of the present study was to evaluate how dif- resin (metil-metacrylate). The resin was cured and the ferent ligatures exposed to usage degradation per- wax was removed from the crowns. The obtained teeth form in maintaining torque control in a customized lin- position in the typodont allowed slots to be passively az gual bracket appliance, using two different wire sizes. engaged by the archwire (Fig. 1). Wires Methods The tested archwires were: 0.016x0.022 NiTi, and rn 0.016x0.024 SS. (Incognito®, 3M Unitek, Monrovia, Typodont Calif). Both wires were first measured with a digital Eight extracted human teeth were collected: a central caliper to verify if the nominal dimension corresponded upper right incisor, two upper lateral incisors (right and to the real one. te left), two upper canines (right and left), two upper first bicuspids (right and left) and one upper second Ligatures bicuspid (left). All teeth were carefully cleaned with Easy-to-tie (L1) and lingual ligatures (L2) were tested In ultrasonic and manual instruments, disinfected with (Alastik, 3M Unitek, Monrovia, Calif). hydrogen peroxide and stored in physiological saline Sodium-Chloride 0.9%, pH 5.5 in order to avoid Testing machine dehydration, elasticity loss, and to prevent the risk of The bracket matching the missing incisor was tied to fractures. the wire as the “testing” bracket on which the ni Transparent metil-metacrylate components (Orthojet, measurements were performed. An extension was Lang. Wheeling, IL 60090 USA) were carefully mixed laser-welded to the bracket in order to apply the not to produce air bubbles and then poured into a 100 necessary force to study it. The extension was a round io mm X 35 mm X 25 wax box (Tenatex Red, Kemdent. steel wire large 1.5 mm in diameter. At the distance of Purton, Swindon Wiltshire, UK) to create a resin base 10 mm a bottleneck was created on the wire, to where the teeth could be accommodated. The resin recognize and keep the same force application point iz was cured in a curing water machine (30°C, 6 atm). trough all tests. The extension was laser welded to the Then the lateral surface of the resin block was dug over back of the bracket. with a denture bur in a straight handpiece, and once The Zwick/Roell Z0.5 machine (sensibility: <1%, Ed enough space had been created, the teeth roots were displacement sensibility 1μm, full scale range 500N) put along a straight line in the pit and encased in fluid was used to apply forces to the system, using forces transparent resin (metil-metacrylate). The teeth were from 0N to 0.6N. The typodont was fixed to the not positioned along the natural shape of the arch, but ZwickLine® machine by bolts and screws that engaged in a straight line, in order to study the mechanical with the grooves on the plate, so that the model was properties of the system. The crowns emerged from the solidly fixed to the machine, in order to create a system IC resin and presented a contact point with each adjacent suitable to the application of forces. tooth; one empty space was left for the missing tooth The model was positioned by placing the side with the (upper left incisor). The block was cured again to obtain largest area on the plate, so that the lingual side of the teeth stability. teeth was above, the vestibular side below, the coronal C A silicone biphasic impression of the obtained typodont portion of the teeth on the right and the roots housed in was taken (Hydrorise, Zhermack. Badia Polesine (RO), the resin on the left. Italy) and sent to the Incognito® lab. A set of The traction system was hooked to the bottleneck customized brackets, an indirect bonding tray and extension of the testing bracket via a rigid metallic © straight sectional wires of different materials and perforated screw. The extension of the testing bracket dimensions were obtained. was placed in the drilling of the screw (Fig. 1). All teeth were sanded with aluminium oxyde (50µ), then A connection -like an enarthrosis joint- was used they were etched for 30 seconds with 32% between the screw and the machine to prevent the orthophosphoric acid (Scotchbond™, 3M Unitek, decomposition of the force in the horizontal Monrovia, Calif), rinsed with water for 30 seconds and components and to maintain a constant vertical 60 Annali di Stomatologia 2018;IX (2):59-64  Torque expression of a customized lingual appliance according to different elastomeric ligatures over time: an in vitro study li na io az rn te Figure 1. Experimental setting (the homemade typodont and the testing machine). In traction. The torque moment [Nmm] was calculated by interquartile ranges. Data were tested for normality multiplying the applied force through the arm, that is using the Shapiro-Wilk test. the distance between the axis of rotation and the point To evaluate differences between ligatures for time- ni of application of the force which was fixed to 10 mm points, a non-parametric analysis of variance was through the whole experiment. The torque angle [°] was performed. Differences with a p-value less than 0.01 algebraically calculated: the ZwickLine® machine is were selected as significant and data were acquired and io able to measure also the displacement performed by analysed using R v3.4.4 software environment (13). the extension, thus knowing the displacement (δ) and the arm (b) we can derive the sine of: Results iz sin θ=δ/b Descriptive statistics are reported in Table 1 and Figure Ed The value of the torque angle (θ) was then derived by 2. Continuous variables are given as median with the arcsine function. When the angle between the range, whereas categorical variables as numbers. The extension and the machine changes, the arm of the non-parametric analysis is reported in Table 2. force changes as well, thus the error was corrected No significant differences were found in angle values after data collection. between ligatures or timepoints when the complete The mechanical testing was repeated for each wire and set of data was tested (p-value=0.7090 and p-value= IC for each type of ligature. For each wire and type of 0.6832). ligature, the typodont was stored in physiological saline Sodium- Chloride 0.9%, pH 5.5 to simulate the oral environment for one month and then the mechanical Discussion C test was repeated. Experimental setting Software Since the introduction of lingual customized appli- The TestXpert® II Zwick-Roell software was used to ances the problem of torque control in the anterior © collect data and to represent the torque moment -on area has been a very important issue, addressed by the ordinate-, with the torque angle -on the abscissa- in different Authors (14-17). a Cartesian graph. Previous studies on torque control with buccal brack- ets had focused mostly on the play between wire size Statistical analysis and slot dimensions. In a study comparing the torque Descriptive statistics are expressed as median and play (degrees) of several lingual brackets with wires Annali di Stomatologia 2018;IX (2):59-64 61  M. Migliorati et al. Table 1. Descriptive statistics. Medians and interquartile ranges of angle values in each wire reading group for all types of ligatures and timepoints. Ligatures: L1: AlastiK™ Easy-to-tie, L2: AlastiK™ lingual ligature. Wires 016x022 NiTi 016x024 ss L1 T0 9.74 [3.84, 13.21] 2.44 [1.39, 3.88] li T1 10.01 [4.37, 13.34] 2.66 [1.20, 4.24] na L2 T0 8.44 [3.36, 12.71] 2.66 [1.56, 4.07] T1 8.77 [3.47, 12.71] 2.60 [1.51, 4.44] io az rn te In ni io Figure 2. Medians and interquartile ranges graph of angle values: a) according to the type of ligatures: Ligature 1, AlastiK™ Easy-to-tie; Ligature 2, AlastiK™ Lingual ligatures; b) according to the status: status 1=fresh ligatures, status 2=stretched ligatures. iz Table 2. Summary of non-parametric analysis. Results are slot. Hence, in these systems the effect of the ligature expressed as coefficient of regression (Coeff.) with 95% type on three dimensional control of anterior teeth be- Ed confidence interval (95%). comes essential, and from a clinical point of view, emphasis is given to particular ligature methods to Variable Coeff. 95% CI obtain a better control. (Intercept) 100.23 64.89; 135.57 Sifakakis et al. compared different lingual brackets Status using a traditional o-ring configuration to compare the torque variation (18). They concluded that cus- IC 1 0 - tomized brackets produced the highest moments, but 2 3.36 -12.85; 19.58 they assumed that the moment is dependent by the ligation mode. Ligature The present study was focused on two ligatures: a C L1 0 - traditional one (AlastiK™ Easy-to-tie) and a type of ligature (AlastiK™ Lingual ligature) specifically devel- L2 -3.18 -22.14; 15.78 oped to sit better the wire into the slot for a better tip and torque control in lingual brackets. The experi- © mental setup was inspired by the lingual torque of various sizes it was found that customized brack- analysis performed by Lossdörfer et al. (19) who ets were the most precise system (17). In fact, in lin- used a customized lingual appliance bonded on a ty- gual orthodontics with customized brackets the final podont. Data collection was improved in the present arch wire is fully engaged into the slot, with less study by a continuous data acquisition, which was ob- space for movements or rotation of the wire into the tained through a mathematical elaboration of the 62 Annali di Stomatologia 2018;IX (2):59-64  Torque expression of a customized lingual appliance according to different elastomeric ligatures over time: an in vitro study movement analysis. The typodont was made of ex- Conclusions tracted human teeth, so that the bonding procedure was the one which is ordinarily applied in the clinical In this in vitro study a torque expression record using practice. Moreover, it was decided to put the teeth on two different ligatures and two wires was obtained for a straight line, and to use wires in a straight shape, in a customized lingual appliance at two different time- order to eliminate any kind of distortion due to the points: wire configuration and to avoid any kind of interfer- - the ligature type did not affect the torque efficiency li ence on the wire-bracket-ligature system. - there were no differences in torque performance na The simulation was completed by applying forces in a between fresh and stretched ligatures. range between 0N and 0.6N: by multiplying the ap- plied force through the 10 mm long arm, we obtained torque values beyond the 6 Nmm threshold. This was References in accordance with the literature, which indicates val- io ues between 5 and 20 Nmm as ideal for torque con- 1. Wei L, Qiguo R, Jiuxiang L, Baohua X. Torque control of the trol (18). Even though there is no general consensus maxillary incisors in lingual and labial orthodontics: A 3-di- on the optimal torque value, it is widely accepted that mensional finite element analysis. Am J Orthod Dentofacial az the minimum value to obtain a torque movement of Orthop. 2009;135:316-322. 2. Hong RK, Lee JG, Sunwoo J, Lim SM. Lingual orthodontics an upper incisor would be 5 Nmm (20, 21). This value combined with orthognathic surgery in a skeletal Class III pa- may differ for each tooth and for each patient, howev- tient. J Clin Orthod. 2000;34:403-408. er optimal values are as near to the minimum to ob- 3. Papageorgiou SN, Sifakakis I, Doulis I, Theodore Eliades T, rn tain a movement without inducing the risk of root re- Bourauel C. Torque efficiency of square and rectangular arch- sorption (3, 22). wires into 0.018 and 0.022 in conventional brackets. Progr In our study the AlastiK™ lingual ligature registered Orthod. 2016;17:5. lower angle values at baseline and over time, which 4. Miethke RR, Melsen B. Effect of variation in tooth morphol- te indicate a better torque expression, even if it did not ogy and bracket position on first and third order correction give any statistically significant difference. with preadjusted appliances. Am J Orthod. 1999;116:329- 335. Other studies in the literature suggest that changes of 5. Morina E, Eliades T, Pandis N, Jäger A, Bourauel C. In ligature performance happen under a permanent Torque expression of self-ligating brackets compared with deformation and that this is directly proportional to the conventional metallic, ceramic, and plastic brackets. Eur J degree of stretching. For example, a permanent Orthod. 2008;30:233-238. deformation of 20% (21.3%) was found when stretched 6. Huang Y, Keilig L, Rahimi A, Reimann S, Eliades T, Jäger by 40 and 56.6% permanent deformation was reached A, et al. Numeric modeling of torque capabilities of self-lig- ni when ligatures were stretched 100% of their original ating and conventional brackets. Am J Orthod Dentofacial length. Finally, the highest percentage of permanent Orthop. 2009;136:638-643. deformation occurred during the first week and was not 7. Seibt S, Salmoria I, Cericato GO, Paranhos LR, Rosario HD, io El Haje O. Comparative analysis of force degradation of la- statistically significant after this period (10). The tex orthodontic elastics of 5/16’’diameter: an in vitro study. ligatures in our study underwent the deformation of a Minerva Stomatol. 2016;65(5):284-290. standard clinical configuration and may not have iz 8. Halimi A, Benyahia H, Doukkali A, Azeroual MF, Zaoui F. A achieved the cited levels of stretching. systematic review of force decay in orthodontic elastomer- ic power chains. Int Orthod. 2012;10(3):223-240. 9. Halimi A, Azeroual MF, Doukkali A, El Mabrouk K, Zaoui F. Ed Limits Elastomeric chain force decay in artificial saliva: An in vitro study. Int Orthod. 2013;11(1):60-70. The results of this study have to be prudently used 10. Yagura D, Baggio PE, Carreiro LS, Takahashi R. Deformation of elastomeric chains related to the amount and time of when reported to clinical practice: other factors could stretching. Dental Press J Orthod. 2013;18(3):136-142. play a role in an in vivo situation, even though this set 11. Aminian A, Nakhaei S, Agahi RH, Rezaeizade M, Aliabadi up has been appositely studied to evaluate the ligation IC HM, Heidarpour M. Evaluation of the effect of different stretch- efficiency in a customized lingual bracket. The decision ing patterns on force decay and tensile properties of elas- to use a straight wire instead of an archwire could also tomeric ligatures. Dent Res J. 2015;12(6):589-595. affect the results, considering that this appliance has a 12. Nakhaei S, Agahi RH, Aminian A, Rezaeizadeh M. Discol- different wire insertion mode in the posterior area oration and force degradation of orthodontic elastomeric lig- C (horizontal, while it is vertical in the anterior), but the atures. Dental Press J Orthod. 2017;22(2):45-54. overall effects should be limited and are typical of this 13. R Core Team. R: A language and environment for statisti- experimental configuration. Other limits of this study cal computing. R Foundation for Statistical Computing, Vi- enna http://www.R-project.org/ may depend on the ligature types: it may be possible © 14. Pauls A, Nienkemper M, Schwestka-Polly R, Wiechmann D. that other ligatures from other companies can perform Therapeutic accuracy of completely customized lingual ap- differently. pliance WIN: A retrospective cohort study. J Orofac Orthop. Finally, it could be useful to repeat the experiment at 2017;78:52-61. 60 and 90 days with a more accurate model of the 15. Inami T, Nakano Y, Miyazawa K, Tabuchi M, Goto S. Adult human saliva composition. skeletal Class II high-angle case treated with a fully cus- Annali di Stomatologia 2018;IX (2):59-64 63  M. Migliorati et al. tomized lingual bracket appliance. Am J Orthod Dentofacial 19. Lossdörfer S, Bieber C, Schwestka-Polly R, Wiechmann D. Orthop. 2016;150:679-691. Analysis of the torque capacity of a completely customized 16. Mathew RN, Katyal A, Shetty A, Krishna Nayak US. Effect lingual appliance of the next generation. Head Face Med. of increasing the vertical intrusive force to obtain torque con- 2014;10:4. trol in lingual orthodontics: A three-dimensional finite element 20. Gmyrek H, Bourauel C, Richter G, Harzer W. Torque capacity method study. Indian J Dent Res. 2016;27:163-167. of metal and plastic brackets with reference to materials, ap- 17. Daratsianos N, Bourauel C, Fimmers R, Jäger A, Schwest- plication, technology and biomechanics. J Orofac Orthop. li ka-Polly R. In vitro biomechanical analysis of torque ca- 2002;63:113-128. pabilities of various 0.018” lingual bracket-wire systems: 21. Harzer W, Bourauel C, Gmyrek H. Torque capacity of met- na total torque play and slot size. Eur J Orthod. 2016;38:459- al and polycarbonate brackets with and without a metal slot. 469. Eur J Orthod. 2004;26:435-441. 18. Sifakakis I, Pandis N, Makou M, Eliades T, Katsaros C, 22. Major TW, Carey JP, Nobes DS, Heo G, Major PW. Me- Bourauel C. A comparative assessment of torque generat- chanical effects of third-order movement in self-ligated ed by lingual and conventional brackets. Eur J Orthod. brackets by the measurement of torque expression. Am J Or- io 2013;35:375-380. thod Dentofac Orthop. 2011;139:e31-44. az rn te In ni io iz Ed IC C © 64 Annali di Stomatologia 2018;IX (2):59-64 

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Original article Photodynamic therapy on a biofilm monospecie of candida albicans: an in vitro study li na Gaspare Palaia1 DDS, PhD Key words: photodynamic therapy, oral candidia- Gianluca Tenore1 DDS, PhD sis, Bio Timer Assay, antifungals. Alessandro Del Vecchio1 DDS, PhD Daniele Pergolini1 DDS Introduction io Lorenzo Tramutola1 DDS Francesca Berlutti2 BScD Umberto Romeo1 DDS The incidence of fungal infections has been increas- az ing since the 1980s, especially for systemic forms in immunocompromised and/or hospitalized populations with other systemic diseases. (1) This increase is 1 Department of Oral and Maxillofacial Sciences, partially due to medical interventions, resulting in im- rn “Sapienza” University of Rome, Rome, Italy munosuppression that leaves patients at risk for de- 2 Department of Public Health Sciences, veloping fungal infections (e.g., patients undergoing “Sapienza” University of Rome, Rome, Italy bone marrow transplants, blood transfusions, im- munosuppressive therapy, invasive surgery, use of te broad-spectrum antibiotics, anti-cancer chemothera- py, and AIDS patients). Moreover, fungal pathogens Corresponding author: have many virulence features, such as the ability to In Gaspare Palaia switch themselves among different morphological Department of Oral and Maxillofacial Sciences, states, biofilm formation and resistance to antifungal “Sapienza” University of Rome drugs (2, 3). Via Feronia 148 Candida albicans, a polymorphic microorganism, has 00157 Rome, Italy become one of the most common agents of nosoco- ni Tel.: +39 3394522515 mial infection in immunocompromised patients and Fax: +39 067806974 those undergoing long-term treatment with antibiotics E-mail: [email protected] or other immunosuppressive therapies. In these pa- io tients, C. albicans invades the deeper tissues and can cause life-threatening systemic infections. Summary Candidemia occurs with an infection rate of 8-10 out iz of 100,000 people a year and is associated with a Antimicrobial photodynamic therapy (aPDT) is a mortality rate of 30-50% (4-6). However, the available medical treatment based on the use of a light epidemiological data are rather heterogeneous be- Ed source at a specific wavelength that activates a cause of the clinical features of infections and the photosensitive molecule causing the formation of lack of official records or statistics. oxidizing agents that provokes the death of the Candidiasis and oral candidiasis are opportunistic in- target cells. The aim of this study was to evaluate fections of the skin and oral cavity. They are common the activity of aPDT against biofilms of Candida in old people, especially denture wearers, children and albicans. Biofilms of C.albicans were subjected to immunocompromised patients. C. albicans is the causal IC aPDT using a diode GaAlAs (λ:635nm) and a tolu- agent in 50% of oral mycosis cases, although in recent idin blue solution (0.1mg/ml) as photosensitizer. years, a high incidence of non-albicans species (C. Three different protocols (1 minute, fluence tropicalis, C. krusei, C. glabrata, C. parapsilosis and C. 24J/cm 2; 2 minutes, fluence 48J/cm 2 and 3 min- dublinensis) has been documented (7, 8). C utes, fluence 72J/cm 2) were tested. To evaluate Candidiasis is the most common intra-oral infection in the number of Candida cells in biofilm before and AIDS patients, and it is caused by an overgrowth of after treatment, Bio Timer Assay was used. Candi- Candida species. In fact, 84% of patients with HIV in- da biofilms treated with aPDT showed significant fection develops candidiasis (9). Patients with can- © reductions of the microbial population as com- didiasis often report other disorders such as burning pared to the control groups. aPDT showed good and taste alteration, as well as pain, dysphagia, nau- antifungal properties in vitro. Clinical trials are sea, vomit and diarrhea at times. Such symptoms can needed to test its efficacy in vivo and to propose disrupt feeding, worsening quality of life. Treatment it as an adjuvant or alternative therapy to conven- with topical or oral antifungal agents, such as nys- tional medical treatment. tatin, amphotericin B or fluconazole can achieve only Annali di Stomatologia 2018;IX (2):65-71 65  G. Palaia et al. transient responses during treatment, generally for 15 Before proceeding to aPDT, the wells were washed days (10). Recurrences are very common, consider- three times with phosphate buffer saline (PBS) to re- ing the multifactorial etiology of candidiasis, and move the non-filmy adherent fungus. widespread use of fungicides has resulted in the de- velopment of resistant species, especially C. albi- Photodynamic treatment cans. The aPDT was performed using a prototype diode In addition, antifungal agents can reduce the effec- laser device GaAlAsat with a wavelength (λ) of 635 li tiveness of antiretroviral drugs, and this reduction is a nm (Doctor Smile, Brendola, Italy), using a power of na serious problem considering the systemic diseases 0.1 mW, in continuous wave mode, with an optical that often affect these patients (11). fiber of 300 μm. Antimicrobial photodynamic therapy (aPDT) is a med- Irradiations were performed maintaining the fiber at ical treatment based on the use of a light source at a the distance of 11 mm from the bottom of the wells specific wavelength that actives a specific photosen- using the fiber sheath that blocked the fiber itself in a io sitive substance, which reacts in the presence of oxy- perforated cover plate. The irradiated area corre- gen causing the formation of oxidizing agents, such sponded to about 50 mm2. as singlet oxygen and free radicals. Therefore, PDT When required, the wells containing C. albicans az causes the death of the target cells through mem- biofilm were treated using the laser light for 1, 2 or 3 brane lysis and protein inactivation. minutes. In these conditions, keeping constant the The use of aPDT for inactivating microorganisms was other parameters, three different energies of 12, 24 first demonstrated more than 100 years ago by Oscar and 36 J, respectively, and a fluence of 24, 48 and 72 rn Raab when he reported the lethal effect of acrinide J/cm2, respectively, were obtained. hydrochloride and visible light on Paramecia cauda- Toluidine blue (TB) (Sigma-Aldrich Co. St. Louis MO- tum (12). However, it is only in recent times that USA) was used as the photo-activating substance. A aPDT has been studied as a medical treatment. total of 50 μl of 0.1 mg/ml TB solution was added to te Photodynamic therapy has been approved in many the wells containing C. albicans biofilm. After 5 min- countries for oncological clinical treatment, especially utes, the TB solution was removed, and then, the in head and neck tumors, Several studies have laser irradiation was performed. The wells were divid- In shown the antimicrobial properties of aPDT against ed into 8 groups and treated as follows: Gram positive and Gram negative bacteria, fungi and Group 1: biofilm subjected to laser irradiation with TB viruses (13, 14); therefore, it may be considered an for 1 minute (L1+P+) effective alternative to the use of antimicrobial Group 2: biofilm subjected to laser irradiation with TB agents. for 2 minutes (L2+P+) ni Despite the promising advantages that aPDT has, Group 3: biofilm subjected to laser irradiation with TB such as the lack of selection of resistant strains, the for 3 minutes (L3+P+) absence of mutagenic effects, and the almost total Group 4: biofilm subjected to laser irradiation for 1 io absence of side effects and drugs interactions in topi- minute in absence of TB (L1+P-) cal applications (15), a standardized protocol for the Group 5: biofilm subjected to laser irradiation for 2 application of such therapy in patients being treated minutes in absence of TB (L2+P-) iz for superficial fungal infection is lacking. Group 6: biofilm subjected to laser irradiation for 3 The aim of this work was to test, in vitro, the efficacy minutes in absence of TB (L3+P-) of aPDT against C. albicans biofilm using a diode Group 7: biofilm exposed to TB in the absence of Ed laser as a light source and toluidine blue (TB) as a laser irradiation (L-P+) photo-activating agent. Group 8: biofilm not subjected to any treatment (L-P). After the treatment, the wells were washed once with PBS to remove the dead fungal cells. Materials and methods Bio Timer Assay IC Biofilm production BTA is an indirect method that measures the concen- In this study, Candida albicans strain ATCC 24433 tration of microbes in biofilm (16-21). BTA employs was used. To obtain C. albicans biofilm, the fungus BioTimer medium with red phenol (BT-PR medium) was plated on Brain Heart Infusion (BHI) agar medi- prepared as follows: BHI 37 g/L, glucose 5 g/L phenol C um and incubated at 37°C for 24 h. After incubation, red 25 mg/L and distilled water to 1000 ml. After ster- 10 isolated colonies were picked from the plate with a ilization at 121°C for 15 minutes, the pH was checked sterile loop and placed into 10 ml of BHI broth medi- and adjusted to 7.2±0.1. The final medium appeared um. After 24 h of incubation at 37°C, the optical den- clear and red. BTA measures the microbial metabo- © sity (λ 600 nm) of the culture was adjusted to obtain a lism: the time required for color switching of the phe- microbial suspension of approximately 1x105 CFU/ml. nol red indicator in BT-PR medium (red-to-yellow) A volume of 0.1 ml was used to inoculate a sterile 96- (Fig. 1), due to fungal metabolism, is correlated to the well plate. The 96-well plate was incubated in a hu- initial fungal concentration. Therefore, the time re- mid atmosphere at 37°C for 72 h to obtain a biofilm quired for a color switch determined the number of adherent to the walls of the wells. fungi present in a sample at Time 0 through a correla- 66 Annali di Stomatologia 2018;IX (2):65-71  Photodynamic therapy on a biofilm monospecie of candida albicans: an in vitro study Figure 1. Reagent with phenol red (BT-PR): initial color (red on the left) and after the “switching” (yellow on the right). li na io az rn tion line. To draw the correlation line specific for Can- equation: t = y = -0.3436x + 7.3616 with r2= 0.9957 dida spp., 0.02 ml of BHI-overnight broth cultures (Fig. 2). te were mixed with 0.18 ml of BT-PR medium. Serial To evaluate the number of C. albicans cells in the two-fold dilutions in 0.1 ml of BT-PR medium were biofilm, the colonized wells were supplemented with performed in 96-well plates (BD, Italy) and simultane- BT-PR medium. The time required for a color switch ously counted using the colony forming unit (CFU) in each well was recorded using the Tecan apparatus In method. The time required for color switching of inoc- and it was used to determine the number of viable ulated 96-well plates was recorded using Tecan Sun- fungi by the correlation line. As the correlation line rise, a fully automatized spectrophotometer appara- was constructed on planktonic cultures, the number tus. The apparatus allowed the incubation at 37°C of of Candida in the biofilm is defined as the planktonic- ni the 96-well plates and the recording of the ODs (λ equivalent CFUs (PE-CFUs). 570 and 450 nm) of each well every 15 minutes for 24 hours. The time for a color switch was plotted ver- Statistics io sus the log10 of CFUs to calculate the correlation line All experiments were repeated at least three times to that relates the time for a color switch with the num- obtain the mean value and standard deviation. Statis- ber of fungi. The correlation line was described by the tical analysis was performed using Student’s T test, iz Figure 2. Correlation curve. Ed IC C © Annali di Stomatologia 2018;IX (2):65-71 67  G. Palaia et al. li na io az rn te Figure 3. Overall results for the group in terms of logCFU/ml with relative DS. In comparing the groups by their average values, and P Discussion (probability) values lower than 0.05 (P≤0.05) were considered significant. The correlation line was ob- C. albicans is a saprophytic fungus that is present in tained using linear regression analysis, and the linear ni the oral cavity of many people (>80%), and it is re- correlation coefficient was calculated with the equa- sponsible for superficial infections of the mucous tion: r=(nΣxy−ΣxΣy)/{sqrt[nΣx2−(Σx)2][nΣy2−(Σy)2]}. membranes (90%) and systemic infection (44-62% of cases) (22). C. albicans can be found in both plank- io tonic and biofilm lifestyles. Results Increasing resistance by fungi versus the various conventional medical therapies, the appearance of iz Results are expressed as the mean value ± standard new emerging pathogens and the antagonism of deviations of the CFU log obtained from at least three drugs in patients are the reasons that push the scien- independent experiments (Fig. 3). tific community to look for alternative therapies. Ed Laser treatments without photoactivator did not effi- Currently, most studies assessing the performance of ciently kill the C. albicans biofilm population, and the anti-Candida laser light at low fluence (LLLT) em- reduction values (of approximately 24%) were not ployed cultures of fungus in the planktonic state. significant according to the length of the treatment (1, The main objective of this study was to evaluate the 2, or 3 minutes). Similarly, the treatment with the pho- effects of three protocols of laser irradiation against toactivator alone did not decrease significantly the C. albicans grown in biofilm, and precisely, the three IC number of CFUs. protocols were as follows: low level laser irradiation in By contrast, the aPDT treatments reduced the C. association with the Toluidine Blu (TB) as photo acti- albicans biofilm population to different extents, de- vator (aPDT protocol), low level laser irradiation in pending on the time of treatment. Comparing values the absence of TB (L), and only TB in the absence of C of the population before and after treatment, aPTD any laser irradiation. TB was chosen according to significantly reduced the number of C. candida cells Souza et al. (2010) (24), which demonstrated that already after 1 minute of laser irradiation. Reduc- employing a diode laser (Ga-Al-As) 660 nm, 0.035W tions ranging from 65 to 79% were recovered, and with fluence of 15.8, 26.3 and 39.5 J/cm2 with 171, © the highest rate of reduction was observed after 2 285 and 428 seconds of irradiation, respectively, had and 3 minutes of treatment (Fig. 4). However, the the highest efficacy against planktonic C. albicans differences in values of Candida reduction between when using TB as a photoactivator. the different times of treatments were not signifi- In our study, a Bio Timer Assay (BTA) was used for cant. the first time to counts of C. albicans biofilms. The 68 Annali di Stomatologia 2018;IX (2):65-71  Photodynamic therapy on a biofilm monospecie of candida albicans: an in vitro study Figure 4. Percent reductions of Can- dida albicans ATCC 24433 popula- tion in biofilm after laser treatment in the absence or in the presence tolui- dine blue as photoactivator. C.albi- cans biofilm was treated for 1, 2, or 3 minutes with laser in the absence li (L1, L2, L3) or in the presence of photoactivator toluidine blue (LP1, na LP2, LP3). io az method, already used for counting Staphylococcus, power of 100 mw for 98 seconds with a fluence of Streptococcus and Enterococcus in biofilms (19-21), 350 J/cm 2 alone or in combination with methylene is the only method that is able to count biofilm sam- blue as a photoactivator on single, double and triple rn ples without any manipulation of the samples (7). For biofilms formed by C. albicans, Sthaphylococcus au- this purpose, a correlation line showing the time of reus and Streptococcus mutans. The study demon- color switches of the BTA medium and the number of strated a significant reduction in all species of mi- planktonic C. albican cells was constructed, and the te croorganisms after the application of laser in combi- correlation line was described by a linear equation. nation with photosensitizer; in particular, mono- species biofilms were more susceptible compared to The results of the present study showed that laser multispecies of biofilms. In treatment without a photoactivator was inefficient in However, it should be underscored that the fluence significantly reducing the Candida biofilm indepen- employed in the abovementioned studies on both dently of the length of treatment. These results planktonic and biofilm Candida were from 5.5- to 30- agreed with Wilson and Mia (1993) (23), which fold higher than the lower fluence used in the present ni showed that the He-Neon laser at a wavelength of study (24, 48 and 72 J/cm 2 ). In fact, our results 632.8 nm and 66.36 J/cm2 of fluence in the absence showed that a significant reduction can be achieved of the photoactivator was unable to kill planktonic C. even when using 24 J/cm2 fluence and that the in- io albicans. In contrast, the combined use of laser and crease in the fluence was not able to raise the killing photoactivator (i.e., methylene blue, crystal violet and rate of Candida biofilm. The explanation for this phe- thionine) reduced planktonic C. albicans by approxi- nomenon could be the different photoactivator con- iz mately 77%. Similar results were obtained against centrations, the intrinsic photoactivator properties, or planktonic C. tropicalis, and C. stellatoidea whose even the responsiveness of the specific strain of C. killing rate was 65 and 63%, respectively. Similar re- albicans. Another possible explanation for this phe- Ed sults were reported by Queiroga et al. (2011) (25); nomenon could be offered assuming the peak of testing the effects of irradiation with a diode laser 640 maximum effectiveness was reached in a time of ap- nm on planktonic Candida ssp using 3 different flu- proximately 60 seconds. ences, i.e., 60, 120 and 180 J/cm2 in the presence of According to previous works on a murine model of methylene blue, showed that the higher reduction of oral candida infection (1, 28-30) and on the treatment Candida was obtained at a fluence of 180 J/cm2. of HIV positive patients with aPDT (10), this study IC When laser treatment was carried out in the presence confirmed the efficacy of photodynamic therapy of the TB photoactivator, significant reductions in the against C. albicans. C. albicans biofilm were observed. The duration of The observation that the killing rate did not change the treatment did not influence the killing rate, and no with increases in fluence is important in the case of C significant differences were recorded after 1, 2 or 3 laser application on patients for the clinical treatment minutes of treatment. of C. albicans oral infections. In fact, the previous The efficacy of laser treatment in the presence of the studies are applicable for clinical use, especially for photoactivator confirmed the efficacy of LLLT in com- the excessively long times of irradiation that are not © bination with photosensitizing agents against plank- reproducible in patients. Moreover, even if the side ef- tonic Candida. However, Authors are focused, nowa- fects of laser irradiation were not described, putative days, on the evaluation the killing rate of laser treat- cell damage cannot be excluded due to the duration of ment against Candida biofilm (26). Our results are in laser applications. Consequently, the possibility of us- agreement with Pereira et al. (2010) (27). The Au- ing a true LLLT by decreasing the putative side effects thors tested the effects of diode laser 660 nm at a may increase the compliance of the patients. Annali di Stomatologia 2018;IX (2):65-71 69  G. Palaia et al. In this study, we verified the framework that emerged of oral candidiasis with methylene blue-mediated photody- in the literature on the effectiveness of photodynamic namic therapy in an immunodeficient murine model.Oral Surg protocols implemented as antifungal treatments. Oral Med Oral Pathol Oral Radiol Endod. 2002;93(2):155- 160. Here, we showed the efficacy of aPDT in significantly 10. Scwingel AR, Barcessat AR, Núñez SC, Ribeiro MS. An- reducing the fungal population of C. albicans ATCC timicrobial photodynamic therapy in the treatment of oral can- 24433 grown in biofilm using a diode laser l 635 nm didiasis in HIV-infected patients. Photomed Laser Surg. as a light source, already at the fluence of 24 J/cm2. li 2012;30(8):429-432. 11. Gallè F, Sanguinetti M, Colella G, Di Onofrio V, Torelli R, na Rossano F, Liguori G. Oral candidosis: characterization of Conclusions a sample of recurrent infections and study of resistance de- terminants. New Microbiol. 2011;34:379-389. Even if more studies are needed to optimize the anti- 12. Nikolaus S, Soukos & J. Max Goodson Photodynamic ther- apy in the control of oral biofilms Periodontology. Candida protocol, this study suggests a possible use io 2000;55:2011, 143-166. of aPDT in “in vivo infection”. For this purpose, it will 13. Demidova TN, Hamblin MR. Photodynamic therapy target- be necessary to carry out clinical trials that could ed to pathogens. Int J Immunopathol Pharmacol. 2004;17 show the real evidence for fungicidal effects of aPDT (3):245-254. az to propose this procedure as an alternative or adju- 14. Sardi JC1, Scorzoni L, Bernardi T, Fusco-Almeida AM, vant to traditional drug therapies currently in use for Mendes Giannini MJ.Candida species: current epidemiolo- the treatment of oral infections. gy, pathogenicity, biofilm formation, natural antifungal prod- ucts and new therapeutic options. J Med Microbiol. 2013;62(Pt rn 1):10-24. Conflict of interest 15. Baltazar LM, Ray A, Santos DA, Cisalpino PS, Friedman AJ, Nosanchuk JD. Antimicrobial photodynamic therapy: an ef- fective alternative approach to control fungal infections. Front The Authors declare that they have no conflict of in- te Microbiol. 2015;6:202. terest. 16. Konopka K, Goslinski T. Photodynamic therapy in dentistry. J Dent Res. 2007;86(8):694-707. 17. Pantanella F, Valenti P, Frioni A, Natalizi T, Coltella L, Berlut- Acknowledgements In ti F. BioTimer Assay, a new method for counting Staphylo- coccus spp. in biofilm without sample manipulation applied to evaluate antibiotic susceptibility of biofilm. J Microbiol Meth- We thank dr. Alessandra Frioni for her cooperation ods. 2008;75(3):478-484. during the experimental part of the work. 18. Pantanella F, Valenti P, Natalizi T, Passeri D, Berlutti F. An- ni alytical techniques to study microbial biofilm on abiotic sur- faces: pros and cons of the main techniques currently in use. References Ann Ig. 2013;25(1):31-42. 19. Berlutti F, Frioni A, Natalizi T, Pantanella F, Valenti P. In- io 1. Sardi JC, Scorzoni L, Bernardi T, Fusco-Almeida AM, fluence of sub-inhibitory antibiotics and flow condition on Mendes Giannini MJ. Candida species: current epidemiol- Staphylococcus aureus ATCC 6538 biofilm development and ogy, pathogenicity, biofilm formation, natural antifungal biofilm growth rate: BioTimer assay as a study model. J An- iz products and new therapeutic options. J Med Microbiol. 2013; tibiot (Tokyo). 2014;67(11):763-769. 62(Pt 1):10-24. 20. Romeo U, Palaia G, Nardo A, Tenore G, Telesca V, Korn- 2. Polvi EJ, Li X, O’Meara TR, Leach MD, Cowen LE. Oppor- blit R, Del Vecchio A, Frioni A, Valenti P, Berlutti F. Effec- Ed tunistic yeast pathogens: reservoirs, virulence mechanisms, tiveness of KTP laser versus 980 nm diode laser to kill En- and therapeutic strategies. Cell Mol Life Sci. 2015;72:2261. terococcus faecalis in biofilms developed in experimental- 3. Nett JE. Future directions for anti-biofilm therapeutics targeting ly infected root canals. Aust Endod J. 2014;41(1):17-23. Candida. Expert Rev Anti Infect Ther. 2014;12(3):375-382. 21. Pantanella F, Berlutti F, Passeri D, Sordi D, Frioni A, Natalizi 4. Pfaller MA, Diekema DJ. Epidemiology of invasive candidi- T, Terranova ML, Rossi M, Valenti P. Quantitative evalua- asis: a persistent public health problem. Clin Microbiol Rev. tion of bacteria adherent and in biofilm on single-wall carbon 2007;20:133-163. nanotube-coated surfaces. Interdiscip Perspect Infect Dis. IC 5. Wilson LS, Reyes CM, Stolpman M, Speckman J, Allen K, 2011;291513. Beney J. The direct cost and incidence of systemic fungal 22. Pfaller MA, Pappas PG, Wingard JR. Invasive fungal infections. Value Health. 2002;5:26-34. pathogens: current epidemiological trends. Clin Infect 6. Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Dis.2006;43:S3-S14. Edmond MB. Nosocomial bloodstream infections in US hos- 23. Wilson M., Mia N. Sensitisation of Candida albicans to killing C pitals: analysis of 24,179 cases from a prospective nation- by low-power laser light. J Oral Pathol Med. 1993;22:354- wide surveillance study. Clin Infect Dis. 2004;39:309-317. 357 7. De Repentigny L, Lewandowski D, Jolicoeur P. Im- 24. Souza RC, Junqueira JC, Rossoni RD, Pereira CA, Munin munopathogenesis of oropharyngeal candidiasis in human E, Jorge AO. Comparison of the photodynamic fungicidal ef- © immunodeficiency virus infection. Clin Microbiol Rev. ficacy of methylene blue, toluidine blue, malachite green and 2004;17:729-759. low-power laser irradiation alone against Candida albicans. 8. Zomorodian K, Haghighi NN, Rajaee N, Pakshir K, Tarazooie Lasers Med Sci. 2010;25:385-389. B, Vojdani M, et al. Assessment of Candida species colo- 25. Queiroga AS, Trajano VN, Lima EO, Ferreira AFM, Limeira nization and denture-related stomatitis in complete denture Jr FA. In vitro photodynamic inactivation of Candida spp. by wearers. Med Mycol. 2011;49:208-211. different doses of low power laser light. Photodiagnosis Pho- 9. Teichert MC, Jones JW, Usacheva MN, Biel MA. Treatment todyn Ther. 2011;8(4):332-336. 70 Annali di Stomatologia 2018;IX (2):65-71  Photodynamic therapy on a biofilm monospecie of candida albicans: an in vitro study 26. Junqueira JC, Jorge AOC, Barbosa JO, Rossoni RD, Vilela Kurachi C, Bagnato VS. Susceptibility of Candida albicans SFG, Costa ACBP, Primo FL, Gonçalves JM, Tedesco AC, to photodynamic therapy in a murine model of oral candidosis. Suleiman JMAH. Photodynamic inactivation of biofilms Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 formed by Candida spp., Trichosporon mucoides, and Ko- Mar;109(3):392-401. damaea ohmeri by cationic nanoemulsion of zinc 2,9,16,23- 29. Martins Jda S, Junqueira JC, Faria RL, Santiago NF, tetrakis(phenylthio)-29H, 31H-phthalocyanine (ZnPc). Lasers Rossoni RD, Colombo CE, Jorge AO. Antimicrobial pho- Med Sci. 2012;27(6):1205-1212. todynamic therapy in rat experimental candidiasis: eval- li 27. Pereira C, Romeiro RL, Costa AC, Machado AK, Junqueira uation of pathogenicity factors of Candida albicans. Oral JC, Jorge AO. Susceptibility of Candida albicans, Staphy- Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 na lococcus aureus, and Streptococcus mutans biofilms to pho- Jan;111(1):71-77. todynamic inactivation: an in vitro study. Lasers Med Sci. 30. Junqueira JC, Martins Jda S, Faria RL, Colombo CE, Jorge 2011;26:341-348. AO. Photodynamic therapy for the treatment of buccal can- 28. Mima EG, Pavarina AC, Dovigo LN, Vergani CE, Costa CA, didiasis in rats. Lasers Med Sci. 2009 Nov;24(6):877-884. io az rn te In ni io iz Ed IC C © Annali di Stomatologia 2018;IX (2):65-71 71 

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Original article The effect of a brushing motion inside a sequence: an in vivo study li na Gianluca Gambarini1 MD, DDS means of analysing torque during intracanal Marco Seracchiani1 DDS shaping provides useful information for a better Lucila Piasecki2 DDS, PhD understanding of the instruments performance in Massimo Galli1 MD, DDS vivo, aiming at improving efficacy and safety. io Federico Valenti Obino1 DDS Dario Di Nardo1 DDS, PhD Key words: torque, speed, nickel-titanium, rotary Luca Testarelli1 DDS, PhD instruments. az 1 Department of Oral and Maxillo-Facial Sciences, Introduction "Sapienza" University of Rome, Rome, Italy rn 2 Department of Public Health Sciences, “Sapienza” The use of nickel-titanium rotary (NTR) instruments University of Rome, Rome, Italy became the most effective and popular method amongst endodontists for shaping root canals, even if there are still many concerns regarding the increased te Corresponding author: risks of intracanal breakage or weakening of the in- Marco Seracchiani struments (1-3). As a consequence, manufacturers Department of Oral and Maxillo-Facial Sciences, since 1990s started to change cross-sectional de- In "Sapienza" University of Rome signs and geometrical traits of instruments to improve Via Caserta 6 both torsional and cyclic fatigue resistance (4-7). In 00161 Rome, Italy the last decade another strategy to achieve this goal E-mail: [email protected] was the use of new manufacturing processes to opti- mize the microstructure of NiTi, basically through in- ni novative thermomechanical processings. NTR instru- Summary ments produced with these technologies (M-wire, CM wire or Twisted Files Technology) showed better io The aim of the present study was twofold: to pro- properties for the endodontic use in terms of flexibility pose a new methodology to analyze instrumenta- and resistance to mechanical stresses when com- tion stress in vivo by measuring the torque pro- pared to traditional NiTi alloy (8-11). More recently, it iz vided by an endodontic motor during the clinical has been introduced a new important innovation: the use of the nickel-titanium rotary (NTR) instru- use of reciprocating motion instead of continuous ro- ments; and to compare the advantage of brushing tation. Current literature data show that reciprocating Ed techniques in reducing operative torque. motion can extend both torsional and cyclic fatigue 40 canals were divided in two groups (n=20) and resistance of the instruments when compared to con- prepared by a skilled endodontist using TF 35. 04. tinuous rotation (12, 13), mainly because it reduces rotary instruments (KerrEndo, Orange, Ca). In one instrumentation stress. group, a 30 s brushing was previously performed Apart from the above mentioned features which are de- with a (TF 25.06) to increase flaring. All instru- pending on manufacturers’ strategies, there are other IC ments were rotated at 500 rpm with maximum clinical factors that significantly affect torsional and torque set at 2,5 N using an endodontic motor cyclic fatigue resistance of NTR instruments (14-16): (Kavo, Biberach, Germany), which automatically the anatomic challenges, the applied pressure and the records and saves torque and speed values every differences in the use among the various clinicians (i.e. C 1/10 seconds. Data were recorded and statistical- pecking or other motions, the creation of a glide path, ly analyzed with the significance level set at p. the tendency to force apically, brushing action, the use Previous coronal flaring (brushing) with the first of torque controlled motors, etc.). All these differences instrument (size 25, taper 06) significantly re- are very difficult to evaluate since they are mostly relat- © duced instrumentation torque (both mean and ed to individual skills, sensitivity and operative choices maximum torque values), time and number of during intracanal instrumentation. steps needed by the second instruments (size 35, Previous studies have clearly shown that the creation taper 04) to reach working length. of an endodontic glide-path positively reduces the The development of new and more sophisticated risk of intracanal fracture both in continuous rotation 72 Annali di Stomatologia 2018;IX (2):72-76  The effect of a brushing motion inside a sequence: an in vivo study and reciprocation (17, 18). It would be interesting to to record instrumentation torque values automatically, assess if and how much clinical performance of in- and save them in a memory card. The motor was struments is affected by a different clinical usage, like based, as every torque measuring device, on torque performing or not a brushing motion. The brushing sensors. The accuracy of the sensors was high, be- motion is meant to increase coronal flaring and theo- ing capable of detecting minute variations of 0.05 N. retically should make apical progression of the next The capability of measuring torque every 0.1 s also instrument within the sequence easier and less provided a large data set, ensuring a precise record li stressful (19, 20). Therefore, the goal of this study of values during intracanal progression, and not only na was to analyze in vivo performance of TF instruments peak torque values (Figs. 1, 2). Root canals were in a continuous motion, aiming at evaluating the clini- then filled with a warm gutta-percha technique and cal advantages of brushing motion, if any and to pro- the teeth restored by a composite filling. pose a new methodology to analyze torque values TF size 35 and .04 taper instruments were manipulat- during intracanal shaping. ed until they reached the working length using a io slight pecking motion without forcing the instruments apically. After each cycle of pecking motion, the in- Materials and methods strument was removed from the canal and the flutes az cleaned to remove debris. Irrigation was performed Twenty patients (12 men, 8 women, age ranging from with syringe using the same amount (6 ml) of 5% 19 to 67 years old), who needed endodontic treat- Sodium Hypochlorite in each canal, 17% EDTA was ment of first upper premolar were randomly selected used as lubricant. In the first group no brushing was rn for the present study. Following cavity access, all performed with the 25.06 instrument; in the second canals (n=40) were negotiated initially with a size 10 group 30 seconds of brushing motion was performed K-file and working length was established using an using the previous instrument, to increase coronal Apex ID digital apex locator (Kerr, Orange, CA, USA). flaring. Instrumentation torque was recorded only dur- A manual glide-path was created in all the canals up to size 20 to ensure similar canal dimensions and more predictable progression of nickel-titanium rotary te ing negotiation with the second instrument (35.04) for both groups and data saved in an excel file. The fol- lowing data recorded in 40 canals were statistically In (NTR) instruments to the canal terminus. Teeth ex- analysed: mean instrumentation time, number of hibiting non patent canals, severe curvatures (>30) steps, mean torque values, maximum torque values. were excluded from the study and canals were ran- One -way ANOVA test was used to assess differ- domly divided in two similar groups (n=20). For each ences between the two groups for the four above- ni tooth, one canal was assigned to a first group, and mentioned parameters. The significance level was set the other one to the second group, to avoid differ- at P<0.05. ences given by dentin hardness and operative posi- io tion. All root canal treatments were performed by the same experienced endodontist, to avoid bias due to Results different hand pressure, using two TF instruments iz (KerrEndo, Orange, CA): size 25 and .06 taper fol- The results showed (Table 1) present the descriptive lowed by size 35 and .04 taper. All instruments were data for TF 35. 04 instrumentation in both. Data was single used according to the manufacturer’s instruc- normally distributed (Shapiro-Wilk’s test, p > 0.05), Ed tions. and there was homogeneity of variances (Levene’s Instruments were rotated at 500 rpm with maximum test, p > 0.05). The one-way ANOVA showed a signif- torque set at 2,5 N using endodontic motor provided icant difference between groups regarding the mean by Kavo (Biberach, Germany) and a Kavo 1:1 Hand- instrumentation time, number of steps, mean torque piece. A prototype software provided by Kavo allowed values, and maximum torque values (p<0.05). IC Table 1. Comparison between the two groups (TF size 35 taper 04 instrumentation). C Previous Brushing No brushing n Mean SD Mean SD Mean Torque 20 0. 12a 0.05 0.29b 0.14 © Max. Torque 20 0.73a 0.19 0.99b 0.38 Instrumentation time 20 3.34a 1.56 6,16b 2.61 Number of steps 10 2,8a 0,4 5,2b 1,6 Different superscript letter indicates statistical significance (p<0.05). Annali di Stomatologia 2018;IX (2):72-76 73  G. Gambarini et al. li na io az Figure 1. ML3 without brushing before. rn Discussion tracanal use in vivo. The motor allowed precise and easy recording of dynamic torque, storage and saving te In the last decades, custom designed torque plat- of all data, by using a memory card and an excel file. forms were proposed to perform in vitro dynamic The images showed (Figs, 1, 2) are examples of how torque tests for NTR instruments, instead of using the the proposed methodology can be useful in the analy- In ISO Standard static torque testing, but only few stud- sis of clinical performance of NTR instruments. They ies were published. The complexity of such dynamic show the torque generated during the in vivo instru- devices and the difficulties in recording and storing a mentation of one canal using. 04 35 TF NTR instru- massive amount of data is involved in this kind of is- ments. The graph provides a detailed reflection of the sue (21-23). The recent progresses in the mechani- performance of the NTR instruments and the low ni cal, motors and sensors, and computer, software and torque values produced, much smaller than the pre- storage, technologies allowed to build new endodon- set torque values of 2.5 Ncm. These low torque val- tic motors, which can visualize or record in vivo in- ues are an ideal clinical situation since ISO3630-1 io strumentation torque. testing has revealed that torsional failure for size In the present study a new device for dynamic torque 35.04 tapered instruments is approximately 1N/cm measurements was used, aiming at precisely analyz- (24). Even if the ISO test is more challenging, since iz ing performance of NTR instruments during their in- the tip is blocked 3 mm from the tip, the lower the Ed IC C © Figure 2. ML3 with brushing before. 74 Annali di Stomatologia 2018;IX (2):72-76  The effect of a brushing motion inside a sequence: an in vivo study torque, the lower the torsional stress, the safer the in- The proposed methodology is therefore considered a strumentation. Both figures clearly show that in- useful tool to analyze the instrument and the tech- tracranal progression was performed by steps with a niques during their use in patients, providing useful pecking motion, continuously changing the engage- information on how to maximize efficiency of NTR in- ment of the instrument against the canal walls and strumentation and minimize the risk of breakage or consequently the variation in the torque generated. metal fatigue during intracanal use. The amplitude of the motion is a function of how easy li was the progression of the instrument inside the References na canal: smaller values reflecting easier progression. In the first part of the graph the operator was enlarging the coronal and middle portion of the canal, which re- 1. Alattar S, Nehme W, Diemer F, Naaman A. The influence quired less torque. In the apical part of the canal the of brushing motion on the cutting behavior of 3 reciprocat- ing files in oval-shaped canals. J Endod. 2015;41(5):703-709. smaller diameters required more torque, even if the io 2. Arias A, Singh R, Peters OA. Torque and force induced by maximum values reached can be still considered ProTaper universal and ProTaper next during shaping of large safe. Overall, the performance of the instrument al- and small root canals in extracted teeth. J Endod. 2014; lowed the working length to be achieved smoothly, 40(7):973-976. az without the tip locking, without excessive torque and 3. Berutti E, Alovisi M, Pastorelli MA, Chiandussi G, Scotti N, in a relatively short time. However, in the brushing Pasqualini D. Energy consumption of ProTaper Next X1 af- group the amount of steps, instrumentation time and ter glide path with PathFiles and ProGlider. J Endod. torque values were lower, as comparison of the two 2014;40(12):2015-2018. rn different graphs can clearly illustrate. 4. Blum JY, Machtou P, Micallef JP. Location of contact areas on rotary Profile instruments in relationship to the forces de- Results from this study showed that previous coronal veloped during mechanical preparation on extracted teeth. flaring (brushing) with the first instrument (size 25, ta- Int Endod J. 1999;32(2):108-114. per 06) significantly reduced instrumentation torque te 5. Boessler C, Paque F, Peters OA. The effect of electropol- (both mean and maximum torque values), time and ishing on torque and force during simulated root canal prepa- number of steps needed by the second instruments ration with ProTaper shaping files. J Endod. 2009;35(1):102- (size 35, taper 04) to reach working length. These im- 106. In provements not only made clinical negotiation easier 6. Boessler C, Peters OA, Zehnder M. Impact of lubricant pa- and faster, but also reduced the instrumentation rameters on rotary instrument torque and force. J Endod. 2007;33(3):280-283. stress. The latter advantage may result in a signifi- 7. Dane A, Capar ID, Arslan H, Akçay M, Uysal B. Effect of Dif- cant reduction of the risk of intracanal breakage or a ferent Torque Settings on Crack Formation in Root Dentin. possible increase of NTR the instrument lifespan, al- ni J Endod. 2016;42(2):304-306. lowing safer re-use of the instruments (25, 26). 8. Diop A, Maurel N, Oiknine M, Patoor E, Machtou P. A nov- The present study also confirmed previous ones el platform for in vitro analysis of torque, forces, and three- showing that instruments within a sequence are sub- dimensional file displacements during root canal preparations: io jected to different intracanal stresses, due to different application to ProTaper rotary files. J Endod. 2009;35(4):568- dimensions and different blade engagement (28). 572. These factors, however, are not only dependent on 9. Gambarini G. Cyclic fatigue of nickel-titanium rotary instru- iz ments after clinical use with low- and high-torque en- design and dimensions, but can be related to the clin- dodontic motors. J Endod. 2001;27(12):772-774. ical method of use (27). The increased coronal flaring 10. Gambarini G, Giansiracusa Rubini A, Sannino G, Di Gior- provided by brushing with the first NTR instrument Ed gio G, Di Giorgio F, Piasecki L, et al. Cutting efficiency of nick- (size 25, taper 06) reduced blade engagement in the el-titanium rotary and reciprocating instruments after prolonged coronal/middle part of the second NTR instrument use. Odontology. 2016;104(1):77-81. (size 35, taper 04), and consequently the torque 11. Gambarini G, Grande NM, Plotino G, Somma F, Garala M, needed to reach the working length (28). De Luca M, et al. Fatigue resistance of engine-driven rotary A previous in vitro study on used instruments also nickel-titanium instruments produced by new manufacturing demonstrated that the coronal flaring provided by the methods. J Endod. 2008;34(8):1003-1005. IC 12. Gambarini G, Piasecki L, Di Nardo D, Miccoli G, Di Giorgio brushing action of the first NTR instrument reduced G, Carneiro E, et al. Incidence of Deformation and Fracture instrumentation stress on the second NTR instrument of Twisted File Adaptive Instruments after Repeated Clini- within the sequence. Resistance to both torsional cal Use. J Oral Maxillofac Res. 2016;7(4):e5. stress (determined by the percentage of flutes defor- 13. Gambarini G, Pompa G, Di Carlo S, De Luca M, Testarelli C mation) and flexural stress (determined by in vitro re- L. An initial investigation on torsional properties of nickel-ti- sistance to cyclic fatigue of used instruments) was tanium instruments produced with a new manufacturing enhanced by the use of a brushing technique (27). method. Aust Endod J. 2009;35(2):70-72. The advantages related to an increased coronal flar- 14. Gambarini G, Tucci E, Bedini R, Pecci R, Galli M, Milana V, © et al. The effect of brushing motion on the cyclic fatigue of ing can be also clinically perceived by clinicians; nev- rotary nickel titanium instruments. Ann Ist Super Sanita. ertheless, the present article is the first that demon- 2010;46(4):400-404. strate and quantify in vivo the efficacy of brushing 15. Grande NM, Plotino G, Silla E, Pedullà E, DeDeus G, Gam- technique in reducing NTR intracanal instrumentation barini G, et al. Environmental Temperature Drastically Affects stress. Moreover, it can estimate the improvements Flexural Fatigue Resistance of Nickel-titanium Rotary Files. with a massive amount of data. J Endod. 2017;43(7):1157-1160. Annali di Stomatologia 2018;IX (2):72-76 75  G. Gambarini et al. 16. Kim HC, Cheung GS, Lee CJ, Kim BM, Park JK, Kang SI. 1228-1230. Comparison of forces generated during root canal shaping 22. Plotino G, Grande NM, Mercadé Bellido M, Testarelli L, Gam- and residual stresses of three nickel-titanium rotary files by barini G. Influence of Temperature on Cyclic Fatigue Re- using a three-dimensional finite-element analysis. J Endod. sistance of ProTaper Gold and ProTaper Universal Rotary 2008;34(6):743-747. Files. J Endod. 2017;43(2):200-202. 17. Kwak SW, Ha JH, Cheung GS, Kim HC, Kim SK. Effect of 23. Sattapan B, Palamara JE, Messer HH. Torque during canal the Glide Path Establishment on the Torque Generation to instrumentation using rotary nickel-titanium files. J Endod. li the Files during Instrumentation: An In vitro Measurement. 2000;26(3):156-160. J Endod. 2018;44(3):496-500. 24. Schäfer E, Oitzinger M. Cutting efficiency of five different types na 18. Liu W, Wu B. Root Canal Surface Strain and Canal Center of rotary nickel-titanium instruments. J Endod. 2008;34(2):198- Transportation Induced by 3 Different Nickel-Titanium Ro- 200. tary Instrument Systems. J Endod. 2016;42(2):299-303. 25. Schrader C, Peters OA. Analysis of torque and force with dif- 19. Pedullà E, Grande NM, Plotino G, Gambarini G, Rapisarda ferently tapered rotary endodontic instruments in vitro. J En- E. Influence of continuous or reciprocating motion on cyclic dod. 2005;31(2):120-123. io fatigue resistance of 4 different nickel-titanium rotary in- 26. Shen Y, Huang X, Wang Z, Wei X, Haapasalo M. Low En- struments. J Endod. 2013;39(2):258-261. vironmental Temperature Influences the Fatigue Resistance 20. Pereira ES, Singh R, Arias A, Peters OA. In vitro assessment of Nickel-titanium Files. J Endod. 2018;44(4):626-629. of torque and force generated by novel ProTaper Next In- 27. Yared GM, Bou Dagher FE, Machtou P. Influence of rota- az struments during simulated canal preparation. J Endod. tional speed, torque and operator’s proficiency on ProFile fail- 2013;39(12):1615-1619. ures. Int Endod J. 2001;34(1):47-53. 21. Plotino G, Giansiracusa Rubini A, Grande NM, Testarel- 28. Wu XC, Zhu YQ. Geometric analysis of root canals prepared li L, Gambarini G. Cutting efficiency of Reciproc and by single twisted file in three different operation modes. Eur waveOne reciprocating instruments. J Endod. 2014;40(8): J Dent. 2014;8(4):515-520. rn te In ni io iz Ed IC C © 76 Annali di Stomatologia 2018;IX (2):72-76 

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Original article The effect of vitamin C on urinary level of an oxidative stress biomarker during at-home tooth bleaching process: a randomized double blinded clinical trial li na Majid Akbari1 DDS, MS along with the tooth whitening period. Urine sam- Atefeh Nemati-Karimooy2,3 DDS, MS ples were obtained in the morning before the study Seyed Isaac Hashemy4,5 PHD was started and were repeated in 5, 10, 15th days Hamideh Sadat Mohammadipour2,3 DDS, MS and five days after the expiration of the bleaching io period. TBARS test was employed to evaluate the urinary level of malondialdehyde (MDA) as an ox- 1 Professor of Restorative Dentistry, Department of idative stress biomarker. Data were analyzed by az Restorative and Cosmetic Dentistry, School of means of independent sample t-test and repeated Dentistry, Mashhad University of Medical Sciences, measurement analysis. Mashhad, Iran Results: Twenty-nine subjects completed the 2 Assistant Professor of Restorative Dentistry, Depart- study. The MDA level increased during the bleaching period in both groups; however, the dif- rn ment of Restorative and Cosmetic Dentistry, School of Dentistry, Mashhad University of Medical Sciences, ference was not significant (P>0.05). In addition, Mashhad, Iran the ascorbic acid application could not present a 3 Dental Research Center, Mashhad University of significant difference in the MDA level (P= 0.34). te Medical Sciences, Mashhad, Iran Conclusion: The application of 15% carbamaide 4 Department of Biochemistry, Faculty of Medicine, Ma- peroxide did not significantly elevate the oxida- shhad University of Medical Sciences, Mashhad, Iran tive stress biomarker in human urine (IRCTID: In 5Addiction Research Centre, Faculty of Medicine, Ma- IRCT2012113011618N1). shhad University of Medical Sciences, Mashhad, Iran Key words: ascorbic acid, at-home tooth bleach- ing, oxidant and antioxidant, oxidative stress, vit- Corresponding author: amin C. ni Hamideh Sadat Mohammadipour Department of Restorative and Cosmetic Dentistry, Mashhad University of Medical Sciences Introduction io Vakil-Abad Blvd, Mashhad 91735, Iran Tel.: +989153213271 Discolored anterior teeth are perceived as a great es- Fax: +985138829500 thetic problem by most patients. Tooth whitening or iz E-mail: [email protected]; bleaching is a very conservative method which em- hm_7264@ yahoo.com ploys oxidizing agents to achieve a lighter and more desirable tooth color. During the course of bleaching, Ed long-chain pigmented molecules oxidize and split into Summary smaller, lighter ones with the release of carbon, water and oxygen (1). Introduction: Oxidizing agents which are used as The bleaching of vital teeth can be accomplished by tooth whitening agents can induce an oxidative either in-office or at-home technique of which the stress, a situation that initiates some systemic second method is performed by the patients them- IC diseases. This clinical study aims to evaluate the selves. The at-home bleaching method has created effect of ascorbic acid (vitamin c) on urinary level an easy performing, safe and low cost bleaching of an oxidative stress biomarker during the at- technique that is available to all socioeconomic class- home tooth whitening period. es of the patients. During this procedure, carbamide C Material and methods: Thirty healthy patients who peroxide, a combination of hydrogen peroxide as an requested for the tooth whitening were involved in effective tooth whitening agent and urea, are com- this trial. Specified bleaching trays were fabricated monly applied in a custom-fit tray for a few minutes to for both arches after making an impression. Each several hours each day, with regards to peroxide con- © participant was given two syringes containing 15% centration and manufacturer recommendations. Al- carbamide peroxide gel and instructed to apply it though strong evidences supported the effectiveness for 6 h per night for 14 consecutive nights. Pa- of this method, nevertheless, it has lower clinical con- tients were divided into two equal groups. In the trol compared to in-office one (2). experimental group, the patients applied two A number of concerns over systemic side effects of tablets containing 500 mg of vitamin C every night the bleaching agents have been raised because the Annali di Stomatologia 2018;IX (2):77-83 77  M. Akbari et al. patient may have swallowed these oxidizing com- ments. The null hypothesis was that, the ascorbic pounds which inevitably come in contact with their acid did not affect the urinary level of the MDA as a teeth and soft tissues for a long time especially dur- marker of oxidative stress. ing night. Genotoxicity, cytotoxicity, and carcinogenic- ity of the tooth whitening materials have been report- ed by many previous animal studies (3-9). They indi- Material and methods cated that hydrogen peroxide might act as a promoter li and ingestion of carbamide peroxide in a dose-de- Study population na pendent manner, induced acute mucosa ulcerations Participants in this randomized double-blind clinical in rats’ stomach. Notwithstanding, multiple exposures trial were selected from dental students with undesir- to hydrogen peroxide might reduced food consump- able tooth discoloration complaint in Mashhad Dental tion, weight gain, and result to changes in blood chem- School (the second biggest city in Iran). Thirty (19 fe- istry (5). The presence of adenoma and duodenum car- males and 11 males) healthy volunteers signed a de- io cinoma alongside hyperplasia was reported following tailed informed consent and this investigation was ap- the ingestion of 0.1 and 0.4% (w/v) of hydrogen perox- proved by the Ethical Board of Mashhad University of ide solution for 8 weeks in rats (5-7). Timblin et al. (10) Medical Sciences (Approval number: 901092). az presented an increase over-expression of proto-onco- The subjects with any of the following criteria were gen c-jun protein in human tracheal epithelial cells. excluded from this assay: However, the International Agency for Research on 1. Participants who had previous anterior restora- Cancer (IARC) has concluded that there is no clear evi- tions, tooth decay, exposed root surfaces, broken rn dence in animal and human experiments for the car- teeth, enamel erosions or poor oral hygiene that cinogenicity of hydrogen peroxide (11). needs further treatments. Certainly, oxidizing agents such as tooth bleaching 2. Participants who experienced the tooth whitening compounds can disturb oxidant-antioxidant body bal- procedures or they used antioxidant drugs (vita- te ance in favor of oxidants and can induce a potentially min C and vitamin E supplements) in the past six harmful challenge known as “oxidative stress”, which months. has a potential in damaging cell structures, alters 3. Patients who are suffering from systemic or enzy- In their functions and contributes in several pathological matic disorders that disturb oxidant-antioxidant conditions and common diseases (12,13). One of the balance and smokers due to synergic oxidant with most important outcomes from the oxidant damage is the bleaching agents. lipid peroxidation (13). Lipid peroxides are unstable 4. Women who are pregnant or lactating mothers. and decompose to form a group of reactive carbonyl 5. Volunteers with temporomandibular disorders or ni compounds like malondialdehide (MDA) (14), which having para-function habits like broxism and can be quantified with thiobarbituric acid-reactive clenching contraindicated for the at-home tooth substances test (TBARS) (15). A recent study con- bleaching method. io ducted by Akbari et al. (16) regarding the systemic side effects of the bleaching agents on human health Bleaching procedure showed that these agents have the potential to dis- To produce an accurate negative mold, alginate im- iz turb the body balance and induce the oxidative pressions (Bayer, Leverkusen, Germany) were ob- stress. They revealed that the serum concentrations tained from both arches for each participant. There- of the MDA, total antioxidant capacity (TAC), and pro- after, casts were poured with dental stone powder Ed oxidant-antioxidant balance (PAB) were increased (Tara, Kheyzaran, Isfahan, Iran) and were trimmed to significantly after the tooth bleaching period. a horseshoe shape with no palatal or tongue sec- Aside body’s defense, exogenous antioxidants as tions, without damaging tooth surfaces and gingival therapeutic adjuncts may well improve the inherent margins. To incorporate reservoir spaces, several human antioxidant capacity and overcome the oxida- layers of nail polish were applied on labial tooth sur- tive damages. Considering the effectiveness of an- faces of stone casts. The bleaching trays were fabri- IC tioxidant vitamins like vitamin C on the oxidative cated with 0.035 inch vacuum formed sheets utilizing stress induced diseases such as Alzheimer disease a vacuum tray-forming machine (Ultravac; Ultradent (17) and atherosclerosis (13) and its effective role in Products Inc., South Jordan, USA). Subsequently, inhibiting lipid peroxidation (15), it may be necessary the trays were trimmed to form scalloped borders on C to equip the human body with a variety of external 2 mm far away from the gingival margins. Two 3-ml origin antioxidants in order to counter balance harm- syringes of 15% carbamide peroxide gel (Opales- ful effects of the tooth whitening oxidants (12). cence, Ultradent Products Inc., South Jordan, USA) To the best of our knowledge, no study has been car- were given to each participant. The patients were in- © ried out on humans regarding the effect of ascorbic structed to place adequate amount of the bleaching acid on tooth bleaching induced oxidative stress. This agent into the tray to cover the facial surfaces of the clinical trial was carried out to investigate whether the teeth which are visible during laughing and speaking. oxidative stress following at-home bleaching could be To obtain maximum benefits of the product and pa- reduced by shifting pro-oxidant-antioxidant balance in tient compliance, participants were asked to wear favor of antioxidants via the use of vitamin C supple- bleaching trays for at least 6 h per night (according to 78 Annali di Stomatologia 2018;IX (2):77-83  The effect of vitamin C on urinary level of an oxidative stress biomarker during at-home tooth bleaching process: a randomized double blinded clinical trial the manufacturer’s instruction) for 2 weeks. After the Results loaded tray is seated, the patients were instructed to gently remove any excess of the bleaching material Twenty-nine participants (19 females and 10 males) with a tissue or a brush. They were cautioned to dis- completed the two-week study period. One of the par- continue the use of bleaching agents in the situations ticipants was excluded from the evaluation as a result of tooth hypersensitivity or gingival problems and of low cooperation, and no adherence to the study alert research team immediately. protocol. None of the participants who completed the li In the end, the volunteers were randomly assigned in study reported any signs of tooth hypersensitivity or na equal numbers to one of the two treatment groups. gingival irritation. The randomization process was carried out by a third Table 1 presents the mean, standard deviation and person who was not involved in the research proto- minimum and maximum value of the MDA in both col. In the experimental group, patients were instruct- control and intervention groups between five sam- ed to chew two tablets containing 500 mg of vitamin pling intervals. io C (Sunkist, Sunkist Growers, USA) before using the The Kolmogorov Smirnow test demonstrated that the bleaching tray every night along with the tooth MDA concentration was normally distributed in all whitening procedure. Participants were reminded by measurements (P>0.05). az a research operator through telephone to take their According to repeated measurement analysis, the uri- daily doses of the ascorbic acid. In the control group, nary concentration of the MDA in both groups gradu- no drug was prescribed. The whole procedure was ally increased during the study period that suddenly clarified by an expert operator for each participant to subsided at the final sample session (Fig. 1), howev- rn increase adherence to the protocol. Neither the oper- er, no significant difference presented between these ator nor the statistician knew the group allocation, five sample sessions in each of the control and ex- both were blinded to the protocol. perimental groups (P value= 0.7 and 0.66, respec- tively). Furthermore, this analysis showed no signifi- te Urine sample cant difference in the MDA concentration during study One milliliter of participants’ morning urine was taken period between two groups (P value= 0.86). on days 0, 5, 10, 15 and 20 of the study. The first Independent sample t-test showed no significant dif- In sample was collected in the morning before the initia- ference between two groups on the baseline with oth- tion of bleaching procedure and was continued every er sampling sessions (P value= 0.79, 0.80, 0.81 and five days until the final sample which was gathered 0.34, respectively). five days after the expiration of the whitening period. The data regarding the comparison of the urinary Regarding sequencing sample collection, the sam- concentration of the MDA between the first and other ni ples were refrigerated at -80°C with no special treat- sampling intervals are presented in Table 2. ment, according to commercial kit recommendation until initiating the assay. io Discussion Thiobarbituric Acid Reactive Substances (TBARS) Assay The findings of the current research could not reveal iz To evaluate the effect of ascorbic acid on the urinary a significant increase in the MDA concentration in level of the MDA, as a product of lipid peroxidation as urine samples during the tooth bleaching procedure well as an index of the oxidative stress, TBARS test (P=0.7). Literally, this study has been designed to Ed (Cayman Chemical, Ann Arbor, MI, USA, Item Num- protect tooth bleaching volunteers from the systemic ber 10009055) was used based on an established side effects of the whitening agents by vitamin C sup- method (18). The pink colored MDA-TBA adduct was plementation, based on a recent study, which was formed by the reaction of MDA and thiobarbituric acid carried out by the same investigators who indicated (TBA) under high temperature (90-100°C) and acidic that the serum concentrations of the MDA, total an- conditions. The absorbance of the MDA-TBA complex tioxidant capacity (TAC), and prooxidant-antioxidant IC was read at 532 nm and the concentration of the balance (PAB) were increased significantly after the MDA in samples was calculated using a standard tooth bleaching period (16). Although this study could curve. not reveal similar results, monitoring of the MDA con- centration from onset to end of the study period C showed the gradual elevation of the MDA that sud- Statistical analysis denly decreased in the final sample session which was taken five days after the expiration of the whiten- The normality of data distribution was examined by ing period. Thus, it cannot entirely rule out the proba- © Kolmogorov Smirnov test. The difference of the MDA bly tooth bleaching induced oxidative damage. To values between the five measurements was carried clarify different outcomes between these two studies, out using repeated measurements and Independent the Authors need to emphasize on some points. Ini- sample test. SPSS version 11.5 software (SPSS, tially, the difference between these two experiments Chicago, IL, USA) was used for statistical analysis may be attributed to the kind of samples that were while level of statistical significance was set at 0.05. taken for the oxidative stress assay. The evaluation Annali di Stomatologia 2018;IX (2):77-83 79  M. Akbari et al. Table 1. The mean, standard deviation, minimum and maximum value of the MDA in both groups between five sampling intervals. !Sampling intervals Study groups ! Mean±SD ! Min ! Max First !Control ! 0.072±0.011 0.059 0.104 li na !Intervention ! 0.074±0.008 0.063 O.092 !Total ! 0.073±0.009 0.059 0.104 !Second !Control ! 0.074±0.013 0.059 0.109 io !Intervention ! 0.074±0.013 0.059 0.112 !Total ! 0.074±0.013 ! 0.059 0.112 az Third !Control ! 0.076±0.017 0.059 0.114 !Intervention ! 0.076±0.011 0.057 0.102 ! rn !Total ! 0.076±0.015 0.057 0.114 !Fourth !Control ! 0.080±0.017 0.051 0.106 te !Intervention In ! 0.080±0.017 0.063 0.111 !Total ! 0.080±0.017 0.051 0.111 !Fifth !Control ! 0.077±0.011 0.065 0.112 ! !Intervention ! 0.073±0.012 0.058 0.101 ni !Total ! 0.075±0.011 0.058 0.112 io iz Ed IC C Figure 1. Repeated measurement analysis of the groups. of oxidative stress biomarkers in human serum sam- hardly be traced in situations with minute quantities in © ples is more popular than that of urine. On the other human serum. In fact, the current research was de- hand, ethical consideration did not permit researchers signed to monitor oxidant status during the bleaching to take five blood samples for the duration of 20 days period and after its expiration, as a multiple time se- (one blood sample in each five days). Moreover, it ries method in response to the limitation of the previ- was determined that urinary level of the MDA is sig- ous study with no evaluation of oxidant changes after nificantly lower than that of blood (19, 20) and can the bleaching period, so as to determine the time 80 Annali di Stomatologia 2018;IX (2):77-83  The effect of vitamin C on urinary level of an oxidative stress biomarker during at-home tooth bleaching process: a randomized double blinded clinical trial Table 2. The comparison of the urinary concentration of MDA between first with other sampling intervals. Comparisons Study groups ! Number ! Mean ± SD P-value First compared with second !Intervention ! 14 ! 0.0002±0.013 0.793 ! interval li !Control ! 15 ! -0.0015±0.020 ! First compared with third interval !Intervention ! 14 -0.0022±0.013 0.809 na !Control ! 15 ! -0.0040±0.022 ! First compared with fourth interval !Intervention ! 14 ! -0.0059±0.017 0.819 !Control ! 15 ! -0.0075±0.019 io ! First compared with fifth interval !Intervention ! 14 ! 0.0010±0.013 0.343 !Control ! 15 ! -0.042±0.015 az needed for the human body to completely recover health risk with the tooth bleaching agents have from the oxidative stress. Also in a previous study largely diminished (22). It was reported that the fre- (16), 9% hydrogen peroxide was used as the whiten- quency of genetic mutation induced by 10% car- ing agent, but in this study, relying on long, success- bamide peroxide is relatively similar to a physiological rn ful clinical application, the 15% carbamide peroxide saline control (23). Sometimes other ingredients in was utilized which released about 5% hydrogen per- the bleaching gels such as carbopol or glycerin may oxide. Finally, the participants of this study were se- be responsible for the poisoning rather than the lected from dental students who strictly adhered to bleaching agent itself (4). In spite of this, salivary per- the described bleaching protocol. Furthermore, the whole procedure was completely described for each patient by an expert clinician and the patients try to te oxidase as a body enzymatic equipment rapidly de- composes large amount of hydrogen peroxide in the oral cavity (22). It has been determined that the oral In follow the treatment instructions immediately. The cavity is capable of decomposing more than 29 mg of well educated participants used the proper amount of hydrogen peroxide per minute, whereas for a night the bleaching agents and removed excess on tray guard bleaching of both arches using 10% carbamide borders to minimize leakage, gingival irritation and peroxide, the total hydrogen peroxide exposure dose ni swallowing. This was based on previous obtained was estimated to be approximately 3.5 mg (24). facts which emphasized that the at-home bleaching On the other hand, the in vitro studies that have fre- procedure should be carried out with high ethical quently emphasized the carcinogenicity, mutagenicity io standards and under full professional supervision, in and teratogenicity of H2O2 (6-9) could not be repro- order to decrease potential systemic side effects (5). duced in vivo due to inappropriate design, conduct There is concern regarding the possible adverse ef- and assessment of the results (24). The overall data iz fects of the at-home bleaching agents by swallowing on bleaching studies accumulated over the last 20 a minute quantity and absorption through the gas- years also confirmed the results of the present study, trointestinal tract or local absorption through the gin- which concluded that the use of low concentrations of Ed gival, especially when they are applied with no dental hydrogen peroxide is still safe (25-28). supervision (21). The probably systemic side effects In the current study, due to the ability of well-de- of hydrogen peroxide are dependent on the amount signed trays to make precise contact with the teeth and the concentration of its compounds ingested. Ac- with no gingival exposure, no participant dropout was cording to the study of Dahl et al. (5), accidental in- reported due to gingival irritation or tooth hypersensi- gestion of 35% hydrogen peroxide has resulted in fa- tivity. Indeed, the gingival irritation which has been IC tal or near-fatal poisonings. Nevertheless, it is not a reported by the at-home bleaching method that used major concern as regards carbamide peroxide which low concentration of carbamide peroxide in custom yields lower concentration of hydrogen peroxide (2). made trays is more likely attributed to an ill-fitting tray In addition, Cherry et al. (3) indicated acute toxicolog- rather than the bleaching agent itself (29). C ical effects of ingested 35% carbamide peroxide in fe- Although several in vitro studies have reported male rats. However, they reported that commercial promising findings about the use of different antioxi- products containing 10 or 15% carbamide peroxide dant agents for treatment and/or prevention of the ox- showed milder symptoms than 35% carbamide perox- idative damages caused by hydrogen peroxide (30- © ide concentration. 32), the present study investigators indicated that the Unfortunately, in each of the previous cases that re- vitamin C supplementation did not significantly re- ported toxic, fatal or near fatal effects of hydrogen duce the urinary level of the MDA as a marker of ox- peroxide, the amount of hydrogen peroxide swal- idative stress following the tooth bleaching procedure lowed was unknown. Considering the dosage and ap- with 15% carbamide peroxide (P=0.66), thus the null plication mode, concerns with potential systemic hypothesis could not reject. Literally, obtained results Annali di Stomatologia 2018;IX (2):77-83 81  M. Akbari et al. from the in vitro studies cannot necessarily be extra- noted that this paper was extracted from thesis num- polated to the clinical situation. It seems that the ber 493. amount of antioxidant delivered to cultured cells in the in vitro studies was much higher than the level of antioxidant reached in the extracellular fluid after oral Conflict of interest administration of 500 mg of ascorbic acid (30-32). In the clinical setting, the achieved outcomes on pro- The Authors of this manuscript clarify that they have li tective antioxidant role of vitamin C administration are no proprietary, financial, or other personal interest of na conflicting. In spite of the study of Harats et al. (33) any sort which has been used in this study. who determined the effective role of vitamin C against oxidative stress in smokers, two other studies in which the diets of smokers were supplemented with the vita- References min C could not significantly reduce plasma TBARS io levels (34, 35). These findings are in line with the re- 1. Zimmerli B, Jeger F, Lussi A. Bleaching of nonvital teeth. A clinically relevant literature review. Schweiz Monatsschr Zah- sults of Padayatty et al. (13) who reported that al- nmed. 2010;120:306-320. though diet rich in fruits and vegetables is associated az 2. Dhillon JS, Narula NB, Kansal N, Kaur A. Tooth Whitening- with lower risk of cardiovascular disease and cancer, A Review. Indian Journal of Dental Sciences. 2011;3(5). it is not clear if vitamin C contributes to these benefits. 3. Cherry DV, Bowers DE, Jr., Thomas L, Redmond AF. Acute In addition, they concluded that the vitamin C treat- toxicological effects of ingested tooth whiteners in female rats. ment in humans could not change oxidation biomark- J Dent Res. 1993;72:1298-1303. rn ers or clinical outcomes which completely confirmed 4. Dahl J, Becher R. Acute toxicity of carbamide peroxide and the outcome of this study. In the field of vitamin C a commercially available tooth-bleaching agent in rats. J Dent supplementations, the unique study of Nyyssönen et Res. 1995;74:710-714. 5. Dahl JE, Pallesen U. Tooth bleaching-a critical review of the al. (35) is of particular interest presented a significant te biological aspects. Crit Rev Oral Biol Med. 2003;14:292-304. increase in plasma TBARS after regular and slow re- 6. Ito A, Watanabe H, Naito M, Naito Y. Induction of duodenal lease of vitamin C and the Authors could not find any tumors in mice by oral administration of hydrogen peroxide. logical etiology for this phenomenon. Gann. 1981;72:174-175. In The present study concluded that the night guard 7. Ito A, Watanabe H, Naito M, et al. Correlation between in- tooth bleaching with 15% carbamide peroxide will not duction of duodenal tumor by hydrogen peroxide and cata- induce oxidative stress and systemic side effects if lase activity in mice. Gann. 1984;75:17-21. the procedure fully described for each patient is regu- 8. Ito A NM, Watanabe H. Implication of chemical carcinogenesis in the experimental animal-tumorigenic effect of hydrogen larly reviewed and monitored. The American Dental ni peroxide in mice. . Hiroshima Daigaku Genbaku Hoshanou Association encourages all patients who are interest- Igaku Kankyusho Nenpo. 1981;22:147-158. ed in tooth bleaching to completely follow dental pro- 9. Ito A NM, Nayto Y, Watanaee H. Induction and charac- fessional advices (22). However, due to the impor- io terization of gastroduodenal lesions in mice given con- tance of the carcinogenicity and relatively limited data tinuous oral administration of hydrogen peroxide. 1982; available on the topic for tooth bleaching, questions 73:315-322. and debates over the systemic risks of bleaching may 10. Timblin CR, Janssen YW, Mossman BT. Transcriptional iz arise periodically. Thus, further clinical research is activation of the proto-oncogene c-jun by asbestos and H2O2 is directly related to increased proliferation and trans- encouraged to clarify the controversy and concerns formation of tracheal epithelial cells. Cancer research. on systemic side effects of hydrogen peroxide as a Ed 1995;55:2723-2726. tooth whitening agent. 11. Humans IWGotEoCRt, Organization WH, Cancer IAfRo. Re- evaluation of some organic chemicals, hydrazine and hy- drogen peroxide. World Health Organization; 1999. Conclusions 12. Birben E, Sahiner UM, Sackesen C, et al. Oxidative stress and antioxidant defense. World Allergy Organ J. 2012;5:9-19. Within the limitations of the current study, the Authors 13. Padayatty SJ, Katz A, Wang Y, et al. Vitamin C as an an- IC tioxidant: evaluation of its role in disease prevention. J Am could not reveal that the tooth bleaching agents pro- Coll Nutr. 2003;22:18-35. moted oxidative stress with lipid peroxidation monitor- 14. Wang LH, Tsai AL, Hsu PY. Substrate binding is the rate- ing on MDA biomarker in human urine samples. But limiting step in thromboxane synthase catalysis. J Biol Chem. the Authors cannot entirely rule out the benefits of the 2001;276:14737-14743. C ascorbic acid on tooth bleaching induced oxidative 15. Huang HY, Appel LJ, Croft KD, et al. Effects of vitamin C and stress. vitamin E on in vivo lipid peroxidation: results of a random- ized controlled trial. Am J Clin Nutr. 2002;76:549-555. 16. Akbari M, Nejat A, Farkhondeh N, et al. Does at‐home bleach- © Acknowledgements ing induce systemic oxidative stress in healthy patients? Aust Dent J. 2017;62:58-64. 17. Zandi PP, Anthony JC, Khachaturian AS, et al. Reduced risk This research project was funded by the Research of Alzheimer disease in users of antioxidant vitamin supple- Council of Mashhad University of Medical Sciences ments: the Cache County Study. Arch Neurol. 2004;61:82-88. (MUMS). The Authors would like to thank the Dental 18. Yagi K. Simple assay for the level of total lipid peroxides in Research Committee at MUMS. Also, it should be serum or plasma. Methods Mol Biol. 1998;108:101-106. 82 Annali di Stomatologia 2018;IX (2):77-83  The effect of vitamin C on urinary level of an oxidative stress biomarker during at-home tooth bleaching process: a randomized double blinded clinical trial 19. Goulart M, Batoreu MC, Rodrigues AS, et al. Lipoperoxidation town, Pa). 1989;10:514-519. products and thiol antioxidants in chromium exposed work- 29. Li Y. Toxicological considerations of tooth bleaching using ers. Mutagenesis. 2005;20:311-315. peroxide-containing agents. J Am Dent Assoc. 1997;128 Sup- 20. Jacob RA, Aiello GM, Stephensen CB, et al. Moderate an- pl:31S-6S. tioxidant supplementation has no effect on biomarkers of ox- 30. Freire A, Souza EM, de Menezes Caldas DB, et al. Reac- idant damage in healthy men with low fruit and vegetable in- tion kinetics of sodium ascorbate and dental bleaching gel. takes. J Nutr. 2003;133:740-743. J Dent. 2009;37:932-936. li 21. Tredwin CJ, Naik S, Lewis NJ, Scully C. Hydrogen peroxide 31. Kanno S-i, Shouji A, Asou K, Ishikawa M. Effects of naringin tooth-whitening (bleaching) products: review of adverse ef- on hydrogen peroxide-induced cytotoxicity and apoptosis in na fects and safety issues. Br Dent J. 2006;200:371-6. P388 cells. J Pharmacol Sci. 2003;92:166-170. 22. Li Y. Safety controversies in tooth bleaching. Dent Clin North 32. Lima AF, Lessa FCR, Mancini MNG, et al. Transdentinal pro- Am. 2011;55:255-263. tective role of sodium ascorbate against the cytopathic ef- 23. Sulieman M, Addy M, MacDonald E, Rees JS. The effect of fects of H 2 O 2 released from bleaching agents. Oral Surg, hydrogen peroxide concentration on the outcome of tooth Oral Med, Oral Pathol, Oral Radiol, and End. 2010;109:e70- io whitening: an in vitro study. J Dent. 2004;32:295-299. e76. 24. Sulieman M. An overview of bleaching techniques: I. History, 33. Harats D, Ben-Naim M, Dabach Y, et al. Effect of vitamin C chemistry, safety and legal aspects. Dent Update. 2004; and E supplementation on susceptibility of plasma lipopro- 31:608-610. teins to peroxidation induced by acute smoking. Atheroscle- az 25. Freedman GA. Safety of tooth whitening. Dentistry today. rosis. 1990;85:47-54. 1990;9:32-33. 34. Mulholland C, Strain J, Trinick T. Serum antioxidant poten- 26. Reddy J, Salkin L. The effect of a urea peroxide rinse on den- tial, and lipoprotein oxidation in female smokers following vi- tal plaque and gingivitis. J Periodontol. 1976; 47:607-610. tamin C supplementation. Int J Food Sci Nutr. 1996;47:227- 27. Shipman B, Cohen E, Kaslick RS. The effect of a urea per- 231. rn oxide gel on plaque deposits and gingival status. J Peri- 35. Nyyssönen K, Poulsen H, Hayn M, et al. Effect of supple- odontol. 1971;42:283-285. mentation of smoking men with plain or slow release ascor- 28. Stindt DJ, Quenette L. An overview of Gly-Oxide liquid in con- bic acid on lipoprotein oxidation. Eur J Clin Ntr. 1997;51:154- trol and prevention of dental disease. Compendium (New- 163. te In ni io iz Ed IC C © Annali di Stomatologia 2018;IX (2):77-83 83 

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Original article Resonance frequency evaluation on immediate loading implants with angled abutments: case series li na Vincenzo Notaro1 DDS Harrogate, UK) during the different stages. Biagio Rapone2 DDS, PG Surg, MSC Results: A six month- follow-up showed implant Giovanni Cagnetta3 DDS survival of 96%. Twenty-four implants were os- Pasquale Sportelli1 MD, DMD seointegrated, a maxillary implant was lost and io Gianna Maria Nardi5 RDM one other implant was excluded from the study. Massimo Corsalini3 MD, DMD The values of ISQ ranged between 53-88 ISQ (av- erage 66 ± 6.1 ISQ, median 67 ISQ) at t0, 51-80 ISQ az (average 70 ± 5.8 ISQ, median 70 ISQ) at t1 and 1 School of Dentistry, University of Turin, Turin, Italy 53-80 ISQ (average 70.8 ± 5.7 ISQ, median 72 ISQ) 2 Department of Basic Medical Sciences, Neuro- at t2. sciences and Sense Organs, “Aldo Moro” University Conclusions: The 24 successful implants out of 25 in 5 patients demonstrate how using 4-6 im- rn of Bari, Bari, Italy 3 Interdisciplinary Department of Medicine (DIM) - plants guarantees sufficient anchorage for a fixed Section of Dentistry, “Aldo Moro” University of Bari, prosthesis and adequate distribution of the pros- Bari, Italy thetic load on the maxillary and mandible bones, te 4 Complex Operating Unit of Odontostomatology, without causing implants failures. “Aldo Moro” University of Bari, Bari, Italy 5 Department of Dental and Maxillofacial Sciences, Key words: resonance frequency, immediate load- In “Sapienza” University, Rome, Italy ing implants, angled abutments. Corresponding author: Introduction Biagio Rapone ni Department of Basic Medical Sciences, Neuro- Immediate loading of implant-supported prosthesis is sciences and Sense Organs, a predictable and standardized therapy for rehabilita- University “Aldo Moro” of Bari tion of partially and totally edentulous patients; it io Piazza Giulio Cesare 10 shows high rates of survival and success, both for the 70121 Bari, Italy implants and for the prosthesis. E-mail: [email protected] In a 2003 paper, Aparicio et al. analyzed advantages iz and disadvantages of immediate load technique. They considered the various factors that could affect Summary outcomes (patients’ selection criteria, quality of Ed bones, fixture length, surface and shape features, Aim: Immediate loading of implant-supported surgeon skillfulness, implant primary stability, oc- prosthesis is a predictable and standardised ther- clusal load) and recognized primary stability as the apy for rehabilitation of partially and totally eden- main goal (1). tulous patients. The present case series evaluate Also in 2003, Malò et al. described a surgical proto- implant success rates by measuring resonance col, the “All on Four” method, for rehabilitation of IC frequency on immediate loading implants with an- four-implant mandibular arches: two in the frontal gled abutments. side and two in the backside. This method showed a Materials and methods: A prospective study was reduction in treatment times, patient discomfort and performed on five partially edentulous patients. biological costs (2). Subsequently, the “All on four” C Twenty-six Neoss ProActive Tapered® (Neoss has been extended to the maxillary bone, resulting in Ltd. Harrogate, UK) implants were inserted: 22 in 98% of implant survival after a 5 years follow-up (3). the maxillary bone and 4 in the mandibular bone. According to a photoelastic analysis on the peri-im- The Osstell ISQ® (Osstell; Integration Diagnos- plant stress levels in vitro, bone around 45° angled © tics, Göteborg, Sweden) was used to evaluate im- implants is more exposed to an occlusal overload in plant stability. Implant Stability Quotient (ISQ) comparison to bone around smaller angulations im- measurements were performed in three stages: at plants. Small stress differences have been reported time of implant insertion (t0), after three (t1) and around fixtures angles of 0°, 15° and 30°; the regions 12 (t2) months. The ISQ values were recorded af- around the fixtures ’coronal third emerged as the ter implant installation of Access® (Neoss Ltd. most stressed (4). Annali di Stomatologia 2018;IX (2):91-96 91  V. Notaro et al. Angled abutments mediate prosthetic rehabilitation of Study population angled implants so that abutments axes of the same The participants were 5 partially edentulous patients: arch result as parallel as possible. 2 males and 3 females aged between 58 and 74 The most used angled abutments in literature are years (average of 66 ± 8 years). They were selected Multi Unit Abutment (MUA®) (Neoss Ltd. Harrogate, according to the following exclusion criteria: UK), Access® (Neoss Ltd. Harrogate, UK) and Low ● Systemic disorders (thrombocytopenia, coagu- Profile® (Neoss Ltd. Harrogate, UK). lopathy, hepatopathy, immunosuppression, dia- li According to a literary review, the clinical perfor- betes, prolonged cortisone therapy, chemothera- na mances of the angled abutments are equal to those py, iv bisphosphonate treatment, radiotherapy, of the straight abutments. The stress produced by ex- myocardiopathy) tra-axial load increases with abutment angulation, yet ● Smoking habits no consensus has been reached about the precise in- ● Bruxism clination that leads to implant failure. ● Temporomandibular disorders io During implant success evaluation, it is essential to ● Severe dental or skeletal malocclusions. distinguish between mandibular and maxillary bone. And the following inclusion criteria: Indeed, a retrospective study on early load with full- ● need for a full-arch bridge maxillary and/or az arches prosthesis resulted in no implant loss in the mandibular supported by 4 or 6 implants mandible, even using only 4 implants, against a ● minimum implant length of 10 mm 10.6% implant loss in the maxillary bone (5). Another ● torque of insertion equal to or greater than 35 study on full load arch prostheses shows a success Ncm rn rate of 97% for mandibular implants and 87.5% for ● prosthesis connected to all the implants maxillary ones two years after surgery (6). ● occlusion with long and wide centric. The successful installation of immediate loading pros- All the examined patients were healthy; 4 of them thesis with a full-arch in the maxillary bone depends took antihypertensive drugs. te on the observation of adequate criteria: patient selec- tion, implant choice, correct surgical technique and Surgical and prosthetic procedures correct prosthesis realization (7). In order to assemble the articulator-mounted plaster In Given the limited number of existing studies on the models and construct the surgical template, the inter- topic (8), the present case series aims to evaluate the maxillary connections must be transferred. A facebow success of immediate-loading implants with angled has to be employed if an occlusal vertical dimension abutments by measuring resonance frequencies. (OVD) increment is required or if the connections be- tween the two maxillary arches are absent. ni In patients with stable occlusion (at least 4 pairs of Clinical series antagonist teeth) alginate impressions were taken and intermazillary relationship was recorded by occlu- io Study design sion wax. Gypsum models were placed in the articu- The study was a case series designed to evaluate lator; the resulting surgical template guided implants the success of immediate-loading of twenty-six post- insertion in the correct prosthetic position and aided iz extractive implants: 22 in the maxillary bone and 4 the choice of the correct Access®. in the mandibular bone. A mandibular implant was In patients with unstable occlusion (less than 4 pairs excluded from the study because angled abutment of antagonist teeth), intermaxillary relationship and Ed was unnecessary. Twenty out of twenty-five im- vertical occlusion dimension (OVD) were registered plants were inserted in post-extraction alveolus using a facebow. while the remaining five in native bone. The inserted Avulsion of every compromised dental element was implants, Neoss ProActive Tapered® (Neoss Ltd. performed; in the same session, 4 or 6 implants were Harrogate, UK), consist of commercially pure titani- inserted both in native bone and in post-extraction um grade 4. sites. The implant insertion sites were planned based IC The Osstell ISQ® (Osstell; Integration Diagnostics, on TC assessment. The chosen areas were the ones Göteborg, Sweden) device was used to evaluate im- with greater bone volume, which did not require a plant stability. The SmartPeg™ (Osstell) is a small, preventive bone regenerative surgery. high-precision disposable aluminium bar screwed on- The maxillary implants have been placed in 1.2, 2.2, C to the implant (or angled abutment) during measure- 1.4 / 1.5, 2.4 / 2.5 regions; the mandibular ones in 3.2 / ments. The ISQ measurements were performed at 3.3, 4.2 / 4.3, 3.4 / 3.5, 4.4 / 4.5 regions. The two poste- the time of implant insertion (t0), after 3 (t1) and 12 rior implants had a mesio-distal inclination of 25-30°, (t2) months. while the two anterior ones inserted in the premaxilla © Cone-beam CT and OPT were employed for patients’ and in the parasymphysis region were straight. clinical, prosthetic and radiographic assessments. The protocols suggested by Neoss served as a refer- All patients underwent oral hygiene sessions; they ence for implant sites preparation. The surgical tem- were further instructed to perform oral hygiene during plate guided the implants’ position and inclination. pre-surgical phase. The implants were inserted using a torque of 35 N/cm 92 Annali di Stomatologia 2018;IX (2):91-96  Resonance frequency evaluation on immediate loading implants with angled abutments: case series at least. A transparent resin mask helped choosing the Access® angle correctors, which had to be direct- Outcomes measures and results ly screwed onto the implant head to parallelise the The obtained ISQ values reflect the stability level on axes of the implant emergencies. the universal ISQ scale, from 1 to 100. Three mea- The resonance frequency analysis made with Osstell® surements were recorded for each direction tested ISQ device measured the primary implant stability at but only the highest value was considered. The ISQ zero time. The ISQ values of anterior implants were values were recorded after implant installation of Ac- li measured by placing the probe in mesial, distal and cess® (Neoss Ltd. Harrogate, UK) during the different na vestibular position; for the posterior implants, the ISQ stages: during surgery (t0), after 3 (t1) and after 12 was taken in the buccal palatal and mesial position. months (t2) from insertion. The values of ISQ ranged Following this, the SmartPeg™ was removed and the ti- between 53-88 ISQ (average 66 ± 6.1 ISQ, median tanium prosthetic cylinders that act as transfers were 67 ISQ) at t0, 51-80 ISQ (average 70 ± 5.8 ISQ, me- installed above the Access®. The surgical template dian 70 ISQ) at t1 and 53-80 ISQ (average 70.8 ± 5.7 io was used as an open tray to take a silicone impression. ISQ, median 72 ISQ) at t2. The occlusal contacts were checked with an articulat- Analyzing the variation tables of the ISQ value over ing paper. The patient was invited to maintain in the time, we note an increase at t1 and a slight increase az maximum intercuspidation position (ICP) throughout or stabilization at t2. In Tables 1, 3 and 5 some im- the swallowing technique. A bite-type silicone was in- plants slightly drop the ISQ values from t0 to t1 and jected between the mask and the vestibule: it blocked an increase them from t1 to t2. In Tables 1, 2 and 5 the intercuspidation position, polymerized and then ISQ values higher than 75 recorded at t0 fall at t1, rn was removed. The ICP impression was used to con- then stabilize or return to growth in the ISQ control struct the temporary prosthesis. The temporary resin performed at t2. In Tables 2, 3 and 4 three out of strengthened by glass fibers was produced based on twenty-five implants have shown a different trend: low- the implants’ emergencies and the wax teeth assem- er ISQ values at t1, which stabilized at t2 in Tables 2 te bly, and after 24 hours was delivered to the patient. and 4 while further decreased at t2 in Table 3. In Ta- At the end of the surgical phase, antibiotic and anti- bles 1, 3 and 4, three implants with ISQ values lower inflammatory therapy was prescribed and a soft diet than 60 at t0 showed a marked increase in the ISQ In was recommended for at least 30 days. value at t1 and t2, conforming to the ISQ values of the The patients were summoned back after 3 months other implants present in the respective Tables. and 12 months after surgery. The final prosthesis was The patient 2 was supplied with prosthesis in both the delivered after 6-8 months from the temporary pros- maxillary bone and the mandible, thus we could draw thesis implant. two distinct tables to monitor the different osseointe- ni After the temporary prosthesis removal, the peri-im- gration of the maxillary and mandibular implants over plant mucosa healing process was evaluated and the time. The ISQ values trend is described above in both ISQ values of each implant were measured. Tables. If the mandibular implant with abnormal ISQ val- io Table 1. The variation table of the ISQ value over time in patient 1. iz Ed IC Table 2. The variation table of the ISQ value over time in patient 2. C © Annali di Stomatologia 2018;IX (2):91-96 93  V. Notaro et al. Table 3. The variation table of the ISQ value over time in patient 3. li na Table 4. The variation table of the ISQ value over time in patient 4. io az rn Table 5. The variation table of the ISQ value over time in patient 5. te In ni ues at control t1 and t2 is neglected, the recorded ISQ In the present case, an anomalous trend was mea- io values in the mandible are higher than those in the sured on three implants: their ISQ value progressively maxillary bone. decreased, suggesting some kind of impairment; Twenty-four implants were osseointegrated whereas however, they remained clinically stable. Temporary iz a maxillary implant was lost one month after immedi- prosthesis occlusal control revealed an occlusal over- ate loading procedure (patient 2). A six months fol- load on those three anomalous implants: the pre-con- low-up showed implant survival of 96%. tact was immediately corrected. Ed Further, the ISQ values measured on the three mandibular implants can be associated with a better Discussion bone quality of the implant insertion site (15, 17). The different angulation Access® devices lead to an The ISQ measurements performed at t0, t1 and t2 indi- ISQ value average decrease if compared with the ISQ cate that implant stability increases over time. This re- measured without intermediate components between IC sult can be due to both new bone formation around im- SmartPeg™ and implant. The 0° Access® reports an plant turns and bone mineralization increase in the average decrease of 1.74-5.01% of the ISQ value; the bone-implant interface. Many studies monitored ISQ Access® 10° an average decrease of 5.07-6.63%; the values shifts over time since implant placement (9-28). Access® 20° a decrease average of 6.79-7.93%; the C Three maxillary implants with ISQ values below 60 at t0 Access® 30° an average decrease of 7.2-8.73%. showed a marked increase in the ISQ value at t1 and Several Authors have searched for an ISQ threshold t2. Huwiler et al.’s study states that the increase in ISQ clinically useful to differentiate early successes and fail- value is higher in type IV bone and lower in type I bone ures. Guler et al. state it is impossible to identify this © 6 weeks after implant insertion (15). In Sim and Lung’s value (12, 13). On the other hand, Andersson et al. af- 2010 paper, ISQ value of type II bone slightly decreas- firm that a substantial ISQ value decrease recorded es after 2 weeks but always remains above 70 ISQ, three month after surgery can predict implant failure. while ISQ value of type III and IV bone continuously According to Fischer et al., an ISQ value lower than 44 grows until it reaches slightly lower values than those indicates imminent failure in 100% of cases (29). recorded in type II bone after 12 weeks (17). Huwiler et al. report similar results: failed implants ISQ 94 Annali di Stomatologia 2018;IX (2):91-96  Resonance frequency evaluation on immediate loading implants with angled abutments: case series values declined from 68 at t0 to 45 after a week (15). analysis. J Prosthodont. 2011 Jan;20(1):16-28. Doi: Both Andersson et al. and Sennerby et al. discourage 10.1111/j.1532-849X.2010.00654.x. immediate loading on implants with an ISQ value of 60: 9. Mozzati M, Arata V, Gallesio G, Mussano F, Carossa S. Im- mediate postextraction implant placement with immediate the failure rate ranges around 6.5% (5, 30). loading for maxillary full-arch rehabilitation: A two-year ret- Eventually, the first measurement is important to un- rospective analysis. Journal of the American Dental Asso- derstand subsequent data. Measurements repeated ciation. 2012;143(2):124-133. with the transducer in the same position allow a li 10. Corsalini M, Genovese K, Lamberti L, Pappalettere C, Carel- meaningful comparison of data. la M, Carossa S. A laboratory comparison of individual Tar- na gis/Vectris posts with standard fiberglass posts. Int J Prosthodont. 2007;20(2):190-192. Conclusions 11. Mussano F, Rovasio S, Schierano G, Baldi I, Carossa S. The effect of glycine-powder airflow and hand instrumentation on peri-implant soft tissues: A split-mouth pilot study. Interna- The present case takes into account immediate load- io tional Journal of Prosthodontics. 2013;26(1):42-44. ing implants with full-arch fixed prosthesis placed in 12. Guler AU, Sumer M, Duran I, Sandikci EO, Telcioglu NT. Res- post-extraction sockets. The implant survival rate af- onance frequency analysis of 208 Straumann dental implants ter 12 months reaches 96%. during the healing period. Eur J Oral Implantol. 2013 az The 24 out of 25 successful implants in 5 patients Apr;39(2):161-167. show how using 4-6 implants (mostly 11-13 mm long) 13. Monje A, Suarez F, Garaicoa CA, Monje F, Galindo-Moreno guarantees sufficient anchorage for a fixed prosthesis P, García-Nogales A, Wang HL. Effect of location on primary stability and healing of dental implants. Implant Dent. 2014 and adequate distribution of the prosthetic load on rn Feb;23(1):69-73. the maxillary and mandible bones, without causing 14. Pettini F, Savino M, Corsalini M, Cantore S, Ballini A. Cy- implants failures. In conclusion: in maxillary bone and togenetic genotoxic investigation in peripheral blood lym- mandible’s post-extraction alveoli of totally edentu- phocytes of subjects with dental composite restorative fill- lous patients, it is possible to insert 4-6 immediate te ing materials. J Biol Regul Homeost Agents. 2015;29(1):229- loading implants equipped with angled abutment and 233. full-arch fixed prosthesis. Further clinical studies will 15. Huwiler MA, Pjetursson BE, Bosshardt DD, Salvi GE, Lang be needed to establish the long-term predictability of NP. Resonance frequency analysis in relation to jawbone In characteristics and during early healing of implant installa- this rehabilitative treatment. tion. Clin Oral Implants Res. 2007 Jun;18(3):275-280. Epub 2007 Mar 12. 16. Corsalini M, Carella M, Boccaccio A, Lamberti L, Pappalet- References tere C, Catapano S, Carossa S. An alternative approach to ni the polishing technique for acrylic resin surfaces. Int J 1. Aparicio C, Rangert B, Sennerby L. Immediate/early load- Prosthodont. 2008 Sep-Oct;21(5):409-412. ing of dental implants: a report from the Sociedad Españo- 17. Sim CP, Lang NP. Factors influencing resonance frequen- la de Implantes World Congress consensus meeting in cy analysis assessed by Osstell during implant tissue inte- io Barcelona, Spain, 2002. Clin Implant Dent Relat Res. gration: I. Instrument positioning, bone structure, implant 2003;5(1):57-60. length. Clin Oral Implants Res. 2010 Jun;21(6):598-604. 2. Malò P, Rangert B, Nobre M. “All-on-Four” immediate-func- 18. Sençimen M, Gülses A, Ozen J, Dergin C, Okçu KM, Ayyıldız iz tion concept with Braemark System implants for complete- S, Altuğ HA. A clinical study. Early detection of alterations ly edentulous mandibles: a retrospective clinical study. Clin in the resonance. Eur J Oral Implantol. 2011 Aug;37(4):411- Implant Dent Relat Res. 2003;5(Suppl 1):2-9. 419. 3. Maló P, de Araújo Nobre M, Lopes A, Francischone C, Rigoliz- Ed 19. Shokri M, Daraeighadikolaei A. Measurement of primary and zo M. “All-on-4” immediate-function concept for completely secondary stability of dental implants by resonance frequency edentulous maxillae: a clinical report on the medium (3 years) analysis method in mandible. Int J Dent. 2013;2013:506968. and long-term (5 years) outcomes. Clin Implant Dent Relat 20. Corsalini M, Carella M, Boccaccio A, Lamberti L, Pappalet- Res. 2012 May;14(Suppl 1):e139-150. tere C, Catapano S, Carossa S.An alternative approach to 4. Begg T, Geerts GAVM, Gryzagoridis J. Stress patterns around the polishing technique for acrylic resin surfaces. Int J distal angled implants in the all-on-four concept configura- Prosthodont. 2008;21(5):409-412. IC tion. Int J Oral Maxillofac Implants. 2009 Jul-Aug;24(4):663- 21. Grassi FR, Rapone B, Scarano Catanzaro F, Corsalini M, 671. Kalemaj Z. Effectiveness of computer-assisted anesthetic de- 5. Andersson P, Degasperi W, Verrocchi D, Sennerby L. A Ret- livery system (STA™) in dental implant surgery: a prospec- rospective Study on Immediate Placement of Neoss Implants tive study. Oral Implantology. 2017;10(4):381-389. ISSN:1974- with the Early Loading of Full-Arch Bridges. Clin Implant Dent 5648. Doi: 10.11138/orl/2017.10.4.381. C Relat Res. 2015 Aug;17(4):646-657. 22. Kalemaj Z, Scarano A, Valbonetti L, Rapone B, Grassi FR. 6. Grunder U. Immediate functional loading of immediate im- Bone response to four dental implants with different surface plants in edentulous arches: two-year results. Int J Peri- topography: a histologic and histometric study in minipigs. odontics Restorative Dent. 2001 Dec;21(6):545-551. Int J Periodontics Restorative Dent. 2016 Sep-Oct;36(5):745- © 7. Peñarrocha-Oltra D, Covani U, Peñarrocha-Diago M, Peñar- 754. Doi: 10.11607/prd.2719. rocha-Diago M. Immediate loading with fixed full-arch pros- 23. Rapone B, Nardi GM, Di Venere D, Pettini F, Grassi FR, theses in the maxilla: review of the literature. Med Oral Pa- Corsalini M. Oral hygiene in patients with oral cancer un- tol Oral Cir Bucal. 2014 Sep 1;19(5):e512-517. dergoing chemotherapy and/or radiotherapy after prosthesis 8. Burak Özcelik T, Ersoy E, Yilmaz B. Biomechanical evalu- rehabilitation: protocol proposal. Oral Implantol (Rome). ation of tooth- and implant-supported fixed dental prosthe- 2016 Dic ;9(Suppl 1):90-97. Doi: 10.11138/orl/2016. ses with various nonrigid connector positions: a finite element 9.1S.090. Annali di Stomatologia 2018;IX (2):91-96 95  V. Notaro et al. 24. Di Venere D, Pettini F, Nardi GM, Laforgia A, Stefanachi G, A. Quantitative analysis of defects at the dentin-post space Notaro V, Rapone B, Grassi FR, Corsalini M. Correlation be- in endodontically treated teeth. Materials. 2015;8,3268- tween parodontal indexes and orthodontic retainers: prospec- 3283. Published online 2015 Jun 4. Doi: 10.3390/ma tive study in a group of 16 patients. Oral Implantology. 2017 8063268. Apr 10;10(1):78-86. Doi: 10.11138/orl/2017.10.1.078. eCol- 28. Di Venere D, Corsalini M, Nardi GM, Laforgia A, Grassi FR, lection 2017 Jan-Mar. Rapone B, Pettini F. Obstructive site localization in patients 25. Corsalini M, Di Venere D, Rapone B, Stefanachi G, Lafor- with Obstructive Sleep Apnea Syndrome: a comparison be- li gia A, Pettini F. Evidence of signs and symptoms of Cran- tween otolaryngologic data and cephalometric values. Oral iomandibular Disorders in Fibromyalgia patients. The Open Implantology. 2017 Jul-Sep;10(3):295-310. Published online na Dent Journal. 2017;11:91-98. Published online 2017 Feb 14. 2017 Nov 30. Doi: 10.11138/orl/2017.10.3.295. Doi: 10.2174/1874210601711010091. 29. Fischer K, Bäckström M, Sennerby L. Immediate and ear- 26. Grassi FR, Pappalettere C, Di Comite M, Corsalini M, Mori ly loading of oxidized tapered implants in the partially G, Ballini A, Crincoli V, Pettini F, Rapone B, Boccaccio A. edentulous maxilla: a 1-year prospective clinical, radiographic, Effect of different irrigating solutions and endodontic seal- and resonance frequency analysis study. Clin Implant Dent io ers on bond strength of the dentin-post interface with and with- Relat Res. 2009 Jun;11(2):69-80. out defects. Int J Med Sci. 2012;9(8):642-654. Published on- 30. Sennerby L, Meredith N. Implant stability measurements us- line 2012 Sep 24. Doi: 10.7150/ijms.4998. ing resonance frequency analysis: biological and biome- 27. Di Comite M, Crincoli V, Fatone L, Ballini A, Mori G, chanical aspects and clinical implications. Periodontol 2000. az Rapone B, Boccaccio A, Pappalettere C, Grassi FR, Favia 2008;47:51-66. rn te In ni io iz Ed IC C © 96 Annali di Stomatologia 2018;IX (2):91-96 

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Case report Computer-guided bone lid osteotomy with piezosurgery li na Stefano Sivolella1 DDS, PhD surgical planning, enabling a safer and easier Giulia Brunello1,2 DDS procedure. Andrea Fincato1 DDS Luca De Stavola1 DMD, MOM Key words: bone lid, CAD-CAM, computer-guided io surgery, customized templates, cyst, piezo- surgery. 1 University of Padova, Department of Neuroscien- az ces, School of Dentistry, Padova, Italy 2 University of Padova, Department of Management Introduction and Engineering, Vicenza, Italy The removal of alveolar bone lesions or impacted rn tooth in the mandible may lead to extensive residual Corresponding author: bone defects, as a result of both the pathology or Giulia Brunello tooth itself and the ostectomy, which must guarantee Department of Neurosciences, School of Dentistry, an adequate access and visibility to the surgical field te University of Padova (1-3). Via Giustiniani 2 As alternative to the traditional ostectomy, the bone 35128 Padova, Italy; lid technique has been proposed as a valuable con- In Department of Management and Engineering, servative method for accessing alveolar bone dis- University of Padova eases (2,4). Briefly, this technique consists in fash- Stradella S. Nicola 3 ioning and removing a bone window, which is subse- 36100 Vicenza, Italy quently repositioned at the end of the surgery. The lid Tel.: 00390498212040 is then fixed in place with miniplates (1,4), transfixa- ni Fax: 00390498218229 tion screws (2), ligatures (5,6), or adhesive acrylic tis- E-mail: [email protected] sue (7). Rigid fixation may not be necessary in case of high stability of the repositioned bone lid (2). io As compared to the traditional approach, this tech- Summary nique provides better access and visibility to the sur- gical site, allows to restore the integrity of the bony iz Aim: The aim of this paper is to present a case of wall avoiding secondary bone defects due to access mandibular cyst in proximity to the left inferior osteotomies and, in cases of close proximity to the alveolar nerve and the adjacent teeth successfully alveolar nerve, allows to easily identify and protect Ed treated with computer-guided bone lid technique. the nerve reducing the risk of neurological damages Case presentation: A patient was referred to our (1, 3, 8). The osteotomy for designing the bony lid Department with an asymptomatic radiolucent le- can be performed with fissure burs (9), oscillating sion in the left mandible coinciding with the eden- saws (10), microsaws (2), or piezosurgery (1, 3, 4, 8). tulous site of a second premolar. The lesion was The use of the piezosurgery enables beveled, thin, confirmed using cone-beam computed tomo- and precise osteotomies, and facilitates the reposi- IC graphic imaging. Two tooth-supported computer- tioning and fixing of the bone lid (1). In addition, its aided design/computer-aided manufacturing guid- use is particularly indicated when the lesion is in ed surgical templates were designed and pro- proximity of delicate structures, such as the inferior duced to guide the piezoelectric tips on the alveolar nerve, considering its selective and soft tis- C planned osteotomy planes. The cystic lesion was sue sparing abilities, avoiding soft tissue injury also in accessed through a buccal bone lid fashioned us- cases of accidental contact with the cutting tip (8, 11). ing a piezoelectric device. The lesion was re- Beside the piezosurgery, computer-aided design and moved and the bone lid was returned to its origi- computer-aided manufacturing (CAD-CAM) can be © nal position and stabilized with fixation mi- used to advantage in the bone lid technique, as they croplates. have demonstrated their validity in various surgical Conclusions: Alveolar bone lesions can be treat- procedures requiring individually guided osteotomies ed successfully with bone lid techniques using (12-14). piezosurgery. Computer-guided bone surgery of- The aim of this case report is to describe the applica- fers the advantages of accurate and conservative tion of computer-guided surgery to controll the angle 84 Annali di Stomatologia 2018;IX (2):84-90  Computer-guided bone lid osteotomy with piezosurgery and depth of the osteotomy lines to use in fashioning The Digital Imaging and Communication in Medicine a bone lid. A mandibular cyst proximal to the (DICOM) datasets were processed with diagnostic mandibular canal and the adjacent teeth was treated and analytical software (3Diagnosys ® 4.0, using two complementary CAD-CAM templates. 3DIEMME®, Como, Italy). Anatomical structures such as the alveolar canal, the mental foramen, the mental nerve and the dental roots in the area of the lesion Case li were identified. Ideal bone cutting planes were de- fined (angle and depth) following specific targets, na 1) Case presentation which included: performing the osteotomies as close A healthy 52-year-old male patient was referred to our as possible to the roots of the adjacent teeth and the Department with a radiolucent lesion in the left mental foramen, while avoiding any contact with them mandible coinciding with the edentulous site of a sec- and not invading the periapical areas of the teeth; en- io ond premolar. The patient was clinically asymptomatic suring the maximal extension of the bone lid in rela- and the lesion was an incidental radiographic finding. tion to the bone disease; creating a long bevel along Preoperative cone-beam computed tomography the osteotomies; fashioning a bone lid of adequate (CBCT) (Fig. 1) revealed an unilocular radiolucent area thickness and area. The projections of the planned az with well-defined margins proximal to the mental fora- cutting planes defined the shape of the surgical guide men, mandibular canal and adjacent teeth. The lesion (Fig. 2). The template’s lateral contours guide the was surrounded by bony walls at least 1 mm thick. piezoelectric insert simply by applying pressure on it. The final guide design, including the anchorage to the rn 2) CAD-CAM workflow adjacent teeth, was shaped using a CAD software The CAD-CAM SafeCut® workflow (SafeCut®, Guid- (PlastyCAD, 3DIEMME®, Como, Italy). Two comple- edSurgery2.0 srl, Padova, Italy) was adopted (15,16). mentary surgical guides were planned to facilitate the te Figure 1. Panoramic view (a) and axial view (b) obtained In from the preoperative CBCT. An unilocular radiolucent area is detectable in the pos- terior left mandible in close proximity to the mandibular ni canal and mental foramen. io iz Ed IC C © Annali di Stomatologia 2018;IX (2):84-90 85  S. Sivolella et al. li na io az Figure 2. Preoperative osteotomy planning. The morphology of the surgical templates is designed so as to obtain os- teotomies at a safe distance about 1-1.5 mm from the adjacent teeth, the mental nerve, and the mandibular canal. The size rn of the bone lid was designed to be as ample as possible, avoiding the crestal area, for the placement of a delayed implant. surgical workflow, one for the upper osteotomy and Discussion and conclusion one for lateral and lower osteotomies. The surgical guides were made of medical polyamide by means of a CAM process (3Dfast srl, Padova, Italy). te Achievements in three-dimensional radiographic imaging techniques and computer technologies, to- In gether with advances in CAD-CAM techniques en- 3) Surgery able digital data from a surgical plan to be trans- Surgery was performed under local anesthesia and ferred to real clinical settings using computer-milled sedation. A full-thickness flap was reflected buccally templates or stereolithographic surgical guides (17). ni and adequate access to the alveolar bone lesion was The proposed method provided the means to control assured by means of a buccal bone lid. The surgical osteotomy design predictably and very safely and guides were inserted and stabilized by anchoring accurately, extending the applicability of the bone lid io them to a tooth. Piezosurgery ® (Mectron Medical technique to sites where there is a risk of damaging Technology, Carasco, Italy) was used in the bone anatomical structures. Tooth-supported surgical tem- mode with the UNIVR tip (Mectron, Italy). plates can be positioned easily, and enable an un- iz The osteotomies were completed by placing the side equivocal insertion. They allow adequate bone lid di- of the piezoelectric insert facing against the outer mensions to be obtained, thereby ensuring an ade- faces of the two surgical guides. The surgical tem- quate access to the alveolar bone lesion, and a clear Ed plates unequivocally defined the direction of the cut- identification of its extension during the surgical pro- ting action. The depth was established on volumetric cedure. Predetermined wide beveled margins can be image analysis. In accordance with the preoperative obtained, facilitating the repositioning of the bone lid plan, the mesial and distal cuts were made to a vari- and increasing the contact surface at the bone-to- able distance of 1-1.5 mm from the adjacent teeth, bone interface, which also improves the bone lid’s while the inferior cut was made at least 1.5 mm revascularization (1, 2, 4). The successful filling of a IC above the mental foramen (Fig. 3a-c). After its re- residual alveolar defect with bone relies mainly on moval (Fig. 3d), the bone lid was placed in sterile the achievement of a stable blood clot in a self-con- saline solution. The diseased tissue was removed tained chamber (18), and the bone lid technique (Fig. 3e) and the buccal bone lid was put back in its seems to favor this biological process. C original position and stabilized with 1.3 mm fixation The bone lid is usually repositioned and secured with microplates (Synthes GmbH, Oberdorf, Switzerland) fixation microplates. Pre-plating can be done during (Fig. 3f). The gingival flap was then put back in place the surgical procedure, before the bone lid is raised, and sutured. Postoperative CBCT scans revealed a or the microplates can be fashioned in advance on a © perfect match between the contours of the templates stereolithographic model (19). Alternatively, custom- and the osteotomic lines performed (Fig. 4). The made titanium CAD-CAM fixation plates can be man- histopathological findings were consistent with a ufactured (13). residual cyst. No complication occurred. Bone lid Computer-guided implant surgery is rapidly develop- healing and bone defect filling were assessed 1 year ing and expanding (17). The use of customized CAD- after surgery on radiological follow-up (Fig. 5). CAM surgical cutting guides has been described in 86 Annali di Stomatologia 2018;IX (2):84-90  Computer-guided bone lid osteotomy with piezosurgery a b li na io c d az rn te In e f ni io iz Ed Figure 3. Surgical procedures. The two complementary surgical guides are shown in (a) and (b). (a) The first surgical guide is inserted and stabilized on the adjacent teeth. Inferior and lateral osteotomies are cut with the side of the piezoelectric in- sert (UNIVR) facing against the external inferior and vertical faces of the surgical guide; (b) the second guide is then insert- ed and the upper osteotomy is performed in much the same way; (c) mandibular buccal bone lid fashioned using piezo- surgery, prior to its detachment; (d) adequate access to the alveolar bone lesion is assured; (e) Residual alveolar bone de- IC fect after removal of the lesion. The mental nerve is clearly intact; (f) the buccal bone lid is put back in place and fixed with microplates. C orthognathic procedures too (12,13,19). Milano et al. In the bone regeneration field, Felice et al. (14) re- (20) reported using the piezocision technique as a ported using guided osteotomies in sandwich tech- combination of micro-incisions and localized piezo- niques and inlay block procedures in the posterior at- electric bone surgery to accelerate orthodontic treat- rophic mandible: they used a customized CAD-CAM © ment in adult patients. Piezocision was combined polymethyl methacrylate surgical template obtained with the use of computed tomography. The depth and by milling. The Authors’ proposed surgical guide location of the corticotomies were planned on a three- helped the surgeon to identify the most appropriate dimensional model of the arch, and a surgical guide osteotomic path on the bone surface, but no 3D infor- was fashioned and used during the procedure to mation was provided on the axes of the cutting avoid damaging the dental roots. planes. Annali di Stomatologia 2018;IX (2):84-90 87  S. Sivolella et al. a li na io az b rn te In ni io iz Figure 4. The first (a) and second (b) templates superimposed on the postoperative CBCT. The osteotomies coincide well with the templates’ surfaces. Ed Also autogenous mandibular bone harvesting apply- In Kocyigit et al. (22), different piezosurgery tips ing computer-guided surgery was described. As in were used for performing the osteotomies, for cyst the present work, bone osteotomy planes were de- enucleation and apicoectomy, when required. No fined beforehand in order to produce a surgical guide, complication occurred in any of the patients treated which imposed the 3D working direction to the bone- using piezosurgery for radicular cyst enucleation; in- cutting instrument (15,16). stead in the conventional surgery group, complica- IC As for implant surgery, time has to be spent on pre- tions were reported, including intraoperative and operative planning (17), and it is not easy to estimate postoperative bleeding, perforation of the cyst ep- the cost-effectiveness of this approach by compari- ithelium and difficulties in its complete removal, and son with conventional surgery, with or without bone recurrence. C lids. In a case of giant dentigerous cyst associated with The use of piezosurgery for the treatment of alveolar an ectopic maxillary third molar (23), several piezo- bone cysts has been described (21-23). surgery tips were successfully used for sinus win- In a randomized clinical study comparing piezo- dow osteotomy, for the atraumatic dissection of the © surgery and conventional rotatory surgery for the cyst and for the extraction of the impacted tooth. enucleation of mandibular cysts, no lesion of the The bone lid technique has been validated as a mandible nerve was detected when piezosurgery was method for preserving alveolar bone (2,4), so every used in combination with the bone lid technique. Con- effort should be made to improve this technique, in- ventional surgery with rotary instruments resulted in cluding CAD-CAM applications based on 3D imag- 8% hypesthesia at least up to one week (21). ing. 88 Annali di Stomatologia 2018;IX (2):84-90  Computer-guided bone lid osteotomy with piezosurgery Figure 5. CT scan, axial view, 1 year after surgery. The bone lid is integrated and no residual bone de- fect is detectable. Fixation screws and miniplates are in place. li na io az rn Conflict of interest te 2. Khoury F. The bony lid approach in pre-implant and implant surgery: a prospective study. Eur J Oral Implantol. 2013;6:375- In 384. The Authors have no financial or personal relation- 3. Chiapasco M, Flora A, Serioli L, Zaniboni M. The removal ships with people or organizations that might inappro- of deeply impacted lower third molars by means of the bone priately bias their work. lid technique with piezoelectric instruments. Italian Journal of Dental Medicine. 2017;2:13-17. ni 4. Sivolella S, Brunello G, Berengo M, De Biagi M, Bacci C. Re- Acknowledgments habilitation with implants after bone lid surgery in the pos- terior mandible. J Oral Maxillofac Surg. 2015;73:1485- The Authors LDS and AF are the inventors of the 1492. io 5. Biglioli F, Chiapasco M. An easy access to retrieve dental PCT/IB2014/061624 “Method for making a surgical implants displaced into the maxillary sinus: the bony window guide for bone harvesting” described in this technique. Clin Oral Implants Res. 2014;25:1344-1351. manuscript. iz 6. Lazaridis N, Tilaveridis I, Venetis G, Lazaridou M. Maxillary sinus osteoplasty with vascularized pedicled bone flap. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:828- Ethical statement/confirmation of patients’ 832. Ed permission 7. Balleri P, Veltri M, Nuti N, Ferrari M. Implant placement in combination with sinus membrane elevation without bio- The Authors confirm that the patient was fully in- materials: a 1-year study on 15 patients. Clin Implant Dent Relat Res. 2012;14:682-689. formed about his condition and consented to the clini- 8. Degerliyurt K, Akar V, Denizci S, Yucel E. Bone lid technique cal and surgical procedures performed, which includ- with piezosurgery to preserve inferior alveolar nerve. Oral Surg ed taking photographs of the lesions and procedures. IC Oral Med Oral Pathol Oral Radiol Endod. 2009;108:e1-5. The Authors confirm that any personal details con- 9. Choi BH, Yoo JH, Sung KJ. Radiographic comparison of os- cerning the patient occurring in any part of the paper seous healing after maxillary sinusotomy performed with and or supplementary materials were removed prior to without a periosteal pedicle. Oral Surg Oral Med Oral submission. Authors declare that the described pro- Pathol Oral Radiol Endod. 1996;82:375-378. C cedures comply with the World Medical Association 10. Choung PH, Choung YH. Vascularized bone flap for access to the maxillary sinus. J Oral Maxillofac Surg. 1997;55:832- Declaration of Helsinki on medical research protocols 835. and ethics. 11. Vercellotti T. Piezoelectric surgery in implantology: a case © report - a new piezoelectric ridge expansion technique. Int J Periodontics Restorative Dent. 2000;20:358-365. References 12. Li B, Zhang L, Sun H, Yuan J, Shen SG, Wang X. A novel method of computer-aided orthognathic surgery using indi- 1. Sivolella S, Brunello G, Fistarol F, Stellini E, Bacci C. The vidual CAD/CAM templates: a combination of osteotomy and bone lid technique in oral surgery: a case series study. Int repositioning guides. Br J Oral Maxillofac Surg. 2013;51:e239- J Oral Maxillofac Surg. 2017;46:1490-1496. e244. Annali di Stomatologia 2018;IX (2):84-90 89  S. Sivolella et al. 13. Mazzoni S, Bianchi A, Schiariti G, Badiali G, Marchetti C. 18. Ettl T, Gosau M, Sader R, Reichert TE. Jaw cysts - filling or Computer-aided design and computer-aided manufacturing no filling after enucleation? A review. J Craniomaxillofac Surg. cutting guides and customized titanium plates are useful in 2012;40:485-493. upper maxilla waferless repositioning. J Oral Maxillofac Surg. 19. Bai S, Shang H, Liu Y, Zhao J, Zhao Y. Computer-aided de- 2015;73:701-707. sign and computer-aided manufacturing locating guides ac- 14. Felice P, Barausse C, Pistilli R, Spinato S, Bernardello F. companied with prebent titanium plates in orthognathic Guided “sandwich” technique: a novel surgical approach for surgery. J Oral Maxillofac Surg. 2012;70:2419-2426. li safe osteotomies in the treatment of vertical bone defects in 20. Milano F, Dibart S, Montesani L, Guerra L. Computer-guid- the posterior atrophic mandible: a case report. Implant Dent. ed surgery using the piezocision technique. Int J Periodon- na 2014;23:738-744. tics Restorative Dent. 2014;34:523-529. 15. De Stavola L, Fincato A, Albiero AM. A computer-guided bone 21. Pappalardo S, Guarnieri R. Randomized clinical study block harvesting procedure: a proof-of-principle case report comparing piezosurgery and conventional rotatory surgery and technical notes. Int J Oral Maxillofac Implants. 2015; in mandibular cyst enucleation. J Craniomaxillofac Surg. 30:1409-1413. 2014;42:e80-85. io 16. De Stavola L, Fincato A, Bressan E, Gobbato L. Results of 22. Kocyigit ID, Atil F, Alp YE, Tekin U, Tuz HH. Piezosurgery Computer-Guided Bone Block Harvesting from the Mandible: versus conventional surgery in radicular cyst enucleation. J A Case Series. Int J Periodontics Restorative Dent. 2017; Craniofac Surg. 2012;23:1805-1808. 37:e111-e119. 23. Marini E, Marini L, Messina AM. Treatment of giant max- az 17. Hultin M, Svensson KG, Trulsson M. Clinical advantages of illary dentigerous cyst and ectopic third molar with piezo- computer-guided implant placement: a systematic review. Clin electric surgery. Italian Journal of Dental Medicine. 2017; Oral Implants Res. 2012;23:124-135. 2:131-136. rn te In ni io iz Ed IC C © 90 Annali di Stomatologia 2018;IX (2):84-90 

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Original article Effect of heat treatment on the cyclic fatigue resistance of NiTi endodontic openers li na Dario Di Nardo DDS, PhD Introduction Antonio Morese DDS Valerio Ferri DDS The introduction of nickel-titanium (NiTi) alloy for rotary io Federico Valenti Obino DDS endodontic instruments improved the clinical skills in Marco Seracchiani DDS root canal treatment, making it safer and more pre- Luca Testarelli DDS, PhD dictable (1-3). NiTi alloy allowed the manufacturers to az produce instruments with a greater mass and taper than the stainless-steel instruments: this resulted in a Department of Oral and Maxillofacial Sciences, more predictable clearness for the root canal system “Sapienza” University of Rome, Rome, Italy (4, 5). The continuous motion guaranteed a higher cut- rn ting ability than the balanced force motion used with the stainless-steel instruments (6-8). Despite the improved performance of rotary instru- Corresponding author: ments, their relatively higher speed of rotation may te Antonio Morese lead to an intracanal separation of the endodontic in- Department of Oral and Maxillofacial Sciences strument (9-11). Quality of the alloy, manufacturing Via Caserta 6 defects, and cyclic stress accumulation are involved 00161 Rome, Italy In in intracanal leakage of endodontic instruments (12- Tel.: +39 366 1905474 14). Intraoperational strain affect the integrity of the E-mail: [email protected] alloy produces microcracks which grow at every ro- tating cycle of the instrument. Microcracks may lead to intracanal separation after certain cycles and this ni Summary is an unavoidable aspect after prolonged use (15-18). Aim of the present study is to evaluate if a propri- Aim: Aim of the present study is to evaluate if a etary thermal treatment could increase the resistance io thermal treatment adopted for endodontic NiTi in- to cyclic fatigue of a high tapered endodontic instru- struments could increase their cyclic fatigue lifes- ment. pan. iz Methods: 25 thermally treated One Flare (MM, Be- sancon, France) and 25 non-thermally treated En- Materials and methods do Flare (MM, Besancon, France) were mechani- Ed cally rotated in a precurved artificial canal until 25 Endo Flare (MicroMega, Besancon, France), tip fracture. Differences between Time to Fracture diameter #25, taper 12%, length 15 mm, and 25 One (TTF) and Fragment Length (FL) were statistically Flare (MicroMega, Besancon, France), tip diameter analyzed (Student’s t test, (p<0.05). #25, taper 9%, length 17mm were tested (n=50). Results: One Flare’s time to fracture (47.24 sec- A validated cyclic fatigue testing device was adopted onds; SD±4.24) was significantly longer when to evaluate time to fracture at known conditions (19- IC compared to Endo Flare’s (21.2 seconds; 20). The electric handpiece was mounted on a mo- SD±3.08) at the same operating conditions bile device to allow reproducible placement of each (p<0.005). Differences between the length of frac- instrument inside the artificial canal to the same tured segments showed no statistical signifi- depth. The artificial canal had a 60° angle of curva- C cance differences (p>0.005). ture and 5 mm radius of curvature. All the instru- Conclusions: Heat treated NiTi alloy showed an ments were inserted at the same length and then ro- improved time to fracture when compared to a tated at 350 rpm with maximum torque until fracture non-thermally treated one at the same operating occurred. For each instrument, the time to fracture © conditions. Thermal treatments could enhance was recorded with a 1/100 sec chronometer. All frag- the characteristics of NiTi improving the lifespan ments were collected and measured. For each of rotary endodontic instruments. group, mean and standard deviation were calculated. Differences among groups were statistically exam- Key words: heat treatment, Endo Flare, One Flare, ined using the Student’s t test (significance level was nickel-titanium, endodontic instruments. set at p<0.05). Data was statistically analyzed using 24 Annali di Stomatologia 2018;IX(1):24-26  Effect of heat treatment on the cyclic fatigue resistance of NiTi endodontic openers the SPSS 13.0 software (SPSS Incorporated, Chica- Discussion go, IL, USA). The thermal treatment applied to the NiTi rotary in- struments allowed changes in the metallurgical Results phase at environmental temperature. At higher tem- li perature the NiTi alloy is in austenitic phase, at lower Results from the cyclic fatigue tests are shown in temperature it is in martensitic phase and at average na Table 1 and Figure 1. Mean values of time to fracture temperature the alloy is in R phase. Thermal treat- for Endo Flare instruments were 21.2 seconds ments allow the achievement of improved qualities (SD±3.08) and were 47.24 seconds (SD±4.24) for for the rotary instruments, such as superelasticity One Flare. Different time to fracture between groups and shape memory (21). The vacuum casting of an showed statistical significance (p<0.005). ingot, hot molding, rolling and cold drawing followed io Mean values for fragment length for Endo Flare in- by heat treatment are typical applied processes for struments were 6 mm (SD±0.8) and for One Flare the NiTi wires. The thermal treatment applied to the were 7 mm (SD±0.8). No statistically significant dif- rotary instrument is usually under patent. Usually, in- az ferences were found between fragment lengths struments are brought to high temperature, between (p>0.005). 450° and 550° degrees, in furnaces that can work in controlled atmosphere or air. This kind of thermal treatment allows an increase in the instrument per- rn formances, reaching the superelastic or the shape memory characteristics (22). Thermal treatments dra- Table 1. Time to Fracture (TtF) in seconds (s) and length matically affect the in vitro instruments’ performance, resulting in an increased cyclic fatigue resistance. te (mm) of fractured fragments (FL). Geometrical design, rotary motion and thermal treat- Endo Flare One Flare ment of the alloy could improve the characteristics of the endodontic instrument (19-24). Superelastic and Group Mean SD Mean SD In shape memory characteristics could be reached TtF (s) 21.2 3.08 47.24 4.24 treating the alloy at certain temperatures at con- trolled atmosphere (15). FL (mm) 6 0.8 7 0.8 The orifice opener is a high tapered instrument used for the enlargement of the coronal third of the en- ni dodontic canal (flaring) due to facilitate irrigation and the penetration of the subsequent instrument (25). Flexibility of One Flare is higher therefore, it may also io allow a safer and more predictable clinical usage. The One Flare seems to be mostly indicated for ob- taining straight access to constricted orifice and\or iz bad positioned orifice. Due to its flexibility and duc- tility, One Flare presents a lower risk of canal perfo- ration and/or stripping. Endo Flare presents a 12% Ed taper, this makes the instrument harder and less flexible when compared to One Flare. In addition, no thermal treatments were applied to its alloy and this could represent a detriment for its cyclic fatigue lifes- pan (26). High tapered instruments should be thermally treated IC to improve their resistance to fracture, contrasting the minor flexibility and ductility given by the in- creased mass of alloy. Data obtained in this study are in accordance with previous studies which en- C lightened the importance of heat treatments in im- proving NTRIs’ resistance to breakage (12, 15, 18, 24, 26). © Conclusions MM proprietary thermal treatment applied at One Flare improves the resistance to cyclic fatigue, allow- ing a safer use by the clinician compared to the non- Figure 1. One Flare vs Endo Flare time to fracture box plot. thermally treated Endo Flare. Apply a thermal treat- Annali di Stomatologia 2018;IX(1):24-26 25  D. Di Nardo et al. ment in manufacturing NiTi endodontic rotary instru- 12. Capar ID, Ertas H, Arslan H. Comparison of cyclic fatigue ments may improve mechanical properties and lifes- resistance of novel nickel-titanium rotary instruments. Aust Endod J. 2015;41:24-28. pan rather than conventionally processed NiTi instru- 13. Gambarini G, Plotino G, Sannino GP, Grande NM, Gian- ments. siracusa A, Piasecki L, et al. Cyclic fatigue of instruments for endodontic glide path. Odontology. 2015;103:56-60. li 14. Plotino G, Costanzo A, Grande NM, Petrovic R, Testarelli L, Declaration of conflicting interests Gambarini G. Experimental evaluation on the influence of au- na toclave sterilization on the cyclic fatigue of new nickel-tita- The Authors deny any conflict of interest. nium rotary instruments. J Endod. 2012;38:222-225. 15. Zinelis S, Darabara M, Takase T, Ogane K, Papadimitriou GD. The effect of thermal treatment on the resistance of nick- el-titanium rotary files in cyclic fatigue. Oral Surg Oral Med References io Oral Pathol Oral Radiol Endod. 2007;103:843-847. 16. Plotino G, Grande NM, Mazza C, Petrovic R, Testarelli L, 1. Kwak SW, Cheung GS, Ha JH, Kim SK, Lee H, Kim HC. Pref- Gambarini G. Influence of size and taper of artificial canals erence of undergraduate students after first experience on on the trajectory of NiTi rotary instruments in cyclic fatigue az nickel-titanium endodontic instruments. Restor Dent Endod. studies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2016;41:176-181. 2010;109:60-66. 2. Rubini AG, Plotino G, Al-Sudani D, Grande NM, Putorti E, 17. Gambarini G, Gergi R, Grande NM, Osta N, Plotino G, Sonnino G, et al. A new device to test cutting efficiency of Testarelli L. Cyclic fatigue resistance of newly manufactured mechanical endodontic instruments. Med Sci Monit. 2014; rn rotary nickel titanium instruments used in different rotation- 20:374-378. al directions. Aust Endod J. 2013;39:151-154. 3. Al-Sudani D, Grande NM, Plotino G, Pompa G, Di Carlo S, 18. Braga LC, Faria Silva AC, Buono VT, de Azevedo Bahia MG. Testarelli L, Gambarini G. Cyclic fatigue of nickel-titanium ro- Impact of heat treatments on the fatigue resistance of different tary instruments in a double (S-shaped) simulated curvature. te rotary nickel-titanium instruments. J Endod. 2014;40:1494- J Endod. 2012;38:987-989. 1497. 4. Ebihara A, Yahata Y, Miyara K, Nakano K, Hayashi Y, Suda 19. Gambarini G, Gergi R, Naaman A, Osta N, Al Sudani D. Cyclic H. Heat treatment of nickel-titanium rotary endodontic in- fatigue analysis of twisted file rotary NiTi instruments used struments: effects on bending properties and shaping abil- ities. Int Endod J. 2011;44:843-849. In in reciprocating motion. Int Endod J. 2012;45:802-806. 20. Gambarini G, Tucci E, Bedini R, Pecci R, Galli M, Milana V, 5. Testarelli L, Plotino G, Al-Sudani D, Vincenzi V, Giansiracusa et al. The effect of brushing motion on the cyclic fatigue of A, Grande NM, Gambarini G. Bending properties of a new rotary nickel titanium instruments. Annali dell’Istituto Supe- nickel-titanium alloy with a lower percent by weight of nick- riore di Sanità. 2016;46:400-404. el. J Endod. 2011;37:1293-1295. ni 21. Hou X, Yahata Y, Hayashi Y, Ebihara A, Hanawa T, Suda 6. Plotino G, Giansiracusa Rubini A, Grande NM, Testarelli L, H. Phase transformation behaviour and bending property of Gambarini G. Cutting efficiency of reciproc and waveone re- twisted nickel-titanium endodontic instruments. Int Endod J. ciprocating instruments. J Endod. 2014;40:1228-1230. 2011;44:253-258. io 7. Gambarini G, Pongione G, Rizzo F, Testarelli L, Cavalleri G, 22. Shen Y, Zhou HM, Zheng YF, Peng B, Haapasalo M. Cur- Gerosa R. Bending properties of nickel-titanium instruments: rent challenges and concepts of the thermomechanical treat- a comparative study. Minerva stomatologica. 2008;57:393- ment of nickel-titanium instruments. J Endod. 2013;39:163- 398. iz 72. 8. Di Fiore PM, Genov KA, Komaroff E, Li Y, Lin L. Nickel-ti- 23. Plotino G, Grande NM, Cotti E, Testarelli L, Gambarini G. tanium rotary instrument fracture: a clinical practice as- Blue treatment enhances cyclic fatigue resistance of vortex sessment. Int Endod J. 2006;39:700-708. Ed nickel-titanium rotary files. J Endod. 2014;40:1451-1453. 9. Gambarini G, Giansiracusa Rubini A, Sannino G, Di Gior- 24. Pereira ES, Peixoto IF, Viana AC, Oliveira II, Gonzalez BM, gio G, Piasecki L, Al-Sudani D, et al. Cutting efficiency of nick- Buono VT, et al. Physical and mechanical properties of a ther- el-titanium rotary and reciprocating instruments after prolonged momechanically treated NiTi wire used in the manufacture of use. Odontology. 2016;104:77-81. rotary endodontic instruments. Int Endod J. 2012;45:469-474. 10. Parashos P, Messer H. Rotary NiTi instrument fracture and 25. Arslan H, Karatas E, Capar ID, Ozsu D, Dogonay E. Coro- its consequences. J Endod. 2006;32:1031-1043. nal Flaring Instruments and Dentinal Crack. J Endod. 11. Plotino G, Grande NM, Cordaro M, Testarelli L, Gambarini IC 2014;40:1681-1683. G. Measurement of the trajectory of different NiTi rotary in- 26. Miccoli G, Gaimari G, Seracchiani M, Morese A, Khrenova struments in an artificial canal specifically designed for cyclic T, Di Nardo D. In vitro resistance to fracture of two nickel- fatigue tests. Oral Surg Oral Med Oral Pathol Oral Radiol En- titanium rotary instruments made with different thermal treat- dod. 2009;108:152-156. ments. Ann Stomatol. 2017;8:53-58. C © 26 Annali di Stomatologia 2018;IX(1):24-26 

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Original article Factors influencing consideration of dental specialisation: a survey of current dental students at the University of Western Australia li na Anthony Giummarra1 DMD Conclusions. Findings highlight that a small pro- Keenan Inderjeeth1 DMD portion of students want to pursue specialisation Dina Celebic1 DMD and the majority of students are unaware of the io Zi Lin Sun1 DMD speciality courses available in Western Australia. Julio Cesar Rincon1 DMD This emphasises the need for greater exposure Iole Vozza DDS, PhD2 and education in dental specialties. Further re- az Alessandro Quaranta3 DDS, PhD search is advised in this field to better understand factors involved in the pathway to dental speciali- sation and how to encourage specialisation. 1 Private practice, Research Program in Oral rn Implantology and Periodontics, Dental School, Key words: dental, specialisation, factors, stu- The University of Western Australia, dents, survey questionnaire. Crawley, Australia 2 Adjunct Professor, Dental School, Department of te Oral and Maxillofacial Sciences, “Sapienza” Introduction University of Rome, Rome, Italy 3 Associate Professor, Dental School, The University The dental workforce is an important healthcare re- of Western Australia, Crawley, Australia In source that allows dentists, through education, diag- nosis and treatment, to provide the public with an essential health service. There are over 15,000 den- Corresponding author: tists in Australia, with 10% of those working as spe- Iole Vozza cialist dentists (1). Dental specialists are trained as ni Department of Oral and Maxillofacial Sciences general practitioners in dentistry but have additional “Sapienza” University of Rome qualifications and experience within a chosen field. Via Caserta 6 In Australia, specialist education and training with io 00161 Rome, Italy Australian Dental Council (ADC) accreditation is of- E-mail: [email protected] fered in 12 specialities (2). Specialists play a key role in maintaining clinical excellence and in providing iz leadership in dentistry. As such, the monitoring and Summary surveillance of dental specialists is imperative as it can provide information about specialist training and Ed Aim. At present, little research exists regarding assist in improving the geographic reach of special- factors that influence dental students and recent ists, especially in supporting primary care (3, 4) In or- graduates to pursue specialist training. Through der to cater for the replacement of retiring specialist the provision of a questionnaire, the study investi- dentists and population growth, adequate training gated student’s perceptions of dental specialities programs aim to maintain the availability of specialist and factors impacting specialisation. dentists within Australia. Furthermore, there is a con- IC Methods. Questionnaires (n=65) were undertaken tinuing need to ensure dental students are well-in- by Doctor of Dental Medicine students in year formed and guided in their decision to pursue spe- three (n=34) and four (n=31) through paper cialist training. means. An analysis was undertaken of the knowl- At present, there is little research regarding the fac- C edge of speciality courses, speciality preferences tors that influence dental students and recent gradu- and the main motivating and deterring factors in- ates to progress into specialist training pathways fluencing specialisation. and postgraduate dental study. A comprehensive re- Results. A response rate of 70% was observed, view of the literature revealed that there were no © revealing that 13% of all participants correctly specific reports on Australian dental students or den- identified the speciality courses available in West- tist’s perceptions of dental specialties. Several stud- ern Australia, with 6% of students wanting to spe- ies have been conducted in the United States to ex- cialise in the long term. Altruistic factors were plore the various reasons dental students chose to most motivating and financial most deterring enter the profession and their subsequent career ex- when considering specialisation. Speciality pref- pectations (5-10). Additional literature exploring erences also varied between cohorts. these factors has been published about dental stu- Annali di Stomatologia 2018;IX(1):27-34 27  A. Giummarra et al. dents in the United Kingdom, Saudi Arabia, United The survey instrument covered the following four ar- Arab Emirates, Thailand, Japan and Sweden (11-14). eas: Demographics, Long-term career goals, Knowl- A small set of additional studies has investigated the edge of specialty Fields, and Factors Affecting future perceptions of dental specialities, influencing factors Specialisation. In the fourth section, Factors affect- on speciality choice and long-term career plans (15- ing future specialisation, participants chose from a li 20). The critical role of dental specialists presents the list of factors known to influence pursuit of postgrad- need to explore these factors in an Australian con- uate specialist studies and future career choices. na text as there is currently a gap in the literature. Students rated the factors on a three point Likert The aim of this paper is to determine which factors scale; motivating, deterring or neutral. The factors motivate and deter current dental students and re- were grouped into four major categories: Financial, cent graduates (within the last two years) at the Uni- Altruistic, Professional and Personal factors which versity of Western Australia (UWA) from pursuing may influence their decision towards dental speciali- io specialisation in the future. Findings from this re- sation. search aim to provide specialists and course con- All hard copy records are kept in a locked cupboard veners at the UWA Dental School with valuable infor- at all times within academic staff offices at the UWA az mation to facilitate specialisation pathways. Further- Dental School. It is only available to the research more, as it is the first study of its kind in Australia, it team and will be retained for a minimum of 7 years. may serve as a pathway for future research regarding All digital records are unidentifiable and kept on factors motivating postgraduate dental students and UWA servers which are protected by user login per- rn newly qualified dentists to consider dental speciali- missions. sation. All participants were given a clear option to opt in or out of the study. They were given a clear explanation of the research aim, objectives and how the data will te Material and methods be used. Consent forms were given to current stu- dents who chose to participate whilst the consent The study design was a cross sectional qualitative forms were combined in the online survey for alumni study aimed at current students and recently gradu- In participants. ated alumni at the University of Western Australia. Data analysis was undertaken to identify the moti- Human ethics approval from the University of West- vating and deterring factors influencing considera- ern Australia was obtained prior to commencement tion to specialise. As such, a combination of de- ni of data collection (27/2/17: RA/4/1/8817). Two forms scriptive and inferential statistics was utilised to as- of data collection were utilized; a voluntary anony- certain knowledge of specialty courses, specialty mous paper questionnaire for the third (n=52) and preferences and the main motivating and deterring fourth (n=41) year students of the Doctor of Dental io factors influencing specialisation. a univariate Medicine (DMD) program, and an online question- analysis was undertaken to present an overview of naire tool, Qualtrics®, for the two alumni classes of findings from the study. 2014 and 2015 (combined n=140). Initially, a single iz trial survey was distributed to the Doctor of Clinical Dentistry (DCD) students to provide feedback re- Results garding ambiguity and possible misinterpretation of Ed questions. Following this, the final, revised survey The questionnaire was completed by 65 DMD stu- was distributed in June 2017, where third and fourth dents out of a possible 93 dental students (52 DMD3 year DMD students were approached after lectures students and 41 DMD4 students). Though the total with a paper questionnaire to complete. Alumni were response rate was 70% across DMD3 and DMD4, contacted with aid of the UWA Alumni Society, via not all questionnaires were completed in full. Ques- email with a Qualtrics® survey link. This was neces- tions which were answered incorrectly or left blank IC sary to protect the identities of participants. Both were voided from the study. The survey had a 0% re- surveys were voluntary and anonymous. Our partici- sponse rate from alumni. pants were chosen as a convenience sample, which allowed for a range of experiences regarding choic- Demographics: The study sample consisted of 34 C es, preferences, and motivations to be investigated. students from third year DMD (DMD3) and 31 stu- Through an analysis of current literature, examples of dents from fourth year DMD (DMD4). Of the 65 stu- survey questions and survey formats were explored dents, there were 32 males (49%) and 33 females and modified for use in this study. Analysis of ques- (51%). The majority of participants were science © tions for relevance were then shortlisted and fi- graduates (n=55, 85%) and the prevalent age group nalised before being presented to the supervisor. amongst participants was “20-24 years old” (n=30, The questions were modified and tailored to an Aus- 46%). The survey found that 54 out of the 65 partici- tralian audience, then grouped to increase statistical pants (83%) had previously obtained a bachelor de- significance of results. gree as their high level of education (Tab. 1). 28 Annali di Stomatologia 2018;IX(1):27-34  Factors influencing consideration of dental specialisation: a survey of current dental students at the University of Western Australia Table 1 - Demographics Table. Long term career goals: The number of respondents who indicated that they wanted to specialise long Class Year DMD3 34 term was 6% (n=4). Additionally, the survey revealed DMD4 31 five participants were considering applying to a post- graduate specialty course. The survey found that li 42% participants (n=27) showed a long-term career Gender Male 32 goal of becoming a general dentist while 52% (n=34) na Female 33 showed a long-term career goal of being a general dentist with a specialty interest (Fig. 1). Previous Science Knowledge of specialty courses: The survey found Degree Non-Science 55 that 51% of respondents (n=33) believed that they io 10 were aware of current specialisation courses of- fered in Western Australia. In addition, 45% (n=29) Age Group 20-24 years 30 stated they were somewhat aware whilst 3% of stu- az 25-29 years 27 dents (n=2) were not aware of the courses avail- 30-34 years 5 able. The results demonstrated that 84% of respon- 35+ years 3 dents (n=56) were incorrect when asked to identify what specialty courses are currently available in rn Western Australia, with only 13% (n=9) correctly re- Marital Single 42 sponding. Two surveys had incomplete responses Status Married 4 for this section and thus they were voided from the results (Fig. 2). te Non-Married 19 Furthermore, the number of students who had dis- Other 0 cussed a speciality interest with their mentor, super- visor or specialist varied between the dental student Education Bachelor 54 In cohorts with 80% of DMD3 students and 19% of Attained Honours 9 DMD4 students stating they had enquired about spe- cialisation. Masters 0 Specialty preferences: The specialty preferences var- ni Doctorate 0 PhD 2 ied between DMD3 and DMD4 as per Figure 3 and Figure 4. Orthodontics was the most preferred spe- cialty (24%) in DMD3 whilst Oral and Maxillofacial io Location WA 34 50 Surgery was the most preferred specialty (29%) Interstate Metropolitan 7 amongst DMD4. No students in either cohort had se- lected Oral Pathology and Radiology as their most iz International 23 Rural 8 preferred specialty. Ed Figure 1. Long term career goals. IC C © Annali di Stomatologia 2018;IX(1):27-34 29  A. Giummarra et al. Figure 2. Knowledge of specialty courses available in UWA. li na io az rn te In ni io iz Ed IC Figure 3. DMD3 Specialisation preferences. C Factors influencing future specialisation: The factors in- (n=172 out of 384 responses) or motivating (n=201 out fluencing specialisation were grouped into the follow- of 384 responses). Personal factors had most respons- ing four groups: Professional, Financial, Altruistic and es as neutral (n=224 out of 384 responses). Overall, the Personal Factors. These were charted on a Likert scale factors which the most number of participants found to © of motivating, deterring or neutral (Fig. 5). Professional be deterring were financial whilst the factors found to factors were found to be either neutral (n=171 out of be the most motivating were altruistic factors. The 384 responses) or motivating (n=166 out of 384 re- question which was the most deterring factor amongst sponses) amongst the sample group. Financial factors students was the “financial impact of returning to were found to be predominantly neutral when influenc- study” whilst the question determined to be the most ing specialisation (n=169 out of 384 responses) whilst motivating factor was the altruistic factor of “providing altruism related factors were predominantly neutral a service to the community”. 30 Annali di Stomatologia 2018;IX(1):27-34  Factors influencing consideration of dental specialisation: a survey of current dental students at the University of Western Australia li na io az rn te Figure 4. DMD4 Specialisation preferences. In ni io iz Ed IC C Figure 5. Factors influencing future specialization. Discussion tors which motivated these students is important in © understanding student’s pathways to specialisation. Long-term career goals As only a small number of participants in this survey The number of students who indicated that they had a view to specialise, this limits any significant had a long-term goal to specialise was only 6% of analysis of factors which may have influenced their respondents (n=4) whilst five participants (8%) stat- decision to consider specialisation. Nevertheless, ed they had an interest in applying to a Doctor of the proportion of our sample group that indicated a Clinical Dentistry (DCD) course. Analysing the fac- desire to specialise was found to be comparable Annali di Stomatologia 2018;IX(1):27-34 31  A. Giummarra et al. with the current specialist workforce within Australia. Specialty preferences There are over 15 000 dentists in Australia with 10% Specialty preferences differed between third and of those working as a specialist dentist (1). fourth year DMD students. Oral and Maxillofacial Thirty-four participants (52%) indicated they had a surgery was the most popular specialty chosen by long-term career goal of becoming a general practi- DMD (n=8, 29%), whereas DMD3 students ranked li tioner with a specialty interest. Therefore, there ap- Orthodontics as their most preferred specialty (n=5, pears to be an interest within our sample group to- 24%) (Figs. 3, 4). This was consistent with existing na wards speciality practice. The factors which moti- literature which found that Oral and Maxillofacial vate or deter students to pursue dental specialisa- Surgery and Orthodontics as the most common spe- tion are especially pertinent to this group. As the cialties favoured by dental students (11-14, 22). Fur- survey has shown they have an interest in specialty thermore, literature indicates that both Orthodontics practices and may choose to undertake specialisa- and Oral and Maxillofacial surgery are the most com- io tion training in the future given the appropriate cir- mon dental specialities throughout the world (23). cumstances. Existing literature which examined the Differences in specialty preference may be influ- proportion of dental students who wish to spe- enced by the structure of the DMD course and both az cialise are varying in their results. In contrast to the the timing and amount of exposure of each specialty results of this study, studies performed in United during the course. At UWA Dental School, oral Arab Emirates and Iran found a high preference for surgery rotations are introduced in third year howev- specialisation around 92% (13). A study at a Lon- er, it is not until final year where students gain sub- rn don Dental School showed that 50% of respon- stantial exposure to minor oral surgery procedures dents wished to extend and refine their skills to such as extractions. Furthermore, there are no ortho- train as a dentist with a special interest, or as a dontic rotations in fourth year, which may be corre- te dental specialist. Of this group, 25% wished to be- lated to the decline in interest observed for Ortho- come specialists and 27% were interested in gener- dontics when compared to the third year prefer- al practice with a specialty interest (21). The pro- ences. In both year groups, no students selected Ra- portion of students in our study who have an inten- diology as a specialty as their first preference for In tion to specialise is reduced relative to the existing specialisation and only 7% of final year DMD stu- literature. dents indicated that they would consider Special Needs dentistry. One possible reason for the low in- Knowledge of specialty programs terest in Special Needs and Radiology is due to the ni Most DMD students were not correctly aware of cur- lack of exposure during the DMD course when com- rent specialty courses available in Western Australia. pared to other specialties. Additionally, these two spe- Nine students (13%) were correctly aware of the spe- cialties are also not offered in Western Australia though io ciality pathways available in Western Australia whilst they are offered at the University of Sydney (Special the remaining students incorrectly believed that they Care Dentistry) and University of Queensland (Special were aware (n=33, 51%) or “somewhat aware” Needs and Dento-Maxillofacial Radiology). iz (n=29, 44%). It is evident that students may be ill-in- formed or unaware about what specialisation cours- Factors influencing future specialisation es are available and thus, students who are not The survey found that the most motivating factors Ed aware of specialisation pathways are less likely to were Altruistic factors when students considered specialise. This reveals a key area in which dental specialisation. When compared with the other cate- schools can improve interest. Course convenors can gories of Professional, Financial and Personal, Altru- use this opportunity to raise awareness of the spe- istic factors were found to be the most motivating, cialty programs available and to stimulate interest for especially the aspect of “providing a service to the students. The low number of correct responses community”. Studies from the United States and IC about the specialty programs offered in Western United Kingdom have shown similar results where Australia is correlated with less than half of students the enjoyment of providing specialist care was the (47%, n=26) discussing specialisation with a mentor, most important factor in pursuing specialist training supervisor or specialist. Additionally, the proportion or career choices. Other factors found to be impor- C of students in DMD4 who had discussed with a men- tant by other studies in long-term career pathways tor, supervisor or specialists was much less than include “work life balance”, “high income/financial those in DMD3. This may be attributed to the infancy security”, “professional development”, “enjoyment of of the DMD course at UWA, with current DMD4 stu- providing care in that field”, “influence of family © dents being the second cohort to enter the program, members in the dental profession” (8, 11, 21, 24, 25). potentially less emphasis has been placed on garner- The most deterring factors for specialisation were ing student interest and informing awareness of den- those within the Financial category, with the most tal specialties. Nevertheless, a target to improve spe- deterring factor identified to be the “financial impact cialisation awareness would be implemented through of returning to full time study”. The second most de- greater discussion between students and academic terring factor, “cost of specialty course” further rein- staff to inform and facilitate interest. forces the negative impact of Financial factors on the 32 Annali di Stomatologia 2018;IX(1):27-34  Factors influencing consideration of dental specialisation: a survey of current dental students at the University of Western Australia pursuit of specialisation. These findings are consis- Conflict of interest tent with existing literature, where financial aspects have been found to negatively impact specialisation. The Authors declare no conflict of interest. The postgraduate nature of the DMD program at UWA may have impact on the priorities and prefer- li ences of the participants of this study, as further References study may place a large financial burden. na 1. Australian Institute of Health and Welfare 2016. In: Oral Health and dental care in Australia: key facts and figures. 2015. Can- Limitations berra: Dental statistics and research series. Whilst this study is the first to contribute to literature 2. Dental Board of Australia. Approved programs of study - qual- on the views of dental students and specialisation in ifications for registration. 2012:4-8. Australia, the Authors of this study recognise the po- io 3. Gallagher J, Wilson N. The future dental workforce? Br Dent tential limitations. Firstly, the data has been collected J. 2009;206(4):195-199. from two cohorts of dental students at the University 4. Maupome G, Hann H, Ray J. Is there a sound basis for de- of Western Australia and thus represents only a small ciding how many dentists should be trained to meet the den- az tal needs of the Canadian population? Systematic Review. sample of the population. Additionally, no responses J Can Dent Assoc. 2001;67(2):87-91. have been obtained from alumni students which had 5. Saeed S, Jimenez M, Howell H, et al. Which factors influ- constituted a large proportion of the intended sample ence students’ selection of advanced graduate programs? size. The small sample size in this study, compound- rn One institution’s experience. J Dent Educ. 2008 Jun;72(6): ed with few students indicating future goals of spe- 688-697. cialising failed to produce any statistically significant 6. Shin JH, Kinnunen TH, Zarchy M, et al. Factors influencing results. Further research that encompasses a larger dental students’ specialty choice: a survey of ten graduat- te sample may yield more meaningful results. The addi- ing classes at one institution. J Dent Educ. 2015 Apr;79 (4):369-377. tion of alumni students to the sample size may be 7. Nashleanas BM, McKernan SC, Kuthy RA, et al. Career in- one such way, however it may skew the results ob- fluences among final year dental students who plan to en- tained as alumni students represent a different sub- set of participants when compared to dental stu- In ter private practice. BMC Oral Health. 2014;8(14):18. 8. Dhima M, Petropoulos VC, Han RK, et al. Dental students’ dents; as they would have experience working in the perceptions of dental specialties and factors influencing spe- dental field, no longer in a tertiary teaching environ- cialty and career choices. J Dent Educ. 2012 May;76(5):562- ment, as well as potentially earning an income. Fur- 573. ni 9. Zarchy M, Kinnunen T, Chang BM, et al. Increasing pre- thermore, the limitations of the questionnaire were doctoral dental students’ motivations to specialize in revealed during data analysis with the demographic prosthodontics. J Dent Educ. 2011;75(9):1236-1243. questions being overly detailed and the four cate- 10. Scarbecz M, Ross JA. The relationship between gender and io gories in Section IV: Factors affecting future speciali- postgraduate aspirations among first-and fourth-year students sation divided into too many subsections. This re- at public dental schools: a longitudinal analysis. J Dent Educ. sulted in an increase in permutations, which may 2007;71(6):797-809. iz have multiplied any potential errors. Lastly, the study 11. Halawany HS. Career motivations, perceptions of the future was conducted by final year dental students, such of dentistry and preferred dental specialties among Saudi Den- tal students. Open Dent J. 2014;8(2):129-135. that a certain degree of subjectivity may be found Ed 12. Mitrakul K, Asvanund P, Kitisubkanchana J. Dental gradu- when analysing the results obtained. ates and dental student’s choice of specialties and factors influencing specialty training selection. M Dent J. 2014; 34(6):338-346. Conclusion 13. Rashid HH, Ghotane SG, Abufanas SH, et al. Short and long- term career plans of final year dental students in the Unit- Dental students need to be well-informed in their de- ed Arab Emirates. BMC Oral Health. 2013;13(1):1-9. IC cision to pursue specialist training following gradua- 14. Karibe H, Kawakami T, Suzuki A, et al. Career choice and attitudes towards dental education amongst dental students tion. This pilot study demonstrates only a small pro- in Japan and Sweden. Eur J Dent Educ. 2009 May;13(2):80- portion of students at present wish to pursue spe- 86. cialisation, with the majority of students not aware of 15. Da Fonseca MA, Pollock M, Majewski R, et al. Factors in- C the specialty courses available in WA. The study em- fluencing candidates’ choice of a pediatric dental residency phasises the need for greater exposure and educa- program. J Dent Educ. 2007 Sep;71(9):1194-1202. tion within dental specialties whilst students are still 16. Noble J, Karaiskos N, Wiltshire WA. Motivations and future at dental school. Additionally, results showed that plans of Canadian orthodontic residents. Am J Orthod Dento- © facial Orthop. 2009 Nov;136(5):644-650. most students were motivated by altruistic factors 17. Mawardi H, Fateh A, Elbadawi L, et al. Background, train- when considering specialisation but deterred by the ing experiences, and career plans of US periodontal residents: financial impact of returning to study. Further re- report of a web-based survey. J Dent Educ. 2015 Jan;79(1): search is advised in this field to better understand 64-71. factors involved in the pathway to dental specialisa- 18. Noble J, Hechter FJ, Karaiskos N, et al. Motivational factors tion and how to encourage specialisation. and future life plans of orthodontic residents in the United Annali di Stomatologia 2018;IX(1):27-34 33  A. Giummarra et al. States. Am J Orthod Dentofacial Orthop. 2010 May;137 22. Newton P, Cabot L, Wilson NHF, et al. The graduate entry (5):623-630. generation: a qualitative study exploring the factors influencing 19. Lewis IE. Interest in pursuing the specialty of periodontolo- the career expectations and aspirations of a graduating co- gy: a perspective from pre-doctoral periodontal directors and hort of graduate entry dental students in one London insti- periodontics residents [Chapel Hill]: University of North Car- tution. BMC Oral Health. 2011;11(1):1-16. olina; 2010. 23. Gallagher J. In: International encyclopedia of public health. li 20. Al-Sowygh ZH, Sukotjo C. Advanced education in 2008. San Diego: Academic. prosthodontics: residents’ perspectives on their current 24. Halawany HS, Binassfour AS, AlHassan WK, et al. Dental na training and future goals. J Prosthond. 2010;19(2):150-156. specialty, career preferences and their influencing factors 21. Gallagher JE, Patel R, Wilson NH. The emerging dental work- among final year dental students in Saudi Arabia. Saudi Dent force: long-term career expectations and influences. A J. 2017 Jan;29(1):15-23. quantitative study of final year dental students’ views on their 25. Che Musa MF, Bernabé E, Gallagher JE. Career expecta- long-term career from one London Dental School. BMC Oral tions and influences among dental students in Malaysia. Int io Health. 2009;23(9):35. Dent J. 2016 Aug;66(4):229-236. az rn te In ni io iz Ed IC C © 34 Annali di Stomatologia 2018;IX(1):27-34 

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Original article Association between age and severity of malocclusion in the pediatric age: a cross-sectional study li na Valeria Luzzi1 DDS, PhD combination of factors dominated by the interaction Mario Di Traglia2 MD between inheritance and environment, when favor- Annarita Vestri2 MD able or unfavorable growth vectors are conditioned by io Gaetano Ierardo1 DDS, PhD postnatal risk factors, represented by spoiled habits Francesco Covello1 DDS (1-10). Primary and secondary orthodontic prevention Denise Corridore1 DDS works by guiding the growth vectors, thus preventing az Maurizio Bossù1 DDS, PhD the establishment or aggravation of a malocclusion Antonella Polimeni1 MD, DDS during the growth stages. Consequently the early tim- ing of orthodontic intervention aims to restore the nor- malization of craniofacial growth vectors (11-13). rn 1 Department of Oral and Maxillofacial Sciences, In a previous study (14) carried out on a sample of “Sapienza” University of Rome, Rome, Italy 579 children from the Caserta area in Southern 2 Department of Public Health and Infectious Diseases, Italy, we observed an overall prevalence of maloc- “Sapienza” University of Rome, Rome, Italy clusions of 49% with a need for orthodontic treat- e ment equal to 19%. These values were significantly lower than those of similar studies in the literature Corresponding author: Valeria Luzzi Department of Oral and Maxillofacial Sciences I nt (15,16) where, however, the average age of the samples was sensibly higher than ours, reaching the age of adolescence and pre-adolescence. “Sapienza” University of Rome From this comparison it was clear that the establish- Via Caserta 6 ment and subsequent worsening of a malocclusion, 00161 Rome, Italy starting from the completion phase of the deciduous ni E-mail: [email protected] dentition, follows a dynamic process of temporal evolution. The aim of this transversal study, based on the same previously described sample, was to in- io Summary vestigate the potential worsening of malocclusions with age, independently of early orthodontic inter- The establishment and subsequent worsening of a ventions, by measuring the relationship between the iz malocclusion is the result of a combination of fac- severity level of orthodontic abnormalities and the tors dominated by the interaction between inheri- age of the subjects. tance and environment and follows a dynamic Ed process of temporal evolution. This transversal study, based on a sample of 579 children from the Materials and methods Caserta area in Southern Italy, investigates the po- tential worsening of malocclusions with age by Our sample included 579 children aged between 2 measuring the relationship between the severity and 9 years. The selection of the sample, which level of orthodontic abnormalities, evaluated availed itself of the collaboration of 45 pediatricians IC through the IONT-DHC classification, and the age from the province of Caserta, and the procedures of the subjects. Our results show that a statistical- used in collecting the data are described in full details ly significant association exists (p < 0.0001) be- in our previous article (14). The research was con- tween the overall severity of the malocclusion and ducted in full accordance with the World Medical As- C the age of the subjects, underlining the impor- sociation Declaration of Helsinki and approved by the tance of an early orthodontic prevention and high- Medical Ethical Committee of Sapienza University of lighting that large sections of the population still Rome. The parents signed an informed consent be- need to be sensitized to orthodontic problems. fore the dental visit. © For each child we measured orthodontic parameters Key words: malocclusion, pediatric age, prevention. related to the malocclusions of overjet, reverse over- jet, overbite, anterior openbite, and crossbite. The need for treatment was then evaluated using the Introduction IONT-DHC (Index of Orthodontic Treatment Need - Dental Health Component) classification (17-19) to The occurrence of a malocclusion is the result of a which we applied some minor modifications to take Annali di Stomatologia 2018;IX(1):35-42 35  V. Luzzi et al. into account our operating methods. Each child was Results then assigned an overall IONT-DHC index, defined as that corresponding to the most severe occlusal The sample consisted of 579 children, 306 males anomaly. The only criterion for exclusion from the (52.8%) and 273 females (47.2%), aged between 2 study was the presence of orthodontic treatments, and 9 years (mean=5.73, SD=1.65, median=6), of li completed or in progress ones. predominantly Italian nationality (99.3%), and in early deciduous and mixed dentition. na Statistical analysis As reported in our previous study (14), the sample To evaluate the association between age and aggra- presented an overall prevalence of malocclusions of vation of the malocclusions, a transversal approach 49.0%, with 95% CI=(44.9-53.1%), and a need for or- was used, thus assuming the ergodicity of the sam- thodontic treatment of 19.3%, with 95% CI=(16.2- ple. io 22.8%), with no statistically significant differences be- The age of the children was discretized into 8 age tween males and females. groups ranging from 2 to 9 years. Table 2 summarizes the result of multinomial logistic Starting from the IONT-DHC index, the severity of the regression analysis for the association between age az malocclusion was divided into 3 classes (Tab. 1) cor- and overall severity of the malocclusion. This model responding to absence of pathology (class 0), pres- shows statistically significant changes with age ence of a mild pathology with no need for treatment (p < 0.0001) with a negative trend for class 0 and with (class 1) and presence of a pathology with need for a positive trend for class 1, while the trend with age rn treatment (class 2). for class 2 is substantially constant (Fig. 1). This re- The association of age with the severity of the exam- sult indicates that as the age increases the number of ined malocclusions (overjet, inverse overjet, overbite, subjects with all occlusal parameters in the norm anterior openbite, and crossbite), taken both individu- e (class 0) decreases from 62% to 41% while that of ally and in combination through the overall IONT- subjects with at least one slightly altered occlusal pa- DHC index, was evaluated using the multinomial lo- gistic regression model. For regression analysis, the Statistica software pack- age from TIBCO Software Inc. (formerly from StatSoft I nt rameter (class 1) increases from 19% to 40%. The exclusion from the study of children with an orthodon- tic treatment in progress or concluded explains the trend with age approximately constant and equal to Inc.) was used. 19% of the percentage of subjects with at least one ni Table 1. Correspondence between value of the IONT-DHC index, status of the occlusal parameters, need for treatment, pathology level, and statistical class. io IONT-DHC index Occlusal parameters Need for treatment Class Pathology 1 Normal Absent 0 Absent iz 2 Mildly altered Absent or not recommended 1 Mild 3,4,5 Altered Present 2 Severe Ed Table 2. Results of regression analysis for the overall malocclusion gravity. Total IONT Classification of cases - Odds ratio: 16.381 Log odds ratio: 2.796 Observed Predicted 0 Predicted 1 Predicted 2 Correct (%) IC 0 285 0 0 100.0 1 10 114 42 68.7 2 0 21 87 80.6 C Parameter estimates distribution: ORDINAL MULTINOMIAL Link function: LOGIT Effect Level of Column Estimate Standard Wald Stat. Lower Upper p effect CL 95% CL 95% © Intercept 1 1 -4.232 0.726 34.01 -5.655 -2.810 <0.0001 Intercept 2 2 2.663 0.601 19.66 1.486 3.841 <0.0001 Age 0 3 -0.911 0.279 197.13 3.365 4.457 <0.0001 Age 1 4 0.478 0.102 22.00 0.278 0.678 <0.0001 Scale 1 0 1 1 36 Annali di Stomatologia 2018;IX(1):35-42  Association between age and severity of malocclusion in the pediatric age: a transversal study li na io az
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Figure 1. Association between age and total IONT-DHC index. (a) level 0: no malocclusion; (b) level 1: mild malocclusion; (c) level 2: malocclusion with treatment need. © severely impaired occlusal parameter (class 2), as For inverse overjet and anterior openbite, the number this group only includes children whose malocclusion of cases present in the sample was not sufficient to had not yet been treated. complete the analysis. In the case of overbite (Fig. 2) Turning now to individual malocclusions, Tables 3, 4, and overjet (Fig. 3), the association of the severity of and 5 report the results of the analysis for overjet, malocclusion with age, despite following trends simi- overbite, and crossbite malocclusions, respectively. lar to those seen for the severity of the overall maloc- Annali di Stomatologia 2018;IX(1):35-42 37  V. Luzzi et al. Table 3. Results of regression analysis for overbite. OVERBITE Classification of cases - Odds ratio: 0.992 Log odds ratio: -0.008 Observed Predicted 0 Predicted 1 Predicted 2 Correct (%) 0 369 51 2 87.4 li 1 61 47 5 41.6 na 2 0 20 4 16.7 Parameter estimates distribution: ORDINAL MULTINOMIAL Link function: LOGIT Effect Level of Column Estimate Standard Wald Stat. Lower CL Upper CL p io effect Error 95% 95% Intercept 1 1 0.93 0.45 4.32 0.05 1.81 0.04 Intercept 2 2 3.79 0.50 56.47 2.80 4.78 <0.0001 az Age 4 0.13 0.07 2.94 -0.02 0.28 0.09 Scale 1 0 1 1 rn Table 4. Results of regression analysis for overjet. OVERJET Classification of cases - Odds ratio: 2,821 Log odds ratio: 1,037 e Observed Predicted 0 Predicted 1 Predicted 2 Correct (%) 0 392 52 0 88.3 1 2 71 0 I 31 7 nt 0 6 30.4 46.2 Parameter estimates distribution: ORDINAL MULTINOMIAL Link function: LOGIT ni Effect Level of Column Estimate Standard Wald Stat. Lower CL Upper CL p effect Error 95% 95% Intercept 1 1 2.320 0.519 20.023 1.304 3.337 <0.0001 io Intercept 2 2 5.846 0.645 82.255 4.583 7.110 <0.0001 Age 4 -0.024 0.083 0.085 -0.187 0.138 0.770 iz Scale 1 0 1 1 Ed Table 5. Results of regression analysis for crossbite. CROSSBITE Classification of cases - Odds ratio: 2,821 Log odds ratio: 1,037 Observed Predicted 0 Predicted 1 Predicted 2 Correct (%) 0 392 52 0 88.3 IC 1 71 31 0 30.4 2 0 7 6 46.2 Parameter estimates distribution: ORDINAL MULTINOMIAL Link function: LOGIT C Effect Level of Column Estimate Standard Wald Stat. Lower CL Upper CL p effect Error 95% 95% Intercept 1 2.619 0.722 13.144 1.203 4.034 0.0003 © Age 2 0.209 0.121 2.986 -0.028 0.447 0.084 clusion, does not show statistically significant varia- empty. For class 2 there is an increasing trend with tions. As for crossbite (Fig. 4), the presence of an al- age, but even in this case it does not reach statistical teration of any entity automatically induces a need for significance (p=0.08). orthodontic treatment and consequently class 1 is 38 Annali di Stomatologia 2018;IX(1):35-42  Association between age and severity of malocclusion in the pediatric age: a transversal study li na io az
e rn I nt ni io iz
Ed IC C ©
Figure 2. Association between age and overbite. (a) level 0: absent; (b) level 1: mild; (c) level 2: severe. Annali di Stomatologia 2018;IX(1):35-42 39  V. Luzzi et al. li na io az
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Figure 3. Association between age and overjet. (a) level 0: absent; (b) level 1: mild; (c) level 2: severe. 40 Annali di Stomatologia 2018;IX(1):35-42  Association between age and severity of malocclusion in the pediatric age: a transversal study li na io az
e rn I nt ni io iz
Figure 4. Association between age and crossbite. (a) level 0: absent; (b) level 2: present. Ed years a statistically significant association exists be- Discussion tween the severity of the overall malocclusion, de- fined as the combination of all considered malocclu- Several Authors (20-21) agree with the implementa- sions, and the age of the subject. The percentage of tion of preventive programs for children, as they state children with class 0 (normal orthodontic parameters) that oral health education to caregivers have led to range from 62% at 2 years of age to 41% at 9 years IC great benefits. Information on oral health care should of age while those with at least one slightly impaired be provided to mothers during pregnancy, to increase parameter (class 1) increase from 19% at 2 years of their knowledge about gestational care of oral health, age to 40% at 9 years, indicating a clear trend of and to prevent problems that may occur both in the worsening of the occlusal state with the increasing C mothers themselves and in their children such as pre- age. term low birth weight (22). Pregnant women who re- The percentage of children with at least one occlusal ceive this information become health promoters in the parameter altered in such a way as to require treat- family, as well as multiplying agents of oral health ed- ment (class 2) is equal to 19% and this is explained © ucation. Alves et al. (23) in their study found that chil- by the study criteria exclusion. In fact the study ex- dren who started participating in the program, and cluded all the children who were undergoing or had women who have received pertinent information completed an orthodontic treatment; that 19% there- since pregnancy, presented fewer oral diseases than fore indicates only the percentage of children who those who never participated in the oral health pro- had not yet started orthodontic treatment despite this gram. being necessary. Such a large number of untreated Our study shows that in the age ranged from 2 to 9 orthodontic cases indicate that in some sections of Annali di Stomatologia 2018;IX(1):35-42 41  V. Luzzi et al. the population there is still a lack of sensitivity to or- Stomatol (Roma). 2011;2(1-2):13-18. thodontic problems. 8. Luzzi V, Ierardo G, Viscogliosi A, Fabbrizi M, Consoli G, Voz- Coming to individual malocclusions, while the visual za I, Vestri A, Polimeni A. Allergic rhinitis as a possible risk factor for malocclusion: a case-control study in children. Int examination of the results shows in all cases a wors- J Paediatr Dent. 2013;23(4):274-278. ening trend similar to that of the overall malocclusion, 9. Luzzi V, Ierardo G, Sfaciotti GL, Polimeni A. Aggiornamen- li the numerical entity of the sample was not sufficient ti in tema di carie della prima infanzia. Dental Cadmos. to highlight in a statistically significant way an associ- 2009;4:61-79. na ation between the age and each of the studied maloc- 10. Trottini M, Bossù M, Corridore D, Ierardo G, Luzzi V, Sac- clusions. This calls for a repetition of this study with a cucci M. Assessing risk factors for dental caries: a statisti- larger sample size. cal modeling approach. Caries Res. 2015;49:226-235. 11. Luzzi V, Ierardo G, Ladniak B, Manzini P, Polimeni A. L'in- tercettamento precoce delle deviazioni mandibolari funzionali io in dentatura decidua mediante l'utilizzo del dispositivo Nite Conclusions Guide: Case Report. Mondo Ortodontico. 2003;3:1-3. 12. Auconi P, Luzzi V, Ierardo G, Polimeni A. When orthodon- The present study identified a statistically significant az tic treatment is really necessary? Medico e Bambino. association (p < 0.0001) between the severity of or- 2006;25:87-94. thodontic malocclusions and the age of the sample 13. Luzzi V, Di Carlo G, Saccucci M, Ierardo G, Guglielmo E, Fab- ranged between 2 and 9 years, also highlighting that brizi M, Zicari AM, Duse M, Occasi F, Conti G, Leonardi E, there are still large sections of the population who Polimeni A. Craniofacial morphology and airflow in children rn with primary snoring. Eur Rev Med Pharmacol Sci. 2016 need to be sensitized to orthodontic problems. Mor- Oct;20(19):3965-3971. phological parameters of the teeth are recorded to 14. Luzzi V, Ierardo G, Corridore D, Di Carlo G, Di Giorgio G, help assess the indication for orthodontic treatment. It Leonardi E, Campus GG, Vozza I, Polimeni A, Bossù M. Eval- e is assumed that significant deviations from average uation of the orthodontic treatment need in a paediatric sam- values compromise the quality of life (24). ple from Southern Italy and its importance among paedia- This result confirms that the establishment of a mal- tricians for improving oral health in pediatric dentistry. J Clin occlusion is a process which progresses with age, underlining the importance of an early orthodontic prevention to intervene before the malocclusion stabi- I nt 15. Exp Dent. 2017;9(8):e995-e1001. Abu Alhaija ES, Al-Nimri KS, Al-Khateeb SN. Orthodontic treatment need and demand in 12-14-year-old North Jor- danian school children. Eur J Orthod. 2004;26(3):261-263. lizes and escalates at a more advanced age. It is also 16. Abu Alhaija ES, Al-Khateeb SN, Al-Nimri KS. Prevalence of necessary to strengthen the awareness of preventive malocclusion in 13-15 year-old North Jordanian school chil- ni measures in the orthodontic field in order to improve dren. Community Dent Health 2005; 22(4):266-271. the oral health status in the pediatric age also 17. Brook PH, Shaw WC. The development of an index of or- through the school environment as access to health thodontic treatment priority. Eur J Orthod. 1989;11:309-320. io promotion for all socio-economic classes (25). 18. Abdullah MS, Rock WP. Assessment of orthodontic treatment need in 5,112 Malaysian children using the IOTN and DAI indices. Community Dent Health. 2001;18(4):242-248. 19. Johansson M, Follin ME. Evaluation of the Dental Health Com- iz References ponent, of the Index of Orthodontic Treatment Need, by Swedish orthodontists. Eur J Orthod. 2009;31:184-188. 1. Bishara SE, Warren JJ, Broffitt B, Levy SM. Changes in the 20. Castilho AR, Mialhe FL, Barbosa Tde S, Puppin-Rontani RM. Ed prevalence of nonnutritive sucking patterns in the first 8 years Influence of family environment on children's oral health: a of life. Am J Orthod Dentofacial Orthop. 2006;130:31-36. systematic review. J Pediatr (Rio J). 2013 Mar-Apr;89(2):116- 2. Cozza P, Baccetti T, Franchi L, Mucedero M, Polimeni A. 123. Sucking habits and facial hyperdivergency as risk factors for 21. Vozza I, Capasso F, Marrese E, Polimeni A, Ottolenghi L. anterior open bite in the mixed dentition. Am J Orthod Dento- Infant and Child Oral Health Risk Status Correlated to Be- facial Orthop. 2005;128(4):517-519. havioral Habits of Parents or Caregivers: A Survey in Cen- 3. Duncan K, McNamara C, Ireland AJ, Sandy JR. Sucking tral Italy. J Int Soc Prev Community Dent. 2017 Mar- IC habits in childhood and the effects on the primary dentition: Apr;7(2):95-99. findings of the Avon Longitudinal Study of Pregnancy and 22. Capasso F, Vozza I, Capuccio V, Vestri AR, Polimeni A, Ot- Childhood. Int J Paediatr Dent. 2008;18(3):178-188. tolenghi L. Correlation among periodontal health status, ma- 4. Katz CR, Rosenblatt A, Gondim PP. Non-nutritive sucking ternal age and pre-term low birth weight. Am J Dent. 2016 C habits in Brazilian children: effects on deciduous dentition and Aug;29(4):197-200. relationship with facial morphology. Am J Orthod Dentofa- 23. Alves APS, Rank RCIC, Vilela JER, Rank MS, Ogawa WN, cial Orthop. 2004;126(1):53-57. Molina OF. Efficacy of a public promotion program on chil- 5. Warren JJ, Bishara SE. Duration of nutritive and nonnutri- dren's oral health. J Pediatr (Rio J). 2017 Sep 25. pii: S0021- tive sucking behaviors and their effects on the dental arch- 7557(17)30197-30203. © es in the primary dentition. Am J Orthod Dentofacial Orthop. 24. Fabian S, Gelbrich B, Hiemisch A, Kiess W, Hirsch C; LIFE 2002;121(4):347-356. Child study team. Impact of overbite and overjet on oral health- 6. Luzzi V, Guaragna M,Ierardo G, Saccucci M, Consoli G, Vestri related quality of life of children and adolescents. J Orofac AR, Polimeni A. Malocclusions and non-nutritive sucking Orthop. 2018 Jan;79(1):29-38. habits: a preliminary study. Prog Orthod. 2011;12(2):114-118. 25. Vozza I, Guerra F, Marchionne M, Bove E, Corridore D, Ot- 7. Luzzi V, Fabbrizi M, Coloni C, Mastrantoni C, Mirra C, Bossù tolenghi L. A multimedia oral health promoting project in pri- M, Vestri A, Polimeni A. Experience of dental caries and its mary schools in central Italy. Ann Stomatol (Roma). 2014 Nov effects on early dental occlusion: a descriptive study. Ann 20;5(3):87-90. 42 Annali di Stomatologia 2018;IX(1):35-42 

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Original article Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice li na Alessandra Impellizzeri DDS maintenance of oral hygiene between public or Roberto Samà DDS private facilities, although the initial level was dif- Roberto Di Giorgio MDS ferent, were eventually revealed to be not statisti- io Ersilia Barbato PhD cally different at the planned controls. There was Gabriella Galluccio DDS indeed a difference between patients in treatment with fixed or removable appliances, showing a az higher level of plaque deposition for the first Department of Oral and Maxillofacial Sciences, group. “Sapienza” University of Rome, Rome Italy Conclusions. The appropriate prescription of an oral hygiene protocol in orthodontic patients and rn the periodical reiteration of the message are posi- Corresponding author: tively correlated with an improvement of oral hy- Gabriella Galluccio giene conditions, in spite of the sort of health fa- Director of Post-graduate Course in Functional cility and mainly related to the ability of the dental te Orthodontics, professionals. The presence of a fixed appliance Vice-President of the Course for Dental Degree strengthened the need for a close control. Department of Oral and Maxillofacial Sciences, “Sapienza” University of Rome In Key words: oral hygiene, orthodontic appliance, Piazzale Aldo Moro 5 public health, compliance. 00185 Rome, Italy E-mail: [email protected] Introduction ni Orthodontics is a specialty of dentistry that deals with Summary prevention, diagnosis and treatment of malposition of io teeth and facial bones. The main objectives of ortho- Aims. To evaluate how the application of ortho- dontic treatment are the correct alignment of the dontic appliances influences the level of collabo- teeth, in order to improve the health prospects of the iz ration in the oral hygiene of the patient and teeth and their supporting apparatus, efficient masti- whether a difference exists between patients catory function, good facial appearance and stability treated in public and private structures. of the occlusion. Ed Methods. From April 2016 to December 2017, two For the treatment of malocclusions, the therapy re- hundred patients, 100 treated in the Orthodontics quires fixed or removable devices, often used in as- Department of “Sapienza” University of Rome and sociation with each other or applied in sequence, ac- 100 treated in a private practice, have been evalu- cording to the specific treatment objective. ated for six months from the start of the treat- Oral hygiene is the set of measures taken to ensure ment. All the 200 patients completed a question- cleanliness of the oral cavity and thus prevent carious IC naire and an evaluation with OHI-S (Oral Health lesions and other diseases such as gingivitis and pe- Index-Simplified) modified oral hygiene index, re- riodontitis (1-3). peated every three months. All data have been For the realization of a correct hygiene during ortho- statistically analyzed to evaluate the level of col- dontic treatment, the use of common aids, such as C laboration to oral hygiene and eventually present manual or electric toothbrush, is suggested and more differences between public vs private structures. specific devices such as brushes, interdental brush- The differences in behavior in oral hygiene with es, end tuft toothbrushes and “Super floss”. All these reference to different orthodontic devices devices help to reach the more common plaque de- © (fixed/removable) were also evaluated and the position area, which is difficult to keep clean with the ability to maintain adequate oral hygiene with re- standard approach, such as below the orthodontic spect to the expected length of orthodontic treat- arches (1-6). ment was assessed. The task of dentist and hygienist is to teach the most Results. A statistically significant difference was suitable technique for performing correct oral hy- found between the initial level of plaque index at giene, based on the characteristics of the patient’s the T0 and T1 time, found at a lower level. The mouth and any dental problems (6). Annali di Stomatologia 2018;IX(1):43-52 43  A. Impellizzeri et al. Orthodontic appliances are selected according to the Richter et al. in 1998 reported that patient compliance specific treatment objective and often, more than one could be achieved through a reward path regardless appliance can be used, in particular, when problems of the repetition of instructions, for example with the of skeletal growth and dental misalignments are as- use of a report card for reporting the goals, taking sociated (1, 6, 7). care to transform them into tangible prizes (13). li The term “removable appliance” means each device The importance of maximizing collaboration in proper that the patients can apply and remove on their own. oral hygiene from orthodontic patients is indicated by na Usually, it is formed by an acrylic resin body, which the results of studies that have assessed changes in retains in its structure both the elements which allow bacterial plaque composition in patients during ortho- it to be anchored to the teeth properly, and the me- dontic treatment (13). chanical elements, such as screws, springs and arcs, Maret et al. carried out a study to highlight any differ- which, once activated, are able to move the teeth (7). ences in salivary microbial load among orthodontic io Mobile appliances need careful daily hygiene, be- patients and related controls. The Authors found an cause bacterial plaque is deposited when they are increase of Streptococcus mutans and Lactobacillus placed in the mouth and when they are stored in their (14). az containers. It is therefore especially important to in- Several Authors evaluated the presence of the micro- struct the patient to properly maintain the appliance, bial load in the oral cavity (Streptococci, Staphylococ- but the patient’s compliance is limited to the perfor- ci, Veillonelle, Lactobacilli and Mycetes) before, dur- mance of normal daily oral hygiene maneuvers (4,8). ing and after orthodontic treatment. The prevalent rn The fixed orthodontic appliance is made up of metal conclusion is that the average bacterial population in- or ceramic attachments, and bands fixed to the teeth, creases and that the anaerobes become prevalent on that are connected and activated by further compo- the remaining bacterial flora. Generally, the increase nents: wires, elastic bands, springs and extra-oral in these bacteria is related to higher incidence of te traction, so as to move the teeth into a correct posi- caries. On the other hand, there is a decrease in the tion. In this case, the devices cannot be removed ex- percentage of Actinomyces (13.3% decrease in the cept by the orthodontist (4, 8). total flora), and smaller reduction in Fusobacterium In Fixed appliances reduce the physiological self-disrup- and Bacteroides species (15). tion mechanisms favoring plaque retention and accu- Although there is no general agreement in the litera- mulation; they also create objective difficulties in the ture on the adhesion pattern of micro-organism dur- execution of daily oral hygiene techniques; therefore, ing the orthodontic treatment, an in vitro study ni the patient in fixed orthodontic therapy requires a showed a lower adhesion for the combination sap- strong motivation and compliance in hygiene maneu- phire brackets/coated wire, while metallic brackets vers (4, 8, 9). and metallic wires showed the worst performance. Orthodontic treatment involves a long period of col- The Authors concluded that the capacity of micro-or- io laboration between patient, orthodontist and hygienist ganisms to adhere and grow is dependent on the ma- (10, 11). terials of the orthodontic appliance (16). The complete understanding of the oral hygiene prob- Hagg et al., analyzed the prevalence of Candida and iz lem, the manual skills of the duly educated patient Enterobacteria in a group of adolescents in orthodon- and the appropriate use of tools and materials are in- tic treatment with fixed appliances. They conclude dispensable, but not sufficient conditions for the daily that the presence of these appliances alters the eco- Ed practice of oral hygiene (12). The “motivation” is the logical balance in the oral cavity, due to the introduc- decisive key, that is the complex of factors that instill tion of new stagnant areas of plaque and debris re- in the patient “mental orientations tending to be con- tention, with a direct effect on the plaque index but a cretized through actions and behaviors aimed and co- contrary and transitory effect over the prevalence and herent” (2, 11). density of Candida and the transmission of Coliforms All patients, although informed, trained and motivated (9). IC by the dentist and/or hygienist, through appointments, The fixed appliances, therefore, interfere with the sessions and oral hygiene instructions, tend to lose practice of oral hygiene and should be considered as motivation relatively quickly, in a few days to a few parts of the surface of the teeth (17). months. This phenomenon requires great consistency The level of collaboration offered is fundamental for C in continuously providing the patient with the neces- the success of orthodontic treatment. While the pa- sary reinforcements to maintain motivation over time tient is asked to use the appliance in the most correct (10). way, it is also necessary to respect scheduled ap- Collaboration is essential for successful treatment in pointments and to maintain an adequate level of oral © orthodontic patients. Failure to collaborate leads to hygiene in order not to make the benefits of the entire an increase in working time for the patient, the parent treatment questionable. So, orthodontic treatment en- and the orthodontist; moreover, in some cases, the visages a constant commitment on the part of the pa- treatment may be compromised, and it may be nec- tient, the parents, the orthodontist and the hygienist, essary to interrupt it prematurely, due to the risk of both as regards the maintenance of oral hygiene and tissue damage, such as demineralization enamel and the duration of treatment and the subsequent thera- recurring gingival inflammation (11). peutic results (13). 44 Annali di Stomatologia 2018;IX(1):43-52  Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice Beckwith et al. (18) have identified some of the pri- males and 61 females of average age 12.3. Of these mary factors that influence the duration of orthodontic 100 patients, 33 were treated with removable ortho- treatment. In this study, parameters were collected dontic devices, while 67 were in orthodontic therapy from 140 cases completed consecutively, including with fixed multiband equipment, 32 of whom also had data from patients being treated in 5 different private a fixed palatal expander appliance. li studies. Significant correlations were found for factors All the 200 patients initially completed a question- related to patient collaboration (number of missed ap- naire, which was repeated every three months over a na pointments, number of rebonded brackets and bands, total period of six months. number of treatment steps, detection of poor oral hy- The questionnaire is a re-elaboration of a pre-existing giene) and only two related to the treatment modality folder concerning oral hygiene in pediatric dentistry, (more than one treatment phase, prescription of ex- modified according to the aims of the present work. traoral traction use). In the first survey, data were collected regarding age, io In a review of the factors concerning the duration of sex, type of orthodontic appliance, methods of oral orthodontic treatment, Mavreas and Athanasiou con- hygiene, number of meals taken during the day and clude that extraction treatment lasts longer than the any reference to oral hygiene; plaque and bleeding az non-extraction therapy, while age does not seem to indices were also detected. In the following two ap- play an important role. Several conditions appear to pointments with the patient, only the detection of the be operator-sensitive; at least various factors includ- oral hygiene indexes was performed. ing the compliance of the patients seem to play a role Oral hygiene instructions were given by the operators rn in prolonging the treatment (19). both to the sample examined in the public sphere and The aim of the study was to evaluate how the appli- in the private sector, before orthodontic treatment. cation of orthodontic appliances influences the level 19% of the patients treated in private practice and 5% of collaboration in the oral hygiene of the patient. of patients treated in the public facility had fluoropro- te The present work also evaluated if the behavior in phylaxis treatments during orthodontic treatment, due oral hygiene is different between patients treated in to previously detected caries susceptibility. public and private structure, as the patient’s coopera- The index considered by this study was the OHI-S tion is based on motivation, information and sense of In (Oral Health Index-Simplified) modified oral hygiene appreciation and interest. This behavior is transmitted index, which is a reversible index used to measure by dental health staff through a program of instruc- the degree of oral hygiene. tions that must be developed for each patient, ac- This epidemiological index allowed the evaluation of ni cording to their needs and the type of appliance ap- the amount of soft residues present on the teeth, and plied. regardless of whether they are plaque or alba matter, The different structuring of the service in the public only the explorer was used, without using revealing sector could be less followed by the individual path of solutions; this system was preferred to simplify the io the patient about the maintenance of oral hygiene detection of indices by operators. and the maintenance of compliance, for reasons of To perform this study, 8 maxillary teeth (1.6; 1.3; 1.2; organization of the structure, while greater personal- 1.1; 2.1; 2.2; 2.3; 2.6) and 8 mandibular teeth (4.6; iz ization and monitoring could be envisaged in the pre- 4.3; 4.2; 4.1; 3.1; 3.2; 3.3; 3.6) were examined; the vention path in the private structure, especially with eventually present plaque was probed, by using an regard to the implementation of the protocols. explorer, around the mesial, buccal and lingual/palat- Ed The present work also aimed to compare how differ- al distal surfaces of the examined teeth (for a total of ent treatment methods can affect the patient’s ability 64 surfaces). to maintain proper oral hygiene. By summing up all the values of the surfaces positive to the presence of plaque and dividing by the total number of surfaces of the teeth considered, multiply- Materials and methods ing by one hundred, the percentage (%) of plaque IC present on the teeth was obtained. The study was conducted on a sample of 200 pa- All data were subjected to statistical analysis with tients in orthodontics, 100 of whom were treated in SPSS software, to evaluate the correlations between the Orthodontics Unit of the Department of Dentistry the indexes collected and the arguments presented in C and Maxillo Facial Sciences, “Sapienza” University of the aim of the work: Rome – named group G1 – and 100 treated at a pri- • evaluation of the influence of orthodontic applica- vate practice – group G2. The observations took tion on the level of collaboration to oral hygiene place between April 2015 and December 2017. by the patient; © N. 57 males and n. 43 females of average age 15.2 • evaluation of differences in behavior in oral hy- formed the sample of the public hospital G1. giene between patients followed in public struc- Of these 100 patients, 16 were in orthodontic therapy ture and patients followed in private practice; with removable devices, 84 in orthodontic therapy • evaluation of differences in behavior in oral hy- with a multiband fixed device, 24 of whom also had a giene in the presence of different orthodontic de- fixed palatal expansion appliance. vices (fixed/removable); The private practice sample, G2, was formed by 39 • assessment of the ability of patients to maintain Annali di Stomatologia 2018;IX(1):43-52 45  A. Impellizzeri et al. adequate oral hygiene with respect to the expect- The average measured at time T0 was equal to: ed length of orthodontic treatment, assessed as T0=0.4994 while at T1 it was equal to: T1=0.4534; this short treatment (<1 year of therapy), or long treat- result, statistically significant since P is equal to: ment (>1 year of therapy). P=0.000, indicated how, even in the presence of an or- The statistical evaluations carried out on the collected thodontic device, if an appropriate oral hygiene proto- li data were: col is applied, plaque indices can improve their level. 1. descriptive statistical analysis of the data; The ANOVA test for repeated measurements, per- na 2. double-tailed test T to evaluate the variation of formed at the time T0, T1, T2, showed that there the plaque index both in the presence of an ortho- were no statistically significant changes in the plaque dontic appliance and in relation to the different index over 6 months; this is probably due to the im- types of appliances (fixed and removable) and to provement of the patient’s compliance which, when compare the values of the plaque index in relation properly stimulated, manages to maintain sufficient io to the various care structures; oral hygiene control over time (Tab. 2, Fig. 2). 3. regression test and linear correlation to compare The same result also comes from the T test for paired results on the progress of the plaque index with data, compared to the plaque index measurements az respect to the duration of orthodontic treatment. made at the time T1 and at the time T2 in the two welfare structures: private and public (Tab. 3, Fig. 3). As can be inferred from the analysis of Table 3, there Results was no statistically significant modification (P=0.407) rn in the plaque index, which remained constant in the Table 1 and Figure 1 showed the results of the T test controls following the time T1. for paired data referred to the plaque index in the The results of the plaque index measurements in re- lation to the different types of appliance: fixed or re- te presence of an orthodontic device at time T=0 and T=1. Through the measurement, we wanted to evalu- movable, carried out at time T=0 and T=1, on the pa- ate whether the presence of an orthodontic appliance tients followed both in the public and private struc- produced a difference in behavior in oral hygiene of ture, are reported in Tables 4, 5 and in Figure 4. the patients of the whole sample examined both in In The analysis of these results confirmed a tendency the public and private structure. for the plaque index to decrease in the presence of an orthodontic device in the first three months of the observation; in both cases, in fact, there were statisti- ni cally significant data: P=0.002 and P=0.000, indica- Table 1. Plaque indexes at T0-T1. tive of an effective improvement of the plaque index. Time Group Media Dev Std ESM From the comparison of these tables, however, it ap- peared that the patients treated with removable de- io T0 200 0.4994 0.2749 0.0194 vices presented better values of plaque index at de- T1 200 0.4534 0.2512 0.0178 tection performed at time T=1 compared to those who were subjected to a fixed therapy. iz Difference 0.0460 0.0237 0.0016 In Table 6 and Figure 5, the results of the plaque in- dex value at time T1 in the fixed therapy patients were 95% Confidence Interval of diff. average: 0.03132 to compared with those in mobile therapy and elaborated Ed 0.06068; T = 6.181 with 199 degrees of freedom; P 0.000. with the T test for paired data. It was possible to no- IC C © Figure 1. Variation of plaque indices. 46 Annali di Stomatologia 2018;IX(1):43-52  Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice Table 2. ANOVA for repeated measures. Time Group Media Dev Std ESM T0 200 0.4994 0.2749 0.0194 li T1 200 0.4534 0.2512 0.0178 na T2 200 0.4675 0.3338 0.0236 Variation source SS GL Estimated variance (MS) Between subjects 557.9536 199 io Within subjects 1051.8080 Treatments 3.8786 2 1.9393 az Residue 1047.9294 398 2.6330 Total 1609.7616 600 rn MStreat 1.939 F = ------------ = --------- = 0.737P = 0.479 te MSres 2.633 In ni io iz Ed IC C Figure 2. Variation of plaque indices at time T0-T1-T2. tice a statistically significant difference in plaque index though the absolute values showed a difference be- in the two different types of appliances for P=0.040. tween the two types of facilities, the values obtained © From the analysis of this result, therefore, it emerged through the elaboration, presented in Table 7 and that the presence of fixed appliances determined the Figure 6, showed statistically insignificant results need for greater collaboration in oral hygiene, com- (P=0.573). pared to the presence of mobile devices. Finally, the results reported in Table 8 showed that We then compared the plaque index values in pa- the expected duration of orthodontic treatment, as tients under orthodontic treatment followed in the communicated to the patients before the acceptance public structure, to those in the private structure. Al- of the therapy, did not determine a statistically signifi- Annali di Stomatologia 2018;IX(1):43-52 47  A. Impellizzeri et al. Figure 3. Variation of plaque indices at T1 and T2 (public structure + private struc- ture). li na io az Table 3. Change of the T1 and T2 time plaque index (pub- Table 4. Plaque indices in mobile devices (public structure rn lic structure) (private structure). + private structure). Time Group Media Dev Std ESM Time Group Media Dev Std ESM T1 200 0.4534 0.2512 0.0178 T0 45 0.4374 0.2584 0.0385 te T2 200 0.4675 0.3338 0.0236 T1 45 0.3856 0.2400 0.0358 Difference -0.0140 0.2391 0.0169 Difference - 0.0518 0.0184 0.0027 In 95% Confidence Interval of diff. average: 0.04739 to 95% Confidence Interval of diff. average: 0.01964 to 0.01929; 0.08396; T = -0.831 with 199 degrees of freedom; P= 0.407. T = 3.246 with 44 degrees of freedom; P= 0.002. ni io iz Ed IC C © Figure 4. Total change of the plaque indices to T1 and T2 (public structure + private structure) for different types of appli- ances (removable/fixed). 48 Annali di Stomatologia 2018;IX(1):43-52  Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice li na io az rn Figure 5. Plaque indices difference at time T1 in public and private structures between mobile and fixed devices. te Table 5. Plaque indices in fixed appliances (public struc- Table 6. Test T. Plaque indices comparison between fixed ture + private structure). and mobile devices (public structure + private structure). Time Group Media Dev Std ESM In Time Group Media Dev Std ESM T0 155 0.5170 0.2777 0.0223 T1 155 0.4728 0.2516 0.0202 T1 155 0.4728 0.2516 0.0202 ni T1 45 0.3856 0.2400 0.0358 Difference 0.0442 0.0261 0.0021 Difference 0.08728 0.04218 io 95% Confidence Interval of diff. average: 0.02751 to 95% Confidence Interval of diff. average: 0.004112 to 0.06076; 0.1705; T = 5246 with 154 degrees of freedom; P=0.000 T= 2.070 with 198 degrees of freedom; P=0.040. iz Ed IC C © Figure 6. Difference of time T1 plaque indices in the different welfare structures (public structure vs private structure). Annali di Stomatologia 2018;IX(1):43-52 49  A. Impellizzeri et al. Table 7. Differences between the different welfare struc- so in the presence of orthodontic appliances. tures. (public structure vs private structure). The average improvement of the level achieved in the first months, as evidenced by the modified OHI-S found Time Group Media Dev Std ESM in the study conducted, was significant in all cases. T1 100 0.4434 0.2598 0.0260 Nevertheless, at inter-proximal level, where the pa- li tient’s greatest difficulty in maintaining an adequate T1 100 0.4635 0.2432 0.0243 level of hygiene is usually found, and also in this na study, we have always found a greater accumulation Difference 0.0201 0.03558 of plaque and food residues, compared to other den- 95% Confidence Interval of diff. average:-0.09027 to- tal surfaces. 0.05007. This data probably demonstrates both a poor habit T= 0.565 with 198 degrees of freedom; P=0.573. prior to keeping the interdental spaces clean, and the io need for a greater degree of manual skill that is re- quired in the presence of an orthodontic appliance, Table 8. Plaque index correlation with respect to length of especially if fixed, in keeping such surfaces clean. az the orthodontic treatment. Regression and linear correla- tion. Usually, in patients who had not been recalled and did not receive oral hygiene instructions again, the Total sample group 200 plaque tends to increase or at least to return to the initial levels, before the hygienist appointments (21). Angular coefficient -0.0658 rn In our sample, the control performed at the time T2=6 Intercept 30.317 months indicated an almost overlapping value with es slope 0.5862 the other controls; it is to be emphasized that proba- bly the demotivation occurs quickly in patients without te es Int 0.3471 planned recall, indicating how crucial their continuous es r 24.659 and constant reinforce is. From a comparison of the data obtained both from r 0.0092 In clinical and statistical observations regarding the cor- t -0.1122 relation between the different type of orthodontic de- vices and plaque indices, we can state that in pa- GL 198 tients in fixed orthodontic therapy, we have a more P 0.9108 ni difficult control of hygiene is present, compared to pa- tients in mobile orthodontic therapy. This aspect is certainly affects by the presence, as we know, of brackets and bands that with their irregu- io cant value, P=0.9108 and r=0.0092, between the larities, retain food residues with formation of greater plaque index and the duration of therapy. percentage of plaque, if the hygiene maneuvers are This result, however, did not imply a lack of correlation not carried out correctly (16). iz between the real treatment duration and bacterial plaque The role of the hygienist is therefore essential, in con- index. It is therefore important to stimulate the patient’s stantly keeping alive the motivation of the orthodontic motivation for oral hygiene maneuvers and orthodontic patient and to be ready to stimulate it when compli- Ed collaboration; it is very much possible to obtain the best ance is reduced. results in terms of orthodontic treatment by reducing the Otherwise, the use of a removable appliance with the risk of diseases such as caries or gingivitis. possibility of being able to be removed both during meals and during daily hygiene maneuvers, allows the patients to carry out the instructions indicated by Discussion dentists with greater ease. IC Based on clinical data and statistical results related to In collecting our records of oral and food hygiene oral hygiene behavior in the two different care facili- habits and the level of compliance, we found a series ties examined, it was shown that there are no statisti- of parameters that were not analyzed in the present cally significant differences. This result is probably C study but which we propose to include in a prospec- because both samples under examination were sub- tive study of wider scope. jected to a hygiene education program, as a function This study highlighted that, even in the presence of of a subsequent orthodontic treatment. This protocol orthodontic devices, usually considered responsible probably produced a positive behavioral response in © for the increase of plaque, gingival inflammation and patients, resulting in improved plaque index even at demineralization around orthodontic brackets and the first control performed three months after the hy- bands (20), in the presence of a correct oral hygiene giene instructions given to them. prevention and instruction program, plaque indices In fact, the statistical comparison of the data related can improve. to the plaque index shows that there is a statistically The importance of a high level of oral hygiene care, significant improvement in patients in orthodontic so fundamental in everyday life, becomes even more treatment in the two different samples belonging to 50 Annali di Stomatologia 2018;IX(1):43-52  Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice both the public and private structure. This situation of oral hygiene, while there is a slight difference be- reflects the importance of health education through tween fixed and removable appliances in the level of motivation and oral hygiene instructions and the im- plaque index. plementation of prevention programs and oral hy- Orthodontic treatment performed in different care fa- giene protocols. cilities has shown statistically insignificant results, li A further elaboration concerning the different types of even if in the public structure it is more complex to apparatus (removable, fixed) gave a statistically sig- rigorously implement the oral hygiene protocols be- na nificant P=0.040 value. The value highlights how mo- cause of the large number of patients daily coming for bile devices, when it is possible to use them, would the control before, during and after orthodontic treat- be preferable to fixed devices in patients with special ment, compared to the private structure. needs or in patients with cooperating difficulty. From the data shown, the importance that health edu- The patient in fixed orthodontic therapy must have cation assumes during these treatments is finally evi- io greater motivation to maintain hygiene, since the re- dent, as is the fact that, to obtain significant results, a tention of bacterial plaque by fixed orthodontic de- simple act of motivation, performed at the beginning vices providing additional retention areas can lead to of orthodontic treatment, is not sufficient, and this az gingivitis, from the lightest to the most severe forms, must necessarily be repeated periodically, with a min- with gingival hypertrophy, in particular of the papillae imum interval of three months. and presence of pseudo-pockets (14). About the methods used to monitor the patient’s ac- In the last question addressed in the present study, quisition of the correct oral hygiene technique, we be- rn concerning the course of the plaque index with re- lieve that the simplified oral hygiene index (OHI-S), spect to the expected duration of treatment, we found alone or associated with the bleeding index, is a sim- the lack of a statistically significant linear correlation ple method of good practical efficiency. between plaque index and the possible duration of te the therapeutic treatment. This does not mean that a long treatment duration Conflict of interest does not affect the worsening of patient plaque in- dices; however, if they are frequently monitored and In No sources of support in the form of grants was re- subjected to hygiene sessions, the risk of damage to ceived for the present paper. the gingival tissues can be reduced in some way, throught the least accumulation of potentially harmful ni plaque (15). 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Periodontology for the is in teaching and motivating patients to oral hygiene. Dental Hygienist. Elsevier Health Sciences. 2015. The results obtained by statistical survey of linear re- 9. Hagg U, Kaveewatcharanount P, Samaranayake YH, Sama- gression performed by data collection at time T=0 ranayake LP. The effect of fixed orthodontic appliances on © months; T=3 months; T=6 months on the plaque in- the oral carriage of Candida species and Enterobacteriaceae. Eur J Orthod. 2004 Dec;26(6);623-629. dex determined that the presence of orthodontic de- 10. Garwood D. Oral Hygiene. The Pharmaceutical Journal. 2003 vices, if the patient is enrolled in a rigorous recall of May;270(3):619-621. oral hygiene instructions, is not associated with a 11. Jung MH. Evaluation of the effects of malocclusion and or- worsening of the level of oral hygiene. thodontic treatment on self-esteem in an adolescent popu- Moreover, there does not seem to be a linear correla- lation. Am J Orthod Dentofacial Orthop. 2010 Aug;138(2):160- tion between expected duration of treatment and level 166. Annali di Stomatologia 2018;IX(1):43-52 51  A. Impellizzeri et al. 12. Sarul M, Lewandowska B, Kawala B, Kozanecka A, An- growth and adherence of microorganism (in vitro study). J toszewska-Smith J. Objectively measured patient coopera- of Clinical Experim Dent. 2013;5(1):36-41. tion during early orthodontic treatment: Does psychology have 17. Boyd RL. Periodontal consideration during orthodontic an impact? Adv Clin Exp Med. 2017 Nov;26(8):1245-1251. treatment. In Bishara SE. Text book of Orthodontics. WB. 13. Richter DD. Nanda RS, Sinha PK, Smith DW, Currier GF. Saunder Company. 2001:442-451. Effect of behavior modification on patient compliance in or- 18. Beckwith RF, Ackerman RJ, Cobb CM, Tira DE. An evalu- li thodontics. Angle Orthod. 1998 Apr;68(2):123-132. ation of factors affecting duration of orthodontic treatment. 14. Maret D, Marchal-Sixou C, Vergnes JN, Hamel O, Georgelin Am JOrthod Dentofacial Orthopedics. 1999;115:439-447. na Gurgel M, Van der sluis L, Sicou M. Effect of fixed orthodontic 19. Mavreas D, Athanasiou AE. Factors affecting the duration appliances on salivary microbial parameters at 6 months: a of orthodontic treatment: a systematic review. Eur J Orthod. controlled observational study. J Appli Oral Science. 2008 Aug;30(4):386-395. 2014;22(1):38-43. 20. Salmerón-Valdés EN, Lara-Carrillo E, Medina-Solís CE, Rob- 15. Freitas AO, Marcuezan M, Nojima Mda C, Alviano DS, Maia les-Bermeo NL, Scougall-Vilchis RJ, Casanova-Rosado JF, io LC. The influence of orthodontic fixed appliances on the oral et al. Tooth demineralization and associated factors in pa- microbiota: a systematic review. Dental Press J Orthod. 2014 tients on fixed orthodontic treatment. Scientific Reports. Mar-Apr;19(2):46-55. 2016;6:363-383. 16. Saloom HF, Mohammed Salih HS, Rasheed SF. The influ- 21. Atassi F, Awartani F. Oral hygiene status among orthodon- az ence of different types of fixed orthodontic appliance on the tic patients. J Contemp Dent Pract. 2010;11:25-32. rn te In ni io iz Ed IC C © 52 Annali di Stomatologia 2018;IX(1):43-52 

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Case report Neuro-occlusal rehabilitation by the Planas direct tracks method: case report li na José Ísper Garbin Artênio, DDS Introduction Gabriela Teruel Peres, DDS Tânia Adas Saliba, DDS The malocclusions can produce changes both from io Bruno Wakayama, DDS the aesthetic and functional points of view, affecting Clea Adas Saliba Garbin, DDS chewing, swallowing, breathing, phonation and the children’s quality of life (1-4). Occlusions are among az the public health problems due to their high São Paulo State University (UNESP), School epidemiological dimension in the childhood phase of Dentistry, Araçatuba (SP), Brazil and are considered by the World Health Organization the third odontological problem, being proceeded by rn periodontal disease and by dental caries (5-7). Corresponding author: Among the occlusions, the anterior and posterior Gabriela Teruel Peres crossbites stand out, being classified didactically in Postgraduate Program in Preventive and Social Den- skeletal, dental and functional. The skeletal crossbite te tistry, is the result of a discrepancy in the maxillary and/or São Paulo State University (UNESP) mandibular bone structure. The dental is caused by José Bonifácio 1193 an altered pattern of eruption of the teeth and the 16015-050 Araçatuba, São Paulo, Brazil In functional is characterized by the existence of E-mail: [email protected] premature contacts that depreciate the occlusion, causing skeletal changes if not treated early. The permanence of functional crossbite can lead to facial Summary and postural asymmetry, temporomandibular and ni masticatory problems (8, 9). Occlusions are among the problems of public Given these points, early corrective and preventive health due to their high epidemiological dimen- interception of crossbite in early childhood and the io sion in the childhood phase and are considered correct choice of treatment are essential. Neuro- by the World Health Organization the third odon- Occlusal Rehabilitation (NOR), using the Planas tological problem. Among them are the cross- Direct Tracks technique, elucidated by Pedro Planas, iz bites, which, if not treated early, may lead to cran- becomes attractive because of its orthopedic iofacial alterations in adulthood, compromising benefits. The NOR in its foundation is intended to the structures of the stomatognathic apparatus. remove occlusal interferences that cause physiolo - Ed The objective of this study was to report the clini- gical and morphological disorders in order to cal case of a male child with a functional unilater- reprogram the patient’s musculature (4, 6, 7, 9, 10). al posterior crossbite, treated by the planas direct The treatment with Planas Direct Tracks is a thera- tracks technique. The clinical case refers to a 3- peutic resource, in which there is the addition of year-old patient, with a left unilateral posterior composite resins applied directly in the occlusal of crossbite and with midline deviation. Following the deciduous teeth, forming a barrier that prevents IC the protocol of neuro-occlusal rehabilitation with the return of the mandible to the deviation position the use of Planas Direct Tracks, wearings were in which it was accustomed, seeking the harmo - performed on the occlusal interferences of the 63 nization of the occlusal plane in relation to the tooth and the confection of slopes in inclined Camper plane, and the altered vertical dimension C planes using composite resin, which was in- pathologically (4, 6). stalled on the upper tooth of the crossed side, in This technique is cited by many Authors as a way to order to promote the occlusal balance. After 31 treat functional crossbite because it presents days of treatment, there was bite uncrossing and advantages as a low cost when compared to © midline leveling. We conclude that the favorable orthopedic and/or orthodontic appliances, uses the clinical outcome has been achieved and that the function as growth stimulus, presents no risk of Planas Direct Tracks technique is effective for the overcorrection, is fast and does not depend on the treatment of functional crossbites. patient collaboration (6, 11, 12). However, despite the citations about the technique, there are few findings Key words: malocclusion, children, corrective or- in the literature that contextualize the theme, making thodontics. it difficult to study and disseminate it, and then being Annali di Stomatologia 2018;IX(1):53-58 53  J. Ísper Garbin Artênio et al. almost unknown in the dental environment. the mandibular deviation from the position of centric In this way, the present study aims to report the relation to maximum habitual intercuspation, clinical case of a male child with a functional characterized by the dental interferences. unilateral posterior crossbite, treated by the Planas No abnormal conditions were detected on panoramic Direct Tracks technique, in order to determine its radiographic examination. For differential diagnosis, it li efficacy and its occlusal stability. was used the data set obtained with the clinical and radiographic exams, study models, intra-buccal and na postural photographs. In the anamnesis, it was Clinical case verified that the patient was breastfed for 3 months, the chewing preference side was the left side and he The present clinical case was performed with a was not in dental treatment at another location (Fig. 4). io patient L.S.B., male, 3 years old, deciduous dentition. Initially, there were made removals of premature He was diagnosed in the initial clinical examination contacts and after that, the tracks were made in with left functional unilateral posterior crossbite, composite resin, following the protocol of adhesive az midline deviation, straight facial pattern, absence of restorations. Prophylaxis, relative isolation of the dental caries lesions and soft tissue normality. The operative field, conditioning of the teeth with 37% patient had a habit of using a baby bottle twice a day, phosphoric acid, application of the adhesive system and the caregiver was instructed to stop this habit and the confection of the tracks, with composite resin rn (Fig. 1-3). photopolymerizable. For this, the insertion of the According to the NOR protocol, there was classified composite resin in an inclined plane on 63 tooth was the functional unilateral posterior crossbite with determinant to establish the correct neuromuscular manipulation of the mandible for the examination of excitation in the rehabilitation of the stomatognathic te the intermaxillary relation. This procedure evidenced system. In Figure 1. Initial of treatment: left functional unilateral posterior crossbite. ni io iz Ed Figure 2. Initial of treatment: left functional unilateral posterior IC crossbite. C © 54 Annali di Stomatologia 2018;IX(1):53-58  Neuro-occlusal rehabilitation by the Planas direct tracks method: case report Figure 3. Initial of treatment: left functional unilateral posterior crossbite. li na io az rn The patient was accompanied with 2 biweekly and 1 te monthly controls for treatment evaluation and for occlusal adjustments. There was leveling of the midline and uncrossing of the bite, showing that the goal of the treatment was reached and, at the end of In this period, the rebalancing of the stomatognathic apparatus (Figs. 5-8). ni Discussion The high prevalence of posterior crossbite in io preschool children warns the need for prevention and early intervention, since this occlusion does not self- correct and causes physiological, social and iz psychological disorders (9, 13-15). Among the main etiological factors of posterior crossbite, genetic factors, mouth breathing, neglect of Ed breastfeeding and sucking habits can be highlighted (9, 16). Since the 40’s, Pedro Planas was concerned with the etiology and diagnosis of childhood occlusion disorders. The reduction in the number of children breastfed, in conjunction with what Planas called IC “civilized feeding”, eliminates some of the stimuli needed for growth and changes the pattern of Figure 4. Initial of treatment: postural photographs. development of the respiratory system (6, 10). Moimaz et al demonstrated that the lack of C stimulation caused by breastfeeding can lead to The restorative material selected was the composite occlusions, including crossbite, a fact evidenced in resin Z100 (3M), in shade A1. It is a microhybrid resin this study, in which the patient’s mother reported that offers adequate resistance to masticatory efforts, breastfeeding for only 3 months (16). © while allowing good smoothness of surface and The NOR as a treatment of posterior crossbite was polishing, avoiding the accumulation of dental biofilm. efficient due to the fast correction of the occlusion The finishing was done with diamond tips numbers and because it was made in a single session. The 1192F and 3118F in high rotation. The final confi - treatment is favorable within 3 to 6 years old children guration of the tracks must be wide enough to block the because it corresponds to the stage of greater growth return of the mandible to the deflected position and thick and development of the cranio-muscular. In the enough for not to fracture when in function. present study, the clinical case was performed in a 3- Annali di Stomatologia 2018;IX(1):53-58 55  J. Ísper Garbin Artênio et al. Figure 5. Clinical case: 30 days after treatment. li na io az Figure 6. Clinical case: 30 days after treatment. rn te In ni io iz Ed Figure 7. Clinical case: 30 days after treatment. IC C © 56 Annali di Stomatologia 2018;IX(1):53-58  Neuro-occlusal rehabilitation by the Planas direct tracks method: case report that they do not require collaboration of the patient, since they are based on “adhesive restorations” and selective wearings that remain active in the stomatognathic system. As pointed out by Pinzan et al., the collaboration of the child in the use of the li removable orthodontic appliance is one of the most critical limitations of his study because it interferes in na the efficacy and time of the treatment (5-7, 12, 20, 21). In the clinical case, the patient obtained at the end of the NOR treatment, correction of crossbite, leveling of the midline and return of facial symmetry. Studies corroborate that facial asymmetries are generally io more frequent in individuals presenting unilateral posterior crossbite in the deciduous dentition than those with normal occlusion. Given that, it is inferred az the importance of the treatment in the growth phase of the individual, since this functional occlusal disharmony can cause changes in the skeletal structures generating after-effects in the adulthood. rn Conclusion te The correction of functional unilateral posterior crossbite through the use of Planas Direct Tracks. The favorable clinical outcome was reached, because In the intervention occurred at an early age and the child’s tissue dynamics was still favorable for remo- deling and accommodation of the stomatognathic apparatus. ni Figure 8. Clinical case: 30 days after treatment. References io 1. Dimberg L, Arnrup K, Bondemark L. The impact of maloc- year-old patient and used the adaptive capacity of the clusion on the quality of life among children and adolescents: a systematic review of quantitative studies. Eur J Orthod. musculature as proposed by many Authors (4, 6, 7, iz 2015;37(3):238-247. 12, 17). 2. Fields HW. Craniofacial growth from infancy through adult- With diagnosis and early intervention, it is observed hood. Background and clinical implications. Pediatric Clin- Ed the reestablishment of normal patterns in facial ics of North America. 1991;38(5):1053-1088. growth and development. This is the objective of the 3. Peres Kg, Traebert ESA, Marcenes W. Differences between treatment of functional crossbites, which aims to normative criteria and self-perception in the assessment of malocclusion. Rev Saúde Pública. 2002;36(2):230-236. change the mandibular posture, by the association of 4. Garbin AJI, Wakayama B, Rovida TAS, Garbin CAS. Neu- the made tracks and selective wearings performed on rocclusal rehabilitation as a treatment for posterior crossbite: premature dental contacts (4, 12, 18, 19). case report. Braz J Surg Clin Res. 2015 Jul;11(4):21-24. IC In this way, it facilitates the deprogramming of the 5. Primozic J, Richmond S, Kau CH, Zhurov A, Ovsenik M. nervous and muscular centers, adapted to the Three-dimensional evaluation of early crossbite correction: deviation, with later remodeling to the appropriate a longitudinal study. Eur J Orthod. 2013 Feb;35(1):7-13. position. The neural and muscular deprogramming 6. Chibinski ACR, Czlusniak GD, Melo MD. Planas direct tracks: C orthopedic treatment to correct functional crossbite. R Clin obtained with the orthopedic treatment has as Ortodon Dental Press. 2005;4(3):64-72. immediate consequence the need to stimulate the 7. Garbin AJI, Wakayama B, Santos RR, Rovida TAS, Garbin patient to adapt to the new mandibular position (6, 7, CAS. Planas direct tracks for the treatment of posterior cross- 11, 12). bite. Rev Cubana Estomatol. 2014;51(1):113-120. © The correction of functional posterior crossbite by the 8. Locks A, Weissheimer A, Ritter DE, Ribeiro GLU, Menezes direct tracks reunites innumerable features that make LM, Carla D’Agostini Derech CD, et al. Posterior crossbite: its use advantageous. It is a resource that presents a more didactic classification. R Dental Press Ortodon Or- top Facial. 2008 Mar/Abr;13(2):146-158. low cost, dispenses material or special equipment for 9. Garbin AJI, Wakayama B, Saliba TA, Garbin CAS. The use its realization, and should be proposed for the public of Planas Direct Track early treatment of posterior crossbite: service, since occlusions are the third public health a case report. Arch Health Invest. 2016;5(4):182-185. problem according to WHO. Moreover, it is the fact 10. Planas P. Reabilitação Neuroclusal. 2 ª ed. Rio de Janeiro: Annali di Stomatologia 2018;IX(1):53-58 57  J. Ísper Garbin Artênio et al. Medsi;1997. 16. Moimaz SAS, Rocha NB, Garbin AJI, Saliba O. The effect 11. Garbin AJI, Wakayama B, Saliba TA, Garbin CAS. Neuro- of breastfeeding in the acquisition of non-nutritive sucking clusal rehabilitation and planas direct tracks in the posteri- habits and malocclusion prevention. Rev Odontol UNESP. or crossbite treatment. RGO, Rev. Gaúch. Odontol. Camp- 2013;42(1):31-36. inas. 2017 Apr/June;65(2). 17. Simões W. Functional orthopedic of the maxillary neuro-oc- 12. Rossi LB, Pizzol KEDC, Boeck ME, Lunard N, Garbin AJI. clusal rehabilitation. 3ºed. Artes médicas. 2003. li Correction of functional anterior crossbite with Planas direct 18. Chibinski ACR, Czlusniak GD. Evaluation of treatment for tracks: A case report. Faculdade de Odontologia de functional posterior crossbite ofthe deciduous dentition us- na Lins/Unimep. 2012 Jul-Dez;22(2):45-50. Jan-Jun 2012. ing Planas direct tracks. Indian J Dent Res. 2011;22(5):654- 13. Rosa GN, Del Fabro JP, Tomazoni F, Tuchtenhagen S, Alves 658. LS, Ardenghi TM. Association of malocclusion, happiness, 19. Ramirez-Yañez GO. Planas direct tracks for early crossbite and oral healthrelated quality of life (OHRQoL) in schoolchil- correction. J Clin Orthod. 2003 Jun;37(6):294-298. dren. J Public Health Dent. 2015 Jul. doi: 10.1111/jphd. 20. Freitas MR, Beltrão RTS, Freitas KMS, Vilas Boas J, Hen- io 12111.1 riques JFC, Janson GRP. A simplified approach for class II, 4. Oliveira CM, Sheiham A. Orthodontic treatment and its im- division 1 open bite malocclusion treatment: a case report. pact on oral health-related quality of life in Brazilian ado- Rev Dent Press Ortodon Ortop Maxilar. 2003 Maio-Jun;8 lescents. J Orthod. 2004 Mar;31(1):20-27. (3):93-100. az 15. Dimberg L, Arnrup K, Bondemark L. The impact of maloc- 21. Pinzan A, Vargas JN, Janson GRP. Orthodontic patient mo- clusion on the quality of life among children and adolescents: tivation and expectations. Ortodontia. 1997 Set-Dez;30 a systematic review of quantitative studies. Eur J Orthod. 2015 (3):40-44. Jun;37(3):238-247. rn te In ni io iz Ed IC C © 58 Annali di Stomatologia 2018;IX(1):53-58 

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Original article Immunoexpression of cytokeratin-19 in the oral lichen planus and related oral squamous cell carcinoma li na Gian Paolo Bombeccari DDS, PD, MS corresponding OLP tissues (Mann-Whitney test, Aldo Bruno Giannì MD P=0.02). Well-differentiated OSCC showed signifi- Francesco Spadari MD cantly lower of C-K19 scores than those moder- io ately differentiated grades (Mann-Whitney, Maxillo-Facial and Dental Unit (Head Prof. AB Giannì) P=0.007). Fondazione Ca’ Granda IRCCS Ospedale Maggiore Conclusions. The quantity and distribution of CK- az Policlinico Milan, Italy - Department of Biomedical, 19 staining in OSCCs showed relevant difference Surgical and Dental Sciences, University of Milan, in comparison with OLP lesions. The increased of Italy CK19 protein expression in OSCC tissues corre- lates significantly with the pathologic differentia- rn tion grade. Gian Paolo Bombeccari Corresponding author: Key words: cytokeratin, oral cancer, oral squa- Department of Biomedical, Surgical, and Dental Sci- mous cell carcinoma, oral lichen planus, head te ences, Unit of Oral Pathology and Medicine, Universi- and neck cancer. ty of Milan Via Della Commenda 10 20122 Milan, Italy Introduction In E-mail: [email protected] Oral lichen planus (OLP) is a chronic inflammatory disorder with a prevalence accepted to be approxi- mately 1% of the general population (1). The alleged potentially malignant character of the ni oral lichen planus has been matter of debate for sev- eral decades. In a seven-year follow-up study of 327 Summary OLP patients the annual malignant transformation io rate amounted to less than 0.5% (2). Aims. Cytokeratin 19 (CK-19) is an epithelium- However, when the incidence of oral cancer is set at specific intermediate filament protein that has 5 per 100.000 per year, then an annual risk of malig- been investigated in oral lichen planus (OLP) le- nant transformation in oral lichen planus patients of iz sions but has not been compared with the expres- 0.5% is a hundred times increased risk (1). sion of CK-19 in the OLP-related oral squamous Cytokeratins (CKs) are epithelium-specific intermedi- cell carcinoma (OSCC). The aim of the present ate filament proteins that maintain cellular integrity Ed study has been to objectively compare the im- and participate in cell-to-cell attachments (3). munohistochemical expression of the CK-19 in Cytokeratins are the main differentiation markers of OLP lesions and subsequent OSCC lesions that the stratified epithelium, and 19 subclasses of CKs developed over time, to evaluate the change of can be classified in according to their molecular the staining pattern among OLP and the grades of weights, and distinguished by the site-specific distrib- differentiation in OSCC. ution in the epithelium (4). Methods. Thirty-six formalin-fixed tissues of 18 IC Cytokeratin-19 (CK-19) has been identified as a use- OLP patients (18 samples from OLP lesion and 18 ful marker of cellular atypia, associated with pre-ma- samples from OLP-related OSCC lesion) were in- lignant lesions in the oral epithelium (5). cluded. The monoclonal antibody for CK-19 was Also, CK-19 expression has been regarded as an im- used at 1:100 dilution for the immuno-staining on C portant clue in the initial events during oral carcino- 4-µm thick sections. Staining pattern of CK-19 genesis (6). was graded into a 4-point scale: (1) no staining, Although a few studies demonstrated positive CK-19 (2) only few cells staining, (3) less than 50% of the staining in the basal layer of some dysplastic and ma- cells stained, and (4) 50% or more of the cells © lignant oral lesions (5, 7, 8), other studies have not stained. Microslides were examined under the shown changes in the CK-19 expression in presence light microscope using objective lenses magnifi- of oral dysplastic lesions, and/or any correlation be- cations of 4×, 10×, and 20×. tween the histological parameters and CK-19 staining Results. The CK19 positive rate in OLP tissues pattern in OLP lesions (9-11). was 33% (6 out of 18) and 56% (10 out of 18) in Since the available data are discordant and the pro- OSCC tissues. The CK19 positive score in OSCC tissues was significantly higher than that in the 104 Annali di Stomatologia 2017;VIII(3):104-109  CK 19 and oral lichen planus duction of Ck-19 in the suprabasal cells of the oral mucosa – usually produced by cells in the basal lay- Immunohistochemistry and evaluation of er- may- indicate alteration in cell behavior and prob- For immunohistochemical staining 4-μm thick sec- immunostaining able premalignant changes (5, 12, 13), more data are tions from formalin-fixed, paraffin-embedded tissue needed to establish a correlation between CK-19 ex- blocks were cut. The monoclonal antibody for CK-19 pression pattern and the oral malignant transforma- (DAB-Ventana-Roche, Benchmark-XT system, Tuc- tion. son, AZ, USA) were used at 1:100 dilution. The incu- li The aim of the present study is to objectively analyze bation period for antibody was 12 hours. The expres- na the immunohistochemical expression of the CK-19 in sion level of CK-19 was analyzed using Biotin free OLP lesions undergoing malignant transformation Multimer Ultraview. As regard CK-19, a positive reac- and subsequent OLP-related oral squamous cell car- tion was considered as clear staining within the ep- cinoma (OSCC), and to compare the change of the ithelium (basal and/or suprabasal) of OLPs and OS- staining pattern among OLP and the grades of differ- CCs sections. The staining pattern of CK-19 was io entiation in OSCC. graded into a 4-point scale: (1) no staining, (2) stain- ing of only few cells, (3) less than 50% of the cells stained, and (4) 50% or more of the cells stained. All az immunostained microslides were examined under the light microscope (Olympus model U-MDO10B, USA) Materials and methods equipped with objective lenses magnifications of 4×, The study was conducted using the oral mucosa 10×, and 20×. Specimen selection rn biopsy samples of 18 Caucasian patients that devel- oped an oral squamous cell carcinoma (OSCC), with- in a group of 683 subjects with clinical and pathologic Frequency tables were analyzed using the Chi- Statistical analysis diagnosis of OLP. The entire cohort of OLP patients square test in order to assess the relevance of the te has been followed from March 2001 through Novem- correlation among the categorical variables. Mann- ber 2015, with a frequency established on the basis Whitney U test were applied with the objective of of the clinical features and need for topical OLP ther- comparing the means of the grades of immunoex- In apy. pression of CK-19 for each diagnostic group (OLP The OLP diagnosis was defined according to revised group and OSCC group). In each analyze the proba- and modified World Health Organization diagnostic bility values less than 0.05 (p< 0.05) were regarded criteria (14). as significant. Statistical calculations were performed For each of the 18 OLP-OSCC patients 2 tissue sam- with the use of STATA 11.1 (College Station, TX, ni ples were taken: the first sample from OLP lesion and USA). second sample from OLP-related OSCC lesion. Clini- cal criteria for biopsy sampling in OLP-OSCC sus- io pected lesions were the evidence of a loss of keratot- ic homogeneity associated with red areas of granular Results appearance and an increased consistency of the OLP Out of 683 OLP patients prospectively followed for iz lesions. The criteria of the American Joint Committee 19-128 months in the mean observation period of on Cancer (AJCC) have been adopted to determine 89.7 months (SD 13.9), 18 of them developed an OS- the clinical cancer stage (15). The Local Ethical Com- CC. The group of 18 OLP-OSCC patients was com- Ed mittee approval was obtained by the Institutional posed of 12 women (67%) and 6 men (33%), with the Board, and each of the patients, once thoroughly in- women’s mean age of 65 years (range 60-71) and the formed, provided oral and written (signed) informed men’s mean age of 62 years (range 55-68). The consent. length of follow-up period before malignant transfor- mation event ranged from 24 to 78 months [mean val- ue 47.3 months (SD 12.90)]. IC The oral biopsy samples of OLP-OSCC group pa- The anatomic sites most commonly involved in sub- Histological examination tients were fixed in 10% formalin, paraffin-embedded sequent malignant transformations of the OLP lesions and processed. Haematoxilin and eosin stained were the tongue [8/18 patients, (44%)] and oral buc- slides of 6 μm were cut for diagnostic procedures. cal mucosa [6/18 patients, (33%)]. C The OLP biopsies were reviewed by an expert oral The observed clinical form of OLP that more fre- pathologist and were deemed to be eligible when the quently underwent malignant transformation was the following histopathologic features were observed: 1) atrophic and/or erosive form, with erosive OLP being the presence of one or more well defined band-like detected in 9 out of the 18 cases (50.0%) of OSCC © zone of cellular infiltration, which was confined to the and the keratotic form in 6 out of 18 patients (33%). superficial part of connective tissue; 2) evidence of Histologically, 13 out of 18 cases (72.0%) of OSCC liquefaction degeneration in the basal cell layer; and presented a well differentiated grade with a microin- 3) absence of epithelial dysplasia. The localization of vasive pattern of infiltration. The remaining 5 out of the OLP lesions in the oral mucosa and site of prima- 18 cases (28.0%) displayed a moderate degree of dif- ry OSCC arising from OLP were recorded. ferentiation. Annali di Stomatologia 2017;VIII(3):104-109 105  G.P. Bombeccari et al. more marked in the OSCC samples versus the OLP specimens (Mann-Whitney, P=0.02). Of the OLP pos- Microscopic evaluation of the immunostained Thirty-six biopsy samples (18 OLP samples and 18 itive samples, 6/18 (33%) were classified in category sections OLP-related OSCC) were studied for CK-19 im- 2 (only few cells staining), with CK-19 staining con- munostaining (Figs. 1-3). For each patient, the stain- fined to the basal cell layer of the oral epithelium. Of ing pattern of CK-19 is shown in Table 1. Cytokeratin- the 10/18 OSCC samples, 5/10 (50%) were catego- 19 expression was positive in 6/18 of the OLP biopsy rized of grade 2 and 5/10 (50%) of grade 3 (less than li na Figure 1. Oral lichen planus immuno- histochemistry: complete negativity for CK-19 staining in the basal and suprabasal layer (10x, CK19). io az rn te In ni Figure 2. Well-differentiated OSCC: positivity for CK-19 in the basal and suprabasal layer with a score of 3 in the io staining pattern (10x, CK19). iz Ed IC C © samples (33%), and 10/18 of the OLP-related OSCC 50% of the cells stained), with CK-19 expressed in biopsy samples (56%), with no significant difference basal-parabasal layer and focally on the superficial between the samples of OLP and OSCC (Mann-Whit- epithelium (Tab. 2). In the paired comparisons of CK- ney, P>0,10). 19 staining scoring, well-differentiated OSCC showed Concerning to the grading of the tissues staining into significantly lower C-K19 scores than those moder- a 4-point scale CK-19, it was statistically significantly ately differentiated grades (Mann-Whitney, P=0.007) 106 Annali di Stomatologia 2017;VIII(3):104-109  CK 19 and oral lichen planus Figure 3. Moderate-differentiated OS- CC: positivity for CK-19 in the basal layer and superficial layer with a score of 3 in the staining pattern (10x, CK19). li na io az rn te In Table 1. Clinical-epidemiological data, oral localization of the lesions and comparative values of CK-19 score for each patient: (1) no staining, (2) only few cells staining, (3) less than 50% of the cells stained, and (4) 50% or more of the cells stained. Sample sex age Lesions site Clinical form of OLP Expression of CK-19 ni OLP OSCC BS F 60 Dorsum of the tongue Atrophic, Erosive 2 3 io CN F 67 Lateral margin of the tongue Keratotic 1 1 DD M 55 Lateral margin of the tongue Atrophic, Erosive 1 1 iz FF F 69 Maxillary gingiva Atrophic, Erosive 2 3 PS M 67 Buccal mucosa Keratotic 1 1 Ed PM M 58 Lateral margin of the tongue Mixed form 1 2 RA F 71 Buccal mucosa Keratotic 1 1 ZL F 63 Buccal mucosa Atrophic, Erosive 1 2 TV F 61 Buccal mucosa Atrophic, Erosive 1 2 BM F 67 Lateral margin of the tongue Keratotic 1 1 IC BT F 62 Ventral tongue mucosa Atrophic, Erosive 2 3 CS M 68 Buccal mucosa Keratotic 1 1 BG M 64 Lateral margin of the tongue Atrophic, Erosive 2 3 C CA F 68 Lateral margin of the tongue Atrophic, Erosive 1 1 PG M 60 Dorsum of the tongue Keratotic 2 3 PE F 64 Lateral margin of the tongue Mixed form 2 2 © LM F 70 Buccal mucosa Atrophic, Erosive 1 1 SE F 61 Mandibular gingiva Mixed form 1 2 P-value 0.045 (Tongue) 0.11 0.10 (OLP VS OSCC) (Expression of CK-19) 0.02 (OSCC+ VS OLP+) CK-19, cytokeratin 19; OLP Oral Lichen Planus; OSCC, Oral Squamous Cell Carcinoma Annali di Stomatologia 2017;VIII(3):104-109 107  G.P. Bombeccari et al. Table 2. Distribution and statistical comparison of CK-19 scores between OLP lesions and OLP-related OSCCs. CK-19 staining pattern Specimens OLP OSCC W-D OSCC M-D OSCC No (%) No (%) No (%) No (%) No (%) li No staining (grade 1) 20 (56) 12 (67) 8 (44) 8 (62) 0 Only few stained cells (grade 2) 11 (30) 6 (33) 5 (28) 4 (30) 1 (20) na <50% of the cells stained (grade 3) 5 (14) 0 5 (28) 1 (8) 4 (80) >50% of the cells stained (grade 4) 0 0 0 0 0 Total number of specimens 36 18 18 13 5 io P-value (CK19- VS CK19+) 0.12 0.15 0.7 0.007 (W-D vs M-D OSCC) CK-19, cytokeratin 19; OLP Oral Lichen Planus; OSCC, Oral Squamous Cell Carcinoma; W-D, Well-Differentiated OSCC; az M-D, Moderately-Differentiated OSCC (Tab. 2). The CK-19 staining pattern was significantly - between 2 and 3 - of the observed staining pattern more frequent in the tongue tissues than in other lo- in the tissue sections. Furthermore, a significantly rn calizations of the oral mucosa (Chi-square test higher CK-19 score in moderately differentiated OS- P=0.045). Regarding the different types of OLP, the CCs than well-differentiated ones was reported. Pre- CK-19 expression has not been statistically signifi- vious studies examined the rate of CK-19 expression te cant in relation with any clinical form of OLP among in relation to the grades of pathological differentiation those reported in Table 1 (Chi-square test P=0.11). in the OSCCs, detecting a positive association (6, 8, 13, 17, 18). The achieved findings are consistent with the results of those studies and could be related to In the progressive increased expression of precursor- cell keratin – as cytokeratin-19 – in less-differentiated Discussion The purpose of the present study was to examine the grades of OSCCs (6, 8, 13). The staining pattern of expression of cytokeratin 19 (CK-19) in both oral CK-19 was detected as significantly more frequent in ni lichen planus (OLP) biopsy samples and those of oral the tongue of the OLP and OSCC patients than in other squamous cell carcinoma (OSCC) developed in the sites of the oral mucosa. This trend is in line with a pre- OLP lesions. Outcomes showed that CK-19 staining vious study by Mattila et al. concerning the topographic io was heterogeneously expressed in the 33% of the expression of CK-19 in OLP lesions (10). As a matter of OLP lesions and the 56% of the OLP-related OSCCs. fact, the tongue appears to be the preferential site of Data collected on the immunostaining OLP lesions primary neoplasia OLP-related, in accordance with pre- are consistent with the results of the study by Mattila viously reported in literature (2, 19). iz et al., which reported a 29% rate of CK-19 marked Although the data achieved in the present study are OLP specimens (10). As for the findings of CK-19 consistent with other reports, the most significant limi- positivity in the OSCC samples our data are coherent tation of this single-center study is the relatively small Ed with a previous study by Safadi et al. which reports number of investigated cases, also due to the low an overall percentage of 66,7% of stained sections rate of malignant transformation that occurring on av- (8). Also, additional evidence showed that the grading erage in the OLP patients. Another limitation can be of CK-19 staining in the OSCC sections was signifi- considered the absence in our cases of poorly differ- cantly more marked in comparison with the OLP sec- entiated OSCCs, that has not made possible a CK-19 tions. In the current study, the aberrant expression staining comparison on all histopathological differenti- IC and localization – basal and suprabasal cells layer – ation grades in the OSCCs. Despite of the all above of CK-19 staining observed in the OSCCs could be mentioned, it could be stated that the positive stain- interpreted as a potential increased progression cor- ing of CK-19 has resulted to be intermittent within related with disturbed stem cells distributions, which both OLP and OSCCs lesions. The marking pattern C are normally present in the basal cell layer (6, 16). In for CK-19 in OLP lesions has been categorized as a previous study of 33 OSCCs cases, Zhong et al. re- scarce and confined to the basal cell layer of the ep- ported that the CK-19 protein expression in OSCCs ithelium in comparison to what observed in OSCCs tissues correlate significantly with a pathologic differ- lesions. The supplementary immunostaining with © entiation grade of the malignant lesions, with an in- monoclonal antibody for CK-19 in the OLP-related creasing m-RNA CK-19 level from well-differentiated OSCCs could contribute to better define their cancerous tissues in comparison with those with histopathological differentiation grade. poorly grade of differentiation (13). In the present The findings obtained in the present study suggest study, the high prevalence (72%) of well-differentiat- that the amount and distribution of CK-19 staining ed OSCCs lesions could explain the medium scoring have significantly increased in OSCCs in comparison 108 Annali di Stomatologia 2017;VIII(3):104-109  CK 19 and oral lichen planus with OLP-related lesions. 7. Schulz J, Ermich T, Kasper M, Raabe G, Schumann D. Cy- This CK-19 staining pattern is significantly more tokeratin pattern of clinically intact and pathologically marked in moderately-differentiated OSCCs than changed oral mucosa. Int J Oral Maxillofac Surg. Feb 1992; well-differentiated ones. 21(1):35-39. 8. Safadi RA, Musleh AS, Al-Khateeb TH, Hamasha AA. Analysis of immunohistochemical expression of k19 in oral epithelial dysplasia and oral squamous cell carcinoma us- li Conflict of interest statement ing color deconvolution-image analysis method. Head Neck Pathol. Dec 2010;4(4):282-289. We have no conflicts of interest connected with this na 9. Jacques CM, Pereira AL, Maia V, Cuzzi T, Ramos-e-Silva work. We declare that we have no competing finan- M. Expression of cytokeratins 10, 13, 14 and 19 in oral lichen cial interest. planus. J Oral Sci. Sep 2009;51(3):355-365. 10. Mattila R, Alanen K, Syrjänen S. Immunohistochemical study on topoisomerase IIalpha, Ki-67 and cytokeratin-19 in oral io lichen planus lesions. Arch Dermatol Res. Jan 2007;298 (8):381-388. Funding 11. Maeda H, Reibel J, Holmstrup P. Keratin staining pattern in None. clinically normal and diseased oral mucosa of lichen planus az patients. Scand J Dent Res. Aug 1994;102(4):210-215. 12. Michel M, Torok N, Godbout MJ, et al. Keratin 19 as a bio- chemical marker of skin stem cells in vivo and in vitro: Ker- atin 19 expressing cells are differentially localized in func- Authors’ contributions GPB has conceived and drafted the manuscript. FS tion of anatomic sites, and their number varies with donor rn and ABG have participated in the design and coordi- age and culture stage. J Cell Sci. 1996;109(Pt5):1017-1070. nation of this study. 13. Zhong LP, Chen WT, Zhang CP, et al. Increased CK19 ex- pression correlated with pathologic differentiation grade and All Authors read and approved the final manuscript. prognosis in oral squamous cell carcinoma patients. Oral Surg te Oral Med Oral Pathol Oral Radiol Endod. 2007;104(3):377- 384. References 14. Van der Meij EH, van der Waal I. Lack of clinicopathologic In correlation in the diagnosis of oral lichen planus based on 1. Van der Waal I. Oral potentially malignant disorders:is ma- the presently available diagnostic criteria and suggestions lignant transformation predictable and preventable? Med Oral for modifications. J Oral Pathol Med. 2003;32:507-512. Patol Oral Cir Bucal. Jul 2014;1;19(4):e386-390. 15. Fleming ID, Cooper JS, Henson DE, Hutter RVP, Kennedy 2. Bombeccari GP, Guzzi G, Tettamanti M, Giannì AB, Baj A, BJ, Murphy GP, et al. AJCC cancer staging manual. 5th ed. Pallotti F, Spadari F. Oral lichen planus and malignant trans- ni Philadelphia: Lippincott-Raven. 1997:29-39. formation: a longitudinal cohort study. Oral Surg Oral Med 16. Fillies T, Jogschies M, Kleinheinz J, et al. Cytokeratin alteration Oral Pathol Oral Radiol Endod. Sep 2011;112(3):328-334. in oral leukoplakia and oral squamous cell carcinoma. On- 3. Fradette J, Germain L, Seshaiah P, et al. The type I keratin col Rep. 2007;18(3):639-643. io 19 possesses distinct and context-dependent assembly prop- 17. Toyoshima T, Vairaktaris E, Nkenke E, et al. Cytokeratin 17 erties. J Biol Chem. 1998;273(52):35176-35184. mRNA expression has potential for diagnostic marker of oral 4. Moll R, Franke WW, Schiller DL, Geiger B, Krepler R. The squamous cell carcinoma. J Cancer Res Clin Oncol Erratum catalog of human cytokeratins: patterns of expression in nor- iz in: J Cancer Res Clin Oncol. 2008;34(4):523; 24,134(4):515- mal epithelia, tumors and cultured cells. Cell. 1982;31:11- 521. 24. 18. Ram Prassad VV, Nirmala NR, Kotian MS. Immunohisto- 5. Lindberg K, Rheinwald JG. Suprabasal 40 kd keratin (K19) chemical evaluation of expression of cytokeratin 19 in different Ed expression as an immunohistologic marker of premalignancy histological grades of leukoplakia and oral squamous cell car- in oral epithelium. Am J Pathol. 1989;134:89-98. cinoma. Indian J Dent Res. 2005;16:6-11. 6. Nie M, Zhong L, Zeng G, Li B. The changes of cytokeratin 19. Lanfranchi-Tizeira HE, Aguas SC, Sano SM. Malignant trans- 19 during oral carcinogenesis. Zhonghua Kou Qiang Yi Xue formation of atypical oral lichen planus: a review of 32 cas- Za Zhi. 2002;37:187-190. es. Med Oral. 2003;8:2-9. IC C © Annali di Stomatologia 2017;VIII(3):104-109 109 

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Original article Oral health knowledge and attitude among caregivers of special needs patients at a Comprehensive Rehabilitation Centre: li an analytical study na Altaf H. Shah1 BDS, MSc, PG Cert (age, gender, experience, literacy). The other part (Sp Care Dent), PhD of the questionnaire was related to the knowledge Mustafa Naseem2 BDS, MDPH and attitude of caregivers regarding importance io Mohammad Shoyab Khan3 BDS, MDS of oral health including oral hygiene practices, Faris Yahya I Asiri4 BDS cause of tooth decay, significance of fluoride, Ibrahim AlQarni5 BDS common oral problems and need for oral health az Shabnam Gulzar6 BDS, MDS education. Comparison between oral health Ramesh Nagarajappa7 BDS, MDS knowledge and oral health attitude of caregivers was done using one-sample t Test. The level of Faculty, College of Dentistry, Dar Al Uloom significance was set as p=0.005*. 1 rn University, Riyadh, Saudi Arabia; Fellow Pacific Results. Adequate oral health knowledge was Academy of Higher Education and Research found to be among 59.2% and favourable attitude University, Rajasthan, India of caregivers towards oral health care was found 2 Assistant Professor, Department of Preventive among 48.3%. The results indicate that though te majority among caregivers had adequate knowl- Dental Sciences, Dar Al Uloom University, Riyadh, edge but their attitude towards oral health was in- Saudi Arabia adequate. 3 Lecturer, Division of Periodontics, Department of In Conclusion. Caregivers showed a deficiency in the Preventive Dental Sciences, Prince Sattam bin proper oral health attitude. To improve oral health Abdulaziz University AlKharj, Saudi Arabia attitudes of caregivers, dental education plus train- 4 Demonstrator, Department of Preventive Dental ing programs should be given high priority. Sciences, College of Dentistry, King Faisal University, Al-Ahsa, Saudi Arabia ni Key words: caregivers, knowledge, oral health, 5 Dentist, Ministry of Health, Alula, AlMadina special needs. Almunawara, Saudi Arabia 6 Lecturer, Division of Paediatric Dentistry, Department io of Preventive dental Sciences, Dar Al Uloom University 7 Professor and Head, Department of Public Health Introduction Dentistry, Institute of Dental Sciences, Siksha ‘O’ Oral health in special need patients is one of the iz Anusandhan University, Kalinganagar, Bhubaneswar, most deserted aspects of care. The degree of unmet Odisha, India dental needs amongst this populace is highly com- promised when compared to the general population Ed (1). Maintaining good and optimal oral health in these physically handicapped and intellectually disabled in- Mustafa Naseem Corresponding author: dividuals is very challenging as they also have a com- Department of Preventive Dental Sciences, College promised general health (1, 2). It is known that good of Dentistry, Dar Al Uloom University oral health can help in improving general health, self- Riyadh, Saudi Arabia esteem, social integration and thereby the quality of IC E-mail: [email protected] life (3, 4). Age, severity of impairment and living con- ditions have been reported to influence oral as well as general health of disabled children and adults (5). Prevention of oral diseases in special needs group C Summary has higher importance due to limited availability of re- sources and poor access to oral health care (6). It has been demonstrated that oral health education is Aim. To evaluate knowledge and attitude of care- well recognised and shows improvement of attitudes givers/healthcare workers regarding oral health of © and knowledge towards dental health care especially special need patients, at a comprehensive reha- among caregivers of special needs patients (7). bilitation centre. These improvements are found to be significant when Material and methods. A validated self-adminis- in parallel with better delivery of oral health care for tered structured questionnaire was used in an in- such people (8). terview style among 120 caregivers at a compre- It has been proposed that educating people involved hensive rehabilitation centre. The first part of questionnaire collected demographic information 110 Annali di Stomatologia 2017;VIII(3):110-116  Oral health knowledge and attitude among caregivers of special needs patients at a Comprehensive Rehabilitation Centre: an analytical study in care of special need patients is beneficial particu- signed in English, Arabic, Hindi and Bangla lan- larly with regard to oral health (1, 9). Disabled chil- guages using support from native speakers in order dren and adults living in long-term accommodations to improve the comprehensibility for the caregivers. are usually dependent on others for their personal The interview style questionnaire for this study was care. Parents, siblings or caregivers usually render piloted using surveys previously conducted by Prab- this care. Hence, it is important that these caregivers hu et al. (16) and Koneru A & Sigal MJ (17). The have the knowledge and are aware of the preventive questionnaire was divided into three sections follow- li practices for maintaining optimal oral health for this ing information about caregivers’ knowledge and atti- na group under their care (10, 11). Unfortunately, majori- tudes. ty among the caregivers lack the knowledge of proper Section I: solicited general demographic and profes- oral health care themselves and thus fail to recognize sional background information. Section II: integrated its importance resulting in not applying proper oral questions about oral health knowledge and personal health behaviour (12). oral health practice by the caregivers. Section III: io The incidence of dental disease is on a rise among comprised of questions, which aimed to assess atti- the disabled people in the gulf region. Several studies tude about oral health care and practice. across the globe have focussed on a need to improve The study was reviewed by the Ethical Committee at az and prevent dental diseases in special care children Salman bin Abdulaziz University and was granted (13, 14). Some of the people with disabilities may be ethical approval. An official permission was attained directly dependent on caregivers for their private care from the director of the comprehensive rehabilitation and the role of these carers is pivotal in the life of centre, AlKharj. Furthermore, a written approval from rn such people. Therefore, interventions should be caregivers was also attained. All ethical procedures aimed towards caregivers in a culturally appropriate were in accordance with the ethical standards and in and acceptable manner that directly improves their harmony with the Helsinki Declaration of 1975 re- knowledge as well as the attitude, towards special viewed in 2008. te needs patients, in providing optimal level of oral care. The data was analysed and managed by Statistical (12, 15). Package for Social Sciences 20 (SPSS Inc. Chicago, To our knowledge, from indexed literature data avail- IL, USA). Descriptive analysis of the data including In able on caregivers knowledge and attitude on Saudi frequencies, percentages and means of caregiver’s population is scarce and limited. Therefore, the ob- knowledge and attitude were calculated. Comparison jective of the study was to assess the knowledge and between oral knowledge and oral health attitude of attitude of caregivers/healthcare workers regarding caregivers was done using one-sample t Test. Level oral health of special need patients, at a comprehen- of significance was set as significant at p=0.05*. ni sive rehabilitation centre in Al-Kharj, Saudi Arabia. The evidence acquired through this study may benefit to assist the level of information and approach, for io oral health care, of caregivers working in special care Results centres. Socio demographic data of the subjects is presented in Table 1. Regarding knowledge of caregivers of iz whether oral health is associated to general health, 78.3% (n=94) responded in positive whereas 21.7% (n=26) stated that there was no relation. Furthermore, Materials and methods Ed An analytical cross-sectional study was conducted 81.7% (n=98) of the caregivers acknowledged that among 120 caregivers at comprehensive rehabilita- people with disabilities were more prone to oral tion centre in AlKharj, Saudi Arabia. The rehabilitation health problems. 87% (n=98) of the caregivers ac- centre accommodated around 168 special needs pa- cepted that it is important to clean teeth, however tients. The caregivers were responsible for providing 13.3% (n=16) did not consider it essential. Regarding various needs to these patients i.e. feeding, giving knowledge about powered tooth brushes only 8.3% IC bath, clipping nails, changing clothing and bedding as (n=10) of caregivers responded that they had knowl- well as oral care. An interview style questionnaire edge about powered toothbrushes while the rest was designed for this study. 91.7% (n=110) did not have knowledge about it. The sample was selected by non-probability conve- Table 2 shows the descriptive knowledge of care- C nience sampling. The total estimated time of the givers regarding oral health care. study was three months. Sample collection was Table 3 describes descriptive analysis of caregiver’s based on the inclusion criteria i.e. all the caregivers attitude. 44.2 (n=53) and 21.7% (n=26) of the care- who returned the consent form were included. Fur- givers accepted that oral health care for the people © thermore, caregivers who did not manage to return with disabilities is difficult and challenging. Majority the consent form or were absent on the day of data among the caregivers 55% (n=66) felt that they collection were excluded from the study. Since the should visit a dentist only when in pain, while the rest caregivers who participated in the study were from 22.5% (n=27) and 13.3% (n=16) replied that the visits Sudan, Philippines, Egypt, India, Bangladesh, Sri should be made once and twice a year respectively. Lanka and Nepal etc., the questionnaire was de- Poor communication 33.3 (n=40), bad smelling mouth Annali di Stomatologia 2017;VIII(3):110-116 111  A. H. Shah et al. Table 1. Socio demographic data. Variables Frequency Percentage Age 19-25 years 32 26.7 26-35 60 50.1 li 36 onwards 28 23.2 na Qualification Less than high school 24 20 High school to higher secondary 96 80 school io Experience az Less than 2 years 60 50 2-5 years 60 50 Care rn Direct Patient care 120 100 Language Arabic 55 45.8 te Non Arabic 65 54.2 and bleeding gums 25% (n=30) were considered the eases and poor oral hygiene status (19, 20). A study In main problems while taking care of the inhabitants. with the same group pointed out high caries rate, On a question asked to the caregivers that how they higher complexity of periodontal disease as well as learnt to take care of individuals with disabilities; higher incidence of retained teeth (21). Almost 3/4 of more than half of caregivers 53.3% (n=64) answered the caregivers believed that it is important to clean that they had learnt from co-workers and others. 75% teeth and that regular oral care can prevent oral dis- ni (n=90) of caregivers established that oral health edu- eases. This indicates that caregivers knowledge cation and training can help in improving the oral about oral hygiene practices were profound, which health of this group. may echo positively on the special care patients of io Table 4 presents difference between the knowledge the rehabilitation centre. Since caregivers who act and attitude mean scores. The means score of oral first themselves on the advice they give, will provide health knowledge among caregivers was 15.36. As good motivation and counselling to patients as well iz far as oral health attitude was concerned the mean (18, 22). difference of scores was 18.14, both were found to be The awareness level of caregivers on fluoride pre- statistically significant at p=0.0001 using a single venting dental decay was acceptable. Almost three in Ed sample T test. five acknowledged that fluoride prevents caries. Fluo- ride tooth pastes have been considered as bench- mark to prevent caries for the past three eras, and is also the most common method of fluoride delivery (23). It is estimated that on average, it reduces 24% Discussion Oral health care of special needs people seems to be of DMF score (24). Previous studies have shown par- IC a challenging task for caregivers (16). Thus, proper ents and caregivers, understanding the importance of knowledge of oral health care is prudent to administer fluoride in preserving healthy oral health (18, 25). best of their services. More than 3/4 of the responses Interestingly, the caregivers showed adequate knowl- by the caregivers agreed that general health is reliant edge regarding frequency of tooth brushing. Half of C on good oral health (10, 18). In addition, more than the health workers recognized that teeth should be 3/4 of caregivers agreed to the fact that disabled indi- brushed twice daily and the rest halve believed that it viduals are more prone to oral health problems. is better to brush teeth once a day. Professional rec- These findings were in relation to different studies ommendation and evidence suggests that tooth © that individuals with disabilities or some other sort of brushing is advised for at least 2-3 minutes, twice impairment (e.g. mental illness, behaviour problems, daily using bass technique (26). In addition, a healthy learning difficulties, etc.) have poorer oral health con- trend by the caregivers was witnessed when asked ditions compared to healthy people. Furthermore, in- about aids of cleaning teeth other than brushing. Al- dividual with disabilities show higher prevalence of most 50% of the caregivers used Miswak as one of oral diseases such as dental caries, periodontal dis- the source to clean their teeth. This tendency can be 112 Annali di Stomatologia 2017;VIII(3):110-116  Oral health knowledge and attitude among caregivers of special needs patients at a Comprehensive Rehabilitation Centre: an analytical study Table 2. Descriptive knowledge of caregivers. Variable Frequency (n= 120) Percentage Is oral health related to general health Yes 94 78.3 No 26 21.7 li Do you think disabled people are more prone to Oral health problems na Yes 98 81.7 No 22 18.3 Do you think cleaning teeth is important Yes 104 86.7 io No 16 13.3 Daily care of teeth can prevent Oral Disease Yes 120 100 az No 0 0 Fluoridated toothpastes prevents dental decay Yes 66 55 No 54 45 How many times it is ideal to brush teeth rn Not necessary 0 0 Whenever possible 0 0 Once daily 58 48.3 Twice daily 60 50 te More than twice daily 2 1.7 What are the aids apart from brushing that is used Rinse with water 25 20.8 Finger In 26 21.8 Mouthwash 20 16.6 Tooth pick 0 0 Miswak 49 40.8 Which things can cause decayed teeth ni Sweetened confectionary 38 31.7 Fruits like date 46 38.3 Tea/ coffee 10 8.3 io Carbonated drink 26 21.7 Have you seen or heard about powered tooth brush Never 0 0 iz Only heard about it 10 8.3 Have seen it but not used 110 91.7 Used it 0 0 Ed considered healthy as there are many oral as well as givers towards oral health was considered unsatisfac- general health benefits quoted by the use of miswak tory and inadequate (Tab. 5). When inquired about (2). These may include anti plaque, anti-fungal, and how many times it is necessary to go for dental anti-microbial effects (2, 27). Miswak is also consid- check-up in a year, more than half of the responders ered as the cost effective, inexpensive, cheap thought only in case of dental problem. This tendency IC method of maintaining good oral health (2, 28). has been shown in previous studies as well where Intriguingly, the awareness level of care providers on utilization and access to care is symptom oriented diet and caries was agreeable. This is important and (29, 30). Regular dental check-up is of prime impor- may provide good wire of knowledge of healthy and tance in the prevention of dental disease. These vis- C balanced diet to the parents plus the disabled individ- its provide an opportunity for dentists to take clinical uals themselves. Balanced dietary habits are very im- preventive measures such as dental prophylaxis, top- portant for disabled individuals as if ignored or not ical fluoride application, etc. and reinforce healthy taken care off may result in compromised oral hy- home dental care. In a study by Watt (31), he ex- © giene status and thus increase in the incidence of plains how majority of the diseases is preventable. caries in the dependents. The caregivers should The challenging task is to carve opportunity, which is strictly adhere to the current and up to date knowl- conducive, both at individual and community level. edge regarding suitable and healthy diet for disabled Though there is a marked advancement in operative individuals (18, 25). dental care, symptoms or treatment oriented ap- In contrast, enthrallingly in the study attitude of care- proaches never can eradicate oral diseases (32). Annali di Stomatologia 2017;VIII(3):110-116 113  A. H. Shah et al. Table 3. Descriptive analysis of caregiver’s attitude. Variable Frequency (n= 120) Percentage How do you rate your personal Oral health Excellent 17 14.2 li Very good 28 23.3 Good 40 33.3 na Fair 24 20.0 Poor 11 9.2 How would you rate the oral health care for the disabled Easy 15 12.5 Difficult 22 18.3 io Very difficult 26 21.7 Challenging 53 44.2 I don’t know 4 3.3 az How many times should we visit a dentist in a year When you have a problem 66 55.0 Frequently 8 6.7 Once every year 27 22.5 Twice every year 16 13.3 rn I don’t know 3 2.5 When you should change your tooth brush Whenever you like 13 10.8 When bristles are out of shape 49 40.8 te Every three months 19 15.8 Every six months 17 14.2 I don’t know 22 18.3 How did you learn to take care of oral health of the In inhabitants Previous training programs 0 0 By myself 15 12.5 From other co workers 64 53.3 ni I did not learn 41 34.2 What is the most common problem faced while taking care of the inhabitants io Non co-operation 25 20.8 Bites or aggressive behaviour 20 16.7 Cannot understand or communicate 40 33.3 iz Bad smelling mouth and bleeding gums 30 25 I don’t know 5 4.2 Do you think oral health training can be helpful for you to Ed deliver better oral care to the inhabitants Yes 90 75.0 No 20 16.7 Don’t know 10 8.3 Which of the following do you think you need to be able to give better oral health care to the present group Audio video training 68 56.7 IC Hands on training 42 35.0 No training required 10 8.3 C A lack of knowledge was felt when asked about when half of the caregivers learnt oral care training by other it is recommended to change toothbrush. More than co-workers while 41% learnt oral training by them- 40% stated that when bristles are out of shape, selves, though 75% of caregivers considered training whereas one in five had no idea about it. These re- in oral care useful. It was also observed that 80% of © sults raise questions on the attitude of caregivers. caregivers was educated until school level and 20% Toothbrushes are considered as one of the vital tools being less than that. This clearly shows that the cur- in achieving acceptable plaque control and improving rent system of training and education is sub-standard periodontal health (26, 33). and disappointing. Caregivers should be educated to The present study revealed that no health care work- a minimal level of standards and should have a ho- ers or caregivers took training in oral care. More than mogenous guidance. These findings were concurrent 114 Annali di Stomatologia 2017;VIII(3):110-116  Oral health knowledge and attitude among caregivers of special needs patients at a Comprehensive Rehabilitation Centre: an analytical study Table . Difference between caregiver’s knowledge and attitude Variables ± SD Mean + Mean Difference P-Value 95% CI of the difference Caregivers Attitude 18.14 (6.7) 18.14 0.0001* Lower Upper 16.91 19.36 li Caregivers 15.36 (1.94) 15.36 0.0001* 15.01 15.71 na Knowledge One Sample T test; *statistical significant. io az rn with the study reported by Sumi et al. (34). In addi- tion, caregivers apparently assumed that better train- te atol (Roma). 2016;7(3):52-59. Epub 2017/02/06. doi: 10.11138/ads/2016.7.3.052. PubMed PMID: 28149451; In PubMed Central PMCID: PMCPMC5231790. ing and up to date oral health education would raise 5. Oredugba FA, Akindayomi Y. Oral health status and treat- the quality of dental care and indirectly improve their ment needs of children and young adults attending a day cen- attitudes (34, 35). tre for individuals with special health care needs. BMC Oral Overall, the study furnished relevant and useful infor- Health. 2008;8:30. Epub 2008/10/24. doi: 10.1186/1472-6831- mation regarding oral health attitudes and knowledge ni 8-30. PubMed PMID: 18945371; PubMed Central PMCID: of caregivers in Comprensive Rehabilitation Centre Al PMCPMC2579283. Kharj, Saudi Arabia. Although, oral health knowledge 6. Lewis C, Robertson AS, Phelps S. Unmet dental care needs of caregivers was satisfactory, but the attitude score among children with special health care needs: implications io for the medical home. Pediatrics. 2005;116(3):e426-431. was relatively unsatisfactory. In order to improve oral 7. Khanagar S, Kumar A, Rajanna V, Badiyani BK, Jathanna health attitudes of caregivers, dental education plus VR, Kini PV. Oral health care education and its effect on care- training programs should be given high priority. Pre- iz givers’ knowledge, attitudes, and practices: A randomized ventive techniques about basic oral health should be controlled trial. J Int Soc Prev Community Dent. 2014; kept in pace with recent evidence. This implementa- 4(2):122-128. Epub 2014/09/26. doi: 10.4103/2231-0762. tion may indirectly improve oral health attitudes result- 139843. PubMed PMID: 25254198; PubMed Central PMCID: Ed ing in further improvement of oral status of the dis- PMCPMC4170545. abled. Lastly, more research should be done on this 8. Frenkel H, Harvey I, Needs K. Oral health care education and area, as previous data available is old and limited. its effect on caregivers’ knowledge and attitudes: a ran- domised controlled trial. Community Dent Oral Epidemiol. 2002;30(2):91-100. 9. Shah AH, Fateel A, Al-Nakhli O. 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Original article Mandible protraction alters Type I collagen, osteocalcin and osteonectin gene expression in adult mice condyle li na Patricia Valerio1 PhD Introduction Head and face growth disorders are very common in Filipi Perfeito2 DDS all racial populations. The prevalence of craniofacial Livia P. Moura1 MDS io anomalies varies among different ethnicities based Deborah N. Ribeiro1 MDS on genetic background, geography, socio-economic Simone O. A. Fernandes2 PhD Almir S. Martins1 PhD status and environmental factors (1). Mandible retru- az Maria F. Leite1 PhD sion prevalence runs from 52 to 56% (2), and the most common treatment is condyle traction generat- ed by the mandible forward repositioning. Mandible 1 Department of Physiology and Biophysics, protrusion enhances functional stimulation on condyle Federal University of Minas Gerais, Brazil rn and generates sagittal growth et al. (3). However, we 2 School of Pharmacy, Federal University of have a huge controversy. Some reports indicate a Minas Gerais, Brazil positive growth response to condyle traction while others indicate a negative or no response to te mandibular advancement (4). Therefore, there is a need to identify the markers for each stage of condy- lar growth and evaluate the effect of functional stimu- Patricia Valerio Corresponding author: In lation on growth pattern. Condyle grows by endo- Department of Physiology and Biophysics, chondral ossification, and some Authors have been Federal University of Minas Gerais studying the early stages of condyle formation, focus- Cristiano Machado 1630/901 ing on the importance of functional stimulation for 31170024 Belo Horizonte, Brazil chondrogenesis. However, the osteogenic phase of ni E-mail: [email protected] condyle formation has been missed. The possible gene expression alteration on this phase, generated by different pattern of stimulation, was not studied yet io (5-10). Moreover, the majority of the reports deals with growing period and do not focus on adult phase Summary (11-16). Considering not only mandible retrusion cor- iz rection but also considering that remodeling alteration Mandible condyle remodeling is a great challenge is the main cause for articular temporomandibular on craniofacial growth studies. The great majority disorders affecting many adults (17), it is important to Ed of the reports deals with growing period. Howev- clarify the mechanisms involved on adult condyle re- er, there is a great necessity to clarify the impor- sponse to functional stimulation. So, our aim was to tance of functional stimulation on adult mandible evaluate the alteration on osteoblast gene expression condyle remodeling. By using an adult mouse pattern, on mouse adult condyle, under different func- model, we investigated the influence of mandible tional stimulation. forwarding on condyle remodeling and gene ex- pression by bone forming cells. Tomographic and IC scintigraphic evaluations showed sagittal growth and cell activity enhancement. RT-PCR showed that Type I collagen, osteocalcin and osteonectin Materials and methods expression level can be altered. We showed that C This study was approved by the Federal University of functional stimulation is necessary to maintain Mandible protrusion protocol Minas Gerais Animal Use and Care Committee (Pro- the regular gene expression by condyle bone tocol 169/2014). 48 female C57 mice (including 24 as forming cells in adult mice. It opens new frame for controls) were used in this work. We decided to in- further investigations aiming new clinical ap- © vestigate the effect of mandible protrusion on condyle proaches to temporomandibular joint problems osteoblasts gene expression. In order to generate treatment, as well as mandible retrusion treat- mandible protrusion, 24 mice (experimental group) ment. had the inferior incisors cut around 1 mm. We used a nail plyer, holding the animal in left hand and using Key words: bone biology, growth evaluation, mol- the plyer on right hand to cut the inferior incisors. It ecular biology, CT, condyle growth, gene expres- sion. Annali di Stomatologia 2017;VIII(3):95-103 95  F. Perfeito et al. generates an increase on the overjet. Because of lets and tap water and were housed at the animal ex- this, they had the necessity of sending the mandible perimentation laboratory. Every 3 days the cutting forward to be able to chew (Fig. 1). procedure was repeated, due to continuous eruption The weight of each animal was checked. Control of the teeth, as well as the weight checking. mice only underwent weight checking to evaluate the regular food intake and consequent weight gain. The animals were provided with free access to food pel- To evaluate the condyle sagittal shape changing, we li Tomography na a io az rn te In ni b io iz Ed IC C Figure 1 a, b. Mandibular advancement. (a) To generate a physiological mandibular advancement, that would lead to stimu- © lation on condyle region, every 3 days during 21 days, the lower incisors were cut by 1 mm to induce protrusion when the animal was feeding. In left panel we can see the control animal with regular distance between inferior and superior incisor, and on right panel we can see the experimental animal immediately after cutting, showing an increase on the overjet; (b) the weight gaining of the animals indicated that on the first days the experimental group was not used to the increase of overjet and had weight loss, but after 9 days they started to eat normally and recover the weight gaining (first point of the graphic is 3 and last point of the graphic is 18, because we checked the weight on the cutting day). 96 Annali di Stomatologia 2017;VIII(3):95-103  Mandible protraction alters Type I collagen, osteocalcin and osteonectin gene expression in adult mice condyle used a tomographic study. The animals were anes- thetized with a combination of ketamine (30 mg/kg) The 99mTechnetium-methylene diphosphonate (99mTc- Scintigraphy and xylazine HCl (2.5mg/kg) intramuscularly. Then, MDP), a specific marker of the anabolic phase of re- they were positioned on a table adapted to the equip- modeling, has been used in the diagnosis of a broad ment as showed on the Figure 2a. The condyle was spectrum of conditions affecting the skeleton. The ra- localized on frontal and coronal plane and measure- diopharmaceutical 99m Tc-MDP was obtained from ments were done on sagittal plane (Fig. 2b). We used UFMG Pharmacy school laboratory. To observe bone li a Gendex CB500 with voxel 0.125 and 4 cm high. metabolic activity in the region of the condyle, bone na io az rn te In a c ni io iz Ed IC C b © Figure 2 a-c. Tomography. (a) After anesthesia, the animals were positioned on the equipment table as showed on the pic- ture; (b) The software used allows the user to measure linear distances in 3 dimensions. After anesthesia, the animals were analyzed in coronal (right panel) and transversal (left upper panel) plane to localize the condyle. The measurement was done on sagittal plane (left lower panel). Measurements were done separately in left and right condyle; (c) After 21 days, the experimental group showed an increase on sagittal dimension of the condyle. Results reflects means ± SD of 3 different ex- periments (p< 0.05). Annali di Stomatologia 2017;VIII(3):95-103 97  F. Perfeito et al. scintigraphic images were taken 7 and 21 days after employing a low-energy high-resolution collimator. starting cutting, using a gamma camera (Nuclide TM Images were acquired using a 256 × 256 × 16 matrix TH 22, Mediso, Hungary). This analysis does not re- size with a 20% energy window set at 140 keV for a quire the animal to be killed, and can be repeated. period of 10 min. The images were analyzed quanti- The animals were anesthetized with a combination of tatively, and the radioactivity was determined in the ketamine (30 mg/kg) and xylazine HCl (2.5 mg/kg) in- demarcation areas of the ROI (region of interest) in- tramuscularly. Aliquots (0.1 mL) containing 10,3 MBq volving the right and left condyle on experimental and li of (99mTc-MDP) were injected intravenously into the control group. The uptake of 99mTc-MDP in the re- tail vein of the animals. Static-planar acquisition was gions was measured. Results were analyzed using T na initiated 1 h after the injection. The animals were student test unpaired. Differences were considered placed in a supine position under a gamma camera significant when p<0.05 (Fig. 3a). io az rn a te In ni io iz Ed IC C b Figure 3 a, b. Bone Scintigraphy. (a) Representative scintigraphic image for the definition of the region of interest (ROI). Red © arrow is reference point to show one ROI at the condyle region. The ROI (circle) was established and the radio isotope count [accumulation count of 99mtechnetium-methylene-diphosphonate (99mTc-MDP)] was measured. As inferred by the color bar scale, red shows a high accumulation of 99mTc-MDP and blue shows a low accumulation of 99mTc-MDP; (b) Up- take ratio of 99mTc-MDP at the condyle region after protrusion of the mandible. The vertical axis shows the uptake ratio. The count rates of 99mTc-MDP in the protruded mandible condyle were significantly higher than control after 21 days. Re- sults express mean ± SD of 2 different experiments for each period (p< 0,05). 98 Annali di Stomatologia 2017;VIII(3):95-103  Mandible protraction alters Type I collagen, osteocalcin and osteonectin gene expression in adult mice condyle be sure that we were dealing with osteogenic cells. Since our objective would be to evaluate the alter- For immunofluorescence, we used 6 well culture flask Condyle cell isolation and Immunofluorescence ation on gene expression by osteoblasts obtained by (Sarstedt) and platted the cells over glass cover slips the macerate of condyles, it was important to first (Fisherbrand). 24 hours later, the cells were fixed check the cell population of this macerate. In order to with 4% paraformaldehyde (Merk, Brazil) in phos- evaluate it, we first used a sequential digestion proto- phate buffered saline (PBS) for 10 min, and washed col. Briefly, we dissected the condyles and freed from three times in PBS. The cells were incubated in li soft tissue, cut into small pieces and rinsed in sterile blocking solution [PBS, 1% bovine serum albumin phosphate-buffered saline without calcium and mag- (Sigma), 5% normal goat serum (Sigma), 0.5% triton- na nesium (Sigma Aldrich). The condyle pieces were in- X (Sigma Aldrich)] and then incubated with the follow- cubated with 1% trypsin-EDTA (Gibco) for 5 min, fol- ing primary antibody: mouse antiosteopontin (R&D lowed by four sequential incubations with 0.2% colla- systems) and secondary: Alexa Fluor (Invitrogen). To genase (Sigma Aldrich) at 37°C for 45 min each. The evidentiate the nucleus, cells were also incubated io digestions produced a suspension of cells. After cen- with propidium iodide (Sigma Aldrich) (Fig. 4). trifugation at 1000 g for 5 min, the pellet was resus- pended in 5 ml of RPMI medium (Gibco) supplement- az ed with 10% FBS (Gibco), 1% antibiotic-antimycotic In order to evaluate differential gene expression from Extracting RNA from condyle in a single step (Gibco). The cells were seeded into 25 ml tissue cul- cells derived from experimental and control animals, ture flasks (Sarstedt), and led to grow in a controlled condyle bones were harvested from the animals, ex- 5% CO2 95% humidified incubator at 37°C. After con- posing them after removing muscles. Any attached fluence the cells were used for immunofluorescence tissue was quickly removed using a scalpel before rn using a marker for bone forming cells (osteopontine the condyle was immersed in liquid nitrogen. The OPN). OPN is produced by cells involved in bone samples were homogenized separately with Trizol® in morphogenesis such as preosteoblasts, osteoblasts, porcelain mortar and pestle with liquid nitrogen. RNA te osteoclasts, osteocytes, odontoblasts, and also hy- was then separated and processed according to the pertrophic chondrocytes. So we decided to use it to manufacturer’s protocol (Trizol ® Reagent, Life Tec- In ni io iz Ed IC C © Figure 4. Immunofluorescence for osteopontin. Confocal images obtained from the condyle macerate. A great number of cells was positive for osteopontin, indicating that they were bone forming cells. Green indicates osteopontin staining and red are nucleus stained by propidium iodide. Transmission image included in merged image. Annali di Stomatologia 2017;VIII(3):95-103 99  F. Perfeito et al. nologie, Carlsbad, California). Total RNA was quanti- used to normalize the expression of the target gene fied and then treated with DNase I® (TURBO DNA- (target gene CT mean - mean CT endogenous con- free Kit, Ambion® Inc., Foster, California, USA). trol) generating ΔCT. Using the ΔCT was calculated ΔΔCT [ΔCT sample - ΔCT calibrator (reference sam- ple)]. Then it was applied the formula 2 -ΔΔCT for de- The RT for sscDNA synthesis was performed from 1 μg termining the relative levels of expression of each tar- Reverse Transcriptase Reaction of total RNA in a final reaction volume of 20.4 μl per get gene. The results of expression levels were li sample. Briefly, RNA was pre-incubated at 70° C for launched in GraphPad Prism 5 software, for statistical na 10 minutes with 10 pmol of each reverse primer spe- analysis, using t student tests unpaired. Differences cific for the target genes, together with 10 pmol of oli- were considered significant when p<0.05. go dT 18 primer, followed by storage on ice at the bench top. Then, was added to samples mix contain- ing RT buffer [250 mM Tris-HCl (pH 8.3), 375 mM Results io KCl, 15 mM MgCl2] and dNTP (10mM each), samples with this mix were incubated at 45° C for 2 min and Sequential cut of inferior incisor generates then placed on ice. Finally added 1 μl of reverse tran- The model used to generate protrusion was adapted condyle sagittal remodeling az scriptase enzyme mix (40 U) into RT buffer [250 mM from Tagliaro et al. (17). In our protocol we did not Tris-HCl (pH 8.3), 375 mM KCl, 15 mM MgCl2] and in- use anesthesia and the cutting using a nail plyer was cubated at 45°C for 1 hour along with previously de- quick, effective and more secure than trimming using scribed RNA and primers. The reaction was terminat- a dental motor, recommended by the Author. On Fig- rn ed at -20°C until used in the real time PCR. All ure 1a we can see the generated increase on overjet. reagents were from Invitrogen™ (Life Technologies, The weight gain of both groups was checked to eval- Carlsbad, CA, USA). uate the experimental group adaptation to the in- creased overjet. When compared to control, experi- te mental group showed, on the first days, a decrease The real time PCR was developed in 7500/ABI on weight gain, indicating that the animals were not Real time PCR PRISM® Sequence Detection System equipment, us- used to the new occlusal situation leading to difficul- In ing the protocol described by the reaction SYBR ties on chewing. We can state that the functional Green PCR Master Mix Kit (Invitrogen™ Life Tech- stimulation during this period decreased. After they nologies, Carlsbad, CA, USA). Samples in triplicate get used to new occlusal scheme they regularized the were applied to 96-well plates (ABI PRISM® Optical food intake and achieved the same weight of the con- 96 -Well Reaction Plate with bar code Invitrogen Life trol group at 21 days as showed on Figure 1b. The to- ni Technologies, Carlsbad, CA, USA) in a final reaction mographic images were taken in order to evaluate volume of 20 μl each. Aliquots of 1.6 μl of sscDNA sagittal dimension alteration of the condyles from the sample were pipetted into each well of the plate, sub- animals submitted to mandible protrusion, since it is io sequently adding 18.4 μl of sybrMix [10 μl of SYBR known that the condyle remodeling follows the direc- Green PCR Master Mix Kit, 1.2 μl of each primer tion of pulling (18). It was adapted a positioner for (sense and antisense; 10 pmol / μl) and 6 μl sterile anesthetized animals as showed on Figure 2a. Im- iz filtered water]. The plate was sealed with optical ad- ages were taken after localizing the condyle on trans- hesive (ABI PRISM® optical adhesive Covers, Invitro- versal and coronal plane. The measurements were gen ® Life Technologies, Carlsbad, CA, USA). Real made with 0,5 mm of accuracy (Fig. 2b). The results Ed time PCR reactions occurred in the following thermal showed that mandible protrusion was able to gener- cycle: [stage 1] a cycle of 50° C/2 min; [stage 2] cycle ate sagittal condyle posterior remodeling on adult ani- at 95°C/10 min; [stage 3] 40 cycles of 95°C/0.15 min, mals, when compared to no protruded controls followed the dissociation curve from 60˚C to analyze (p<0.05) (Fig. 2c). the specificity of the amplicons. The mRNA value for each gene was normalized relative to the housekeep- IC ing mouse S26 mRNA levels in RNA samples. Primer Mandible protrusion leads to increase on condyle sequences (forward and reverse) were as follows: cellular activity and enhanced expression of Type S26, 5`- CGTGCTTCCCAAGCTCTATGT -3` and 5` - On the scintigraphy, the selected regions of interest I collagen, osteocalcin and osteonectin CGATTCCTGACAACCTTGCTATG -3`; (ROI) on condyle were evaluated in both sides of ex- C Bglap3, 5`-CTTGGTGCACACCTAGCAGA -3` and 5`- perimental and control animals (Fig. 3a). The plotted ACCTTATTGCCCTCCTGCT -3`; results indicated that on 7 days it was not possible to Col1a1, 5`- GCTCCTCTTAGGGGCCACT -3` and 5`- register a statistical difference of 99mTc-MDP capita- ATTGGGGACCCTTAGGCCAT -3`; tion comparing experimental and control groups. But © Sparc, 5`- AAACATGGCAAGGTGTGTGA -3` and 5`- after 21 days it was possible to see a statistical rele- AAGTGGCAGGAAGAGTCGAA-3`. vant increase on the capitation by the condyles sub- For relative quantification was performed a compara- mitted to traction by protrusion (p<0.05) (Fig. 3b), tive analysis of the expression of target transcripts corroborating the results obtained by the tomography. genes versus endogenous control using the compara- After isolation and expansion of the cell population tive CT method, which the endogenous control was obtained from sequential digestion of condyle macer- 100 Annali di Stomatologia 2017;VIII(3):95-103  Mandible protraction alters Type I collagen, osteocalcin and osteonectin gene expression in adult mice condyle ate, it was possible to show that a great number of Since condyle remodeling occurs due to endochon- bone forming cells were present on the population. dral ossification, the majority of the works have Osteopontin antibody stained the majority of the cells been trying to investigate the chondrogenesis (8, as shown in Figure 4, indicating that the condyle 25, 26). We focused, instead, on the next step of macerate could be used for total RNA extraction to bone formation, trying to investigate if the functional evaluate differential gene expression of bone forming stimulation of mandible would lead to different ex- markers. The expression of Type I collagen, osteocal- pression of bone forming markers by condyle os- li cin and osteonectin by the bone forming cells isolated teoblasts. We choose 3 specific bone markers to be from the condyle were affected by the mechanical na evaluated. Since collagen Type I gene expression stimulation. During the first days, when the animals occurs during all process of bone formation (27), it from experimental group were not able to chew prop- was our first choice. osteocalcin and osteonectin are erly we observed a decrease on the expression of the also well known specific markers for osteogenesis three genes compared to control animals. After they (28, 29). Using primers for these 3 genes, we per- io start to chew normally and had to protrude in order to formed a Real-time PCR and found that all of them compensate the increased overjet, there was a recov- had the expression level diminished when the ex- ering on the expression of these genes allowing at 21 perimental animals were not able to chew, indicating az days no statistical difference on their level (p<0.05) that even in adults, the maintenance of adequate (Fig. 5a-d). As soon as the animals started to in- functional stimulation is necessary to keep the regu- crease the condyle traction, due to mandible protru- lar level of gene expression. On the other hand, the sion, gene expression pattern of Type I collagen, os- functional stimulation enhancing, generated by rn teocalcin and osteonectin increased. condyle traction, after the animals get used to big overjet, lead to an increase on osteogenic markers gene expression level. Type I collagen synthesis is of particular interest. te Discussion The synthesis of this collagen is closely regulated, Little is known about the mechanisms involved on since deficiencies or excess of the protein can mandible remodeling under functional stimulation. In cause serious disorders (30). Osteonectin, recently, In a recent integrative review conducted by our group appears as a promising target for preventing or (19) we found only 15 relevant works dealing with this treating bone diseases (31). Osteocalcin, since last subject in the last 20 years. It is well known that func- decade, is recognized as an important regulator of tional stimulation interferes with condyle remodeling bone mechanotransduction (32-34). So, knowing during growing periods (17, 20-22). However, it re- that functional stimulus interferes so much on Type ni mains unclear the role of functional stimulus on adult 1 collagen, osteonectin and osteocalcin expression condyle remodeling. Our adapted protrusion model opens new frame for therapeutic approaches, not allowed the investigation of condyle remodeling in only related to mandible retrusion but also to tem- io adult mice. On the beginning the animals diminished poromandibular joint disorders. the food intake. The difficulty on chewing demonstrat- Together, our results corroborated previous findings ed by the animals immediately after the initial cutting and expanded them, now showing that the synthesis iz is in accord to orofacial proprioception neurophysiolo- of Type I collagen, osteocalcin and osteonectin can gy. It is known that body needs an adaptation period have the expression pattern altered by changes on when changes in occlusal scheme occurs. It gener- functional stimulation, in adults. These current ob- Ed ates a delay on regular food intake (23). So, our ex- servations highlight the needing for further investi- perimental group delayed to get used to increased gations. overjet and due to that diminished the food intake. But the curve of weight gain (Fig. 1b) indicated that the experimental group after recovering the capacity of regular chewing, even having to protrude, was able Conclusion IC to equalize the weight gain with the control group. It Functional stimulation is necessary to maintain the indicates that the animals learned how to forward the regular gene expression of collagen, osteocalcin mandible in order to chew, making our model ade- and osteonectin by condyle bone forming cells, in quate for the study. The tomographic study demon- adult mice. Protraction of mandible generates alter- C strated that adult mice showed change on condyle ation on these genes expression by condyle cells. shape when submitted to mandible forwarding. It was also observed by scintigraphic study a higher cellular activity when compared to control (Fig. 2, 3). It is in accord with a previous study, conducted in rats, where © Aknowledgements the changing of occlusal scheme, by removing some We would like to thank the ARCATA clinic staff for teeth, lead to alteration on condyle shape (24). Our re- the kind help with the tomography. This work was sults reinforced the effect of functional stimulus on supported by CAPES, CNPq and FAPEMIG grants. condyle shape and cell activity even being an adult. Annali di Stomatologia 2017;VIII(3):95-103 101  ! F. Perfeito et al. ! ! $ !"#$ ! " #$ % + , - ( * 9 9 .% & 6% :6/ ; < = 6! % )$ 0 $ 4 21 4 10 , - % * + 8 8 .' ( 6' 96/ : ; < 6! " #$ % 6& % ( / 0 ).> * 7 6? 8 6@ 4 A 6( ' * / $ #.= + 7 6> ? 6@ 4 A B 0 ( ? .' ( 0 ( 8 6C & .' D $ 23 B $ * > .) * $ * ? 6C ( .) 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C 3 12 2 3 /- 4/5 - . 6) - 07 !! !!! !! ! io 3 10 & " ' (' ) >## $ ! % 0 12 iz !"# !"$ %# 0 10 & ' ( ) $ ' *+ , - " + $ ./ + ( ) # * Ed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c ! d 4 3 56 # 7 8 © Figure 5. Real-time PCR. Diferential expression of: (a) Collagen (Col1), (b) Osteocalcin (Bglap) and (c) Osteonectin (Sparc) ! evaluated at 7 days and 21 days. All of them showed lower expression on experimental group at 7 days, compared to con- trol (p<0.05). On 21 days no statistical difference on gene expression was observed (p<0.05), indicating that the experimen- tal group showed an enhance on gene expression during the period from 7 to 21 days; (d) Differential expression of Type I Collagen, Osteocalcin and Osteonectin by experimental group $ analyzed in terms of control % (p<0.05). 102 Annali di Stomatologia 2017;VIII(3):95-103  Mandible protraction alters Type I collagen, osteocalcin and osteonectin gene expression in adult mice condyle (2):79-83. 19. Valerio P, Macedo FJM, Simoes WA. Remodelative alter- References 1. Joshi N, Handam A, Fakhouri WD. Skeletal malocclusion: ations of TMJ with the use of protraction appliances: an in- a developmental disorder with a life long morbidity. J Clin Med tegrative review. Ortodontia SPO. 2014;47(3):218-223. Res. 2014;6(6):399-308. 20. Watahiki J, Yamaguchi T, Irie T, Nakano H, Maki K, 2. 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Reducing dietary load- io in situ hybridization study of the insulin-like growth factor sys- ing decreases mouse temporomandibular joint degradation tem in developing condylar cartilage of the fetal mouse induced by anterior crossbite prosthesis. Osteoarthritis mandible. Eur J Histochem. May 2008;2356(2):e23. Cartilage. Feb 2014;22(2):302-312. 6. Liu Q, Gibson MP, Sun H, Qin C. Dentin sialophosphopro- 23. Kumar A, Grigoriadis J, Trulsson M, Svensson P, Svensson az tein (DSPP) plays an essential role in the postnatal devel- KG. Effects ofshort-term training on behavioral learning and opment and maintenance of mouse mandibular condylar car- skill acquisition during intraoralfine motor task. Neuro- tilage. J Histochem Cytochem. Oct 2013;61(10):749-758. science. Jul 2015;7;306:10-17. 7. Morimoto H, Baba R, Haneji T, Doi Y. Double-stranded RNA- 24. Yokoyama M, Atsumi T, Tsuchiya M, Koyama S, Sasaki K. 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Case report Subcutaneous emphysema during root canal therapy: endodontic accident by sodium hypoclorite li na Gianluca Tenore, DDS dodontic treatment of the upper left lateral in- Gaspare Palaia, DDS cisor. Chiara Ciolfi, BDS Discussion. An extrusion during an inappropriate io Mohamed Mohsen, PhD endodontic treatment may occasionally be report- Andrea Battisti, DMD ed and can cause tissue damage. NaOCl is one of Umberto Romeo, DDS the best and most commonly used irrigating solu- az tions because of its efficacy, but it can also nega- Department of Oral and Maxillofacial Sciences, tively affect the periapical tissues. “Sapienza” University of Rome, Rome, Italy Conclusion. Determining the correct working length, even when performing an intraoperative rn periapical radiograph and confirming the root canal integrity, could help avoid these kinds of Mohamed Mohsen Corresponding author: accidents. Department of Oral and Maxillofacial Sciences, te “Sapienza” University of Rome Key words: subcutaneous emphysema, root canal Via Caserta 6 therapy, sodium hypochlorite. 00161 Rome, Italy Tel.: 00393478048688 In E-mail: [email protected] Introduction Debridement of the root canal system is essential for endodontic success, and it is composed of mechani- cal instrumentation and the use of antimicrobial irri- ni gating solutions. Root canal irrigants are ideally used Summary for flushing out debris, dissolving organic tissue, killing microbes, destroying microbial products and Introduction. Cervicofacial subcutaneous emphy- io removing the smear layer. These objectives can be sema is defined as the abnormal introduction of achieved with irrigating solutions reaching the work- air in the subcutaneous tissues of the head and ing length of the canal without extruding the periapi- neck. It is mainly caused by trauma, head and cal tissues (1-3). Sodium hypochlorite solution (NaO- iz neck surgery, general anesthesia, and coughing Cl) is the most commonly used irrigating solution for or habitual performance of Valsalva manoeuvre. its strong antimicrobial and proteolytic activity. NaOCl The occurrence of subcutaneous emphysema af- in concentrations ranging from 0.5 to 5.25% is com- Ed ter dental treatment is rare, and diffusion of gas monly used for irrigating root canals. A better bacteri- into the mediastinum is much rarer, especially cidal activity can be reached by increasing the con- when the procedure is a nonsurgical treatment. centration of NaOCl, but its damaging activities can Presented here is a case of subcutaneous emphy- also be intensified. In fact, NaOCl at high concentra- sema that occurred after sodium hypochlorite irri- tions can cause damage to vital tissues, such as gation during endodontic treatment, and the de- haemolysis, ulceration, inhibition of neutrophil migra- IC scription of its etiologies and prevention during tion, damage to endothelial and fibroblast cells, facial nonsurgical endodontic treatment. nerve weakness and necrosis after extrusion during Endodontic success can be essentially achieved inappropriate endodontic treatment (4, 5) These toxic via good debridement of a root canal, and an ideal effects can occur because of the solution alkalinity endodontic irrigant is effective in removing the C (pH 10.8-12.9) and hypertonicity, which can oxidate smear layer, opening the dentinal tubules, and proteins and lipid membranes (6). When some of producing a clean surface for closer obturation. these effects occur, subcutaneous emphysema can Case report. A 60-years-old woman had an abnor- appear. Subcutaneous emphysema is obtained when mal swelling and pain during an endodontic treat- © gas or air is in the layer beneath the skin. Since the ment accompanied by her dentist to the emer- air is generally emitted from the chest cavity, subcu- gency room and was referred to our observation taneous emphysema usually occurs on the chest, for complaining of severe pain, ecchymosis and neck and face. It has a characteristic crackling feel to severe swelling on the left side of her face. The the touch, also known as subcutaneous crepitation. aforementioned symptoms appeared after sodium These situations can occur after an infection, trauma hypochlorite irrigation and aggressive use of air spray for drying the root canal during the en- Annali di Stomatologia 2017;VIII(3):117-122 117  G. Tenore et al. or a surgical procedure. In the odontostomatological an allergic episode was excluded. The extraoral ex- environment, emphysema can arise after the irrigat- amination revealed that the patient had difficulty ing solution’s extrusion during inappropriate endodon- opening the left eye, with swelling and an ecchymosis tic treatment and even after repair of facial fractures, affecting even the upper labial region, the mandibular periodontal surgery, temporomandibular joint surgery region and the contralateral infraorbital region. There and the extraction of teeth such as a mandibular third was also evidence of an issue on the left cheek. molar (7). Anaphylactic reactions to local anaesthe- Paresthesia of the dental nerves was not diagnosed, li sia, haematoma and infection are usually included in but the patient was referred upon altered sensation of the differential diagnosis (8). the left upper lip region. na The paper investigates tissue damage after NaOCl Intraoral examination revealed that the affected tooth solution extrusion during root canal treatment and ex- had its own crown destroyed by decay processes. amines how to treat these kinds of accidents. The part was slightly sensitive to vertical and horizon- tal percussion and palpation with a mobility of grade io 2 was reported (Fig. 2). There was evidence of periapical swelling. A CT of the head and the maxillary district was prescribed Case report az A 60-years-old woman had an abnormal swelling and (Figg. 3-5). pain during an endodontic treatment accompanied by The whole condition was diagnosed as air emphyse- her dentist to the emergency room and was referred ma resulting from sodium hypochlorite solution ex- to our observation for complaining of severe pain, ec- travasation during the endodontic treatment. Antibiot- chymosis and severe swelling on the left side of her ic and antiseptic therapy (ceftriaxone) and analgesic rn face (Fig. 1). The aforementioned symptoms ap- and antiedema therapy (betamethasone) were pre- peared after sodium hypochlorite irrigation and ag- scribed. Symptoms and the overall conditions of the gressive use of air spray for drying the root canal dur- patient improved three days afterwards (Fig. 6). te ing the endodontic treatment of the upper left lateral A panoramic radiograph was then prescribed. After incisor. one month, extraction of the upper left lateral incisor The woman’s medical history was performed. She re- was done, the ecchymosis and the swelling appeared ported several episodes of hypersensitivity to differ- to be fully resolved and the patient’s eye opening had In ent drugs, asthma and previous thyroid cancer. First, returned back to normal (Fig. 7). ni io iz Ed IC C © Figure 1. Woman with ecchymosis and severe swelling on the left side of the face immediately after the en- dodontic accident. 118 Annali di Stomatologia 2017;VIII(3):117-122  Subcutaneous emphysema during root canal therapy: endodontic accident by sodium hypoclorite Figure 2. The intraoral situation. li na io az rn te In ni io iz Ed IC C © Figures 3-5. CT of the maxillary district (black and white). Annali di Stomatologia 2017;VIII(3):117-122 119  G. Tenore et al. Figure 6. The situation after three days of pharmacolog- ical therapy. li na io az rn te In ni Figure 7. The extraoral situation after one month: the ecchymosis and swelling appeared fully resolved. io iz Ed IC C © 120 Annali di Stomatologia 2017;VIII(3):117-122  Subcutaneous emphysema during root canal therapy: endodontic accident by sodium hypoclorite The subject gave informed consent, and the study wide-gauged and apical-opened needle (14). was therefore performed in accordance with the ethi- Professionals in this line of work must be careful cal standards of the Declaration of Helsinki (as re- about how far the irrigating needle is placed into the vised in Brazil 2013). canal. This can prevent irrigation accidents. Any nee- dle should either be bound in the canal or applied in the proximity of the working length. A gentle flow rate should be used to avoid extravasation. Using a Luer- li Lock lateral-opened needle is also advised (15, 16). Discussion Recent studies have suggested the use of an Endo- na Surgical procedures are not the only cause for devel- opment of subcutaneous emphysema, as cases have Vac irrigation system to obtain safe irrigation through- been described during restorative, crown and en- out the working length. Nielsen and Baumgartner’s dodontic procedures. Emphysema also has been re- study in fact pinpoints the use of an EndoVac system ported during oral laser surgery. Air can be intro- resulting in statistically significant more debris re- io duced unto the soft tissue spaces by several routes, moval at 1 mm from the working length than needle but it usually passes through the dentoalveolar mem- irrigation with a downturn in extravasation accidents brane or a root canal (9). (17). az In accordance with recent studies, the efficacy of the It is important to know the working length and to be sodium hypochlorite solutions depends on its concen- certain about the integrity of the root canal system tration. A previous study evaluated the efficacy in vit- before irrigating with any concentrated solution (17). ro of three different concentrations of NaOCl against Some advantages in the decontamination of the root canal system can be provided also by laser devices, rn Enterococcus faecalis (10). This study demonstrated the higher efficacy of the highest concentration used which have been described by the Authors of previ- (5.25%). The correlation between concentration and ous studies. In fact, the use of KTP laser and a 980- antimicrobial action is confirmed as well. The efficacy nm diode laser revealed statistically highly significant te of sodium hypochlorite antimicrobial action also de- differences (P ≤ 0.01) compared to traditional en- pends on its pH, its osmolarity, its flow through the dodontic procedures in the reduction of the load of root canals, its quantity and time of persistence in the Enterococcus faecalis biofilms (higher than 96 and 93%, respectively) (18, 19). In canals (11). Although providers perform an adequate endodontic Alongside its antimicrobial activity, sodium hypochlo- therapy, if a subcutaneous emphysema arises, pro- rite is an extremely cytotoxic chemical solution (11). fessionals should first and foremost apply an ice-pack In fact, when it gets into contact with vital tissues, on the involved part. Second, they should administer NaOCl causes a whole series of diseases such as ni antibiotics, analgesics and cortisone-based therapy, if haemolysis, ulceration, inhibition of neutrophil migra- needed. These actions will help to control the inflam- tion, damage to endothelial and fibroblast cells, facial matory reaction (20). nerve weakness, and necrosis. These toxic effects io can occur because of this solution alkalinity (pH 10.8- 12.9) and the hypertonicity of oxidating proteins and lipid membranes (12, 13). iz Conclusion Human tissues exposed to NaOCl solution can be af- This paper report investigates a case in which extru- fected by subcutaneous emphysema, which is a con- sion of NaOCl caused severe tissue damage when dition characterized by the presence of air in the tis- unintentionally injected beyond the root canal fora- Ed sues under the skin due to oxygen liberation into the men. Side effects include pain, ecchymosis and same tissues. swelling of the face. Determining the correct working When subcutaneous emphysema occurs, the patients length, even when performing an intraoperative peri- report severe pain, ecchymosis and swelling. Some apical radiograph and confirming the root canal in- patients report temporary nerve paresthesia as well. tegrity, could help avoid these kinds of accidents. The swelling can occur in different areas according to Lower concentrations of NaOCl may be helpful, and IC the tooth involved. If the sodium hypochlorite extrava- using a negative-pressure system of irrigation, such sation occurs in an upper tooth, the swelling can af- as an Endo-Vac, could help to properly perform en- fect the maxillary upper part, comprising the eye, the dodontic treatment. maxillary sinus, the wing of the nose and the cheek. C Otherwise, if the tooth involved is mandibular, the swelling can extend to the check, the angle of the mandible and, in the worst cases, the ear and the Aknowledgements neck. Authors did not receive any financial grants nor other © Most of these cases arise because of incorrect deter- fundings. mination of the working length or canal anatomical anomalies such as reabsorption or open-apex, lateral perforation and iatrogenic widening of the apical fora- men. Many subcutaneous emphysema cases are References caused by use of positive pressure irrigation with a 1. Mohammadi Z, Jafarzadeh H, Shalavi S. Antimicrobial effi- Annali di Stomatologia 2017;VIII(3):117-122 121  G. Tenore et al. cacy of chlorhexidine as a root canal irrigant: a literature re- mouth randomized clinical trial. Quintessence Int. 2013; view. J Oral Sci. 2014;56(2):99-103. 44(2):113-122. 2. Stavileci M, Hoxha V, Görduysus Ö, Tatar I, Laperre K, 12. Witton R, Henthorn K, Ethunandan M, Harmer S, Brennan Hostens J, et al. Evaluation of Root Canal Preparation Us- PA. 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Pelka M, Petschelt A. Permanent mimic musculature and 2013;24(1):21-24. io nerve damage caused by sodium hypochlorite: a case re- 15. Kishor N. Oral tissue complications during endodontic irri- port. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. gation: literature review. N Y State Dent J. 2013;79(3):37- 2008;106(3):e80-33. 42. 6. Singh PK. Root canal complications: ‘the hypochlorite ac- 16. Shuping G, Ørstavik D, Sigurdsson A, Trope M. Reduction az cident’. SADJ. 2010;65(9):416-419. of intracanal bacteria using Nickel-titanium rotary instru- 7. Olate S, Assis A, Freire S, de Moraes M, de Albergaria-Bar- mentation and various medications. J Endodon. 2000;26:751- bosa JR. Facial and cervical emphysema after oral surgery: 755. a rare case. International Journal of Clinical and Experimental 17. Nielsen BA, Craig Baumgartner J. Comparison of the En- Medicine. 2013;6(9):840-844. doVac system to needle irrigation of root canals. J Endod. rn 8. Barkdull TJ. Pneumothorax during dental care. J Am Board 2007;33(5):611-615. Fam Pract. 2003;16(2):165-169. 18. Romeo U, Palaia G, Nardo A, Tenore G, Telesca V, Korn- 9. Romeo U, Galanakis A, Lerario F, Daniele GM, Tenore G, blit R, et al. Effectiveness of KTP laser versus 980 nm diode Palaia G. Subcutaneous emphysema during third molar laser to kill Enterococcus faecalis in biofilms developed in te surgery: a case report. Braz Dent J. 2011;22(1):83-86. experimentally infected root canals. Aust Endod J. 2015;41 10. Berber VB, Gomes BPFA, Sena NT, Vianna ME, Ferraz CCR, (1):17-23. Zaia AA, et al. Efficacy of various concentrations of NaOCl 19. Palaia G, Romeo U, Pacifici L, Ripari F, Gambarini G, Mo- In and instrumentation techniques in reducing Enterococcus fae- roni C, et al. In vitro antimicrobial activity of Ni-Ti endodon- calis within root canals and dentinal tubules. Int Endod J. tic therapy. Journal of Dental Research. Jun 2003;82B:184. 2006;39(1):10-17. 20. Heling I, Rotstein I, Dinur T, Szwec-levine Y, Steinberg D. 11. Lima RA, Carvalho CB, Ribeiro TR, Fonteles CS. Antimicrobial Bactericidal and cytotoxic effects of sodium hypochlorite and efficacy of chlorhexidine and calcium hydroxide/camphorated sodium dichloroisocyanurate solutions in vitro. J Endod. ni paramonochlorophenol on infected primary molars: a split- 2001;27(4):278-280. io iz Ed IC C © 122 Annali di Stomatologia 2017;VIII(3):117-122 

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Case report The three-dimensional reconstruction of the jaw with “bone slat technique” in conjunction with third molar removal li na Mario Santagata1, MD, PhD Results. The final results demonstrated an in- Atirge Cecere1, MD crease in length of 5 mm after bone slat technique Rosario V.E. Prisco2, MD, DDS (from 9.5 mm to 13.5 mm) and an increase in io Gianpaolo Tartaro1, MD width of 1 mm (from 5.7 mm to 6.7 mm). ISQ mea- Salvatore D’Amato1, MD, DDS surements were recorded at the time of implant placement (the mean was: 68.5) and immediately az Medical Director - Multidisciplinary Department of after individualized screw-retained provisional 1 Medical and Dental Specialties; crown (the mean was: 77). Oral and Maxillofacial Surgery Unit, AOU University Conclusions. This technique is reliable and aes- of Campania “Luigi Vanvitelli”, Naples, Italy thetic and functional results appear to be stable 2 CAGS Prosthodontics, Private Practice Naples, rn and respect this requisite: simple and fast graft Italy harvesting and low risk of morbidity especially in conjunction with third molar removal. te Key words: alveolar ridge augmentation, alveolar Salvatore D’Amato Corresponding author: bone grafting, esthetics, bone slat technique. Multidisciplinary Department of Medical and Dental Specialties, AOU - SUN In University of Campania “Luigi Vanvitelli” Via B. Croce 18 Introduction 80059 Torre del Greco (NA), Italy The bone available for the implant placement may be E-mail: [email protected] insufficient due to tooth extraction, trauma, periodon- ni titis, infection, or the long-term use of removable prostheses (1, 2). This resorption of the alveolar crest often reduces the possibility of correct three-dimen- sional implant placement for teeth replacement. io Summary Severely resorbed alveolar bone requires a ridge augmentation procedure to achieve the appropriate Background. The purpose of this study was to re- width and height of bone to enable successful implant iz port the outcome of the management of both hori- placement. zontal and vertical defects of alveolar crest using Therefore, preparation of the implant site can require the bone slat technique approach in conjunction augmentation with autologous bone grafts. Different Ed with third molar removal prior to implant place- extra- and intraoral donor sites are available (3-6). ment in the aesthetic area. Other techniques used to treat bone defects and that Methods. We present a 20-year-old female patient can be utilized: edentulous ridge expansion, guided who lost a maxillary lateral incisor. The objective bone regeneration and sandwich bone osteotomy (7, of treatment was to replace the lateral incisor with 8). As well as, several Authors used connective tis- an implant-supported crown restoration without sue graft to improve the aesthetic results (9, 10). interfering with the integrity and topography of IC The purpose of this article is to present the applica- the adjacent gingival tissues. Because the future tion of a new procedure for reconstruction of the at- implant site showed horizontal and vertical bone rophic maxilla in conjunction with third molar removal: defect the Authors decided to perform bone re- three-dimensional reconstruction with bone slats of generation. The need for such bone augmentation C about 1 mm thickness taken directly from the donor in the younger patient often coincides with the site; space between the bone slats and the alveolar timing for third molar removal. By combining bone was filled with bone chips harvested by bone third molar extraction with bone harvest and alve- scraper. olar grafting, the patient undergoes only one sur- © This technique is reliable and aesthetic and functional gical approach. The bone height (9.5 mm) and results appear to be stable and respect this requisite: width (5.7 mm) were measured at the point of in- simple and fast graft harvesting and low risk of mor- terest (tooth 12) both before and after implant bidity especially in conjunction with third molar re- placement in the reconstructed panoramic and moval. parasagittal views by Cone Beam Computed To- mography (CBCT) scan. Annali di Stomatologia 2017;VIII(3):123-130 123  M. Santagata et al. Bietigheim-Bissingen, Germany) of region 12 (FDI tooth numbering system), and Cone Beam Computed Case description The requirements of the Helsinki Declaration were Tomography (CBCT) scan (Scanora 3D - SOREDEX, observed and the patient gave informed consent for Tuusula, Finland) were performed to plan the surgical all surgical procedures. A 20-year-old female patient procedure. was referred to the Authors to save her maxillary right The CBCT scan revealed a great vertical and hori- lateral incisor. The tooth was slightly mobile (grade zontal bone dehiscence of both buccal and palatal li 2), vital, and extremely sensitive to palpation. Radio- plate in the maxillary right lateral area with a bone density of D5 using Misch’s classification (11) (mean na graphic examination (panoramic) revealed a marked bone loss. This rapid bone loss was pathognomonic 32 HU). The bone height (9.5 mm) and width (5.7 for aggressive periodontal disease (Fig. 1). The prog- mm) were measured at the point of interest (tooth 12) nosis of the tooth was hopeless, and it was destined both before and after implant placement in the recon- for extraction. Moreover, the patient presented agen- structed panoramic and parasagittal views (Fig. 2). io esis of 18 with inclusion of 28, 38 and 48. Surgical procedure was performed under local anes- After the diagnostic work-up was completed, a treat- thesia (mepivacaine 2% + epinephrine 1:100.000) ment plan was developed using a specialist team ap- plus oral sedation (midazolam 5 mg). The patient was az proach. The proposed treatments included orthodon- premedicated 1 hour prior with amoxicillin plus clavu- tic treatment and tooth replacement by implantology. lanic acid 2 g orally. Immediately before surgery, the In fact, orthodontic therapy can improve the periodon- patient rinsed his mouth with a 0.3% chlorhexidine tal situation in patients with pathologic migration by solution for one minute. providing good function and improved aesthetics after rn realignment. The maxillary right lateral incisor was extracted and A crestal incision slightly shifted on the palatal was Recipient Site the extraction socket was carefully curetted. The followed by a sulcular incision from the tooth 11 to te crown of the extracted tooth was used as a temporary the tooth 13, with one relieving incision that the tooth and was pegged to the orthodontic device dur- mesial line angle of tooth 11 extending along the up- ing orthodontic alignment with arch wire technique per labial frenulum. A full-thickness flap was elevat- applied to the brackets. ed, and all inflammatory and granulation tissue were In The objective of treatment was to replace the lateral debrided with a curette. The incisive nerve was incisor with an implant-supported crown restoration saved. To ensure tension-free wound closure, the pe- without interfering with the integrity and topography of riosteum was slit basal of the flap immediately before the adjacent gingival tissues. Because the future im- surgery, to prevent bleeding at the time of suture. ni plant site showed horizontal and vertical bone defect The bony defect was measured using a periodontal the Authors decided to perform bone regeneration. probe to determine the size of the bone slat (Fig. 3). The need for such bone augmentation in the younger io patient often coincides with the timing for third molar removal. By combining third molar extraction with Donor Site bone harvest and alveolar grafting, the patient under- iz goes only one surgical approach. Access to the ramus area for bone harvest was Flap design gained through an extension of the commonly used envelope flap for third molar removal: a buccal enve- Ed lope flap with a sulcular incision was performed from the first to the second mandibular molar with a distal Surgical planning A single X-ray (Vistascan mini view - DURR dental, incision along the mandibular ramus. IC C © Figure 1. Clinical preoperative situation. Preoperative panoramic radiographic analysis. 124 Annali di Stomatologia 2017;VIII(3):123-130  The three-dimensional reconstruction of the jaw with “bone slat technique” in conjunction with third molar removal li na io az rn Figure 2. Presurgical CBCT study in the area of maxillary right lateral incisor. te Figure 3. The bony defect was mea- In sured using a periodontal probe to de- termine the size of the bone shells. ni io iz Ed The mucoperiosteal flap was reflected from the tegrity of the underlying mandibular nerve (Fig. 4). mandibular body, exposing the third molar area and After, by the use of a bone scraper (safe scraper IC buccal plate of the ramus. The flap was elevated su- twist, Meta, Reggio Emilia, Italy), the bone particles periorly along the external oblique ridge to the base were collected for later use. of the coronoid process and stopped in this position using a klemmer. C The bone slats were anchored in the host bone with ti- Bone graft placement tanium microscrews (Stoma Set, Germany) (Fig. 5). The osteotomy was performed following the Piezo- Space between the bone slats and the alveolar bone Osteotomy surgery (Mectron, Genova, Italy) technique. The bone was filled with bone chips harvested by bone scraper © was harvested, to obtain the bone slat of about 1 mm (safe scraper twist, Meta, Reggio Emilia, Italy) (Fig. 6). of thickness from the buccal plate. A thin chisel is The bone graft was covered with a mucoperiosteal flap gently tapped along the entire length of the external and the wound was closed with interrupted sutures. oblique osteotomy, taking care to parallel the lateral The mesial and distal alveolar contours were consid- surface of the ramus. This technique leaves intact the ered as reference points for adaptation of the bone bone medullary of the mandible preserving the in- slats. Annali di Stomatologia 2017;VIII(3):123-130 125  M. Santagata et al. li na io Figure 4. A thin chisel is gently tapped along the entire length of the external oblique osteotomy, taking care to parallel the lateral surface of the ramus. This technique leaves intact the bone medullary of the mandible preserving the integrity of the underlying mandibular nerve. az rn te In ni io iz Figure 5. The bone slats were anchored in the host bone with titanium microscrews. Ed in width of 1 mm after bone augmentation (from 5.7 Because the third molar tooth was completely impact- mm to 6.7 mm) (Fig. 8). Third molar surgery ed, it was helpful to procure the graft first to visualize the submerged crown. After the bone harvest per- formed, the third molar was removed, the socket was After a 3-month healing period, re-entry surgery was Implant Placement inspected, dental follicular tissue was curetted, the performed for implant insertion. IC socket was irrigated copiously with normal saline, the Following local anesthesia (mepivacaine 2% + flap was then repositioned and sutured (prolene 5/0, epinephrine 1:200.000), a standard mucoperiosteal Ethicon). flap was elevated including sulcular incisions at both teeth facing the single-tooth gap via a palatally orient- C ed crestal incision. The osteosynthesis titanium mi- croscrews were removed (Fig. 9). Thereupon, the pa- tient received one commercially available implants: Results CBCT scan was performed 3 months after maxillary MIS Seven (MIS, Barlev, Israel) 3.75 mm of diameter reconstruction. The CBCT scan showed reconstruc- and 13 mm of length. A correct 3-D positioning of the © tion of both buccal and palatal plate and improvement implant, as described by Grunder et al., was per- of bone density from (32 HU) to (92 HU) according to formed (12). At the time of surgery, small-diameter Misch’s classification (Fig. 7) (11). The final results healing abutments were placed (Fig. 10). The mu- demonstrated an increase in length of 5 mm after coperiosteal flap was sutured at the mesial and distal bone graft (from 9.5 mm to 13.5 mm) and an increase aspect (prolene 5/0, Ethicon). Post-operative instruc- 126 Annali di Stomatologia 2017;VIII(3):123-130  The three-dimensional reconstruction of the jaw with “bone slat technique” in conjunction with third molar removal tions included continued antibiotic treatment for 6 days and analgesic therapy. Oral disinfection was recommended for 2 weeks. Sutures were removed 10 days post-operatively. The implant stability coefficient, termed RFA analysis, li Implant stability quotient was measured by Osstell (Integration Diagnostics na AB, Goteborg, Sweden). It was necessary to screw a disposable magnetic attachment (Smartpeg™) to im- plant 4-5 Ncm. Magnetic attachment cannot have any contact with any metallic instrument before it is screwed. Smartpegs™ compatible with diameter 4.2 io mm, 3.75 mm: seven implants (MIS, Barlev, Israel), system connection was used. ISQ measurements were recorded at the time of implant placement. Four az different measurements were taken (facial or buccal, lingual, mesial, distal), and then an average value of these 4 values was taken; ISQ was: 68.5. rn Figure 6. Space between the bone slats and the alveolar bone was filled with bone chips. te Figure 7. The CBCT scan sho- wed reconstruction of both buc- cal and palatal plate and im- provement of bone density from In (32 HU) to (92 HU) according to Misch’s classification. ni io iz Ed Figure 8. The final results demonstrated an increase in lenght of 5 mm after bone graft (from 9.5 to 13.5 mm) and an in- crease in width of 1 mm after bone augmentation (from 5.7 to 6.7 mm). IC C © Annali di Stomatologia 2017;VIII(3):123-130 127  M. Santagata et al. li na io az rn te In Figure 9. The osteosynthesis titanium microscrews were removed. ni io iz Ed IC C Figure 10. A correct 3-D positioning of the implant was performed. At the time of surgery, small-diameter healing abutments were placed. © The CBCT scan showed reconstruction of both buc- After 5 months from implant surgery a CBCT scan cal and palatal plate and improvement of bone densi- Restorative Procedure was performed immediately after individualized screw- ty from D5 (92 HU) to D2 (1246 HU) according to retained provisional crown (Fig. 11) and ISQ measure- Misch’s classification (Fig. 12) (11). The final results ments were recorded with 4 different measurements. demonstrated an increase in length of 5 mm after The ISQ average of these 4 values was 77. bone graft (from 9.5 mm to 13.5 mm) and an increase 128 Annali di Stomatologia 2017;VIII(3):123-130  The three-dimensional reconstruction of the jaw with “bone slat technique” in conjunction with third molar removal li na io az Figure 11. After 5 months post-op, one screw-retained pro- visional crown was delivered. Figure 13. The final results demonstrated an increase in length of 5 mm after bone graft (from 9.5 mm to 13.5 mm) rn and an increase in width of 1 mm after bone augmentation (from 5.7 mm to 6.7 mm). Saw) from the retromolar region, were placed to re- te shape the alveolar crest and to protect the particular bone (placed in the cavity between the shells), from resorption. Harvesting the bone shells and extraorally In trimming with a cutting wheel is very technique-sensi- tive. Additional, harvesting of bone chips is also nec- essary. In particular, the harvested bone block was cut along its long axis into two thinner blocks with the same diamond disk used previously. These two ni blocks were thinned to a thickness of 1 mm using a bone scraper; bone chips were collected at the same time. io The major advantage of this technique, in comparison to a bone block augmentation placed as an onlay graft, is the regeneration of vital bone (15, 16). The iz Figure 12. The CBCT scan showed reconstruction of both bone laminae of about 1 mm thickness prevent re- buccal and palatal plate and improvement of bone density sorption of the bone chips and provide the shape of from D5 (92 HU) to D2 (1246 HU) according to Misch’s the graft. Blood supply from the host bone ensures Ed classification. survival of the bone chips. Based on these biological concepts described by Khoury et al. (15, 16) we have made changes on the in width of 1 mm after bone augmentation (from 5.7 establishment of three-dimensional reconstruction of mm to 6.7 mm) (Fig. 13). the atrophic ridge (6); in fact, the bone slat of about 1 mm thickness was obtained directly from the donor IC site by piezosurgery Medical device with surgical tip Discussion MT1S-10 (Mectron®, Carasco, Genova, Italy), and wasn’t necessary his extraoral trimming. Further- The use of bone removed from the posterior more, the intraoral bone lamina harvested was exclu- C mandible during mandibular third molar extraction al- sive cortical bone (Fig. 4), this avoid the possibility of so has been described (13). The Author, in this clini- injury the inferior alveolar nerve with paraesthesia or cal study, used the piezosurgery Medical device with anesthesia; or injury of the buccal nerve with de- surgical tip MT1S-10 (Mectron®, Carasco, Genova, creased sensitivity in the posterior vestibular mucosa. © Italy) to remove the third (14). Moreover, we performed the harvesting of the bone Khoury et al. (15, 16) described the shell technique lamina of about 1 mm thickness directly from the for three-dimensional hard tissue grafting. Their tech- donor site avoiding the possibility of the bone con- nique included the harvesting technique followed the tamination and vitality stress during the cutting along methodology of the MicroSaw. Thin cortical bone its long axis into two thinner blocks with the diamond shells, harvested with a special cutting wheel (Micro- disk and bone scraper. Annali di Stomatologia 2017;VIII(3):123-130 129  M. Santagata et al. The final results of this clinical case demonstrated an 6. D’Amato S, Tartaro G, Itro A, Santagata M. Mandibular bone increase in length of 5 mm after bone graft (from 9.5 regeneration after bone slat technique. Ann Stomatol to 13.5 mm) and an increase in width of 1 mm after (Roma). 3 Jul 2017;8(1):39-44. bone augmentation (from 5.7 to 6.7 mm). 7. Santagata M, Sgaramella N, Ferrieri I, Corvo G, Tartaro G, D’Amato S. Segmental sandwich osteotomy and tunnel tech- In addition, we observed an improvement of bone den- nique for three-dimensional reconstruction of the jaw atro- sity after implant loading: from D5 (92 HU) to D2 (1246 phy: a case report. Int J Implant Dent. Dec 2017;3(1):14. HU) according to Misch’s classification. We think that li 8. Santagata M, Guariniello L, Tartaro G. Modified edentulous this improvement in bone quality is linked to the change ridge expansion technique and immediate implant placement: of the bone architecture under load so that the bone na a 3-year follow-up. J Oral Implantol. Apr 2015;41(2):184-187. structure will be able to support the chewing load. 9. Santagata M, Tartaro G, D’Amato S. Clinical and histolog- ic comparative study of subepithelial connective tissue graft and extracellular matrix membrane. A preliminary split- mouth study in humans. Int J Periodontics Restorative Dent. io Jan-Feb 2015;35(1):85-91. Conflict of interest 10. Santagata M, Guariniello L, Prisco RV, Tartaro G, D’Ama- No potential conflict of interest relevant to this article to S. Use of subepithelial connective tissue graft as a bio- was reported. logical barrier: a human clinical and histologic case report. az J Oral Implantol. Aug 2014;40(4):465-448. 11. Misch CE. Density of bone: effect on treatment plans, sur- gical approach, healing, and progressive bone loading. Int J Oral Implantol. 1990;6(2):23-31. References 1. Lekovic V, Kenney EB, Weinlaender M, Han T, Klokkevold 12. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone- rn P, Nedic M, Orsini M. A bone regenerative approach to alve- to-implant relationship on esthetics. Int J Periodontics Res- olar ridge maintenance following tooth extraction. Report of torative Dent. 2005;25:113-119. 10 cases. J Periodontol. Jun 1997;68(6):563-570. 13. Misch CM. The harvest of ramus bone in conjunction with 2. Ong CT, Ivanovski S, Needleman IG, Retzepi M, Moles DR, third molar removal for onlay grafting before placement of te Tonetti MS, Donos N. Systematic review of implant outcomes dental implants. J Oral Maxillofac Surg. 1999;57:1376-1379. in treated periodontitis subjects. J Clin Periodontol. May 2008; 14. Itro A, Lupo G, Marra A, Carotenuto A, Cocozza E, Filipi M, 35(5):438-462. D’Amato S. The piezoelectric osteotomy technique compared In 3. Lundgren AK, Lundgren D, Hämmerle CH, Nyman S, Sen- to the one with rotary instruments in the surgery of includ- nerby L. Influence of decortication of the donor bone on guid- ed third molars. A clinical study. Minerva Stomatol. Jun ed bone augmentation. An experimental study in the rabbit 2012;61(6):247-253. skull bone. Clin Oral Implants Res. Apr 2000;11(2):99-106. 15. Khoury F, Hanser T. Mandibular bone block harvesting from 4. Misch CM. Comparison of intraoral donor sites for onlay graft- the retromolar region: a 10-year prospective clinical ni ing prior to implant placement. Int J Oral Maxillofac Implants. study. Int J Oral Maxillofac Implants. May-Jun 2015;30 Nov-Dec 1997;12(6):767-776. (3):688-697. 5. D’Amato S, Tartaro G, Itro A, Nastri L, Santagata M. Block 16. Khoury F, Khoury CH. Mandibular bone block grafts: diag- versus particulate/titanium mesh for ridge augmentation for nosis, instrumentation, harvesting techniques and surgical io mandibular lateral incisor defects: clinical and histologic anal- procedures. In: Khoury F, Antoun, H, Missika P, eds. Bone ysis. Int J Periodontics Restorative Dent. Jan-Feb 2015;35 Augmentation in Oral Implantology. Berlin: Quintessence, (1):e1-8. 2007. iz Ed IC C © 130 Annali di Stomatologia 2017;VIII(3):123-130 

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Case report Surgical approach to malformation of maxillary central incisor following trauma to its predecessor. Two case reports li na tition ranges from 12 to 74% (1-5). The most common cause of trauma is falls, and the Gerardo La Monaca1, DDS, PhD highest incidence of injuries occurs before the age of Iole Vozza2, DDS, PhD 2 years, as psychomotor development and poor mo- Susanna Annibali2, MD, DD io tor skill predispose children to fall (5-8). At this age Rita Giardino2, DDS, PhD there are no significant differences in the prevalence Nicola Pranno2, DDS, PhD among boys and girls (6, 8, 9). The injuries of primary Maria Paola Cristalli3, DDS, PhD az dentition followed by a higher incidence of develop- 1 Department of Sense Organs, “Sapienza”, Universi- mental anomalies in the permanent dentition are ty of Rome, Rome, Italy avulsion and intrusive luxation (3-5, 7, 10-12). 2 Department of Oral and Maxillo-Facial Sciences, These types of injury are related to the high resilience “Sapienza”, University of Rome, Rome, Italy and flexibility of the primary teeth supporting struc- rn 3 Department of Biotechnologies and Medical Surgical tures, the large volume of teeth in relation to the bone Sciences, “Sapienza”, University of Rome, Rome, Italy and the short roots (1, 6). The sequelae on the permanent teeth depends on the te direction of the traumatic force, the type and the severity of trauma, the degree of primary root resorp- Gerardo La Monaca tion and the developmental stage of the permanent Corresponding author: “Sapienza” University of Rome tooth at the time of the injury, and mainly to the In Via Caserta 6 child’s age (Tab. 1) (1, 4, 13). The child’s age was re- 00161 Rome, Italy ported to have a statistically significant association Tel.: +39 06 49976651 with the severity of the developmental sequelae in the Fax: +39 06 44230811 permanent maxillary central incisors: lower the age ni E-mail: [email protected] greater the severity (4, 12). This may be explained as the germ of the permanent maxillary central incisor in the early stages of devel- io opment is localized palatally and above the apex of the deciduous predecessor (14). Between 3-5 years Summary of age this tooth change its eruption pathway proceeding forward and downward and its crown be- iz In the case reports, two different approaches have coming closer to the resorbing primary root (14). been described to treat the developmental distur- Furthermore in this area the presence of the bances in the maxillary central incisors due to trau- connective tissue, that is not permeable to the Ed ma to its predecessor. displacement of the primary teeth, infection or The treatment plan was chosen according to the necrosis explains the risk of developing disturbances type and severity of the malformations, the exact in the succeeding permanent teeth after injuries to location and the morphology of the involved teeth. their predecessors (1, 14). In the first case, the disimpaction of the maxillary The purpose of the present report is to describe two right central incisor was achieved with the com- cases of malformation of maxillary central incisor fol- IC bined of surgical and orthodontic therapy, that was lowing traumatic injury in its predecessor, in which planned in two consecutive stages. different approaches were adopted. In the second case the severe root angulation and the failure of the previous orthodontic traction made impossible the repositioning of the upper C right central incisor, which was surgical removed. Case reports Key words: tooth injuries, deciduous tooth, perma- A 7-year-old boy was referred to the “Sapienza” nent dentition, tooth abnormalities, tooth unerupt- I Case © Rome University, Department of Oral and Maxillofa- ed, tooth extraction. cial Sciences, Oral Surgery Unit by his parents. The chief complaint was the eruption delay of the perma- nent maxillary right central incisor. Introduction The prevalence of developmental disturbances in up- The past medical history was negative, except for per central incisors due to trauma in the primary den- traumatic injury to the premaxilla at 3-year-old age. Annali di Stomatologia 2017;VIII(3):131-138 131  G. La Monaca et al. Table 1. Sequelae on the permanent teeth following trauma to primary teeth Pathologic Alteration Clinical Features Clinical Features Age White or yellow-brown discoloration The affected enamel appears as a white or yellow-brown area, 2-5 years of enamel extent varying, sharply demarcated, without detectable defects in the enamel surface. li The white colour was due to a lower mineral statement and the yellow-brown colour was due to a bleeding spread where the na enamel is developing. White or yellow-brown discoloration Hypoplastic defects may be caused by a localized damage to the 2 years of enamel with circular enamel enamel matrix during the secretory phase of the ameloblasts, hypoplasia before the mineralization is completed. This malformation is characterized by a narrow horizontal groove io around the crown in cervical position with respect to the areas with white or yellow-brown discoloration. Crown dilaceration Crown dilaceration is a deviation of the crown in relation to the long 1.5- 3.5 az axis of the tooth as a consequence of the traumatic non-axial years displacement between unmineralized and mineralized tissues of the developing tooth germ The curve can be located at the cervical portion, midway along the root or even just at the apex of the root. Half of these teeth become rn impacted, whereas the remaining half erupts normally either in facial or in lingual version. Root duplication Root duplication is the result of a traumatic division of the cervical 2-5 years te loop that develops two separate roots. Radiographically, it can be demonstrated a mesial and distal root, which extend from a partially formed crown. Histologically there is a calcium-traumatic line separating the hard tissue formed before the injury. Vestibular root angulation or In Vestibular root angulation is a marked curvature confined to the 2-5 years dilaceration root, due to the gradual change in the direction of development. The malformed tooth is usually impacted and the crown palpable in the labial sulcus. This malformation is unique feature of the maxillary central ni incisors. Lateral root angulation or Lateral root angulation or dilaceration are mesial or distal bending 2-5 years dilaceration of the root of the tooth. The dilaceration is caused when the impact io force is transferred along an imaginary oblique line that goes through the incisal edge of the permanent incisor and causes this crown to turn upwards into its tooth follicle. The permanent incisor root already formed wheels and it creates an unusual angle iz between the pre- and post-traumatic parts of the tooth. Partial or complete arrest of root Partial or complete arrest of root formation is a rare complication 1-3 years formation characterized by missing eruption or mobility, as a result from Ed inadequate periodontal support. Normal root development can be compromised by direct injury to Hertwig’s epithelial root sheath resulting in a calciotraumatic line separating the hard tissue deposited before and after the injury. Sequestration of permanent tooth This rare complication is characterized by swelling, suppuration 1-3 years germs and fistula formation. IC Radiographic examination discloses osteolytic changes around the tooth germ, including disappearance of the outline of the dental crypt and expanded cortical alveolar bone. Disturbance in eruption Disturbances in permanent tooth eruption include: impaction, 1-3 years ectopic eruption, delayed eruption, scar plate formation and C ankylotic primary teeth. Impaction is very common in the cases in which there is crown or the root malformations. The ectopic eruption is related with the early loss of primary © incisors due to lack of eruption guidance. The delayed eruption is related with the abnormal changes in the connective tissue after the early loss of primary incisors (avulsion or extraction). Odontoma-like malformation This malformation occurs during early stage of odontogenesis and 1-3 years affect the morphogenetic stages of ameloblastic development. The hystologic analysis shows a conglomerate of hard tissue, having the morphology of a complex odontoma or separate tooth elements. 132 Annali di Stomatologia 2017;VIII(3):131-138  Management of a permanent tooth after trauma to deciduous predecessor The panoramic radiograph showed in the right side of started to correct the patient’s malocclusion and to the maxillary jaw the presence of the deciduous in- place the tooth into its proper position in the dental cisors and the inclusion of the permanent central in- arch (Fig. 5). cisor with the crown underneath the anterior nasal spine and with its incisal edge upwards. In the left side the rotated permanent left central incisor and the A 12-year-old boy was referred to the “Sapienza” II Case lateral primary incisor were present (Fig. 1). Rome University, Department of Oral and Maxillofa- li The computer tomography confirmed the position of cial Sciences, Oral Surgery Unit by his parents, com- na the right central incisor across the premaxilla and plaining of the failure of surgical-orthodontic reposi- showed its incomplete root formation, developing on tioning of the maxillary right central incisor lasted the long axis of the crown (Fig. 2). three years. The child was healthy and his medical In agreement with the orthodontist, it was decided to history did not reveal any important information. The try the surgical exposure and orthodontic traction of parents reported that the patient at the age of 22 io the affected tooth, before performing the orthodontic months underwent intrusion of central primary incisor, treatment for the correction of the malocclusion and spontaneously re-erupted after 3 weeks. the repositioning of the right central incisor into prop- The intraoral examination revealed the permanent az er position. right central incisor missing, the partial loss of its In view of the incisor position, surgical exposure was space due to the migration of the adjacent teeth and planned in two stages. the crown of the maxillary right lateral incisor affected In the first a full-thickness buccal flap was made un- by white or yellow-brown discoloration of enamel and rn der local anaesthesia to gain access to cortical plane circular enamel hypoplasia (Fig. 6). of the maxilla, and the primary incisors were extract- In periapical radiograph, the crown of the maxillary ed (Fig. 3a). After bone removal, the crown was ex- right central incisor appeared with its incisal edge up- posed and an orthodontic bracket with ligature wire wards underneath the anterior nasal spine (Fig. 7). te was bonded onto the palatal surface of the maxillary The cross-sectional images of the computer tomogra- right central incisor (Fig. 3b). The flap was reposi- phy confirmed the buccal angulation with a severe tioned and sutured. Two weeks later, orthodontic curvature, already suspected in the conventional ra- In forces were applied to pull the crown in buccal and diograph and provided valuable information about the horizontal direction, in order to move away the incisor morphology of the root (Fig. 8). from the roots of the adjacent teeth. In this case the severe root angulation and the failure The second surgical stage was performed when the of the previous orthodontic traction made impossible crown was visible through the buccal mucosa (Fig. the central incisor repositioning, therefore its surgical ni 4a). Using an apically repositioned flap, the crown removal was preferred. was exposed and a bracket was bonded on its labial A full-thickness buccal flap was reflected, the ostecto- surface to change direction to orthodontic traction in my was carried out on the labial cortical plane to ex- io order to straighten the tooth (Fig. 4b). pose the crown completely, and the impacted tooth After 14 months the recovering of the maxillary right was easily removed (Fig. 9a, b). The debridement of incisor was achieved and the orthodontic therapy was the scars following to the previous intervention of the iz Ed Figure 1. Panoramic radio- graph showing in the right side of the maxilla the de- ciduous incisors and the in- clusion of the permanent central incisor and in the left IC side the rotated permanent left central incisor and the lateral primary incisor. C © Annali di Stomatologia 2017;VIII(3):131-138 133  G. La Monaca et al. li na io az rn te In ni io iz Figure 2. Computer tomography showing the position of the right central incisor across the premaxilla and its incomplete Ed root formation. Figure 3a, b. The first stage of the surgical ex- IC posure of the maxillary right central incisor: a) a full-thickness buccal flap and the extraction of the C primary incisors were carried-out; b) the crown was exposed and an or- thodontic bracket was bonded onto its palatal © surface. 134 Annali di Stomatologia 2017;VIII(3):131-138  Management of a permanent tooth after trauma to deciduous predecessor Figure 4a, b. The second surgical stage: a) the crown was visible through the buccal mucosa; b) the crown was exposed using an apically repositioned flap and a bracket was li bonded on its labial sur- face. na io az rn te In ni Figure 5. The recovering of the maxillary right central in- cisor. io crown exposure was performed and the site, covered by periodontal dressing, was left healing by sec- iz Figure 6. The intraoral examination: the permanent right ondary intention (Fig. 9c, d). central incisor missing, the partial loss of its space due to the migration of the adjacent teeth and the crown of the Ed maxillary right lateral incisor affected by white or yellow- brown discoloration of enamel and circular enamel hy- poplasia. Discussion Developmental disturbances of permanent incisors following trauma to the primary dentition have a phys- ical, aesthetic and psychological impact both for chil- lationship between deciduous teeth and the perma- IC dren and their parents. nent successors. In these cases, the choice of the appropriate treat- The combined surgical and orthodontic therapy is the ment modalities is very important and depends on the method of choice for many clinicians. The success type of lesion, the exact location and the morphology rate of this treatment depends on the degree of mal- C of the involved teeth. formation, position and root formation of the tooth. Although panoramic or periapical radiographs are Studies have also shown that the bone loss after or- conventionally used for preoperative examination, thodontic treatment and the chance of injury to the more accurate information are achieved with comput- tooth during traction is directly connected to the © er tomography, because this methodic produces quantity of bone removed during surgical exposure. three-dimensional images without enlargement or su- However with the combined surgical/orthodontic ther- perimposition of anatomical structures (13). apy, ankylosis, pulp necrosis, root resorption, gingival Infact to allow a correct diagnosis it is mandatory to recession, delay in periodontal healing, bone loss determine the exact position of the involved teeth, and decrease in the width of keratinized gingiva may their morphology and degree of root formation, the re- occur (14). Annali di Stomatologia 2017;VIII(3):131-138 135  G. La Monaca et al. When surgical exposure and orthodontic traction fail or they are undesirable or impossible, such as in the case of odontoma like-malformation, the only option is the surgical tooth extraction as soon as possible. However, if the location is deep in the maxillary bone, without any eruption disturbance of the adjacent teeth, it is possible to decide to not remove the mal- li formed tooth, but clinical follow-ups and periodic ra- diographs to rule out any pathologic development are na necessary (15). This kind of non-treatment has the advantage of not exposing the patient to extensive surgery under general anesthesia, but it requires re- call examinations over time and annual repetitive ra- io diation exposure (15). az Conclusion Determining prognosis and treatment planning for a retained tooth are often difficult tasks. Two different treatments approaches to manage a traumatized per- rn manent tooth need to be considered: surgical expo- sure with orthodontic traction vs extraction and pros- thetic replacement with fixed bridge or implant place- te ment later when growth had ceased. Figure 7. Periapical radiograph showing the crown of the An appropriate diagnosis with both clinical and radio- maxillary right central incisor with its incisal edge upwards graphic examination is needed for the choice and the underneath the anterior nasal spine. success of the treatment plan. In ni io iz Ed IC C © Figure 8. Computer tomography showing the permanent right central incisor with a marked buccal curvature of its root. 136 Annali di Stomatologia 2017;VIII(3):131-138  Management of a permanent tooth after trauma to deciduous predecessor li na io az rn te In ni Figure 9a-d. Surgical intervention: a) extraction of the maxillary right central incisor; b) clinical view of the extracted tooth; c) io debridement of the scars following to the previous intervention of the crown exposure; d) periodontal dressing. The sequelae to the permanent dentition after trauma predecessors: a longitudinal study of 8 years. Dent Traumatol. iz to the primary dentition may require a multidisci- 2009;25(3):300-304. plinary approach involving Pediatric Dentist, Or- 2. Arenas M, Barbería E, Lucavechi T, Maroto M. Severe trau- thodontist, Periodontist, Oral Surgeon and Prostho- ma in the primary dentition-diagnosis and treatment of se- Ed quelae in permanent dentition. Dent Traumatol. 2006;22(4): dontist. 226-230. 3. Sennhenn-Kirchner S, Jacobs HG.Traumatic injuries to the primary dentition and effects on the permanent successors Conflict of interest and source of funding - a clinical follow-up study. Dent Traumatol. 2006;22(5):237- 241. IC statement 4. Lenzi MM, Alexandria AK, Ferreira DM, Maia LC. Does trau- The Authors have stated explicitly that there are no ma in the primary dentition cause sequelae in permanent suc- conflicts of interest in connection with this article. cessors? A systematic review. Dent Traumatol. 2015;31(2):79- 88. 5. Bardellini E, Amadori F, Pasini S, Majorana A. Dental Anoma- C lies in Permanent Teeth after Trauma in Primary Dentition. J Clin Pediatr Dent. 2017;41(1):5-9. Authors declarations 6. Coutinho TC, Cajazeira MR. Retrospective study on the oc- All Authors gave final approval and agree to be ac- currence of primary incisor trauma in preschool children of countable for all aspects of the work. © a low-income area in Brazil. Eur J Paediatr Dent. 2011;12(3): 159-162. 7. Da Silva Assunção LR, Ferelle A, Iwakura ML, Cunha RF. Effects on permanent teeth after luxation injuries to the pri- mary predecessors: a study in children assisted at an emer- References 1. Do Espírito Santo Jácomo DR, Campos V. Prevalence of se- gency service. Dent Traumatol. 2009;25(2):165-170. quelae in the permanent anterior teeth after trauma in their 8. Altun C, Cehreli ZC, Güven G, Acikel C. Traumatic intrusion Annali di Stomatologia 2017;VIII(3):131-138 137  G. La Monaca et al. of primary teeth and its effects on the permanent successors: teeth and sequelae on the permanent successors. Dent Trau- a clinical follow-up study. Oral Surg Oral Med Oral Pathol Oral matol. 2005; Dec;21(6):320-323. Radiol Endod. 2009;107(4):493-498. 13. Gurgel CV, Lourenço Neto N, Kobayashi TY, Garib DG, da 9. Cardoso M, de Carvalho Rocha MJ. Traumatized primary Silva SM, Machado MA, et al. Management of a permanent teeth in children assisted at the Federal University of San- tooth after trauma to deciduous predecessor: an evaluation ta Catarina, Brazil. Dent Traumatol. 2002;18(3):129-133. by cone-beam computed tomography. Dent Traumatol. 10. De Amorim Lde F, Estrela C, da Costa LR. Effects of trau- 2011;27(5):408-442. li matic dental injuries to primary teeth on permanent teeth-a 14. Topouzelis N, Tsaousoglou P, Pisoka V, Zouloumis L. Di- clinical follow-up study. Dent Traumatol. 2011;27(2):117-121. laceration of maxillary central incisor: a literature review. Dent na 11. Renton T, Yilmaz Z, Gaballah K. Evaluation of trigeminal nerve Traumatol. 2010;26(5):427-433. injuries in relation to third molar surgery in a prospective pa- 15. Shaked I, Peretz B, Ashkenazi M. Development of odontoma- tient cohort. Recommendations for prevention. Int J Oral Max- like malformation in the permanent dentition caused by in- illofac Surg. 2012;41:1509-1518. trusion of primary incisor-a case report. Dent Traumatol. 12. Christophersen P, Freund M, Harild L. Avulsion of primary 2008;24(3):395-397. io az rn te In ni io iz Ed IC C © 138 Annali di Stomatologia 2017;VIII(3):131-138 

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Original article Prevention of neurological injuries during mandibular third molar surgery: technical notes li na Gerardo La Monaca1 DDS, PhD tooth or its fragment into the sublingual or sub- Iole Vozza2 DDS, PhD mandibular space; (II) to avoid inappropriate or Rita Giardino2 DDS, PhD excessive dislocation proceedings, in order to io Susanna Annibali2 MD, DDS prevent lingual cortex fracture; (III) to perform Nicola Pranno2 DDS, PhD horizontal mesial-distal crown sectioning of the Maria Paola Cristalli3 DDS, PhD, lingually inclined tooth; (IV) to protect the lingual az flap with a retractor showing the cortical ridge; and (V) to pass the suture not too apically and Department of Sense Organs, “Sapienza” University from the inner side in a buccal-lingual direction in 1 of Rome, Rome, Italy the retromolar area. 2 Department of Oral and Maxillo-Facial Sciences, rn “Sapienza” University of Rome, Rome, Italy Key words: inferior alveolar nerve injury, lingual 3 Department of Biotechnologies and Medical Surgical nerve injury, intraoperative complications, third Sciences, “Sapienza” University of Rome, Rome, molar, oral surgery. te Italy Introduction Surgery to the mandibular third molar is common, but In injuries to the inferior alveolar nerve (IAN) and the lin- Gerardo La Monaca gual nerve (LN) remain well-recognized complica- Corresponding author: Department of Sense Organs, tions. The reported incidence of nerve damage during “Sapienza” University of Rome this procedure has been reported to range from 0.26 ni Via Caserta 6 to 8.4% for IAN and from 0.1 to 22% for LN (1). The 00161 Rome, Italy wide variability of these values makes it impossible to E-mail: [email protected] provide a reliable estimate owing to differences in io surgical technique, examined samples, follow-up and evaluation criteria used in the studies that have been reported in the literature. The following risk factors for IAN injuries in third mo- iz lar surgery have been reported in the literature: high- Summary er patient’s age, pre-existing disease, deep impaction and close anatomic relationship between the tooth Ed Surgery to the mandibular third molar is common, roots and the inferior alveolar canal (IAC), intraopera- and injuries to the inferior alveolar nerve and the tive exposure of the nerve trunk, less-experienced lingual nerve are well-recognized complications surgeon, use of the lingual split surgical technique, of this procedure. The aim of these technical use of rotary instruments for bone removal or tooth notes is to describe operative measures for re- sectioning and compression of the nerve during root ducing neurological complications during mandi- elevation (1-5). In addition to increasing age, deep IC bular third molar surgery. and distal impaction, and the use of the lingual split The following procedure should be used to pre- technique, the risk factors for LN involvement have vent damage to the inferior alveolar nerve: a well- been mainly related to iatrogenic causes such as designed mucoperiosteal flap, to obtain appropri- poor flap design, using a periosteal elevator to raise ate access to the surgical area; a conservative os- C and retract the lingual flap, clumsy instrumentation, tectomy on the distal and distal-lingual side; and iatrogenic fracture of the lingual plate (1, 6-8). tooth sectioning, to facilitate its removal by de- Nerve damage may also be related to trauma during creasing the retention zones; tooth dislocation in the injection of a local anaesthetic nerve block, intra- the path of withdrawal imposed by the curvature © operative haemorrhage or post-operative complica- of the root apex; and careful socket debridement, tions including swelling, haemorrhage and perineural when the roots of the extracted tooth are in inti- inflammation (5, 9). Damage to the IAN causes hy- mate contact with the mandibular canal. poaesthesia, anaesthesia, paraesthesia or dysaes- To prevent injury to the lingual nerve, it is impor- thesia of the lower lip, chin, teeth and buccal mucosa tant (I) to assess the integrity of the mandibular on the homologous side, whilst altered sensations of inner cortex and exclude the presence of fenes- tration, which could cause the dislocation of the Annali di Stomatologia 2017;VIII (2):45-52 45  G. La Monaca et al. li na io az rn Figure 1. (a) Panoramic radiograph shows impaction of 4.8 in the presence of the overlap of root tips and inferior alveolar canal; (b) CT cross-sections demonstrate the exact course of the mandibular canal in contact with the roots of 4.8. the tongue are due to LN lesions (1). Furthermore, depending on the involved nerve and the severity of te third molar involves anaesthesia, incision and eleva- tion of mucoperiosteal flap, ostectomy and tooth sec- In the damage, there may be an association with func- tioning, elevation and avulsion according to the root tional deficits, such as burning sensation of the axis, socket debridement, and suturing. These vari- tongue, chewing and speech difficulties, involuntary ous procedures are described in detail below. biting of the lip and/or tongue, and dysgeusia (7, 9, Local anaesthesia is generally preferred, and can be 10). To minimize intra- and post-operative neurologi- induced using an IAN block (mepivacaine 3% without ni cal complications, a preoperative radiological exami- epinephrine) and tissue infiltration (mepivacaine 2% nation is mandatory for assessing the presence of with 1:100,000 epinephrine). General anaesthesia risk factors and to decide on the most appropriate could be restricted to patients who are not coopera- io surgical technique. Panoramic radiography is most tive, long or complex interventions, or when there is a commonly used for this purpose, but this method high risk of intraoperative complications requiring fur- does not reveal (I) the true relationship between the ther treatment, such as jaw fractures. iz IAC and third molar in the presence of the overlap of A well-designed mucoperiosteal flap for obtaining ap- root tips and IAC; (II) diversion, narrowing or interrup- propriate surgical access is the most important step tion of the IAC; (III) curvature, darkening, deflection or in the removal of impacted mandibular third molars. A Ed narrowness of the roots; or (IV) a bifid root apex (Fig. triangular or linear buccal flap is likely to be optimal. 1a) (5, 10-14). Computed tomography is recommended In this type of flap, to preserve the integrity of the LN, in these cases for demonstrating the three-dimensional a distal releasing incision should be made in the relationship between the two structures due to its sensi- retromolar area from the dista-buccal crown edge of tivity and specificity both being significantly superior to the second molar slightly oblique in the vestibular di- panoramic images (11). Indeed, the additional informa- rection, without involving the lingual side of the cre- IC tion provided regarding the position of the third molar stal mucosa. The mucoperiosteal flap must be elevat- and on the nerve and root anatomy makes it possible to ed on the buccal surface of the mandible, and eleva- improve the surgical approach and reduce the risk of tion of the lingual soft tissues, which is usually limited injury (Fig. 1b) (5, 15-19). However, this method cannot to a few millimetres, should be performed carefully in C be used to localize the LN. order to prevent accidental slippage of the periosteal The purpose of this article is to describe operative elevator (Fig. 2). protocols that should minimize the risk of damage to When the third molar position requires a lingual flap, the IAN and LN during mandibular third molar it should be wide enough to allow adequate access to © surgery. the operating field, and the releasing incision should be located some distance from the site of inclusion, within the safety zone, to avoid unintended traction or lacerations of the LN. Before and after raising and re- tracting the subperiosteal lingual flap using a curved Surgical technique The surgical approach for removing the mandibular periosteal elevator, a lingual broad retractor with no 46 Annali di Stomatologia 2017;VIII (2):45-52  Prevention of neurological injuries in third molar surgery: technical notes li na io az rn Figure 2. Mucoperiosteal flap: the distal releasing incision in the retromolar area should not involve the lingual side of the crestal mucosa. sharp edges must be placed carefully in the perios- teum and the bone plate in order to improve visibility te In and to protect the lingual soft tissue and the LN dur- ing ostectomy, tooth sectioning and elevation (20, 21). Ostectomy is usually carried out from the occlusal plane down to the cemento-enamel junction of the ni mandibular third molar, and it should be as conserva- tive as possible on the distal and distal-lingual side so as to not involve the IAN and LN (Fig. 3) (22). To io avoid thermal trauma, the bone tissue should be re- moved using tungsten-carbide round and fissure burs mounted on a low-speed handpiece under copious iz refrigerated irrigation (4). Tooth sectioning is designed to allow disengagement of the element by decreasing its zone of retention and Ed to avoid compression or stretching of the IAN. The sectioning performed using a tungsten-carbide round bur mounted on a high-speed handpiece should not exceed the peripheral limits of the tooth, so as to leave a thin diaphragm of intact dental tissue near the nerve trunk. In order to complete the sectioning pro- IC cedure, the diaphragm will be fractured in a cautious manner using elevators (Fig. 4). Figure 3. Ostectomy: should be as conservative as possi- Tooth removal should be performed with a root eleva- ble on the distal and distal-lingual side. tor, directing the force vector in the path of withdrawal C imposed by the curvature of the root apex, to avoid the risk of nerve compression or stretching. Socket debridement is performed after tooth extrac- Suturing in the retromolar pad area should be per- tion with extreme care, especially when removing the formed with the needle piercing the mucosa from © lingual portion of the follicular remnants from sur- the inner side in a buccal-lingual direction, because rounding tissues to avoid tearing the lingual mucosa a passage in the opposite direction could expose so as to not damage the LN. The socket was then irri- the LN to the risk of a puncture lesion and to injury gated with sterile saline solution at room temperature due to its shrinkage during the knotting procedure (Fig. 5). (Fig. 6). Annali di Stomatologia 2017;VIII (2):45-52 47  G. La Monaca et al. li na io az rn Figure 4. Tooth sectioning is designed to allow disengagement of the element by decreasing its zone of retention and to avoid compression or stretching of the IAN. te In ni io iz Ed IC Figure 5. Socket debridement is performed with extreme care, avoiding to tear the lingual mucosa not to damage the LN. C Discussion Different surgical techniques have been described for © preventing neurological injury during mandibular third Figure 6. Suturing in the retromolar pad area should be molar surgery. Coronectomy (partial odontectomy or performed with the needle piercing the mucosa from the in- root retention) consists of removing only the crown of ner side in a buccal-lingual direction not to expose the LN an impacted mandibular third molar, leaving part of to the risk of puncture and shrinkage lesions during the its roots at least 3 mm below the crestal bone, and knotting procedure. 48 Annali di Stomatologia 2017;VIII (2):45-52  Prevention of neurological injuries in third molar surgery: technical notes without performing pulpal treatment (23, 24). Coro- can reduce neurological complications. nectomy seems a reliable procedure for reducing the Regarding the type of anaesthesia, some Authors incidence of injuries to the IAN (0-9.5%) and LN (0- have found the incidence of nerve damage to be low- 2%), with low rates of post-operative failure (on aver- er and the neuropathic area to be larger when the age less than 10%) and post-operative complications surgery is performed under general rather than local (pain, swelling, infection, dry socket and root migra- anaesthesia (10, 32). This could be due to the in- tion) (23, 25, 26). In some cases, accidental intraop- creased difficulty of specific surgical procedures and li erative loosening or mobilization of the roots and to the aggressiveness of the surgeon when an inter- na post-operative root exposure made it mandatory to vention was carried out with the patient under general perform conventional surgical extraction. However, anaesthesia (10). In a single prospective study of 718 this technique is considered controversial by many mandibular third molar extractions, Brann et al. found oral surgeons due to the potential adverse effects of that the incidence of LN and IAN damage was five the retained roots. New randomized clinical studies times higher when the surgery was performed under io involving larger samples and long follow-up periods general anaesthesia (18%) than under local anaes- are needed to accurately assess the long-term suc- thesia (3%). However, they found no significant asso- cess of this approach. ciations between surgical difficulty, eruption status, az The orthodontic-assisted extraction requires surgical age and preoperative pathology (32). In contrast, the exposure of the third molar crown, placement of an prospective longitudinal study of Rehman et al. found orthodontic anchorage and orthodontic extrusion in no links between the choice of local (105 teeth) or order to move the roots away from the IAC; the ex- general (474 teeth) anaesthesia and nerve damage rn traction is then performed after 3-6 months, when the during the removal of 614 mandibular third molars tooth has moved sufficiently in the occlusal plane (27- when the difficulty of surgery was taken into account 29). Although this technique can improve periodontal (33). healing distal to the second molar, it has disadvan- Nerve damage can also occur as a complication of te tages of being complex to perform, not well tolerated mandibular block anaesthesia, which affects the LN by the patient due to discomfort of the orthodontic de- significantly more often than the IAN (34, 35). Al- vice, time-consuming and expensive (25). though the reasons are unknown, the sensory alter- In Another procedure requiring a double surgical inter- ations reportedly occur due to direct trauma by nee- vention is the staged approach, which involves sec- dle during penetration or retraction from bone con- tioning the mesial portion of the third molar crown to tact, compression by intraneural bleeding or neuro- provide adequate space distal to the second molar to toxicity of certain anaesthetic formulations (e.g. 4% promote migration of the roots away from the IAN, articaine and 3-4% prilocaine). To prevent nerve in- ni which are extracted in the second surgical session juries related to local anaesthesia, high concentra- (30). We consider that compared with the orthodon- tions of anaesthetic agent and multiple blocks should tic-assisted technique, this technique improves pa- be avoided whenever possible (10). io tient comfort and reduces the chair time and procedu- The flap design was planned preoperatively accord- ral costs, since no intraoral appliances are required ing to the depth of the inclusion and the position of (30). the third molar. During flap incision it is important to iz Pericoronal ostectomy also consists of two stages to avoid both the LN and facial artery. In the mandibular complete the extraction of the third molar. In stage 1, third molar region, the LN runs about 2.5 mm medial- pericoronal bone is removed to eliminate bony inter- ly and inferiorly to the alveolar ridge, although in Ed ferences and create an adequate “eruptive space” to some cases it may lie above the bone or within the allow occlusal movement of the tooth, with light luxa- soft tissues of the retromolar pad area (36, 37). tion (subluxation) of the tooth to improve its eruptive These variations in the position of the LN predispose potential; this is followed some weeks later by extrac- it damage throughout the surgical procedure, and in- tion in stage 2 (31). The drawbacks of this procedure juries are not always avoidable (6). are the involvement of a staged operation, the possi- Once flap incision and dissection are completed, it is IC bility of LN injury in rare cases necessitating the full important to keep the soft tissue retracted and pro- exposure of the coronal surface at the lingual aspect tected during ostectomy, tooth sectioning and dislo- and a (low) risk of IAN injury (31). The use of this cation. Several studies have shown that while the use staged approach and pericoronal ostectomy is actual- of a lingual flap and the placement of a lingual retrac- C ly based on a very small sample with a short follow- tor can cause transient LN damage, this procedure up, and so its effectiveness and safety still need to be does not appear to be a cause of permanent LN dam- comprehensively assessed in randomized controlled age (38, 39). Many studies have criticized the use of trials involving large samples. a Howarth elevator, since although this can be used © Alternative surgical techniques have been proposed to retract the lingual tissue, it does not adequately for the removal of mandibular third molars, but the protect the LN, and the bur can slip in front or behind conventional surgical extraction with a buccal ap- the elevator and still damage the LN (40). Moss et al. proach remains the most common procedure world- proposed that the key to successful lingual retraction wide. We consider that the technical notes described was creating an area of “tissue freedom” before in- in this article suggest intraoperative measures that serting a retractor in order to avoid unnecessary Annali di Stomatologia 2017;VIII (2):45-52 49  G. La Monaca et al. stretching of the nerve. This theory suggests extend- ing the lingual flap to the distal side of second molar Conclusion to allow the insertion of a wider retractor, a technique Minimizing intra- and post-operative neurological that reportedly resulted in a lower incidence rate in a complications requires a good knowledge of anatomy single operator series (41). Where necessary, the use in order to identify the presence of risk factors and to of a lingual retractor provides the surgeon with better decide on the most appropriate surgical technique. visualization of the third molar, better access and the The role of expertise and professional experience in li ability to remove distal bone, distal-lingual bone and the incidence of complications associated with third na even lingual bone, since protection is provided by re- molar removal should also not be underestimated, tractor. Raising a lingual flap and using a lingual re- since complications reportedly occur more often tractor for selected indications is therefore felt to be among inexperienced surgeons than among those an acceptable protocol during the removal of with experience related to IAN and LN injury (6, 20, mandibular third molars (6, 24). Note that the lingual 38-40, 45, 47). However, some Authors have also io retractor must be broad and have no sharp edges to found higher rates of IAN deficits in surgery per- ensure that the LN is protected and not damaged (2). formed by specialists/consultants than surgical The ostectomy was always performed under copious trainees/residents or undergraduates (1, 33, 45). Le- az irrigation to prevent overheating and using new and ung and Cheung assumed that the greater involve- sharp burs. There are some reports of higher rates of ment of specialists/consultants in post-operative IAN IAN and LN damage after extraction of third molar deficits could be due to them encountering more diffi- with total bone impaction, because damage to these cult and deeply impacted third molars compared with rn nerves is significantly related to the technique used the operators having less surgical experience (1). for bone removal (3, 6, 9, 41). This research did not receive any specific grant from To reduce surgical morbidity caused by manipulation funding agencies in the public, commercial, or not- and to minimize damage during ostectomy, the tooth- for-profit sectors. te sectioning technique is a standard procedure that fa- cilitates the removal of the impacted tooth by de- creasing its zone of retention (4). Ultrasound bone In Conflict of interest and source of funding surgery may also be useful in selected cases for re- statement ducing the risk of nerve damage during ostectomy and tooth sectioning. This technique can be used to The Authors have stated explicitly that there are no make micrometric, precise and smooth cuts into min- conflicts of interest in connection with this article. eralized tissues while adjacent soft tissues are pre- ni served, provided that very low pressure is applied (42-44). Nevertheless, the operating time is much All Authors gave final approval and agree to be ac- Authors Declarations longer compared to when using conventional rotary io instruments. countable for all aspects of the work. It must also be remembered that inappropriate tooth dislocation may cause the displacement of the entire iz tooth or part thereof into the sublingual or submandi- References bular space due to internal fracture of the alveolar 1. Leung YY, Cheung LK. 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Original article In vitro resistance to fracture of two nickel-titanium rotary instruments made with different thermal treatments li na Gabriele Miccoli DDS Key words: endodontics, endodontic instruments, Gianfranco Gaimari DDS, PhD nickel-titanium, cyclic fatigue. Marco Seracchiani DDS io Antonio Morese DDS Tatyana Khrenova DDS Introduction In the last decades the introduction of nickel-titanium Dario Di Nardo DDS az (NiTi) alloy in the manufacturing of endodontic instru- ments resulted in a significant improvement for root Department of Oral and Maxillo-Facial Sciences, canal preparations which resulted easier in shaping “Sapienza” University of Rome, Rome, Italy procedures, faster, and more predictable (1-3). The superior mechanical properties of the NiTi alloy al- rn lowed the clinical use of NiTi rotary instruments with greater tapers (4, 5). This increase in dimensions and continuous rotation movements significantly improved te Dario Di Nardo effectiveness and rapidity of the cutting and simplified Corresponding author: Department of Oral and Maxillo-Facial Sciences, the achievement of a successful root canal treatment "Sapienza" University of Rome (6-8). Unfortunately, these features could also lead to Via Caserta 6 an increased risk of intracanal separation of the in- In 00161 Rome, Italy struments (9-11). E-mail: [email protected] Several clinical and experimental studies demonstrat- ed that multiple factors contribute to instrument’s sep- aration: cyclic fatigue has been proven to be one of ni the leading causes (12-14). Fatigue failure usually begins with the formation of microcracks that arise from the surface’s irregularities of the instruments. Summary During each loading cycle, microcracks develop and io deepening until complete separation of the file (15- Aim. Aim of the study was to evaluate effective- 17). All NiTi rotary instruments show some irregulari- ness of different heat treatments in improving Ni- ties and inner defects on the surface as a conse- iz Ti endodontic rotary instruments’ resistance to quence of the manufacturing processes and the dis- fracture. tribution of these defects influences their strength Methods. 24 new NiTi instruments similar in (18). Ed length and shape: 12 M3 instruments, tip size 25 In recent years, manufacturers tried to find different and .06 taper (United Dental, Shanghai, China), solutions to develop instruments with enhanced resis- and 12 M3 Pro Gold instruments tip size 25 and tance to flexural and torsional stresses, aiming at re- .06 taper (United Dental, Shanghai, China), were ducing the incidence of intracanal breakage. The tested in a 60° curved artificial root canal. Each three basic ways to achieve these improvements group received a different heat treatment. Cycles were mainly related to changes in design, heat treat- to fracture were calculated for each instrument. IC ments of the alloy and the use of reciprocating mo- Differences among groups were evaluated with an tions (19-23). Different and proprietary heat treat- analysis of variance test (significance level was ments have been developed and commercialized in set at P<0.05.). the last decade, aiming at improving both flexibility Results. Statistical analysis found significant dif- C and resistance to breakage, but they are not dis- ferences (p<0.0213) between groups. The M3 Pro closed by manufacturers in detail (24). Changing the Gold instruments were significantly more resis- thermal history of the alloy, could produce an alloy tant to fatigue (mean values = 1012, SD +/- 77) with different characteristics for the endodontic use. than M3 instruments (mean values = 748, SD +/- © By changing the thermal treatments, manufacturer 62). No statistically significant differences were can quickly and significantly modify clinical perfor- found between fragments’ lengths (p>0,05). mance of NiTi instruments, with no need of modifica- Conclusions. An increased flexibility and the re- tions to the quality of the raw material or grinding ma- duction of internal defects produced by heat chines. M3 Rotary and M3 Pro Gold are an example treatments during or after manufacturing pro- of similar instruments, produced by same manufac- cesses, may be responsible for improving resis- tance to cyclic fatigue and flexural stresses. Annali di Stomatologia 2017;VIII (2):53-58 53  G. Miccoli et al. turer (United Dental, Shanghai, China), but with dif- on cyclic fatigue resistance (25, 26). The device con- ferent performance due to different heat treatments. sists of a mainframe to which is connected the elec- The aim of the present study was to evaluate the hy- tric handpiece and a stainless-steel block containing pothesis that different heat treatments can significant- the artificial canal. The electric handpiece was ly affect the in vitro resistance to cyclic fatigue of NiTi mounted on a mobile device to allow precise and re- rotary instruments. The null hypothesis was that no producible placement of each instrument inside the difference would be found between similar instru- artificial canal to the same depth (18 mm) (Fig. 1). A li ments with different heat treatments. simulated root canal with a 60° angle of curvature na and 5 mm radius of curvature was used for all the tested instruments. All instruments were inserted at the same length (16 mm) and then rotated at 350 rpm with maximum torque until fracture occurred. For Material and methods A total of 24 new NiTi instruments 25 mm in length each instrument, the time to fracture was visually as- io was used in the present study: 12 M3 instruments, tip sessed and recorded with a 1/100 sec chronometer. size 25 and .06 taper (United Dental, Shanghai, Chi- Number of cycles to fracture was calculated for each na) and 12 M3 Pro Gold instruments tip size 25 and instrument (NCF). Fragments were collected, mea- az .06 taper (United Dental, Shanghai, China). All instru- sured and underwent to fractographic analysis per- ments were the same in size and design, but they re- formed by a scanning electron microscope (SEM) to ceived a different heat treatment. All of them had determine fracture mode. been previously inspected using an optical stereomi- All data were recorded. For each group mean and rn croscope at x20 magnification for morphological anal- standard deviations were calculated. Differences ysis and checked for any signs of visible deformation. among groups were statistically evaluated with an If defective instruments were found, they were dis- analysis of variance test (significance level was set at carded. P<0.05.). Data was statistically analyzed using the te The cyclic fatigue testing device used in the present SPSS 17.0 software (SPSS Incorporated, Chicago, study has been used for previously performed studies IL, USA). In ni io iz Ed IC C © Figure 1. The testing device for cyclic fatigue. 54 Annali di Stomatologia 2017;VIII (2):53-58  In vitro resistance to fracture of two nickel-titanium rotary instruments made with different thermal treatments Table 1. Results of cyclic fatigue tests (number of cycles to failure). Group NCF Mean Values SD Mean Fragment Lenght SD M3 748 (+/- 62) 5,4 (+/- 0,4) M3 ProGold 1012 (+/- 77) 5,5 (+/- 0,5) li na Table 2. Time to fracture in seconds (s). Discussion Group Seconds to fracture SD NiTi endodontic alloys can exhibit three phases (27): M3 128,3 (+/- 11,6) the high-temperature B2 austenitic phase, the low- io temperature B19’ martensitic phase (monocyclic M3 ProGold 173,5 (+/- 14,7) structure) and intermediate temperature R-phase (rhombohedral structure). Transformations of these az phases are fundamental, because they determine the superelastic and shape memory characteristics of these instruments and their mechanical and function- Results Results from the cyclic fatigue tests are shown in Ta- al properties and performance. These transforma- tions can proceed by various ways, depending on the rn bles 1 and 2. Mean values for time to fracture for M3 Pro Gold instruments were 173,5 seconds (SD +/- thermal history of the alloy during the manufacturing 14,7) and for M3 instruments were 128,3 seconds processes (18). (SD +/- 11,6). Statistical analysis found significant dif- The heat treatment’s parameters which are chosen to te ferences (p < 0.0213) between the two groups. The set the properties of the NiTi instruments are critical M3 Pro Gold instruments were significantly more re- (23). In general, temperatures as low as 400°C and sistant to fatigue (NCF mean values = 1012, SD +/- times as short as 1-2 minutes can set the shape, but In 77) than M3 instruments (NCF mean values = 748, generally, endodontic instrument’s manufacturers SD +/- 62). Mean value of the fragments’ length for prefer temperatures closer to 500°C for over 5 min- M3 Pro Gold instruments was 5,5 mm (SD +/- 0,5) utes. A rapid cooling of the instruments is preferred and for M3 instruments was 5,4 mm (SD +/- 0,4). No via water quench or rapid air cool. Longer heat treat- statistically significant differences were found be- ment times and higher temperatures will increase the ni tween fragment lengths (p > 0,05), showing proper in- actuation temperature and often give a sharper ther- sertion of the instruments inside artificial canals and mal response (in the case of shape memory ele- consequently the same mechanical stresses applied ments). However, there is usually a concurrent drop io on the same portions of the instruments (Fig. 2). either in peak force (for shape memory alloys) or in iz Ed IC C © Figure 2. Differences between instruments' time to fracture, number of cycles to fracture (NCF) and lenght of the fractured segment Annali di Stomatologia 2017;VIII (2):53-58 55  G. Miccoli et al. plateau stresses (for superelastic alloys). There is al- ments are induced (11). Moreover, also room temper- so an accompanying decrease in the ability of the in- ature can dramatically influence fatigue resistance of struments to resist permanent deformation (28). the NTRIs, as shown in recent studies (29, 30). Clinically, such changes result in different mechanical Therefore a correct comparison can only be made if properties and behaviour. Even if the raw material the NTRIs are tested with the same device and artifi- and the machining processes are the same, the dif- cial canal in the same conditions. ferent and proprietary heat treatment exhibits more Fractographic analysis using SEM showed similar li evident superelastic characteristics. On the contrary, fracture patterns in both instruments. Metal fatigue M3 Pro Gold instruments are more ductile and softer, commonly leads to ductile fracture with some plastic na exhibiting more evident shape memory characteris- deformations and a typical dull dimpled surface (10). tics. Differently than M3, M3 Pro Gold can be easily The dimpling involve the whole fracture surface, with precurved for easier insertion in curved canal and to some microvoids present as black dots (Figs. 3, 4). In reduce restoring forces. In the present study, the last ductile fracture, microvoids are produced inside the io characteristic allowed M3 Pro Gold instruments to metal and their cohalescence weaken the structure better withstand the bending stresses. The null hy- and results in fracture. pothesis was rejected: M3 Pro Gold instruments were NiTi instruments have constantly gained popularity az found to be significantly more resistant to fatigue during last decades because they offer more distinct when compared to M3. The originality of the present clinical advantages with curved root canals than study was in the possibility of testing instruments pro- stainless-steel instruments, due to their higher flexi- duced by the same manufacturer with the same NiTi bility, by virtue of their superelasticity. The superelas- rn alloy, but with different heat treatments. In the majori- ticity has made it possible to carry out conservative ty of previous studies about heat treated NTRIs, dif- and better centered shapes, with less canal trans- ferent instruments were tested from different manu- portation and with more respect of the original anato- facturers. In many cases, when manufacturers pro- my (22). NiTi shape memory alloys undergo transfor- te duce a new version of endodontic instruments with a mation from cubic austenitic to monocyclic martensite different heat treatment, they also change instru- when the applied stress in the austenitic phase is ments’ design and this could make more difficult to enough to promote the stress-induced transformation In evaluate the real effect of the heat treatment. The da- (27). This stress-induced martensitic transformation ta are in accordance with previous studies which en- reverses spontaneously upon release of the stress lightened the importance of heat treatments in im- and the material returns to its original shape and size proving NiTi rotary instruments’ resistance to break- (23). Furthermore, the rhombohedral R-phase forma- age (12, 15, 18). tion, thermoelastic phase, often precedes the marten- ni However, it is always difficult to compare different sitic transformation under certain conditions and is cyclic fatigue studies, because many factors can in- considered to be the main reason for increased flexi- fluence the final results. The main factor is the shape bility of NiTi instruments over traditional stainless io and dimension of the artificial canal (16). Each varia- steel instruments. Such an increased flexibility and tion of canal curvature and diameter may affect the the reduction of internal defects produced by heat way that mechanical loads are applied and conse- treatments during or after manufacturing processes, iz quently different mechanical stresses on the instru- are responsible for greater resistance to flexural Ed IC C © Figure 3. SEM microscope image of a fractured M3 Pro Gold instrument. 56 Annali di Stomatologia 2017;VIII (2):53-58  In vitro resistance to fracture of two nickel-titanium rotary instruments made with different thermal treatments Figure 4. SEM microscope image of a fractured M3 Pro Gold instrument. li na io az rn stresses and consequently to cyclic fatigue. Further dodontic instruments: effects on bending properties and studies, however, are needed to evaluate how much shaping abilities. Int Endod J. 2011 Sep;44(9):843-849. te different heat treatments affect torsional resistance 5. Testarelli L, Plotino G, Al-Sudani D, Vincenzi V, Giansira- cusa Rubini A, Grande NM, Gambarini G. Bending prop- and hardness of the alloy in NiTi rotary instruments. erties of a new nickel-titanium alloy with a lower percent In by weight of nickel. Journal of Endodontics. 2011;37 (9):1293-1295. Conclusions 6. Plotino G, Giansiracusa Rubini A, Grande N.M, Testarelli L, Gambarini G. Cutting efficiency of reciproc and Changing the thermal treatments, allows manufactur- waveone reciprocating instruments. Journal of Endodon- ni ers to quickly and significantly improve clinical perfor- tics. 2014;40(8):1228-1230. mance of NTRIs, with no need of changing quality of 7. Gambarini G, Pongione G, Rizzo F, Testarelli L, Cavalleri the raw material or modifying the grinding machines. G, Gerosa R. Bending properties of nickel-titanium instru- ments: a comparative study. Minerva stomatologica. M3 Rotary and M3 Pro Gold are an example of NTRIs io 2008;57(9):393-398. with same design and alloy, produced by the same 8. Di Fiore PM, Genov KA, Komaroff E, Li Y, Lin L. Nickel-ti- manufacturer, which show different resistance to tanium rotary instrument fracture: a clinical practice as- cyclic fatigue due to different heat treatments. iz sessment. Int Endod J. 2006 Sep;39(9):700-708. 9. 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The effect of brushing motion MG. Impact of heat treatments on the fatigue resistance on the cyclic fatigue of rotary nickel titanium instruments. of different rotary nickel-titanium instruments. J Endod. Annali dell’Istituto Superiore di Sanità. 2010;46(4):400- az 2014 Sep;40(9):1494-1497. 404. 19. Plotino G, Grande N.M, Cotti E, Testarelli L, Gambarini G. 27. Hou X, Yahata Y, Hayashi Y, Ebihara A, Hanawa T, Suda Blue treatment enhances cyclic fatigue resistance of vor- H. Phase transformation behaviour and bending property tex nickel-titanium rotary files. Journal of endodontics. of twisted nickel-titanium endodontic instruments. Int En- 2014;40(9):1451-1453. dod J. 2011 Mar;44(3):253-258. rn 20. Pereira ES, Peixoto IF, Viana AC, Oliveira II, Gonzalez 28. Alapati SB, Brantley WA, Iijima M, Schricker SR, Nusstein BM, Buono VT, Bahia MG. Physical and mechanical prop- JM, Li UM, Svec TA. Micro-XRD and temperature-modu- erties of a thermomechanically treated NiTi wire used in lated DSC investigation of nickel-titanium rotary endodon- the manufacture of rotary endodontic instruments. Int En- tic instruments. Dent Mater. 2009 Oct;25(10):1221-1229. te dod J. 2012 May;45(5):469-474. 29. Plotino G, Grande NM, Mercadé Bellido M, Testarelli L, 21. Gambarini G, Di Nardo D, Miccoli M, Guerra F, Di Giorgio Gambarini G. Influence of Temperature on Cyclic Fatigue R, Di Giorgio G, Glassman G, Piasecki L, Testarelli L. Resistance of ProTaper Gold and ProTaper Universal Ro- In The Influence of a New Clinical Motion for Endodontic In- tary Files. J Endod. 2017 Feb;43(2):200-202. struments on the Incidence of Postoperative Pain () Clini- 30. Grande NM, Plotino G, Silla E, Pedullà E, DeDeus G, ca Terapeutica. 2017;168(1):23-27. Gambarini G, Somma F. Environmental Temperature 22. Plotino G, Testarelli L, Al-Sudani D, Pongione G, Grande Drastically Affects Flexural Fatigue Resistance of Nickel- N.M, Gambarini G. Fatigue resistance of rotary instru- titanium Rotary Files. J Endod. 2017 May 2 (Epub ahead ni ments manufactured using different nickel-titanium alloys: of print). io iz Ed IC C © 58 Annali di Stomatologia 2017;VIII (2):53-58 

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Original article Evaluation of microbiota associated with Herpesviruses in active sites of generalized aggressive periodontitis li na Claudio Passariello DDS1* monas micra and Fusobacterium nucleatum sub- Pierangelo Gigola MD2 sp. polymorphum; iii) HSV-1 with Porphyromonas Luca Testarelli DDS3 gingivalis, Tannerella forsythia, Fusobacterium io Monica Puttini MD4 periodonticum and Staphylococcus aureus. Serena Schippa PHD1 Conclusions. Microbiological data suggest that Stefano Petti DDS1 Herpesviruses are probably not mere spectators az of disease progression and that specific patterns 1 Department of Public Health and Infectious of subgingival plaque are correlated with the Diseases, “ Sapienza” University of Rome, Rome, Italy presence of different Herpesviruses. 2 Department of Medical-Surgical Specialties, rn Radiologic and Public Health Sciences University of Key words: generalized aggressive periodontitis, Brescia, Brescia, Italy herpesviruses, microbiota, disease progression. 3 Department of Odontostomatologic and Maxillo- Facial Sciences, “Sapienza” University of Rome, te Introduction Rome, Italy 4 Free Practice in Dentistry, Genova, Italy Periodontitis is a group of infectious disorders char- acterized by inflammation affecting periodontal tis- sues and causing an inconstant, episodic progression In in breakdown of the teeth-supporting tissues. In some Claudio Passariello patients progression of periodontitis is characterized Corresponding author: Department of Public Health and Infectious Diseases, by shortened periods of remission, leading to a clini- cal presentation called aggressive periodontitis, that “Sapienza” University of Rome ni can be either generalized or localized (1-3). The rea- P.le Aldo Moro 5 sons leading some patients to undergo generalized 00185 Rome, Italy aggressive periodontitis (GAP) are poorly under- E-mail: [email protected] io stood, and no definite useful molecular or microbio- logical markers or predictors of disease progression have been identified yet (4, 5). Recent reports sug- gest moreover that atypical pathogens are frequently iz Summary associated with progression of periodontal lesions and resistance to conventional treatments in aggres- Aims. The present study aimed to investigate mi- sive periodontitis and have disclosed interesting as- Ed crobial patterns associated with disease progres- sion and coinfection by different Herpesviruses in sociations (6, 7). These atypical pathogens, including generalized aggressive periodontitis (GAP). and different members of the family Enterobacteri- Staphylococcus aureus, Pseudomonas aeruginosa Methods. Microbiological samples were obtained from active (AS) and non-active (n-AS) sites in aceae, are known to possess virulence factors that 165 subjects affected by GAP and were analyzed could account for the accelerated tissue destruction characterizing GAP. IC for 40 bacterial species by the Checkerboard DNA-DNA Hybridization technique and for Herpes Recent studies by our group have shown higher Staphylococcus aureus oral carriage rates in peri- odontitis affected patients as compared to healthy simplex 1 (HSV-1), Human Cytomegalovirus controls (8). Moreover, we showed that isolation of S. (CMV), and Epstein Bar virus (EBV) by PCR. C aureus from subgingival sites of GAP positively corre- Common Factor Analysis and Multiple Regression lates with disease progression, with higher levels of Analysis were applied to disclose specific micro- inflammatory mediators and with faster periodontal bial patterns associated with the three viruses. breakdown (9). Results. Herpesviruses were detected in 37.6% of © Subgingival isolates of S. aureus from active sites of subjects. Detection of each of the searched virus- GAP were shown to possess a set of genes encoding es was associated with specific patterns of sub- for pathogenicity and virulence factors (9) which are gingival biofilm in AS. Logistic regression analy- already known to be involved in the pathogenesis of a ses evidenced several virus/bacteria associa- variety of severe staphylococcal infections (10). tions: i) EBV with Aggregatibacter actino- Among factors potentially able to trigger and amplify mycetemcomitans; ii) CMV with A. actino- mycetemcomitans, Veillonella parvula, Parvi- Annali di Stomatologia 2017;VIII (2):59-70 59  C. Passariello et al. tissue destruction in GAP, co-infection by different pesviruses can influence the qualitative and quantita- Herpesviruses has been given wide consideration in tive composition of subgingival plaque and play a role the last decades. in the progression of lesions in GAP. Studies started about three decades ago have shown The present study was consequently designed as an that HSV-1, EBV and CMV are detected with high observational study aimed to characterize the subgin- prevalence and at high copy counts in progressive gival microbiota of active sites of GAP and to corre- periodontal diseases (11-13). late microbial patterns with the presence/absence of li Association and immunologic studies have provided a three species of Herpesviruses. na solid base of evidence supporting a periodontopathic role of Herpesviruses, although at present the specif- ic molecular and cellular mechanisms which enable these viruses to exacerbate periodontitis are still to Materials and methods be clarified. io In a recent review of the literature Slots in summariz- Patients with a clinical diagnosis of GAP (1) and with Studied population and samples ing results from studies performed by different groups at least one active site were selected for the present in different countries evidenced that mean percent- observational study as described previously (9). az ages of sites of aggressive periodontitis reported to Briefly, microbiological samples were obtained from be positive for detection of Herpesviruses are 49% for subjects attending 12 private dental practices for peri- CMV, 45% for EBV and 63% for HSV (11). A detailed odontal problems. analysis of available data evidenced the existence of All patients were recruited from structures located in rn significant differences among published studies and a highly urbanized areas (Genua, Brescia, Piacenza, possible bias coming from the fact that in most stud- Savona, Milan) and consisted prevalently of subjects ies sampling was performed regardless of disease with high school or university degrees. Overall, 214 activity. patients were selected during first visits, basing on an te In a recent report Stein et al. failed to find any associ- initial diagnosis of generalized aggressive periodonti- ation between aggressive periodontitis and the pres- tis. The following criteria were used for inclusion in ence of Herpesviruses in a sample of patients in Ger- the study: age ranging ≥ 18 - ≤ 39 years; presence of In many (14). ≥ 20 teeth in the mouth; presence of at least 6 teeth Sunde et al. found that 40% and 12% of periodontitis with Periodontal Probing Depth (PPD) ≥ 5 mm and sites were positive, respectively, for EBV and CMV, with bleeding on probing (including at least one in- although viral loads were close to detection limits cisor and one first molar). The following criteria were (15). Consequently they considered a role for these used for exclusion from the study: presence of sys- ni viruses in the pathogenesis of periodontal lesions un- temic diseases or conditions known to affect antibac- likely and, possibly, only the consequence of contam- terial defences, and/or soft tissues and epithelial bar- ination by blood or saliva or of an accumulation of rier integrity; subjects who had assumed antibiotics, io lymphoid cells harbouring viruses in the inflamed tis- and/or topic antimicrobials, and/or who underwent pe- sue. riodontal treatment in the previous 6 months; preg- On the other hand many other Authors found a posi- nant or breast feeding subjects. iz tive correlation between detection of Herpesviruses Periodontal status was assessed in terms of Visible and severity and progression of periodontal lesions of Plaque Index (VPI), Gingival Bleeding Index (GBI), both chronic and aggressive periodontitis (11, 16-19). and Periodontal Probing Depth (PPD) at the begin- Ed Histomolecular analyses demonstrated that gingival ning of the study (T0), and after 45 days (T45). Peri- epithelial cells of periodontitis affected sites are fre- odontal sites showing a significant increase in both quently infected by one or more Herpesviruses and PPD and GBI between T0 and T45 were considered that viral loads positively correlate with disease as active sites (AS) and were distinguished from non- severity (20, 21). active sites (n-AS). Overall, experimental data collected by different re- VPI and GBI were evaluated separately at the four IC search groups in different geographical areas sug- main aspects of each tooth, while PPD was evaluated gest that human Herpesviruses could play a relevant at six sites for each tooth, using a Michigan periodon- role in both chronic and aggressive periodontitis (12- tal probe with Williams markings. 16), although some Authors hypothesize that the Enrolment in the study was confirmed upon detection C prevalence of HSV, CMV, and EBV in periodontal le- of at least one AS between T0 and T45. sions could vary also on a geographical and ethnic Each patient was examined at T0 and T45 by the base (22). same examiner. It is well known that many viruses are able to act as All clinical evaluations were performed separately by © strong promoters of bacterial pathogenicity and viru- two experienced clinicians (P.G. and M.P.), calibrated lence, thus facilitating the onset and progression of to provide consistent diagnoses as follows: twenty acute, aggressive infections in many districts of the subjects were selected among those participating in human body (23-25). It is consequently conceivable the study. Each examiner recorded values of PPD at that, as a consequence of specific molecular mecha- the 6 aspects of 6 selected teeth (2 molars, 2 premo- nisms of cooperation, co-infection by different Her- lars and 2 incisors) for each subject; measures were 60 Annali di Stomatologia 2017;VIII (2):59-70  Herpesviruses and microbiota in periodontitis repeated after 48 hours at the same sites. Values kit (Fermentas). Quantitative determinations were recorded by the two examiners at the same time were performed following detection by a densitometric used to calculate inter-examiner reproducibility. Val- scanner (BioRad GS800 calibrated densitometer) us- ues recorded by each examiner at different times ing the Quantity One® analysis software (BioRad) were used to calculate intra-examiner reproducibility. and expressed as percent of total DNA counted in the Inter- and intra-examiner reproducibility was mea- sample. Samples giving no signal were all reported sured through Cohen’s weighted kappa which result- as scoring 0.1% of total bacterial DNA in the sample, li ed 0.70 (intra-examiner 1), 0.88 (intra-examiner 2) to account for limits of sensitivity of the test. na and 0.75 (inter-examiner), suggesting substantial to almost perfect agreement (26). One hundred and sixty-five of 214 patients (77.1%) A second set of samples was obtained from each se- Detection of Herpesviruses (mean age 32.3±3.8 years, ages ranging 18 to 39) lected AS and n-AS, as described above, to detect were selected for microbiological sampling. Of these, the presence of Herpes simplex type 1 (HSV-1), Hu- io 81 were males (mean age 32.4±3.6 years, ages rang- man Cytomegalovirus (CMV) and Epstein Bar virus ing 21 to 39) and 84 were females (mean age (EBV), using previously described specific PCR 32.3±4.1 years, ages ranging 18 to 39). methods (30, 31). az The sampled patients participated voluntarily, were Patients were split into four groups according to posi- explained the nature of the study and invited to sign tivity for detection of HSV-1 (HSV+), EBV (EBV+), an informed consent in conformity with the Helsinki CMV (CMV+), and negativity for detection of any of Declaration on Ethical Principles for Medical Re- the searched viruses (HHV-). rn search Involving Human Subjects. During the 45 days of observation all patients were invited to maintain their standard oral hygiene procedures. The Student’s t-test for paired samples was per- Statistics The study design was approved by the ethical com- formed to detect AS, i.e. those sites showing signifi- te mittee of the University of Brescia. cant differences in clinical variables (PPD and GBI) between T0 and T45. Significance of differences in the percentages of In Following clinical evaluation at T45, samples of sub- species-specific DNAs between AS and n-AS and, Microbiological sampling gingival biofilm were obtained from one AS and one within AS, among the four groups (i.e. HSV+, EBV+, n-AS in each subject. Selection of AS and n-AS in CMV+ and HHV-) were evaluated through the one- each patient was made paying attention to select two way analysis of variance (ANOVA) for dependent sites resembling each other as much as possible with samples. The Tukey’s HSD test was performed as ni regard to position and PPD at the time of sampling. post hoc test to detect differences between pairs of Samples of subgingival biofilm were collected follow- groups. ing careful removal of supragingival biofilm by a ster- In order to investigate the relative frequencies of sub- io ile Columbia Universal curette: a sterile nr. 40 en- gingival microbiota potentially associated with EBV, dodontic paper point was inserted into the pocket and CMV and HSV-1 in AS, three logistic regression maintained in place for 60 seconds. Samples were analyses were designed using EBV, CMV and HSV- iz then transferred into 1.5 ml screw cap vials contain- 1, dichotomized into detected/undetected, as re- ing 0.5 ml of sterile DNAse free molecular grade wa- sponse variables and the relative frequencies as ex- ter, vortexed for 2 minutes, stored at -80° C and planatory variables, adjusted for patient’s age and Ed processed within 48 hours from sampling. gender, VPI and GBI as confounders. Preliminarily the existence of inter-correlated bacteri- al species was investigated by performing the corre- Total bacterial DNA was extracted and purified from lation matrix with the Pearson’s correlation coeffi- Purification of bacterial DNA each sample as described previously (27) using the cients “r” among species (threshold value was set at Nucleospin Genomic DNA purification Kit (Macherey- r≥0.5). Common Factor Analysis (CFA) was then IC Nagel GmbH Düren, Germany) according to instruc- used to reduce the number of bacterial variables (32- tions of the manufacturer. Purified DNA was quanti- 34). fied by the QubitTM quantitation system (Invitrogen, CFA generated a small set of non-inter-correlated Milan, Italy) and stored at -80° C until used. factors (i.e. groups of inter-correlated bacterial C species). The association between each generated factor and Forty selected bacterial species (listed in Tab. 1) EBV, CMV and HSV-1 was initially explored with lo- Quantitation of specific bacterial DNA in samples were quantitatively detected in total DNA samples by gistic regression analysis. Factors resulting more © a modified checkerboard DNA-DNA hybridization strongly associated with EBV, CMV, and HSV-1 were technique (CKB) (28, 29). first tested for multi-collinearity and then chosen for Species specific probes were prepared by the Biotin the multiple logistic regression analysis (35). DecaLabel™ DNA Labeling Kit (Fermentas, Thermo The goodness of fit of the models was assessed Fisher Scientific), and detected after high stringency through the likelihood ratio c2 test (p<0.05) and pseu- hybridization using the Biotin Chromogenic detection do-R 2 . The analysis was validated by splitting the Annali di Stomatologia 2017;VIII (2):59-70 61  C. Passariello et al. Table 1. Bacterial strains used to prepare specific species probes for the modified checkerboard DNA-DNA Hybridization analysis. Bacterial Taxa Strain Actinomyces gerencseriae CCUGa 32936T CCUG 18307T li Actinomyces israelii CCUG 18310T na Actinomyces naeslundii Actinomyces oris DSMb 23056 Actinomyces odontolyticus DSM 19120 DSM 2008 io Veillonella parvula Streptococcus gordonii DSM 6777 Streptococcus intermedius DSM 20573 DSM 12643 az Streptococcus mitis Streptococcus oralis DSM 20623 Streptococcus sanguinis DSM 20567 DSM 8324 rn Aggregatibacter actinomycetemcomitans Capnocytophaga gingivalis DSM 3290 DSM 7171 te Capnocytophaga ochracea Capnocytophaga sputigena DSM 7273 Eikenella corrodens DSM 8340 DSM 19528 Campylobacter gracilis In Campylobacter rectus DSM 3260 Campylobacter showae DSM 19458 DSM 3993 ni Eubacterium nodatum Fusobacterium nucleatum ss. nucleatum DSM 15643 DSM 20482 io Fusobacterium nucleatum ss. polymorphum Fusobacterium nucleatum ss. vincentii DSM 19507 Fusobacterium periodonticum ATCCc 33693 iz Parvimonas micra ATCC 33270 Prevotella intermedia ATCC 25611 Ed Prevotella nigrescens ATCC 33563 Streptococcus constellatus DSM 20575 Tannerella forsythia ATCC 43037 Porphyromonas gingivalis ATCC 33277 DSM 14222 IC Treponema denticola Eubacterium saburreum ATCC 33271 Gemella morbillorum DSM 20572 DSM 1135 C Leptotrichia buccalis Neisseria mucosa DSM 17611 Prevotella melaninogenica ATCC25854 DSM 20563 © Streptococcus anginosus Selenomonas noxia DSM 19578 Treponema socranskii ATCC 35536 Staphylococcus aureus ATCC 12600 62 Annali di Stomatologia 2017;VIII (2):59-70  Herpesviruses and microbiota in periodontitis sample into two subsamples of equal size, and as- EBV+,CMV+, and HHV-. sessing the coefficients using one subsample and the At T0, AS of CMV+ subjects showed significantly goodness of fit using the other subsample. higher mean VPI values as compared to those of Statistical analysis was made by a blinded statistician HHV- subjects (Tab. 2).The AS of both HSV+ and (S.P.) who was not aware of the bacterial and viral CMV+ subjects showed significantly greater increase taxa at the moment of analysis. The statistical soft- in PPD between T0 and T45 as compared to those of ware StatView 5.0.1 (SAS® Institute Inc., NC, USA) HHV- subjects (Tab. 2). li was used. The level of significance was set at 95%. na The quantitative detection of 40 bacterial species in Characterization of subgingival biofilm subgingival biofilm samples by the CKB technique, as expected, showed the existence of several significant Results By adopting the selection criteria described in the differences between AS and n-AS (Fig. 1). AS were io materials and methods section, 165 AS and 165 n-AS overall characterized by the presence of significantly were selected for microbiological sampling. Both the higher amounts of Aggregatibacter actinomycetem- AS group and the n-AS group comprised 45 upper az molars, 41 lower molars, 19 upper premolars, 16 low- tum, Fusobacterium nucleatum subsp. nucleatum, comitans, Campylobacter rectus, Eubacterium noda- er premolars, 31 upper incisors and 13 lower incisors. Overall, according to clinical values recorded at T0, Prevotella intermedia, Prevotella nigrescens, Tan- AS and n-AS were comparable in terms of PPD ma denticola, Treponema socranskii, and S. aureus nerella forsythia, Porphyromonas gingivalis, Trepone- (mean values being 5.5 mm and 5.6 mm respectively, as compared to n-AS (Fig. 1). As opposite, Actino- rn P = 0.24), VPI (mean values being 1.6 and 1.5 re- spectively, P = 0.35), and GBI (mean values being myces gerencseriae, Actinomyces naeslundii, Veil- 1.7 and 1.6 respectively, P = 0.39). In accordance lonella parvula, Streptococcus mitis, Capnocythopha- te with criteria adopted for selection, AS alone showed a ga gingivalis, Capnocythophaga ochracea, Eikenella significant increase in both PPD and GBI between T0 lorum, and Neisseria mucosa, were represented in corrodens, Eubacterium saburreum, Gemella morbil- and T45, while values of VPI did not change signifi- significantly lower amounts in AS as compared to n- cantly. AS (Fig. 1). In Significant differences were also detected in the quantitative composition of subgingival biofilm from Sixty-two out of 165 subjects (37.6%) resulted posi- AS of HSV+, EBV+, CMV+ subjects as compared to Detection of Herpesviruses in subgingival plaque tive for the detection of one of the 3 searched virus- HHV- subjects (Fig. 2). ni es. Prevalence was 14.5, 13.9 and 9.1% for HSV-1, In fact, sites of HSV+ subjects were characterized by EBV, and CMV respectively. None of the studied significantly higher amounts of T. forsythia, P. gingi- sites resulted positive for detection of more than one valis, and S. aureus and by significantly lower io of the searched viruses. No difference was observed amounts of A. actinomycetemcomitans, C. showae, in positivity for the three searched viruses between E. nodatum, F. nucleatum subsp. nucleatum, P. inter- AS and n-AS in the single patients. No statistically media, P. nigrescens and G. morbillorum as com- iz significant differences were observed with regard to pared to HHV- subjects (Fig. 2). age and gender among subjects divided in HSV+, Sites of EBV+ subjects were characterized by signifi- Ed Table 2. Distribution of theCytomegalovirus sample according to positivity or no for detection of type 1 HerpesMean Simplex Virus of (HSV+), Epstein Bar Table 2. Distribution of the sample according to positivity for detection of type 1 Herpes Simplex virus (HSV+), Epstein Bar Virus (EBV+) and Human Cytomegalovirus (CMV+) or no Human Herpesvirus (HHV-). Mean values of Visible Plaque Index virus (EBV+) and Human (CMV+) Human Herpesvirus (HHV-). values Visible Plaque Index (VPI), Gingival Bleeding Index (GBI) and periodontal probing depth (PPD) detected in AS at T0 and their mean variations (VPI), Gingival Bleeding Index (GBI) and periodontal probing depth (PPD) detected in AS at T0 and their mean variations between T0 and T45 (∆VPI, ∆GBI, ∆PPD). between T0 and T45 (!VPI, !GBI, !PPD). IC Patient group Number VPI GBI PPD !VPI !GBI !PPD according to virus out of mean mean mean mm mean score mean mean detection 165 score score (± SD) T45-T0 score mm C (± SD) (± SD) T45-T0 T45-T0 HSV+ 24 1.5 1.5 5.6 0.1 0.5 1.5* (±0.5) (±0.5) (±0.7) (±0.3) (±0.5) (±0.5) © EBV+ 23 1.4 1.5 5.5 0.1 0.5 1.2 (±0.50) (±0.5) (±0.6) (±0.3) (±0.5) (±0.4) CMV+ 15 1.7* 1.6 5.5 0.1 0.5 1.3* (±0.5) (±0.5) (±0.5) (±0.5) (±0.5) (±0.5) HHV- 103 1.5 1.7 5.6 0.0 0.4 1.1 (±0.50) (±0.5) (±0.6) (±0.3) (±0.5) (±0.3) Annali di Stomatologia 2017;VIII (2):59-70 63  C. Passariello et al. li na io az rn te In Figure 1. Plot of differences of percentages of total DNA probe count of the 40 test species in subgingival biofilm samples between 165 AS and 165 n-AS of generalized aggressive periodontitis. Significant differences between AS and n-AS for each species are indicated with an asterisk. Species were ordered and grouped according to the complexes described by ni Socransky et al., 1998 (28). io cantly higher amounts of A. actinomycetemcomitans with factor 8 and inversely associated with factor 1 and by significantly lower amounts of F. nucleatum (Tab. 3). subsp. vincentii, F. periodonticum, T. forsythia, P. According to the simple logistic regression analyses, iz gingivalis, and E. saburreum as compared to HHV- three factors (factors 2, 4, and 8) were marginally subjects (Fig. 2). (i.e., 0.20<p<0.05) or significantly (i.e., p≤0.05) as- Sites of CMV+ subjects were characterized by signifi- sociated with EBV, three (factors 5, 8, and 11) with Ed cantly higher amounts of A. actinomycetemcomitans CMV, and three (factors 1, 8, and 10) with HSV and by significantly lower amounts of F. nucleatum (Tab. 4). subsp. vincentii, T. forsythia, P. gingivalis, and E. Multiple logistic regression analysis showed that: 1) saburreum as compared to HHV- subjects (Fig. 2). factor 8 was the only one being significantly and in- versely associated with EBV; 2) factor 11 was signifi- cantly and directly associated with CMV, while factors Analysis of the association of subgingival microbiota IC Analysis of values of skewness and kurtosis showed 5 and 8 were significantly and inversely associated with Herpesviruses. that percentages of total DNA probe counts of the with CMV; 3) factor 8 was significantly and directly studied bacterial species followed a reasonably nor- associated with HSV-1, while factors 1 and 10 were mal distribution (data not shown). Analysis of the significantly and inversely associated with HSV-1 C Pearson’s correlation coefficients between relative (Tab. 5). The three regression models were not dis- frequencies of bacterial species strongly justified the turbed by multi-collinearity, (VIFs = 0.10). The likeli- use of CFA (data not shown). CFA generated 19 fac- hood c2 tests resulted highly significant (P<0.0001), tors; of these, 15, showing eigenvalues >1, were se- while the Pseudo-R2 values were all 0.6 for the three © lected as meaningful and subjected to factor rotation. models. These tests suggest that the variables in- After oblique and orthogonal rotation, the 15 selected cluded in the regression models were highly predic- factors accounted for variance proportions ranging tive. between 4.1 and 13.2% (Tab. 3). All bacterial taxa Following validation analysis, factors 2 and 4 were no were included in only one factor, excluding P. gingi- longer associated with EBV, factor 5 was no longer valis and T. forsythia which were directly associated associated with CMV, and factor 10 was no longer 64 Annali di Stomatologia 2017;VIII (2):59-70  Herpesviruses and microbiota in periodontitis li na io az rn te Figure 2. Mean percentage (±standard deviation) of the total DNA probe count of the 40 test species in subgingival biofilm In samples from 165 AS of generalized aggressive periodontitis distinguished according to positivity for detection of HSV-1 (HSV+), EBV (EBV+), CMV (CMV+) or no Herpesvirus (HHV-) specific sequences. Significance of differences for each species between AS of HSV+, or EBV+, or CMV+, and HHV- sites is indicated by replicating the symbol corresponding to each category at the top of the plot. Species were ordered and grouped according to the complexes described by Socran- ni sky et al., 1998 (28). io Table 3. Meaningful factors generated by Common Factor Analysis and bacterial species resulting strongly directly or inversely associated with each dimension (i.e. factor loading assessed with Pearson’s correlation coefficients between bacterial species and dimension ≥0.33). iz Factor Accounted Bacterial species associated with dimension Ed Variance (%) Directly Inversely 1 13.2 E.nodatum, P.intermedia, P.nigrescens S.aureus, T.forsythia, P.gingivalis 2 10.4 A.israelii, T.denticola, T.socranskii 3 7.2 C.rectus, S.noxia 4 7.0 A.oris, N.mucosa IC 5 7.1 E.suburreum, F.nucleatum subsp vincentii 6 6.4 C.gracilis, S.anginosus 7 6.5 A.odontolyticus, C.gingivalis 8 8.7 C P.gingivalis, T.forsythia, F.periodonticum A.actinomycetemcomitans 9 6.9 S.intermedius, P.melaninogenica, S.constellatus 10 4.7 G.morbillorum L.buccalis 11 4.3 P.micra, F.nucleatum subsp. polymorphum © V.parvula 12 4.8 E.corrodens, S.sputigena S.sanguinis 13 4.1 A.gerencseriae, A.naeslundii S.gordonii 14 4.1 C.showae, C.ochracea 15 4.6 S.mitis, S.oralis Annali di Stomatologia 2017;VIII (2):59-70 65  C. Passariello et al. Table 4. Association (OR with 95% confidence interval -95CI) between each single factor and EBV, CMV and HSV-1, adjusted for confounders and assessed through logistic regression analysis. Factors with p<0.20 were included in the fi- nal logistic regression models. Factor Association with OR (95CI) li EBV CMV HSV-1 1 Inverse 0.1 (0.1-0.3) ** na 2 Direct 1.4 (0.9-2.2)* 4 Direct 1.4 (0.9-2.2) * 5 Inverse 0.6 (0.4-1.1) * io 8 Inverse 0.1 (0.03-0.2) ** Inverse 0.1 (0.05-0.3) ** Direct 4.1 (1.7-10.1) ** 10 Inverse 0.7 (0.4-1.0) * az 11 Direct 2.2 (1.2-4.1) ** * 0.20<p<0.05: marginally associated; included in the final model. ** p≤0.05: significantly associated; included in the final model. rn Table 5. Multivariate association (OR with 95% confidence interval -95CI) between the meaningful factors and Epstein Bar Virus (EBV), Human Cytomegalovirus (CMV), and type 1 Herpes Simplex Virus (HSV-1), adjusted for confounders te and assessed through logistic regression analysis. Factor In OR (95CI) EBVa CMVb HSV-1c 1 0.1 (0.04-0.3) – p<0.0001 2 1.8 (0.8-4.0) – p=0.14d ni 4 2.0 (0.9-4.5) – p=0.08d 5 0.4 (0.2-0.9) – p=0.02d io 8 0.05 (0.01-0.2) – p<0.0001 0.07 (0.02-0.3) – p<0.0001 12.7 (2.1-75.5) – p=0.005 10 0.5 (0.2-1.0) – p=0.05d iz 11 4.6 (1.6-13.6) – p=0.005 Whole model goodness of fit: Ed a likelihood-ratio χ2 =84.16; p<0.0001. Pseudo-R2=0.63 7df b likelihood-ratio χ2 =59.99; p<0.0001. Pseudo-R2=0.60 7df c likelihood-ratio χ2 =83.22; p<0.0001. Pseudo-R2=0.61 7df d validation analysis did not confirm the statistically significant association IC associated with HSV-1. The likelihood c 2 tests re- ing able to trigger the activation of sites are still de- mained highly significant (P<0.0001). bated (36, 37). Most Authors agree to recognize in a limited number of microbial species, grouped in a few complexes, the C principal and most frequent etiologic agents of com- mon clinical forms of periodontal disease28. Neverthe- Discussion Powerful molecular methods of investigation intro- less, it has been suggested that non typical bacterial duced during the last few decades enabled a sub- species and some Herpesviruses might also cooper- © stantial improvement of our knowledge on different ate to accelerate disease progression and its suscep- aspects of the oral and periodontal microbiota and on tibility to periodontal treatments (6, 7, 9, 11, 16, 17, its interactions with host defenses. 19, 22, 38). Nevertheless, the etiopathogenesis of different clini- The role of Herpesviruses in the etiopathogenesis of cal forms of periodontitis, the specific mechanisms periodontal diseases is still the object of discussion accounting for its episodic progression and those be- and different Herpesviruses have been detected with 66 Annali di Stomatologia 2017;VIII (2):59-70  Herpesviruses and microbiota in periodontitis variable prevalence in a number of different studies, to data reported in other studies (11, 15, 16, 19, 22). starting to be published about three decades ago. The fact that we found full correspondence with re- Large part of these studies evidenced that HSV-1, gard to positivity/negativity for detection of viruses EBV and CMV are detected with high prevalence in between experimental (AS) and control sites (n-AS) is periodontal lesions, that they directly infect gingival not surprising, nor in contrast with previous studies in epithelial cells and that viral loads positively correlate which experimental, diseased sites were compared to with disease severity (11-13, 16-21). control healthy sites demonstrating the existence of li Although some recently published studies failed to significant differences in viral loads between the two na find any association between aggressive periodontitis groups (11, 15-17, 19-22). and the presence of Herpesviruses (14), or detected Analysis of clinical data of patients, aggregated ac- the three viruses at very low levels, and suggested cording to positivity/negativity for detection of each of that their detection could possibly be the conse- the three searched viruses, evidenced that the four quence of contamination by blood or saliva or of lym- groups were comparable with regard to age and gen- io phoid cells (15), available data, considered altogether der. At T0 they were also comparable with regard to suggest that human Herpesviruses probably play a VPI, GBI and PPD (Tab. 2). Exception to this were relevant role in both chronic and aggressive peri- CMV+ ASs showing significantly higher VPI values at az odontitis (12-16), and that differences can in large T0 as compared to those of HHV- subjects (P=0.04). part be explained on the basis of geographical and HSV-1+ and CMV+ ASs showed significantly greater ethnic variability (22). increase of PPD between T0 and T45 as compared to In a critical review of the literature that was published HHV- ASs (P<0.01). These data suggest that at least rn recently, Slots evidenced that the possibility to corre- CMV and HSV-1 are not mere spectators of the pro- late the presence of Herpesviruses with periodontal gression of GAP lesions. disease progression is biased by the fact that in most The second sample from each studied site was used studies sampling was performed regardless of dis- to analyze composition of the subgingival biofilm by te ease activity. means of a modified CKB technique (28, 29); main Recently we demonstrated that subjects affected by modifications regarded inclusion in the panel of an S. periodontal diseases show higher prevalence of S. aureus specific probe, and column purification of In aureus in their oral microbiota and that they common- metagenomic DNA, instead of simple alkaline lysis, in ly host highly toxigenic strains of such an opportunis- order to obtain more efficient DNA extraction from tic pathogen (9). Gram positives and to reduce interference due to mi- Moreover, we showed that the isolation of S. aureus crobial proteins in crude lysates. from subgingival sites of GAP correlates with disease The comparative, semiquantitative analysis of the ni progression. metagenome from subgingival biofilm samples ob- Having cumulatively considered the above observa- tained from AS and n-AS (Fig. 1) substantially con- tions, data on composition of the subgingival micro- firmed previous observations by other Authors and io biota of GAP, and data on detection of Herpesviruses reinforced evidence of the role played by certain from subgingival sites of GAP, we designed the pre- known periodontopathogens and atypical pathogens sent study to characterize the subgingival microbiota (namely S. aureus in our study) in the progression of iz of AS of GAP and to correlate microbial patterns lesions of GAP (4-7, 9). found in these sites with the presence/absence of Data presented here confirm previous reports and Herpesviruses. suggest that the presence of Herpesviruses affects Ed To this purpose, one AS and one n-AS were selected composition of the subgingival biofilm in GAP and in a population of subjects affected by GAP. Attention prevalence of certain periodontopathogens (22). was dedicated at selecting two sites that differed al- Moreover, they show that virus specific microbial pat- most only with regard to activity of the lesion; basing terns characterize both AS and n-AS and that, during on a protocol of repeated clinical examination extend- active progression of lesions, the prevalence of cer- ing over a period of 3 months the time interval of 45 tain bacterial species in the subgingival biofilm IC days was found as the most appropriate to detect ac- changes in a virus specific manner. tively progressing sites in the studied population (9). To our knowledge this is the first investigation aiming Two samples of subgingival biofilm were obtained to characterize microbial patterns associated with ac- from each selected site. tive progression of lesions of GAP and to evaluate at C One sample for each studied site was processed to the same time if the presence/absence of three detect the presence of HSV-1, EBV, or CMV by stan- species of Herpesviruses is associated with specific dard PCR methods. The analyzed sites were conse- microbial patterns. quently distinguished in four groups according to pos- In order to disclose specific microbial patterns associ- © itivity for detection of HSV-1, EBV, CMV or negativity ated with the presence/absence of each of the three for Herpesviruses (HHV-). Herpesviruses and with active progression of lesions Adoption of standard PCR methods and the fact that required an articulated analysis of data, in which the only two samples were analyzed from each subject relative frequencies of the searched bacterial species could account for the relatively low number of sites were evaluated considering the potential influence of that resulted positive for Herpesviruses as compared general variables (age, gender, hygienic skills, reac- Annali di Stomatologia 2017;VIII (2):59-70 67  C. Passariello et al. tivity of the host, local anatomy) and specific vari- munity, on the expression of proteins at the surface ables (co-variation of groups of inter-related bacterial of epithelial cells, and on the expression of adhesins species) (34). and toxins by microorganisms (28, 40-43). Consequently data obtained by CKB from subgingival Recent researches showed that polymicrobial syner- biofilm samples of AS, divided according to positivi- gy can occur during infection and that these interac- ty/negativity for detection of HSV-1, EBV, or CMV tions can affect health and disease (44). were preliminary analyzed by CFA to disclose the ex- The high prevalence of S. aureus in HSV-1+ sites li istence of bacterial taxa whose relative frequencies and its correlation to lesion activity deserves consid- eration. A consistent mass of experimental and clini- na varied among samples in an inter-correlated manner. CFA enabled to reduce the number of microbial vari- cal data shows that polymicrobial infections involving ables and to prevent the negative impact of inter-cor- S. aureus exhibit enhanced disease severity and relation on results of logistic regression analysis (33- morbidity (44). 35). S. aureus possesses and uses strategies to survive io At the end of CFA a small set of non-inter-correlated in many different ecological niches and to counterat- factors was generated, each factor being character- tack the competing bacteria. Such cooperative and ized by a group of inter-correlated bacterial species. competitive interactions enable this flexible oppor- az The association between each single factor and EBV, tunist to evolve rapidly towards persistent phenotypes CMV or HSV-1, adjusted for individual characteristics characterized by multidrug resistance and increased and clinical indices, was explored with logistic regres- virulence (45). sion analysis. With regard to the possible role of S. aureus in the progression of lesions of GAP, we have previously rn Those factors resulting more strongly associated with EBV, CMV, or HSV-1 were chosen for multiple logis- shown that subgingival isolates from AS of GAP are tic regression analysis. characterized by a richer armamentarium of virulence Such an analytical process of microbiological and and pathogenicity factors as compared to supragingi- te clinical data was able to return reliable information on val isolates (9). bacterial species that are significantly associated with Altogether data presented here and data of the recent literature suggest that although the presence of Her- the three viruses and how. pesviruses is not necessary for the progression of pe- In This information can be summarized as follows: I) riodontal lesions of GAP, it can facilitate it, possibly coinfection by EBV is directly associated with a high- by promoting pathogenicity and virulence of periodon- er prevalence of A. actinomycetemcomitans and in- topathogenic and other bacteria in a virus and bacter- versely associated with that of P. gingivalis, T. for- ial species dependent manner. Furthermore they sug- sythia and F. periodonticum; II) coinfection by CMV is ni gest existence of a complex cooperative interaction directly associated with a higher prevalence of A. promoted by HSV-1 infection, involving S. aureus and actinomycetemcomitans, V. parvula, P. micra and F. the periodontopathogens P. gingivalis, T. forsythia, nucleatum subsp. polymorphum and inversely associ- io and F. periodonticum, that could promote an acceler- ated with that of P. gingivalis, T. forsythia and F. peri- ate progression of lesions of GAP. odonticum; III) coinfection by HSV-1 is directly asso- Further studies will be necessary to demonstrate and ciated with a higher prevalence of P. gingivalis, T. for- characterize this cooperation at the cellular and mole- iz sythia, F. periodonticum and S. aureus and inversely cular level. associated with that of A. actinomycetemcomitans, E. nodatum, P. intermedia and P. nigrescens. Ed The observation that changes in the subgingival biofilm are virus specific suggests that they cannot be Acknowledgements explained simply by the immunosuppressive effect of This work was supported by a grant from MIUR (Pro- Herpesviruses and are probably consequence of spe- ject PRIN 2007LXNYS7 003) to CP. The Authors de- cific mechanisms of cooperation between each of the clare that they have no conflict of interests with re- 3 viruses and some bacterial species. gard to this work. IC The existence of cooperative interactions involving different viruses and bacterial species, including S. aureus, is well known and can depend on different cellular and molecular mechanisms (23-25). Coopera- References C tive interactions have also been demonstrated be- 1. Armitage G. Development of a classification system for pe- tween CMV and A. actinomycetemcomitans and are riodontal diseases and conditions. 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Original article Comparison of two different debonding techniques in orthodontic treatment li na Luca Piccoli DDS, PhD age during debonding. In both types of composite Guido Migliau MD, DDS resins (photopolymerizable or self-curing), the de- Laith Konstantinos Besharat DDS, PhD tachment occurs at the interface bracketing adhe- io Stefano Di Carlo MD, DDS, PhD sive. In this case the amount of remaining adhe- Giorgio Pompa MD, DDS, PhD sive material on the tooth must be removed with Roberto Di Giorgio MD, DDS, PhD further methods, which in addition, increase the az risk of iatrogenic injury as well as the working Department of Oral and Maxillofacial Sciences, hours. “Sapienza” University of Rome, Rome, Italy Key words: orthodontics, debonding, adhesion. rn Introduction Laith Konstantinos Besharat Corresponding author: Department of Oral and Maxillofacial Sciences, In order to guarantee the success of a fixed orthodon- te “Sapienza” University of Rome tic treatment, efficient adhesion of the bracket on the Via Caserta 6 surface of the tooth is required for the duration of the 00161 Rome, Italy orthodontic treatment, which prevents an eventual detachment or change of its initial position during the In E-mail: [email protected] application of orthodontic force. On the other hand, at the end of the treatment, the procedure of debonding should be able to be imple- mented effectively, allowing the detachment of the Summary ni bracket from the tooth surface as well as leaving the enamel surface intact. Aim. The purpose of this research is to investi- The adhesive system for orthodontic attachments gate whether and how the adhesive bond failure io should fulfill two tasks which in fact are mutually ex- site varied in relation to the material used for the clusive, therefore the majority of the studies in this orthodontic bonding and debonding technique field of orthodontics has focused on the evaluation of applied. the mechanical and physical properties of the adhe- iz Materials and methods. Two different methods of sive materials used for the direct bonding of ortho- orthodontic debonding were included in our sur- dontic brackets, including their adhesive strength and vey; cutters for orthodontics and debonding plier. enamel condition during, and at the end of the treat- Ed Three different materials for the adhesion of the bracket: composite light curing, self-curing com- ment (1, 2). posite and glass ionomer cement. The remaining It has been shown that each material presents differ- amount of adhesive on the tooth surface is an im- ent molecular structures and different physico-me- portant parameter that gives information on how chanical properties, which also justifies the different the location of the posting site varied during the behaviors in response to the applied force during the debonding procedures. In particular, it was shown IC debonding. 60 dental elements, maxillary and mandibular, previously extracted for orthodontic that the forces applied to allow the detachment of the bracket from the enamel surface do not act in a ho- mogenous way, but focus mainly on specific weak- reasons, as well as periodontal, were included in nesses of the adhesive bond (3-5). our research. We investigated a possible signifi- C In detail regarding the failure of the adhesive bond cant correlation between different variables site, Artun and Bergland in 1984 developed an index (debonding technique and materials for member- called ARI (Adhesive Remnant Index), thus identify- ship) and the ARI index. ing two different failure patterns in the tooth-bracket- Conclusions. The use of orthodontic cutters or © adhesive system, namely the formation of a gap in debonding pliers does not affect the adhesive the enamel-adhesive or bracket-adhesive bonding bond failure site and both techniques have a ten- surfaces. dency to leave a significant amount of adhesive Inquiring about the posting site is crucial due to the on the surface enamel. In the resin-reinforced fact, that both failure modes have 0 clinical implica- glass ionomer cements, detachment occurs at the tions that should be considered during an orthodontic interface enamel-adhesive and this pattern of de- tachment increases the risk of the enamel dam- Annali di Stomatologia 2017;VIII (2):71-78 71  L. Piccoli et al. treatment. In the first case, namely in the event of a • Intact vestibular surface detachment at the enamel-adhesive interface in- • Absence of caries creases the risk of fractures and permanent damage • No fillings to the enamel, whilst in the second case when follow- • Lack of enamel defects. ing the fact that the gap formed between the bracket and adhesive leaving a large amount of composite on The extracted dental elements were thoroughly the vestibular surface of the tooth, the risk of damage cleaned from any tissue and fluid and stored in dis- li to the enamel will be reduced but additional proce- tilled water and 1% thymol for 24 hours to prevent de- na dures to remove the composite from the tooth surface hydration. will be necessary, which will then result in an in- Subsequently they were stored in distilled water until crease of working time (6). the moment of their use. In light of the above and the growing scientific inter- Before use, the vestibular surface of all the teeth was est on the subject, it seemed interesting to focus on cleaned and polished with a rubber pad mounted on io the matter and in particular investigate whether and a low-speed handpiece for 10 seconds. how the adhesive bond failure site varied in relation The sample was divided into 6 groups each one con- to the material used for the orthodontic bonding and sisting of 10 dental elements (Table 1). az debonding technique used. The purpose of this re- search is to evaluate the possible influence of two dif- ferent methods of orthodontic debonding: Cutters for Orthodontics and debonding pliers. Bonding of the bracket to the enamel rn surface Procedures for bonding of the bracket in groups 1 Materials and methods and 2 te Three different materials for the adhesion of the The vestibular surface of dental elements was etched MATERIALS: light-curing adhesive system bracket were used: using 37% orthophosphoric acid for 30 seconds, was 1. Composite light curing subsequently rinsed for 15 seconds and dried with air In 2. Self-curing composite jet to obtain a chalky appearance of the enamel. 3. Glass ionomer cement. It was then applied with a brush, the © Transbond XT primer (3M Unitek, Monrovia, California) on the previ- The remaining amount of adhesive on the tooth sur- ously etched surface and stretched by a gentle jet of face is an important parameter that gives information air to obtain a thin layer of primer disposed uniformly ni on how the location of the posting site varied during on the enamel. the debonding. The primer was photoactivated using a curing light for The study is divided into four different phases: 10 seconds. io 1. Preparation and subdivision of the sample: At this point, we selected the self-ligating bracket cor- the sample has been properly prepared and divided responding to the teeth used, and after placing on the into groups; bracket base an adequate amount of light-curing iz 2. Bonding: composite © Transbond XT Adhesive Paste, the at- three different materials were used to allow the adhe- tack was positioned on the surface of the correspond- sion of the bracket to the extracted teeth; ing tooth with DOOR pliers. Ed 3. Debonding: Once we removed the excess material from the pe- we used two different methods of debonding to re- riphery of the bracket the composite was light-cured move the bracket previously applied to the vestibular with a light power equal to 740 mW/cm2 and a wave- surface of the teeth; length of 470 nm to 480 nm for 20 seconds on each 4. Evaluation of sticker remaining: side (mesial, distal, incisal and gingival). we evaluated the remaining amount of composite or IC cement on the surface of the tooth through the ARI index; Procedures for bonding of the bracket in groups 3 5. Statistical analysis of data: and 4 we investigated a possible significant correlation be- The vestibular surface of the dental elements was MATERIALS: self-curing adhesive system C tween variables (debonding technique and materials etched using 37% orthophosphoric acid for 30 seconds, for membership) and the ARI index. and was subsequently rinsed for 15 seconds and dried with air jet to obtain a chalky appearance of the enamel. A thin layer of Ortho-one No Mix Primer (BISCO Inc. © U.S.A.) was applied with a brush both on the tooth surface previously etched, and stretched with a faint Preparation and subdivision of the sample The sample consists of 60 dental elements, both jet of compressed air, or on the base of the bracket. maxillary and mandibular previously extracted for or- The primer in this case contains a catalyst molecule thodontic reasons, as well as periodontal selected ac- that once in contact with the adhesive paste initiates cording to the following sample inclusion criteria: the curing process. 72 Annali di Stomatologia 2017;VIII (2):71-78  Comparison of two different debonding techniques in orthodontic treatment Table 1. Sample division into six groups. Adhesive Debonding Bracket Etching Primer composite Technique type li 37% primer Transbond na Orthophosphoric Transbond XT Cutters for Group 1 XT Self ligating bracket acid (3M) Orthodontics (3M) (3M) 37% primer Transbond io Orthophosphoric Transbond XT Group 2 XT Debonding plier Self ligating bracket acid (3M) (3M) (3M) az 37% Ortho-one No Mix Ortho one No Mix Orthophosphoric Cutters for Group 3 Primer Paste Self ligating bracket acid Orthodontics (Bisco) (Bisco) (3M) rn 37% Ortho-one No Mix Ortho-one No Mix Orthophosphoric Group 4 Primer Paste Debonding plier Self ligating bracket acid te (Bisco) (Bisco) (3M) In Liquid Powder Etching of glass of glass Debonding Technique Bracket type onomer cement ionomer cement ni 10% Polyacrylic Fuji Ortho Group 5 Fuji Ortho liquid Cutters for Orthodontics Self ligating bracket acid powder io 10% Polyacrylic Fuji Ortho Group 6 Fuji Ortho liquid Debonding plier Self ligating bracket acid powder iz Ed At this point an adequate amount of adhesive paste ionomer cement (Fuji Ortho and Fuji Ortho liquid (Ortho-one No Mix paste) is placed on the bracket powder) were mixed according to the manufacturer’s base and the attack is positioned on the surface of instructions, and once it reached the desired consis- the tooth with a clamp bracket, making sure to tency, the glass ionomer cement was applied with a properly join the attack on the enamel surface and to brush in a thin layer on the bracket base. The attack remove any excess material from the periphery of the was positioned on the surface of the corresponding IC bracket. tooth, which was previously cleaned and polished. In this case the polymerization, made possible by the Excess material from the periphery of the bracket catalyst contained in the primer, occurred in about 5 was removed with a calliper bracket. The material minutes. was light cured with a light power equal to 740 C mW/cm2 and a wavelength of 470 nm to 480 nm for 20 seconds on each side (mesial, distal, gingival and incisal). Procedures for bonding of the bracket in groups 5 and 6 © The vestibular surface of the teeth was conditioned MATERIALS: glass ionomer cement with 10% polyacrylic acid for 20 seconds, sub - In all six groups metallic self-ligating brackets were Bracket used sequently rinsed for 15 seconds, and adequately used, the base of the bracket had a single 80 gauge dried with an air jet afterwards. mesh morphology with a mesh spacing equal to 3,2 x The paste and liquid components of the glass 10 -2 mm2. Annali di Stomatologia 2017;VIII (2):71-78 73  L. Piccoli et al. scans with a special software which made it possible to calculate the perimeter and the area occupied by Debonding the residual material (Fig.1). By calculating the area occupied by the remaining ad- Procedures in groups 1-3-5 debonding The brackets attached to the surface of the dental el- hesive material and having available the information METHOD USED: cutters for orthodontics ements were removed through the use of nippers for relating to the area of the base of the bracket used it orthodontics, by placing the beaks of the pliers at the was possible to calculate the index ARI (Adhesive li base of the bracket fins and applying a force directed Remnant Index) described by Artun and Bergland. mesio-distally to promote the detachment of the na The ARI Index involves the assignment of values bracket from the enamel surface. ranging from 0 to 3: 0: Absence of adhesive material remaining on the tooth surface 1: Presence of less than half of the adhesive materi- Procedures in groups 2-4-6 debonding io The dental elements were subjected to a debonding al remaining on the tooth surface METHOD USED: debonding plier procedure through the use of a dedicated tool. The 2: Presence of more than half of the adhesive mate- beaks of the pliers of the debonding chisel were posi- rial remaining on the tooth surface az tioned as near as possible to the base of the bracket 3: Presence of all of the adhesive material on the and shear force was applied to allow the detachment tooth surface. of the bracket. rn Statistical analysis Evaluation of the remaining quantity of adhesive material on the dental surface Statistical analysis was performed using SPSS Inc. ver. 13.0, Chicago, IL, USA. Chi-squared test was te used for statistical evaluation of proportions. In cases The dental elements, after the debonding procedures Scan 3D of more than 2 independent means we used the were subjected to 3D scans. ANOVA test. A p-value of less than 0.05 was consid- The scanner used was a SYNERGY SCAN, which is In ered significant. A 95% CI was used in all of the a sophisticated 3D optical scanner that can acquire analysis. In order to assure data reliability, data were non-contact three-dimensional shapes. entered in two different personal computers by two The technology used in the scanner is called active examiners; the two data files were compared in order stereo vision and is the projection of a structured light to detect entry errors. The two files resulted identical. ni pattern on the surface of interest that is captured Statistical tests were performed, to investigate any through two cameras. significant correlations between the type of material, Advanced image processing algorithms to retrieve the debonding technique and the ARI index. For fur- io the aquiered surface’s depth were used and a recon- ther analysis, the statistical Chi-square test was used. struction of a three-dimensional image that can be easily viewed and manipulated on the PC screen was The Chi-square test is a nonparametric statistical test, achieved. which allows the comparison of two related reports or iz The entire scanning step is fully automated with the frequencies, in order to exclude, with a certain degree help of an automated rotating table that allows us to of probability, that their difference is due to the chance. acquire different views of the object. Any statistical program will result in a transformation of Ed The teeth were placed on Support Single Silicon and the test result in probability (p). This probability of error dulled by spray cleaner before being subjected to should also be assessed according to the level of sig- scanning. nificance chosen by the investigator. This is because many objects have a surface that is not easy to detect with the light beam used by the scanner. IC Results If the objects are transparent, too dark, opaque, or black they have refractive and reflective qualities, We carried out two different surveys. which do not allow the camera to detect the ray of In the first we compared the different materials used light which is deformed or reflected erratically. In for the bonding and the ARI index, while in the sec- C these cases it is impossible to perform the scanning ond we compared the debonding techniques to the unless you opacify the object with preferably a white ARI index. opaque layer, which renders the area appropriate. The spray used (Renfert - scan spray) allows treating © the surface at an optimal level for the scan. In this study we used the statistical Chi-square test Survey 1 with 95% confidence interval, to determine any signif- icant correlation between the three different materials To determine the remaining amount of adhesive on used for orthodontic bonding (a light-curing compos- Calculation of the ari index the labial surface of the dental elements after ite, a composite and a self-curing glass ionomer ce- debonding, we processed the images of the digitized ment), and the ARI index. 74 Annali di Stomatologia 2017;VIII (2):71-78  Comparison of two different debonding techniques in orthodontic treatment Figure 1. Digitized scans. li na io az rn te In ni io iz Ed IC Between the dental elements in which a light-cured Between the elements where dental self-curing com- composite for the bonding of orthodontic brackets posite for the bonding of orthodontic brackets was was used on a total of 20 teeth: used on a total of 20 teeth: • 1 element reported value of ARI 0 • 4 items reported a value of ARI 0 C • 5 elements have reported a value of ARI 1 • 4 elements have reported a value of ARI 1 • 11 elements have reported a value of ARI 2 • 5 elements have reported a value of ARI 2 • 3 elements have reported a value of ARI 3. • 7 elements have reported a value of ARI 3 (Fig. 2). Between the dental elements in which a self-curing The graph shows that among the elements in which a © composite for the bonding of orthodontic brackets glass ionomer cement was used, 61% of the sample was used on a total of 20 teeth: presented a value of ARI 0 (no remaining sticker on • 4 items reported a value of ARI 0 the surface of the tooth) compared to 8% of the items • 4 elements have reported a value of ARI 1 in which a light-curing composite was used and 31% • 5 elements have reported a value of ARI 2 among the elements in which a self-curing composite • 7 elements have reported a value of ARI 3. was used (Fig. 3). Annali di Stomatologia 2017;VIII (2):71-78 75  L. Piccoli et al. li na io az rn Figure 2. First survey (p value = 0.05). te In ni io iz Ed IC Figure 3. ARI 0 percentage in the three adhesive materials. Among the elements in which a wire cutter for ortho- In this analysis we investigated by the use of the sta- dontics was used to remove brackets from the buccal Survey 2 C tistical Chi-square test, with a 95% confidence inter- surface, out of a total of 30 teeth: val, any significant correlation between the two differ- • 9 elements reported a value of ARI 0 ent debonding techniques and the ARI index. • 8 elements reported a value of ARI 1 Among the elements in which pliers were used to re- © • 8 elements reported a value of ARI 2 move brackets from the vestibular surface, out of a • 5 elements reported a value of ARI 3. total of 30 teeth: • 4 elements reported a value of ARI 0 • 6 elements reported a value of ARI 1 This investigation showed no significant values (p • 12 elements reported a value of ARI 2 value> α) (Fig. 4). • 8 elements reported a value of ARI 3. 76 Annali di Stomatologia 2017;VIII (2):71-78  Comparison of two different debonding techniques in orthodontic treatment '# li '" na 4)0!" & 4)0!' % io 4)0!!# $ 4)0!7 az # " rn ,8((.)/!!9*)!*)(-*3*+(0,/ 3.5*! +30 ! +6!1:0.)/ ! Figure 4. Correlation between the two different debonding techniques and the ARI index. Discussion te The finding of a statistically significant correlation be- In particular the highest values of ARI index were recorded with the use of a light-cured composite. This behavior is probably due to an incomplete poly- In tween the type of material used for orthodontic bond- merization of the resin below the base of the bracket ing and the Adhesive Remnant Index, confirms the due to the difficulty of the curing light to reach and data reported in the literature according to which, the activate the material located immediately below the adhesive bond failure site during the debonding metal base. In addition, the effect of air entrapment ni varies depends on the material used for bonding (7). below the bracket during the procedures of bonding, In particular, the results show that in the elements in allows the oxygen to cause a partial inhibition of the which a glass ionomer cement was used, the adhe- free radicals necessary for polymerization and can be io sive failure in the debonding procedures resulted responsible for the failure of the adhesive bond in mostly in the adhesive enamel interface, unlike ele- bracket-adhesive interface. This effect is only report- ed in the literature for the light cured composites (14, ments in which a composite was used where the fail- 15). iz ure of the bond took place mostly in the bracket ad- The reasons for the same behavior of the self-curing hesive interface. composites, however, lie in their high rate of polymer- The reasons that the glass ionomer cements binds ization which create a very high adhesive force, giv- Ed more efficiently to the metal base of the bracket in re- ing an explanation for the material separation in the spect to composite resins are to be discovered, be- bracket adhesive interface. cause unlike the latter, the glass ionomer cements It is reported in the literature that when you reach permit a chemical bond both to the base of the brack- very high values of bond strength, applying a separa- et and the enamel. tion force to allow for the debonding of the bracket, a In addition, in the glass ionomer cement, the mechan- fracture plane is created that propagates into the ma- IC ical component of the adhesive bond, which is made terial and at the interface-bracketing adhesive. possible by the creation of micropores in the enamel, No statistically significant differences were found be- is greatly diminished, because these materials do not tween the two debonding techniques used (orthodon- need an etching with strong acid (orthophosphoric tic wire cutters and debonding pliers) in relation to the C acid at 37%) which demineralizes the enamel (8, 9), ARI index. but rather need etching with a weak acid (10% poly- Both tools used have shown a tendency to leave a acrylic acid), which demineralizes very mildly the significant amount of adhesive on the enamel sur- enamel and has mainly the aim of cleaning the sur- face. © face from the acquired film and debris (10-13). These findings are similar to data reported in several As for the elements in which composite resins were previous studies (3, 16-19). used (photopolymerizable and self-curing) for ortho- Our results are in concordance with international liter- dontic bonding, the adhesive failure in the debonding ature and confirm that during debonding the type of procedures, occurred for the majority of the samples force applied affects the remaining amount of adhe- at the bracket adhesive interface. sive and not the type of instrument used. Annali di Stomatologia 2017;VIII (2):71-78 77  L. Piccoli et al. In particular by applying shear forces on the gap site totoxicity of conventional and resin modified glass ionomer localizes mainly to the interface bracket-adhesive, cements. Bosnian journal of basic medical sciences/Udruzen- while applying tensile forces the posting site is trans- je basicnih mediciniskih znanosti= Association of Basic Med- ferred to the interface between the enamel and the ical Sciences. 2012;12(4):273-278. 6. Salehi P, Pakshir H, Naseri N, Baherimoghaddam T J. The adhesive (20). effects of composite resin types and debonding pliers on the Both debonding orthodontic instruments analyzed in amount of adhesive remnants and enamel damages: a stere- the current study apply a shear force to the bracket li omicroscopic evaluation. Dent Res Dent Clin Dent Prospects. which explains in both methods, the presence of a sig- 2013 Fall;7(4):199-205. nificant amount of adhesive on the surfaces of dental na 7. Rasheed NA. A comparative clinical study between light cured elements following the procedures of debonding. and chemically cured (no mix) bonding systems. J Bagh Col- lege Dentistry. 2012;24(3). 8. Yassaei, Soghra, Azadeh Soleimanian, and Zahra Ebrahi- mi Nik. Effects of Diode Laser Debonding of Ceramic io Brackets on Enamel Surface and Pulpal Temperature. Conclusions Journal of Contemporary Dental Practice. 2015;16(4). The use of orthodontic cutters or debonding pliers, 9. Zhu JJ, et al. Acid etching of human enamel in clinical ap- does not affect the adhesive bond failure site and plications: A systematic review. The Journal of prosthetic den- az both techniques have a tendency to leave a signifi- tistry. 2014;112(2):122-135. cant amount of adhesive on the surface enamel. 10. Navimipour EJ, Oskoee SS, Oskoee PA, Bahari M, Rikhte- The type of material used for orthodontic bracket garan S, Ghojazadeh M. Effect of acid and laser etching on bonding significantly affects the release site. In par- shear bond strength of conventional and resin-modified glass- ticular, in the resin-reinforced glass ionomer cements, ionomer cements to composite resin. Lasers. Med Sci. 2012 rn detachment occurs at the enamel-adhesive interface Mar;27(2):305-311. and this pattern of detachment increases the risk of 11. Pashley DH, et al. State of the art etch-and-rinse adhesives. Dental materials. 2011;27(1):1-16. the enamel damage during debonding. 12. Ravindranath MJ, et al. Comparison of Morphological Vari- te In both types of composite resins (photopolymeriz- ation and Shear Bond Strength Between Conventional able or self-curing) the detachment occurs at the Acid Etchant at Different Etch Times and Self Etching Primer- bracketing adhesive interface. In this case the An in Vitro Study. Group. 2015;1(20):9-4035. amount of the remaining adhesive material on the In 13. Sargison AE, McCabe JF, Millett DT. A laboratory investi- tooth must be removed by resorting to subsequent gation to compare enamel preparation by sandblasting or acid steps which in addition increase the risk of iatrogenic etching prior to bracket bonding. British journal of or- injury as well as working hours. thodontics. 2014. 14. Guarita MK, et al. Effect of Different Surface Treatments for ni Ceramic Bracket Base on Bond Strength of Rebonded Brack- ets. Brazilian dental journal. 2015;26(1):61-65. 15. Gkantidis N, et al. Comparative assessment of clinical per- References formance of esthetic bracket materials. The Angle Or- io 1. Soghra Yassaei, Abdolrahim Davari, Mahjobeh Goldani thodontist. 2012;82(4):691-697. Moghadam, Ahmad Kamaei. Comparison of Shear Bond 16. Bishara SE, Ostby AW, John Laffoonc, John J. Warrend. Strength of RMGI and Composite Resin for Orthodontic Brack- Enamel Cracks and Ceramic Bracket Failure during Debond- et Bonding. J Dent (Tehran). 2014 May;11(3):282-289. iz ing In Vitro. Angle Orthod. 2008 Nov;78(6):1078-1083. 2. Poggio C, Beltrami R, Scribante A, Colombo M, Lombardi- 17. Bishara SE, Fehr DE. Comparisons of the effectiveness of ni M. Effects of dentin surface treatments on Shear Bond pliers with narrow and wide blades in debonding ceramic Strenght of Glass-Ionomer Cements. Ann Stomatol. Roma. bracket Am J Orthod Dentofacial Orthop. 1993 Ed 2014 Jan-Mar;5(1):15-22. Mar;103(3):253-257. 3. Choudhary G, et al. Comparison of the Debonding Char- 18. Bishara SE, Ostby AW. Bonding and debonding from met- acteristics of Conventional and New Debonding Instrument al to ceramic: Research and its clinical application. Semin used for Ceramic, Composite and Metallic Brackets-An In- Orthod. 2010;16(1):24-36. vitro Study. Journal of clinical and diagnostic research. 2014 19. Ostby AW, Bishara SE, Laffoon JF, Warren JJ. In vitro com- Jul;8(7):ZC53-ZC55. parison of the debonding characteristics of 2 pliers used for 4. Algera TJ, et al. A comparison of finite element analysis with ceramic brackets. Semin Orthod. 2010;16(1):76-82. IC in vitro bond strength tests of the bracket-cement-enamel sys- 20. Sargison AE, McCabe JF, Millett DT. A laboratory investi- tem. The European Journal of Orthodontics. 2011;33(6):608- gation to compare enamel preparation by sandblasting or acid 612. etching prior to bracket bonding. British journal of or- 5. Selimović-Dragaš M, et al. A comparison of the in vitro cy- thodontics. 2014. C © 78 Annali di Stomatologia 2017;VIII (2):71-78 

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Original article Digital evaluation of occlusal forces: comparison between healthy subjects and TMD patients li na Giacomo Ferrato DDS remains to be fully clarified. Further research is Giovanni Falisi MD, DDS needed to investigate whether studying occlusal Gaetano Ierardo DDS, PhD force distributions in both healthy subjects and io Antonella Polimeni MD, DDS TMD patients. Carlo Di Paolo MD, DDS Key words: T-Scan III, occlusogram, occlusal forces, az Department of Oral and Maxillofacial Sciences, TMD, occlusal contacts. “Sapienza” University of Rome, Italy Introduction Years of scientific research investigating the patho- rn Giacomo Ferrato genetic factors of temporomandibular disorders Corresponding author: Department of Oral and Maxillofacial Sciences, (TMDs) have typically been focused on different as- “Sapienza” University of Rome pects, such as the occlusion, which is one of the most te Via Caserta 6 controversial and debated aspects (1, 2). 00195 Roma, Italy The current reference patterns for functionally evalu- E-mail: [email protected] ating the occlusion refer to simple and generic schemes proposed over 50 years ago. One present- In ed by Beyron has been recently quoted because it is regarded as the most reliable basis for a therapeutic occlusal scheme design in prosthetics, both for natu- Summary ral teeth and dental implants. This scheme provides ni the opportunity for the dental contact to be evenly Aim. Continuous technological innovation has distributed in a centric occlusion with a greater load in provided the clinicians to access to a computer- the posterior lateral areas, the absence of interfer- ized device that can analyse the different charac- io ence, and a stable occlusal relationship in a relaxed teristics of occlusal contacts. The purpose of this closure such that the occlusal model is convenient research was to use this device to study the oc- and does not disturb stomatognathic functions (3, 4). clusal forces comparing healthy subjects and Many researchers have studied occlusal contacts and iz TMD patients. their possible relationship with TMDs (5, 6). Materials and methods. The study was conducted by following specific criteria to select partici- Some Authors (7-9) have significantly associated an asymmetric occlusal contact distribution with TMDs. Ed pants; the sample was divided into two homoge- neous groups: control group (CG) comprising No study has been able to clarify whether changes in healthy subjects, and dysfunctional group (DG) the distribution of occlusal contacts occurred before comprising TMD patients. The occlusal force or after the onset of TMD or their role. analysis was performed using the computerized The continuous development of biomedical technolo- system T-Scan III V 5.20 T. The data were anal- gies has provided researchers with tools to quantita- tively and qualitatively analyse occlusal contact IC forces. With the advent of digitalization, Maness et al. ysed with statistical methods. (10) developed a high-precision, easy-to-use comput- Results. The most significant differences erized system called T-Scan (produced by Tek-Scan, emerged between the groups in the average oc- Boston USA). T-scan has been constantly improved clusal load distribution and in the location of the C in both its sensitivity and software (6); the latest evo- centre of occlusal forces (COF). In particular, lution, the T-Scan III, is now available in its ninth ver- compared with the CG and the functional stan- sion (T-Scan Novus). The system uses a sensor that dard, reductions in the molar field forces on the is interposed between the arches to transform the da- second and first molars of 27% and 6.9%, respec- © ta from the occlusal contact into a numeric value ex- tively, were observed in the DG. The COF was lo- pressed as a percentage (1, 11, 12). In this way, cated in the most forward position in TMD pa- each tooth can be assigned its own percentage of tients compared with healthy subjects. strength, reconstructing a model of the distribution Conclusions. Although the differences in the dis- and intensity of the occlusal contact loads (13-15). tribution of the occlusal forces and the location of The model of distribution of the occlusal forces pro- the occlusal centre of gravity were significant, the relationship between occlusal contacts and TMD Annali di Stomatologia 2017;VIII (2):79-88 79  G. Ferrato et al. posed by Maness, expected a greater load on the ical guidelines of the 1975 Helsinki Declaration were first upper molars which thus represented the “center followed, the research was approved by the Depart- of thrust” of occlusion (20). ment and Ethics Committee: Department of Oral and After Maness, one of the first Authors to use this digi- Maxillofacial Sciences, Sapienza University of Rome. talized occlusal contacts analysis method to recon- struct a distribution pattern of the occlusal forces was Garcia Cartagena et al., in 1997 (13). His study used Members of the DG: were selected between Septem- li Selection of the two groups the T-Scan II and showed that the maximum load was ber 2014 and February 2015 from among those who located on the second lower molars, decreasing to- spontaneously came for a first specialist visit at the na wards the incisors, and that the average occlusal load Gnathology Service Clinic Head and Neck Depart- was greater on the left side. More recently, two initial ment of the Policlinico Umberto I “Sapienza” Universi- studies of the pattern of occlusal forces in healthy ty of Rome. The number of patients admitted during subjects and TMD patients were conducted by the this period was 152; subjects were selected from this io Authors of this work in 2010 and 2011 (15, 16). The group according to specific inclusion and exclusion results showed that the maximum load fell in the area criteria listed in Table 1. In all, 35 patients (28 fe- of the first upper molars at the mesial-palatal cusp, males and 7 males) with an average age of 39.8 az and these data were partially confirmed by Ma et al. years were included. in 2013 (17). In 2012, Qadeer et al. stated that the Members of the CG: were selected from among stu- digital T-Scan III technology could effectively aid (18) dents of the Degree Course in Dentistry of the the analysis of occlusal contacts as an alternative to “Sapienza” University of Rome according to the same the use of conventional, non-digital indicators (19). inclusion / exclusion criteria (Tab. 1). The CG com- rn The aim of this study was to use the T-Scan III to prised 28 subjects (16 females and 12 males) with an analyse and compare the distribution patterns of oc- average age of 26.3 years. clusal forces in healthy and TMD patients. te Instrument and method used to analyse the oc- The digital occlusion analysis was performed using clusal forces in the two groups the T-Scan III v. 5.20 T. All examinations were per- Materials and methods In The study included two groups of subjects: the dys- formed by the same dentist, who specialised in the functional group (DG), comprising patients diagnosed use of the system. The resulting data were evaluated with TMD according to the Diagnostic Criteria for by a second person with the same characteristics TMD, and the control group (CG), comprising healthy who knew neither the patients nor the subjects of the ni subjects. A questionnaire regarding privacy laws al- CG. The computerized occlusion T-Scan III analysis lowing the use of sensitive data for research purpos- was performed in maximum intercuspation in accor- es and an informed consent form to participate in dance with the following protocol: io clinical research were given to each participant. The 1. Patient remains in the sitting position without sup- study also statistically examined the data obtained port head gear but with the support of the sensor from the two groups. In all stage of the study, the eth- parallel to the floor. iz Table 1. Inclusion and exclusion criteria adopted for the selection of the two groups. Ed IC C © 80 Annali di Stomatologia 2017;VIII (2):79-88  Digital evaluation of occlusal forces: comparison between healthy subjects and TMD patients 2. Filling in the patient’s medical records as required tre of occlusal forces (COF). According to the produc- by the software, including data concerning sex, er of the T-Scan, the COF represents the centre of age, upper central incisor size, lack of dental ele- gravity of the occlusion, i.e., the balance point of the ments, and the presence of prosthetic crowns. occlusal forces obtained by summing the moments of 3. Choosing a small or large sensor for a proper fit the forces pressing on individual occlusal contacts. in relation to arch size. This assessment is only graphical-positional, is pro- 4. Setting the size of the central incisor support, allow- cessed directly by the software within a predefined li ing the software to calculate the size of the arch to area, and was not considered sufficiently reliable by report the dental contacts of individual teeth. na the Authors; therefore, to obtain a more accurate as- 5. Informing the patient of the nature of the test and sessment of the COF, a different methodology was performing preliminary motions. developed. The graphical representation of the oc- 6. Carrying out the examination first without activat- clusal provided by the software was divided into sec- ing the recording but with the sensor inserted in tors by building a grid with eight straight lines, four io the mouth. each parallel to the MOL and to the interincisive line. 7. Checking whether the sensitivity setting is set cor- These straight lines are perpendicular to each other rectly; if on maximum strength, 4 or 5 columns ap- and are traced by considering some easily detectable az pear at maximum intensity. points on the chart provided by the programme. The 8. Asking the patient to bite the sensor firmly after straight lines parallel to the MOL are determined by recording activation and to keep teeth clenched in the union of the emerging central points from the the intercuspal position for a few seconds. meeting point of the midline of the occlusal forces 9. Visually assessing the video and processing the rn and the line segments bordering the occlusal sur- data. faces of premolars and canines. The straight lines Of the three tests performed, the occlusal recordings parallel to the interincisive line are traced in the fol- in both the CG and DG contained the most informa- lowing manner: first, the two straight lines passing te tion was considered. The analysis of the occlusal forces was performed by through the points of contact between the median line evaluating the data for each dental element and for of the occlusal forces and the line segments delimit- each side (left and right) and sector (back and front), ing the distal surfaces of the two upper central in- In following the same procedure for each examined sub- cisors are drawn; then, the other two straight lines ject. The right side was distinct from the left, as indi- passing them to the identified point are drawn, always cated by the interincisive line drawn on the occlusal on the median line, by calculating half the distance axis. The front area was distinct from the back, con- between the first two lines and the interincisive line. ni sidering the maximum occlusal load (MOL) line as the Compared with the interincisive line, the COF can be demarcation limit. This line is defined by the straight located on the right (D) or left (S). Each side was fur- line joining the two mesiopalatal cusps of the first up- ther divided into three encoded areas: the first area, as indicated by D1 or S1; the second area, as indicat- io per molars that represent the major occlusal loading area (Fig. 1). In the event that asymmetry prevented ed by D2 or S2 and corresponding to the second half to joining of these cusps with a single line, by con- of the incisor in question; and the third area, as indi- vention it was decided to refer to that passing through cated by D3 or S3 on the outer remaining portion af- iz the mesiopalatal cusp of the first superior molar on ter the first two (Fig. 2). the right. Another evaluation parameter examined was the cen- Ed IC C © Figure 2. Graphical representation of the subdivision of the Figure 1. Graphical representation of the MOL. occlusal plane for the graphical-positional evaluation of COF. Annali di Stomatologia 2017;VIII (2):79-88 81  G. Ferrato et al. Three possible variables were obtained with this method pressed as percentages. compared with the MOL: 1. Coincident (C); 2. Rear (P); In the CG, the greatest occlusal loading was detected 3. Front (A). In turn, variable A is divided into 4 sectors, in the area of the first upper molar with an average numerically coded and indicated by A1, A2, A3 and A4. percentage of 14.35% strength. On the second molar, The distance of the COF from the MOL and the inter- the percentage of detected force was 13.6%. On the incisive line was used as a parameter for assessing other elements, proceeding in the posterior-anterior its location in both the CG and the DG. direction (premolars, canines, incisors), progressively li The descriptive analysis of the occlusal forces was inferior values were registered until the incisal area. conducted considering the absolute values, averages There were some differences in the occlusal loads na and the respective standard deviations. detected in the DG compared with the CG. In particu- lar, in the area of the first and second molars, these differences were 13.35 and 9.85%, respectively, cor- The basic descriptive statistical evaluation was per- responding to percentage decreases of 6.97 and 27% Statistical analysis io formed in two stages: 1. Analysis of the occlusal load in the DG. The percentages of force detected on the percentage of any single tooth; 2. Analysis of the second and first premolars were 6.2 and 6.0%, re- arithmetic average of the occlusal load. This last spectively, with reductions of 10.8 and 1.64%. az point has been evaluated both for side (left and right) In the area of the front group, an average load of and for sector (anterior and posterior). All evaluations 4.3% was detected on the canines. On the lateral and were performed in the same process for the two central incisors, average loads of 1.9 and 4.05% were groups of patients also considering the standard devi- detected, with increases of 59.25, 192.30 and 143.24%, respectively, compared with the CG. rn ation. All data were sent for statistical processing to a spe- To obtain a full view of the occlusal force distribution cialist for determining the significance of the data ob- pattern, the Authors added the recorded average da- tained using a significance level of P<0.05 and the ta for single teeth to a Cartesian axis system, produc- te student t-test, which is a parametric test, to verify that ing a graph defined as an occlusogram for each significant differences between the two groups were group (Charts 1, 2). not due to chance but instead to an actual difference Standard deviation was assessed by analysing the deviations of single teeth in the two groups (Tab. 3). In between the averages of the two populations from which the samples were derived. Evaluated in the two groups showed significant differ- ences. These differences are expressed as percent- ages and reached a maximum of 193.54% on the up- ni Results As stated above, the analysis of the forces was con- ducted for individual dental elements, per side and io per sector. A separate analysis was performed for evaluating the COF. iz Analysis of the occlusal forces for single dental Force values expressed as a percentage for individu- elements Ed al teeth in members of the CG and DG were consid- ered for this assessment. The arithmetic averages and the respective standard deviations were deter- mined. Table 2 shows the average values detected for single dental elements in the two groups ex- Chart 1. Occlusogram in the CG. IC Table 2. Average measured force per tooth element in the two groups. C © 82 Annali di Stomatologia 2017;VIII (2):79-88  Digital evaluation of occlusal forces: comparison between healthy subjects and TMD patients per central incisors. This finding is represented in the Table referring to all the teeth analysed. In the following Charts (Charts 3), the average oc- clusal force in the two groups is represented by verti- cal column histograms that represent individual teeth show the respective standard deviations. The detected data were analysed using the student t- li test and are presented in Table 4. This Table shows na the average forces recorded for each dental element as percentages with the relative levels of P-values significance. The statistical analysis revealed significant results for elements 17, 13 and 11, which show greater variation io Chart 2. Occlusogram in the DG. between the two groups. az Table 3. Standard deviation values in the two groups. rn te In ni io iz Ed IC C © Chart 3. Comparison of standard deviations occlusal forces between CG and DG. Annali di Stomatologia 2017;VIII (2):79-88 83  G. Ferrato et al. Table 4. Average measured force for each dental element in the two groups with the relative levels of significance, with a threshold of P<0.05. li na io az The analysis of the side forces also highlighted that in The assessment of the occlusal forces on the right these groups, on average, the left side has a greater Analysis of the occlusal forces per side and left sides was performed considering the average load percentage than the right side. rn values and respective standard deviations detected in the two groups. Even these data were analysed using the student t- As mentioned above, the anterior region is bordered Analysis of the occlusal forces per sector test to verify whether the differences between the av- from the rear by the MOL. In fact, it is in correspon- erages of the two samples were significant; the ob- tained values are shown in Table 5. There were no significant differences between the te dence to this zone that the MOL is usually located and referred to more generically as the first upper molar. In Table 5 lists the average values per sector In two groups. However, an increase in the main differ- (front and back) in the two groups. The standard devi- ence in the DG was noted compared with the CG ations and the average differences observed between (from 0.5 to 5.7), as well as an increase in standard the two corresponding sectors are also given. deviation from 7.7 in the CG to 10.5% in the DG. These data were also analysed using the student t- ni Table 5. Average measured force per side and sector in the two groups with the respective standard deviations, mean dif- ferences and level significance. io iz Ed IC C © 84 Annali di Stomatologia 2017;VIII (2):79-88  Digital evaluation of occlusal forces: comparison between healthy subjects and TMD patients test to verify whether the differences between the av- erages of the two samples were statistically signifi- cant; the values obtained are reported in Table 5. The P-values obtained were not significant. However, the differences between the two groups seemed to in- dicate a recurring tendency, i.e., an increase in the percentage of strength in the anterior region in the li DG compared with the CG. na Analysis of COF position in the posterior-anterior As described above, the assessment of the COF lo- direction cation in the anteroposterior direction is considered a io function of its distance from the MOL. The Authors identified and marked with numerical code 3 specific areas for the evaluation of the COF position with re- Chart 4. Graphical representation of the COF position in az spect to the MOL: 1. coincident (C); 2. posterior (P); the CG. and 3. anterior (A). As area A was larger, it was fur- ther divided into 4 numerically encoded sectors: A1, the remaining portion of the first molar; A2, at the second premolar; and A3 and A4, corresponding to rn the first bicuspid and canine areas, respectively. Table 6 shows the rates (expressed as percentages) at which the centre of gravity was located in different te areas in the two groups. These data are also repre- sented graphically. The analysis of the COF position highlighted that in the CG, on average, the COF coincided with the MOL In (or remains in A1), while in the DG, the COF tended be positioned more towards the rear (P) or the front areas (A2, A3, A4) (Charts 4, 5). ni Analysis of COF position in the latero-lateral di- Chart 5. Graphical representation of the COF position in To evaluate the COF position in the latero-lateral di- rection the DG. io rection, its distance from the interincisive line was considered, thus identifying three areas (1-3) for both the right (D) and the left (S) parts. Table 7 shows the the S2 and S3 areas more often, showing a greater frequencies (expressed as percentages) with which range of localization (Charts 6, 7). iz the COF was localized in the different areas in the two groups. These data are also represented graphi- cally. Ed The analysis of the COF position showed that it was Discussion more frequently located on the left side in both The data recorded on the individual teeth of healthy groups. In the DG, the COF tended to be located in subjects indicate that there is a recurring pattern in Table 6. Localization of COF detected in the two groups. IC C © Annali di Stomatologia 2017;VIII (2):79-88 85  G. Ferrato et al. Table 7. Localization of COF detected in the two groups. li na io az rn te In ni Chart 6. Graphical representation of the COF position in Chart 7. Graphical representation of the COF position in the CG. the DG. io the distribution of the occlusal forces, which in the normal occlusion (29 males and 24 females) and iz limits of the examined sample, could be referred to as claimed to have found data supporting a model in “normal” or a reference (9, 16-19). This model has which the MOL was located in an area between the been defined as an occlusogram, which showed that first premolar to the second molar. Ed the area with the highest load, i.e., the MOL, was lo- In spite of an incomplete accordance of data in the cated at the mesiopalatal cusp of the first upper mo- literature, the Authors consider the presented model lars. Within this area, the occlusal loads tended to to be valid. This conclusion is supported by other fac- steadily decrease in the rear direction, towards the tors of the clinical examination conducted, such as second and third molars, but more so in the anterior repeatability, sensitivity and simplicity. If carried out direction, towards the incisors. properly, the digitalized occlusion examination is sim- IC The identification of the maximum load at the level of ple, repeatable, and largely operator independent. the first upper molars, apart from being in accordance Moreover, the occlusogram is very sensitive to any with the classical gnathology concepts now widely re- acute modification of the occlusion. The simplicity of ported in texts by Authors such as Maness and the scheme is in line with the most recent statements C Pedoloff (20), Okeson (21), Dawson and Arcan (22), regarding occlusal models proposed for prosthetics and Ciancaglini (9), is also in agreement with the that reflect the concepts expressed by Beyron (3, 4) work of others; in 1996 and 2002, the previously in the fifties and quoted in a work by Manfredini (24). mentioned Ciancaglini performed a study with oc- Additionally, regarding the COF evaluation, the re- © clusal waxes and obtained similar results (23). When sults revealed a recurring and statistically prevailing analysing occlusal forces with a T-Scan II in 1996, pattern. On average, it is located in a frontal area im- Garcia Cartagena et al. (13) had proposed a slightly mediately adjacent to the MOL, and the statistical different model by singling out the major load on the analysis of the frequencies of its location in healthy second inferior molar. However, in 2013, Ma et al. subjects showed a Gaussian behaviour, with a maxi- (17) used a T-Scan III on 53 healthy subjects with mum frequency in the A1 area, which decreases in 86 Annali di Stomatologia 2017;VIII (2):79-88  Digital evaluation of occlusal forces: comparison between healthy subjects and TMD patients the front and rear directions. The study of the fre- the COF. It ’should finally point out that the T-Scan III quency with which the COF is located in a given area system does not yet permit any pathogenic interpre- was made possible by the specific graphical-position- tation of the causes of such a behaviour as well as al evaluation grid conceived and developed by the any diagnostic evaluation of temporomandibular joint Authors. dysfunction. The use of the map designed by the Authors makes it Further investigation is still needed to confirm the difficult to compare other data from the literature ob- preliminary hypotheses proposed and to better under- li tained using different systems or processed by the stand future potential applications. na software supplied with the device. Regarding the comparison of data from the two groups, both the occlusogram and COF analyses The Authors have carried out the required revision. Report on the review showed statistically significant differences. The English translation was made at the American Specifically, the occlusogram in the DG showed a re- Journal Expert (AJE) that has released its editorial io duced occlusal load in the posterior region and an in- certification. creased load in the frontal area (Charts 1, 2). This re- sult, which seems far from those of other Authors, az could be a physiological pattern and is repeated even with wide individual variations in the DG. References In the DG, the COF was located with a maximum fre- 1. Ciancaglini R, Gherlone EF, Redaelli S, Radaelli G. The dis- quency in front of or behind the A1 zone, the more tribution of occlusal contacts in the intercuspal position and temporomandibular disorder. J Oral Rehabil. 2002;29:1082- rn balanced area, and this change has been translated 1090. graphically, showing a loss of the Gaussian charac- 2. Watanabe EK, Yatani H, Kuboki T, Matsuka Y, Terada S, teristic, which represents the distribution of normal Orsini MG, et al. The relationship between signs and symp- variations; the appearance of a bipolar curve is toms of temporomandibular disorders and bilateral oc- te shown in Charts 5. Additionally, compared with the clusal contact patterns during lateral excursions J Oral Re- CG, the standard deviation analysis of the DG habil. 1998;25:409-415. showed a substantial increase in all the evaluations 3. Beyron H. Occlusal relationship. Int Dent J. 1952;2:467. In performed, per single dental element, per side and 4. Beyron HL. Characteristics of functionally optimal occlusion per sector. A high standard deviation value is indica- and principles of occlusal rehabilitation. J Am Dent Assoc. 1954;48:648-656. tive of an abnormal and non-repetitive distribution of 5. Manfredini D, Stellini E, Marchese-Ragona R, Guarda-Nar- occlusal forces, a behaviour that appears in the DG dini L. Are occlusal features associated with different tem- and not in the CG. ni poromandibular disorder diagnoses in bruxers? Cranio. Studying these variables was enabled by carefully 2014;32:283-288. mapping the occlusal surface and paying scrupulous 6. Haralur SB. Digital evaluation of functional occlusion pa- attention during the tests. The results revealed sever- rameters and their association with temporomandibular dis- io al trends and significant differences in the distribution orders. J Clin Diagn Res. 2013;7:1772-1775. of occlusal forces and the centre of gravity between 7. Ciancaglini R, Gherlone EF, Radaelli G. Unilateral tem- poromandibular disorder and asymmetry of occlusal contacts. healthy subjects and TMD patients. iz J Prosthet Dent. 2003;89:180-185. 8. Liu ZJ, Yamagata K, Kasahara Y, Ito G. Electromyograph- ic examination of jaw muscles in relation to symptoms and Ed Conclusions occlusion of patients with temporomandibular joint disorders. J Oral Rehabil. 1999;26:33-47. The research has highlighted two limits the sample 9. Ciancaglini R. Posture, occlusion and general health. Pro- size and that the values considered are obtained by ceedings of the Research Forum. Milan: International Meet- the software. ing in Clinical Gnatology. 1997:224. Despite these limitations, the findings of the study are 10. Maness WL, Benjamin M, Podoloff R, Robick A, Golden RF. Computerized occlusal analysis: a new technology. suggestive to a new possibility of using this digital IC Quintessence Int. 1987;18:287-292. system both for clinical and research applications. In 11. Koos B, Godt A, Schille C, Göz G. Precision of an instru- particular, the recurring statistically significant data mentation-based method of analyzing occlusion and its re- achieved from healthy and dysfunctional subjects, sulting distribution of forces in the dental arch. J Orofac Or- could become a reference in the study of occlusal thop. 2010;71:403-410. C forces and in the evaluation of the functionality of the 12. Throckmorton GS, Rasmussen J, Caloss R. Calibration of stomatognathic system. The method used has proved T-Scan sensors for recording bite forces in denture patients. good repeatability and low operator dependence. It is J Oral Rehabil. 2009;36:636-643. necessary to remember that the examinations must 13. Garcia Cartagena A, Gonzalez Sequeros O, Garrido Garcia © VC. Analysis of two methods for occlusal contact registra- be conducted by carefully following the correct indica- tion with the T-Scan system. J Oral Rehabil. 1997;24:426- tion and the data must be interpreted in a way that is 432. coherent to what is being measured. The exam, in 14. Garrido García VC, García Cartagena A, González Sequeros fact, analyses, before, during and after a specific O. Evaluation of occlusal contacts in maximum intercuspa- therapy, the occlusal force distribution per dental ele- tion using the T-scan system. J Oral Rehabil. 1997;24:899- ment, side and sector and assesses the position of 903. Annali di Stomatologia 2017;VIII (2):79-88 87  G. Ferrato et al. 15. Ferrato G, Boccassini A, Panti F, Di Paolo C. Poster Den- Prosthodont. 2012;4:7-12. tal contacts and TMD: a comparison between clinical data 19. Afrashtehfar Kl, Qadeer S. Computerized occlusal analysys and T-scan data. Collegio Docenti di Odontoiatria; Chieti. 2010 as an alternative occlusal indicator. Cranio. 2016;34:52-57. Aprile:21-23. 20. Maness WL, Pedoloff R. Distribution of occlusal contacts in 16. Ferrato G, Boccassini A, Panti F, Di Paolo C. Poster Anal- maximum intercuspation. J Prosthet Dent. 1989;62:238-242. ysis of occlusal forces in TMD with T-Scan III. Collegio Do- 21. Okeson JP. Management of Temporomandibular Disorders centi di Odontoiatria; Siena. 2011 Aprile:14-16. and Occlusion. Bologna: Elsevier Edizioni Martina s.r.l. 2014. li 17. Ma FF, Hu XL, Li JH, Lin Y. Normal occlusion study: using 22. Dawson PE, Arcan M. Attaining harmonic occlusion through T-Scan III occlusal system. Zhonghua Kou Qiang Yi Xue Za visualized strain analysis. J Prosthet Dent. 1981;46:615-622. na Zhi. 2013;48:363-367. 23. Ciancaglini R. Gnatologia e dolori oro-facciali: libro di testo. 18. Qadeer S, Kerstein R, Kim RJ, Huh JB, Shin SW. Relationship Milano: Elsevier Masson. 2007. between articulation paper mark size and percentage of force 24. Manfredini D. Occlusione in implantoprotesi: elementi bio- measured with computerized occlusal analysis. J Adv fisiologici e gnatologici. Il dentista moderno. 2010 Dic:9. io az rn te In ni io iz Ed IC C © 88 Annali di Stomatologia 2017;VIII (2):79-88 

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Case report An atypical case of craniometaphyseal dysplasia. Case report and surgical treatment li na Giorgio Novelli MD Introduction The term “osteochondrodysplasia” includes a group Emanuela Ardito MD of uncommon genetic disorders of bone remodeling, Fabio Mazzoleni MD io which are characterized by an increased skeletal Alberto Bozzetti MD density. Some of these disorders are relatively ordi- Davide Sozzi MD nary; others, that are less common can also be lethal. az OU Maxillofacial Surgery (Head: Prof. Alberto Bozzet- Initially, this heterogeneous group of diseases was ti), Department of Medicine and Surgery - School of grouped under the generic term of “marble bone” or Medicine, University of Milano-Bicocca, San Gerardo Albers-Schonberg diseases. From the critical analysis Hospital, Monza, Italy of Gorlin, Spranger and Koszalka (1969), according rn to the Paris nomenclature, constitutional disorders of bone can be broken down into four subgroups: Osteoscleroses, Craniotubular dysplasias, Craniotu- Davide Sozzi Corresponding author: bular hyperostoses, Miscellaneous sclerosing and hy- te OU Maxillofacial Surgery perostotic disorders. Craniometaphyseal dysplasia to- Department of Medicine and Surgery, gether with Pyle’s disease is included in the cranio- University of Milano-Bicocca tubular dysplasia group (1). Viale Regina Margherita 5 In The definition Craniometaphyseal dysplasia (CMD) 20122 Milano, Italy was coined by Jackson et al. in 1954 to describe a E-mail: [email protected]; rare hereditary bone disease presenting metaphyseal [email protected] widening of the tubular bone, sclerosis of craniofacial bones and bony overgrowth of the facial and skull ni bones (2-4). The disease was better framed by Gorlin et al. in 1969, when it was recognized as a separate clinical io Summary entity of the autosomal dominant (AD) and autosomal recessive (AR) forms of CMD diseases (5). Introduction. Craniometaphyseal dysplasia is a Patients with the autosomal dominant form are usu- iz rare hereditary bone disease presenting metaphy- ally in good general health and they lead a normal seal widening of the tubular bones, sclerosis of lifestyle, their intellect is unimpaired, and have a craniofacial bones and bony overgrowth of the fa- normal size of the body without evidence of bone Ed cial and skull bones. Craniometaphyseal dyspla- fragility. Clinically, the patient may have mandibular sia occurs in an autosomal dominant (AD) and an prognathism and malocclusion caused by progres- autosomal recessive (AR) form. sive bone overgrowth. Distortion of the face in AR is Case report. We present a 32-year-old patient ar- very severe (2). The paranasal bossing, occurring rived at our unit in May 2009. His main discomfort during childhood, tends to regress with growth. The was a major limitation of the mouth opening, in abnormal growth of the facial bones can lead to IC the context of a craniofacial deformity. Relying on nerve compression of the seventh and eighth cranial patient’s medical history and the performed diag- nerve, with varying degrees of facial palsy and deaf- nostic tests, the diagnosis of craniometaphyseal ness. In AR CMD cranial nerve compression is se- dysplasia was made. vere and, in addition, visual loss may result from in- Conclusion. After careful evaluation of the clinical C volvement of the optic nerve (2, 6). In severe forms case, in accordance with the requirements of the of the disease, the narrowing of the foramen mag- patient, we opted for a surgical treatment aimed at num with compression of the medulla can cause a correction of functional limitation of temporo- quadriparesis or death (3, 7). mandibular joint and aesthetic improvement of the © AD CMD diagnosis is made after the execution of the facial bones. The stability of the clinical results led radiological examinations, in fact clinical signs with- us to suggest and to undertake the surgical path, out radiological investigation are not exhaustive. Ra- also due to the lack of safe and consolidated non- diographic features in AR CMD include non-sclerotic surgical treatments for the specific case. widening of the metaphysis with cortical thinning and sclerosis of the skull; in adulthood, sclerosis may be Key words: craniometaphyseal dysplasia, ANKH, CMD. Annali di Stomatologia 2017;VIII (2):89-94 89  G. Novelli et al. especially evident along the cranial sutures (8). The teoblast activity, the long-term results are a reduction paranasal bony bossing, featured during childhood, of bone remodeling without a change in bone density. may give an appearance of hypertelorism. The air si- The low oral intake of calcium promotes, instead, a nus obliteration and the mandibular prognathism are state of hypocalcemia that stimulates the osteoclasts common (2). activation. Calcitriol has the function to stimulate The widening of the methaphysis is more visible at bone absorption, activating the osteoclasts. Somato- the lower end of the femur, the metaphyseal flaring statin seems to have a role in slowing the hyperosto- li results in an Erlenmeyer flask appearance in child- sis progression (7, 8). na hood, and a club-shaped deformity in adulthood (3, Surgical treatment is intended to correct the deformity 7). The bones of the pelvis and spine are normal and of the skull and providing cranial nerve decompres- in the chest a slight modeling defect of the medial sion. However, the removal of sclerotic bone is rather portion of the clavicles and the costochondral junc- complicated and it often does not produce the desired tions may be found (2). results, showing relapse. Nerve decompression ad- io Although radiographic examinations are necessary to dressing the facial nerve and optic nerve is a complex make the diagnosis of CMD, the bone abnormalities surgery, which is not without complications and risks. shown are not pathognomonic of CMD; indeed Pyle’s However, surgical management obtained good re- az disease, craniodiaphyseal dysplasia and frontometa- sults in conductive hearing loss due to ossicular fixa- physeal dysplasia may have similar radiological find- tion, with an improvement of hearing (7, 8). ings. A genetic analysis is therefore necessary to pro- vide a definitive diagnosis (3, 9). rn ANKH is the only gene which is known to be associa- ted with CMD: sequence analysis of ANKA detects Case report mutations in about 90% of affected individuals. The patient LS, male, 32 years old, referred to our The autosomal dominant form is linked to chromoso- unit in 2009. His chief complaint was a major limita- te me 5p15.2-p14.1, within a region harboring the hu- tion of his mouth opening, in the context of a cranio- man homolog (ANKH) of the mouse progressive facial deformity. ankylosis gene (ank) (3, 10). ANKH encodes a 429- The anamnestic evaluation reported natural birth from In amino acid multipass transmembrane protein that is non consanguineous parents. The birth weight was involved in transport or cotransport of intracellular py- 3,450 kilos. By the age of 3, the patient reported an rophosphate (PPi) into extracellular matrix (8, 11, 12). initial appearance of gingival hypertrophy and frontal Experimental studies have shown that CMD muta- bossing. tions in ANK lead to decreased PPi levels in bone ex- From early childhood, mental and physical develop- ni tracellular matrix, which in turn cause increased den- ment was slowed compared to his peers, with a delay sity and progressive thickening of cranial bones (11, in speech and in locomotion. 13). At the age of 10, the patient presented dorso-lumbar io AR form of CMD has been mapped to a 7cM interval S Italic scoliosis with a moderate rotation of the lum- on chromosome 6q21-22 (11, 14). bar bodies, associated with a misalignment of the AR form is more severe, more difficult to diagnose, pelvis, where the right iliac wing was raised com- iz and rarer than the dominant form (3). The CMD is in pared to the contralateral. differential diagnosis with Methaphyseal dysplasia One meaningful piece of date in the remote patholog- (Pile’s disease), Craniodiaphyseal dysplasia, Paget’s ical anamnesis is the hospital admission, to a pedi- Ed disease, osteopetrosis (as previously mentioned). atric clinic of another centre, when he was 11 years Pile’s disease is an autosomal recessive disease pre- old, for a diagnostic work up for a possible genetic senting gross metaphyseal widening, and where syndrome, suggested by a skull X ray analysis. pelvic bone and thoracic cage are expanded (1, 7). Those radiographic examinations showed a severe The skull is spared, apart from a broadening of the thickening of the cranial bones and an alteration of supraorbital rims, which is normally associated to this the bony density of the maxillary bones. IC disease (7, 9). From the performed diagnostic tests (spine, hands, The patients are clinically normal, except for valgus elbows, chest, pelvis, skull and legs X-ray; rx opt; Ct deformities of the knees. Craniodiaphyseal dysplasia skull; blood tests; chromosome map and ophthalmol- is characterized by a more significant flaring of the di- ogy examination), the diagnosis was a dysplasia of C aphyseal region, without metaphyseal involvement, Mellnick-Needles. This diagnosis has been recently with severe sclerosis and hyperostosis of the skull. excluded. There is a medical therapy for CMD, based on the When he was 18 years old, the patient was subjected control of calcium homeostasis and the regulation of to the Wechsler Intelligence test for adults, showing © the activity of osteoclasts and osteoblasts, through slight mental retardation. Over the years, the bilateral the consumption of somatostatin, calcitriol, calcitonin, hearing loss due to poor transmission progressively or a low calcium intake (3, 6, 8). become worse with the persistence of a walking drag Calcitonin therapy reduces bone resorption by inhibit- with incorrect right limb. The skull deformities also in- ing osteoclast activity and secondarily by impeding creased over the years, especially the frontal, bone formation through feedback coupling to limit os- mandibular and mastoid hyperostosis. 90 Annali di Stomatologia 2017;VIII (2):89-94  An atypical case of craniometaphyseal dysplasia. Case report and surgical treatment At the time of hospitalization in May 2009, the exami- dance with the requirements of the patient, we opted nation showed bone bossing in the frontal, mastoid for a surgical treatment aimed at correction of func- and occipital regions, bone bossing of smaller thick- tional limitation of temporomandibular joint and aes- ness at the angles and mandibular symphysis. thetic improvement of the facial bones. The CT allowed us to highlight, in addition, the sub- The patient was subjected to 2 surgeries under gen- version of the normal anatomy of the temporo- eral anesthesia. In the first, performed in May 2009, mandibular joints in the lower jaw, which was causing the patient was subjected to partial right mastoidecto- li limitations in the mandibular movements. The inspec- my, right coronoidectomy and removal of multiple ex- na tion of the oral cavity highlighted a class II type mal- ostoses of the right mandibular body. occlusion, associated with gingival hypertrophy and In the second surgery, performed one month after the hyperostosis of the upper and lower alveolar bone. first, we proceeded to left coronoidectomy and to the The patient also presented skin folds in the nuchal re- removal of the massive cranial exostoses, which gion (Figs. 1, 2). The patient had, moreover, hearing were in the frontal area (a median one and a lateral io loss with severe bilateral transmission deficit and an one) and at the level of the right superior orbital X-ray of the knee showed a deterioration of the bony frame (Fig. 3). component with cortical thickness reduction and Histological examination showed fragments of lamel- az widespread reduction in calcium content. lar cortical bone which was mature compact, dense After careful evaluation of the clinical case, in accor- with medullary component containing blood forming rn te In ni io iz Ed IC C © Figure 1. (A, B) Clinical aspects; (C) Intraoral view showing gingival hypertrophy, hyperostosis of the upper and lower alveo- lar and bone; (D) Major limitation of the mouth opening. Annali di Stomatologia 2017;VIII (2):89-94 91  G. Novelli et al. li na io az rn te In ni io iz Ed Figure 2. (a-d) 3D CTscan showing bone bossing in the frontal, mastoid and occipital regions and bone bossing of smaller IC thickness at the angles and mandibular symphysis. tissues and adipocytes; those findings are compatible the disease in the resected areas. There is a good C with osteoma. During the first surgery a sampling of mandibular function and, thanks to the correction of skin from the nuchal region has also been performed facial aesthetics, the patient has improved his social with a diagnostic outcome of small chronic dermal fi- relations (Fig. 4). brosis with mild periadnexal inflammation and papillo- © matosis of the epidermis. To complete diagnosis, we decided to subject the pa- tient to a genetic study, which was negative for ex- Discussion and conclusions plorable syndromic genetic diseases. The dysplastic disease which affects facial bones, and At the moment, the patient is being followed up with particularly diseases presenting abnormal growth of monthly checks. After 2 years there is no relapse of bone or fibro-osseous tissue, often generates serious 92 Annali di Stomatologia 2017;VIII (2):89-94  An atypical case of craniometaphyseal dysplasia. Case report and surgical treatment li na io az rn te In ni Figure 3. (A, B) Frontal bone resection; (C) Mandibular symphysis resection; (D) Mastoid resection. io iz Ed IC Figure 4. (A, B) Post-operative clinical aspects; (C) Post-operative mandibular function. C functional problems originating from a mutated significant clinical need for function and aesthetics eurhythmy of the face which causes psychological and arising from the patient. social issues. Our choice for a surgical approach, even if a genetic A diagnosis of these forms is often very difficult and it confirmation was not provided, derived from a careful © is not rare to find cases with sporadic genetic muta- clinical and radiological evaluation of the pathology. tions which are not yet classifiable in existing syndro- Therefore, we chose, with a first surgery, to unlock the mes or can be defined as new kind of diseases or va- mandibular function and partially reshape facial bones riation of existing ones. to improve patient’s aesthetics. In the case we reported, apart from a dutiful clinic and In the second surgery, we performed a global nosological framework of the disease, we had a remodeling of the face, particularly of the voluminous Annali di Stomatologia 2017;VIII (2):89-94 93  G. Novelli et al. frontal and mandibular sinuses. 6. Kim YH, Roh DH, Choi BY, Oh SH Craniometaphyseal dys- The histological examination of excised bone and the plasia. Acta Otolaryngol. 2005;125(7):797-800. clinical controls, showing no relapse, confirmed the 7. Ahmad FU, Mahapatra AK, Mahajan H. Craniofacial surgery correct indication for the programmed surgery. for craniometaphyseal dysplasia. Neurol India. 2006;54(1):97- 99. The stability of the clinical results led us to suggest and 8. Sheppard WM, Shprintzen RJ, Tatum SA, Woods CI. Cran- implement the surgical path, also because of lack of iometaphyseal dysplasia: a case report and review of med- safe and consolidated non-surgical treatments for the li ical and surgical management Int. J Pediatric Otorhinolaryngol. specific case. 2003;67:687-693. Currently, we are performing other genetic analysis, na 9. McKay DR, Fialkov JA. Autosomal dominant craniometa- more specific, to identify a possible genetic mutation physeal dysplasia with atypical features. Br J Plast Surg. which might help us to frame this particular form into 2002;55(2):144-148. CMD or assess it as a new rare form of the disease. 10. Nürnberg P, Thiele H, Chandler D, et al. Heterozygous mu- tations in ANKH, the human ortholog of the mouse progressive io ankylosis gene, result in craniometaphyseal dysplasia. Nat Genet. 2001;28(1):37-41. References 11. Reichenberger E, Tiziani V, Watanabe S, et al. Autosomal dominant craniometaphyseal dysplasia is caused by muta- az 1. Beighton P, Horan F, Hamersma H. A review of the os- tions in the transmembrane protein ANK. Am J Hum Genet. teopetroses. Postgard Med J. 1977;53(622):507-516. 2001;68(6):1321-1326. 2. Beighton P. Craniometaphyseal dysplasia (CMD), autoso- 12. Ho AM, Johnson MD, Kingsley DM. Role of the mouse ank mal dominant form. J Med Genet. 1995;32(5):370-374. gene in control of tissue calcification and arthritis. Science. 3. Lamazza L, Messina A, D’Ambrosio F, Spink M, De Biase. 2000;289(5477):265-270. rn A Craniometaphyseal dysplasia: a case report. Oral Surg Oral 13. Gurley KA, Reimer RJ, Kingsley DM. Biochemical and ge- Med Oral Pathol Oral Radiol Endod. 2009;107(5):23-27. netic analysis of ANK in arthritis and bone disease. Am J Hum 4. Gorlin RJ, Spranger J, Koszalka MF. Genetic craniotubular Genet. 2006;79(6):1017-1029. bone dysplasias and hyperostosis. A critical analysis. Birth 14. Iughetti P, Alonso LG, Wilcox W, Alonso N, Passos-Bueno te Defects. 1969;5(4):79-95. MR. Mapping of the autosomal recessive (AR) cran- 5. Gorlin RJ, Koszalka MF, Spranger J. Pyle’s disease (famil- iometaphyseal dysplasia locus to chromosome region 6q21- ial metaphyseal dysplasia). A presentation of two cases and 22 and confirmation of genetic heterogeneity for mild AR argument for its separation from craniometaphyseal dysplasia. In spondylocostal dysplasia. Am J Med Genet. 2000;95(5): J Bone Joint Surg Am. 1970;52(2):347-354. 482-491. ni io iz Ed IC C © 94 Annali di Stomatologia 2017;VIII (2):89-94 

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Reviews article Classification review of dental adhesive systems: from the IV generation to the universal type i al Eshrak Sofan, PhD Introduction n The development and regular use of adhesive materi- Afrah Sofan, PhD als has begun to revolutionize many aspects of Gaspare Palaia, PhD io restorative and preventive dentistry. Attitudes to- Gianluca Tenore, MD, DDS wards cavity preparation are altering since, with ad- Umberto Romeo, MD, DDS hesive materials, it is no longer necessary to prepare Guido Migliau, MD, DDS az the cavity to provide mechanical retention through Department of Oral and Maxillofacial Sciences, such features as dovetails, grooves, undercuts, sharp University of Rome “Sapienza”, Rome, Italy internal angles in order to retain the filling (1). These techniques are, therefore, responsible for the conser- rn vation of large quantities of sound tooth substance, which would otherwise be victim to the dental bur. Mi- Guido Migliau Corresponding author: croleakage a major dental problem, which is probably Department of Oral and Maxillofacial Sciences, responsible for many cases of secondary caries, may te “Sapienza” University of Rome be reduced or eliminated. These adhesive are there- Via Caserta 6 fore critical for the success of aesthetic materials 00162 Rome, Italy restorative in modern dentistry. E-mail: [email protected] In Dental adhesives are solutions of resin monomers that make the resin dental substrate interaction achievable (2). Adhesive systems are composed of monomers with both hydrophilic groups and hy- Summary ni drophobic groups. The former enhance wettability to the dental hard tissues, while the latter allow the in- Adhesive dentistry has undergone great progress in teraction and co-polymerization with the restorative the last decades. In light of minimal-invasive io material (3). The chemical composition of adhesives dentistry, this new approach promotes a more con- also includes curing initiators, inhibitors or stabilizers, servative cavity design, which relies on the effec- solvents and, in some cases, inorganic fillers (3). tiveness of current enamel-dentine adhesives. Ad- iz However, it is necessary to consider the anatomy of hesive dentistry began in 1955 by Buonocore on the tooth. In particular, composition and structure of two benefits of acid etching. With changing tech- main tissues, enamel and dentine, need to be exam- nologies, dental adhesives have evolved from no- Ed ined in order to understand how they influence adhe- etch to total-etch (4th and 5th generation) to self-etch sive bonds. Details of the composition of these tis- (6th, 7th and 8th generation) systems. Currently, sues are shown in Table 1. The mineralized part of bonding to dental substrates is based on three dif- the tooth is a complex structure made of different ferent strategies: 1) etch-and-rinse, 2) self-etch and hard tissues, which have a quite distinct ultra-mor- 3) resin-modified glass-ionomer approach as pos- phology and composition. Enamel is composed of a sessing the unique properties of self-adherence to IC hard solid crystalline structure-hydroxyapatite (HAp) the tooth tissue. More recently, a new family of with strong intermolecular forces, high-energy sur- dentin adhesives has been introduced (universal or face, besides water and organic material. Dentin is a multi-mode adhesives), which may be used either biological composite of HAp that envelops collagen. as etch-and-rinse or as self-etch adhesives. C Dentin is intrinsically humid, and less hard than The purpose of this article is to review the litera- enamel, with low intermolecular forces and low-ener- ture on the current knowledge for each adhesive gy surfaces. The dentin is different from enamel, as it system according to their classification that have has smear layer, organic contents and presence of been advocated by many authorities in most op- @ fluid inside the dentinal tubules. In addition, the den- erative/restorative procedures. As noted by sever- sity of dentinal tubules varies with dentinal depth and, al valuable studies that have contributed to un- as well as the water content of dentin, is lowest in su- derstanding of bonding to various substrates perficial dentin and highest in deep dentin. In superfi- helps clinicians to choose the appropriate dentin cial dentin, which contains fewer tubules, the perme- bonding agents for optimal clinical outcomes. ation of resin into intertubular dentin will be responsi- ble for most of the bond strength. In deep dentin, Key words: dental bonding agents, smear layer, adhesive systems, self-etch, etch-and-rinse. Annali di Stomatologia 2017;VIII (1):1-17 1  E. Sofan et al. Table 1. Composition of tooth tissues. could provide a surface suitable for bonding with risen and also to improve the retention of acrylic resin to pit- and-fissures (8). The mechanism of acid-etch en- hanced adhesion was not published until 1968 (9), Components Enamel Dentine Inorganic phase (mainly 94-96 50-70 hydroxyapatite) (%) when Buonocore, Matsui and Gwinnett discussed the effect of phosphoric acid conditioning, which produced Calcium phosphate ratio 1.64 1.56 “prism-like” tags of resin materials that penetrated i al Organic phase (mainly 4-5 20-30 enamel surfaces. These resin tags were not seen in collagen ) (%) unconditioned enamel. The effect of phosphoric acid on enamel resulting in increased adhesion was now Water (%) 1-4 10-20 part of the dental literature, but it would be many years n later that this principle would be widely accepted. This was the pioneering research of Minimally Invasive io dentinal tubules are more in number: the intratubular Dentistry (10). Enamel conditioning with phosphoric permeability of resins will be responsible for higher acid results in the formation of microporosities where bond strength (4). Dentin is also a substrate that un- resin penetrates to form “prism-like” resin tags. This az dergoes change with age in an asymmetrical physio- yields an enamel bonding predominantly microme- logical aging process, leading to an increase of chanical (11). While the same concept applied to dentin thickness and decrease in dentin permeability dentin in 1958 remained problematic, due to the use of (5). Furthermore, sclerotic and carious dentin suffers strictly hydrophobic resins. As well, the high polymer- rn structural changes that result in a higher mineraliza- ization shrinkage of acrylic filling materials gave tion and a consequently reduced permeability (5). Un- Buonocore’s invention only little impact on Restorative like dentin, enamel can be dried easily: so bonding Dentistry at this time. The advent of composite materi- process to enamel is different from that of dentin. te als with reduced polymerization shrinkage gave the necessary input to finally enter the era of “Adhesive Dentistry”. By the mid 1960S, the first commercially available pit-and-fissure sealants and composite resin In materials utilizing this new adhesive technology were History and Evolution The history of dental adhesives started as early as used clinically. Buonocore theorized that risen tags fill- 1949, when Dr. Hagger, a Swiss chemist who worked ing the defects created by the etchant were responsi- for DeTrey/Amalgamated Dental Company, applied the ble for enamel adhesion, and by the late 1960s, he al- ni patent for the first dental adhesive: only dentin was ini- so proposed that bonding to dentin was possible (11). tial substrate for bonding not the enamel. Hagger Since then, dental adhesive has been developed that patented a “Cavity Seal” material to be used in combi- provide numerically higher bond strength and more io nation with the chemically curing resin “Sevriton”, in substantive bonded interfaces to both enamel and 1951. This product contained an adhesive called glyc- dentin. In the 1970s, for the first time, the concept of erolphosphoric acid dimethacrylate, which was poly- smear layer that blocked adhesion to dentin, as identi- iz merized using a sulfinic acid initiator, later known as fication by Eick, using the scanning electron micro- “Sevriton Cavity Seal”. This adhesive rely on acidic scope (SEM) (12), and simultaneously, total-etch con- monomers capable of etching and interacting on a cept were being used. By the 1980s, etch-and-rinse Ed molecular level with tooth surfaces in order to form adhesive had gained widespread acceptability. physical/chemical bonds between the restoration and Nakabayashi, in 1982 (13), was the first to demon- the tooth. Hagger’s concept was soon adopted by oth- strate true hybrid layer formation, and also who named er investigators and different generations of dental ad- this new biocomposite by name of hybrid layer. More- hesives evolved thereafter, despite the fact it was the over, he demonstrated that resin could infiltrate into first time that bonding to tooth structure became com- acid-etched dentin to form a new structure composed IC mercially available through the formation of an inter- of a resin-matrix reinforced by collagen fibrils. At the face very similar to what is called today the hybrid lay- same time, hybrid layer was considered as the main er (6). In 1952, it was postulated by Mclean and bonding mechanism of bonding agents. This was best Kramer, that this material, “Sevriton Cavity Seal”, observed by transmission electron microscopy, but C chemically bonded to tooth structure (7). This was the was later demonstrated by scanning electron mi- first report of changes in dentin promoted by an acidic croscopy following argon ion beam etching (14). In the monomer and may be considered to be the precursor early 1990s, the introduction of the three-step total- of the hybrid layer concept (7). That concept is obvious etch adhesive system represented a revolution in ad- @ in the development of newer generation of dentin ad- hesive dentistry. Once dentin is etched with phosphor- hesive. In 1954, Buonocore conducted successfully his ic acid and the etchant is rinsed off, hydrophilic primers first experiments on adhesion to enamel trough acid are used before applying a uniform layer of hydropho- etching and he focused on altering the enamel surface bic resin to complete hybridization. However, two-step to obtain a bond with filling material. Besides his total-etch adhesive systems and two-step self-etch ad- groundbreaking research, in 1955 he described using hesives were introduced into the market in the late 85% phosphoric acid to alter the enamel surface that 1990s (Fig. 1). Whereas original simple bonding agents 2 Annali di Stomatologia 2017;VIII (1):1-17  Classification review of dental adhesive systems: from the IV generation to the universal type Figure 1. The Evolution of Bonding Adhesives. i n al io az rn Figure 2. Adhesives by generations. te In ni io iz Ed IC evolved to multi-step systems, recent development fo- tubule to a depth of 1-10 mm is known as smear cuses on simplification of the application procedure in plugs. These smear plugs are contiguous with smear C order to abate technique sensitivity and reduce manip- layer consisting of shattered and crushed hydroxyap- ulation time (Fig. 2). atite, as well as fragmented and denatured collage that should not be underestimated. The thickness and morphology of the smear layer to the underlying den- @ tine is related to the cavity preparations, while its composition has the characteristics of the tissue that Smear layer Cavity preparation alters the uppermost layer of tooth was cut (these may also be contaminated by bacteria tissue, covering the tooth surface with a 1.0 µm layer and saliva). In clinical conditions, a smear layer be- of cutting debris, called smear layer (15) (Fig. 3). haves as a true physical barrier, reducing dentinal However, the orifices of the dentin tubules are ob- permeability by 86% (16). In order to overcome this structed by debris tags which may extend into the smear layer obstacle, a certain degree of etching is Annali di Stomatologia 2017;VIII (1):1-17 3  E. Sofan et al. Figure 3. SEM: micrograph of smear layer. i n al io az rn required before chemical bonding to the dentin sur- erties by considering the hydrophilic groups enhance face regarding to the bond strength and durability of the wettability to the dental hard tissues; however, te adhesion to dental hard tissues. Early non acidic ad- the hydrophobic groups interact and copolymerize hesives failed enough to establish a bond with the with the restorative material and are thus called am- underlying intact dentin. There are basically two op- phiphilic (18). In other words, adhesives are com- tions to overcome low bond strengths due to smear pounds containing both hydrophilic and hydrophobic In layer: the removal of the smear layer prior to bonding monomers. The major difference between hydrophilic following an etch-and rinse procedure, or the use of and hydrophobic adhesives is the chemistry of their bonding agents that can penetrate beyond the smear monomers and solvents. The monomers most used in layer while incorporating it following a self-etch ap- adhesive system are the hydroxylethyl methacrylate ni proach. In case of total-etch adhesive systems, the (HEMA) and the Bisphenol glycidyl methacrylate (bis- smear layer is essentially dissolved with phosphoric GMA). The first one, HEMA, is totally miscible in wa- acid (H3PO4) and subsequently washed away during ter and serves as an excellent polymerizable wetting io the rinsing step. With self-etching systems, various agent for dental adhesives. Bis-GMA, instead, is the acidic primers are used to modify, disrupt, and/or sol- main monomer used in most dental composites and ubilize the smear layer and, although the remnants many adhesives, is much more hydrophobic and will iz are not washed away as with total-etch systems, still only absorb about 3% water by weight into its struc- permit direct adhesive interaction with the dentin sub- ture when polymerized (19). A mixture of the two has strate. For both approaches, micromechanical inter- intermediate characteristics and serves as a useful Ed locking is the basic mechanism of adhesion to enam- adhesive for the tooth. In order to enhance the wet- el and dentin. ting, spreading and penetration of the polymerizable monomers into the dentin substrate, solvents are al- ways added to the mixture as “thinning” agents. These solvents are typically water, ethyl alcohol, butyl alcohol or acetone. The first three are very hy- Variables in adhesive dental bonding system IC Many resin adhesive systems and types have been drophilic and thus enhance the interaction of the developed to achieve a durable bond to dental tis- monomers with surface water, while acetone is good sues. Further complication are associated with the at displacing water from within the dentin. However, heterogeneity of tooth structure and composition, the any solvent not displaced during the placement pro- C hydrophilicity of the exposed dentine surface, the fea- cedure, such as by drying appropriately, will be incor- tures of the dental substrate after cavity preparation porated into the bonding layer and may serve as a and the characteristics of the adhesive itself, such as weakening contaminant. The monomers present in its physicochemical properties and its strategy of in- dental adhesives are similar to those used in dental @ teraction with enamel and dentine (3, 17). Despite the composite restoratives, thus ensuring that there will major difference in the manner of etching between be strong interaction between the adhesive and the etch-and-rinse and self-etch adhesives, the other fun- overlying composite. damental steps for adhesion, namely the ‘priming’ Although adhesion is established and predictable and actual ‘bonding’ phase, can be either separate or clinical procedure, acid etching of dentin has always combined. Dental bonding systems are resin blends concerned both clinical and researchers, as critical that possess both hydrophilic and hydrophobic prop- and definite factor for the quality of adhesion. More- 4 Annali di Stomatologia 2017;VIII (1):1-17  Classification review of dental adhesive systems: from the IV generation to the universal type over, inadvertent over-drying of etched dentin after one are more likely to survive polymerization contrac- acid rinsing substantially increases the risk of col- tion stresses and remain bonded to the tooth. This lapse of collagen mesh, which restricts the diffusivity may be a problem, because Class I preparations of resin monomers throughout the intertubular have a mean C-factor of 4.03 and Class II prepara- dentin. De Goes et al. (19) recommended to brush tions have a mean C-factor of 1.85 (21). The negative out the excess water with a cotton pellet, a dispos- effect of C-factor is supported by He et al. (22), who able brush, or a tissue paper. In the same fashion, reported that bulk filling a cavity with a C-factor of five i al over-wet conditions also results in lower bond produced the lowest bond strength: more microleak- strengths due to dilution of the adhesive. In addition, age has been reported as the C-factor increases. An excessive etching of dentin may produce weak in vivo study has also reported that the resin-dentin n bonding due to the possibility that the resin interdiffusion zone was detached from the overlying monomers may not be able to penetrate into the resin in restorations with a C-factor of five (23). Con- open dentinal tubules and diffuse across the hydrat- sequently, the higher the value of C-factor, the io ed demineralized collagen network as deep as the greater is the polymerization shrinkage. Therefore, etchant agent and allows fluid movement in the three-dimensional tooth preparations (Class I) have dentinal tubules. This movement of fluid pulls on the the highest (most unfavorable) C-factor and thus are az odontoblastic process and the patient experiences it at more risk to the effects of polymerization shrink- as pain or postoperative sensitive. Thus, this lack of age. C-factor plays a significant role when tooth penetration leaves behind non-impregnated or poor- preparation extends up to the root surface causing a ly infiltrated, unsupported areas at the base of hy- V-shaped gap formation between the composite and rn brid layer, which are more prone to micro-and nano- root surface due to polymerization shrinkage. leakage, collagen hydrolysis and degradation of the interface over time. The literature and manufacture te established the time for etching enamel and dentin that should be 15-30 s respectively, in order to ob- Actuality and Classification of Contemporary tain adequate bond performance. All of these molds Adhesives can affect bond strength, physical properties of the Dentin bonding agent can be defined as “a thin layer In cured resin composite and stress generated during of resin applied between the conditioned dentin and resin polymerization. Also, the large, flat surfaces resin matrix of composite”. Over the years, there used in most laboratory bonding studies may over- have been numerous classifications of dentin bonding estimate the actual clinical bond strengths achieved. agents that have been advocated by many authori- ni ties. Some of them are based on generation, the number of clinical steps and on the modern adhesive strategy. io Configuration or “C-factor” The cavity configuration, or C-factor, was introduced by Prof. Carol Davidson and his colleagues in 1980s. The concept of generation was used because of the Classification by generation iz The configuration factor (C-factor) is the ratio of complexity of bonding agents, the variety of classifica- bonded surface of the restoration to the unbonded tions refers to when and in what order this type of ad- surfaces (20). The C-factor can be used to predict hesive was developed by the dental industry. Adhesive Ed which restorations are most likely to exhibit bond fail- dentistry began in 1955 by Buonocore on the benefits ures between the resin and the tooth. According to of acid-etching. With changing technologies, dental ad- Feilzer et al., restorations with a C-factor less than hesives have evolved from no-etch to total-etch (4th and Table 2. Classification of dental bonding systems by generations. IC Generation Number of steps Surface pre-treatment Components Shear bond strength (MPa) 1st 2 Enamel etch 2 2 C 2nd 2 Enamel etch 2 5 3nd 3 Dentine conditioning 2-3 12-15 4th 3 Total etch 3 25 @ 5th 2 Total etch 2 25 6th 1 Self-etch adhesive 2 20 7th 1 Self-etch adhesive 1 25 8th 1 Self-etch adhesive 1 Over 30 Annali di Stomatologia 2017;VIII (1):1-17 5  E. Sofan et al. 5th generation) to self-etch (6th, 7th and 8th generation) existed that dentin ought not to be etched. After the systems (24) and the details of these are shown in primer was added, an unfilled resin was placed on Table 2. Each generation has attempted to reduce the both dentin and enamel. The weak link with this gen- number of bottles involved in the process, to minimize eration was the unfilled resins that simply did not the number of procedural steps, to provide faster appli- penetrate the smear layer effectively according to cation techniques and to offer improved chemistry to fa- Tao et al. in 1988 (30). cilitate stronger bonding (Tab. 2). i al In 1980s and 1990s, fourth generation dentin bonding Fourth Generation The first generation bonding systems were published agents were introduced. The fourth generation mate- First Generation by Buonocore in 1956, who demonstrated that use of rials was the first to achieved complete removal of n glycerophosphoric acid dimethacrylate (NPG-GMA) smear layer (27) and still considered as the golden containing resin would bond to acid etched dentin standard in dentin bonding. In this generation, the io (25). These bonding agents were designed for ionic three primary components (etchant, primer and bond- bonding to hydroxyapatite or for covalent bonding ing) are typically packaged in separate containers (hydrogen bonding) to collagen. However, immersion and applied sequentially. The concept of total-etch az in water would greatly reduce this bond. After nine technique and moist dentinal hallmarks of the 4th gen- years, Bowen used a coupling agent to overcome this eration systems (27, 31), where dentin and enamel problem (26). He addressed this issue using that act- are etched at the same time with phosphoric acid ed as NPG-GMA a primer or adhesion promoter be- (H3PO3) for a period of 15-20 s (32). However, the rn tween enamel/dentin and resin materials by chelating surface must be left moist “wet bonding”, in order to with surface calcium, where one end would bond to avoid collagen collapse. The application of a hy- dentin, and other would polymerize with composite drophilic primer solution can infiltrate the exposed te resin (26). Overall, this generation leads to very poor collagen network forming the hybrid layer (27, 33). clinical results as well as low bond strength in the 1-3 The hybrid layer is formed by the resin infiltrated sur- MPa range (27). face layer on dentin and enamel. The goal of ideal hybridization is to give high bond strengths and a In dentin seal (13). Bond strengths for these adhesives The second generation of dentin bonding agents were in the low- to mid-20 MPa range and significant- Second Generation were introduced in the late 1970s, and sought to im- ly reduced margin leakage compared to earlier sys- prove the coupling agents that were utilized in the tems (8). This system was very technique sensitive ni first generation of adhesives. The 2nd generation of and required an exacting technique of controlled dentin adhesives primarily used polymerizable phos- etching with acid on enamel and dentin, followed by phates added to bis-GMA resins to promote bonding two or more components on both enamel and dentin. io to the calcium in mineralized tooth structure (27, 28). These systems are very effective when used correct- Bonding mechanism involves formation of ionic bond ly, have good long-term clinical track record, and are between calcium and chlorophosphate groups. This the most versatile of all the adhesive categories, be- iz ionic bond would rapidly degrade in water submer- cause they can be used for virtually any bonding pro- sion (again analogous to saliva) and even the water tocol (direct, indirect, self-cure, dual-cure or light- within the dentin itself, and cause debonding and/or cure). These systems are still the standards by which Ed micoleakage (27). The smear layer was still not re- the newer systems are judged. However, these sys- moved, and this contributed to the relatively weak tems can be very confusing and time consuming with and unreliable bond strengths of this second genera- so many bottles and application steps. Because of tion (27). The smear layer is really a smooth layer of the complexity of multiple bottles and steps, dentists inorganic debris that remains on the prepared dentin began requesting a simplified adhesive system. surface as a result of tooth preparation with rotary in- IC struments (the drill). This generation of bonding agents is no longer used, due mainly to failed at- In the 1990s and in the ongoing decade, the fifth gen- Fifth Generation tempts to bond with a loosely bond smear layer. Bond eration bonding systems sought to simplified the strength: 4-6 Mpa (29). process of fourth generation adhesion by reducing C the clinical steps which results in reduced working time. These are distinguished by being “one step” or In the late 1970s and early 1980s, third generation “one bottle” system. In addition, an improved way Third Generation dentin bonding agents were presented. The third gen- was needed to prevent collagen collapse of deminer- @ eration bonding systems introduced a very important alized dentin and to minimize if not totally eliminate, change: the acid etching of the dentin in an effort to postoperative sensitivity (17, 27, 34). So the most modify or partially remove the smear layer (27). This common method of simplification is “one bottle sys- opened the dentin tubules and allowed a primer to be tem” combined the primer and adhesive into one so- placed after the acid was completely rinsed away. lution to be applied on enamel and dentin simultane- While this method achieved a greater bond, it was ously with 35 to 37% phosphoric acid for 15-20 s. considered controversial in dentistry as the feeling This single bottle, etch-and-rinse adhesive type 6 Annali di Stomatologia 2017;VIII (1):1-17  Classification review of dental adhesive systems: from the IV generation to the universal type shows the same mechanical interlocking with etched “over-etch” situation where the demineralization zone dentin occurs by means of resin tags, adhesive later- is too deep for subsequently placed primers to com- al branches and hybrid layer formation and shows pletely penetrate (33). While data indicates that 6th high bond strength values to dentin with marginal generation adhesives will adhere well to dentin (41 MPa seal in enamel (33). These kinds of adhesives sys- at 24 hours), the bond to enamel is at least 25% weak tems may be more susceptible to water degradation to enamel then both the 4th and 5th generation adhe- over time than the fourth generation. This is because sives in pooled data studies. Several respected clini- i al the polymerized primer of the “one bottle system” cians have utilized 6th generation adhesives for bonding tends to be hydrophilic in nature. However, when us- to dentin after selectively etching the enamel. ing the fourth generation, the hydrophilic primer is covered by a more hydrophobic resin, making it less n susceptible to water sorption. Not all 5th generation The seventh generation bonding systems was intro- Seventh Generation adhesives are compatible with dual and self-cured or duced in late 1999 and early 2005. The seventh gen- io core materials. The lower PH of the Oxygen-inhibited eration or one-bottle self-etching system represents layer, or the monomers in some simplified products, the latest simplification of adhesive systems. With are too acidic and thereby de-activate the tertiary these systems, all the ingredients required for bond- az amine in chemical-cured composites. As well as the ing are placed in and delivered from a single bottle same in regards to the number of applications (un- (33, 37). This greatly simplifies the bonding protocol filled need more applications), so it is critical to follow as the claim was that could be achieved consistent the manufacturer’s directions. bond strengths while completely eliminating the er- rn Several long term studies indicate that 5th generation rors that could normally be introduced by the dentist dental adhesive achieve high clinical bond strengths. In or dental assistant who had to mix the separate com- addition, the resin-dentin bond is prone to water degra- ponents with other more complicated systems. How- te dation, 5th generation adhesives are more prone to wa- ever, incorporating and placing all of the chemistry ter degradation than 4th generation dental adhesive. required for a viable adhesive system into a single Representative dentin bond strength is 3 to 25 MPa. bottle, and having it remain stable over a reasonable period of time, poses a significant challenge (33). In These inherently acidic systems tend to have a signif- The sixth generation bonding systems introduced in icant amount of water in their formulations and may Sixth Generation the latter part of the 1990s and the early 2000s also be prone to hydrolysis and chemical breakdown (37, known as the “self-etching primers”, were a dramatic 38). Furthermore, once placed and polymerized, they ni leap forward in technology. The sixth generation are generally more hydrophilic than two-step self- bonding systems sought to eliminate the etching step, etching systems; this condition makes them more or to include it chemically in one of the other steps: prone to water sorption, limits the depth of resin infil- io (self-etching primer + adhesive) acidic primer applied tration into the tooth and creates some voids (39). to tooth first, followed by adhesive or (self-etching ad- The advantage of this generation was not any mixing hesive) two bottles or unit dose containing acidic required and the bond strengths were consistent. iz primer and adhesive; a drop of each liquid is mixed However, the seventh generation adhesives have and applied to the tooth. It is recommended that the proven to have the lowest initial and long term bond components are mixed together immediately before strengths of any adhesive on the market today that Ed use. The mixture of hydrophilic and hydrophobic resin may be considers as disadvantage. Seventh genera- components is then applied to the tooth substrate tion adhesives involve the application of etch, primer, (35). Evidently, these bonding systems are character- and adhesive which have already been mixed, fol- ized by the possibility of achieving a proper bond to lowed by light curing the tooth. Seventh generation enamel and dentin using only one solution (27). The adhesives are “all-in-one” (40) if there has ever been biggest advantage of the sixth generation is that their such a thing. The clinical and scientific data on these IC efficacy appears to be less dependent on the hydra- adhesives proves that they are hydrophilic and de- tion state of the dentin than the total-etch systems grade more rapidly. In addition, the chemistry mast (33). Unfortunately, the first evaluations of these new be acidic, as etch is involved in this liquid, and this systems showed a sufficient bond to conditioned has been shown to adversely react with the compos- C dentin while the bond with enamel was less effective. ite initiator systems. This may be due to the fact that the sixth generation systems are composed of an acidic solution that can- not be kept in place, must be refreshed continuously In 2010, voco America introduced voco futurabond Eighth Generation @ and have a pH that is not enough to properly etch DC as 8th generation bonding agent, which contains enamel (36). In order to overcome this problem, it is nanosized fillers (41). In the new agents, the addition recommended to etch enamel first with the traditional of nano-fillers with an average particle size of 12 nm phosphoric acid prior to using it. However, those uti- increases the penetration of resin monomers and the lizing this technique should take care to confine the hybrid layer thickness, which in turn improves the me- phosphoric acid solely to the enamel. Additional etch- chanical properties of the bonding systems (42, 43). ing of the dentin with phosphoric acid could create an Nano-bonding agents are solutions of nano-fillers, Annali di Stomatologia 2017;VIII (1):1-17 7  E. Sofan et al. which produce better enamel and dentin bond etch bonding agents is typically an acidic strength, stress absorption, and longer shelf life (24). monomer that also serves as the primer. It has been observed that filled bonding agents pro- 2. Primer: the primer is composed of hydrophilic duced higher in vitro bond strength. These new agent monomers usually carried in a water-soluble sol- from self-etch generations have an acidic hydrophilic vent (acetone, ethanol, water) to promote good monomers and can be easily used on the etched flow and penetration into hydrophilic dentin, which enamel after contamination with saliva or moisture can influence the resulting bond strength. Self- i al (44). Based on the manufacturer, nano-particles act- etch bonding agents utilize primers that are acidic ing as crosslinks, will reduced the dimensional monomers. changes (42, 43). The type of nano-fillers and the 3. Dentin bonding agent (or Dentin Adhesive): can method that these particles are incorporated affect be defined as a thin layer of (usually unfilled) n the adhesive viscosity and penetration ability of the resin applied between the conditioned dentin and resin monomers into collagen fibers spaces (43). resin matrix of a composite. The adhesive pro- io Nano-fillers, with dimensions larger than 15-20 nm or motes bonding between enamel or dentin and a content of more than 1.0 percent by weight, both resin composite restorative material or resin ce- can increase the viscosity of the adhesives, and may ment. Adhesives act as a link between the hy- az cause accumulation of the fillers over the top of the drophilic resin primer and the hydrophobic resin moistured surface. These clusters can act as flaws composite. Proper curing is required to provide which may induce cracks and cause a decrease in good retention and sealing. Seventh generation the bond strength (43). bonding agents utilize primer-adhesives that are rn acidic monomers. 4. Fillers: recently nanofillers have been added ranging from 0.5% to 40% by weight in the 8th Classification by mechanism of adhesion/clinical te At this stage it was proposed a classification of bond- generation adhesive systems. Fillers control han- step ing systems, which reflects their essential mode of dling and may improve strength. Fillers may in- use, rather than historical development: crease film thickness of the adhesive layer. 1. Three-steps: involving etch, prime and bond. 5. Solvent: solvents include acetone, ethanol and In These bonding systems are supplied as three bot- water. The solvent affects the evaporation rate on tles, one each from etchant, primer and bonding the tray and in the mouth. Acetone evaporates agent. These are the most complicated to use in quickly and requires the shortest drying time in the clinic, but result in highest bond strengths (17) the mouth. Ethanol evaporates more slowly and ni and greatest durability. requires moderate drying time. Water evaporates 2. Two-steps 1: here the steps are etch, then finally very slowly and requires longest drying time. prime and bond in a single coating. Bonding sys- Bonding agents should be dispensed immediately io tems of this type employ substances in two bot- before use to prevent premature evaporation of tles, one consisting of etchant, and the other of the solvent. the combined prime and bond formulation. In current times, development of new products is oc- iz 3. Two-steps 2: for these systems, the two steps are curring at an unprecedented rate. Dentin adhesives etching and priming combined followed by bonding. are currently available as three-step, two-step and It uses two bottles of components, the first contain- single-step systems, depending on how the three car- Ed ing a self-etching primer and the second the bond- dinal steps of etching, priming and bonding to tooth ing agent. The self-etching primer modifies the substrate are accomplished or simplified (46). More- smear layer on the surface of the dentine, and in- over, they also considered the number of clinical corporates the products in the coating layer. steps required to apply the adhesives: 1. one-step 4. One-step: this uses a single bottle containing a adhesives that modify the smear layer; 2. two-step formulation that blends a self-etching primer and adhesives that: a) modify the smear layer; b) dissolve IC bonding agent. Clinically, this is the easiest to the smear layer; c) eliminate the smear layer; 3. use, and bond strengths are generally reported to three-step adhesives that eliminate the smear layer. be acceptable, despite the simplicity of bonding However, the classification based on the adhesive operation (45). strategy was proposed; three adhesion mechanisms C In order to understand the hybrid layer formation us- are currently used by modern adhesive systems: ing total etch technique and the self etch technique, it 1. etch-and-rinse adhesives; 2. self-etching adhe- is necessary to understand the components of bond- sives; 3. glass ionomer adhesives and resin-modified ing systems that consist of three main components: glass ionomers (19), which differ significantly in the @ 1) etchant, 2) primer and 3) bonding resin: manner they deal with tooth tissue (17). Considering 1. Etchant: in total-etch technique the etchant used the differences in professional judgment and manu- is 35-37% phosphoric acid. It prepares enamel facturers’ instructions regarding the selection of the and dentin to receive the primer. It creates micro- adhesive strategy and the number of steps that give porosities, up to 7.5 microns which helps to cre- the dentist the opportunity to decide which bonding ate the resin tag formation and thereby results in agents and techniques to utilize for different clinical micro mechanical bonding. The etchant in self- treatment (Fig. 4; Tabs. 3-7). 8 Annali di Stomatologia 2017;VIII (1):1-17  Classification review of dental adhesive systems: from the IV generation to the universal type i n al io az rn Figure 4. Modern adhesive strategies. te Table 3. List of bonding agents available of 4th generation. In Generation Brand name Manufacturer Polymerisation 4th generation All-Bond 2 Bisco Schaumburg, IL, USA Dual cured Three-steps All-Bond 3 Bisco Schaumburg, IL, USA Light cured, Dual Etch-Rinse Clearfil Liner Bond Kuraray (Kurashiki, Japan) Light or self cured ni Scotchbond Multi-Purpose (3M ESPE, St. Paul, Minn. USA) Light cured Adper Scotchbond Multi Purpose (3M ESPE, St. Paul, Minn. USA) Light cured, Dual Plus io Optibond Dual Cure (Kerr, Orange, CA, USA) Light cured Optibond FL (Kerr, Orange, CA, USA) Light cured Permagen Light cured iz Syntac Classic (Ultradent Prod Inc, Utah, USA) Light cured Denthesive (Ivoclar-Vivadent, Schann, Liechtenstein) Light cured Gluma Solid Bond (Heraeus Kulzer, Wehrheim Germany) Light cured Ed EBS (Heraeus Kulzer Hanau, Germany) Light cured Gluma CPS ESPE (now 3M ESPE; Seefeld, Germany) Light cured Bayer (Heraeus-Kulzer; Leverkusen, Permaquik Germany) Self cured Amalgabond Kerr (Ultradent) Light cured Cmf Parkell, Farmingdale, NY Light cured FL Bond Saremco, Rebstein, Switzerland) Light cured IC ProBond (Shofu Inc. Kyoto, Japan) Light cured, Dual Bond-it (Dentsply Caulk) Light cured, Dual Pentron Corporation, Wallingford, CT, Ecusit-Primer/Mono USA Light cured C Solobond Plus DMG, Hamburg, Germany Light cured Luxa bond total etch VOCO, Cuxhaven, Germany Light cured, Dual DMG America @ sive. Each of the three-steps can accomplish multiple tasks ending with sealing the bonded interface with a Etch and Rinse Etch-and-rinse adhesive systems are the oldest of relatively hydrophobic adhesive layer. Consequential- the multi-generation evolution of resin bonding sys- ly, an inter-diffusion layer is formed that called hybrid tems. The three-steps total-etch adhesive systems layer. Etch-and-rinse adhesives are characterized by were introduced in early 1990s (47), that involve acid- an initial etching step, followed by a compulsory rins- etching, priming and application of a separate adhe- ing procedure which is responsible for the complete Annali di Stomatologia 2017;VIII (1):1-17 9  ineare a cosa? il mio originale è diverso comunque ora forse è corretta E. Sofan et al. Table 4. List of bonding agents available of 5th generation. Generation Brand name Manufacturer Polymerisation th 5 Generation Admira Bond Voco, (Cuxhaven, Germany) Light cured Two-steps Solobond M Voco, (Cuxhaven, Germany) Light cured i Etch-Rinse Polibond Voco, (Cuxhaven, Germany) Dual cured al Excite Ivoclar Vivadent (Schaan, Lichtenstein) Light cured Excite DSC Ivoclar Vivadent (Schaan, Lichtenstein) Dual cured ExciTE F Ivoclar Vivadent (Schaan, Lichtenstein) Light cured Gluma 2000 Bayer, (now Heraeus-Kulzer; Leverkusen, Light cured n Germany) Gluma Comfort Bond Heraeus Kulzer, Hanau, Germany Light cured io Gluma One Bond Heraeus Kulzer, Hanau, Germany Light cured One-Coat Bond Coltène Whaledent (Altstätten, Light cured Switzerland) az Optibond Solo Plus Kerr (Orange, Calif. USA) Light cured Optibond SoloPlus Dual cure Kerr (Orange, Calif. USA) Dual cured Prime&Bond 2.0 Dentsply-Detrey (Konstanz, Germany) Light cured Prime&Bond 2.1 Dentsply-Detrey (Konstanz, Germany) Light cured rn Prime&Bond NT Dentsply-Detrey (Konstanz, Germany) Dual cured XP Bond Dentsply-Detrey (Konstanz, Germany) Self cured Stae Southern Dental Industries (Victoria, Light cured Australia) te Syntac Single-Component Ivoclar Vivadent (Schaan, Liechtenstein) Light cured One Step Bisco Inc., Schaumburg, IL, USA Light cured One-Step Plus Bisco Inc., Schaumburg, IL, USA Light cured Adper Single Bond Plus, (Adper 3M ESPE, St. Paul, MN,USA Light cured Single Bond 2) Scotchbond 1 (Single Bond) In 3M ESPE (Seefeld,Germany) Kuraray (Osaka, Japan) Light cured Clearfil Liner Bond 2 Kuraray (Osaka, Japan) Light cured Clearfil SE Kuraray Medical Inc, Tokyo, Japan Dual cured ni Clearfil Photobond Kuraray Medical Inc, Tokyo, Japan Self cured Clearfil New Bond Pentron Corporation, Wallingford, CT, USA Light cured Bond-1 Sun Medical Co, Shiga, Japan Dual cured io Superbond C&B Bisco Schaumburg, IL, USA Self cured All bond plus Bisco Schaumburg, IL, USA Light cured iz removal of smear layer and smear plugs. On enamel, (51). In the bonding step, a solvent-free adhesive acid-etching selectively dissolves the enamel rods, resin is applied on the prepared surface, leading to creating macro-and micro porosities which are readily the penetration of hydrophobic monomers not only in- Ed penetrated, even by ordinary hydrophobic bonding to the inter-fibrilar spaces of the collagen network but agents, by capillary attraction (48). Upon polymeriza- also into dentine tubules. After infiltration, these tion, this micromechanical interlocking of tiny resin monomers are polymerized in situ, resulting in the tags within the acid-etched enamel surface still pro- formation of a hybrid layer, which in combination with vides the best achievable bond to the dental sub- the presence of resin tags inside dentine tubules pro- strate (49). Dentin adhesion is more challenging than vides micromechanical retention to the composite IC enamel adhesion due to dentin composition, render- restoration (52). From the traditional three-step etch- ing the etch-and-rinse strategy a highly sensitive and-rinse adhesives, simplified two-step adhesives technique (50). Concurrently, acid-etching promotes have been developed that combine the primer and dentine demineralization over a depth of 3-5 lm, the adhesive resin into one single solution. These C thereby exposing a scaffold of collagen fibrils that is simplified adhesives present a reduced ability to infil- nearly totally depleted of hydroxyapatite (23). The fol- trate the demineralized dentine substrate, thereby lowing step consists of the application of a primer producing suboptimal hybridization when compared containing specific monomers with hydrophilic proper- to their three-step counterparts (53). Moreover, the @ ties, such as 2-Hydroxy ethyl meth-acrylate (HEMA), hydrophilic nature of such adhesives render them dissolved in organic solvents like acetone, ethanol or more prone to water sorption and consequently more water. While HEMA is responsible for improving the susceptible to the effects of hydrolytic degradation. wettability and promoting the re-expansion of the col- The solvent present in such adhesives is also more lagen network, the solvents are able to displace water difficult to evaporate, frequently remaining entrapped from the dentine surface, thus preparing the collagen within the adhesive layer after polymerization (54). network for the subsequent adhesive resin infiltration The etch-and-rinse technique is considered to be crit- 10 Annali di Stomatologia 2017;VIII (1):1-17  Classification review of dental adhesive systems: from the IV generation to the universal type Table 5. List of bonding agents available of 6th generation. Generation Brand name Manufacturer Polymerisation 6th Generation ART Bond Coltene (Alstatten, Switzerland) Light cured Two-steps PUB 3 Denstply (Konstanz, Germany) Light cured Self-Etch Clearfil SE Kuraray (Tokyo, Japan) Light cured i Clearfil Protect Bond Kuraray (Osaka, Japan) Light cured al Denthesive 2 Heraeus Kulzer (Wehrheim, Germany) Light cured Tyrian SPE Bisco (Schaumburg, IL, USA) Light cured Adhe SE Ivoclar Vivadent (Schaan, Dual cured n Liechtenstein) Adper Scotchbond SE 3M ESPE (St. Paul, MN, USA) Light cured io self-etch FL bond II Shofu Dental Light cured Clearfill Liner bond 2V Kuraray (Tokyo, Japan) Dual cured az Contax DMG America Dual cured Nanobond Pentron Clinical Dual cured Clearfil S3 Bond Kuraray (Osaka, Japan) Light cured G Bond GC Corp (Tokyo, Japan Light cured AQ Bond plus Sun Medicals Light cured rn Hybrid Bond Vivadent (Schann, Liechtenstein) Light cured All Bond SE Bisco (Inc., Schaumburg, IL, USA) Light cured iBond Gluma inside Heraeus Kulzer (Hanau, Germany) Light cured te Fluoro bond Shake One Shofu, (Tokyo, Japan) Light cured One up Bond F+ Tokuyama Corp, (Tokyo, Japan) Light cured PSA Dyract Dentsply, (Konstanz, Germany) Light cured Xeno III Dentsply, (Sankin) Light cured Prompt Adper Prompt L-Pop L-Pop In 3M ESPE (St. Paul, Minn. USA) 3M ESPE (St. Paul, Minn. USA) Light cured Light cured Brush and bond Parkell Light cured Table 6. List of bonding agents available of 7th and 8th generation. ni Generation Brand name Manufacturer Polymerisation io 7/8th Generation One Coat 7.0 Coltène/Whaledent (AG, Altstätten, Switzerland) Light cured One-step Xeno IV Dentsply Caulk (Milford, DE, USA) Light cured AdheSE One F (no mix) Ivoclar Vivadent, (Schaan, Principality of Light cured iz Self-Etch Liechtenstein) G-BOND GC America (Alsip, IL, USA) Light cured OptiBond All-In-One Kerr (Orange, CA, USA) Light cured Ed Clearfil S3 Bond Plus Kuraray (Tokyo, Japan) Light cured Adper Easy one 3M ESPE (St. Paul, Minn. USA) Light cured Bond force (no mix) Tokuyama Dental Light cured Clearfill DC bond Kuraray (Tokyo, Japan) Dual cured Xeno IV DC Dentsply Caulk (Milford, DE, USA) Dual cured Futura bond DC Voco (Germany) Dual cured IC Table 7. List of bonding agents available of Universal generation. C Generation Brand name Manufacturer Polymerisation Multi- All-Bond Universal Bisco (Inc., Schaumburg, IL, USA) Light cured, Dual mode or Prime&Bond Elect Dentsply Caulk (Milford, DE, USA) Light cured @ Universal Xeno Select Dentsply Caulk (Milford, DE, USA) Light cured AdheSE Universal Ivoclar Vivadent (Schaan, Principality of Light cured Liechtenstein) G-aenial Bond GC America (Alsip, IL, USA) Light cured Clearfil Universal Bond Kuraray (Tokyo, Japan) Light cured, Self cured Scotchbond Universal 3M ESPE (St. Paul, MN, USA) Light cured Adhesive Futurabond U Voco (Cuxhaven, Germany) Light cured Annali di Stomatologia 2017;VIII (1):1-17 11  E. Sofan et al. ical and highly sensitive, because the over-dried cause less dentinal fluid flow than etch-and-rinse ad- dentin causes both demineralized collagen fibers to hesives. The role of water is to provide the medium collapse and low monomer diffusion among the for ionization and action of these acidic resin fibers, hampering the formation of a functionally suit- monomers. Self-etch adhesive systems also contain able hybrid layer (HL), however the sensitivity is HEMA (2-hydroxyethyl-methacrylate) hydrophilic mostly related to the etching step itself and to the os- monomer, because of its low molecular weight HEMA tensibly antagonistic role of water in the bonding pro- acts as a co-solvent, minimizing phase separation i tocol. In ‘over-wet’ conditions, seems to cause phase and increasing the miscibility of hydrophobic and hy- al separation between the hydrophobic and hydrophilic drophilic components into the solution and to in- components of the adhesive, resulting in the forma- crease the wettability of dentin surface (65). Bi or tion of blister- and globule-like voids at the resin- multi-functional monomers are added to provide n dentine interface (55). In addition, the excessive strength to the cross-linking formed from monomeric presence of humidity may result in incomplete matrix (3). Because self-etch adhesive systems do io monomer polymerization and water adsorption in the not require a separate acid conditioning step as they HL. These effects can decrease the mechanical qual- contain acidic monomers that simultaneously ‘condi- ity of the HL formed, causing its early degradation tion’ and ‘prime’ the dental substrate (66), they are az (56). However the conditions of over-dry and over- considered as simplified adhesive materials. Possi- wet remains a major concern and difficult to standard- bly, self-etching systems alter the ‘‘smear layer’’ that ize; must be considered not only extrinsic, but also in- covers the dentin after tooth bur preparation, creating trinsic sources of humidity when an adhesive proce- a thin HL of 0.5-1.2 mm thickness (67). For this sys- rn dure is clinically performed. Therefore, the surface tem, the created tags are short (16 mm) and narrow. should be gently dried until the etched enamel pre- However, due to low acidity, the presence of a sents its white-frosted appearance and dentine loses ‘‘smear layer’’ or ‘‘smear plugs’’ obliterates the tubule its shine and turns dull (57). Although etch-and-rinse orifices is common after adhesive procedures, limiting te adhesives are still the gold standard for dental adhe- hybridization of the peritubular dentin and resin tag sion and the oldest of the marketed adhesives, it formation. In spite of forming a thin HL, this system seem to be incapable of preventing nanoleakage, exhibits a chemical bond to the dentin substrate. Fur- In (58) despite their satisfactory long-term clinical per- thermore, self-etch dentin adhesive claimed to mini- formance (50). Although occurring even in the ab- mize post-operative hypersensitivity, because resid- sence of interfacial gaps, nanoleakage seems to play ual smear plugs are left which expose less dentinal a negative role in bonding, especially in terms of tubules and causes less dentinal fluid flow than etch- durability (59). Thereby, the current trend is to devel- and-rinse bonds, but the disadvantage is an insuffi- ni op simplified self-etching materials (60). cient enamel etching ability resultant from their less acidity and less injurious to the dental substrate than etch-and-rinse adhesives (68). Thus, it is very impor- io tant to use these dentin adhesives properly in various clinical situations. On the basis of the steps of appli- Self-etch Self-etching systems were introduced to control the cation, they can be categorized as: a two-steps “self- iz sensitivity to humidity of the etch-and-rinse technique etch primers” (SEP) that is mostly solvent-free and a as well as to simplify the clinical procedures of adhe- one-step “self-etch adhesives” (SEA) depending on sive application, reducing clinical time (61). The self- whether a self-etching primer and adhesive resin are Ed etch adhesive systems are classified based on the separately provided or are combined into one single number of clinical application steps: two-steps or solution. Two-step self-etching adhesive systems one-step adhesives. The basic composition of self- (SEA) require the use of two separate components: etch primers and self-etch adhesive systems an the first bottle containing primer and acid and the aqueous solution of acidic functional monomers, with second bottle containing hydrophobic bond resin. The a pH relatively higher than that of phosphoric acid self-etching primer (SEP) used to condition the dental IC etchants. Therefore, self-etching adhesives have substrate, followed by the application of a hydropho- been classified according to their acidity: as strong bic bonding resin (69). The self-etching primer are (pH≤1), intermediate (pH=1.5), and mild (pH≥2) (62) aqueous acidic solutions containing various vinyl Mild self-etch adhesives demineralize dentin only su- monomers (acidic, hydrophilic and hydrophobic C perficially leaving hydroxyapatite crystals around the monomers) which can simultaneously etch and infil- collagen fibrils available for possible chemical inter- trate dental tissues, then photopolymerize with the action. Usually, the smear plug is not completely re- bonding resin, thus forming a bond between the den- moved from the dentine tubule. As a result, a shallow tal substrate and the restorative material applied after @ hybrid layer is formed with submicron measures (63), wards. Single-step self-etch adhesives that combine as do the ultra-mild self-etch adhesives (64); on the the functions of a self-etching primer and a bonding contrary, strong self-etch adhesives demineralize agent have been developed. One-step adhesives can dentin comparably to etch-and-rinse adhesives. The be further subdivided into ‘two-component’ and ‘sin- mild self-etch adhesives are assumed to cause less gle-component’ one-step self-etch adhesives. By sep- post-operative pain, as they use the smear layer as arating ‘active’ ingredients (like the functional bonding substrate, leaving residual smear plugs that monomer from water), two-component self-etch adhe- 12 Annali di Stomatologia 2017;VIII (1):1-17  Classification review of dental adhesive systems: from the IV generation to the universal type sives theoretically possess a longer shelf life, but ad- that have been used since 2011 in clinical practice. ditional and adequate mixing of both components is These new products are known as “multi-mode″ or needed. The single-component one step adhesives ″multi-purpose″ adhesives because they may be can be considered as the only true ‘one-bottle’ or ‘all- used as self-etch (SE) adhesives, etch-and-rinse in-one’ adhesives, as they combine ‘conditioning’, (ER) adhesives, or as SE adhesives on dentin and ‘priming’ and ‘application of the adhesive resin’, and ER adhesives on enamel (a technique commonly re- do not require mixing (69). This kind of adhesive sys- ferred to as “selective enamel etching”) (75, 76). This i al tem combines acidic functional monomers, hydrophilic versatile new adhesion philosophy advocates the use monomers, hydrophobic monomers, fillers, water and of the simplest option of each strategy, that is, one- various solvent (acetone, ethanol, buthanol) and resin step self-etch (SE) or two-step etch-and-rinse (ER) component, photo-inhibitors for bonding in a single (77), using the same single bottle of adhesive solu- n solution. They are so-called as 7th generation dentin tion which is definitely much more challenging to den- adhesive and undoubtedly the most convenient. The tal substrates of different natures (i.e., sound, cari- io use of water as a solvent is indispensable for single- ous, sclerotic dentin, as well as enamel) (78). Before- step self-etch adhesives to ensure the ionization of hand etching enamel with phosphoric acid is often the acidic functional monomers, and the organic sol- recommended, in particular when bonding to un- az vents are added to facilitate mixing of the hydrophilic ground enamel. Indeed, the priming and bonding and hydrophobic components (69). The presence of components can be separated or combined, resulting water and acidic functional monomers may compro- in three steps or two steps for etch-and-rinse sys- mise the bonding durability of single-step self-etch tems, and two steps or one step for self-etch adhe- rn adhesives. However, the main disadvantages of one- sives. Contemplating these two bonding strategies, step self-etch adhesives is related to their excessive adequate bonding to dentin can be completely hydrophilicity that makes the adhesive layer more achieved with either etch-and-rinse or self-etch adhe- te prone to attract water from the intrinsically moist sub- sives; however, at enamel, the etch-and-rinse ap- strate (39). Due to such increased water affinity, proach using phosphoric acid remains the preferred these adhesives have been reported to act as semi- choice (79, 80). In relation to the application mode, permeable membranes, even after polymerization, al- self-etch adhesive systems reduce the possibility of In lowing water movement from the substrate through- iatrogenic induced clinical mis-manipulation during out the adhesive layer (46). As a consequence, small acid conditioning, rinsing and drying, which may oc- droplets can be found at the transition between the cur when etch-and-rinse systems are used (81). On adhesive layer and the lining composite, especially the other hand, some drawbacks may be listed for ni when polymerization of the latter is delayed. Besides these SE materials. Unfortunately, one of the main promoting a decrease in bond strength between com- drawbacks from applying SE adhesives to dentin and posite and substrate (70), such permeability of the enamel is their inability to etch enamel to the same io adhesive layer seems to contribute to the hydrolysis depth that phosphoric acid does, which is likely re- of resin polymers and the consequent degradation of sponsible for the higher rates of marginal discol- tooth-resin bond over time (71). In addition, acetone oration in the enamel margins of cervical restoration iz has a so-called “water-chasing” effect (72), thus it due to their lower acidity. Thereby the degradation of can infiltrate rapidly into the exposed dentinal SE was attributed to its acidic content, which increas- tubules. However, its vapor pressure is much higher es the hydrophilicity of the adhesive layer and leads Ed than that of other solvents like ethanol or water, and to water uptake and plasticization (82). So the long- the adhesive may not infiltrate sufficiently in some sit- term performance of simplified one-step adhesives is uations. It was observed that the poor performance of inferior in terms of bond durability (60, 83), in particu- self-etch adhesives could depend upon shallow resin lar when compared to the gold-standard three-step tag penetration produced by the self-etching process, etch-and-rinse approach. To overcome the weakness an inefficient curing caused by their acidic nature, or of previous generations of single-step self-etch adhe- IC solvent retention and phase separation phenomena sives, universal adhesives have been developed that due to the coexistence of both hydrophilic and hy- allow for application of the adhesive with phosphoric drophobic moieties in the same product (73). Most acid pre-etching in the total etch or selective-etch ap- single-step dentin adhesives are very hydrophilic so proaches in order to achieve a durable bond to enam- C that they can interact with underlying dentin. Howev- el and has been accepted by showing good results in er, it may form water permeable adhesive layer, thus vitro (84) and in vivo studies (85-87). Despite the sim- compromising bonding performance (74). To over- ilarities between adhesives, the composition of uni- come this problem, All-Bond Universal contains mini- versal adhesive differs from the current SE systems @ mum amount of ethanol and water as their solvent. by the incorporation of monomers that are capable of producing chemical and micromechanical bond adhe- sion to the dental substrates (75, 76). Its composition is an important factor to be taken account, since most of these adhesive contain specific carboxylate and/or Universal adhesive systems One of the most recent novelties, in adhesive den- phosphate monomers that bond ionically to calcium tistry, was the introduction of universal adhesives, found in hydroxyapatite (Ca10[PO4]6[OH]2) (88, 89), Annali di Stomatologia 2017;VIII (1):1-17 13  E. Sofan et al. that could be influence the bonding effectiveness two bottles, or require the use of an additional activa- (77). For example, Methacryloyloxydecyl Dihydrogen tor, or have chemistries that must be mixed prior to phosphate (MDP) is a functional monomer found in use, or bond most optimally to porcelain and zirconia certain new adhesives, but not for older-generation with separately applied and dedicated primers, or are bonding agents. This is a hydrophilic monomer with not compatible with a total-etch protocol. Further, mild-etching properties. MDP is one of the monomers there is an advantage in having an adhesive that can that enable a universal adhesive to be used with any operate on these two procedures since it allows the i al etching techniques. Stable MDP-calcium salts are dentist to choose his procedure according to the clini- formed during this reaction and deposited in self-as- cal case in order to optimize the final result. For in- sembled nano-layers of varying degrees and quality stance, when the restoration requires strong bonding depending on the adhesive system (90, 91). It also to enamel or in case of sclerotic dentin, it may be ad- n helps promote strong adhesion to the tooth surface visable to apply prior etching. The etching step can via formation of non-soluble Ca2 salts. Furthermore, it be modulated according to the length of time the io contains biphenyl dimethacrylate (BPDM), dipen- phosphoric acid gel is applied prior to rinsing. On the taerythritol pentaacrylate phosphoric acid ester (PEN- other hand, it may be preferable to benefit completely TA) (92) and polyalkenoic acid copolymer may en- from the self-etch path way, when dealing with cases az hance adhesion to tooth structures and have been confronting difficult access, limited time or poor pa- part of the composition of different materials for tient compliance in very young patients. decades. This may be important in terms of durability, as water sorption and hydrolytic breakdown of the ad- rn hesive interface over time has been implicated as one of the primary causes of bond failure (93, 68). Conclusions Additionally, the matrix of universal is based on a Increasing demands for aesthetic restorative treat- te combination of monomers of hydrophilic (hydrox- ments have led to recent advances in dentistry, de- yethul methacrylate /HEMA) hydrophobic (decandiol veloping adhesive integrated materials (such as ad- dimethacrylite /D3MA) and intermediate (bis-GMA) hesive systems and composites) and techniques nature. This combination of properties allows univer- aimed at restoring the natural tooth appearance, es- In sal adhesives to create a bridge over the gap be- pecially in the anterior segment (97). The major re- tween the hydrophilic tooth substrate and hydropho- quirement of adhesive aesthetic materials is the abili- bic resin restorative, under a variety of surface condi- ty to achieve an excellent color matching with the nat- tions. Moreover, some universal adhesives may con- ural teeth and the maintenance of the optical proper- ni tain silane in their formulation, potentially eliminating ties over time. The goals for esthetic dental restora- the silanization step when bonding to glass ceramics tions are to obtain morphologic, optical and biologic or resin composites, for instance. Nevertheless, it is result miming natural enamel and dentine. This color io known that simplified materials are associated with matching is performed in order to obtain harmony lower in vitro bond strength results and poorer in vivo with the surrounding anatomical structures (98). longevity of restorations, (94, 95). These findings are Further the evolution of these materials and tech- iz probably a result of the complex formulation of simpli- niques has recently took steps forward and succeed fied adhesives and their high content of solvents, in preserving teeth instead of extracting them. Most which may impair complete solvent volatilization and of these improvements were evident in conservative Ed consequently lead to poorer adhesive polymerization dentistry and in particular, adhesive dentistry (99). (96). This multi-approach capability enables the clini- This review about adhesive dentistry describes all the cian to apply the adhesive with the so-called selective “generations” and types of adhesive product designs enamel etching technique that combines the advan- that have been introduced during the last 30 years. tages of the etch-and-rinse technique on enamel, with Since the introduction of the acid etched into clinical the simplified self-etch approach on dentine with ad- practice, various dentin bonding agents were devel- IC ditional chemical bonding on remnant carbonated ap- oped to improved the quality of adhesives and com- atite crystallites in those bonding substrates. There- posites restoration. The manufactures have been on- fore, the universal adhesives have much broader ap- going progress in the development of new dentin ad- plications than 7 th generation systems. Additionally, hesive aiming to simplify the process, attempted to C manufacturers typically state that universal adhesives improve clinical results correlates to their stability can be used for the placement of both direct and indi- over time and to their bond strength performance rect restorations and are compatible with self-cure, consequently lead to improve their effect on the dura- light-cure and dual-cure resin-based cements and bility of the resin bond. The new adhesive systems al- @ bonds to metals, zirconia, porcelain and composite. so can be attributed to their ability to decrease or While, the manufacturers of some universal adhe- eliminate postoperative sensitivity, improve marginal sives still recommend the use of separate “activator” seal, reduce microleakage and enhance the flow of and dedicated primers to optimize bond strength to resin into fissure. The development of functional substrates such as porcelain and zirconia. Thus, it monomers with strong and stabile chemical affinity to appears, at least in certain situations and with some hydroxyapatite is without doubt a valuable direction to products, that universal adhesives actually consist of continue for improvement of dental adhesion. Fur- 14 Annali di Stomatologia 2017;VIII (1):1-17  Classification review of dental adhesive systems: from the IV generation to the universal type thermore, long-term ageing also requires evaluation dimethacrylate-based dental resins. Biomaterials. 2003;24: of its effect in establishing a long-term success of 655-665. composite restoration. 20. Feilzer AJ, de Gee AJ, Davidson CL. Setting stress in com- posite resin in relation to configuration of the restoration. J Dentl Researc. 1987;66(11):1636-1639. 21. De la Macorra JC, Gomez-Fernandez S. Quantification of the configuration factor in Class I and II cavities and simulated i References cervical erosions European Journal of Prosthodontic Restora- al 1. 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Original article Radiographic technical quality of root canal treatment performed by a new rotary single-file system i n al Marco Colombo DMD, PhD dents was acceptable in 60,78% of the cases. Cristina Bassi DMD Riccardo Beltrami DMD, PhD Key words: apical periodontitis, nickel-titanium io Paolo Vigorelli DMD files, quality of root canal treatment, root filling. Antonio Spinelli DMD Andrea Cavada DMD az Alberto Dagna DMD Introduction The aim of root canal treatment is to prevent and Marco Chiesa DMD treat apical periodontitis (1), with the objective of Claudio Poggio MD, DDS eliminating microorganisms and necrotic pulp through rn Department of Clinical-Surgical, Diagnostic and Pedi- chemomechanical debridement, and providing an ad- atric Sciences, Section of Dentistry, University of equate root filling (2) in order to seal the canals and Pavia, Pavia, Italy prevent reinfection (3). Several Authors reported a lower incidence of peri- te apical periodontitis in teeth with adequate root fillings, so this variable should be taken into consideration Claudio Poggio when evaluating root canal treatment success (4). In Corresponding author: In Department of Clinica-Surgical, Diagnostic and the study performed by Azim et al. (1), they reported Pediatric Sciences that poor root filling density, short root filling length Section of Dentistry, Policlinico “San Matteo” (> 2mm short form the radiographic apex) are associ- Piazzale Golgi 3 ated with unfavorable outcome, and in teeth with 27100 Pavia, Italy overextended filling a delayed healing could be ex- ni E-mail: [email protected] pected. The quality of root canal treatment undertaken in dif- ferent populations by students (5) and general practi- io tioners (6, 7) has been extensively investigated, and it was observed that the technical quality of root fill- Summary ings was poor and unsatisfactory in most cases. iz Treatment success can be related to lots of reasons Aim. The aim of the present study was to evaluate such as patient age or immune conditions, but proba- radiographically the technical quality of root bly also to poor canal cleansing and shaping, use of canal filling performed by postgraduate students Ed inadequate aseptic techniques and lack of rubber with a new single-file Nickel-Titanium System (F6 dam, which could contribute to the persistence or in- Skytaper Komet) in clinical practice. troduction of microbes into the canal system (8). Methods. Records of 74 patients who had re- Shaping of the root canal was achieved by using ceived endodontic treatment by postgraduate stu- stainless steel hand files, but the introduction of nick- dents at the School of Dentistry, Faculty of Medi- el-titanium instruments in the last decades has led to cine, University of Pavia in the period between IC a significant improvement of quality of root canal September 2015 and April 2016 were collected shaping and less iatrogenic damage, even in severely and examined: the final sample consisted 114 curved canals (9, 10). Over the years, several gener- teeth and 204 root canals. The quality of en- ations of file systems have been introduced, instru- dodontic treatment was evaluated by examining C ment design has changed considerably intending to the length of the filling in relation to the radi- improve on previous generations. ographic apex, the density of the obturation ac- The fifth generation of shaping files is the last that cording to the presence of voids and the taper of has been introduced, with instruments characterized root canal filling. Chi-squared analysis was used @ by having the centre of mass and/or rotation offset, to determine statistically significant differences with a design, which should minimize the engage- between the technical quality of root fillings ac- ment between the file and the dentin (11). F6 SkyTa- cording to tooth’s type, position and curvature. per system (Komet, Brasseler GmbH & Co., Lemgo, Results. The results showed that 75,49%, 82,84% Germany) belongs to fifth generation, is a single-file and 90,69% of root filled canals had adequate endodontic systems, which are used in continuous ro- length, density and taper respectively. tation, with two sharp cutting edges in a double-S Conclusions. Overall, the technical quality of root canal fillings performed by postgraduates stu- 18 Annali di Stomatologia 2017;VIII (1):18-22  Radiographic technical quality of root canal treatment cross-section design, and it is made up of 5 different different sizes and three lengths with 6% taper; the instruments (12). rotational speed advised for these instruments, which The purpose of this study is to evaluate, analyzing is 300 rpm, and a torque of 2,2 Ncm for 020-030 files periapical radiographs, the technical quality of root and 2,8 Ncm for 035-040 files, are controlled by an canal treatment performed by postgraduate students endodontic motor (EndoPilot, Komet Brasseler GmbH at the School of Dentistry, Faculty of Medicine, Uni- & Co., Lemgo, Germany) (14). For each tooth, a new versity of Pavia. F6 was used and canal preparation was accom- i al plished with continuous irrigation with 5,25% sodium hypoclorite and 17% EDTA solution; afterwards teeth were filled with a carrier-based filling system (F360 Fill Obturators, Komet Brasseler GmbH & Co., Lem- n Materials and methods go, Germany) with a root filling material based on Records of 74 patients who had received endodontic epoxy resin (EasySeal, Komet Brasseler GmbH & io Patient selection treatment by postgraduate students at the School of Co., Lemgo, Germany). Dentistry, Faculty of Medicine, University of Pavia in the period between September 2015 and April 2016 az were collected and examined. The final sample con- Digital periapical radiographs were taken using a par- Radiographic examination sisted of periapical radiographs of 204 root canals, alleling device (XCP, Dentsply Rinn, Elgin, IL, USA) for a total of 114 teeth. All endodontic treatment was with an intraoral X-ray equipment set on 7mA, 70kVp, performed by postgraduate students, with the super- 50/60 Hz (BlueX IntraOs 70, BIOTEX S.A., Athens, rn vision of teaching assistants. First, every patient was Greece) and examined using the equipment own soft- required to give informed consent together with med- ware (Digora Soredex-Finndent Medical Systems, ical and dental history, then the teeth and soft tissues Helsinki, Finland), which provides the options for te were clinically examined for tenderness, swelling, measuring root lengths and also the distance be- crown fracture, and finally, if necessary, they have tween the end of the filling and the root apex. The ra- been treated and information about root canal fillings diographs were evaluated independently by two dif- was acquired. ferent operators and the results were compared, then In Preoperative and postoperative periapical radi- a final evaluation was agreed. ographs were taken for every tooth and, when neces- The quality of endodontic treatment was determined sary, also the intraoperative radiograph was taken. by the length of the root filling in relation to the radi- Radiographs with over-projection of anatomical struc- ographic apex, the density of the obturation according ni tures, poor quality and not visible apex were excluded to presence of voids and the taper of root canal fill- from the study to eliminate the possibility of radi- ings (consistent taper from coronal to apical aspect of ographic misinterpretation. the root), according to the criteria of Barrieshi-Nusair io et al. (15). The root canal obturation ending more than 2 mm from the radiographic apex was consid- All patients were treated with the following protocol: ered under filling while extending beyond the radi- Canal preparation iz local anesthesia was administrated (if needed) and ographic apex was considered over filling. Presence then an aseptic isolation with rubber dam technique of voids, no homogenous root canal fillings were con- was applied in all the cases. After the access prepa- sidered as poor filling, moreover not consistent taper Ed ration, to eliminate coronal interferences and for a from the coronal to the apical part of the filling was quick enlargement of the canal entrance, an Opener considered as poor taper (Tab. 1). OP10 (Komet Brasseler GmbH & Co., Lemgo, Ger- The relation of root canal length, density and taper many) was used, then working length was acquired adequacy to canal curvature, arch and tooth position using 0,10 K-file with an apex locator (Endopilot, (mandibular/maxillar) was assessed. The teeth were Komet Brasseler GmbH & Co., Lemgo, Germany). In classified according to their location in the arch. IC every root canal a glide path was created first using a Canal curvature was recorded as straight or curved. K-file and then with the PathGlider PG03 of 0.03 ta- A straight line parallel to the long axis of the canal per (Komet Brasseler GmbH & Co., Lemgo, Ger- was drawn using an endodontic ruler along the coro- many), whose rotational speed was set on 300 rpm nal straight portion of the root canal space. If this line C and torque of 0,5 Ncm. A mechanical preflaring helps passed through and intersected the apical foramen, to create a safe and easy glide path and maintain the the canal was considered straight. If the line deviated original canal anatomy even when used by inexpert and did not pass through the apical foramen, the clinician (13). canal was considered curved, according to Barrieshi- @ Then, a suitable F6 SkyTaper file was chosen ac- Nusair (15). cording to the size of the previously used manual file, and finally the root canal was instrumented with a crown down technique in continuous clockwise rota- The analysis of the data was performed using SPSS Statistical analysis tion with gentle in- and out-motion for quick and safe 14.0 for Windows (SPSS Inc., Chicago, IL, USA). root canal preparation. The F6 SkyTaper System is Sample means and their standard errors were used composed of highly flexible nickel-titanium files in five to describe every item listed on the evaluation form. Annali di Stomatologia 2017;VIII (1):18-22 19  M. Colombo et al. Table 1. Criteria for the standard of the examined root canal treatment. Variable Criteria Definition Lenght of root canal filling Acceptable Root filling end 0-2 of radiographic apex Overfilled Root filling ending beyond the apex i Underfilled Root filling ending > 2 mm short of radiographic apex al Density of root filling Acceptable Uniform density of root filling without voids Poor No uniform density of root filling with clear space is visible n Taper of root filling Acceptable Consistent taper from the coronal to the apical part Poor No consistence taper from coronal to apical part io az The chi-square test of independence was used to to the tooth type, more than half of the canals compare obturation quality of root filling in term of (56,86%) belonged to molars teeth, while canals of length, density and taper in relation to canal prepara- anteriors and premolars were respectively 42 tion technique. Because of the low relative frequen- (20,59%) and 46 (22,55%). Only 18,6% of the canals rn cies Fisher’s exact test was alternatively used. A P- treated were considered curved. value <0,05 was considered statistically significant. Tables 2 and 3 show relative and percentage fre- quencies for length, density and taper according to canal curvature and position (anterior, premolars, mo- te lars). No relation was established between tooth posi- tion (anterior/posterior) and the involved parameters Results A sample of 74 patients, 20 females and 54 males, (P >0,05). Similarly, the shape of the canals did not In aged 56,5 on average, was included in the study, for show any relation with the adequacy of length, densi- a total number of 114 teeth and 204 canals, with the ty and taper of the root fillings (P >0,05). predominance of maxillary teeth (56,86%). According Table 4 shows the length, density and tapering of the ni Table 2. Lenght, density and taper of canal filling in relation to canal curvature. io Root Total Lenght Density Taper canal acceptable overfilled underfilled acceptable poor acceptable poor iz Straight 166 125 19 22 138 28 152 14 (81,37%) (75,30%) (11,45%) (13,25%) (83,13%) (16,87%) (91,57%) (8,43%) Ed Curved 38 29 5 4 31 7 33 5 (18,63%) (76,32%) (13,16%) (10,53%) (81,58%) (18,42%) (86,84%) (13,16%) Total 204 154 24 26 169 35 185 19 (100%) (75,49%) (11,76%) (12,75%) (82,84%) (17,16%) (90,69%) (9,31%) IC Table 3. Lenght, density and taper of canal filling in relation to teeth position. C Root Total Lenght Density Taper canal acceptable overfilled underfilled acceptable poor acceptable poor Anterior 42 27 10 5 38 4 39 3 @ (20,59%) (64,29%) (23,81%) (11,90%) (90,48%) (9,52%) (92,86%) (7,14%) Premolar 46 35 4 7 38 8 44 2 (22,55%) (76,09%) (8,70%) (15,22%) (82,61%) (17,39%) (95,65%) (4,35%) Molar 116 92 10 14 93 23 102 14 (56,86%) (79,31%) (8,62%) (12,07%) (80,17%) (19,83%) (87,93%) (12,07%) Total 204 154 24 26 169 35 185 19 (100%) (75,49%) (11,76%) (2,75%) (82,84%) (17,16%) (90,69%) (9,31%) 20 Annali di Stomatologia 2017;VIII (1):18-22  Radiographic technical quality of root canal treatment Table 4. Lenght, density and taper of canal filling in relation to the teeth location. Lenght Density Taper Root canal Total acceptable overfilled underfilled acceptable poor acceptable poor 116 96 14 6 94 22 105 11 Maxillary i (56,86%) (82,76%) (12,07%) (5,17%) (81,03%) (18,97%) (90,52%) (9,48%) al 88 58 12 18 75 13 80 8 Mandibular (43,14%) (65,91%) (13,64%) (20,45%) (85,23%) (14,77%) (90,91%) (9,09%) n 204 154 24 26 169 35 185 19 Total (100%) (75,49%) (11,76%) (12,75%) (82,84%) (17,16%) (90,69%) (9,31%) io Figure 1. Length of the root canal filling in relation az to the arch. rn te In ni io iz root canal filling in the maxilla or mandible; tests of independence between the root canal location and adequacy of the canal filling length showed that tooth Ed location is related to length adequacy. There were significantly more mandibular canals (20,45%) with short fillings compared to maxillary canals (5,17%) (P <0,05) (Fig. 1). Considering the overall adequacy, adequate density IC was found in 82,84% of the cases, and adequate ta- per in 90,69% of the cases. A good quality root canal filling (defined as adequate length, density and taper) was found in 60,8% (124 C canals) of all evaluated teeth (Fig. 2). @ Discussion This study aimed to evaluate the quality of root canal treatment carried out by postgraduate students with a new rotary single-file system (F6 SkyTaper Komet) at the School of Dentistry, Faculty of Medicine, University of Pavia. Periapical radiographs were used for assess- ment. The quality of root canal obturation was evaluat- Figure 2. Overall quality of root canal treatment. Annali di Stomatologia 2017;VIII (1):18-22 21  M. Colombo et al. ed according to the criteria of Barrieshi-Nusai et al. 4. Vukadinov T, Blažić L, Kantardžić I, Lainović T. Technical (15). To increase the objectivity of the study, two differ- quality of root fillings performed by undergraduate students: ent examiners evaluated the periapical radiographs. a radiographic study. ScientificWorldJournal. 2014;28:751274. Quality of root canal treatment has been investigated 5. Khabbaz MG, Protogerou E, Douka E. Radiographic qual- ity of root fillings performed by undergraduate students. Int in many countries and often resulted to be inade- Endod J. 2010;43:499-508. quate. In this study the density resulted to be ade- 6. Peak JD, Hayes SJ, Bryant ST, Dummer PM. The outcome quate in 82,84% of the cases, more than the study of i of root canal treatment. A retrospective study within the armed Khabbaz (33,5%) (5) and Moradi (34,1%) (16) and al- al forces (Royal Air Force). Br Dent J. 2001;190:140-144. so the taper, acceptable in 90,69%, of the cases, is 7. Ertas ET, Ertas H, Sisman Y, Sagsen B, Er O. Radiographic better than other studies such as Rafeek (72,2%) (17) assessment of the technical quality and periapical health and Barrieshi (85,3%) (15), showing that the Ni-Ti of root-filled teeth performed by general practitioners in a n files and the new system perform well even when Turkish subpopulation. ScientificWorldJournal. 2013;2013: used by recently graduated students without great ex- 514841. io 8. Loftus JJ, Keating AP, McCartan BE. Periapical status and perience. quality of endodontic treatment in an adult Irish population. It was observed that the mandibular molars had a Int Endod J. 2005;38:81-86. higher percentage of short fillings, similar to the re- 9. Yared G. Canal preparation using only one Ni-Ti rotary in- az sults of the studies of Khabbaz (5), Vukadinov (4) and strument: preliminary observations. Int Endod J. 2008;41:339- Barrieshi (15). This may be explained partly by the 344. anatomy of such teeth, especially the presence of 10. Peters OA. Current challenges and concepts in the prepa- more than one canal in a root, and curvature of such ration of root canal systems: a review. J Endod. 2004;30:559- rn roots, which makes root canal treatment more chal- 567. lenging (15), or because of difficulty in isolation (18). 11. Ruddle CJ, Matchou P, West JD. The shaping movement: The results of the present study demonstrated ade- fifth generation technology. Dent Today. 2014;33:118-123. 12. Kaval ME, Capar ID, Ertas H, Sen BH. Comparative evalu- quate quality of root fillings in 60,78% of root canals, te ation of cyclic fatigue resistance of four different nickel-tita- more than the study of Barrieshi (47,4%) (15), Khab- nium rotary files with different cross-sectional designs and baz (33,5%) (5) and Elsayed (24%) (18) but lower alloy properties. Clin Oral Investig. 2016. Jul 26. [Epub ahead than the frequency reported by Benenati (91,05%) of print] (19) and Al-Yahya (20), even if it’s difficult to make In 13. Berutti E, Cantatore G, Castellucci A, Chiandussi G, Pera comparison between different studies. F, Migliaretti G, Pasqualini D. Use of nickel-titanium rotary Within the limitations of the presented study, it can be PathFile to create the Glide Path: comparison with manual concluded that 60,78% of root canal fillings per- preflaring in simulated root canals. J Endod. 2009;35:408- formed by postgraduate students resulted radi- 412. ni 14. Dagna A, Gastaldo G, Beltrami R, Chiesa M, Poggio C. F360 ographically adequate, which is quite satisfactory and and F6 Skytaper: SEM evaluation of cleaning efficiency. Ann the new endodontic system F6 SkyTaper Komet is re- Stomatol (Roma). 2016;12:3-4. ally effective. io 15. Barrieshi-Nusair KM, Al-Omari MA, Al-Hiyasat AS. Radio- graphic technical quality of root canal treatment performed by dental students at the Dental Teaching Center in Jordan. Dent J. 2004;32:301-307. iz Conflict of interest statement 16. Moradi S, Gharechahi M. Quality of root canal obturation per- The Authors of this study have no conflict of interest formed by senior undergraduate dental students. Iran Endod to disclose. J. 2014;9:66-70. Ed 17. Rafeek RN, Smith WA, Mankee MS, Coldero LG. Radio- graphic evaluation of the technical quality of root canal fill- ings performed by dental students. Aust Endod J. 2012;38:64- 69. References 1. Azim AA, Griggs JA, Huang GTJ. The Tennessee study: fac- 18. Elsayed RO, Abu-bakr NH, Ibrahim YE. Quality of root canal tors affecting treatment outcome and healing time following treatment performed by undergraduated dental students at the University of Khartoum, Sudan. Aust Endod J. 2011;37:56- IC nonsurgical root canal treatment. Int Endod J. 2016;49:6-16. 2. Chugal NM, Clive JM, Spangberg LSW. Endodontic infec- 60. tion: some biologic and treatment factors associated with out- 19. Benenati FW, Khajotia SS. A radiographic recall evaluation come. Oral Surg, Oral Med, Oral Pathol, Oral Radiol and En- of 849 endodontic cases treated in a dental school setting. dod. 2003;96:81-90. J Endod. 2002;28:391-395. C 3. Young GR, Parashos P, Messer HH. The principles of tech- 20. Al-Yahya A. Analysis of student’s performance in an under- niques for cleaning root canals. Aust Dent J. 2007;52:52-63. graduate endodontic’s program. Saudi Dent J. 1990;2:58-61. @ 22 Annali di Stomatologia 2017;VIII (1):18-22 

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Original article Effects of different kinds of beers on the surface roughness of glazed and polished methacrylate and Silorane-based composites: a 1-month study i n al Ugur Erdemir PhD, DDS1 ishing procedure used, the exposure time in the Murat Tiryaki PhD, DDS1 solutions and the type of composite resin. Gunce Saygi DS1 io Taner YücelPhD, DDS1 Key words: surface roughness, glaze, beer, me- Sevda Ozel Yildiz PhD2 thacrylate composite, silorane composite. Esra Yıldız PhD, DDS2 az Department of Restorative, Faculty of Introduction 1 Dentistry, Istanbul University, Istanbul, Turkey Nanotechnology has already opened up to dentistry 2 Department of Biostatistics, Faculty of Medicine, by manufacturing new composites based on rn Istanbul University, Istanbul, Turkey nanofillers which generate both aesthetics and me- chanics. These nanostructured composites have combined the mechanical properties of “hybrid com- posites” and the polishing ability of “microfilled com- te Ugur Erdemir posites” (1). Studies showed that lower surface Corresponding author: Department of Restorative Dentistry, roughness values and better results on longevity Faculty of Dentistry, Istanbul University were gained after the polishing of these resin com- 34093 Istanbul, Turkey In posites (2-5). E-mail: [email protected] In the past few years, Silorane-based resin compos- ites have been introduced with highly related oxirane groups and filler particles, which claim to have low shrinkage and less water sorption as a result of better ni polymerisation (1, 6). Because of the improvement of the types of composite materials, the longevity of Summary restorations is expected to be higher. Not only the io aesthetics, but also the physical properties of the Background: The aim of this in vitro study was to restorations should stay stable since the operation evaluate the effect of different kind of beers on day. Considering the dynamic environment of the oral the surface roughness of glazed and polished iz cavity, it is impossible for restorations not to be af- methacrylate- and Silorane-based resin compos- fected by forces. One of the most important factors ites after different immersion periods. for restorations to maintain their physical properties is Methods: Methacrylate-based resin composites Ed the polishing procedures. With a high quality of pol- (Tetric N-Ceram, Ceram-X) and a Silorane-based ishing, surfaces become more resistant to wear and resin composite (Filtek Silorane) were tested in staining, thus increasing the longevity of the restora- the study. A total of 126 specimens (n=42 for each tion (7). In addition, plaque accumulation, gingival irri- composite) were fabricated using a cylindrical tations and unaesthetic appearance of the restora- custom metal mould. Surface roughness mea- tions could be inhibited (7, 8). surement was performed using a profilometer at IC The polishing of composites could be done with a baseline and after a 1-week and 1-month immer- wide variety of instruments, including abrasive discs, sion in different kind of beers or distilled water. strips, silicone-impregnated burs, rubberised points The results were analysed using repeated mea- and polishing pastes. Although all of these polishing sure ANOVA and Tukey’s HSD test (α=0.05). C instruments produce a glossy surface on resin com- Results: Repeated measure ANOVA results re- posite restorations, it has been reported that the pol- vealed that immersion period was a significant ishing instruments can also leave irregularities on the factor in the surface roughness of the tested surface in different degrees (7, 9). To eliminate these specimens (p<0.001). The lowest surface rough- @ irregularities, filling the microporosities and micro- ness values were obtained with the specimens’ gaps, surface sealing could be used (10, 11). These polished Optidisc+BisCover LV. Regardless of the materials can easily penetrate through the microc- polishing systems used, Tetric N-Ceram showed racks and irregularities formed during the finishing the statistically lowest surface roughness values and polishing procedures because of low viscosity (p<0.05), whereas Filtek Silorane showed the and wettability characteristics (12, 13). It has been re- highest surface roughness (p<0.001). ported that the application of surface sealant material Conclusion: The surface roughness values of the tested resin composites were affected by the pol- Annali di Stomatologia 2017;VIII (1):23-28 23  U. Erdemir et al. into the restoration surface provides a more uniform (VIP; Bisco Inc., Schaumburg, IL, USA) with a light and smooth surface, thereby affecting the longevity of intensity of 600 mW/cm2, as measured using a curing the restoration by enhancing smoothness (14, 15). Be- radiometer (Hilux Ledmax Light Curing Meter, Benli- sides, some studies have determined the diminishing of oglu Dental Inc., Ankara, Turkey) following manufac- the surface roughness of composites in both in vitro turer instructions for 20 seconds. The light curing unit and clinical conditions (16-18). It may be beneficial to tip was positioned perpendicular to the specimens’ use the surface sealants after restoring composite surfaces, and the distance between the tip and the i al resins for patients who have excessive erosive habits. specimen was standardised using a glass microscope Moreover, behavioural factors could cause the sur- slide (1 mm in thickness). After the removal of the face irregularities of resin composites, such as con- specimens from the moulds, they were numbered, sumption of staining food and drinking acidic and al- identifying the bottom surface of each with a scalpel. n coholic drinks. As healthy living is becoming a popu- All the specimens were stored in distilled water at lar lifestyle worldwide, many fruit juices have been 37±1°C for 24 hours for the completion of the poly- io consumed regularly. Consumption of alcoholic drinks merisation. Then, the specimens were randomly as- has been thought to have declined with this new con- signed to three groups (n=42) (TN: Tetric N-Ceram, cept; however, the rate of beer drinking has in- CX: Ceram-X and FS: Filtek Silorane) and two sub- az creased during the last 3 years. According data, beer groups [polishing (Optidisc, KERR, California, USA) is the third most consumed drink all over the world, and polishing + surface sealant application (Glazed) after tea and water (19, 20). Beers, with their ethanol (Optidisc+BisCover LV, Bisco Inc., Schaumburg, content and low pH, have been found to change the USA)]. For the subgroups, seven specimens from rn resin matrix of composites and to cause wear and each resin composite were randomly assigned. All surface degradation (6, 21). Although, beer is the the materials were used according to manufacturer most consumed beverage in the world, its effect on instructions, and procedures were performed using te the surface texture of tooth-coloured restorative ma- the same operator in order to eliminate operator-de- terials is very limited. Therefore, this in vitro study pendent variables. Low-viscosity surface sealant ma- was mainly aimed at evaluating the effect of different terial was applied into the restoration surface after 15 kinds of beer on the surface roughness of glazed and seconds of orthophosphoric acid (Uni Etch-37; Bisco In polished methacrylate- and Silorane-based resin Inc., Schaumburg, IL, USA) application and five sec- composites after different immersion periods. In addi- onds of air drying. Thereafter, a uniform layer of sur- tion, the related changes on surface roughness de- face sealant material (Fortify, Bisco Inc., Schaum- pending on the type of beer, type of composite and burg, IL, USA) was applied over the etched and dried ni type of surface treatments would become apparent sample surface using a microbrush, which was gently by this experimental study. The hypothesis tested air-thinned for 15 seconds, and then the surface was was that there would be no statistically significant dif- polymerised for 10 seconds. Compositions and direc- io ference in surface roughness among different glazed tions for use of all the materials used in this study are and polished resin composites after they are im- shown in Table 1. mersed in different types of beer following different In the sequel, the specimens were exposed to immer- iz immersion periods. sion regimen. The specimens of each group were im- mersed into 30 ml of a regular (RB) or a dark (DB) type of beer (Leffe, NV/SA InBev Inc., Belgium) 2 Ed hours a day at cold temperature (~ 4°C). Distilled wa- ter was used as control (W). Between the immersion Materials and Methods A total of 126 disc-shaped specimens (8 mm in diam- periods, the specimens were kept in distilled water at eter and 2 mm in thickness) were prepared from two 37±1°C. The immersion regimen was followed for 1 nanohybrid resin composites (Tetric N-Ceram, Ivoclar month. Vivadent, Schaan, Liechtenstein; Ceram-X, Dentsply, Surface roughness measurements were performed IC Konstanz, Germany) and a Silorane-based resin using a profilometer (Taylor Hobson Surtronic 3, Tay- composite (Filtek Silorane, 3M ESPE, Seefeld, Ger- lor Hobson Ltd., Leicester, UK) at baseline at the end many) using a custom-made stainless steel mould of 1 week and 1 month. Before each measurement, (n=42 for each group). The resin material was insert- the profilometer was calibrated against a standard. C ed into the mould standing on a glass plate with a The surface roughness (Ra) values of each specimen transparent polyester strip in one increment. Subse- were measured on the centre part in five different di- quently, the top surface of the resin-filled mould was rections, and the mean Ra values were determined covered with another polyester strip, and a glass with a cut-off value of 0.8 mm, a transverse length of @ plate was placed onto it. Standard pressure (with a 1 4.0 mm and a stylus speed of 0.1 mm/s. kg weight) was applied on the glass plate for 15 sec- onds to let the excess resin out from the specimen surface to obtain a flat specimen surface without bub- ble formation. Following the removal of the weight Statistical Analysis and the glass plate, the resin material was poly- The relevant significance was approved at p=0.05. merised with a conventional halogen light curing unit Statistical analysis was performed using repeated 24 Annali di Stomatologia 2017;VIII (1):23-28  Effects of different kinds of beers on the surface roughness of glazed and polished methacrylate and Silorane-based composites: a 1-month study Table 1. Materials used in the study. Material Type Composition Manufacturer Batch Tetric Nanohybrid Bis-GMA, UDMA, TEGDMA, Bis-EMA, 57% of Ivoclar-Vivadent, K08783 i N-Ceram composite filler: Barium glass, ytterbium trifluoride, mixed Schaan, al oxides and silica dioxide particles (0.04 - 3.0 nm, Liechtenstein mean size 0.7 nm). Ceram-X Nanohybrid Methacrylate modified polysilane, dimethcrylate Dentsply, DeTrey, 0707000986 n composite resin, 76 wt% of filler; Barium aluminoborosilicate Konstanz, glass, silica nanofiller, PPF (Glass: 1 µm; silica: Germany io 0.02 µm) Filtek Silorane- Silorane (3,4- 3M ESPE, 3M N175794 Silorane based epoxycyclohexylethylcyclopolymethyl-siloxane, ESPE, Seefeld, az microhybrid bis-3,4- epoxycyclohexylethylphenylmethyl- Germany composite silane), Silanized quartz, yttrium fluoride, 76 wt% Optidisc Polishing Polyester impregnated with aluminum oxide KerrHawe, 4625964 Disk particles Bioggio, rn Switzerland BisCover Glaze Dipentaerythritol diacrylate esters, ethanol Bisco Inc., 110001566 LV material Iastasca, IL, USA measure analysis of variance (ANOVA), factors (pol- ishing system) and beverages (dark or regular beer) te tested solutions on different resin composites (p=0.245). Evaluating the results in detail, the SR val- In affecting the roughness of the surfaces of composites ues for every composite used in the study were lower with different formulas. Tukey’s HSD test was used to in glazed specimens than polished ones in each solu- compare the roughness values between groups. All tion. The complete results of the tested materials are analyses were performed using a commercially avail- given in Table 3. ni able software package (SPSSWIN 17.0, SPSS, Based on the baseline results, specimens obtained Chicago, IL, USA). from group TN had the lowest SR values overall. Pol- ished specimens in group DB had the highest SR val- io ues (0.13±0.05), followed by groups RB (0.12±0.04) and W (0.11±0.05), respectively. As for the values for group CX, specimens immersed in RB and DB Results iz Repeated measure ANOVA results (Tab. 2) revealed showed exactly the same SR values (0.15±0.04). In that immersion period and polishing systems were other respects, specimens of W showed the lowest significant factors in the surface roughness (SR) of SR values (0.13±0.04) in all polishing groups. Group Ed the tested specimens (p<0.001). There were no sig- CX had the highest SR values in glazed groups nificant differences in surface roughness among the (0.11±0.05). Polished specimens of group FS had the Table 2. Repeated measures of ANOVA results. IC Source Type III Sum df Mean Square F Sig. of Squares 30.917 1 30.917 7658.734 C Time .000 Material 0.266 2 0.133 32.987 .000 Solution 0.011 2 0.006 1.409 .245 0.976 1 0.976 241.781 @ Polishing system .000 Material * Solution 0.039 4 0.01 2.408 .048 Material * Polishing 0.061 2 0.03 7.533 .001 Solution * Polishing 0.035 2 0.018 4.386 .013 Material * Solution * Polishing 0.02 4 0.005 1.248 .290 Annali di Stomatologia 2017;VIII (1):23-28 25  U. Erdemir et al. Table 3. Mean values and standard deviations of tested materials in immersion medias. Material Immersion Distilled water Regular beer Dark beer period Polished Glazed Polished Glazed Polished Glazed 0.11±0.05 0.08±0.04 0.12±0.04 0.07±0.02 0.13±0.05 0.08±0.04 i 0.14±0.06 0.09±0.04 0.14±0.04 0.08±0.03 0.15±0.06 0.10±0.05 Tetric N Ceram Baseline al 0.16±0.05 0.09±0.02 0.13±0.13 0.10±0.04 0.18±0.07 0.10±0.04 1 week 1 month 0.13±0.04 0.11±0.05 0.15±0.04 0.10±0.05 0.15±0.04 0.10±0.04 n 0.13±0.03 0.11±0.05 0.15±0.04 0.12±0.05 0.15±0.06 0.11±0.04 Ceram-X Baseline 0.13±0.03 0.11±0.05 0.14±0.03 0.13±0.07 0.14±0.04 0.11±0.04 1 week io 1 month 0.17±0.1 0.1±0.07 0.15±0.07 0.11±0.07 0.16±0.09 0.09±0.04 0.17±0.08 0.13±0.15 0.15±0.08 0.14±0.1 0.19±0.12 0.1± 0.05 Filtek Silorane Baseline az 0.2±0.1 0.13±0.06 0.16±0.08 0.12±0.07 0.19±0.11 0.13±0.09 1 week 1 month rn highest SR values among all groups. Glazed speci- Throughout, all the changes in oral environment, it is mens of RB had the highest SR scores (0.11±0.07), crucial for restorations to maintain their surface char- followed by groups control (0.10±0.07) and DB acteristics. The purpose of this study was to evaluate (0.09±0.04), respectively. the surface roughness values of different kinds of te Based on the 1-week results of SR values, group FS composites immersed in different kinds of beer. Wa- had the highest values among all polished groups. ter was used as “control” to imitate the wear capacity Specimens of DB in all polished groups had the high- of saliva and to compare the roughness scores of est SR values among all immersion medias as well. In other groups. In TN groups, RB specimens showed slightly better Considering the clinical results of surface roughness, results (0.14±0.04) than W groups (0.14±0.06) in both initial plaque accumulation would occur if the values polished and glazed specimens. In CX groups, speci- are measured above 0.2 µm (23). Based on a 1- mens of DB had slightly higher results (0.15±0.06) month experiment period, Tetric N-Ceram had the ni than RB specimens (0.15±0.04). The W group had lowest values, while the Filtek Silorane composite the lowest scores among polished specimens. In had the highest results, which were at the exact glazed specimens, RB had the highest values threshold level in the study (0.20 µm). Hence, Silo- io (0.12±0.05). In FS groups, polished specimens of DB rane-based composites were more prone to plaque had the highest values (0.19±0.12). Specimens of the accumulation than methacrylate-based composites. W group showed higher SR values (0.17±0.08) than The hypothesis is rejected based on the fact that the iz those of the RB group (0.15±0.08). Comparing the roughness values of Silorane- and methacrylate- glazed specimens, the DB group had the lowest based groups showed statistically significant results scores (0.10±0.05). at the end of the experiment period. Ed At the end of 1 month, SR values followed about the The roughness values of the composites depend on same pattern as before. FS groups had the highest the particle size, type and concentration of the fillers. values among all polished groups. Regardless of the Larger fillers do cause rougher surfaces than smaller polishing systems used, TN groups (W, RB and DB) fillers (24). Despite having smaller averaged particles showed the statistically lowest surface roughness val- (0.47 nm) than Tetric N-Ceram (0.7 nm) and Ceram-X ues (p<0.05), whereas FS groups showed the highest (1 µm) composites, Filtek Silorane had the roughest IC surface roughness values (p<0.001). surface of them all following by Ceram-X. Then, eval- uating the filler concentration, lowest roughness val- ues were shown by Tetric N-Ceram and that could be attributed to its nanosized inorganic fillers with 57% C loading. Both Filtek Silorane and Ceram-X are more Discussion Composites with different formulas in chemical com- intensively concentrated (76%) with fillers than Tetric position are produced commercially. Because of their N-Ceram. Even though Filtek Silorane had smaller varying contents, composites have gained different particles than Ceram-X, silorane had rougher scores, @ advantageous properties. The surface characteristics which is consistent with Bansal’s (6) and Benetti’s of composites are one of the most effective properties (25) studies. However, there are conflicting results on which directly affect the longevity of restorations. this issue in that some studies (24, 26) claim the op- With the chemical changes happening in the oral en- posite or find similar results among composite types vironment, degradation of the surface of composite (27, 28). The different roughness values of Filtek restorations would occur and consequently, a change Silorane and Ceram-X could be due to different types in the roughness values would be observed (22). of main inorganic fillers. Filtek Silorane has silanised 26 Annali di Stomatologia 2017;VIII (1):23-28  Effects of different kinds of beers on the surface roughness of glazed and polished methacrylate and Silorane-based composites: a 1-month study quartz as inorganic filler, while Ceram-X has mostly fect; besides, their alcoholic content is mostly miss- silica nanofillers. ing. Meanwhile, a study (6) on the effects of whisky The surface roughness of a composite depends on on composites was evaluated and yielded results par- not only the inner structures but also the polishing allel to the results of our study. In a study collaborat- procedures done following restoration (28). In this ing with our results (22), the effects of alcoholic bev- study, Optidiscs were used for polishing, and a sur- erages on surface roughness of different types of face sealant, BisCover LV, was used to glaze the composites have compared and beer had found to i al specimens after the polishing system. One of the change the surface roughness the most after follow- main reasons of manufacturing these low-viscosity ing whisky in 1 month. The attributed changes were, surface sealants is that they have the ability to cover likewise in our study, thought to be related with the up micro porosities and to complete surface integrity low pH (4.1) of the related beer. Further studies are n (10). Based on the results at every time period, the needed to investigate the effects of beers on other glazed groups of all composites had lower roughness physical properties of composites. As the present io values than the polished groups. It is certain that study is processed in in vitro situations, the effect of glazing did achieve better surfaces in this study, the cleaning property of saliva is missing. Moreover, whose results corroborate with those of dos Santos’s oral habits that may enhance permanent forces on az studies (17, 18). Regardless of the composite type, it teeth and restorations such as tooth brushing may al- is revealed that glazing had a significant role in cor- ter the surface properties as well. It is obvious that recting surface irregularities and had a better perfor- the present study is limited to in vitro situations. mance than polishing procedures. rn Evaluating the effects of different kinds of beer on composites was one of the purposes of this study. Two types of beer from the same company (Leffe, Conclusion The surface roughness values of the tested resin te NV/SA InBev Inc., Belgium) were used to standardise the manufacturing properties. Distilled water was in- composites were affected by the polishing procedure cluded as “control” just like in many studies (6, 25, used and the type of composite resin. Silorane based 29). Although, groups immersed in water of methacry- composites had statistically inferior roughness scores In than nanohybrid composites. Moreover, glazing pro- late-based composites had smoother surfaces than beer groups without any statistically difference, the cedure had better surface characteristics than only- water group of Silorane-based composites had rough- polished samples. When choosing the optimum com- ness scores between dark and regular types of beer. posites, it should be taken into consideration that, ni The results could be attributed to differences in the drinking habits could irruptive effect on the surface chemical composition of the composite groups or pos- characteristics. Therefore, dietary anamnesis should sible inabilities of an in vitro experiment. also guide when selecting the material type and de- io Based on the 1-month results, groups immersed in ciding on using polishing systems. dark beer had higher roughness values than groups Even though the present study provides only 1- immersed in regular beer. This may be caused by the month results, it emphasises the differences between iz physical properties of the beers. The effects of alco- Silorane- and methacrylate-based composites and holic drinks on composite materials were obvious, in highlights the performance of glazing procedures and which ethanol concentration causes disassociation of the effects of different types of beer on surface Ed substances from the surface. Water absorbance of roughness. The effects of longer immersion periods the materials could cause plasticisation of organic should be recorded, and additional methods, such as matrices and accelerate decomposition. Also, ethanol atomic force microscopy, may be used in further stud- has directly penetrated through the resin matrix, bro- ies to detect surface irregularities in detail. ken down the polymeric structure (25), separated the bonding between the filler and displaced the filler par- IC ticles finally resulting in inferior mechanical properties of the composites (22), which could be more impor- Conflicts of interest tant than prolonged immersion in water. The alcohol None declared. concentrations of regular and dark beer were nearly C the same, 6.6 and 6.5%, respectively. The hydrogen ion concentrations (pH) of beverages could cause the erosion of polymers and initiate surface degradation References as well. Although the types of malts have been 1. Buchgraber B, Kqiku L, Allmer N, Jakopic G, Städtler P. Sur- @ changed in order to identify beers as “regular” (light face roughness of one nanofill and one silorane composite after polishing. Coll Antropol. 2011;35:879-883. malt) and “dark” (roasted malt), alcohol concentration 2. Yap AU, Yap SH, Teo CK, Ng JJ. Comparison of surface fin- and pH values (4.43 and 4.22, respectively) are simi- ish of new aesthetic restorative materials. Oper Dent. lar. This could be the reason of no statistically signifi- 2004;29:100-104. cant roughness values resulted between beer types. 3. Turssi CP, Ferracane JL, Serra MC. Abrasive wear of resin Studies on the effects of beers on surface roughness composites as related to finishing and polishing procedures. are lacking. Beers are thought to have a colorant ef- Dent Mater. 2005;21:641-648. Annali di Stomatologia 2017;VIII (1):23-28 27  U. Erdemir et al. 4. Silikas N, Kavvadia K, Eliades G, Watts D. Surface char- 17. Dos Santos PH, Consani S, Correr Sobrinho L, Coelho Sin- acterization of modern resin composites: a multitechnique horeti MA. Effect of surface penetrating sealant on roughness approach. Am J Dent. 2005;18:95-100. of posterior composite resins. Am J Dent. 2003;16:197-201. 5. Mitra SB, Wu D, Holmes BN. An application of nanotech- 18. Dos Santos PH, Pavan S, Consani S, Sobrinho LC, Sinhoreti nology in advanced dental materials. J Am Dent Assoc. MA, Filho JN. In vitro evaluation of surface roughness of 4 2003;134:1382-1390. resin composites after the toothbrushing process and meth- 6. Bansal K, Acharya SR, Saraswathi V. Effect of alcoholic and ods to recover superficial smoothness. Quintessence Int. i non-alcoholic beverages on color stability and surface 2007;38:247-253. al roughness of resin composites: An in vitro study. J Conserv 19. Nelson M. The Barbarian’s Beverage: A History of Beer in Dent. 2012;15:283-288. Ancient Europe. Routledge: Abingdon, Oxon, UK. P. 1, 2005. 7. Senawongse P, Pongprueksa P. Surface roughness of nanofill 20. Drink. https://en.wikipedia.org/wiki/Drink. Accessed, October and nanohybrid resin composites after polishing and brush- 13, 2015. n ing. J Esthet Restor Dent. 2007;19:265-273. 21. Sarret DC, Coletti, Peluso AR. The effect of alcoholic bev- 8. Erdemir U, Sancakli HS, Yildiz E. The effect of one-step and erages on composite wear. Dent. Mater. 2000;16:62-67. io multi-step polishing systems on the surface roughness and 22. DA Silva MA, Vitti RP, Sinhoreti MA, Consani RL, Silva-Júnior microhardness of novel resin composites. Eur J Dent. JG, Tonholo J. Effect of alcoholic beverages on surface rough- 2012;6:198-205. ness and microhardness of dental composites. Dent Mater 9. Kumari RV, Nagaraj H, Siddaraju K, Poluri RK. Evaluation J. 2016;35:621-626. az of the effect of surface polishing, oral beverages and food 23. Bollen CM, Lambrechts P, Quirynen M. Comparison of sur- colorants on color stability and surface roughness of face roughness of oral hard materials to the threshold sur- nanocomposite resins. J Int Oral Health. 2015;7:63-70. face roughness for bacterial plaque retention: a review of the 10. Saygı G, Karakoç P, Serbes I, Özel Yildiz S, Erdemir U, Yü- literature. Dent Mater. 1997;13:258-269. rn cel T. Effect of surface sealing on stain resistance of a nano- 24. Tuncer S, Demirci M, Tiryaki M, Ünlü N, Uysal Ö. The effect hybrid resin composite. J Istanbul Univ Fac Dent. 2015;49:23- of a modeling resin and thermocycling on the surface hard- 30. ness, roughness, and color of different resin composites. J 11. Lopes MB, Saquy PC, Moura SK, Wang L, Graciano FM, Cor- Esthet Restor Dent. 2013;25:404-419. te rer Sobrinho L, Gonini Júnior A. Effect of different surface 25. Benetti AR, de Jesus VCBR, Martinelli NL, Pascotto RC, Poli- penetrating sealants on the roughness of a nanofiller com- Frederico RC. Colour stability, staining and roughness of silo- posite resin. Braz Dent J. 2012;23:692-697. rane after prolonged chemical challenges. J Dent. 12. Ergücü Z, Türkün LS. Surface roughness of novel resin com- 2013;41:1229-1235. posites polished with one-step systems. Oper Dent. In 26. Marghalani HY. Effect of finishing/polishing systems on the 2007;32:185-192. surface roughness of novel posterior composites. J Esthet 13. Antonson SA, Yazici AR, Okte Z, Villalta P, Antonson DE, Restor Dent. 2010;22:127-138. Hardigan PC. Effect of resealing on microleakage of resin 27. Pettini F, Corsalini M, Savino MG, Stefanachi G, Di Venere composite restorations in relationship to margin design and D, Pappalettere C, Boccaccio A. Roughness analysis on com- ni composite type. Eur J Dent. 2012;6:389-395. posite materials (microfilled, nanofilled and silorane) after dif- 14. Takeuchi CY, Orbegoso Flores VH, Palma Dibb RG, Panz- ferent finishing and polishing procedures. Open Dent J. eri H, Lara EH, Dinelli W. Assessing the surface roughness 2015;9:357. io of a posterior resin composite: effect of surface sealing. Oper 28. Karaman E, Tuncer D, Firat E, Ozdemir OS, Karahan S. In- Dent. 2003;28:281-286. fluence of different staining beverages on color stability, sur- 15. Bertrand MF, Leforestier E, Muller M, Lupi-Pégurier L, Bol- face roughness and microhardness of silorane and methacry- la M. Effect of surface penetrating sealant on surface tex- late-based composite resins. J Contemp Dent Pract. iz ture and microhardness of composite resins. J Biomed Mater 2014;15:319-325. Res. 2000;53:658-663. 29. Hui R, Choi IH, Hussein I, Hockey J, Hetrelizides D, Wong 16. Dickinson GL, Leinfelder KF. Assessing the long-term effect RHK. The effect of drinks and, temperature on the staining Ed of a surface penetrating sealant. J Am Dent Assoc. 1993; of resin composites coated with surface sealants. J Dent Bio- 124:68-72. mater. 2014;1:16-22. IC C @ 28 Annali di Stomatologia 2017;VIII (1):23-28 

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Original article Comparison between three glass fiber post cementation techniques i al Guido Migliau MD, DDS, PhD1 SPSS Inc. ver. 13.0, Chicago, IL, USA. n Luca Piccoli DDS, PhD1 Results. Group A values of bond strenth ranged Stefano Di Carlo MD, DDS, PhD1 from a minimum of 10.14 Mpa to a maximum value io Giorgio Pompa MD, DDS, PhD1 of 14.73 Mpa with a mean value of 12.58 Mpa. In Laith Konstantinos Besharat DDS, MsC, PhD1 Group B the highest value of bond strength was Marco Dolci MD, DDS, PhD2 6.54 Mpa and the minimum 5.55 Mpa. The mean az value of the bond strength for the entire group Department of Oral and Maxillofacial Sciences, was 6.58 Mpa. In Group C the highest bond 1 “Sapienza” University of Rome, Rome, Italy strength was 6.59 Mpa whereas the lowest bond 2 Department of Medical, Oral and Biotechnological strength was 4.84 Mpa. Mean value of the bond rn Sciences, “G. D’Annunzio” University of Chieti, strength of Group C was calculated at 5.7 Mpa. Chieti, Italy Conclusions. Etching with orthophosphoric acid combined with a dual-curing adhesive system and a dual-cured resin-composite cement was the te technique that guaranteed the highest bond Laith Konstantinos Besharat Corresponding author: strength. Lowest bond strength values were ob- Department of Oral and Maxillofacial Sciences, In tained when dual self-adhesive cement was used. “Sapienza” University of Rome, Via Caserta 6 Key words: glass fiber post, self-adhesive ce- 00161 Rome, Italy ment, etching. E-mail: [email protected] ni Introduction Summary For a complete understanding of the several aspects of adhesion, it is fundamental to know and recognize io the substrates the materials work on. Enamel, dentin and cementum represent very different adhesive sur- Objective. The aim of this experimental study was faces due to their composition, morphology and to compare the traditional cement systems with iz biomechanical characteristics. The adhesion obtained those of the latest generation, to assess if indeed through the adhesive systems is both chemical and these could represent of viable substitutes in the especially micro-mechanical, with the formation of the cementation of indirect restorations, and in the Ed hybrid layer and resin tags, which are achieved specific case of endodontic posts. through the etching time: it increases the available Methods. The assessment of the validity of the surface and, consequently, the contact with the resin. cementing methods was performed according to All the above remarks hold true in the restoration of the test of the push-out, conducted on sections endodontically treated teeth, as well. In this sort of obtained from the roots of treated teeth. The sam- teeth, the substrate with which the adhesion is ob- ples were divided into three groups. Group A (10 IC tained is basically the dentin, at both a pulp chamber samples): etching for 30 seconds with 37% or- and root canal. Post cementation is a delicate proce- thophosphoric acid (Superlux-Thixo-etch-DMG) dure where the cement must have the ability to bond combined with a dual-curing adhesive system (1-7) to three different surfaces; the post, the dental (LuxaBond-Total Etch-DMG), dual-cured resin- C tissue and the restorative material. In detail two dif- composite cement (LuxaCore-DMG) and glass ferent types of cementation can be described. Firstly, fiber posts (LuxaPost-DMG). Group B (10 sam- the standard classical cementing procedure that in- ples): self-adhesive resin cement (Breeze-Pentron cludes the use of adhesive systems (8, 9) and resin Clinical) and glass fiber posts (LuxaPost-DMG). @ composite cements combined with etching pretreat- Group C (10 samples): 3 steps light-curing, self- ment of the tooth surface. Secondly, the last genera- etching, self-conditioning bonding agent (Contax- tion cementing involves the use of self-etching com- Total-etch-DMG), dual-cured resin-composite ce- posite cements. These cements are introduced di- ment (LuxaCore-DMG) and glass fiber posts rectly into the root canal (10-14) without having to (LuxaPost-DMG). The survey was conducted by use any adhesive system beforehand, since they examining the breaking resistance of the post-ce- contain components that allow the enclosure of the ment-tooth complex, subjected to a mechanical force. Stati stical analysis was performed using Annali di Stomatologia 2017;VIII (1):29-33 29  G. Migliau et al. adhesion procedure in one step and therefore simpli- hypochlorite at 5% (Niclor5, Ogna), with a final wash fying and significantly reducing the operative time. (for 2 minutes) with the same product at 37 °C. The root canal filling was carried out with cold lateral con- densation technique with ISO standardized gutta-per- cha cones and cement containing epoxy resin Top Seal (Dentsplay, Maillefer). Preparation of the post Experimental Analysis space was carried out with Largo 1 and 2 burs i al The aim of this experimental study was to compare (Dentsplay, Maillefer) at the length of 10 mm for each Objective of the study the traditional cement systems with the cement sys- sample. tems of the latest generation, to assess if indeed the The samples were then divided into 3 groups: latest generation could represent viable substitutes in - group A (10 samples): etching for 30 seconds n the cementation of indirect restorations (15, 16), and with 37% orthophosphoric acid (Superlux-Thixo- in the specific case of endodontic posts. etch-DMG) combined with a dual-curing adhesive io The non-metallic posts had several advantages com- system (LuxaBond-Total Etch-DMG), dual-cured pared to the metallic ones, such as the realization of resin-composite cement (LuxaCore-DMG) and a homogeneous tooth-reconstruction system (17, 18), glass fiber posts (LuxaPost-DMG) az the low cost, the easy usage and a vast field of appli- - group B (10 samples): self-adhesive resin cement cation; reasons that favored the selection of the fiber- (Breeze-Pentron Clinical) and glass fiber posts glass posts (LuxaPost-DMG) for this study. (LuxaPost-DMG) The assessment of the validity of the cementing - group C (10 samples): 3 steps light-curing, self- rn methods was performed according to the push-out etching, self-conditioning bonding agent (Contax- test, conducted on sections obtained from the roots of Total-etch-DMG), dual-cured resin-composite ce- treated teeth and performed at the Department of ment (LuxaCore-DMG) and glass fiber posts te Biomedicine at the University of Trieste. (LuxaPost-DMG). Material and Methods In Preparation of the samples for the mechani- Comparison of the retentive efficiency (19, 20) of cal test three different types of cementation using the same The portion of each root corresponding to the bonded type of post (LuxaPost-DMG) was performed for all fiber post was transversally sectioned into 1mm-thick ni samples. The survey was conducted by examining serial slices, using a microtome (Micormet-Remet) the breaking resistance of the post-cement-tooth posting a low speed saw (Norton-Dia Wheel), 0.2 mm complex, subjected to a mechanical force. thick, under water-cooling operating at 2.240 spins io The following products were used in our sample per minute. The sections were realized in apical-coro- preparation: nal direction and each section was marked on the - a dual-curing adhesive system (LuxaBond-Total apical surface to put it exactly under the punch of the iz Etch-DMG) machine for the push-out test. A number was as- - phosphoric acid at 37% (Superlux-Thixo-etch- signed to each root and a progressive alphabetical DMG) letter to each slice from the apical surface to the Ed - conventional dual-cured resin-composite cement coronal one (Fig. 1). (LuxaCore-DMG) - dual self adhesive cement (Breeze-Pentron Clin- ic) - a 3 steps light-curing, self-etching, self-condition- The push-out test ing bonding agent (Contax-Total-etch-DMG) Push-out load was applied using a universal testing IC - fiber posts (LuxaPost-DMG). machine Galdabini-Sun 500 at a crosshead speed of 0.5 mm/min to obtain the extrusion of the post. The punch was positioned to touch the post only, without stressing the surrounding dentinal walls. The load was C applied on the apical surface of the slice in apical-coro- Sample preparation We examined 30 roots of monoradicular teeth, ex- nal direction, with the purpose of preventing the coni- tracted for periodontal reasons and stored in water. cal shape of the canal from withstanding the dislodg- The applied protocol concerning the preparation of ment of the post. Push-out strength data was calculat- @ the root canal filling and post-space is described be- ed in Newtons (N), which was converted to MegaPas- low. cals (Mpa) by dividing the load by the bonded surface All samples were prepared using the simultaneous area. In order to obtain the bonded surface area of technique with NiTi M2 instruments (Sweden & Marti- each sample, we took pictures of the apical surface us- na) with the following sequence: 10/taper 4% - 15/ta- ing an optical microscope (Zeiss laser scan). We used per 5% - 20/taper 6% - 25/taper 6%. Irrigation, during for each picture the same angle of view and enlarge- preparation, was performed by the use of sodium ment (50x) after the Push-out test (Fig. 2). 30 Annali di Stomatologia 2017;VIII (1):29-33  Comparison between three glass fiber post cementation techniques i n al Figure 1. Marked slices after sectioned. io Where R is the coronal post radius, r the apical post az radius, and h the thickness of the slice. Each slice was submitted to the same procedure. Statistical analysis was performed using SPSS Inc. ver. 13.0, Chicago, IL, USA. Chi-squared test was used for statistical evaluation of proportions. In cases rn of more than 2 independent means we used the ANOVA test. A p-value of less than 0.05 was consid- ered significant. A 95% CI was used in all analysis. In te order to assure data reliability, data were entered in two different personal computers by two examiners; the two data files were compared in order to detect In entry errors. The two files resulted identical. Results ni For each analyzed section we obtained the bond strength between the post and the dentin (MPa). Re- sults were analyzed using the ANOVA test. io For the samples of the group A the values of the vari- ous samples ranged from a minimum value of 10.14 Mpa for the slice A6 to a maximum value of 14.73 Mpa iz for the A1 sample with a mean value of 12.58 Mpa. In group B the highest value of bond strength was re- ported in the B1 slice with 6.54 Mpa and the minimum Ed at the B8 with 5.55 Mpa. The mean value of the bond strength for the entire group was 6.58 Mpa. Finally, in group C the highest bond strength was re- ported at the C6 slice with 6.59 Mpa whereas the low- Figure 2. Pictures obtained with the optical microscope af- est bond strength was reported at the C2 slice with ter the push-out test. 4.84 Mpa. Mean value of the group C was calculated IC at 5.7 Mpa. (Tab. 1). The results obtained are reported in the Table 1 be- low. Similarly a picture of a marked size (1 mm) was tak- C en. Image processing software provided with the opti- cal microscope was used to analyze the pictures after calibrating the space using the marked size. The visi- Discussion ble circumference size was found, following the line In this study, we show that the adhesion force is @ of the fracture. Knowing the thickness of the sample greater for the group A, differences are statistically (1 mm) and the taper of the apical surface of the significant when group A is compared to group B and post, we calculated the lateral surface area of a trun- group C. Moreover, highest bond strength values ob- cated cone which is the bonded surface area through tained in group B compared to group C aren’t statisti- [ ] the formula: cally significant. Lowest bond strength values were SL = π (R + r) (h2+ (R – r)2 0.5 obtained where the etching step wasn’t performed. Our results can be useful for comparison with recent Annali di Stomatologia 2017;VIII (1):29-33 31  G. Migliau et al. Tabella 1. Results obtained after the push-out test. Group A samples Mpa Group B samples Mpa Group C samples Mpa A1 4 14.73 B1 5 7.54 C1 6 6.04 A2 5 12.98 B2 4 6.58 C2 5 4.84 i A3 5 12.01 B3 4 5.95 C3 4 5.75 al A4 5 13.47 B4 5 6.6 C5 5 5.91 A5 5 11.25 B5 5 7.07 C5 6 4.97 n A6 5 10.14 B6 5 6.73 C6 6 6.59 io A7 5 14.5 B7 6 6.8 C7 5 6.39 A8 6 14.23 B8 5 5.55 C8 6 6.07 az A9 5 11.33 B9 5 7.41 C9 5 5.33 A10 5 11.2 B10 5 5.91 C10 5 5.58 Mean 12.58 Mean 6.58 Mean 5.7 rn te similar studies (21). Etching with orthophosphoric and micro- and macrostructure alterations. Quintessence Int. acid combined with a dual-curing adhesive system 2007 Oct;38(9):733-743. and a dual-cured resin-composite cement is the tech- 8. Ferrari M, Cagidiaco MC, Goracci C, Vichi A, Mason PN, Radovic I, Tay F. Long-term retrospective study of the clin- nique that guarantees a satisfying bond strength, a In ical performance of fiber post. Am J Dent. 2007;20(5):287- dual self adhesive cement could be used in situations 291. in our daily clinical practice where the patient doesn’t 9. Ferrari M, Mannocci F, Vichi A, Cagidiaco MC, Mjör IA. Bond- fully collaborate and we have to diminish execution ing to root canal: structural characteristics of the substrate. time and simplify the post cementation procedure. Am J Dent. 2000 Oct;13(5):255-260. ni Further studies need to be carried out on this issue 10. Hashimoto M, Ohno H, Endo K, Kaga M, Sano H, Oguchi taking into account new dual self-adhesive cements H. The effect of hybrid layer thickness on bond strength: dem- that will be launched next year from several multina- ineralized dentin zone of the hybrid layer. Dent Mater. 2000 io tional dental companies such as 3M and Kerr. Nov;16(6):406-411. 11. Hashimoto M, Ohno H, Kaga M, Sano H, Tay FR, Oguchi H, Araki Y, Kubota M. Over-etching effects on micro-tensile iz bond strength and failure patterns for two dentin bonding sys- References tems. J Dent. 2002 Feb-Mar;30(2-3):99-105. 12. Hayashi M, Takahashi Y, Hirai M, Iwami Y, Imazato S, Ebisu 1. Abu-Hanna A, Gordan VV, Mjor I. The effect of variation in S. Effect of endodontic irrigation on bonding of resin cement Ed etching times on dentin bonding. Gen Dent. 2004 Jan- to radicular dentin. Eur J Oral Sci. 2005 Feb;113(1):70-76. Feb;52(1):28-33. 13. Lopes GC, Cardoso Pde C, Vieira LC, Baratieri LN. Mi- 2. Migliau G, Piccoli L, Besharat LK, Di Carlo S, Pompa G. Eval- crotensile bond strength to root canal vs pulp chamber dentin: uation of over-etching technique in the endodontically treat- effect of bonding strategies. J Adhes Dent. 2004 Sum- ed tooth restoration. Ann Stomatol (Roma). eCollection 2015 mer;6(2):129-3. Jan-Mar. 2015 May18;6(1):10-14. 14. Rosella D, Rosella G, Brauner E, Papi P, Piccoli L, Pompa IC 3. Ahid F, Andrade MF, Campos EA, Luscino F, Vaz LG. In- G. A tooth preparation technique in fixed prosthodontics for fluence of different dentin etching times and concentrations students and neophyte dentists. Ann Stomatol (Roma). 2016 and air-abrasion technique on dentin microtensile bond Feb12;6(3-4):104-109. strength. Am J Dent. 2004 Dec;17(6):447-450. 15. Marshall GW Jr, Marshall SJ, Kinney JH, Balooch M. The 4. Bouillaguet S, Troesch S, Wataha JC, Krejci I, Meyer JM, dentin substrate: structure and properties related to bond- C Pashley DH. Microtensile bond strenght between adhesive ing. J. Dent. 1997;25(6):441-458. cements and root canal dentin. Dent Mater. 2003;19(3):199- 16. Morris MD, Lee KW, Agee KA, Bouillaguet S, Pashley DH. 205. Effects of sodium hypochlorite and RC-Prep on bond 5. Brajdić D, Krznarić OM, Azinović Z, Macan D, Baranović M. strenghts of resin cement to endodontic surfaces. J Endod. @ Influence of different etching times on dentin surface mor- 2001;27(12):753-757. phology. Coll Antropol. 2008 Sep;32(3):893-900. 17. Musikant BL, Deutsch AS. Post design and his impact on the 6. Migliau G, Piccoli L, Besharat LK, Romeo U. Benchmarking root and crown. Compend Contin Educ Dent. 2006 Feb;27 matching color in composite restorations. Ann Stomatol (2):130-133. (Roma). 2016 Jul19;7(1-2):29-37. 18. Migliau G, Besharat LK, Sofan AA, Sofan EA, Romeo U. 7. Dietschi D, Duc O, Krejci I, Sadan A. Biomechanical con- Endo-restorative treatment of a severly discolored upper in- siderations for the restoration of endodontically treated teeth: cisor: resolution of the “aesthetic” problem through Componeer a systematic review of the literature - Part 1. Composition veneering System. Ann Stomatol (Roma). 2016 Feb12;6(3- 32 Annali di Stomatologia 2017;VIII (1):29-33  Comparison between three glass fiber post cementation techniques 4):113-8.eCollection 2015 Jul-Dec. Review. sile bond strength. Am J Dent. 1998 Oct;11(5):202-206. 19. Perdigão J, Gomes G, Augusto V. The effect of dowel space 21. Durski MT, Metz MJ, Thompson JY, Mascarenhas AK, Crim on the bond strengths of fiber posts. J Prosthodont. 2007 May- GA, Vieira S, Mazur RF. Push-Out Bond Strength Evalua- Jun;16(3):154-164. tion of Glass Fiber Posts With Different Resin Cements and 20. Pioch T, Stotz S, Buff E, Duschner H, Staehle HJ. Influence Application Techniques. Oper Dent. 2016 Jan-Feb;41(1):103- of different etching times on hybrid layer formation and ten- 110. doi: 10.2341/14-343-L. Epub 2015 Sep 2. i n al io az rn te In ni io iz Ed IC C @ Annali di Stomatologia 2017;VIII (1):29-33 33 

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Original article Minimally invasive orthodontics: elastodontic therapy in a growing patient affected by Dentinogenesis Imperfecta i n al Gaetano Ierardo DDS, PhD elastodontic devices do not require adequate Valeria Luzzi DDS, PhD dental retention and define a minimum interven- Giuliana Nardacci DDS tion on the surfaces of the teeth. io Iole Vozza DDS, PhD Antonella Polimeni MD, DDS Key words: dentinogenesis imperfecta, orthodon- tics, elastodontic device. az Department of Oral and Maxillofacial Sciences, “Sapienza” University of Rome, Rome, Italy Introduction Dentinogenesis Imperfecta (DI) is a disorder of tooth rn development. It’s characterized by severe hypominer- alization of dentin and altered dentine structure (1-3). In 1973, Shield determined a classification of three Giuliana Nardacci dentinal disorders: type I, II and III Dentinogenesis te Corresponding author: Department of Oral and Maxillofacial Sciences, Imperfecta and two types of dentin dysplasia (1). “Sapienza” University of Rome Dentinogenesis Imperfecta type I is the phenotype Via Caserta 6 that is often related to a genetic fragile bone condi- 00161 Rome, Italy In tion, Osteogenesis Imperfecta. This is usually E-mail: [email protected] caused by a defect in the two genes encondin type I collagen (1). The type I is also related to other systemic diseases, such as Ehlers-Danlos and Goldblatt syndromes (1). ni This type is characterized by opalescent brown dis- coloration in both dentitions, and due to reduced sup- Summary port of the dentin, the overlying enamel fractured eas- io ily (1). There are also several steps of progressive Aim. The aim of the study was to report the use of pulp obliteration which usually begins as soon as the an elastodontic therapy in a growing patient af- eruption of the teeth occurs. iz fected by Dentinogenesis Imperfecta, second Clinically teeth are often opalescent. class malocclusion, deep bite and lower arch The second type of Dentinogenesis Imperfecta is an crowding from the deciduous dentition to perma- autosomal dominant condition with a prevalence rate Ed nent one. of approximately 1:8000. It’s caused by a mutation of Case report. At first, the 5-year-old patient was treated with an elastodontic device known as DSPP gene. “Nite-Guide”. When the patient was 7 years old, The clinical and radiographic features are similar to during her first permanent molars and incisors the first type, even though they are expressed more eruption and after optimal house-practices, an consistently (1). Dentinogenesis Imperfecta type III is also caused by IC Occlus-o-Guide Series G was placed at night and on daylight (two hours a day) performing exercis- the same DSPP mutation as type II, but shows vari- es aimed to activate facial muscles and facilitate able discoloration and morphology of the teeth, rang- ing from normal appearing teeth to shell teeth with dentin formation reduction (1, 4, 5). the deep bite reopening. At 9 years of age, with C This clinic condition can be related to Osteogenesis totally deep bite resolution, she used the Occluso- Imperfecta (6, 7). Guide only at night to hold down previous results From a radiographic point of view, teeth affected from and follow patient’s dental growth. At 11 years of DI are called “specter teeth” because of the empti- age, after successful teeth switching, we pre- @ ness appearance which makes possible to observe scribed an Occlus-o-Guide Series N, which is only the polished outlines. functional for permanent dentition and guaran- In these patients with a no real retention and sub- teed an eruptive guide for last dental elements. stance of the teeth, a good anchorage is hard to ob- Conclusions. This clinic case could be consid- tain; for this reason this study offers a treatment pos- ered an example of approach for all those pa- sibility in order to solve some orthodontic problems of tients with systemic and/or dental diseases that these patients. do not allow adequate dental retention, which is necessary for most orthodontic appliances; 34 Annali di Stomatologia 2017;VIII (1):34-38  Minimally invasive orthodontics: elastodontic therapy in a growing patient affected by Dentinogenesis Imperfecta In order to correct second class malocclusions there DI, second class malocclusion, deep bite and lower are a lot of different orthodontic appliances described arch crowding from the deciduous dentition to perma- in literature although in the last years the elastodontic nent one. devices are the most used. The elastodontic appliances are made with a vinyl resin that is called Elvax® which has optimal charac- teristics of resilience. i Case report al These appliances are removable, easy to use, com- The study reports the case of a 5 years old age child fortable, safe and simple in construction and function, (G.P.) affected by DI. and they are indicated both in primary and in sec- She was totally treated with elastomeric devices n ondary dentition. since five years to twelve years of age. They are both functional devices and positioners (8). The extraoral exam underlined these orthodontic They are realized in order to correct different ortho- characteristics: long face and flat profile with a verti- io dontic problems: mandibular crowing, deep-bite, cal asymmetry (12). open-bite, increased overjet, mandible retrusion. The intra-oral exam showed: deep-bite, distal step on These appliances are characterized by a preformed the right and on the left, deep dental wear (Fig. 1). az bite construction that allows a mandibular advance- The cephalometric analysis underlined increased ment, concurrently with a vertical opening in the ante- overjet (3, 7), increased overbite, normal divergence rior region to provide a greater vertical development (FMA=23), SNA=73.2, SNB=72, Jarabak poly- of the posterior teeth (9). gon=400 (Figs. 2, 3). rn Positioners usually achieve minor tooth movement af- At first, the patient was treated with an elastodontic ter orthodontic treatment as a result of the elastomer- device known as “Nite-Guide”, which is only for pri- ic material (8). mary dentition from 5 to 7 years old kids. It guides the te They use the lip-bumper effect thanks to their labial eruption of primary mandibular incisors and defines a and oral “shields”. first class of malocclusion and corrects overjet and Depending on the type of elastomeric devise, the overbite (13). teeth have their recesses that guide the correct posi- She carried the Nite-Guide device both at night and In tion in the mouth. on daylight (two hours a day) performing exercises Hence elastomeric devices can solve not only the aimed to activate facial muscles and facilitate the second class malocclusions through a mandibular ad- deep bite reopening (Fig. 4). Waiting for mandibular vancement and increase in lower and anterior face permanent incisors eruption, overjet and overbite ni height, but also determines a lot of important dental were corrected. Because of the lower crowding we effect: lingual tipping and regression of the maxillary extracted the deciduous mandibular incisors. incisors, correction of molar relationships, decrease At a later stage, when the patient was 7 years old, io overjet and overbite (10). during her first permanent molars and incisors erup- They can solve these orthodontic problems with a tion and after optimal house-practices, an Occlus-o- minimum operation on teeth, because they don’t Guide Series G was placed. iz need much anchoring. Hence they can be as well This kind of Occlus-o-Guide is used in mixed dentition used in some cases with oral/systemic diseases (11). in order to: correct second class of malocclusion and The aim of the study was to report the use of an guide the permanent teeth in the right position in the Ed elastodontic therapy in a growing patient affected by arch as well as to decrease the overjet and overbite. Figure 1. Clinical case at 5 years of age. IC C @ Annali di Stomatologia 2017;VIII (1):34-38 35  G. Ierardo et al. At 9 years of age, with totally deep bite resolution, she used the Occlus-o-Guide only at night to hold down previous results and follow patient’s dental growth. At 11 years of age, after successful teeth switching, we prescribed an Occlus-o-Guide Series N, which is functional for permanent dentition and guaranteed an i al eruptive guide for last dental elements. In these series the recesses are also for first and sec- ond molars in order to preserve and define the over- Figure 2. Initial Orthopanoramics. n bite and the correction of second class of malocclu- sion. She carried the device just at night in order to pre- io serve the correct overbite and improve the molar rela- tionship (Figs. 6-8). az Discussion and Conclusions Dentinogenesis imperfecta (DI) is a genetic disorder rn affecting the structural integrity of the dentin and re- sulting in weakened dentin. The posterior teeth often need to be extracted due to severe wear or fracture. te This frequently yields a loss of posterior occlusion and occlusal vertical dimension. This case shows as the patient optimally corrected her second class mal- occlusion, deep bite and dental misalignment without In a severe intervention on surfaces of the teeth. The elastodontic devices allowed a proper eruptive guide for all teeth in different steps of dentition. G.P. used all these appliances with comfort and facility ni Figure 3. Initial cephalometric skull. and only few hours a day. Very early, she carried the devices only at night be- cause the deep-bite was corrected in the initial steps io The recesses are for all teeth except first molars in of therapy. order to have an extrusion of these teeth and an ad- On Literature there are no case report about ortho- ditional decrease of the overbite. dontic rehabilitation of patients affected by DI in iz G.P. used Occlus-o-Guide all night long and 2-4 mixed dentition. Bencharit et al. (14) demonstrated hours in the afternoon at home and she did the exer- that restoring functional occlusion and esthetics for cises to activate the muscle (Fig. 5). adult patient with DI can be completed successfully Ed Figure 4. Intraoral photos with Nite- Guide at 7 years of age and correction of deepbite. IC C @ 36 Annali di Stomatologia 2017;VIII (1):34-38  Minimally invasive orthodontics: elastodontic therapy in a growing patient affected by Dentinogenesis Imperfecta Figure 5. Intraoral photos with Occlus- o-Guide series G at 9 years of age. i n al io az rn Figure 6. Intraoral photos with Occlus- o-Guide series N at 11 years of age. te In ni io iz Ed IC C using implant therapy and adhesive dentistry. Row et as a transitional treatment step for the anterior teeth al. (15) proposed a multidisciplinary approach for a of an eight-year old boy with DI. This clinic case @ seventeen-year old patient through adhesive den- could be considered an example of approach for all tistry, periodontal surgery, implant-supported prosthe- those patients with systemic and/or dental diseases ses, orthodontic treatment and orthognathic surgery. that do not allow adequate dental retention, which is Huth (16) proposed restoration of the primary teeth necessary for most orthodontic appliances; with stainless steel crowns and composite crowns in elastodontic devices do not require adequate dental a 4-year-old child. Ubaldini et al. (17) described an retention and define a minimum intervention on the esthetic solution through composite resin restorations surfaces of the teeth (18). Annali di Stomatologia 2017;VIII (1):34-38 37  G. Ierardo et al. of dental hard tissues in primary teeth with Dentinogenesis Imperfecta Type II: Correlation of 3D imaging using X-ray mi- crotomography and polarising microscopy. Arch Oral Biol. 2015 Jul;60(7):1013-1020. 5. Ierardo G, Calcagnile F, Luzzi V, Ladniak B, Bossu M, Cel- li M, Zambrano A, Franchi L, Polimeni A. Osteogenesis im- perfecta and rapid maxillary expansion: Report of 3 pa- i tients.Am J Orthod Dentofacial Orthop. 2015 Jul;148(1):130- al 137. 6. Devaraju D, Devi BY, Vasudevan V, Manjunath V. Dentino- genesis imperfecta type I: A case report with literature re- view on nomenclature system. J Oral Maxillofac Pathol. 2014 n Sep;18(Suppl 1):S131-134. Figure 7. Orthopanoramics at 11 years of age. 7. Orsini G, Majorana A, Mazzoni A, Putignano A, Falconi M, io Polimeni A, Breschi L. Immunocytochemical detection of dentin matrix proteins in primary teeth from patients with dentinogenesis imperfecta associated with osteogenesis im- perfecta. Eur J Histochem. 2014 Dec1;58(4):2405. az 8. Laganà G, Cozza P. Interceptive therapy with elastodontic appliance: case report. Annali Stom. 2010 Jul-Dec(3-4):22- 28. 9. Saccucci M, Tecco S, Ierardo, G, Luzzi V, Festa F, Polimeni rn A. Effects of interceptive orthodontics on orbicular muscle activity: a surface electromyographic study in children. J Elec- tromyogr Kinesiol. 2011 Aug;21(4):665-671. 10. Janson G, Nakamura A, Ciqueto K, Castro R, De Freitas MR, te Costanza Henriques JF. Treatment stability with the erup- tion guidance appliance. Am J Ortho dentofacial orthop. 2007;131(6):717-718. 11. Ierardo G, Luzzi V, Panetta F, Sfasciotti GL, Polimeni A. Noo- In nan syndrome: A case report. Eur J Paediatr Dent. 2010 Jun;11(2):97-100. 12. Auconi P, Caldarelli G, Scala A, Ierardo G, Polimeni A. A net- work approach to orthodontic diagnosis. Orthod Craniofac Res. 2011 Nov;14(4):189-197. ni 13. Polimeni A. Odontoiatria Pediatrica. Elsevier 2012. 14. Bencharit S, Border MB, Mack CR, Byrd WC, Wright JT. Full- mouth rehabilitation for a patient with dentinogenesis im- io Figure 8. Cephalometric skull at 11 years of age. perfecta: a clinical report. J Oral Implantol. 2014 Oct;40 (5):593-600. 15. Roh WJ, Kang SG, Kim SJ. Multidisciplinary approach for a patient with dentinogenesis imperfecta and anterior trau- iz ma. Am J Orthod Dentofacial Orthop. 2010 Sep;138(3):352- 360. References 1. Seow WK. Developmental defects of enamel and dentine: 16. Huth KCh, Paschos E, Sagner T, Hickel R. Diagnostic fea- Ed challenges for basic science research and clinical man- tures and pedodontic-orthodontic management in dentino- agement. Australian Dental Journal. 2014 jun;59suppl1:143- genesis imperfecta type II: a case report. Int J Paediatr Dent. 154. 2002 Sep;12(5):316-321. 2. Akhlaghi N, Eshghi AR, Mohamadpour M. Dental Manage- 17. Ubaldini AL, Giorgi MC, Carvalho AB, Pascon FM, Lima DA, ment of a Child with Dentinogenesis Imperfecta: A Case Re- Baron GM, Paulillo LA, Aguiar FH. Adhesive Restorations port. J Dent (Tehran). 2016 Mar;13(2):133-138. as An Esthetic Solution in Dentinogenesis Imperfecta. J Dent Child (Chic). 2015 Sep-Dec;82(3):171-175. IC 3. Li F, Liu Y, Liu H, Yang J, Zhang F, Feng H. Phenotype and genotype analyses in seven families with dentinogenesis im- 18. Ierardo G, Luzzi V, Vestri A, Sfasciotti GL, Polimeni A. Eval- perfecta or dentin dysplasia. Oral Dis. 2017 Apr;23(3):360- uation of customer satisfaction at the Department of Paediatric 366. Dentistry of “Sapienza” University of Rome. Eur J Paediatr 4. Davis GR, Fearne JM, Sabel N, Norén JG. Microscopic study Dent. 2008 Mar;9(1):30-36. C @ 38 Annali di Stomatologia 2017;VIII (1):34-38 

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Case report Mandibular bone regeneration after bone slat technique i al Salvatore D’Amato MD, DDS1 and soft tissue, in quantity and quality, for place- n Gianpaolo Tartaro MD1 ment of implants. Angelo Itro MD2 Conclusion. The surgical technique was found to io Mario Santagata MD, DDS3 be easy in terms of technique and surgical trau- ma. 1 Multidisciplinary Department of Medical and Dental az Specialties, AOU - SUN, University of Campania “Lui- Key words: bone slat technique, mandible recon- gi Vanvitelli”, Naples, Italy struction, implant dentistry, autologous bone 2 Director of Multidisciplinary Department of Medical block graft. and Dental Specialties, University of Campania rn “Luigi Vanvitelli”, Naples, Italy 3 Division of Oral and Maxillofacial Surgery, Introduction Multidisciplinary Department of Medical and Dental The reconstruction of alveolar ridges for implant Specialties, AOU, University of Campania placement is still a challenging surgical procedure, te “Luigi Vanvitelli”, Naples, Italy especially in the case of extensive vertical and hori- zontal bone atrophy. A number of surgical procedures have been utilized to reconstruct the alveolar crest. In These procedures include “split-ridge” (osteotomy for Salvatore D’Amato lateral expansion), osteodistraction, bone grafting Corresponding author: Multidisciplinary Department of Medical and Dental with various grafting materials (autogenous bone, al- Specialties, AOU - SUN lograft, xenograft and alloplastic materials), guided University of Campania “Luigi Vanvitelli” bone regeneration (GBR) alone or in combination ni Via B. Croce 18 with grafting materials and other techniques (1-18). 80059 Torre del Greco, (NA), Italy Therefore, the purpose of the present study was to E-mail: [email protected] clinically and cone beam computerized tomography io (CBCT) evaluate the quantity and quality of newly re- generated bone for mandibular posterior lateral de- fect utilizing autogenous cortical as a membrane with iz autogenous particulate bone to facilitate placement of implants. Summary Ed Background. The reconstruction of alveolar ridges for implant placement is still a challenging surgical procedure, especially in the case of ex- Case report A 52-year-old female non-smoker, good general con- tensive vertical and horizontal bone atrophy. ditions, edentulous in the posterior mandible, pre- Objective. The objective of the present study was sented for implant rehabilitation. Clinical and radio- to evaluate the quantity and quality of newly re- IC graphic examinations (cone beam computerized to- generated bone; clinically by means of direct clin- mography: panorex and cross section view) showed ical measuring, ridges augmented by autogenous severe vertical mandibular atrophy [7 mm of bone cortical bone associated with autogenous particu- height from the ridge to the mandibular canal and 3 late bone graft in the posterior lower jaw defect. C mm of bone width Occlusal Vertical Dimension (OVD) Methods. For the preliminary study, a bone de- was increased because of bone atrophy] (Figs. 1, 2). fects in partially edentulous in patient aged 52 Posterior mandibular vertical ridge augmentation was years were selected to receive horizontal ridge planned to allow for future placement of implants. augumentation prior autolougous bone block and @ The exclusion criteria were: particulate graft. The donor site was the ramus of • local infection the same side. Prior the clinical evaluation, peri- • smoking(more than 10 cigarettes/day) apical X-ray and the cone beam computerized to- • uncontrolled diabetes (HbA1c >53 mmol/mol) mography (CBCT) was observed the quality, • previous radiotherapy in head and neck region quantity and the stability the soft and hard tissue • chemotherapy in progress healing process, final result and the outcome. • liver, kidney or hematological diseases Result. The bone augmentation achieved with this technique created the ideal bone volume of hard Annali di Stomatologia 2017;VIII (1):39-44 39  S. D’Amato et al. i al Figure 1. a, b Clinical view: horizontal defect; clinical evaluation of the soft tissue and intermaxillary relationship; c. clinical view of the bone defect. n io az rn te In ni io iz Figure 2. CBCT evaluation the horizontal bone defect and the donor site choosing. Ed • immunosuppression the space created between the bone slat and the native • corticosteroid therapy in progress lingual bone (Fig. 3b-d); finally, a resorbable collagen • pregnancy membrane (Bioguide, Geistlich AG, Wolhusen, Switzer- • inflammatory or autoimmune diseases of the oral land) was placed to protect the augmented site (Fig. cavity 3e). The flap was completely release and closed with • poor oral hygiene and lack of motivation. nonabsorbable monofilament sutures 5/0 (Fig. 3f). IC Surgery was carried out under local anesthesia (2% Amoxicillin plus clavulanic acid (825/125 mg 2 times a mepivacaine and adrenalin 1:100 000). A supracrestal day for 6 days) and ibuprofen (600 mg 3 times a day for incision was made in the edentulous ridges and on the 3 days) were administered. Patients were instructed not mucogingival line in the anterior region, and a full mu- to brush the surgical site and to continue rinsing with C coperiosteal flap was raised. The emergence of right in- 0.20% chlorexidine twice a day till suture removal, 15 ferior dental nerves at the mentonian foramina was ex- days later. posed. A bone slat graft from the mandibular ramus of the same side was harvested using piezoelectric equip- @ ment (Piezosurgery, Mectron, Garlasco, Italy) (Fig. 3a). The bone slat graft was fixed on the top of the ridge Clinical measurements with osteosynthesis screws (Stoma Storz am Mark ® Bone height and width were measured by a periodontal Emmingen-Liptingen GmbH). A particulate autologous probe (Hu-Friedy Unc/cp 15) and recorded, by the bone graft was harvested from the mandibular ramus same operator approximating to 0.5 mm, at baseline by cortical bone collector “safescraper twist” (Meta, surgical procedure and at time of implant placement Reggio Emilia, Italy) of the same side placed inside of (re-entry). Two horizontal measurements were taken: 40 Annali di Stomatologia 2017;VIII (1):39-44  Mandibular bone regeneration after bone slat technique i n al io az rn te In ni io Figure 3. a, b. The ramus as donor site, block and particulate. Clinical view the bone harvested using piezosurgery. Note iz very slim the osteotomy thickness; c, d. The block was fixed prior two mini screws and the space making was filled with au- tologous particulate bone; e. The surgical site of the bone augmentation was been covered with a resorbable collagen mem- brane in a double layer; f. The flap, after periosteum incision, was relaxed to obtain a correct suturing. Ed one at the point of greatest coronal convexity of the ad- augmentation (Fig. 5b, c) and were loaded 2 months af- jacent teeth and one at the greatest concavity of the ter placement. No implant failures were recorded 36 defects. For this second measurement the distance to months after loading (Figs. 5d-7a, b). the adjacent teeth cement-enamel junction was record- IC ed to standardize the height of measurement. Vertical measurements were taken at the maximum bone defi- ciency, and compared to adjacent bone peaks. Discussion Two MIS V3 implants (MIS) 5.0 mm diameter and 10 In cases of a three-dimensional ridge defect, a non- C mm length in correspondence of the tooth 46 and 3.9 absorbable membrane with a supporting titanium mm diameter and 11.5 mm length in tooth 44 were in- frame is required (19). The possibility of grafting-ma- serted as prosthetically planned. terial collapse or premature membrane exposure is greatly increased (20). As an alternative to the single @ block onlay graft, a method using a thinner cortical blocks (laminae) was introduced. These can be fixed into the defect area to create the occlusal bone plate Results The postoperative clinical and radiographic examina- and the vestibular plate or the buccal and lingual tion (periapical x ray and CBCT scan) showed an in- walls (21) and Khoury first used thin mandibular corti- crease in the height and the width of the alveolar ridge cal bone blocks (laminae) to reconstruct the buccal (Figs. 4a, b, 5a). Implants were placed 3 months after and palatal (lingual) walls or the occlusal wall of verti- Annali di Stomatologia 2017;VIII (1):39-44 41  S. D’Amato et al. i al a b Figure 4. a, b Clinical and radiographic (CBCT Scan) view after 3 months. n io az rn te In ni io Figure 5. a. Bone healing after 3 months; b. Implants placement; c. Healing abutment and connective tissue graft; d. soft tis- sue healing around implants after 12 months. iz Ed IC Figure 6. a, b. Clinical view immediate delivery of the prosthesis in 2013; c. Periapical X-Ray. cal defects, filling the intervening space with autoge- and good fit between the graft and the recipient site C nous bone (21). We modified this technique because had been obtained during the first surgery. we prefer to harvest the laminae autologous bone di- In the present study no exposure of the bone slat rectly from the donor site in single slats differently graft was observed. This phenomenon, which is from that described by Khoury (21) that harvests the rather commonly reported (22), was carefully avoided @ block and than perform the splitting of the block in by a complete release of the flaps during the first several laminae. surgery. According to our study, the bone augmentation tech- Moreover, several Authors, have described neurologi- niques generated a sufficient amount of bone to in- cal problems due to bone harvesting from the sert an implant properly. At reentry, the autologous mandibular ramus and symphysis, characterized by bone slat grafting appeared clinically well-incorporat- paraesthesia, anaesthesia, hyperalgesia of the chin ed into the native bone, suggesting that good contact area (23, 24). 42 Annali di Stomatologia 2017;VIII (1):39-44  Mandibular bone regeneration after bone slat technique i n al io Figure 7. a. Clinical view after 3 years; b. Periapical X-Ray after 3 years. This technique involves the removal only of the corti- grafts and implants: a 3-year report of a prospective clinical az cal bone by way of slats thus avoiding the possibility study. Clinical Implant Dentistry and Related Research. of damaging neurovascular underlying structures 2007;9:46-59. making it safe and effective. 10. Hammerle CH, Jung RE, Yaman D, Lang NP. Ridge aug- mentation by applying bioresorbable membranes and de- Further studies are needed to increase the sample proteinized bovine bone mineral: a report of twelve con- rn size, to verify augmentation stability over time, suc- secutive cases. Clinical Oral Implants Research. 2008;19:19- cess of implant therapy in the medium and long term 25. and eventual differences in the incidence of biological 11. Jensen SS, Terheyden H. Bone augmentation procedures or aesthetic complications using this technique. The te in localized defects in the alveolar ridge: clinical results with bone slat technique was found to be easy, effective different bone grafts and bone-substitute materials. Inter- and surgically atraumatic. national Journal of Oral and Maxillofacial Implants. 2009;24(Suppl):218-236. In 12. Gonzalez-Garcia R, Monje F, Moreno C. Alveolar split os- teotomy for the treatment of the severe narrow ridge max- illary atrophy: a modified technique. International Journal of References 1. D’Amato S, Tartaro G, Itro A, Nastri L, Santagata M. Block Oral and Maxillofacial Surgery. 2011;40:57-64. versus particulate/titanium mesh for ridge augmentation for 13. Simion M, Baldoni M, Zaffe D. Jawbone enlargement using ni mandibular lateral incisor defects: clinical and histologic anal- immediate implant placement associated with a split-crest ysis. Int J Periodontics Restorative Dent. 2015;35(1):e1-8. technique and guided tissue regeneration. Int J Periodontics 2. Santagata M, Tartaro G, D’Amato S. Clinical and histolog- Restorative Dent. 1992;12:462-473. io ic comparative study of subepithelial connective tissue 14. Scipioni A, Bruschi GB, Calesini G. The edentulous ridge ex- graft and extracellular matrix membrane. A preliminary split- pansion technique: a five year study. Int J Periodontics mouth study in humans. Int J Periodontics Restorative Dent. Restorative Dent. 1994;14:451-459. 15. Schwartz-Arad D, Levin L. Multitier technique for bone aug- iz 2015;35(1):85-91. 3. Moura LB, Carvalho PH, Xavier CB, Post LK, Torriani MA, mentation using intraoral autogenous bone blocks. Implant Santagata M, Chagas Júnior OL. (2016) Autogenous non- Dent. 2007;16(1):5-12. vascularized bone graft in segmental mandibular recon- 16. Boyne PJ, Cole MD, Stringer D, Shafqat JP. A technique for Ed struction: a systematic review. Int J Oral Maxillofac Surg osseous restoration of deficient edentulous maxillary ridges. 45(11):1388-1394. J Oral Maxillofac Surg. 1985;43(2):87-91. 4. Santagata M, Guariniello L, Tartaro G. Modified edentulous 17. Marchetti C, Corinaldesi G, Pieri F, Degidi M, Piattelli A. ridge expansion technique and immediate implant placement: Alveolar distraction osteogenesis for bone augmentation a 3-year follow-up. J Oral Implantol. 2015;41(2):184-187. of severely atrophic ridges in 10 consecutive cases: a his- 5. Santagata M, Guariniello L, Prisco RV, Tartaro G, D’Ama- tologic and histomorphometric study. J Periodontol. 2007; IC to S. Use of subepithelial connective tissue graft as a bio- 78(2):360-366. logical barrier: a human clinical and histologic case report. 18. Buser D, Bornstein MM, Weber HP, Grütter L, Schmid B, J Oral Implantol. 2014;40(4):465-468. Belser UC. Early implant placement with simultaneous 6. Santagata M, Guariniello L, Tartaro G. A modified edentu- guided bone regeneration following single-tooth extraction lous ridge expansion technique for immediate placement of in the esthetic zone: a cross-sectional, retrospective study C implants: a case report. J Oral Implantol. 2011;37SpecNo:114- in 45 subjects with a 2- to 4-year follow-up. J Periodontol. 119. 2008;79(9):1773-1781. 7. Santagata M, Guariniello L, D’Andrea A, Tartaro G. A mod- 19. Funato A, Ishikawa T, Kitajima H, Yamada M, Moroi H. A nov- ified crestal ridge expansion technique for immediate place- el combined surgical approach to vertical alveolar ridge aug- @ ment of implants: a report of three cases. J Oral Implantol. mentation with titanium mesh, resorbable membrane, and 2008;34(6):319-324. rhPDGF-BB: a retrospective consecutive case series. Int J 8. Widmark G, Andersson B, Ivanoff CJ. Mandibular bone graft Periodontics Restorative Dent. 2013;33:437-445. in the anterior maxilla for single-tooth implants. Presentation 20. Misch CM, Jensen OT, Pikos MA, Malmquist JP. Vertical bone of surgical method. International Journal of Oral and Max- augmentation using recombinant bone morphogenetic pro- illofacial Surgery. 1997;26:106-109. tein, mineralized bone allograft, and titanium mesh: a ret- 9. Sjostrom M, Sennerby L, Nilson H, Lundgren S. Recon- rospective cone beam computed tomography study. Int J Oral struction of the atrophic edentulous maxilla with free iliac crest Maxillofac Surg. 2015;30:202-207. Annali di Stomatologia 2017;VIII (1):39-44 43  S. D’Amato et al. 21. Khoury F, Khoury CH. Mandibular bone block grafts: diag- 1996;11(3):387-394. nosis, instrumentation, harvesting techniques and surgical 23. Nkenke E, Schultze-Mosgau S, Radespiel-Tröger M, Kloss procedures. In: Khoury F, Antoun, H, Missika P, eds. Bone F, Neukam FW. Morbidity of harvesting of chin grafts: a Augmentation in Oral Implantology. Berlin: Quintessence. prospective study. Clin Oral Implants Res. 2001;12(5):495- 2007. 502. 22. Von Arx T, Hardt N, Wallkamm B. The TIME technique: a 24. Raghoebar GM, Louwerse C, Kalk WW, Vissink A. Morbid- new method for localized alveolar ridge augmentation prior ity of chin bone harvesting. Clin Oral Implants Res. i to placement of dental implants. Int J Oral Maxillofac Implants. 2001;12(5):503-307. n al io az rn te In ni io iz Ed IC C @ 44 Annali di Stomatologia 2017;VIII (1):39-44 

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Review article Access to oral health care services among adults with learning disabilities: a scoping review i al Mustafa Naseem1 Objectives. The objectives of the review were to Altaf H Shah1,2 identify barriers in accessing oral health care that n Muhammad Faheem Khiyani3 persists within society, enabling or disabling peo- Zohaib Khurshid4 ple with learning disabilities. io Muhammad Sohail Zafar5 Methods. Using the Arksey O’Malley framework, a Shabnam Gulzar6 scoping review was conducted on PubMed/Med- AlBandary H. AlJameel7 line, OVIDSP, and EMBASE. Studies were evaluat- az Hesham S. Khalil8 ed and short-listed based on the inclusion criteria, which consisted of: (1) study participants or popu- lation with learning disabilities, (2) aged 16 years 1 Department of Preventive Dental Sciences, College or over, (3) reporting on access to oral health ser- rn of Dentistry, Dar Al Uloom University, Riyadh, vices, (4) published in the English language. Those Saudi Arabia that justified the inclusion criteria were carefully 2 Fellow, Pacific Academy of Higher Education and Re- chosen after a blind peer-reviewed process when search (PAHER) University, Udaipur, Rajasthan, India relevance and quality were debated. te 3 Oral Health and Rehabilitation Research Unit, Results. Nine studies were eventually included Biomedical Sciences Faculty of Medicine, Universite from searches. Tabulation of data was done under de Montreal, Montreal, Canada the heading of study type, outcomes, the year of 4 Department of Prosthodontics and Implantology, In publication and patient selection. The majority of School of Dentistry, King Faisal University, Al-Ahsa studies provided a biomedical overview of access Saudi Arabia for adults with learning disabilities. 5 Department of Restorative Dentistry, College of Conclusions. The concept of access for people with ni Dentistry, Taibah University, Medinah Munnawarrah, disability is still ill-defined and obscure. Access to Saudi Arabia oral health care and needs of people with learning 6 Division of Pediatric Dentistry, Department of disabilities are complex and multi-facet. io Preventive Dental Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, Saudi Arabia Key words: learning disability, access, oral 7 Department of Periodontics and Community Dentistry, health, health service utilization, scoping review. iz College of Dentistry, King Saud University, Riyadh, Saudi Arabia 8 Department of Oral and Maxillofacial Surgery, Introduction Ed College of Dentistry, King Saud University, Riyadh, Saudi Arabia Access to affordable and acceptable health care, in- cluding access to oral health services is a basic and fundamental human right (1). Unfortunately, an in- Corresponding author: verse relationship exists in this context, and people Mustafa Naseem who have greater health needs are the ones who re- IC Department of Community and Preventive Dentistry ceive the least amount of care (2). This is also evi- Dar Al Uloom University, KSA Riyadh dent when it comes to the oral health of marginalized Exit 7 Alfalah groups, like those with mental, intellectual or behav- 75540 Riyadh, Saudi Arabia ioral challenges, and physical disabilities (3-5). C E-mail: [email protected] It is observed that similar to other marginalized groups, people with learning disabilities also have poorer oral hygiene status and a higher prevalence of dental caries Summary and periodontal disease (6, 7). As a consequence, poor @ oral health not only affects the physical well-being of Background. The prevalence of oral diseases in- these groups but also has a marked impact on their cluding dental caries and periodontal conditions quality of life, overall health and self-esteem (8). In a is remarkably higher in people with disabilities. recent study, it was proposed that groups with special The provision of accessible oral health services needs may present with complex needs that can be for people with learning disabilities may be chal- met through prevention and which require extensive fo- lenging. cus towards further research (9). 52 Annali di Stomatologia 2016;VII (3):52-59  Access to oral health care services among adults with learning disabilities: a scoping review Models of disability and access to care health, social care, and general medicine. Although evidence of good practice has been reported under The term “disability” has been defined and utilized in these areas, yet more research is needed in this do- various forms in recent years. The medical model and main (23). Although Authors found a systematic re- the social model of disability present two contrasting view (24) of the oral health of people with intellectual concepts that define disability in completely different disabilities and access to healthcare for disabled peo- context and setting (10). While the medical model ple (25), yet the Authors did not find any review ana- i lyzing disparity in access to oral health care for peo- al proposes that disability physical or behavioral should be seen as individualistic, the social model sees dis- ple with learning disabilities. Therefore, the aim of ability through a social lens and considers it as a this scoping review was to review access to oral challenge for the society as a whole. It focuses on health care for people with learning disabilities, along n systems structure that enables the society to access with identifying barriers to accessing oral health care and utilize health care, thus preventing disability from that persists within society. io becoming a handicap (11). Oliver and Zarb critique that health systems based on the biomedical model of health promotion influence the objectification, clas- Methods az sification and categorization of people, thus promot- ing discrimination, labeling and victim blaming (12, The study followed the framework presented by Ark- 13). sey O’Malley for scoping reviews (26). The review fol- Access to services for people with learning disabili- lowed five stages: (1) Identifying the research ques- rn ties appears multi-dimensional and multi-faceted (14, tion; (2) Literature search; (3) Study selection; (4) Da- 15). The poor oral health status of people with learn- ta extraction; and (5) Summarizing and reporting the ing disabilities reflects the barriers to access faced by results. A broad research question was selected in them and is evident as the marked variation seen in order to scope the extent of research available on the te the utilization of these services (16). This eventually subject and to avoid early exhaustion of literature results in detrimental oral health outcomes (17). The during the search process. most commonly identified barrier to health or oral An initial search of broader concepts using various health service utilization is physical access (18, 19). In search terms was conducted on PubMed and a log of While physical access to roads, transportation, hospi- relevant terms was maintained. Three major concepts tal buildings and clinical facilities is crucial, the ability were used: learning disability, oral health, and access to access a workforce which is conducive and trained to care. The pilot search developed the final research ni to cater to the special needs of marginalized groups question and dictated the inclusion and exclusion cri- is of equal importance (20). teria. Various models of access including various criteria Research question: what are the barriers to the ac- cess of oral health care services for adults (16 years io have been proposed by different Authors (17, 19, 21). However, there seems to be a variation in utilization and over) with learning disabilities? of services. These variations in the uptake of services A detailed search strategy was then developed using are due to attitudes, research, and policies based on relevant MeSH terms and keywords, with the assis- iz the biomedical model of access rather than the social tance of an expert librarian (Tab. 1). The final search model (22). strategy, with database specific modifications, was Ed Most of the work done on access for people with executed on Medline via OvidSP, PubMed, and EM- learning disabilities has taken place in the field of BASE. Table 1. Search Strategy on Medline. 1. *developmental disabilities/ or *intellectual disability/ or exp learning disorders/ or exp Communication Disorders/ IC 2. (Intellectual disabilities or learning disability or communication disorder or developmental disability or developmental disorder).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier] C 3. exp Dental Care for Disabled/ or exp Dental Health Services/ or *Oral Health/ 4. (Oral health services or dental health services).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier] @ 5. exp “Delivery of Health Care”/ 6. (((health service access or delivery of health care or access to health care or health) adj3 utilization) or access).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol sup- plementary concept word, rare disease supplementary concept word, unique identifier] 7. (1 or 2) and (3 or 4) and (5 or 6) 8. limit 7 to “all adult (19 plus years)” Annali di Stomatologia 2016;VII (3):52-59 53  M. Naseem et al. Studies meeting the following inclusion criteria were Endnote Citation Manager X7 was used to catalog subsequently included in the scoping review: (1) the studies according to database, duplicates, initial study participants or population with learning disabili- screening and final inclusion. An of the scoping re- ties, (2) aged 16 years or over, (3) reporting on ac- view process according to PRISMA guidelines is pre- cess to oral health services, (4) published in English sented in Figure 1. language. The exclusion criteria to filter out the stud- ies were (1) any gray literature, (2) non-peer re- i viewed articles, (3) articles which were not focusing Results al on oral health and focused on children disability (4) articles other than English were excluded. There Around 195 studies were retrieved from the search were no date limitations applied for study designs or strategy and 3 studies were shortlisted through other n year of publication, and all studies published until resources. Following duplicate removal (n=31) 167 February 2016 were considered for eligibility. An age studies were screened for title and abstract and 88 io limit was applied restricting the results to studies pub- studies were selected for full-text review. Following lished on an adult study population “All adults-16 plus review and discussion, nine studies were included in years” in Medline and “18 to 64 years” in EMBASE). the study (Fig. 1) Prisma Flow diagram. az Table 2 illustrates a list of databases, search engines Table 3 shows the general characteristics of studies and library resources used for the literature search. considered in this scoping review. A total of nine arti- Screening and study selection: two reviewers (Author cles were included in the final synthesis. These arti- 1 and 2) conducted literature screening, and study cles had been published between years 1991 to rn selection independently, following duplicate removal 2011. Among the nine reviewed articles, three studies after initial title and abstract screening, relevant stud- were quantitative studies (27-29) with cross-sectional ies meeting the research question theme were select- study design. Two were verifiable CPD papers (17, ed for full-text review. Following the full-text review, 30) based on the existing literature and two were te studies meeting the inclusion criteria were included in qualitative studies based on interviews and opinions the scoping review. Data extraction for each study in- (5, 16). Two studies were review articles (19, 29). cluded in the final selection was carried out, using a One-third of the studies used quantitative study de- data extraction form, recording information on the In signs to explore access to services with broader sam- main characteristics and findings of each study. ples. The total number of responders (sample) Disagreements were resolved by discussion with a ranged 485 to 1984 for quantitative researches. In third reviewer (Author 3) and a consensus was the qualitative study the sample of the study partici- ni achieved. The online search was further complement- pants ranged from 10 to 40. ed by hand searching and sifting through the bibliog- In general, CPD papers (17, 30) highlighted ways to raphy of studies shortlisted for inclusion. address unmet needs and improve access to the io Table 2. List of data bases, search engines, libraries resources used for literature search. iz  

 

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Figure 1. Prisma flow diagram. iz most vulnerable sections of society i.e. disabled indi- plain access to dental services for people with dis- Ed viduals. Similarly, in quantitative studies both internal abilities, they lean towards the biomedical model with and external barriers were identified, which compro- minimal emphasis on the social aspect of care and mised utilization of dental services among adults with access. Only those aspects of access are taken into disabilities. In all nine studies, access was poorly de- account which may pose as physical barriers to oral fined and the term remains ambiguous for people care for adults with learning disabilities, while little at- with learning disabilities. tention is given to other multi-dimensional aspects of IC access. Similarly, Koneru and Sigal (27) and Cumella et al. Discussion (5) also cite access as the “ability to obtain and use services”. The definition moves towards an indicator C The present study was based on the hypothesis that of access without describing what “access” really access to oral health care for adults with learning dis- means for people with disabilities (31). abilities is similar to the general population. To our This was observed throughout the studies reviewed. understanding from indexed literature, this is the first Policy makers, professionals and Authors when at- @ scoping review that systematically reviewed access tempting to suggest effective health care reforms, to Oral health care among adults with learning dis- tend to assign different meanings to the term “ac- abilities. cess” based on the feasibility and suitability of the Interestingly, the majority of studies included in this profession without justifying comprehension and com- review define access on the basis of the single con- plexity of issue (21, 32). cept of “utilization of services”. While both papers by Recently, a renewed emphasis was given for access Dougall and Fiske (17), Gallagher and Fiske (30) ex- to oral care by Owens et al. (16) who presented a Annali di Stomatologia 2016;VII (3):52-59 55  @ 56 Table 3. List of studies and their general characteristics included in the review. 

 
 
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Annali di Stomatologia 2016;VII (3):52-59 57  M. Naseem et al. ported barrier to access dental services was fear, ing according to adults with intellectual disabilities: towards lack of knowledge, and awareness of carers to visit tailoring health promotion initiatives. J Intellect Disabil Res. dental services along with poor attitudes and skills of 2016;60(3):228-241. 2. Hart JT. The inverse care law. The Lancet. 1971;297(7696): the dentist as pointed out by Owens et al. (16), 405-412. Cumella et al. (5), Pradhan et al. (29), Koneru and 3. de Castilho LS, Abreu MH, de Oliveira RB, Souza ESME, Sigal (27). Resende VL. Factors associated with mouth breathing in The needs of people with disabilities are diverse, i children with -developmental -disabilities. Spec Care complex and go beyond the sole provision of oral al Dentist. 2016. healthcare (17). Gallagher and Fiske (30) suggested 4. Scott A, March L, Stokes ML. A survey of oral health in a that the need for Special Care Dentistry (SCD) is the population of adults with developmental disabilities: com- much-needed necessity of today’s time. SCD can ad- parison with a national oral health survey of the general n dress the oral health care needs of people with pro- population. Aust Dent J. 1998;43(4):257-261. found and severe disabilities, who require personal- 5. Cumella S, Ransford N, Lyons J, Burnham H. Needs for io oral care among people with intellectual disability not in con- ized one on one care (37, 39). Therefore, the Authors tact with Community Dental Services. J Intellect Disabil Res. emphasized on the need for the commissioning of 2000;44 ( Pt 1):45-52. Dentists With Special Interests (DwSI), who may hold az 6. Merrick J, Kandel I, Lotan M, Aspler S, Fuchs BS, Morad competencies between general and special dentists M. National survey 2007 on medical services for persons and may be able to, form a skilled workforce in order with intellectual disability in residential care in Israel. Int to address the unmet needs of people with learning J Adolesc Med Health. 2010;22(4):575-582. disabilities (4, 30). 7. Niazi F, Naseem M, Khurshid Z, Zafar MS, Almas K. Role rn of Salvadora persica chewing stick (miswak): A natural toothbrush for holistic oral health. European journal of den- tistry. 2016;10(2):301. Conclusion 8. Raftery J. NICE: Faster access to modern treatments? Anal- te ysis of guidance on health technologies. British Medical Within the limitations of this current scoping review, it Journal. 2001;323(7324):1300. can be concluded that access for people with disabili- 9. Shah A, Bindayel N, AlOlaywi F, Sheehan S, AlQahtani H, ties is a multi-dimensional concept, which continues AlShalwi A. Oral health status of a group at a special needs In centre in AlKharj, Saudi Arabia. Journal of Disability and to be poorly demarcated and under-addressed. A bet- Oral Health. 2015;16:3. ter understanding of the problem at hand from a so- 10. Scambler S, Low E, Zoitopoulos L, Gallagher J. Profes- cial perspective has the potential to effectively ad- sional attitudes towards disability in special care dentistry. dress the challenges present and fill the gaps in ac- Journal of Disability and Oral Health. 2011;12(2):51. ni cess to care. 11. Rapley M. The social construction of intellectual disabili- ty. Cambridge University Press; 2004. 12. Oliver M, Zarb G. The politics of disability: a new approach. io Recommendations Disability, Handicap & Society. 1989;4(3):221-239. 13. Khurshid Z, Naseem M, Sheikh Z, Najeeb S, Shahab S, Zafar MS. Oral antimicrobial peptides: Types and role in It is vital that a more integrated model of access is iz the oral cavity. Saudi Pharmaceutical Journal. 2015. defined, which takes into consideration both models 14. Shakespeare T. Disability rights and wrongs revisited. Rout- of disability (i.e. social and medical) and seeks to un- ledge; 2013. derstand the complexity of the lives of people with 15. Thomas C. Sociologies of disability and illness: Contest- Ed learning disabilities. It must also be taken into consid- ed ideas in disability studies and medical sociology. Pal- eration that people with learning disabilities are spe- grave Macmillan; 2007. cial individuals and each will experience access in a 16. Owens J, Mistry K, Dyer T. Access to dental services for people with learning disabilities: Quality care? Journal of different way. Additionally, in order to provide better Disability and Oral Health. 2011;12(1):17. access to care for people with learning disabilities, 17. Dougall A, Fiske J. Access to special care dentistry, part the role of ‘carers’ should be enhanced as they are IC 1. Access. British dental journal. 2008;204(11):605-616. considered as their gate keepers. 18. Scully C, Dios PD, Kumar N. Special care in dentistry: hand- Furthermore, this scoping review follows the Arksey book of oral healthcare. Elsevier Health Sciences; 2006. O’Malley framework (40) of scoping review. While the 19. Owens J, Dyer TA, Mistry K. People with learning disabilities framework continues to be the widely used, recent and specialist services. Br Dent J. 2010;208(5):203-205. C improvements such as the JBI framework have the 20. Oliver M. Understanding disability: From theory to prac- potential to provide a more robust methodology to the tice. St Martin’s Press; 1996. scoping review process. It is therefore recommended 21. Penchansky R, Thomas JW. The concept of access: def- inition and relationship to consumer satisfaction. Medical that in future, researchers may consider utilizing this @ care. 1981;19(2):127-140. improved framework. 22. Power TJ, Eiraldi RB, Clarke AT, Mazzuca LB, Krain AL. Improving Mental Health Service Utilization for Children and Adolescents. School Psychology Quarterly. 2005;20(2):187. References 23. Oliver M, Sapey B, Thomas P. Social work with disabled people. Palgrave Macmillan; 2012. 1. Kuijken NM, Naaldenberg J, Nijhuis-van der Sanden 24. Anders PL, Davis EL. Oral health of patients with intellectual MW, van Schrojenstein-Lantman de Valk HM. Healthy liv- disabilities: a systematic review. Special Care in Dentistry. 58 Annali di Stomatologia 2016;VII (3):52-59  Access to oral health care services among adults with learning disabilities: a scoping review 2010;30(3):110-117. sity Microfilms; 1987. 25. Gibson J, O’Connor R. Access to health care for disabled 33. Donabedian A. Models for organizing the delivery of per- people: a systematic review. Social care and Neurodis- sonal health services and criteria for evaluating them. The ability. 2010;1(3):21-31. Milbank Memorial Fund Quarterly. 1972;50(4):103-154. 26. Arksey H, O’Malley L. Scoping studies: towards a method- 34. Guay AH. Access to dental care: the triad of essential fac- ological framework. International journal of social re- tors in access-to-care programs. The Journal of the search methodology. 2005;8(1):19-32. American Dental Association. 2004;135(6):779-785. i 27. Koneru A, Sigal MJ. Access to dental care for persons with 35. Hallberg U, Klingberg G. Giving low priority to oral health al developmental disabilities in Ontario. J Can Dent Assoc. care. Voices from people with disabilities in a grounded the- 2009;75(2):121. ory study. Acta Odontologica Scandinavica. 2007;65(5):265- 28. Wu B, Plassman BL, Liang J, Wei L. Cognitive function and 270. dental care utilization among community-dwelling older 36. Browne T. A small-scale exploratory study of the needs of n adults. American Journal of Public Health. 2007;97(12): learning disabled patients presenting for an x-ray exami- 2216-2221. nation. Radiography. 1999;5(2):89-97. io 29. Pradhan A, Slade G, Spencer A. Access to dental care 37. Dougall A, Fiske J. Access to special care dentistry, part among adults with physical and intellectual disabilities: res- 6. Special care dentistry services for young people. Br Dent idence factors. Australian dental journal. 2009;54(3):204- J. 2008;205(5):235-249. 211. 38. Lennox N, Diggens J, Ugoni A. The general practice care az 30. Gallagher J, Fiske J. Special care dentistry: a professional of people with intellectual disability: barriers and solutions. challenge. British Dental Journal. 2007;202(10):619-629. Journal of Intellectual Disability Research. 1997;41(5):380- 31. Savedoff WD. A moving target: universal access to 390. healthcare services in Latin America and the Caribbean. 39. Fiske J, Griffiths J, Jamieson R, Manger D. Guidelines for rn Working paper//Inter-American Development Bank, Re- oral health care for long-stay patients and residents. search Department;2009. 40. Perreira TA, Innis J, Berta W. Work motivation in health 32. Khan AA-M. Evaluating the performance of a regional health care: a scoping literature review. International Journal of care service system: a geographic methodology. Univer- Evidence-Based Healthcare. 2016. te In ni io iz Ed IC C @ Annali di Stomatologia 2016;VII (3):52-59 59 

https://www.annalidistomatologia.eu/ads/article/view/64

Original article Protective effects of a zinc-hydroxyapatite toothpaste on enamel erosion: SEM study i al Marco Colombo Zn-HAP technology can provide in protecting ena- Riccardo Beltrami mel from erosive acid challenges. n Davide Rattalino Maria Mirando Key words: enamel erosion, fluoride, hydroxyap- io Marco Chiesa atite, SEM, surface analysis, toothpastes. Claudio Poggio Introduction az Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Section of Dentistry, The prevalence of dental erosion (erosive tooth wear) University of Pavia, Italy is thought to be increasing, due to the wide availability, rn and frequent consumption of acidic drinks such as soft drinks, sports drinks and fruit juices (1). The develop- Corresponding author: ment of erosion involves a chemical process in which Claudio Poggio the inorganic phase of the tooth is demineralized, te Department of Clinical, Surgical, Diagnostic and thereby reducing the hardness of tooth substrates (2). Pediatric Sciences To prevent dental erosion many strategies have been Section of Dentistry, Policlinico “San Matteo” developed (3). To improve enamel and dentin resis- Piazzale Golgi 3 In tance, toothpastes were considered effective and af- 27100 Pavia, Italy fordable vehicles (4). The incorporation of protective E-mail: [email protected] agents in toothpastes has become increasingly com- mon; also because dental sensitivity, a problem often related to acid erosion, is a common complaint ni Summary among patients. Currently, conventional fluoride- based toothpastes do not seem to be able to effec- Aim. The aim of the present in vitro study was to tively protect teeth against erosion (5). Recently, new io evaluate the protective effects of a zinc-hydroxya- toothpastes formulations have been introduced to patite toothpaste against an erosive challenge contrast enamel and dentin erosion. Among the large produced by a soft drink (Coca-Cola) using Scan- amount of commercially available products, several iz ning Electron Microscopy (SEM). new toothpaste technologies were subject of our pre- Methods. Forty specimens were assigned to 4 vious studies (6, 7). Changes in tooth structure due to groups of 10 specimens each (group 1: no ero- extrinsic factors, such as acidic challenges from food Ed sive challenge, no toothpaste treatment, group 2: and drink, have been widely investigated through erosive challenge, no toothpaste treatment, group Scanning Electron Microscopy (SEM). The aim of the 3: erosive challenge, fluoride toothpaste treat- present study was to test the impact of toothpaste ment, group 4: erosive challenge, zinc-hydroxyap- with Zinc-Hydroxyapatite (Zn-HAP) on preventing atite toothpaste treatment). The surface of each enamel erosion compared to toothpaste with fluoride specimen was imaged by SEM. A visual rating by using Scanning Electron Microscopy (SEM). IC system was used to evaluate the condition of the enamel surface; results were analyzed by non- parametric statistical methods. Materials and methods Results. Statistically significant differences were C found between the samples untreated and those The test toothpaste was: Zn-HAP (Microrepair®) immersed in Coca-Cola (group 1, 2); the highest toothpaste, without fluoride (Biorepair; Coswell grade of damage was found in group 2, while the S.P.A., 40050 Funo, Italy). The control toothpaste lowest grade was recorded in the samples of was: fluoride toothpaste, 1450 ppm F- as NaF (Eu- @ group 4. Comparing the groups, the two analyzed fresh; CIO Farmaceutici s.r.l., 81100 Caserta, Italy). toothpaste tended to protect in different extend. The study involved four different treatment groups: Conclusions. In this study treatment of erosively group 1: no erosive challenge, no toothpaste treat- challenged enamel with Zn-Hap toothpaste ment; showed a clear protective effect. This was greater group 2: erosive challenge, no toothpaste treatment; than the effect observed for a normal fluoride group 3: erosive challenge, fluoride toothpaste treat- toothpaste and confirmed the potential benefit the ment; 38 Annali di Stomatologia 2016;VII (3):38-45  Protective effects of a zinc-hydroxyapatite toothpaste on enamel erosion: SEM study group 4: erosive challenge, zinc-hydroxyapatite tooth- 36 h; during these intervals the specimens were kept paste treatment. in artificial saliva. The specimens of group 2, 3 and 4 were immersed in 6 ml of the soft drink for 2 min at Specimen preparation room temperature before rinsing with deionized wa- ter. Four consecutive intervals of the immersion pro- Specimens were prepared from 40 human incisors, cedure were carried out (8). The immersions in the extracted for orthodontic and periodontal reasons. soft drink were repeated as described above at 0, 8, i Debris and soft tissue were eliminated and teeth were 24 and 36 h. al inspected for cracks, hypoplasia, white spot lesions and reconstruction. Teeth were cleaned to remove Scanning Electron Microscopy (SEM) soft tissue and stored in a solution of 0.1% (wt/vol) n thymol. The enamel specimens were cut at the enam- The specimens were gently air dried, dehydrated with el-dentin junction with a high-speed diamond rotary alcohol, sputter‐coated with gold. Enamel and dentin io bur with a water-air spray. The samples were placed were characterized using a field emission scanning into Teflon molds measuring 10 x 8 x 2 mm and em- electron microscope (FE‐SEM, MIRA3, TESCAN). bedded in self-curing, fast-setting acrylic resin (Rapid Serial SEM microphotographs of the surfaces of each az Repair, DeguDent GmbH, Hanau, Germany) in such specimen at 2.50 KX and 5.00 KX original magnifica- a way that the exposed buccal surface was plano- tions were obtained (9). A systematic assessment parallel to the bottom of the mold. method was adopted for grading the SEM images. SEM images recorded were evaluated in terms of rn Demineralization and remineralization enamel damages by three experienced assessors who randomly examined the samples twice in a blind A soft drink (Coca Cola, Coca Cola Company, Milano, manner. A scoring scale (Tab. 2) was adopted to de- Italy) was chosen for the demineralization process scribe the enamel surface (10). te (6). The pH at 20˚C, buffering capacity, and concen- tration of calcium and phosphate of the beverage Statistical Analysis were measured by standard chemical methods. The pH of soft drink was measured with a pH meter (Acc- In Descriptive statistics for the scores of the morphologi- umet AB15, Fisher Scientific, Pittsburgh, PA). Ca 2- cal analysis were calculated. Data were analyzed and PO43- were determined by flame atomic absorp- with the Kruskal-Wallis test. The Mann-Whitney U tion (Perkin Elmer 1100 B spectrophotometer). Mea- test was performed for post hoc comparisons. Signifi- surements were performed in triplicate and average cance was set at a P value <0.05. In order to check ni values calculated (Tab. 1). the intra - and inter-observer reliability the Intraclass The samples were then assigned to the four treat- Correlation Coefficient was calculated; it was greater ment groups with 10 specimens per group. than 0.9. io The toothpastes were applied neat onto the surface of the specimens to cover the enamel surface without brushing and then wiped off with distilled water wash- Results iz ing after every treatment to remove residual tooth- paste; the control specimens (group 1) were taken on The mean amounts of scores for the morphological storage for the whole experimentation and they did analysis of the images are reported in Table 3 and in Ed not receive any treatment. The toothpastes were ap- Figure 1. The Kruskal-Wallis test showed the pres- plied to the enamel surfaces for 3 min at 0, 8, 24 and ence of significant differences among the different Table 1. Chemical properties of the soft drink used in the study. IC Beverage Ph Buffering Capacity Po4 (Mg/L) Ca (Mg/L) Coca Cola 2,44 0,0056 175,7 20,83 C Table 2. Scoring criteria used for the evaluation of SEM images. Grade Status @ 0 Enamel surface remained perfectly intact with no grooves, pits, and porosity 1 Presence of surface irregularities on enamel surface, without demineralization of prismatic and/or interprismatic enamel 2 Presence of wrinkles and demineralization of prismatic/interprismatic enamel 3 Diffuse demineralization involved the rod core, with decomposition of morphology of prism Annali di Stomatologia 2016;VII (3):38-45 39  M. Colombo et al. Table 3. Means and standard deviations of the morphological SEM scores provided by the three observers and overall. Different superscript letters indicate significant differences (p <0.05). Observer 1 Observer 2 Observer 3 Overall Group 1 0.53 ± 0.52 0.68 ± 0. 44 0.63 ± 0.61 0.61 ± 0.52 a Group 2 2.73 ± 0.46 2.44 ± 0.66 2.89 ± 0.34 2.69 ± 0.49 i b al Group 3 2.2 ± 0.41 2.11 ± 0.57 1.97 ± 0.44 2.1 ± 0.47 c Group 4 1.27 ± 0.46 1.18 ± 0.35 1.45 ± 0.33 1.3 ± 0.38 d n io groups (p<0.05). On enamel surfaces not exposed to Discussion and conclusions the erosive challenge by the soft drink (group 1), the typical structures of sound enamel such as grooves In this study the morphological analysis of enamel az and perichimata lines were apparent; also small de- surfaces after an erosive acid challenge from a soft pressions or ditches or grinding marks were found in- drink followed by treatment with Zn-Hap toothpaste dicative of the cumulative mechanical effects the showed a clear protective effect. This was greater teeth have experienced were observed (Figs. 2, 3). than the effect observed for a normal fluoride tooth- rn The enamel surface of teeth exposed to the acidic paste and confirmed the potential benefit the Zn-HAP challenge by the soft drink clearly demonstrated deep technology can provide in protecting enamel from changes in enamel structure (Figs. 4, 5). After 32 min erosive acid challenges. eosure to the acidic challenge (four immersions of 8 The morphological analysis of enamel was based on te min each) an irregular pattern of surface erosion images taken by scanning electron microscopy could be observed and the presence of honeycomb (SEM), a technique that is suitable for use with native structures suggests demineralization of enamel unpolished surface samples and enamel having been prisms. The morphological scores for the acid chal- In exposed to acidic challenge or toothpaste treatment. lenged specimens were significantly higher than the In the present in vitro study, SEM was used to verify scores for the specimens not exposed to acid chal- the protective effect of the two toothpastes on enamel lenge (Mann-Whitney U test, p<0.05). exposed to erosive action of a soft drink. The SEM ni The acid-challenged specimens treated with the con- study allowed to understand qualitatively the process- trol and test toothpastes demonstrated a lower de- es of demineralization of the enamel surface through gree of demineralization on the enamel surface as the observation of specific morphological and struc- io evident in the SEM images, Figures 6-9 respectively. tural features that characterize the enamel itself. This is reflected in the lower morphological scores for A classification scale was used in order to help quan- these two groups compared to the acid-challenged tifying and describe the damage grade on enamel. iz samples not treated with toothpaste. In the SEM im- Scoring criteria modification of demineralization eval- ages (Figs. 6, 7) of the specimens treated with fluo- uation (11) was followed, as reported in Table 2: a ride toothpaste (group 3) honeycomb structures that score of zero was assigned to enamel surface per- Ed were typical of the demineralization enamel were still fectly intact with no grooves, pits and porosity, while visible, and a slight irregular pattern of erosion could a score of three to those where diffuse demineraliza- be observed. The average morphological score of tion involved the rod core, resulting in a lesion form- this group was significantly lower than the scores for ing the “keyhole” like structure. the acid challenged specimens (p<0.05). The experimental protocol of the present study was The specimens treated with the Zn-HAP toothpaste conducted in attempt to better simulate the daily IC (group 4) showed evidence of deposited material in habits of soft drink consumption. To predict the ero- the SEM images (Figs. 8, 9), with little evidence of sive potential of a soft drink, the method used should erosive damage to the tooth surface. simulate what happens in vivo when the drink enters Specimens of group 4 showed the lowest morphologi- the mouth. For this reason, the method used in the C cal SEM scores of even if not as similar as intact present study (four consecutive intervals of 2 minutes enamel (P<0.05). Overall mean and standard devia- for four times, at 0, 8, 24 and 36 hours) was consid- tions of the morphological SEM scores confirmed that ered to mimic, as closely as possible, the natural con- Zn-HAP toothpaste provided the lowest evidence of sumption of cola drink during the main daily meals. @ erosive damage to the tooth surface (p < 0.001). During the entire experimental protocol, the speci- Thus, if comparing the action of Zn-HAP (group 4) mens were maintained in fresh artificial saliva until and fluoride (group 3) toothpastes against an eroded the next time of application of pastes. This means enamel surface (group 2), it resulted that enamel that the specimens were in contact with the bioactive specimens of group 4 tended to be significantly more agent for 12 min without suffering a demineralizing protected after the treatment. acid attack and then stayed in remineralizing solution. 40 Annali di Stomatologia 2016;VII (3):38-45  Protective effects of a zinc-hydroxyapatite toothpaste on enamel erosion: SEM study Figure 1. Means and standard deviations of the morphological SEM scores provided by the three observers. i n al io az rn Figure 2. SEM image at 5.00 KX magnifi- cation of intact enamel surface (Group 1). te In ni io iz Ed Figure 3. SEM image at 2.50 KX magnifi- cation of intact enamel surface (Group 1). IC C @ Annali di Stomatologia 2016;VII (3):38-45 41  M. Colombo et al. Figure 4. SEM image at 5.00 KX magnifi- cation of enamel exposed to Coca-Cola (Group 2). i n al io az rn Figure 5. SEM image at 2.50 KX magnifi- cation of enamel exposed to Coca-Cola (Group 2). te In ni io iz Ed Figure 6. SEM image at 5.00 KX magnifi- cation of intact enamel surface treated with Eufresh (Group 3). IC C @ 42 Annali di Stomatologia 2016;VII (3):38-45  Protective effects of a zinc-hydroxyapatite toothpaste on enamel erosion: SEM study Figure 7. SEM image at 2.50 KX magnifi- cation of intact enamel surface treated with Eufresh (Group 3). i n al io az rn Figure 8. SEM image at 5.00 KX magnifi- cation of intact enamel surface treated with Biorepair (Group 4). te In ni io iz Ed Figure 9. SEM image at 2.50 KX magnifi- cation of intact enamel surface treated with Biorepair (Group 4). IC C @ Annali di Stomatologia 2016;VII (3):38-45 43  M. Colombo et al. In the oral environment, host factors (such as the agents since they are used routinely as an oral hy- mineral concentration of the tooth, and the pellicle giene measure. Jager et al. (21) showed that different and plaque formation) can influence the progression exposure times to acid beverages also result in very of demineralization (12-14). different estimates of erosive potential, and that effect Salivary factors, such as the salivary flow rate, com- of the choice of study methodology may affect the re- position and buffering capacity, might exert protective sults of the study. action on dental surface (12, 15, 16). For this reason, For this reason, the effects of dentifrices on dental i erosion have been exhaustively studied (12, 22-24). al a further step was taken in this study to enhance the relevance of the model by storing specimens in artifi- While some studies have shown that products with cial saliva between the experimental procedures. bioactive agents such as fluoride, CPP-ACP, and cal- Among soft drinks, Cola drink has the highest erosive cium sodium phosphosilicate have the potential to n potential (17, 18) and this was the rationale for using prevent enamel demineralization (20, 23, 24), other it in the present study. studies have shown no favorable effects of these io The effect of demineralizing, acidic drinks such as agents (12, 22). Coca Cola was assessed in this study by comparing the SEM images of enamel treated with the drink with az those of the unchallenged samples, shown in Figure Acknowledgements 2 and 3. As expected, the surface of enamel treated with an acidic drink shows the presence of honey- We are grateful to Clara Cassinelli (Nobil Bio Ricerche comb structures, which suggests demineralization of S.r.l., Portacomaro, Asti, Italy) for providing the SEM rn enamel prisms. Diffuse demineralization involved the images and technical assistance. rod core, with decomposition of morphology of prims: they were severely affected and a greater prism-core Conflict of interest statement te dissolution compared with that in the interprismatic areas gave the enamel a “keyhole pattern” or “honey- The Authors of this study have no conflict of interest comb pattern” of demineralization (Figs. 4, 5). to disclose. The main aim of the present study was to evaluate, In by SEM analysis, the protective efficacy of a Zn-HaP toothpaste on enamel after acidic challenge, com- References pared to a standard fluoride toothpaste and untreated 1. Lussi A, Hellwig E, Zero D, Jaeggi T. Erosive tooth wear: di- controls. The results presented in Table 3, supported ni agnosis, risk factors and prevention. American Journal of Den- by the images in Figures 2-9 clearly demonstrate that tistry. 2006;19:319-25. the Zn-HAP technology was superior to standard fluo- 2. Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental Ero- ride toothpaste in protecting the enamel surface. sion - an overview with emphasis on chemical and histopatho- io As expected, the highest degree of damage was logical aspects. Caries Research. 2011;45:2-12. found in the samples challenged by the acidic drink 3. Magalhães AC, Wiegand A, Rios D, Honório HM, Buzalaf MA. and without toothpaste treatment (group 2), as the Insights into preventive measures for dental erosion. Jour- iz enamel prism pattern showed a predominant dissolu- nal of Applied Oral Sciences. 2009;17:75-86. 4. Kato MT, Lancia M, Sales-Peres SH, Buzalaf MA. Preventive tion of rods exposing interprismatic enamel (Figs. 4, effect of commercial desensitizing toothpastes on bovine enam- 5). The lowest score of damage was recordered in el erosion in vitro. Caries Research. 2010;44:85-9. Ed the samples treated with Zn-HAP containing tooth- 5. Moron BM, Miyazaki SS, Ito N, Wiegand A, Vilhena F, Buza- paste (Figs. 8, 9) after acidic challenge. laf MA, Magalhães AC. Impact of different fluoride concen- In the case of the Zn-HAP technology, this indicates trations and pH of dentifrices on tooth erosion/abrasion in vit- that supplying calcium-phoshate minerals is a suit- ro. Australian Dental Journal. 2013;58:106-11. able and effective route to counteract the effect of an 6. Poggio C, Lombardini M, Vigorelli P, Ceci M. Analysis of erosive challenge. The mode of action is a combina- Dentin/Enamel Remineralization by a CPP-ACP Paste: IC tion of reducing the demineralization effect of the AFM and SEM Study. Scanning. 2013;35:366-74. 7. Lombardini M, Ceci M, Colombo M, Bianchi S, Poggio C. Pre- acidic challenge and a remineralization/repair effect ventive effect of different toothpaste on enamel erosion: AFM brought about by the extra provision of calcium and and SEM studies. Scanning. 2014;36:401-10. phosphates. The grade of damage observed in enam- 8. Barbour ME, Finke M, Parker DM, Hughes JA, Allen GC, Addy C el surfaces after treatment with Zn-HAP containing M. The relationship between enamel softening and erosion dentifrice (group 4) highlighted the persistence of rod caused by soft drinks at a range of temperatures. Journal of integrity resembling a less advanced demineralization Dentistry. 2007;34:207-13. level if compared with samples treated with fluoride 9. Bertassoni LE, Habelitz S, Pugach M, et al. Evaluation of sur- @ containing toothpaste (group 3). face structural and mechanical changes following reminer- alization of dentin. Scanning. 2010;32:312-9. Toothpastes have been considered effective and ac- 10. Nucci C, Marchionni S, Piana G, Mazzoni A, Prati C. Mor- cessible vehicles to provide enamel resistance and to phological evaluation of enamel surface after application of improve enamel resistance to further erosive attacks the two “home” whitening products. Oral Health & Preven- (19). tive Dentistry. 2004;2:221-9. According to Rao et al. (20) dentifrices would be the 11. Alessandri Bonetti G, Pazzi E, Zanarini M, Marchionni S, preferable mode of delivering topical protective Checchi L. The effect of zinc-carbonate hydroxyapatite ver- 44 Annali di Stomatologia 2016;VII (3):38-45  Protective effects of a zinc-hydroxyapatite toothpaste on enamel erosion: SEM study sus fluoride on enamel surfaces after interproximal reduc- juices. Journal of Dental Research. 2006;85:226-30. tion. Scanning. 2014;36:356-61. 18. Torres CP, Chinelatti MA, Gomes-Silva JM, Rizóli FA, Oliveira 12. Lussi A, Megert B, Eggenberger D, Jaeggi T. Impact of dif- MA, Palma-Dibb RG, et al. Surface and subsurface erosion ferent toothpastes on the prevention of erosion. Caries Re- of primary enamel by acid beverages over time. Brazilian Den- search. 2008;42:62-7. tal Journal. 2010;21:337-45. 13. Ferreira MC, Ramos-Jorge ML, Delbem AC, Vieirac Rde S. 19. Lussi A, Jaeggi T, Zero. The role of diet in the aetiology of Effect of Toothpastes with different abrasives on eroded hu- dental erosion. Caries Research. 2004;38:34-44. i man enamel: An in situ/ex vivo Study. The Open Dentistry 20. Rao SK, Bhat GS, Aradhya S, Devi A, Bhat M. Study of the al Journal. 2013;7:132-9. efficacy of toothpaste containing casein phosphopeptide in 14. da Silva E, de Sá Rodrigues C, Dias D, da Silva S, Amaral the prevention of dental caries: A randomized controlled tri- C, Guimarães J. Effect of toothbrushing-mouthrinse-cycling al in 12- to 15-year-old high caries risk children in Banga- on surface roughness and topography of nanofilled, micro- lore, India. Caries Research. 2009;43:430-5. n filled, and microhybrid resin composites. Operative Dentistry. 21. Jager DH, Vieira AM, Ruben JL, Huysmans MC. Estimated 2014;39:521-9. erosive potential depends on exposure time. Journal of Den- io 15. Manton DJ, Cai F, Yuan Y, Walker GD, Cochrane NJ, tistry. 2012;40:1103-8. Reynolds C, et al. Effect of casein phosphopeptide-amor- 22. Lennon AM, Pfeffer M, Buchalla W, Becker K, Lennon S, At- phous calcium phosphate added to acidic beverages on tin T. Effect of a casein/calcium phosphate containing tooth enamel erosion in vitro. Australian Dental Journal. 2010;55: cream and fluoride on enamel erosion in vitro. Caries Re- az 275-9. search. 2006;40:154-157. 16. Wongkhantee S, Patanapiradej V, Maneenut C, Tantbirojn 23. Oshiro M, Yamaguchi K, Takamizawa T, Inage H, et al. Ef- D. Effect of acidic food and drinks on surface hardness of fect of CPP-ACP paste on tooth mineralization: an FE-SEM enamel, dentine, and tooth-coloured filling materials. Jour- study. Journal of Oral Sciences. 2007;49:115-20. rn nal of Dentistry. 2006;34:214-20. 24. Tantbirojin D, Huang A, Ericson MD, Poolthong S. Change 17. Jensdottir T, Holbrook P, Nauntofte B, Buchwald C, Bardow in surface hardness of enamel by a cola drink and a CPP- A. Immediate erosive potential of cola drinks and orange ACP paste. Journal of Dentistry. 2008;36:74-9. te In ni io iz Ed IC C @ Annali di Stomatologia 2016;VII (3):38-45 45 

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Original article Quantitative volumetric analysis of cross-linked gutta-percha obturators i al Carla Zogheib1 compaction technique. Results show that these Monique Hanna2 obturation techniques were equally sufficient n Damiano Pasqualini3 concerning apical adaptation making them appro- Alfred Naaman4 priate to use in endodontic obturations. io Key words: guttacore, gutta fusion, micro-ct, ob- 1 Ass Pr, Department of Endodontics, St Joseph turation, voids. az University, Beirut, Lebanon 2 Department of Endodontics, St Joseph University, Beirut, Lebanon Introduction 3 Ass Pr, Department of Endodontics, University rn or Turin, Italy One of the main goals of endodontic treatment is 4 Pr, Department of Endodontics, St Joseph achieving a hermetic seal of root canals (1). In order to University, Beirut, Lebanon increase success of endodontically treated teeth, the seal must be effective coronally and apically prevent- te ing bacterial recontamination leading to failure (2, 3) Corresponding author: consequently blocking the circulation of tissue fluids Carla Zogheib that could be diffused from the periapex. Many at- Ass Pr, Department of Endodontics, St Joseph In tempts based on variations in obturation techniques University, Beirut have been made to solve problems, such as lack of Street/P.O. BoxRue de Damas, P.O. Box 175-208 surface adaptation, incorporation of apical voids com- Beirut, Lebanon bined with time effect on sealer composition. Simplified E-mail: [email protected] methods of thermoplasticizing gutta-percha have be- ni come increasingly popular. Schilder introduced the concept of warm vertical compaction WVC of gutta- Summary percha in 1967, using an electrically heated plugger to io condense apically (4). In 1978, Johnson proposed a Aim. The purpose of this study was to evaluate gutta-percha coated metallic obturator oven-heated in the effects of technique on the filling quality of 2 order to be plasticized before it is inserted into the root iz recently introduced obturation systems compara- canal (5). This system has undergone numerous im- tively with warm vertical compaction using micro- provements: the metal core was replaced by a plastic computed tomography. support (1991) and more recently, with a cross-linked Ed Methods. 36 single-rooted teeth were selected, root gutta-percha core obturator. The latest on the market canals prepared, and assigned to 3 groups (n=12), are GuttaCore® (Dentsply Tulsa Dental Specialties, according to the filling technique: warm vertical Tulsa, OK) and Gutta Fusion® (VDW, Germany). compaction technique WVC, GuttaCore (Dentsply These systems promise to be efficient, safe, biocom- Tulsa Dental Specialties, Tulsa, OK) and Gutta Fu- patible, and more effective in filling the complexities of sion (VDW, Germany). Each specimen was scanned the root canal system, compared to other methods cur- IC using a micro-CT. Percentage of voids was calcu- rently available (6, 7).To assess the quality of root fill- lated and data statistically analyzed using Kruskal ings, various experimental methods have been used, Wallis test with a significance level of 5%. such as fluid filtration, dye penetration, radioisotope, Results. All obturations showed satisfactory similar SEM analysis, bacterial leakage evaluation and recent- C results at the apical level. Differences between the ly micro-computed tomography (micro-CT). Micro-CT, three obturation methods were not significant at 1 a three-dimensional imaging tool, has the virtues of be- mm (-p-value >0.05), 3 mm (-p-value >0.05) and 5 ing highly accurate and nondestructive, so it over- mm (-p- value >0.05). No root fillings were void-free. comes the limitations of the previously used methods @ No significant difference was found between the (8).The aim of this study was to investigate and to cal- WVC technique, the GuttaCore technique and the culate the percentage of volume of voids and gaps in Gutta Fusion technique concerning percentage of root canals filled with GuttaCore and Gutta Fusion ob- apical voids regardless of canal level. turators comparatively with WVC using micro-CT. The Conclusion. This study shows the efficiency of null hypothesis was that there was no significant differ- cross-linked obturators in filling root canals her- ence between the three techniques considering the metically by comparing them to the warm vertical volume and distribution of voids. 46 Annali di Stomatologia 2016;VII (3):46-51  Quantitative volumetric analysis of cross-linked gutta-percha obturators Materials and methods ber markers set accordingly on the obturators. The prefitted obturator was heated in the oven [GuttaCore Sample Selection and Specimen Preparation TMOven (Dentsply Tulsa Dental Specialties, Tulsa, OK) and Gutta Fusion®Oven (VDW Munich, Ger- 36 single-rooted extracted teeth with less than 10 de- many)]. A thin layer of the AH Plus® sealer was ap- grees curvature, as determined by Schneider’s plied to the canal walls with the verifier. After comple- tion of the heating cycle, the obturator was removed i method (9), were collected. Teeth with root resorp- al tions, fracture or immature apices were excluded from the oven and slowly inserted (6 to 7 seconds) in- from the study. Preliminary radiographs were taken in to the canal to the WL. The handle of the carrier was bucco-lingual and mesio-distal directions using a digi- stabilized with finger pressure and then separated at the orifice of the canal. All roots were stored at 37 °C n tal sensor (ERLM Digora® Optime - Soredex, Fin- land). Teeth with previous root canal treatment, multi- with 100% humidity for about 72 hours to allow the ple canals and intracanalar irregularities were dis- sealers to set completely until being imaged by a mi- io carded. After scaling of root surfaces, teeth were cro-CT scan. rinsed under running water then kept in Formol 10% for 1 week. The crowns were removed with a water- Micro CT az cooled diamond disc (KG Sorensen, Barueri, SP, Brazil) and root length adjusted at 16 mm. A #10 K- The qualitative analysis of the root-canal fillings was flexofile (Dentsply, Maillefer, Switzerland) was intro- carried out using a micro-CT. A v|tome|x 240D (Gen- duced, when it reached the apical foramen, working eral Electric, MA, USA) high-resolution micro-CT was rn length (WL) was determined and a radiograph taken. used to scan the specimens. After adjusting the ap- propriate parameter, each tooth was positioned on Root canal instrumentation the specimen stage and scanned with an isotropic te resolution of 4 μm, rotational step of 0.60°, and rota- After introduction of hand files and establishment of a tional angle of 360°. With the datos|x 2.0 software, glide path, WaveOne Primary® (25/08) (Dentsply Tul- images obtained from the scan were reconstructed to sa Dental Specialties, Tulsa, OK) was used in a reci- show slices of the inner structure of the roots in 2D In procating movement with light pressure. Afterwards, and velo/CT for the 3D volumetric visualization. a size #10 K-file was taken to the WL to check paten- Two different parameters were assessed: on axial cy and irrigation followed with 1ml of 5.25% NaOCl. sections at 1, 3, and 5 mm from apex, area of The previous sequence was repeated until the instru- voids/gaps in square micrometers and ratio between ni ment reached the WL. WaveOne Large® (40/08) voids/gaps and the total canal area in the section was (Dentsply Tulsa Dental Specialties, Tulsa, OK) was calculated. In 3D surface-rendered reconstructions, then used to the WL. A final flush of 2 mL 17% EDTA the volume of voids in cubic micrometers was calcu- io (pH=7.7) SmearClear (SybronEndo, Orange, CA, lated then the ratio between volume of voids/gaps USA) was used to eliminate the smear layer. Then, and the total canal volume (Figure 1). Each section the canals were washed with 5 mL saline solution was assessed by the same observer. iz and dried with paper points (Dentsply Maillefer). Root canal filling Statistical analysis Ed After preparations, all roots were randomly assigned Statistical analyses were performed using a software to 3 experimental groups (n=12) according to the program (SPSS for Windows, Version 18.0, Chicago, choice of filling technique. The first group was filled IL). The level of significance was set at α=0.05. Vari- with WVC technique. A fine-medium sized gutta-per- able was tested for normal distribution using the Kol- cha cone (Dentsply Tulsa Dental) was selected as mogorov Smirnov test. Kruskal Wallis tests were IC the master cone, and trimmed to fit within 0.5 mm of used to explore significant difference among groups. the WL. The prefitted master cone coated with a thin layer of AH Plus® sealer (Dentsply International) was inserted into the canal and down-packed to 5 mm Results C from the WL with a Touch n’ Heat source (SybronEn- do, Orange, CA). Subsequently, 3-4 mm segments of Mean and standard-deviation of the percentage of gutta-percha were backpacked with the Obtura II unit voids among groups are presented in Table 1 and (SybronEndo, Orange, CA) until the canals were Figure 2. @ completely obturated. The second group was obturat- This study showed that the volume of voids was mini- ed with GuttaCore and AH Plus® and the third with mal in the three groups and results within the 3 Gutta Fusion and AH Plus®. In those two groups, groups were equivalent. None of the root canal filled canals were filled with GuttaCore (Dentsply Tulsa teeth were void-free, and no significant difference Dental Specialties, Tulsa, OK) and Gutta Fusion was found within the three obturation methods at 1 (VDW Munich, Germany) obturators selected by pas- mm (-p-value=0.288), 3 mm (-p-value=0.440) and 5 sively inserting a verifier to WL-0.5 mm and the rub- mm (-p-value=0.287). Annali di Stomatologia 2016;VII (3):46-51 47  C. Zogheib et al. i n al io az rn te In ni Figure 1. Micro-CT three-dimensional reconstructions and horizontal cross-sections at 1, 3 and 5 mm from the apex of root canal systems obturated with warm vertical compaction techniques (V12), GuttaCore (GC8) and Gutta Fusion (GF3). Voids, when present, are shown in colored spots and calculated at 1, 3 and 5 mm from apex. io Discussion tional ones have shown several disadvantages: radi- iz ographs provide 2D interpretations only, while the The role of root canal filling is to avoid leakage of oral canal system should be analyzed by a three dimen- fluids containing bacteria and their products from the sionally imaging technology; with the root sectioning, Ed oral cavity to the apical periodontium through the root there could be loss of material which might mimic canal, and to prevent the exit to the periapex, of mi- voids; the time taken for fluid filtration and clearing croorganisms that persisted in the root canal after techniques might affect the results, dye penetration cleaning and shaping (10). Voids can be captured dur- studies do not correlate clinically and dye extraction ing root filling procedures. In fact, internal voids are studies evaluate only the apical third of the tooth. IC not in communication with the canal walls, thus they Bacterial microleakage studies need long periods of could be considered less clinically significant for the observation and don’t allow quantification of the num- endodontic prognosis. In other words, residual bacte- ber of penetrating bacteria. A noninvasive in vitro an- ria, if present, are confined in an unfavorable environ- alytical method for imaging has been described. Thus, C ment (11). But external and combined voids form a the analysis using micro-CT can be repeated on the gap between the filling materials and the canal walls same specimen, results obtained from such analysis resulting in a space where bacteria can grow and were comparable to histological studies (14). Artefacts leakage takes place due to failure of the sealer (12). can be eliminated, hence, the data are objective and @ Leakage or percolation was defined by the AAE quantitative or qualitative evaluations are reliable (American Association of Endodontists) as the move- (15). In endodontics, this technology has been used ment of periradicular tissue fluids, micro-organisms for the evaluation of root canal anatomy, assessment and their toxins along the interface between dentinal of root canal morphology after instrumentation, and walls and the filling materials (13). New methods analysis of obturated root canals. Several compar- have been used to evaluate the sealing ability of root- isons between obturation techniques in vitro com- filling techniques and materials because the conven- pared different parameters such as length of fill, de- 48 Annali di Stomatologia 2016;VII (3):46-51  Quantitative volumetric analysis of cross-linked gutta-percha obturators Table 1. Mean percentage of voids among groups. Percentage of voids Methods Mean Standard Deviation WVC 1.111 2.350 1 mm GuttaCore 1.343 1.901 Gutta Fusion 1.388 1.466 i al WVC 0.613 1.225 3 mm GuttaCore 0.728 0.712 Gutta Fusion 1.377 1.551 n WVC 0.805 1.712 io 5 mm GuttaCore 1.007 1.285 Gutta Fusion 0.827 0.832 az Figure 2. Mean percentage of voids among groups. rn te In ni io iz fect replication and gutta-percha density. In this stu- canal obturations (17, 18). Endodontic sealers differ dy, a volume analysis was performed with micro-CT in physical properties which might determine the seal- Ed in which the focus was on the volume of voids creat- ing ability of the root filling (11). The AH 26® and AH ed in the fillings. Micro-CT can differentiate the vol- Plus® (Dentsply International) used in association ume percentage of gutta-percha and sealer in the ob- with gutta percha, have been known for their quality turating material by different colors. But, like in previ- and advantages; this is why most of the studies in- ous micro-CT studies (8, 16), sealer and gutta-percha cluding ours that compared the microleakage of gut- were segmented together and analyzed as a single ta-percha with any other filling material use this seal- IC root-filling entity because the majority of obturators er. Besides, the good dimensional stability of AH fillings sealer was indistinguishable from gutta-per- Plus® sealer has been demonstrated (19, 20) and its cha. Since, micro-CT offers the possibility of repeated application can be suggested. scanning; it will be possible to evaluate changes of It is important to obturate the whole length of root C filling over time (15). On the other hand, the micro-CT canal. However, since the apical third is especially has limitations with in vivo applications, and the use important, all the measurements were done for the of this technique is restrained to the examination of apical third. One of the reasons for the inadequately specimens of limited size (15). In this study, the use of filled canals could be that the canal anatomy prevents @ WaveOne Large® 40/8 till the WL has been support- adequate cleaning of the narrow fissured areas with ed by several previous studies because the increase circular root files since the canal lumen is irregular in the final preparation taper improves irrigant re- and the risk of subsequently creating voids is high placement and wall shear stress. Moreover, enlarging (21, 22). Moreover, inadequately filled canals could the apical third (especially the last 3 mm) of root be the consequence of root filling technique. canals to an 8% taper is necessary to achieve a bet- Based on the results of the present study, none of the ter sealing ability and thus long-term success for root tested techniques provided a void-free filling at the Annali di Stomatologia 2016;VII (3):46-51 49  C. Zogheib et al. apical third. This finding is similar with the study of Aknowledgements Somma et al. in 2011 who compared the quality of root fillings completed by two thermoplasticized gutta- This study was supported by the Saint Joseph Uni- percha techniques (Thermafil and System B) and a versity Research Committee, Beirut, Lebanon. cold gutta-percha technique (single point) by micro- CT analysis. Conflict of interest statement All techniques produced comparable results in terms All Authors declare that there is no conflict of interest i of percentage of filling and void distribution (11). In al of any kind regarding the publication of this paper. particular, most of filling techniques do not completely fill the root canal system (8, 11, 16). However, when ultrasonic (UL) was used to lower gap volumes be- References n tween gutta-percha cones and sealer (23), the filled volume obtained by WV compaction was similar to 1. Schilder H, Cleaning and shaping the root canal. 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Int Endod J. 2010;43:909-16. percentage of apical voids regardless of canal level. 18. Zogheib C, Naaman A, Sigurdsson A, Medioni E, Arbab-Chi- In addition to the in vitro studies, clinical studies eval- rani R. Influence of apical taper on the quality of thermo- uating the different endodontic obturation systems plasticized root fillings assessed by micro-computed to- would be beneficial. mography. Clin Oral Investig. 2012;16(5):1493-8. 50 Annali di Stomatologia 2016;VII (3):46-51  Quantitative volumetric analysis of cross-linked gutta-percha obturators 19. McMichen FRS, Pearson G, Rahbaran S, Gulabivala K. A by an endodonticcore-carrier system with crosslinked gut- comparative study of selected physical properties of five root- ta-percha carrier in single-rooted canals. J Dent. canal sealers. Int Endod J. 2003;36:629-35. 2014;42(9):1124-34. 20. Garrido ADB, Lia RCC, Franc a ̧ SC, da Silva JF, Astolfi-Fil- 25. Marciano MA, Ordinola-Zapata R, Cunha TV, Duarte MA, ho S, Sousa-Neto MD. Laboratory evaluation of the physic- Cavenago BC, Garcia RB, et al. Analysis of four gutta-per- ochemical properties of a new root canal sealer based on cha techniques used to fill mesial root canals of mandibu- Copaifera multijuga oil-resin. Int Endod J. 2010;43:283-91. larmolars. Int Endod J. 2011;44:321-9. i 21. Van der Sluis LW, Wu MK, Wesselink PR. An evaluation of 26. Gencoglu N. Comparison of 6 different gutta-percha tech- al the quality of root fillings in mandibular incisors and maxil- niques. Part II. Thermafil, JSQuick-Fill, Soft Core, Mi- lary and mandibular canines using different methodologies. croseal, System B, and lateral condensation. Oral Surg Oral J Dent. 2005;33:683-8. MedOral Pathol Oral Radiol Endod. 2003;96:91-5. 22. Hörsted-Bindslev P, Andersen MA, Jensen MF, Nilsson JH, 27. Ozawa T, Taha N, Messer HH. A comparison of techniques n Wenzel A. Quality of molar root canal fillings performed with for obturating oval-shapedroot canals. Dent Mat J. 2009; the lateral compaction and the single-cone technique. JEn- 28:290-4. io dod. 2007;33:468-71. 28. Gambarini G, Piasecki L, Schianchi G, et al. In vitro evalu- 23. Ho ESS, Chang JWW, Cheung GSP. Quality of root canal ation of carrier based obturation technique: a CBCT study. fillings using three gutta-percha obturation techniques. Annali di Stomatologia. 2016;7(1-2):11-15. Restorative Dentistry & Endodontics. 2016;41(1):22-28. 29. Juhlin JJ, Walton RE, Dovgan JS. Adaptation of thermafil com- az 24. Li GH, Niu LN, Selem LC, et al. Quality of obturation achieved ponents to canal walls. J Endod. 1993;19:130-5. rn te In ni io iz Ed IC C @ Annali di Stomatologia 2016;VII (3):46-51 51 

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Original article TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty) i al Piero Cascone1 Key words: TMJ, internal derangement, TMJ Valerio Ramieri1 surgery, functional arthroplasty. n Paolo Arangio1 Valentino Vellone1 io Achille Tarsitano2 Introduction Claudio Marchetti2 TMD (temporo-mandibular joint disorder) is a collec- az tive term used to describe a number of related disor- 1Unit of Maxillofacial Surgery, Policlinico Umberto I, ders affecting the temporo-mandibular joint (TMJ), Sapienza University of Rome, Italy masticatory muscles and associated structures, with 2Department of Biomedical and Neuromotor Sciences, a variety of common symptoms such as pain and lim- rn Section of Maxillofacial Surgery, University of ited mouth opening (1). TMDs are a common cause Bologna, Policlino S. Orsola, Bologna, Italy of persistent facial pain, headaches, jaw clicking, and jaw locking. Internal Derangement (ID) is one of the most common type of disorder affecting the TMJ (2). te Corresponding author: Internal derangement can be classified by 5 stages of Valentino Vellone dysfunction according to Wilkes (3). The reciprocal Unit of Maxillofacial Surgery, Policlinico Umberto I, clicking of the joint, considered as the early stage of Sapienza University of Rome In ID, is common, affecting about 40% of the general Via del Policlinico population (4-7). Whereas, later stages such as disc 04100 Latina, Italy displacement without reduction and TMJ degenera- E-mail: [email protected] tive changes are less frequent (8-10). Procedures in- volving the temporo-mandibular joint, including open ni surgery and arthroscopy have been used to correct Summary either position or structural problems of the disc, ar- ticular eminence and the condyle. Open surgery is io Objective. The purpose of this study was to as- still considered to be the “last chance” for patients af- sess the outcomes of temporomandibular joint fected by chronic recurrent TMD for which other ther- (TMJ) “functional arthroplasty” on the inferior apies have failed to improve signs and symptom, pre- iz compartment and disc reposition as a surgical ferring minimally invasive surgical techniques. Some treatment for internal derangement (ID). studies (11) have indicated that nonsurgical treatment Patients and methods. By retrospective chart re- can eliminate ID signs and symptoms in patients with Ed view, all patients who had TMJ surgery on the in- TMD, considering it as a self-limiting pathology. Al- ferior compartment for TMJ ID from 1985 to 2010 though these studies might demonstrate the thera- were identified. Their charts were reviewed and peutic prevalence of nonsurgical treatments com- subjective data as well as objective data was col- pared with surgery ones, they seem to have not sta- lected. tistical significance and sufficient follow-up period Results. The chart review yielded 352 patients (12). Main role of IDs surgical correction has been IC treated through this approach for a total of 696 described as relief of symptoms and pain (13). In joints involved. Analysis of the data showed that 1994, Dolwick and Dimitroulis (14) stated that the in- there was a good health improvement. The mid dications for performing surgery could be divided into VAS about pre surgical TMJ pain was 58.3, after relative and absolute. Absolute indications were TMJ C surgery 7.7. tumors, ankylosis and condyle growth abnormalities. About headache and cervical pain the pre surgery Relative indications were usually ascribed to those mid VAS was 47.7, after surgery 16.7. pathologies in which surgery appears to have a less Conclusions. Outcome data presented show that defined role, such as internal derangement with ab- @ TMJ surgery on the inferior compartment and disc normal disc position and arthritic changes. Inauspi- reposition could be an effective and successful ciously, the failure of non-surgical therapy appears to surgical treatment of TMJ ID. This success has suffer from misdiagnosis or incomplete diagnosis of been seen and maintained also in long term fol- TMDs, which could account for about 20% of failed low up in this specific patient population. For this cases (15, 16). Some studies (17, 18) have demon- reason, we propose to call this procedure “func- strated that more the patient can define and localize tional arthroplasty”. their symptoms, more effective the surgery and out- 60 Annali di Stomatologia 2016;VII (3):60-64  TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty) comes can be. The Authors propose a logical approach ringer lactate lavage was performed. The inferior to internal derangement with an early minimally inva- compartment was then access by using a 15 blade sive technique, that could result in an immediate effec- cutting through the lateral ligaments of the disc. After tive and long-lasting reduction in patient’s symptoms entering the inferior compartment care was taken to such as atypical orofacial pain, neck pain and protect the disc, retrodiscal tissues and medial aspect headaches. The Authors present a 25-year- retrospec- of the capsule by placing three retractors on the head tive study and a different technique in treating ID with of the condyle. A high condylectomy (about 1-2 mm) i al an open surgery called “functional arthroplasty”. was then accomplished by using a straight fizzure bur or piezo surgery. After removal of this piece and smoothing off the edges, the joint and retrodiscal tis- Patients and methods sues were evaluated from the inferior compartment n for perforations, adhesions, or anomalies. After cor- In this study the Authors performed a retrospective recting any perforations with suture or freeing any ad- io analysis of all patients with a diagnosis of internal de- hesions, the lateral ligaments of the disc were su- rangement who underwent to “functional arthroplasty” tured in a posterior lateral fashion. The last step was with the same surgeon (P.C), from 1985 to 2010 for a a washing of the inferior compartment using lactated az total number of 565 patients. Inclusion criteria were ringer solution (200 cc) and the surgical site closed as follows: the patients must have had internal de- using two layers. Patients are closely followed up rangement according to Wilkes criteria II or higher during the first weeks to restore the correct function. (3); no other TMJ operations performed in the past; a rn minimum follow-up period of 5 years whether by phone or in person. Results Every patient included in the study had been evaluat- te ed in the following issues: Out of the inner sample of 565 patients only 352 a) internal derangement and laterality (62.3%) satisfied inclusion criteria. 337 patients had b) chief complaint as pertaining to the TMJ diagnosis of bilateral internal derangement (in this c) localization and laterality of pain associated with case diagnosis was given in relation to the worse In each joint TMJ pathology) and 22 had monolateral involvement d) headache and cervical pain. for a total number of 696 treated joints. The sample The Authors adopted a Visual Analogue Scale (VAS) was composed by 299 females (85%) and 53 males ranging from 0 to 100 to evaluate pain. All values had (15%). In relation to age, the lowest value observed ni been approximated to the closest whole number. In was of 16 years to the highest of 68 with a mean val- relation to symptom the Authors have divided the ue of 32. Long-term follow up was accomplished in sample before and post surgery in condyle luxation, every patient from the smallest value of 5 years to the io only pain, crepitus, disc displacement with reduction highest of 27 with a mean value of 12.5 years. and disc displacement without reduction. These con- In relation to symptom 5% suffered from condyle lux- ditions were very often associated with temporo- ation, 6% only pain, 24% crepitus, 30% click, 35% iz mandibular pain according to Wilkes stages. lock) (Fig. 1) while after surgery 77% of patients re- VAS was used to evaluate pain. The patient were ported no symptoms, 9% presented with click, 2% grouped values into 5 main classes before and post lock and 12% crepitus (Fig. 2). Ed surgery: Class I absence of pain, Class II pain rang- These conditions were very often associated with ing from 1 to 25, Class III pain ranging from 25 to 50, temporomandibular pain according to Wilkes stages Class IV pain ranging from 50 to 75 and Class V pain (Stages I and II 82.3%; III and IV 97.1%; V 100%). ranging from 75 to 100. The issue “Headache and VAS was used to evaluate pain. The patients were cervical pain” has been investigated before and post grouped values into 5 main classes: Class I absence surgery with the VAS considering the same classes of pain, Class II pain ranging from 1 to 25, Class III IC of values. pain ranging from 25 to 50, Class IV pain ranging from 50 to 75 and Class V pain ranging from 75 to 100. Surgical technique Before surgery 6% of patients was classified in VAS C group ranged from 1-25, 11% in 25-50 VAS, 13% no Open surgery. A pre-auricolar post-tragal incision pain, 31% 50-75 VAS, 39% 75-100 VAS) (Fig. 3). was performed with a bevelled 45° inclination, ap- After surgery 78% of patient reported no pain, 10% proximately 1.5 cm long. The temporal vessels are were classified in VAS group ranged from 1-25, 6% in @ then isolated and ligated with 3-0 silk suture. Dissec- VAS group 25-50, 4% in VAS group 50-75 while only tion was then carried down to the TMJ capsule, with 2% in VAS group 75 to 100 (Fig. 4). special care given not to damage the facial nerve. The issue “Headache and cervical pain” has been in- The aim is to preserve as much as possible the TMJ vestigated before surgery with the VAS considering biomechanics. A diagnostic arthroscopy was then the same classes of values as shown in Chart 3 (13% carried out in the superior compartment to check for 1-25 VAS, 17% 25-50 VAS, 18% no pain, 23% 50-75 perforations in the disc and adhesions and 200 cc VAS, 29% 75-100 VAS) (Fig. 5). Annali di Stomatologia 2016;VII (3):60-64 61  P. Cascone et al. Figure 1. Evaluation of presurgical main symptom. i n al io Figure 2. Evaluation of postsurgical main symptom. az rn te In Figure 3. Evaluation of presurgical pain. ni io iz Ed IC Figure 4. Evaluation of postsurgical pain. C @ 62 Annali di Stomatologia 2016;VII (3):60-64  TMJ inferior compartment arthroplasty procedure through a 25-year follow-up (functional arthroplasty) Figure 5. Evaluation of presurgical headache. i n al io az After surgery 54% of patient reported no headache and the lateral ligament most of the time bilateral surgical cervical pain, 22% was classified in VAS group ranged treatment. As pertaining to the high condylectomy it is from 1-25, 11% in VAS group 25-50, 6% in VAS group Authors’ opinion that, essentially, it brings the following rn 50-75, while 7% in VAS group 75 to 100 (Fig. 6). results: a) eliminates condylar disparities which are al- ways observed in case of long lasting disc displace- ment; b) it widens the articular space which has been Discussion reduced by the vertical height loss; c) creates scar ad- te hesions between disc and condyle thus leading to a To date there is no agreement about when to do an greater after surgical stability. Performing the surgery open surgery of the TMJ. Several approaches in the bilaterally bring a better result because ID affects most past have shown a variety of results with poor long In of the time both joints in a variety of pathology. It was term outcome. interesting to observe some patients had crepitus after Moreover, there are not adequate comparative studies surgery especially if they were affected by chronic lock. (19) and an unique classification is not widely recog- A complete crepitus resolution was observed in pa- ni nized. Many surgical strategies, such as discectomy or tients with a previous diagnosis of crepitus. This partic- articular prosthesis, mainly deal with patient referred ular phenomenon has to be referred to the physiologi- pain and don’t take into account the anatomical and cal sliding of the malformed disc. It was felt that this io morphological issues (20-22). Other strategies aimed to treatment worked because it restored balance to the restore the anatomy, however they have not seen long TMJs bilaterally, created space for the disc and condyle lasting results such as those that have used proplast- to function once again in harmony, and made it possi- iz teflon substitution of the disc (23, 24). From the 1985, ble for the patient to once again have normal range of when was first approached this surgery, impressive out- motion of their mandible. This procedure respects comes were seen and since then the surgical technique anatomy and biomechanical function and restriction Ed has never been changed in its basic principles: high that guides TMJ movements. For this reason, we would condylectomy, disc repositioning and reconstruction of like to call this surgery “functional arthroplasty”. Figure 6. Evaluation of postsurgical IC headache. C @ Annali di Stomatologia 2016;VII (3):60-64 63  P. Cascone et al. Conclusions cause of craniomandibular pain and dysfunction: A unifying concept. J Oral Maxillofac Surg. 1989;47:249. 10. Stegenga B, de Bont LG, Boering G, van Willigen JD. Tis- This study adds to previously reported successful re- sue responses to degenerative changes in the temporo- sults (25) and encourages surgeons to pursue open mandibular joint: a review. J Oral Maxillofac Surg. technique respecting TMJ anatomy and biomechani- 1991;49:1079. cal functional restriction. 11. Dimitroulis, G. The role of surgery in the management of The outcome data showed that “functional arthroplas- i disorders of the temporomandibular joint: a critical review al ty” on the inferior compartment with disc repositioning of the literature. Part 1. Int J Oral Maxillofac Surg. 2005; could be an effective and successful surgical treat- 34:107-113. ment option for patients with TMJ ID especially those 12. Murakami K, Kaneshita S, Kanoh C, Yamamura I. Ten-year who have problems bilaterally. In conclusion, “func- outcome of nonsurgical treatment for the internal derange- n tional arthroplasty” on the inferior compartment is an ment of the temporomandibular joint with closed lock. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. effective and successful surgical treatment for TMJ ID io 2002;94(5):572-5. in our specific patient population. This success has 13. Pedullà E, Meli GA, Garufi A, Mandalà ML, Blandino A, Ca- been continued for over 25 years. scone P. Neuropathic pain in temporomandibular joint dis- orders: case-control analysis by MR imaging. AJNR Am J az Neuroradiol. 2009;30(7):1414-8. Conflict of interest 14. Dolwick MF, Dimitroulis G. Is there a role for temporo- mandibular joint surgery? Br J Oral Maxillofac Surg. 1994; The Authors declare that there is no conflict of inter- 32:307-313. rn est in publishing this paper. 15. Dimitroulis G. The role of surgery in the management of dis- orders of the temporomandibular joint: a critical review of the literature. Part 2. Int J Oral Maxillofac Surg. 2005;34:231-237. Funding 16. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular This research did not receive any specific grant from te joint arthrocentesis: a simplified treatment for severe, lim- funding agencies in the public, commercial, or not- ited mouth opening. J Oral Maxillofac Surg. 1991;49(11):1163- for-profit sectors. 1167. 17. Cascone P. Terapia chirurgica della lussazione anteriore del In menisco. Dental Cadmos. 1987;11:17-12. References 18. Cascone P, Ungari C, Paparo F, Marianetti TM, Ramieri V, Fatone M. A new surgical approach for the treatment of chron- 1. Dimitroulis G. Temporomandibular disorders: a clinical up- ic recurrent temporomandibular joint dislocation. J Cranio- date. BMJ. 1998;317:190-194. fac Surg. 2008;19(2):510-2. ni 2. Fricton JR, Look JO, Schiffman E, Swift J. Long-term study 19. Politi M, Sembronio S, Robiony M, Costa F, Toro C, Undt of temporomandibular joint surgery with alloplastic im- G. High condylectomy and disc repositioning compared to plants compared with nonimplant surgery and nonsurgical arthroscopic lysis, lavage, and capsular stretch for the treat- io rehabilitation for painful temporomandibular joint disc dis- ment of chronic closed lock of the temporomandibular placement. J Oral Maxillofac Surg. 2002;60:1400-1411. joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 3. Wilkes CH. Internal derangements of the temporomandibular 2007;103:27-33. joint: pathological variations. Arch Otolaryngol Head Neck 20. McKenna SJ. Discectomy for the treatment of internal de- iz Surg. 1989;115:469. rangements of the temporomandibular joint. J Oral Maxillo- 4. Schiffman EL, Fricton JR, Haley DP, Shapiro BL. The preva- fac Surg. 2001;59:1051-1056. lence and treatment needs of subjects with temporo- 21. Mercuri LG. The Christensen prosthesis. Oral Surg Oral Med Ed mandibular disorders. J Am Dent Assoc. 1990;120:295. Oral Pathol. 1996;81:134-135. 5. Gross A, Gale EN. A prevalence study of the clinical signs 22. Wolford LM, Dingworth DJ, Talwar RM, Pitta MC. Compar- associated with mandibular dysfunction. J Am Dent Assoc. ison of 2 temporomandibular joint total joint prosthesis sys- 1983;107:932. tems. J Oral Maxillofac Surg. 2003;61:685-690. 6. Solberg WK, Woo MW, Houston JB. Prevalence of mandibu- 23. Henry CH, Wolford LM. Treatment outcomes for temporo- lar dysfunction in young adults. J Am Dent Assoc. 1979;98:25. mandibular joint reconstruction after proplast-teflon implant failure. J Oral Maxillofac Surg. 1993;51:352-358. IC 7. Helkimo M. Studies on function and dysfunction of the mas- ticatory system: IV. Age and sex distribution of symptoms 24. Cascone P, Di Paolo C, Leonardi R, Pedullà E. Temporo- of dysfunction of the masticatory system in Lapps in the north mandibular disorders and orthognathic surgery. J Craniofac of Finland. Acta Odontol Scand. 1974;32:255. Surg. 2008;19(3):687-692. 8. Wilkes CH. Structural and functional alterations of the tem- 25. Abramowicz S, Dolwick MF. 20-year follow-up study of disc C poromandibular joint. Northwest Dent. 1978;57:287. repositioning surgery for temporomandibular joint internal de- 9. Stegenga B, de Bont LG, Boering G. Osteoarthrosis as the rangement. J Oral Maxillofac Surg. 2010;68:239-242. @ 64 Annali di Stomatologia 2016;VII (3):60-64 

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Original article Splint-assisted disc plication surgery i al Omar Sheikh1 Signs and symptoms commonly include TMJ pain, Greg Logan1 muscle pain, clicking, crepitus, restricted mouth n Deepak Komath2 opening, deviation on opening or closing and hea - Patrick Grossman3 daches. Tinnitus has also been reported as symp- io Peter Ayliffe4 tom with studies reporting that when the most com- mon causes of tinnitus are excluded, it is correct to evaluate the functionality of the temporo-mandibular az 1 London North West Hospitals, London, UK joint (2). 2 Royal Free Hospital Disruption of joint function by excessive/overloading 3 Lister House Private Practice causes chronic irritation to the discs and synovium 4 Great Ormond Street Hospital, University College resulting in inflammation and disc displacement (3). rn Hospital, London, UK Up to 75% of the population exhibits one recordable sign of TMD with 5-33% of subjects reporting subjec- tive symptoms. Symptoms peak between 20-40 years Corresponding author: of age with a ratio of 3.3:1 females to males (4). te Omar Sheikh TMD is a multifactorial disease. Studies have quoted London North West Hospitals variable levels of trauma and dental treatment previ- Watford Road, ous to the development of symptoms. Some patients London, HA13UJ, UK In also have an element of systemic disease such as E-mail: [email protected] joint hypermobility or arthritis with one study quoting the figure at 13.1% (5). Given a lack of consensus regarding best treatment Summary methods, the American Association of Oral and Max- ni illofacial Surgeons (AAOMS) issued a statement re- Chronic disc displacement may lead to long-term garding TMD syndrome. This categories TMD into 1. pain. Temporomandibular joint surgery is re- extracapsular disorders, muscular in origin including io served for those patients whose symptoms re- parafunction and pain referred from systemic muscle main severe despite conservative treatment. We conditions and 2. intracapsular disorders involving disc looked at the of effect of modified meniscopexy displacement. Degenerative changes including os- iz on patients with chronic disc displacement with- teoarthritis, rheumatoid arthritis, TMJ dislocation, anky- out reduction who did not respond to non-surgi- losis and fractures are also responsible for TMD (6). cal pain management treatment. In this retrospec- Initial management is non surgical and includes phys- Ed tive study a total of 59 joints was treated and all ical therapy, occlusal appliance therapy, drug therapy patients except one underwent splint assisted bi- (topical and systemic), intraarticular injection and lateral meniscopexy: this patient had splint as- arthrocentesis, diet alteration and life style adapta- sisted unilateral meniscopexy. tion. Splint therapy has been reported with success At the time of presentation and following treat- by Tsuga 1989, Gray 1991, Davies 1997 and shows ment all patients underwent clinical examination to reduce muscle activity and providing neuromuscu- IC and were required to complete a pain and func- lar balance to the TMJ (7-9). tional questionnaire. All patients reported im- A Cochrane review of 12 randomised controlled trials provement following treatment. demonstrated no significant difference in the effec- tiveness of stabilisation splint treatment compared to C Key words: temporomandibular joint, splint, other active treatments. This review also stated that meniscopexy. occlusal adjustments make no difference to outcome. TMJ surgery is reserved for those patients whose symptoms remain severe despite conservative treat- @ Introduction ment. Surgical options include: - disc repair and disc repositioning procedures Temporomandibular disorders (TMD) are a heteroge- (meniscopexy) neous group of pathologies and the most common - menisectomy with/without autogenous implants orofacial pain conditions of non-dental origin affecting - condylectomy the temporomandibular joint (TMJ), the masticatory - condylotomy muscles or both (1). - eminectomy. Annali di Stomatologia 2016;VII (3):73-78 73  O. Sheikh et al. No one procedure is a panacea for all TMJ patholo- - clinical examination of the head and neck includ- gies (10). ing palpation of 90 osseous and muscular In contrast to open joint procedures, arthrocentesis anatomical landmarks; a record was also made of and arthroscopy are less invasive, comparatively eas- maximum mouth opening, left and right lateral ex- ier and less expensive (11). cursions, spontaneous pain, pain on movement, A review of arthrocentesis and arthroscopy found no presence of clicking/crepitus and/or locking. statistically significant difference between these inter- In total 59 joints were treated and all patients except i al ventions in terms of pain. However the complication one underwent bilateral meniscopexy, this patient rate for TMJ arthrocentesis is considered to be less had unilateral meniscopexy. than that for TMJ arthroscopy (12). Following surgery all patients underwent clinical ex- Guo et al. (2009) state there is insufficient evidence amination and were required to complete a pain and n (should conservative management fail) to support or functional questionnaire. The categories in the pain refute other strategies (13). questionnaire were None, Rare, Slight, Occasional, io Our retrospective study focused on disc displacement Moderate and Constant. without reduction (DDWoR) which can happen when The meantime interval from surgery to completing the the ligaments are stretched beyond their elastic po- questionnaire was 8.5 years, with a range of 22 months az tential. It can be described as a ‘door jam’ preventing to 16 years. normal joint movement. Presurgical technique rn Materials and methods Prior to surgery all patients underwent splint therapy Inclusion criteria: for 3 months. The mandibular flat plane pivot-type te Patients that had disc displacement without reduction splint was worn 24 hours a day, 7 days a week and confirmed on an MRI scan. Patients that did not re- only removed for cleaning. The purpose of the splint, spond to splint therapy. the height of which is determined by the swallow Patients that did not respond to conservative mea- technique, is to decompress the TMJ, thereby creat- In sures such as physiotherapy for a minimum of 6 ing superior joint space, obviating the need for condy- months, the average having such measures up to 18 lar surgery. months. Only the upper mesiopalatal cusps of the terminal Various options for surgery including arthrocentesis molars contact the splint creating a bilateral occlusal ni and arthroscopy were discussed with the patients. interference that limits postero-superior movement of Due to the prolonged nature of symptoms it was felt the condyle and reducing loading forces on the that modified meniscopexy to restore normal anatomy condylar head (Fig. 1). Any osteoarthritic process in io of the joint would provide the best result for these pa- the inferior compartment is therefore reduced or even tients. arrested. One week before surgery the splint is resur- Prior to surgery, all patients underwent an MRI scan faced to a highly indexed version locating the iz followed by 3 months of fulltime splint treatment. The mandible into an idealised relationship to the maxilla scans of all but 7 patients were classified according and this so-called anterior repositioning splint is worn to Wilkes below: during surgery. Ed Patients were considered for surgery if demonstrat- ing: - decreased inter-incisal opening Surgical technique - severe pain during function - audible crepitus A modified preauricular approach is used and then - consistent muscle hyperactivity with unstable tem- dissection proceeds to the superficial temporal fascia, IC poromandibular joints then blunt dissection anteriorly in this plane. After - no medical contraindications to surgery identifying the lateral capsular ligament, a horizontal - no mental/emotional contraindications to surgery. incision is required at its superior aspect to enter the superior joint space. The disc is then located (Fig. 2). C Further dissection to the lateral aspect of the articular Patients eminence and anterior to this may be required for this. The disc is then relocated and sutured laterally The study included 26 females and 4 males of which, and posteriorly to the capsular ligament. No wedge @ 9 were self referred, 16 referred by their general den- resection of the retrodiscal tissues is needed unless tal practitioner, 5 from maxillofacial surgeons and 1 they prevent relocation of the disc into its normal po- from a chiropractor. All patients completed: sition. - a TMJ medical, social and family history Prior to closure the joint is flushed with 2% lignocaine - a diagnostic pain questionnaire and 1:100,000 adrenaline. The mandible manipulated - a pictographic representation by the patient indi- up and down making sure that the occlusal surfaces cating pain sites (head, neck, face and shoulders) of the maxillary teeth correspond to the index in the 74 Annali di Stomatologia 2016;VII (3):73-78  Splint-assisted disc plication surgery Figure 1. Splint in situ demonstrat- ing occlusal interference thereby de- creasing load on condylar head. i n al io az rn mandibular repositioning splint. This allows open in- minutes per hour for the following 10 weeks. Patients spection for movement of the meniscus and determi- are expected to have an active mouth opening of 48- te nation of the stability of sutures and surgical reposi- 52 mm after 90 days. Most patients prefer a soft diet tioning. for the first few weeks although no restrictions are placed. In The repositioning splint is worn 24 hours a day in- cluding eating, for up to 12 months postoperatively. As postsurgical oedema reduces and the masticatory musculature relaxes, adjustments to the splint need ni to be undertaken initially every 3-4 weeks for the first few months. At 12 months when full healing has been attained, splint therapy is concluded and any restora- io tive or orthodontic treatment can then be undertaken. Analyses of the results were conducted retrospective- ly by independent researchers. Information was ob- tained from the patients’ clinical notes, pre-treatment iz and post-treatment pain questionnaires, MRI and hospital reports. The determination for success of Ed treatment was two fold, firstly the patients’ subjective evaluation and secondly the objective change in physical signs. Results IC The overall subjective improvement reported by the patients was measured on a visual analogue scale (VAS) as part of the post surgical questionnaire: in this study the mean improvement was 86% on a VAS C of 1-10, with 1 being nil improvement and 10 maxi- Figure 2. Location of disc: relocation and suturing laterally mum improvement. The minimum improvement was and posteriorly to the capsular ligament. 40% and the maximum was 100%. The majority of patients felt that they had benefited from the proce- @ Postsurgical treatment dure (Tab. 1). Shows overall improvement of the patients’ quality of Aggressive physical therapy is initiated within 24 life in response to 5 questions: the majority of pa- hours of surgery with a Therabite Exerciser. Patients tients exhibited improved opening except for one pa- are instructed to use it for 5 minutes every half hour tient whose opening decreased by 10 mm, this pa- (during waking hours) for the first 2 weeks and for 5 tient had a pre-operative mouth opening of 60 mm Annali di Stomatologia 2016;VII (3):73-78 75  O. Sheikh et al. that decreased to 50 mm. She had constant pain on TMJ locking prior to treatment was a constant prob- opening and a dull ache at rest, this was reduced to lem for 20% of the patient group with 33.3% stating rarely. The mean increase in mouth opening was 8.6 this was of moderate or occasional concern. mm and the maximum increase was 20 mm (Tab. 2). Following surgery, TMJ locking and crepitus was re- The AAOMS states that the average inter-incisal dis- solved for the entire group. tance is 50-60 mm and this measurement is an objec- Both locking and crepitus are objective observations tive assessment of joint function. In this study the aver- and less open to bias or interpretation unlike psycho- i age pre-op distance=37.5 mm (range of 25-60 mm). logical factors which may depend on the patients’ sta- al This method improves mouth opening and function tus at the time of questioning. but not every patient achieved the 50-60 mm range Neck pain is frequently associated with TMJ pain. reported by AAOMS. TMJD whilst not causative can exacerbate an existing n Clicking of the TMJ was as reviewed and is present- neck pain. 60% of patients reported constant neck ed in Table 3: 53.3% of patients reported constant pain pre-treatment, with only 3.3% of patients report- io clicking preoperatively whilst none reported constant ing constant pain post-treatment. However, after clicking postoperatively, confirming a marked im- treatment 70% still experienced occasional/rare pain. provement in symptoms. Pain is the most reported symptom of TMJD (6). az Table 4, shows that constant spontaneous jaw pain The improvement in reported pain pre and post treat- reduced in all but 3.3% of patients: 36.7% of patients ment. presented with crepitus preoperatively with complete 14 of the 30 patients reported constant joint pain pre- resolution for all patients after surgery. operatively while 4 never reported pain. Post-opera- rn Table 1. Pre-treatment Wilkes classification. te Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 0 0 14 22 9 In Table 2. Global post-operative subjective impressions. Overall improvement ni Question: Better Same Worse Overall my physical well-being is? 74% 19.3% 6% io Overall my mental/emotional state is? 64.5% 29% 6% Overall my ability to deal with stress is? 48.3% 48.3% 4.4% iz Overall my enjoyment of life is? 70.9% 22.5% 6.6% Overall my quality of life is? 77% 19% 4% Ed Table 3. Overall improvement in TMJ Clicking. Frequency of clicking Constant Rare Occasionally Never Pre op Clicking 53.3% 13.3% 3.3% 30% IC Post-op Clicking 0% 0% 6.7% 93.3% Table 4. Spontaneous jaw pain Pre and Post treatment. C Pre-treatment pain Post-treatment pain None 2 7 @ Rare 3 9 Slight 0 1 Occasional 1 10 Moderate 2 2 Constant 22 1 76 Annali di Stomatologia 2016;VII (3):73-78  Splint-assisted disc plication surgery Table 5. It shows the improvement in reported pain pre vs post operatively. Frequency of Pain Constant Moderate Occasionally Rare Never Pre operatively 66.67% 10% 6.67% 10% 6.67% Post operatively 3.33% 6.67% 33.33% 33.33% 23.33% i al tively 7 patients never experienced joint pain and only - access is confined to the superior joint space; 1 patient reported constant pain (Tab. 5). - the relocated disc is sutured posterolaterally to the cap- Chronic pain sufferers did not report complete resolu- sule and not posteriorly to the retrodiscal tissues; n tion of symptoms which may suggest that the most - the splint is worn during surgery; significant improvement is conferred on those pa- - aggressive physical therapy commences 24 hours io tients with a lower pre-operative level of pain. post surgery (16, 17); One patient suffered temporary right facial nerve palsy - the splint is worn full-time post surgery for 12 post-surgery with loss of ability to raise the right eye- months prior to any orthodontic/restorative proce- az brow. There were no post-treatment orthodontic compli- dures; cations. At the time of surgery two tears were seen in - As postsurgical oedema reduces and the mastica- the disc itself and two tears in retro-discal tissue. tory musculature relaxes, the splint is adjusted every 3-4 weeks for the first few months. rn The multiple adjustments of the splint gradually re- Discussion duce superior joint space allowing the disc to retain its correct anatomical position and prevent the disc This study reviewed a group of patients (n=30) treat- relapsing anteriorly, preventing a relatively common te ed by the senior Authors who presented with disc dis- complication. The suture posterolaterally also aids placement without reduction, either unilateral or bilat- this. Other studies have discussed the use of Mitek eral. Anterior repositioning splints can be used to cre- screws and double pass sutures to stabilise the artic- ate superior joint space as well as an idealised maxil- In ular disc in its correct anatomical position. However lo-mandibular relationship which is subsequently sta- very rarely did these methods result in a ‘click free’ bilized by disc relocation. The need to wear the splint joint for every patient post surgery in their respective prior to surgery is mandatory as it is during surgery to study groups (18-20). The weakness of the study is that the pre- and post- ni prevent relapse of the disc into the painful pre-surgi- surgical questionnaire was not aligned with OHIP and cal position. therefore limited in scope. Patients with disc displacement without reduction Furthermore, outcomes were reliant on subjective io show condyles that are superiorly positioned in the and functional improvements which could not be di- fossa reducing superior joint space. Occlusion, al- rectly associated to disc repositioning, since no post- though not a causative factor, maintains the patholog- operative MRI scans were taken. iz ical condyle/fossa relationship by virtue of intercuspa- tion. Creation of superior joint space is key to provid- ing disc space and stability thereafter. Previous at- Conclusion Ed tempts at creating space have involved condylar surgery but this does not address muscle spasm. To ensure long-term stability and relief of symptoms, Furthermore, such surgery carries complications in- all aspects of disc derangement aetiology must be cluding adhesion formation, bone degeneration and addressed. Patients in this study presented with disc ankyloses (14). displacement without reduction, occlusal dishar- Splint therapy allows non-invasive creation of superi- monies, degenerative change, muscle spasm and ab- IC or joint space, elongation of the masticatory muscles normal condylar position. together with a functional maxillomandibular relation- By restoring normal joint anatomy with subsequent ship. The surgeon and orthodontist opted for the mini- orthodontic stabilisation treatment which provided oc- mally invasive soft tissue procedure of disc plication clusal support, predictable long-term results can be C as it poses fewer post-surgical complications as com- achieved for this group of challenging patients. pared with more invasive techniques. Invasive tech- Whilst not a cure-all procedure, splint assisted disc pli- niques can damage the connective tissue covering of cation surgery can be recommended for refractory pa- osseous tissues thereby reducing the possibility for tients with chronic disc displacement without reduction. @ remodeling and healing (15). The surgical protocol differs from other published studies in the following ways: References - all surgery was preceded by 3 months of full-time splint therapy; 1. Leresche L. Epidemiology of temporomandibular disorders: - surgical intervention is strictly a soft tissue proce- implications for the investigation of etiologic factors. Crit dure; Rev Oral Biol Med. 1997;8:291-305. Annali di Stomatologia 2016;VII (3):73-78 77  O. Sheikh et al. 2. Attanasio G, Leonardi A, Arangio P, Minni A, Covelli E, Puc- 1991;49(11):1163-7. ci R, Russo FY, De Seta E, Di Paolo C, Cascone P. Tinni- 11. Kaplan A. Natural history of internal derangement of tem- tus in patients with temporo-mandibular joint disorder: Pro- poromandibular joint. In: Thomas M, Brostein S. editor(s). posal for a new treatment protocol. J Craniomaxillofac Surg. Arthroscopy of the Temporomandibular Joint. Philadelphia: 2015;43(5):724-7. WB Saunders. 1991:70-4. 3. Manfredini D, Guarda-Nardini N, Winocur E, Piccotti F, 12. Tozoglu S, Al-Belasy FA, Dolwick MF. A review of techniques Ahlberg J and Lobbezoo F. Research diagnostic criteria for of lysis and lavage of the TMJ. Br J Oral Maxillofac Surg. i temporomandibular disorders: a systematic review of axis 2011;49(4):302-9. doi: 10.1016/j.bjoms.2010.03.008. al I epidemiologic findings. Oral Surg Oral Med Oral Pathol Oral 13. Guo C, Shi Z, Revington P. Arthrocentesis and lavage for Radiol Endod. 2011;112:453-462. treating temporomandibular joint disorders. Cochrane 4. Tanaka E, Detamore MS, Mercuri LG. Degenerative disor- Database of Systematic Reviews. 2009;Issue 4. Art. No.: ders of the temporomandibular joint: etiology, diagnosis and CD004973. n treatment. J Dent Res. 2008;87:296-307. 14. Mercuri LG. Surgical Management of TMJ Pathology. A Fol- 5. Di Paolo C, Costanzo G, Panti F, Rampello A, Falisi G, Pil- low-up Study. International Association of Oral and Max- io loni A, Cascone P, Iannetti G. Epidemiological analysis on illofacial Surgeons. Ninth International Congress on Oral and 2375 patients with TMJ disorders: basic statistical aspects. Maxillofacial Surgery. Vancouver, B.C. Canada. May, 1986. Annali di Stomatologia. 2013;4(1):161-169. 15. Andradeemail NN, Kalra R, Shetye SP. New protocol to pre- 6. Tsuga K, Akagawa Y. A short-term evaluation of the effec- vent TMJ reankylosis and potentially life threatening com- az tiveness of stabilization-type occlusal splint therapy for spe- plications in triad patients. International Journal of Oral & Max- cific symptoms of temporomandibular joint dysfunction syn- illofacial Surgery. 2012;41(12):1495-1500. drome. The Journal of Prosthetic Dentistry. 1989;61(5):610- 16. Rocabado M. Physical therapy for the post surgical TMJ pa- 3. tient. Cranio. 1989;3:75-82. rn 7. Gray RJ, Davies SJ, Quayle AA, Wastell DG. A comparison 17. Austin BD, Shupe SM. The role of physical therapy in recovery of two splints in the treatment of TMJ pain dysfunction syn- after temporomandibular joint surgery. JOMS. 1993;51:495- drome. Can occlusal analysis be used to predict success of 498. splint therapy? British Dental Journal. 1991;170:5. 18. Göçmen G, Varol A, Karatas B, Basa S. Evaluation of tem- te 8. Davies SJ, Gray RJ. The pattern of splint usage inthe man- poromandibular joint disc-repositioning surgery with Mitek mini agement of two common temporomandibular disorders. Part anchors. National Journal of Maxillofacial Surgery. 2013; II: The stabilisation splint in the treatment of pain dysfunc- 4(2):188-192. tion syndrome. British Dental Journal. 1997;183(7):247-51. 19. Goizueta Adame CC, Muñoz-Guerra MF. The posterior dou- 9. Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny AM. Sta- In ble pass suture in repositioning of the temporomandibular bilisation splint therapy for temporomandibular pain dys- disc during arthroscopic surgery: a report of 16 cases. J Cran- function syndrome. Cochrane Database of Systematic Re- iomaxillofac Surg. 2012;40(1):86-91. views. 2004;Issue 1. Art. No.: CD002778. 20. Ruiz Valero CA, Marroquin Morales CA, Jimenez Alvarez JA, 10. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular Gomez Sarmiento JE, Vallejo A. Temporomandibular joint ni joint arthrocentesis: A simplified treatment for severe, limited meniscopexy with Mitek mini anchors. J Oral Maxillofac Surg. mouth opening. Journal of Oral and Maxillofacial Surgery. 2011;69(11):2739-45. io iz Ed IC C @ 78 Annali di Stomatologia 2016;VII (3):73-78 

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Case report Childhood overweight-obesity and periodontal diseases: is there a real correlation? i al Gian Luca Sfasciotti Conclusions. These results focus the attention on Roberta Marini the negative impact of obesity on gingival health n Andrea Pacifici in young subjects, probably due to a combination Gaetano Ierardo of metabolic and inflammatory profiles and the re- io Luciano Pacifici sult of a careless attitude towards prevention dis- Antonella Polimeni eases of the oral cavity. az Key words: periodontal diseases, gingival dis- Department of Oral and Maxillofacial Sciences, eases, pediatric obesity, child nutrition disorders, “Sapienza” University of Rome, Italy food habits. rn Corresponding author: Introduction Roberta Marini Department of Oral and Maxillofacial Sciences, Obesity is defined as an excess of body fat that caus- te “Sapienza” University of Rome es an alteration in the balance of the physical person Via Caserta 6 who is affected. The Body Mass Index (BMI) is the 00168 Rome, Italy most scientifically accurate system to determine the E-mail: [email protected] In amount of fat mass in a subject: it is measured divid- ing the weight of the subject in kilograms and the square of his height in meters (Kg/m 2). The World Summary Health Organization (WHO) and the National Heart, Lung and Blood Institute (NHLBI) define overweight ni Objective. The association between obesity and people with a BMI between 25 and 29.9 and obese periodontitis has been extensively investigated in with BMI>30 (1, 2). adults but not in young people. The aim of this The prevalence of obesity has increased dramatically io study was to examine the association between in a rather short period of time, doubling for adults overweight-obesity and periodontal disease in pe- and tripling in children and adolescents (3-8). Around diatric subjects. 31% (about 59 million) of American adults is obese iz Methods. Controlled cross-sectional study involv- and more than 65% reported a BMI>25. In addition, ing 100 school children of both gender (50 M and 15.8% of children (6-11 years) and 16.1% of adoles- 50 F) between 7 and 12 years of age (mean age cents (12-19 years) are suffering from obesity (1-3). Ed 9,19±1,57). Two groups were formed based on The United States of America reflect the prevalence Body Mass Index value: test group with BMI ≥ 25 internationally regarding obesity, except for the Kg/m2 and control group with BMI ≤ 24 Kg/m2. Di- African continent (3). et intake and oral hygiene habits were recorded Obesity is not only an aesthetic problem but is con- by a specific questionnaire and the periodontal sidered a chronic disease caused by multifactorial eti- clinical parameters were evaluated. ology represented by genetic, environmental, socio- IC Results. The periodontal examination in the con- economic and behavioral components (9-13). trol group revealed a full-mouth plaque score The association between obesity and inflammatory (FMPS) value equal to 21.86% against 50.08% in process has long been known. Adipose tissue is in the group of patients overweight/obese; the full- fact an endocrine organ, metabolically active, produc- C mouth bleeding score (FMBS) in the control group ing immuno-regulatory factors involved in the regula- amounted to 12.7% against 26.24% of test group. tion of vascular and metabolic processes associated No patient in either group included in the study with alterations like high blood pressure, osteoarthri- presented a probing pocket depth (PPD) ≥3, so a tis, other respiratory disorders, diseases of the gall- @ significant difference regarding this value was not bladder, the hyperlipidemia, atherosclerosis, pancre- found. Regarding the frequency and quantity of atitis, hepatitis and diabetes mellitus (3, 14). food consumption, the number of obese patients Regarding the association between obesity and peri- who did not follow a balanced diet largely exceed- odontal disease, several hypotheses have been for- ed the number of normal-weight patients (70 ver- mulated with the aim to explain the biological interac- sus 20%). tions including impaired glucose tolerance, abnormal Annali di Stomatologia 2016;VII (3):65-72 65  G. L. Sfasciotti et al. lipid profile, deficiency of the immune system, an in- Inclusion criteria: creased activation of macrophages, alterations of the • Children aged between 7-12 years (males and fe- microcirculation and secretion of pro-inflammatory males); substances by the adipose tissue such as TNF-a, IL- • Absence of systemic diseases; 6 and C-reactive protein (15-19). • No drugs intake within 7 days before the visit. Although the topic has been treated and investigated Exclusion criteria: in the literature, few appear to be the studies con- • Girls had menarche. i ducted on groups of patients with a specific age To avoid bias related to teeth eruption states, the al range and still today lack the scientific explanations measures were made only on the first permanent mo- that may justify the higher incidence of periodontal lars and the upper and lower central and lateral in- disease in overweight/obese children. cisors. The deciduous teeth were not included in the n The purpose of this study was firstly to assess the periodontal evaluation. state of periodontal health in a group of obese and For each patient an anamnestic folder containing in- io normal children between 7 and 12 years in order to formation about the personal data and medical histo- determine if there was a real correlation between pe- ry was compiled: in addition children were asked to riodontal diseases and obesity and, secondly, to find fill out a questionnaire regarding their oral hygiene az a possible cause of this relationship. habits – i.e. how many times the child brushes his teeth, the presence of pain and/or bleeding during the tooth brushing etc., and their lifestyle – i.e. their food Material and methods habits, possible food intolerances, but also the time rn spent watching TV and/or playing sports, etc. More- One hundred patients (50 males; 50 females) aged 7- over, the Authors investigated about the possible 12 years (mean age 9.19±1.57), referred at Depart- presence of sleep disorders (such as noisy breathing, ment of Oral and Maxillo-Facial Sciences - “Sapien- apnea, para-functions, etc.). te za” University of Rome, Division of Pediatric Den- The following data were collected for every patient: tistry, between September 2013 and September • Age 2014, were included in the study. The selected pa- • Weight (Kg) tients were divided into 2 groups based on Body In • Height (cm) Mass Index (BMI): the test group included 50 patients • BMI (Body Mass Index) value, according to the overweight/obese with BMI ≥ 25 kg/m²; the control program of the ‘US Department of Health & Human group was represented by 50 children of normal Services’. weight with BMI ranging between 18.5-24.9 kg/m². For each patient both a photographic examination, ni The ethical committee of “Sapienza” University of comprising 5 photos (Fig. 1), and an evaluation of the Rome approved the study protocol (CE 3732 – periodontal health, using mirror and periodontal probe 26/10/2015), and for each patient the relative in- UNC 15 (Fig. 2), were performed by a single operator io formed consent form was obtained. to evaluate the following clinical parameters: The study was designed as an observational case-con- • full mouth plaque score (FMPS): the full-mouth trol to assess the state of periodontal health in children plaque score is defined as the percentage of sites iz obese/overweight versus normal weight children. where plaque is present divided by the number of The statistical analysis of data was performed by mean sites examined; ± standard deviation of each measured parameter. • full-mouth bleeding score (FMBS): the full-mouth Ed Figure 1. Photographic examination. IC C @ 66 Annali di Stomatologia 2016;VII (3):65-72  Childhood overweight-obesity and periodontal diseases: is there a real correlation? Figure 2. Periodontal evaluation. i n al io az bleeding score is defined as the percentage of sites ≥ 25 and a control group consisting of 50 children of rn bleeding with respect to the number of sites examined; normal weight (25 M and 25 F) of the same age. • probing pocket depth (PPD): is the distance from The group of overweight/obese had a weight average the gingival margin to the bottom of the gingival of 50.76±9.24 kg (mean value ± SD) and an height te sulcus/pocket. It is measured by means of a grad- measured in centimeters of 142.38±10.64. From uated periodontal probe with a standardised tip these data was obtained the mean value of BMI = diameter of 0.5 mm. Measurement is taken for 26.38±1.42 kg/m², ranging from 25 (36% of the sam- each tooth at the mesio-buccal line angle, the ple) to a maximum value of 30 (only 1 patient, 2% of In mid-buccal, the distobuccal line angle, the dis- the test group). The children in test group had a tolingual line angle, the mid-lingual and the mean age of 9.26±1.62 years old. mesio-lingual line (six sites for each tooth). The The control group included children defined as nor- physiological value of PPD is considered to be ≤ 3 mal weight based on the classification of the World ni mm. PPD allows an immediate evaluation of dis- Health Organization (WHO) with an average weight eased sites. of 35.12±4.97 kg and a height of 134.7±8.53 cm: the mean value of BMI was 18.79±2.52kg/m². The aver- io age age in this group was 9.36±1.78 years old. The Results characteristics of two groups are summarized in Fig- ures 3, 4. iz A total of 100 patients (50 males and 50 females), di- The difference in weight between the two groups is vided into two groups in accordance with the classifi- statistically significant, with a value of 15,64 kg. Re- cation of BMI (Body Mass Index), were included in garding the height of the children, the test group Ed the study: a test group consisting of 50 children (25 M showed to be 7,68 cm higher compared to the control and 25 F) aged between 7 and 12 years with a BMI group, but this difference is less significant. IC Figure 3. Characteristics of the control group. C @ Annali di Stomatologia 2016;VII (3):65-72 67  G. L. Sfasciotti et al. Figure 4. Characteristics of the test group. i n al io az Questionnaire: when compared with those of normal weight, evi- rn Although the questionnaire had been specially de- dence that helps explain the apparent gingival inflam- signed to be well understood by children, all ques- mation of patients overweight/obese. tions were posed to the parents too in order to avoid The percentages of the answers regarding the oral possible bias in the compilation and understanding of hygiene habits of the two groups are summarized in te the same. Tables 1, 2. As regards to the oral hygiene, the majority of sub- The food habits and lifestyle questionnaires revealed jects in both groups reported brushing their teeth at that the majority of patients in both groups (respec- least twice a day (75 and 81%, respectively for the In tively 90% of obese/overweight children and 85% of overweight/obese and normal group) with oscillators normal weight patients) did not have food intoler- and rotators movements, especially using the manual ances. Consumption of fruits and vegetables was toothbrush. high both in the test and in the control groups (re- The majority of subjects in both groups reported to spectively 85 and 90%). Regarding the frequency and ni have recently gone to the dentist for a check-up visit quantity of food consumption, the number of obese (51 and 70%, respectively, for test and control patients who did not follow a balanced diet largely ex- group). Despite these results, in both groups were ceeded the number of normal-weight patients (70 ver- io found incorrect procedures in oral hygiene. In fact, sus 20%). In both groups, the majority of patients the 85% of test group’s patients reported to brush practiced sports. The study finally reported sleep their teeth with less than 2 minutes and 75% to anomalies in patients overweight/obese: 80% of iz change the brush only when it broke. these children, in fact, were affected by sleep disor- The overweight/obese children have also shown a ders such as noisy breathing, apnea and/or parafunc- worse predisposition in oral hygiene procedures tional habits of the stomatognathic system (clenching, Ed Table 1. Percentages of the answers regarding the oral hygiene habits of the control group. CONTROL GROUP IC How many times brushing teeth 1 2 3 4% 81% 15% Time spend to brushing 1 min < 2 min >2min 4% 85% 11% C Toothbrush chancing Every month Every 2 months When it broken 25% 70% 15% @ Gingival pain Yes No 15% 85% Gingival bleeding Yes No 15% 85% Topical fluoride use Yes No 60% 40% 68 Annali di Stomatologia 2016;VII (3):65-72  Childhood overweight-obesity and periodontal diseases: is there a real correlation? Table 2. Percentages of the answers regarding the oral hygiene habits of the test group. TEST GROUP How many times brushing teeth 1 2 3 15% 75% 10% Time spend to brushing 1 min < 2 min >2min i al 10% 85% 5% Toothbrush chancing Every month Every 2 months When it broken 5% 20% 75% n Gingival pain Yes No 80% 20% io Gingival bleeding Yes No 80% 20% az Topical fluoride use Yes No 80% 20% rn teeth grinding), compared to 20% of the subjects en- and obesity has been extensively studied in adults, rolled in the control group. this correlation was not as investigated in children The specific percentages for each answer regarding population. In this study, the Authors examined 100 te these topics are summarized in Tables 3, 4. children referred at the Unit of Pediatric Dentistry, Department of Oral and Maxillo-Facial Sciences, Clinical evaluation: “Sapienza” University of Rome, with aiming to test The clinical examination of periodontal health in the In the association between obesity and periodontal dis- control group revealed a FMPS value equal to ease in children between 7 and 12 years, assessing 21.86% against 50.08% in the group of patients over- the FMPS, FMBS and PPD. The choice of this range weight/obese; the FMBS in the control group amount- age was dictated by the need to have subjects that ed to 12.7% against 26.24% of test group. No patient presented the central and lateral permanent in- ni in either group included in the study presented a cisors, upper and lower, and the first permanent mo- PPD≥3, so a significant difference regarding this val- lars. The decision to not evaluate subjects with ue was not found. more than 12 years old has been established to pre- io The periodontal measures of both groups are sum- vent potential bias related to hormonal disorders of marized in Table 5. menarche. The results showed that the presence of plaque is the iz most significant early sign of gingival inflammation. Discussion An high value of FMPS (%) is in fact recorded in all studied subjects: our results showed that an increase Ed While the relationship between periodontal disease in fat mass corresponds to an increase of the plaque Table 3. Percentages for each answer regarding food and life habits of the control group. CONTROL GROUP IC Food intolerances Yes No 15% 85% Consumption of fruits and vegetables Yes No C 90% 10% Balanced diet Yes No 80% 20% Sport Yes No @ 95% 5% Watch tv more than 1 hour/day Yes No 100% 0% Sleep disorders Yes No 15% 85% Annali di Stomatologia 2016;VII (3):65-72 69  G. L. Sfasciotti et al. Table 4. Percentages for each answer regarding food and life habits of the test group. TEST GROUP Food intolerances Yes No 10% 90% Consumption of fruits and vegetables Yes No i al 85% 15% Balanced diet Yes No 30% 70% n Sport Yes No 95% 5% io Watch tv more than 1 hour/day Yes No 100% 0% az Sleep disorders Yes No 80% 20% rn Table 5. Periodontal results of both groups. TEST GROUP CONTROL GROUP te FMPS% FMBS% FMPS% FMBS% 50.08% 26.24% 21.86% 12.7% In FMPS= Full mouth plaque score; FMBS= Full-mouth bleeding score. index and gingivitis, as well as demonstrated in other creasing weight and waist circumference. In particu- ni studies (15, 16, 20). Resulting clear the mechanism lar, it was found that in subjects between 17 and 21 by which adipose tissue secretes cytokines and acti- years, each increase of 1 kg was associated with a vates molecules involved in inflammation, still the sci- 6% increase in the risk of periodontal disease; simi- io entific opinion is confused and contradictory regard- larly, every increase of 1 inch of waist circumference ing the relationship between obesity and periodontal was related to a 5% increase in the risk of periodonti- disease. Saxlin et al. (21) have shown in a long-term tis. In contrast, there was no relationship between iz study, which involved 396 obese subjects with a these parameters in younger children aged between mean follow-up of 4 years, as obesity is associated 13 to 16 years. with periodontal disease but does not constitute a risk Modéer et al. (28) have recently investigated pedi- Ed factor. In contrast, in another longitudinal study of atric obesity as an indicator risk for periodontal dis- 3,590 Japanese adults, a dose-dependent correlation ease comparing a group of 52 obese children and between BMI and the development of periodontitis adolescents between 11 and 17.9 years and a group was demonstrated (22). Another study carried out on of 52 subjects of the same age of normal weight. The 4,246 adults of Korean nationality revealed that sub- study reported a worse oral hygiene, an higher inci- jects with a BMI>25 had a minimal risk compared to dence of bleeding on probing (BOP%) and the pres- IC individuals of normal weight to develop periodontitis, ence of pathological periodontal pockets (>4 mm) in while subjects with abdominal fat were significantly obese subjects compared to the control group. exposed to the gingival disease (23): this result is to Our results do not resolve the dilemma on the causes suggest that the metabolic syndrome plays a role in of the correlation between periodontal diseases and C inflammation of the periodontium, like suggested in excess body fat: what is evident though is that the ac- other studies (24-26). cumulation of plaque and the consequent gingival in- On the other hand, some Authors have pointed out flammation is much more common in children with that the scientific evidence supporting the presence BMI>25. Obese children show, in addition, a lifestyle @ of a biological mechanism underlying the association less correct than normal-weight peers. While for between obesity and periodontal infection is not fully adults the correlation between unhealthy lifestyles convincing, assuming a bias related to poor oral (smoking, high-calorie diet, physical activity) and on- health of obese individuals. Reeves et al. (27) ana- set of periodontitis is well-known, the same cannot be lyzed this possible correlation in a group of American said for children because all the patients declared to teenagers between 13 and 21 years concluding that devote insufficient time to brushing teeth and to con- the onset of periodontitis may be associated with in- sume high amounts of cariogenic foods. 70 Annali di Stomatologia 2016;VII (3):65-72  Childhood overweight-obesity and periodontal diseases: is there a real correlation? Conclusions Jan;107(1):81-91. 12. Cinar AB, Murtooma H. Interrelation between obesity, oral health and life-style factors among Turkish school children. In conclusion, the results want to focus the attention Clinical oral invest. 2011 Apr;15(2):177-184. on the negative impact of obesity on gingival health 13. Wardle J, Carnell S, Haworth CM, Plomin R. Evidence for in young subjects, probably due to a combination of a strong genetic influence on childhood adiposity despite the factors, like metabolic and inflammatory profiles and force of the obesogenic environment. Am J Clin Nutr. 2008 the result of a careless attitude towards prevention i Feb;87(2):398-404. al diseases of the oral cavity, including hygiene proce- 14. Mohamed-Ali V, Pinkey JH, Copack, SW. Adipose tissue as dures at home, knowledge of a balance diet and re- an endocrine and paracrine organ. Int J Obes Relat Metab spect for periodic check-up to the dentist (29, 30). In Disord. 1998 Dec;22(12):1145-58. the literature is described the possibility of using 15. Scorzetti L, Marcattili D, Pasini M, Mattei A, Marchetti E, Mar- n protective microorganisms present in dental plaque zo G. Association between obesity and periodontal disease as Lactobacillus brevis to suppress the growth of in children. Eur J Paediatr Dent. 2013 Sep;14(3):181-4. io 16. Dalla Vecchia CF, Susin C, Rösing CK, Oppermann RV, Al- pathogenic bacteria. Lactobacillus brevis has anti- bandar JM. Overweight and obesity as risk indicators for pe- inflammatory activity due to its ability to inhibit, in riodontitis in adults. J Periodontol. 2005 Oct;76(10):1721-8. particular macrophages, the nitrogen oxide synthase az 17. D’Aiuto F, Sabbah W, Netuveli G, Donos N, Hingorani AD, activity, indirectly causing a reduction in the levels Deanfield J, Tsakos G. Association of the metabolic syndrome of inflammatory cytokines (31). These considera- with severe periodontitis in a large U.S. population-based sur- tions suggest the need to investigate more deeply vey. J Clin Endocrinol Metab. 2008 Oct;93(10):3989-94. the relationship between severe obesity and peri- 18. Chaffee BW, Weston SJ. The association between chron- rn odontal health, evaluating the possible presence of ic periodontal disease and obesity: a systematic review with microbiological alterations at the level of saliva meta-analysis. J Periodontol. 2010 Dec;81(12):1708-24. and/or the crevicular fluid in the test group respect 19. Ylöstalo P, Suominen-Taipale L, Reunanen A, Knuuttila M. Association between body weight and periodontal infection. the control sample (32, 33). te J Clin Periodontol. 2008 Apr;35(4):297-304. 20. Franchini R, Petri A, Migliario M, Rimondini L. Poor oral hy- Conflict of interest giene and gingivitis are associated with obesity and over- The Authors disclosure that they have not been any weight status in paediatric subjects. J Clin Periodontol. 2011 conflict of interest for the study. In Nov;38(11):1021-8. 21. Saxlin T, Ylo¨stalo P, Suominen-Taipale L, Mannisto S, Knu- uttila M. Association between periodontal infection and obe- References sity: results of the Health 2000 Survey. J Clin Periodontol. 2011 Mar; 38(3):236-42. ni 1. Ritchie CS. Obesity and periodontal disease. Periodontol. 22. Morita I, Okamoto Y, Yoshii S, Nakagaki H, Mizuno K, Shei- 2000. 2007;44:154-163. ham A Sabbah W. Five-year incidence of periodontal dis- 2. Pischon N, Heng N, Bernimoulin JP, Kleber BM, Willich SN, ease is related to body mass index. J Dent Res. 2011 Feb; io Pischon T. Obesity, inflammation, and periodontal dis- 90(2):199-202. ease. J Dent Res. 2007;86:400-409. 23. Kim EJ, Jin BH, Bae KH. Periodontitis and obesity: a Study 3. Zermeño-Ibarra JA, Delgado-Pastrana S, Patiño-Marín N, of the Fourth Korean National Health and Nutrition Exami- iz Loyola-Rodríguez JP. Relationship between overweight-obe- nation Survey. J Periodontol. 2010 Apr; 82(4):533-42. sity and periodontal disease in Mexico. Acta Odontol Lati- 24. Andriankaja OM, Sreenivasa S, Dunford R, De Nardin E. As- noam. 2010;23(3):204-9. sociation between metabolic syndrome and periodontal dis- ease. Aust Dent J. 2010 Sep;55(3):252-9. Ed 4. Seidell JC. Obesity: a growing problem. Acta Paediatr Sup- pl. 1999;88(428):46-50. 25. Benguigui C, Bongard V, Ruidavets JB, Chamontin B, Sixou 5. Wang Y, Lobstein T. Worldwide trends in childhood over- M, Ferrières J, Amar J. Metabolic syndrome, insulin resis- weight and obesity. Int J Pediatr Obes. 2006;1(1):11-25. tance, and periodontitis: a cross-sectional study in a mid- 6. Han, JC, Lawlor DA, Kimm SY. Childhood obesity. Lancet. dleaged French population. J Clin Periodontol. 2010 Jul;37 2010; 15;375(9727):1737-48. (7):601-8. 7. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obe- 26. Timonen P, Niskanen M, Suominen-Taipale L, Jula A, Knu- IC sity and trends in body mass index among US children and uttila M, Ylo stalo P. Metabolic syndrome, periodontal infection, adolescents, 1999-2010. JAMA. 2012;1;307(5):483-90. and dental caries. J Dent Res. 2010 Oct;89(10):1068-73. 8. Graf C, Koch B, Dordel S, Schindler-Marlow S, Icks A, 27. Reeves AF, Rees JM, Schiff M, Hujoel P. Total body Schüller A, Bjarnason-Wehrens B, Tokarski W, Predel HG. weight and waist circumference associated with chronic pe- riodontitis among adolescents in the United States. Arch Pe- C Physical activity, leisure habits and obesity in first-grade chil- dren. Eur J Cardiovasc Prev Rehabil. 2004;11(4):284-90. diatr Adolesc Med. 2006 Sep;160(9):894-9. 9. Saito T, Shimazaki Y. Metabolic disorders related to obesi- 28. Modéer T, Blomberg C, Wondimu B, Lindberg TY, Marcus ty and periodontal disease. Periodontol. 2000. 2007;43:254- C. Association between obesity and periodontal risk indicators 66. in adolescents. Int J Pediatr Obes. 2011 Jun;6(2-2):e264-70. @ 10. Hirschler V, Calcagno ML, Clemente AM, Aranda C, Gon- 29. Trottini M, Bossù M, Corridore D, Ierardo G, Luzzi V, Sac- zalez C. Association between school children’s overweight cucci M, Polimeni A. Assessing risk factors for dental and maternal obesity and perception of their children’s weight caries: a statistical modeling approach. Caries Res. 2015; status. J Pediatr Endocrinol Metab. 2008;21(7):641-9. 49(3):226-35. 11. Perichart-Perera O, Balas-Nakash M, Schiffman-Selechnik 30. Kesim S, Çiçek B, Aral CA, Öztürk A, Mazıcıoğlu MM, Kur- E, Barbato-Dosal A,Vadillo-Ortega F. Obesity increases toğlu S. Oral Health, Obesity Status and Nutritional Habits metabolic syndrome risk factors in school-aged children from in Turkish Children and Adolescents: An Epidemiological an urban school in Mexico city. J Am Diet Assoc. 2007 Study. Balkan Med J. 2016 Mar;33(2):164-72. Annali di Stomatologia 2016;VII (3):65-72 71  G. L. Sfasciotti et al. 31. Ierardo G, Bossù M, Tarantino D, Trinchieri V, Sfasciotti GL, in the oral fluid of health patients. 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Original article Qualitative evaluation of the adesive interface between lithium disilicate, luting composite and natural tooth Nicola Mobilio, DDS ramic restorations is influenced by the type of cementa- Alberto Fasiol, DDS tion (5, 6). A strong point claimed for using lithium disili- Santo Catapano, MD, DDS cate is adhesive cementation. As glass-ceramic, the in- ner surface of lithium disilicate may be etched by fluo- ridric acid to increase the surface energy and conse- Department of Prosthodontics, Dental School, Dental quently the bond strenght (7, 8). After etching and Clinic, University of Ferrara, Ferrara, Italy cleaning the surface, a silane coupling agent is used to establish a chemical bond between luting composite and ceramic surface. Corresponding author: A recent study investigated the retentive strength of Alberto Fasiol lithium disilicate crowns cemented on natural teeth (9). Department of Prosthodontics, Dental School, Dental Posterior teeth restored with adhesively-cemented disil- Clinic, University of Ferrara icate crowns most often failed by fracturing the root, Corso Giovecca 203 suggesting a real adhesion between dental structure 44121 Ferrara, Italy and ceramic reconstruction rather than merelya luting. E-mail: [email protected] Such an adhesive interface needs to be deeply investi- gated. Aim of this work was to qualitatively evaluate the inter- Summary face between tooth, luting composite and lithium disili- cate surface using a scanning electron microscope Aim of this work was to qualitatively evaluate the in- (SEM). terface between tooth, luting composite and lithium di- silicate surface using a scanning electron microsco- pe (SEM). An extracted restoration-free human molar Materials and methods was stored in physiological solution until it was em- bedded in an autopolimerysing acrylic resin. A stan- A restoration-free human molar, extracted for periodon- dard preparation for overlay was completed and after tal reason, was cleaned from dental plaque and peri- preparation an anatomic overlay was waxed on the odontal tissues with ultrasonic instruments and curet- tooth and then hot pressed using lithium disilicate ce- tes. The tooth was embedded in a self-curing acrylic ramic. After cementation the sample was dissected and resin block (ProBase Cold, Ivoclar Vivadent AG, the section was analysed using an Automatic Micro- Schaan, Liechtenstein) up to 2 mm below the cement- met (Remet s.a.s) and the section was analyzed using enamel junction (CEJ) and with its long axis perpendic- a scanning electron microscope (SEM). SEM evalua- ular to the base of the block. The tooth was horizontally tion of the tooth showed the three layers seamlessly; sectioned by using a diamond disk and 2 perpendicular by increasing the enlargement the interface did not grooves were made on the horizontal surface by using change. a spherical diamond bur, to facilitate the positioning of the restoration (Fig. 1). Key words: adhesive, lithium disilicate, cementa- tion, SEM. ! Introduction The use of lithium disilicate as ceramic material for fixed dental prosthesis combines good mechanical properties to excellent aesthetic results. This ceramic is indicated for single crowns, veneers and inlays, and compared with other glass-ceramics, it demonstrates very good performance (1). Lithium disilicate represents a clinical option in both an- terior and posterior region (2, 3), showing successful rates from 95.39 to 100% at 3 years (4). It is generally assumed that clinical success of all-ce- Figure 1. Preparation and restoration. Annali di Stomatologia 2016;VII (1-2): 1-3 1  N. Mobilio et al. An anatomic onlay was waxed and hot pressed using ! lithium disilicate (IPS e.max PRESS LT A1, Ivoclar Vi- ! vadent AG, Schaan, Liechtenstein). The inner surface of ceramic was etched with 5% hy- drofluoridric acid (IPS Ceramic, Ivoclar Vivadent) for 20 second, then rinsed and cleaned in pure alcohol in ul- trasonic bath for 10 minutes. ! Therefore it was treated with universal primer (Monobond Plus, Ivoclar Vivadent AG, Schaan, Liecht- enstein) and then dried with hot air. ! The tooth was cleaned and dried, and then an adhesive (Multilink Primer, Ivoclar Vivadent AG, Schaan, Liecht- enstein) was brushed on and dried. The cement (Multi- link Automix, Ivoclar Vivadent AG, Schaan, Liechten- stein) was applied on the inner surface of the ceramic and then the onlay was seated on the prepared teeth until the end of polymerization (Fig. 2) After cementation the tooth was sectioned along the vertical axis using a diamond disk and the section was analyzed using a scanning electron microscope (SEM). Figure 4. SEM evaluation at 800 X. Figure 2. Cementation. Figure 5. SEM evaluation at 1.37K X. ! Figure 3. SEM evaluation at 558 X. Results SEM evaluation of the tooth section at 558 X (i.e. 20 μm) showed the three layers (tooth, luting composite and lithium disilicate) seamlessly (Fig. 3). With increas- ing enlargement at 800 X, 1.37 K X and until 3.67 K X, Figure 6. SEM evaluation at 3.67K X. the interface did not change (Figs. 4-6). 2 Annali di Stomatologia 2016;VII (1-2): 1-3 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Qualitative evaluation of the adesive interface between lithium disilicate, luting composite and natural tooth Discussion composite luting is mandatory to achieve adhesion both to the dental tissue and to inner ceramic layer (12, 13). Traditionally, definitive cementation is considered a fun- In conclusion, within the limits of this qualitative SEM damental step among restorative procedures. The cor- evaluation, the adhesive interface between tooth, luting rect cement selection and correct cementation proce- composite and ceramic appeared to be with no inter- dure are crucial for adequate marginal sealing and ruption. Further quantitative in vitro studies are needed proper retention of the restoration in time (10). In to better address this issue. restoring teeth by using metal-free restoration, the ce- mentation step acquires an additional value. In this case, indeed, cementation is not just a luting proce- References dure, but it realises a true adhesion between two differ- ent materials, i.e. dental tissue and ceramic restoration. 1. Denry I, Holloway JA. Ceramics for dental applications: A re- Using an adhesive cementation has a large impact on view. Materials. 2010;3:351-368. 2. Valenti M, Valenti A. Retrospective survival analysis of 261 clinical decisions and procedures. First of all, it is possi- lithium disilicate crowns in a private general practice. Quin- ble to prepare a tooth with insufficient retention form: it tessence Int. 2009;40:573-579. happens very often in case of partial reconstructions 3. Gehrt M, Wolfart S, Rafai N, Reich S, Edelhoff D. Clinical re- (veneers or onlays), that would not be possible with tra- sults of lithium-disilicate crowns after up to 9 years of ser- ditional, not adhesive procedures. Furthermore, the ad- vice. Clin Oral Investig. 2012;17:274-285. hesive interface between tooth and ceramic has the 4. Fabbri G, Zarone F, Dellificorelli G, Cannistraro G, de Loren- ability to increase the mechanical properties of the lat- zi M, Mosca A. Clinical evaluation of 860 anterior and poste- ter, improving the fracture resistance of the whole sys- rior lithium disilicate restorations: retrospective study with a tem (11). For this reason it is possible to use all-ceram- mean follow-up of 3 years and a maximum observational pe- ic restorations also in load-bearing areas (e.g. posterior riod of 6 years. Int J Periodont Restor Dent. 2014;34:165-177. 5. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: A re- region).Therefore, it is recognized that the success of view of the literature. J Prosthet Dent. 2003;89:268-274. an all-ceramic restoration greatly depends on the quali- 6. Blatz MB, Oppes S, Chiche G, Holst S, Sadan A. Influence ty of the adhesive interface. For this reason in the pre- of cementation technique on fracture strength and leakage sent study such an interface has been evaluated by of alumina all-ceramic crowns after cyclic loading. Quintes- SEM. The SEM analysis revealed a continuous inter- sence Int. 2008;39:23-32. face from dentine to luting composite to lithium disili- 7. Ozcan M, Vallittu PK. Effect of surface conditioning meth- cate. Such evidence was confirmed by increasing the ods on the bond strength of luting cement to ceramics. Dent enlargement. Such a perfect interface may be most Mater. 2003;19:725-731. likely responsible of the very good performance of all- 8. Tian T, Tsoi JK, Matinlinna JP, Burrow MF. Aspects of bond- ing between resin luting. Cements and glass ceramic ma- ceramic crowns in a recent study (9). Teeth restored terials. Dent Mater. 2014;30:e147-e162. with adhesively-cemented lithium disilicate crowns most 9. Mobilio N, Fasiol A, Mollica F, Catapano S. Effect of Differ- often failed by fracture of the tooth instead of decemen- ent Luting Agents on the Retention of Lithium Disilicate Ce- tation of the crown in a in vitro pull-out test. Where ad- ramic Crowns. Materials. 2015;8:1604-1611. hesive cementation was not used, the most of the teeth 10. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed failed by decementation. prosthodontics. St. Louis, Mo.: Mosby/Elsevier, 2006. Among glass ceramics, lithium disilicate has the highest 11. Guess PC, Zavanelli RA, Silva NR, Bonfante EA, Coelho PG, flexural strength and for this reason has many clinical Thompson VP. Monolithic CAD/CAM lithium disilicate versus indications, also in high stress areas or conditions. Fur- veneered Y-TZP crowns: Comparison of failure modes and thermore, disilicate as a glass ceramic may be chemi- reliability after fatigue. Int J Prosthodont. 2010;23:434-442. 12. Chu SJ. Current clinical strategies with lithium-disilicate cal etched and this is a clear advantage relative to restorations. CompendContinEduc Dent. 2012;33:64-67. more performing polycrystalline ceramics as zirconia. 13. Manso AP, Silva NR, Bonfante EA, Pegoraro TA, Dias RA, For this reason a true adhesion to the tooth is possible Carvalho RM. Cements and adhesives for all-ceramic to achieve with lithium disilicate and not with zirconia. A restorations. Dent Clin North Am. 2011;55:311-332. Annali di Stomatologia 2016;VII (1-2): 1-3 3 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Original article Fracture resistance of endodontically treated teeth restored with a bulkfill flowable material and a resin composite Almira Isufi, DDS, PhD1 was recorded as favorable or unfavorable. Data Gianluca Plotino, DDS, PhD1 were statistically analyzed with one-way analysis Nicola Maria Grande, DDS, PhD2 of variance (ANOVA) and Bonferroni tests Pietro Ioppolo3 (P<0.05). Luca Testarelli, DDS, PhD1 Results. No statistically significant differences Rossella Bedini3 were found among groups (P<0.05). Fracture re- Dina Al-Sudani, DDS4 sistance of endodontically treated teeth restored Gianluca Gambarini, MD, DDS1 with a traditional resin composite and with a bulk fill flowable composite (SDR) was similar in both maxillary and mandibular molars and showed no 1 Endodontics Unit, Department of Oral and Maxillo- significant decrease in fracture resistance com- Facial Sciences, “Sapienza” University of Rome, Italy pared to intact specimens. 2 Department of Endodontics, Catholic University of Conclusions. No significant difference was ob- Sacred Heart, Rome, Italy served in the mechanical fracture resistance of 3 Istituto Superiore di Sanità, Technology and Health endodontically treated molars restored with tradi- Department, Rome, Italy tional resin composite restorations compared to 4 Department of Restorative Dental Sciences, College bulk fill flowable composite restorations. of Dentistry, King Saud University, Riyadh, Saudi Arabia Key words: fracture resistance, endodontic treat- ment, bulk fill flowable composite, resin compos- ite. Corresponding author: Almira Isufi Endodontics Unit, Department of Oral and Maxillo- Introduction Facial Sciences, “Sapienza” University of Rome Via Caserta 6 The functional and aesthetic rehabilitation of en- 00161 Rome, Italy dodontically treated teeth has been the subject of dif- E-mail: [email protected] ferent studies (1). The restoration should not only provide function, aesthetic and marginal sealing, but also protect the remaining tooth structure (2, 3). Dif- Summary ferent studies have shown that the preparation of en- dodontic access cavities reduces the strength of the Aim. To determine and compare the fracture re- teeth, because of deep and extended cavity prepara- sistance of endodontically treated teeth restored tions which critically reduce the amount of dentin (4- with a bulk fill flowable material (SDR) and a tradi- 8) and increase cuspal deflection during function (9). tional resin composite. The importance of conserving the bulk of dentin was Methods. Thirty maxillary and 30 mandibular first demonstrated in maintaining the structural integrity molars were selected based on similar dimen- and in the prognosis of endodontically restored teeth sions. After cleaning, shaping and filling of the (10-13), as the fracture resistance and stress distribu- root canals and adhesive procedures, specimens tion of endodontically treated teeth is directly affected were assigned to 3 subgroups for each tooth type by the amount of residual coronal dentin (4, 14-18). (n=10): Group A: control group, including intact In posterior preparations, especially when the cervi- teeth; Group B: access cavities were restored cal margin is located in dentin, the polymerization with a traditional resin composite (EsthetX; shrinkage effects can be significant, producing mar- Dentsply-Italy, Rome, Italy); Group C: access cav- ginal defects and gaps despite careful application ities were restored with a bulk fill flowable com- (19). Several techniques and a variety of restorative posite (SDR; Dentsply-Italy), except 1.5 mm layer materials, which would minimize the stresses gener- of the occlusal surface that was restored with the ated on the interface of the restoration by modifying same resin composite as Group B. The speci- some physical and mechanical properties have been mens were subjected to compressive force in a proposed to reduce the effects of polymerization material static-testing machine until fracture oc- shrinkage (20-22). Furthermore, inadequate polymer- curred, the maximum fracture load of the speci- ization throughout the restoration may compromise its mens was measured (N) and the type of fracture physical properties and increase elution of monomer 4 Annali di Stomatologia 2016;VII (1-2): 4-10 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Fracture resistance of endodontically treated teeth restored with a bulkfill flow able material and a resin composite (23-26) and may lead to undesirable effects, such as dures and were restored with a resin composite gap formation, marginal leakage, recurrent caries. It (EsthetX; Dentsply-Italy, Rome, Italy); may also negatively affect pulp tissue and may lead • Group C, which included 10 maxillary and 10 to premature failure of the restoration (27, 28). mandibular molars, which were subjected to en- Several manufacturers have recently developed and dodontic access cavity and endodontic proce- introduced new types of resin composites, so-called dures and were restored with a bulk fill flowable “bulk fill” materials, which can be applied to the cavity composite (SDR; Dentsply-Italy), except 1.5 mm and light cured to a maximal increment thickness of 4 layer of the occlusal surface that was restored mm (29-32) with enhanced curing, shrinkage and with the same resin composite as Group B. physical properties (33). Bulk fill flowable resin com- The access cavity was prepared using water-cooled posites are used in association with conventional round-ended cylindrical diamond burs and non-end- composites for aesthetic restorations in posterior cutting diamond burs mounted on a high-speed hand teeth, having lower polymerization stress, better flow piece with different diameters. Root canals were ne- with easy placement, an excellent adaptation to the gotiated with size 10 K-type files (Flexofile; Dentsply cavity walls and low modulus of elasticity, which can Maillefer, Ballaigues, Switzerland) to the major apical reduce the stress generated on the cavity walls (34). foramen and canals instrumented to length with NiTi The purpose of this in vitro study was to compare the rotary instruments (Mtwo; Sweden & Martina, Padova, fracture resistance of endodontically treated upper Italy) up to the #25 tip size and 0.06 taper file. During and lower molars restored with direct traditional and the endodontic treatment 5.25% sodium hypochlorite bulk fill flowable resin composite restorations. The (Niclor 5, Ogna, Muggiò Milan, Italy) for irrigation was null hypothesis tested was that there was a difference intermittently deposited using Pro Rinse side-vented in the fracture resistance and the mode of failure be- 30-G needles (Dentsply Tulsa Dental Specialties, Tul- tween endodontically treated maxillary and mandibu- sa, OK). The canals were dried with paper points and lar molars restored with traditional and bulk fill flow- filled with gutta-percha (single-cone #25/0.06 taper) able resin composite. and a resin-based endodontic sealer (AH-Plus, Dentsply Maillefer, Ballaigues, Switzerland). After the cleaning, shaping and filling procedures, post-opera- Materials and methods tive radiographs were taken in the two perpendicular dimensions (MD and BL) to evaluate the endodontic Sixty intact recently extracted human maxillary and treatment. Then, the enamel and dentin of the access mandibular molars with completely formed apices cavity were etched with 37% phosphoric acid for 30 were used in this in vitro study. The exclusion criteria and 15 seconds respectively, rinsed for 30 seconds for tested teeth were the presence of caries, previous with a water/air spray, and gently air-dried to avoid restoration and visible fracture lines or cracks. After a desiccation. A light-polymerizing primer-bond adhe- debridement with hand scaling instruments and sive (XP Bond, Dentsply International, York, USA) cleansing with rubber cup and pomice, the teeth were was applied, gently air-thinned and exposed to LED stored in individually numbered containers with 0.1% polymerization for 40 seconds. In group B access cav- thymol solution at 4° C until used. Thirty maxillary ities were restored with direct resin composite (Es- first molars with three separate roots and 30 thetX; Dentsply-Italy, Rome, Italy) with material incre- mandibular first molars with two separate roots were ments of maximum 2 mm. The specimens in Group C selected based on similar anatomical crown height, were restored with a bulk fill flowable composite with measured from the occlusal surface to the cemento- maximal increment thickness of 4 mm (SDR; enamel junction on the four sides of the teeth, and Dentsply-Italy), except for 1.5 mm layer of the occlusal bucco-lingual (BL), mesio-distal (MD) dimensions at surface that was restored with the same resin com- the occlusal surface. Tooth measurements were tak- posite as Group B (Fig. 1). en with a digital caliper. Preliminary radiographs were All the specimens were marked 2 mm below the ce- taken in two perpendicular directions (MD and BL) to mento-enamel junction and were covered with approx- determine root canal anatomy and measure the imately 0.25 mm-thick wax. The specimens were em- length and degree of canal curvature using the bedded in autopolymerizing acrylic resin (SR Ivolen; Schneider method (35). Specimens were subse- IvoclarVivadent, Schaan, Lichtenstein) in metallic cylin- quently assigned to 3 groups (n=10) for each tooth drical molds in position with their long axis parallel to that type creating homogenous groups considering the of the cylindrical molds. To simulate the periodontal average of teeth dimensions in order to minimize the ligament, at the first signs of the beginning of polymer- influence of size and shape variations on the results: ization, the teeth were removed from the resin blocks • Group A, the negative control group, which includ- and the wax was cleaned from the root surfaces. A ed 10 maxillary and 10 mandibular molars that standardized silicone layer was created using a light- were left intact for fracture testing, without any body silicone-based impression material (Aquasil ultra cavity preparation or root canal treatment; light bodies, Dentsply International, York, USA) which • Group B, which included 10 maxillary and 10 was injected into the polymerizing resin bases. The mandibular molars, which were subjected to en- teeth with now wax-free root surfaces were inserted in- dodontic access cavity and endodontic proce- to the resin bases immediately after the silicone injec- Annali di Stomatologia 2016;VII (1-2): 4-10 5 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  A. Isufi et al. Figure 1. Representative images of enamel and dentin of access cavity etched with 37% phosphoric acid (A), application of a light-polymerizing primer-bond adhesive (B), application of a bulk fill flowable composite with maximal increment thickness of 4 mm (C) , and final restoration of 1.5 mm layer of the occlusal surface restored a traditional resin composite (D). tion (36). All the specimens were stored in buffered man-Keuls test for multiple comparisons (Prism 5.0; saline plus 1.5% thymol at room temperature (24-28° C) GraphPad Software, Inc, La Jolla, CA) with the sig- until the fracture testing procedure. nificance level established at 5% (P < .05). All the 60 specimens were mounted in a mechanical material testing machine (LR30K; Lloyd Instruments Ltd, Fareham, UK) equipped by a (5k ± 5) N load Results cell. The teeth were loaded at their central fossa at a 30° angle to the long axis of the tooth (Fig. 2). The The mean of the bucco-lingual (BL) and mesio-distal continuous compressive force at a cross- head (MD) dimensions at the occlusal surface and the speed of 1.6 mm/s was applied with a 6 mm diame- anatomical crown height of the teeth tested are pre- ter ball-ended steel compressive head until visible sented in Table 1. No significant difference was found or audible evidence of fracture was shown. The comparing all teeth dimensions in control and test force at fracture was measured in Newton (N) and groups (P > .05). type of fracture was recorded as “favorable” be- No statistically significant differences were found cause restorable, when the failures were above the among groups (P<0.05). Fracture resistance of en- level of bone simulation (site of fracture above the dodontically treated teeth restored with a traditional acrylic resin) and as “unfavorable” because non-re- resin composite and with a bulk fill flowable compos- storable, when the failures were extending below ite (SDR) was similar in both maxillary (Group B: the level of bone simulation (site of fracture below 1072±525N; Group C: 1241±388N) and mandibular the acrylic resin). The data were verified with the molars (Group B: 1332±318N; Group C: 1527±449N). Kolmogorov-Smirnov test for the normality of the Restored teeth showed no significant decrease in distribution and the Levene test for the homogeneity fracture resistance compared to intact specimens of variances. Thus, they were statistically evaluated similar in both maxillary (Group A: 1183±313N) and by the analysis of variance test and Student-New- mandibular molars (Group A: 1620±170N) (Tab. 2). 6 Annali di Stomatologia 2016;VII (1-2): 4-10 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Fracture resistance of endodontically treated teeth restored with a bulkfill flow able material and a resin composite Figure 2. Simulated occlusal loading using a 6-mm-diameter steel sphere placed on the central fossa with lingual orientation in& axio-occlusal & line at 30° angle to the long axis of a mandibular molar tooth. Table 1. Mean and Standard Deviation of the Mesio-Distal (MD) and Buccal-Lingual (BL) dimensions and the anatomical crown height (measured at the four sides of the tooth) of the tested teeth in each group. Groups Control Bulk fill material (SDR) Traditional resin composite Tooth Type Occlusal Anatomical Occlusal Anatomical Occlusal Anatomical (n=10) Surface Crown Surface Crown Surface Crown Height Height Height MD BL MD BL MD BL a a b a a b a Upper 9.9 9.7 5.4 (0.1) 10.0 10.1 5.6 (0.6) 9.9 10.1a 5.4 (0.4)b Molars (0.6) (0.7) (0.5) (1.1) (0.5) (0.9) Lower 10.7 a 10.3 a 5.7 (0.4)b 10.6a 10.1a 5.5 (0.4)b 10.4a 10.2a 5.6 (0.7)b Molars (1.2) (0.6) (0.8) (0.7) (1.2) (0.8) Similar upper letter case in the same row indicates no statistically significant differences (P > .05). Table 2. Load at fracture (mean ± standard deviation) and type of fracture, Favorable (F) or Unfavorable (U) for intact teeth (control, Group A), and teeth restored with traditional resin composite (Group B) or with bulk fill flowable material (SDR) (Group C) assessed after the static test using the Instron Universal Machine. Tooth Type Load at Fracture (N) Type of Fracture (n=10) F U F U F U Group A Group B Group C Group A Group B Group C Upper Molars 1172 (598)a 1001 (453)a 1313 (428)a 8a 2b 3b 7a 3b 7a Lower Molars 1572 (639)a 1375 (310)a 1484 (471)a 7a 3b 3b 7a 2b 8a Similar upper letter case in the same row indicates no statistically significant differences (P > .05). Annali di Stomatologia 2016;VII (1-2): 4-10 7 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  A. Isufi et al. 60.8% of the failures in total were unfavorable (Group teeth. These findings may be attributed to the elastic B 70%; Group C, 75%; control group, 25%). No sig- buffer effect of using low viscosity flowable composite nificant differences were found in the mode of failure and the characteristic low contraction stress and low of the differently restored teeth between Group B and modulus of elasticity of SDR flow (44, 45). High flex- Group C, while intact teeth presented significantly ural modulus can inhibit the ability of a material to re- more favorable fractures compared to restored speci- sist deformation due to loading and promote the ac- mens (both Group B and Group C). cumulation of surface and bulk defects, which may lead to premature failure (46, 47). These findings are in agreement with those of Atiyah et al. (48), who re- Discussion ported increased fracture resistance of endodontically treated premolars restored with SDR. The null hypothesis investigated in the present study In the present study 75% of the samples in the intact can be rejected, as the results obtained support that control teeth presented favorable fracture type that there is no difference in the fracture resistance and in was an important statistical difference with the re- the mode of failure between endodontically treated stored groups. In fact, the majority of the teeth re- maxillary and mandibular molars restored with a bulk stored with SDR (75%) and with a traditional resin fill flowable resin composite (SDR) or a traditional composite (70%) reported unfavorable type of frac- resin composite. ture. However, no significant differences were found Fracture susceptibility of root-filled teeth is affected in the mode of failure between restored teeth. Fur- mostly by the amount of the remaining dentin (4, 37) thermore, all failures of the restored teeth were cohe- and it is not related to its biomechanical properties af- sive fractures, regardless of the type of restoration. ter endodontic treatment, such as hardness and The low elastic modulus may explain the severity of toughness (38). Some studies have shown that the fracture type presented in restored teeth groups and reduction of tooth structure results in weaker teeth the occurrence of unfavorable fracture. These find- due to restorative procedures (6-8). However, accord- ings are in agreement with previous reports that ing to Reeh et al. (4), endodontic procedures have found an increased frequency and severity of cuspal only a small effect on the tooth, reducing the relative fracture due to removal of cervical dentin (49). rigidity by 5%, which is contributed entirely by the ac- The limitations of this study must be recognized. The cess opening. Restorative procedures and, particular- experimental methods used for in vitro analyses do ly, the loss of marginal ridge integrity, were the great- not accurately reflect intraoral conditions, in which fail- est contributors to loss of tooth resistance. The loss ures occur primarily due to fatigue. Future research in of 1 marginal ridge resulted in a 46% loss in tooth this area should use cyclic loading and other fatiguing rigidity, and a MOD preparation resulted in an aver- simulation to more accurately reproduce the clinical age loss of 63% in relative cuspal rigidity. environment. Additional clinical studies are necessary Several studies were conducted to determine the ide- to determine the long-term prognosis of endodontical- al materials and techniques to restore endodontically ly treated maxillary and mandibular molars restored treated teeth because their long-term prognosis de- with bulk fill flowable resin composite. pends on the quality of the final restoration (39-42). Within the limitations of this in vitro study, endodonti- Usually, to restore endodontically treated teeth sever- cally treated upper and lower molars restored with al resin increments are required to fill the cavity bulk fill flowable resin composite presented a resis- preparation because of the large volume of the tance to fracture under simulated compressive force restoration. Thus, the clinician must compensate the not significantly different than that of traditional resin polymerization shrinkage of traditional resin-based composite restorations. Restored teeth showed no composite, by filling the cavities in several increments significant decrease in fracture resistance compared (43). A new category of flowable resin-based com- to intact specimens. Furthermore, no differences posites has been introduced as bulk fill base material were found in the mode of failure of the differently re- that can be applied in 4 mm thick bulks instead of us- stored teeth, while intact teeth presented statistically ing the incremental placement technique, without more favorable fractures. negatively affecting the polymerization shrinkage, Bulk fill flowable composites can be used to restore cavity adaptation or the degree of conversion (30). endodontically treated posterior teeth using 4 mm The results of the present study show that there were maximum increments and 1.5 mm occlusal traditional no significant differences in the static fracture resis- layer because this does not reduce the mechanical tance of endodontically treated molars restored with resistance of the restored teeth, while making the bulk fill flowable resin composite (SDR) and a tradi- procedure easier, less stressful and with a reduced tional resin composite. Moreover, the mean fracture chair side time. load for teeth restored with SDR was higher com- pared with the mean fracture load of specimens re- stored with traditional resin composites, without any Acknowledgements statistical significance. Furthermore, the results of this study showed that there was no significant differ- The Authors deny any conflicts of interest. ence between teeth restored with SDR and intact The Authors affirm that we have no financial affiliation 8 Annali di Stomatologia 2016;VII (1-2): 4-10 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  Fracture resistance of endodontically treated teeth restored with a bulkfill flow able material and a resin composite (e.g., employment, direct payment, stock holdings, re- treated bovine anterior teeth. J Prosthet Dent. 2010;104:306- tainers, consultant ships, patent licensing arrange- 317. ments or honoraria), or involvement with any com- 18. Dietschi D, Scampa U, Campanile G, Holz J. Marginal adap- mercial organization with direct financial interest in tation and seal of direct and indirect Class II composite resin restorations: an in vitro evaluation. Quintessence Int. the subject or materials discussed in this manuscript, 1995;26:127-138. nor have any such arrangements existed in the past 19. Furness A, Tadros MY, Looney SW, Rueggeberg FA. Effect three years. Any other potential conflict of interest is of bulk/incremental fill on internal gap formation of bulk-fill disclosed. composites. J Dent. 2014;42(4):439-449. 20. Lindberg A, van Dijken JW, Lindberg M. Nine-year evalua- tion of a polyacid-modified resin composite/resin compos- References ite open sandwich technique in Class II cavities. J Dent. 2007;35(2):124-129. 1. Meyenberg K. The ideal restoration of endodontically treat- 21. Aguiar FH, Ajudarte KF, Lovadino JR. Effect of light curing ed teeth - structural and esthetic considerations: a review of modes and filling techniques on microleakage of posterior the literature and clinical guidelines for the restorative clin- resin composite restorations. Oper Dent. 2002;27(6):557-562. ician. Eur J Esthet Dent. 2013;8(2):238-268. 22. Ruyter IE, Oysaed H. Conversion in different depths of ul- 2. Steele A, Johnson BR. In vitro fracture strength of en- traviolet and visible light activated composite materials. Acta dodontically treated premolars. J Endod. 1999;25:6-8. Odontol Scand. 1982;40:179-192. 3. Krejci I, Duc O, Dietschi D, de Campos E. Marginal adap- 23. Ferracane JL, Mitchem JC, Condon JR, Todd R. Wear and tation, retention and fracture resistance of adhesive com- marginal breakdown of composites with various degrees of posite restorations on devital teeth with and without posts. cure. J Dent Res. 1997;76:1508-1516. Oper Dent. 2003;28:127-135. 24. Poskus LT, Placido E, Cardoso PE. Influence of placement 4. Reeh ES, Messer HH, Douglas WH. Reduction in tooth stiff- techniques on Vickers and Knoop hardness of class II com- ness as a result of endodontic and restorative procedures. posite resin restorations. Dent Mater. 2004;20:726-732. J Endod. 1989;15:512-516. 25. Sideridou ID, Achilias DS. Elution study of unreacted Bis- 5. Owen CP. Factors influencing the retention and resistance GMA, TEGDMA, UDMA, and Bis-EMA from light-cured den- of preparations for cast intracoronal restorations. J Prosthet tal resins and resin composites using HPLC. J Biomed Mater Dent. 1986;55(6) 674-677. Res B Appl Biomater. 2005;74:617-626. 6. Fokkinga WA, Kreulen CM, Vallittu PK, Creugers NH. A struc- 26. Musanje L, Darvell BW. Curing-light attenuation in filled-resin tured analysis of in vitro failure loads and failure modes of restorative materials. Dental Materials. 2006;22:804-817. fiber, metal, and ceramic post-and-core systems. Int J 27. Ferracane JL, Greener EH. The effect of resin formulation Prosthodont. 2004;17:476-482. on the degree of conversion and mechanical properties of 7. Panitvisai P, Messer HH. Cuspal deflection in molars in re- dental restorative resin. Journal of Biomedical Materials Re- lation to endodontic and restorative procedures. J Endod. search. 1986;20:121-131. 1995;21(2):57-61. 28. Quixfil Scientific Compendium. Dentsply DeTrey; 2003. 8. Mondelli J, Steagall L, Ishikiriama A, de Lima Navarro MF, 29. Surefil SDR flow Directions For Use. Dentsply Caulk; 2009. Soares FB. Fracture strength of human teeth with cavity 30. Venus Bulk Fill Product Profile. Heraeus Kulzer; 2011. preparations. J Prosthet Dent. 1980;43:419-422. 31. Tetric Evo Ceram Bulk Fill Press Release. Ivoclar Vi- 9. Tang W, Wu Y, Smales RJ. Identifying and reducing risks vadent; 2011. for potential fractures in endodontically treated teeth. J En- 32. Ilie N, Hicke lR. 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Original article In vitro evaluation of carrier based obturation technique: a CBCT study Gianluca Gambarini, MD, DDS1 TH and 1 in Group SC). The percentages of voids Lucila Piasecki, PhD, DDS2 in both groups were very low with no significant Giovanni Schianchi, DDS1 difference (Z test, p>0.05). Conclusions. The two Dario Di Nardo, DDS1 tested CBO techniques showed similar positive Gabriele Miccoli, DDS1 results in terms of performance, even if, after Dina Al Sudani, PhD, DDS3 checking with verifiers, in most cases the size of Roberto Di Giorgio, DDS1 the selected Soft-Core obturator was one size Luca Testarelli, PhD, DDS1 smaller than Thermafil. Key words: endodontic obturation, Thermafil, 1 Department of Oral and Maxillo-Facial Sciences, Soft-Core, Cone-beam Computed Tomography. “Sapienza” University of Rome, Italy 2 Department of Periodontics and Endodontics, University at Buffalo (NY), USA 3 Department of Restorative Dental Sciences, Introduction College of Dentistry, King Saud University, Riyadh, Saudi Arabia The success of endodontic therapy is directly related to the sealing of the root canal system, by means of a three-dimensional hermetic endodontic filling (1, 2). Corresponding author: The primary objective of the endodontic obturation in Lucila Piasecki root canal treatment is to prevent the ingress of mi- Department of Periodontics and Endodontics, croorganisms or fluids, from both oral cavity or peri- University at Buffalo apical area, and also refrain the growth of any resid- 240 Squire Hall ual bacteria left in the canal system (1-4). An inade- 14214 Buffalo (NY), USA quate seal might result in contamination of the canal E-mail: [email protected] spaces, thus leading to periapical disease (1, 2, 4). The combination of gutta-percha with a layer of en- dodontic sealer is the most commonly used material Summary for root canal obturations. A variety of techniques have been developed to provide the proper adapta- Aim. The goal of the study was to compare the abil- tion of the gutta-percha root canal walls, aiming the ity of two different carrier based obturation (CBO) complete filling of the root canal system (2, 4). John- techniques to reach working length and fill in three- son (5) developed an obturation technique using flexi- dimensions root canal systems, by using CBCT. ble metal/plastic carriers coated with α-phase gutta- Materials and Methods. Twenty-six extracted mo- percha (Thermafil Endodontic Obturator, Tulsa Dental lars were scanned with CBCT and 40 curved Products, Tulsa, OK, USA). The main goal of this car- canals were selected (between 30° and 90°) and rier based obturation (CBO) technique is to obtain a divided in two similar groups (n=20). All canals predictable thermo-plasticization and the consequent were prepared up to size 25 taper .06 using nick- flow of the gutta-percha, by using a specific oven with el-titanium instrumentation. The canals in the a precise temperature control. Group SC were obturated using Soft-Core obtura- Previous studies have reported a good sealing ability tors (Kerr, Romulus, Mi, USA), while Group TH of Thermafil obturations (6-10). The advantages of canals (n= 20) were obturated using Thermafil En- the carrier-based obturation (CBO) are related to the dodontic Obturators (Tulsa Dental Products, Tul- flow of the gutta-percha inside the root canal space, sa, OK, USA), strictly following manufacturers’ in- which is achieved by the combination of the heating structions for use. The obturations were analyzed process and the fact that the carrier facilitates the in- by means of CBCT to measure the distance from sertion of filling material and also slightly pressure it the apical limit of obturation to the apical foramen alongside the canal walls. Moreover, the simplicity of and the presence of voids inside root canals. the CBO prevents the risks and problems related to Results. There was no significant difference be- the use of spreaders, pluggers, heaters and com- tween the two groups in the mean distance of the pactors inside complex root canals. Therefore, differ- apical extent of the obturation (t test, p>0.05). ent types of CBO have been developed, such as the Overfilling occurred in only 3 cases (2 in Group Soft-Core™ obturators (Kerr, Romulus, MI, USA). Ac- Annali di Stomatologia 2016;VII (1-2): 11-15 11  G. Gambarini et al. cording to the manufacturer, the Soft-Core obturators Soft-Core, while Thermafill Obturators were used for present one universal taper size and a thinner core in the Group TH (n= 20). For each group the correspon- apical part to allow greater flexibility to navigate curved dent oven and verifiers were used, strictly following canals. manufacturers’ instructions for use. Briefly, first it was On the other hand, the disadvantages of CBO tech- inserted a verifier up to the WL to check the correct niques include the possible risk of overfilling (apical obturator size. Then, the root canal was coated with a extrusion of the sealer, gutta-percha, and/or carrier) small layer of endodontic sealer (Tubliseal Xpress, and underfilling, if the obturators do not reach the full Kerr, Romulus, MI, USA) with the aid of a K-10 file. working length (WL) due to the complex canal curva- The obturator was calibrated at the WL with a rubber tures or less tapered preparation (11, 12). Another stop, heated in the oven and then inserted into the potential disadvantage of CBO, especially in severely root canal. All the procedures were conducted by the curved canals, is the gutta-percha separating from same operator. the carrier, thus leading to the formation of gaps The teeth of both groups were radiographed in me- (voids) between the root canal filling and the canal siodistal and buccolingual directions and then kept at walls. Moreover, CBO might be influenced by many 100% humidity and 37° C for 1 week, for the setting factors (e.g., different ovens with different tempera- of the sealer. The post-operative CBCT was taken by tures, type/amount of gutta-percha, design/dimen- using the i-Cat 500 (0,12 mm resolution). The quality sions of carrier, flexibility and material of the carrier, of obturation was assessed by an experienced radiol- etc.), which might impair the apical sealing, mostly in ogist, using the I-Cat Vision software (Kavo, Biberach curved canals (11, 13, 14). an der Riss, Germany). Therefore, the aim of the present study was to com- Images were analyzed in the three planes (coronal, pare the two different CBO brands, Thermafil and transversal and sagittal) to detect visible voids and to Soft-Core, in the ability to fill curved root canal sys- check the apical limit of obturation. The number of tems, by using Cone-beam computed tomographic visible voids were calculated for each canal, while the (CBCT) evaluation. underfilling was measured by determining the dis- tance (in mm) from the apex to the end of the root canal obturation. The CBCT images were submitted Materials and methods to a rendering process to visualize more clearly any defects of the obturation (voids or underfilling) in the A total of 26 molar was obtained from a pool of ex- three-dimensional reconstructions. Data was submit- tracted teeth. A pre-operative CBCT scan evaluation ted to statistical analysis with significance set at was conducted to analyze the anatomical parameters p<0.05. and 40 canals presenting curvatures between 30 o and 90o were selected. The canals were divided into two groups (n=20), with similar curvatures. Results After access cavity in the teeth, each selected canal was checked for patency and the working length was In three cases a slight overfilling of gutta-percha was established 0.5 mm short to the apical foramen. A observed of the root canals (2 in the Group TH and 1 mechanical glide path was performed with manual in for the SC). These cases were excluded for the stainless steel K-files attached to the M4 handpiece measurement of the distance between the limit of ob- (SybronEndo, Glendora, CA, USA), up to a size 15. turation and the apical foramen (Tab. 1). No signifi- Then, each canal was prepared using TFA nickel-tita- cant differences were noted between the mean dis- nium instruments (SybronEndo, Glendora, CA, USA) tances of the groups (t test, p>0.05). Visible voids sizes 04.20 and 06.25. Irrigation was performed after were detected only in three canals (2 of Group TH each instrument using NAOCl 5% and final rinse with and 1 of Group SC) and in only one case more than 3 mL of 17% EDTA and saline. After shaping proce- one void was present inside the canal (Fig. 1). The dures were completed, all canals were checked for proportions Z test showed no difference in the per- patency with a 10 K-file and dried by paper points. centage of canals with voids between the two groups The Group SC canals (n=20) were obturated using (p >0.05). Table 1. Distance between the apical limit of the obturation to the apical foramen (mm) and percentage of the cases with voids. Distance Voids Group n Mean (SD) n % Thermafil 18 0.32 a (0.24) 2 10% a Soft-Core 19 0.27 a (0.18) 1 5% a Different superscript letters indicate statistically significant difference within column. 12 Annali di Stomatologia 2016;VII (1-2): 11-15 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  In vitro evaluation of carrier based obturation technique: a CBCT study Figure 1. The CBCT (sagittal plane) and 3D rendering of the same obturated tooth showing the presence of voids (ar- rows). Discussion Several methods have been proposed to investigate the quality of root canal fillings technique (1, 3, 8, 9, 11-13, 15-17), such as radiographs, biolumines- cence, histological sections, dye leakage, microleak- age models and clearing techniques. The use of CT or CBCT is a quite recent methodology, which has many advantages: convenience, decreased examina- tion time, lack of removal dentinal tissue, lack of dam- age of samples, possibility of different plane of exam- ination and different sections of canals, and repeata- bility. CT is more costly and time consuming, but more precise. CBCT is easier and quicker to perform, and is more similar to clinical imaging. Moreover, the CBCT analysis allowed not only the evaluation of voids, but also the precise measurement of the apical length of the obturation. Although the CBCT images can be more easily visualized by three-dimensional rendering using specific softwares (Fig. 1), this image processing was made as an experimental model to confirm the CBCT findings (Fig. 2). Results of the present study showed that there was Figure 2. Detection of voids (arrow) and measurement of no significant difference between the two tested CBO distance between apical foramen and obturation (dashed techniques in the apical extent of the root canal fill- line), using 3D rendering. ing. Differently from some previous studies (11, 12), we found that despite the canal curvature, the apical limit of obturation was very satisfactory. Most of ca- smaller coronal dimensions and a bigger plastic core, nals were sealed very close to the established work- while Soft-Core obturators have a thinner core and a ing length, and a slight overfilling of gutta-percha was greater amount of gutta-percha. A thinner core could recorded in only two Thermafill cases and in a Soft- also be related to a denser filling, since a greater gut- Core one, but there was no carrier protrusion beyond ta-percha ratio is considered preferable in maintain- the apex. ing the long-term apical seal (8, 9). These positive results are clearly related to a proper The apparently mismatch of sizes among the CBO use of verifiers. Although the root canals were brands proved not to be clinically relevant because shaped up to a taper .06 and size 25, for the SC the results of both were similar and satisfactory. This group the majority of canals (n=16) were filled with might be explained by the fact that in a CBO tech- obturator size 20. It was observed that the Soft-Core nique, the obturator is always well plasticized along verifier size 20 was correctly reaching WL while the its entire length. Accordingly, Marciano et al. showed size 25 verifier was short in thoses cases. For TH that both Thermafil and System B were more effec- group, 18 all canals were obturated with size 25. This tive than cold condensation techniques in the obtura- difference between the brands are probably related to tion of roots with isthmuses (9). Therefore, the gutta- their features: the Thermafil obturators present a percha flows not only apically but also laterally, filling Annali di Stomatologia 2016;VII (1-2): 11-15 13 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  G. Gambarini et al. a slightly wider canal space adequately, especially if we have more mass of gutta-percha, likewise in the Soft-Core obturators. Nevertheless, CBO are less ef- fective than other warm obturation techniques in the filling of internal resorptive cavities (15). Moreover a more flexible and smaller size carrier will reach working length with less risk of striping of the gutta-percha (11). Clinicians need only to pay atten- tion at not pushing the carrier beyond the apex, which can be easily achieved by correctly placing the rubber stop on the obturator at the proper working length. Overall, when size 20 was used, Soft-Core obturators reached working length in severely curved canals more easily and predictably than Thermafil size 25. Table 1 shows the mean data concerning the dis- tance between the apical foramen and root canal fill- ing for both techniques. Likewise, no significant difference in terms of voids and gaps was found between the two techniques, showing the excellent performance of CBO in severe curvatures. The 3D rendering images clearly shows how canals were three-dimensionally filled (Figs. 3, 4). Present results are in agreement with previous re- Figure 4. 3D rendering of a tooth obturated with Thermafil. searches that also showed no difference in the per- centage of canal area filled and voids between Ther- mafil and Soft-Core (15). rates when filling the root canals with Soft-Core or lat- There have been many studies comparing obturation eral condensation. Another clinical study (20) did not methods in vitro showing the effectiveness and sim- find any difference in clinical outcomes between the plicity of CBO techniques (6-10, 15). The findings of lateral condensation and CBO technique performed the present study confirmed these positive results, with Thermafil obturator. with a minimal amount of voids and underfilling. De Hence we may conclude that the two tested CBO Moor and Hommez compared different obturation ma- showed similar positive results. Both filling systems terials with a dye leakage study and found that there were quick and easy to perform even when severe were no differences in the long-term sealing ability curvatures were present. The present study empha- between Thermafil and Soft-Core (18). A prospective tized the need to precisely verify the matching be- clinical study (19) found no difference in success tween preparation and obturators with verifiers. References 1. Gillen BM, Looney SW, Gu L-S, Loushine BA, Weller RN, Loushine RJ, et al. Impact of the Quality of Coronal Restora- tion versus the Quality of Root Canal Fillings on Success of Root Canal Treatment: A Systematic Review and Meta-analy- sis. J Endod. 2011 Jul;37(7):895-902. 2. Johnson WT, Kulild JC. Obturation of the cleaned and shaped root canal system, in Cohen’s Pathways of the Pulp, Harg- reaves KM, Cohen S. Eds, Mosby, St. Louis, Mo, USA, 10th edition. 2010;349-351. 3. Hale R, Gatti R, Glickman GN, Opperman LA. Comparative analysis of carrier-based obturation and lateral compaction: A retrospective clinical outcomes study. Int J Dent. 2012;2012. 4. Schilder H. Filling root canals in three dimensions. Dental Clin- ics of North America. 1967;11:723-744. 5. Endodontics JOB, Report W. A New Gutta-Percha Technique. 1978;4(6). 6. Gutmann JL, Saunders WP, Saunders EM, Nguyen L. An assessment of the plastic Thermafil obturation technique. Part 2. Material adaptation and sealability. Int Endod J. 1993;26: 179-183. 7. Abarca AM, Bustos A, Navia M. A comparison of apical seal- ing and extrusion between Thermafil and lateral condensa- Figure 3. 3D rendering of a tooth obturated with Soft-Core. tion techniques. J Endod. 2001;27:670-672. 14 Annali di Stomatologia 2016;VII (1-2): 11-15 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.  In vitro evaluation of carrier based obturation technique: a CBCT study 8. De-Deus G, Gurgel-Filho ED, Magalhães KM, Coutinho-Fil- canal fillings. Sci World J. Hindawi Publishing Corporation. ho T. A laboratory analysis of gutta-percha-filled area obtained 2014;2014. using Thermafil, System B and lateral condensation. Int En- 15. Gencoglu N, Yildirim T, Garip Y, Karagenc B, Yilmaz H. Ef- dod J. 2006;39(5):378-383. fectiveness of different gutta-percha techniques when filling 9. Marciano M, Ordinola-Zapata R, Cunha TVRN, Duarte MAH, experimental internal resorptive cavities. Int Endod J. Cavenago BC, Garcia RB, et al. Analysis of four gutta-per- 2008;41(10):836-842. cha techniques used to fill mesial root canals of mandibu- 16. Dummer MH, Lyle L, Kennedy JK. A laboratory study of root lar molars. Int Endod J. 2011;44(4):321-329. fillings in teeth obturated by lateral condensation of gutta- 10. Gencoglu N, Garip Y, Bas M, Samani S. Comparison of dif- percha or Thermafil obturators. 1994;32-38. ferent gutta-percha root filling techniques: thermafil, Quick- 17. 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J Contemp Dent Pract. 2009;10: resin root canal sealer used with five gutta-percha obtura- 74-81. tion techniques. Endod Dent Traumatol. 2000;16(6):291-297. 20. Chu CH, Lo ECM, Cheung GSP. Outcome of root canal treat- 14. Alhashimi RA, Foxton R, Romeed S, Deb S. An in vitro as- ment using Thermafil and cold lateral condensation filling tech- sessment of gutta-percha coating of new carrier-based root niques. Int Endod J. 2005;38:179-185. Annali di Stomatologia 2016;VII (1-2): 11-15 15 Copyright © 2016 CIC Edizioni Internazionali Unauthorized reproduction of this article is prohibited.